snap, rubs, knocks, & plop chapter 10 are g. talking, md, facc instructor patricia l. thomas,...
TRANSCRIPT
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Snap, Rubs, Knocks, & PlopChapter 10
Are G. Talking, MD, FACC
Instructor
Patricia L. Thomas, MBA, RCIS
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Outline
• Opening Snap of Mitral Stenosis
• Opening Snap of Tricuspid Stenosis
• Pericardial Friction Rub
• Pericardial Knock
• Mediastinal Crunch
• Tumor Plops
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Opening Snap of Mitral Stenosis
• Heard in Early Diastole a characteristic sign of mitral stenosis
• Sharp, medium frequency, & moderately loud sounds
• Early diastole at the end of the isometric relaxation period
• Occurs .06 to .12 sec after the A2
• Severe Stenosis-LA pressure is higher & forces the valve quickly forward to an early snap
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Causes
• In mitral stenosis, scarring & thickening of the valve leaflet edges has bound them together; the most common cause is rheumatic heart disease
• Opening snap is a result of the anterior leaflet becoming taut, and snaps to a halt, producing a sharp early diastolic sound that is diagnostic of mitral stenosis
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Where to Listen
• Use the diaphragm of the stethoscope between the apex the lower left sternal border at the fourth intercostal space
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Associated Findings
• See figure 10-2
• Phonocardiogram of MS & Sinus Rhythm
• Opening Snap crescendo diastolic murmur
• Loud first heart sound
• Accentuated presystolic component
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Intensity of the Snap• Mitral Stenosis the opening snap is almost
always heard• Moderately calcified valve leaflets
– Soften opening snap
• Severely calcified valve leaflets– No opening snap
• Physical activity & opening snap– LA mean is high louder opening snap
• Aortic insufficiency– May decrease the intensity of the OS because of the
reduced rate of anterior motion of the mitral leaflets in early diastole
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Pericardial Friction Rub• Inflammation of the pericardial membrane or pleural sac at
the 3rd and 4th interspace at the left sternal border. Louder during inspiration
• Scratchy, like sandpaper being used, a match being struck, or leather squeaking
• Sound present when the epicardial & pericardial surfaces, roughened by inflammation, slide over one another during atrial & ventricular systole & during the passive motion of rapid ventricular filling
• 3 components– Atrial Systolic (A)– Ventricular Systolic (V)– Ventricular Diastolic (D)
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Percardial Knock
• Sharp, high-pitched sound present in 90% or more of patients with constrictive pericarditis
• Heard in diastole• Occurs .09 to .12 sec after S3
• See figure 10-5• Occurs after Heart Surgery, radiation
therapy, viral infection, TB pericarditis• Diaphragm of the stethoscope listen at the
lower left sternal border
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Tumor Plops
• Clues to a Myxoma– Cardiac silhouette on X-Ray consistent with
atrial enlargement– An ECG showing signs of LA enlargement– Light-headedness – A very short presystolic murmur– Extra sound in diastole
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Tumor Plops• Left Atrial Tumors
– Loud, low-frequency thud heard in early diastole & caused by abrupt movements of the tumor inside the LA
– It strikes the wall of the chamber or comes to a sudden halt as the pedicle reaches the limit its stretch
• Mitral Valve Vegetation– Echo demonstrates a physical movement of
vegetation across the mitral valve apparatus– Listen with the diaphragm of the stethoscope at
the point of PMI with patient in the left lateral position
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THE ENDOF
CHAPTER 10
Tilkian, Ara MD Understanding Heart Sounds and Murmurs,
Fourth Edition, W.B. Sunders Company. 2002, pp. 107-120