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PHYSIOLOGY | Dr. R. Manalo| Aug.

17, 2013

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S1
S2
S3
S4

HEART SOUNDS
closure of AV valves
closure of semilunar valves
phase of rapid filling of ventricles
due to atrial contraction
APEX
S1
Lubb
Long
Louder
Low pitch

Remains the same on


inspiration and expiration
Lubb durrap
Highly significant in Atrial
SeptalDeffect

Widened Split
Presence of splitting during
expiration and widens on
inspiration
Dup
Diagnostic of Right Bundle
Shorter
Branch Block
Louder
Due to blockage in the
High pitch
RBB, impulse goes to LBB
depolarizing left ventricle
and to the right ventricle
(normally, ventricles are
depolarize in parallel)
Ventricles are depolarize
in series (Left first then to
the right)
During expiration the aortic
valve closes first and pulmonic
closes later because of the
block - responsible for the split
during expiration
During inspiration the block plus
the increase in venous return
further delays the closure of the
pulmonic valve further
separation of the S2
components widened split
during inspiration

BASE
S2

Dup
Shorter
Softer
High pitch

S1
Lubb
Long
Softer
Low pitch

S3 and S4
Physiologically in pediatrics
Pathologically in adults
(significant of heart failure
gallop)
Conduction System of Heart

AV closes earlier than Pulmonic Valve


however S2, during expiration would
almost appear single.
During Inspiration there is an
increased venous return due to the
increased negativity of intrathoracic
pressure, therefore this delays the
closure of pulmonic valve. NORMAL
S2 SPLITTING
S2
LUBB dup on expiration
LUBB durrap on inspiration
Fixed S2 splitting

Paradoxical S2 splitting
Left Bundle Branch Block
Splitting on expiration, second
heart sound becomes single
during inspiration
Opposite of physiologic S2
splitting
Pulmonic component appears
earlier and aortic component
delay
During expiration, there is no
increase in venous return the
activation causes the right
ventricle to contract earlier
the pulmonic valve closes
earlier, early appearance of P2
followed by the activation of left
ventricle which then causes the
aortic component to lag behind.

Notes taken by: Adrian Ang

S3
a.k.a. ventricular gallop/protodiastolic
gallop
earliest sign of HF
LUBB duppa/ Kentucky
S4
Atrial gallop
Lubba dup / Tennessee
Quadruple rhythm
Presence of S1, S2, S3, S4
LUBBA duppa / Mississippi
Stroke Volume
Amount of blood ejected per
beat
Cardiac output
SV x 1min
MURMURS
Results from 2 events:
1. Vortex Shedding/Eddying
Creates a whirling motion in the
vibrations in the fluid of the
blood vessel
2. Turbulence
Increased output state
Anemia
Pregnancy
Thyrotoxicosis
Beriberi
Generalization:
Systolic murmurs may or may not be
pathologic
Diastolic Murmurs are always
pathologic
Pansystolic/Holosystolic
Cover the entire systole
Machinery Murmur/Gibsons Murmur
Holosystolic and Holodiastolic

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During inspiration, there is an


increase of venous return on
right side that also delays the
closure of pulmonic valve, the
delay on both sides fuse to
produce 1 sound.

PHYSIOLOGY | Dr. R. Manalo| Aug. 17, 2013


Pathognomonic of Patent
DuctusArteriosus
Stills murmur
Heard in preschool children (before
the age of 5)
Musical murmur heard during early
systole
Hemic Murmurs
Early systole
Heard in high output state
Clinical Valve Location:
5th ICS,
Mitral Valve Area
midclavicular line
Subxyphoid
Tricuspid Valve
Area
2nd Right ICS,
Aortic Valve Area
parasternal
border

2nd Left ICS,


Pulmonic Valve
parasternal
Area
border
Clinical Valve Location does not
correspond to Anatomical Valve
Location
Heart Valve
Injury
Stenosis
Scar formation (eg.
RHD)
Fixed orifice Fishmouth lesion
Insufficient/Regurgitation
Backflow of blood
Murmur
Valve Position
Lesion
Semilunar
Stenosis
Systolic

AV
Regurgitation
Regurgitati
Semilunar
Diastolic
on
AV
Stenosis
Rheumatic Heart Disease
Peak incidence: 5-15 years old
End result of rheumatic fever but not
all rheumatic fever end up with RHD
Post Strep throat
Glomerulonephritis (2-12 years old)

Notes taken by: Adrian Ang

Anti-streptolysin O
Delayed Ab
Fully developed after 4-6 weeks
after throat infection
Since throat infection is gone, it
will find a suitable target which
is the same as lipoteichoic
acid Collagen fibers
(abundant in the heart valves,
basal ganglia of the brain and
extremities manifestations are
subjected to these areas)
Modified Jones Criteria:

Carditis

Arthritis

Chorea

Erythema marginatum

Subcutaneous nodules

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Strep throat stimulation immune system


production of antibody (Anti-streptolysin
O) targets lipoteichoic coat of
streptococcus

PHYSIOLOGY | Dr. R. Manalo| Aug. 17, 2013

Arthritis and Carditis


Common manifestation in Asia
Inverse relationship
The more severe the
arthritis the less serious
the carditis and vice
versa
Destroy heart valves
First is Mitral valve (favorite)
followed by the aortic valve
Mitral regurgitation or Mitral
stenosis
Once patient develops mitral
stenosis Left atrium tries to
empty content opening is
constricted burden thrown
to the left atrium Giant left
atrium pressure deflected
back to the lungs breaks
bronchial arteries
HEMOPTYSIS
Patient with Mitral Stenosis
Presence of:
1. S1 Accentuation
2. Opening snap
Occur after S2
3. Mid Diastolic rumbling
4. Presystolic accentuation
LUBB trrrrrrrrrrap

Notes taken by: Adrian Ang