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A2
Closure of the aortic valve
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P2
Closure of the pulmonic valve
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S2 splits into what two components?
A2 and P2
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What causes a normal split of S2?
Physiological split- splits with inspiration, joins with expiration
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Fixed split of S2
Atrial septal defect or RBBB (if it is a widened fixed split of S2
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Paradoxical split of S2
LBBB- (splits with expiration and joins with inspiration which is the opposite of normal and fixed splitting)
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Where is the S3 best heard?
Apex with the bell
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S3 sound
- Best heart at the apex with the bell
- patients should be in the left lateral decubitus possition
- Early diastole
- normal in children and adolecents
- pathological in adults-
- passive filling of ventricle
- rapid filling due to pregnancy or anemia
- Excesse volume: congestive heart failure, regurgitant murmurs (MR)
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S4 Atrial Gallop
- Atrial Gallop (ten-nes-see)
- Best heart at the apex with the bell
- Patient should be in the left lateral decubitus position
- Late diastole
- Always pathological
- Filling of the ventricle during atrial contraction
- Non-compliant (stiff) ventricle causing excess pressure
- Chronic hypertension
- Left ventricular hypertrophy
- Ischemia or infarction
- ATP depletion and lack of relaxation
- MUST HAVE ATRIAL CONTRACTION NO S4 IN V-FIB
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Thrills are always _____
Pathological
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Grade I murmur
Barely Audible
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Grade II murmur
Quiet but clearly audible
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Grade III murmur
Moderatly loud but no Thrill
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Grade IV murmur
Loud and associated with a thrill
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Grade V murmur
Very loud with stethoscope partially off chest increased thrill
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Grade IV murmur
Audible with stethoscope off the chest, visible thrill
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Name the systolic murmurs (7)
- Aortic stenosis
- pulmonic stenosis
- mitral regurgitation
- mitral valve prolapse
- Tricuspid regurgitation
- atrial septal defect
- ventricular septal defect
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Name the diastolic murmurs (4)
- Aortic insufficency (regurgitation)
- Pulmonic insufficency (regurgitation)
- Mitral stenosis
- Tricuspid stenosis
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What murmurs do you listen for at the Right upper sternal boarder?
Aortic stenosis
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What murmurs do you listen for at the LUSB?
pulmonic murmurs and splitting of S2
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What murmurs do you listen for at Erb's point?
- Aortic reguritation,Hypertrophic cardiomyopathy (according to packet)
- ASD, VSD, HCM and aortic insufficency (AIS) (according to murmur sheet)
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What murmurs do you listen for in the Tricuspid area?
Tricuspid stenosis, Tricuspid regurgitation, ASD and VSD (according to the packet)
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What murmurs do you listen for in the Apex/Mitral area?
Mitral Stenosis, Mitral Regurgitation, S1, S3, S4
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What are the High pitched murmurs? (6)
S1, S2, Mitral regurgitation, Aortic regurgitation, pulmonic regurgitation, mid systolic click.
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What are the medium pitched murmurs? (2)
Aortic Stenosis, HCM
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What are the Low pitched murmurs? (4)
S3, S4, Mitral Stenosis, tricuspic stenosis (Best in left lateral decubitus)
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What does inspiration increase?
Right ventricular return that increases the splitting of S2, Increases right sided murmurs and Gallops
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What does squatting increase?
increases preload and afterload, which increases most murmurs, decreases HCM and Delays the onset of the click in mitral valve stenosis
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Abrupt Standing does what physiologically and changes what murmurs?
Decreases preload and slightly increses afterload and pulse, this decreases most murmurs including VSD, it will increase the murmur in HCM and will make an earlier onset click in Mitral Valve stenosis
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Valsalva is most similar to what other way to autment a murmur?
abrupt standing
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What murmurs are increased with the Hand grip manuver?
- Increases regurgitant murmurs especially aortic insufficency and Mitral regurg.
- It will help differentiate between Atrial stenosis and Mitral regurge because it will decrease atrial stenosis, and increase mitral regurg.
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Aortic Stenosis
- Location: 2nd ICS RSB (aortic area)
- Radiation: right clavicle and neck
- Pitch: medium
- Murmur: crescendo-decrescendo
- Other sounds: ejection click
- Timing: systolic ejection to mid systolic ejection
- S2: soft
- Possition: sitting or laying
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Aortic insufficiency
- Location: 3rd ICS LSB
- Radiation: None
- Murmur: decrescendo blowing
- Other sounds: none
- Timing: early to mid diastolic
- S1: soft
- Position: sitting up, leaning forward, exhailing
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Mitral stenosis
- Location: 5th ICS MCL
- Radiation: none
- Pitch: low
- Murmur: soft, rumbling, mid to holodiastolic
- Other sounds: OS
- Timing: holodiastolic mid to late diastolic
- Position: left lateral decubitus position
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Mitral Regurgitation
- Location: 5th ICS MCL
- Radiation: Left axilla or back
- Pitch: high
- Murmur: pansystolic
- Other sounds: Midsystolic click, with Mitral valve prolapse
- timing: pansystolic
- possiton: left lateral decubitus possiton
- louder with isometric exercises
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Hypertrophic cardiomyopathy
- Location: 3rd ICS LSB
- Radiation: none
- Pitch: medium
- Murmur: midsystolic
- Other sounds: none
- Timing: mid systolic
- Position: Louder upon sudden standing or valsalva
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