E1- Murmurs

Diastolic or Systolic: Mitral regurgitation

Systolic

Diastolic or Systolic: Tricuspid regurgitation

Systolic

Diastolic or Systolic: Aortic stenosis

Systolic

Diastolic or Systolic: Pulmonic stenosis

Systolic

Diastolic or Systolic: Mitral stenosis

Diastolic

Diastolic or Systolic: Tricuspid stenosis

Diastolic

Diastolic or Systolic: Aortic regurgitation

Diastolic

Diastolic or Systolic: Pulmonic regurgitation

Diastolic

Continuous musical hum of grade 1-2 intensity

Venous hum

Where is a venous hum located?

Infraclavicular areas

Where is a venous hum louder?

Right infraclavicular area

What resolves a venous hum?

Turning the child's neck, placing the child supine, compressing the jugular

What accentuates a venous hum?

Diastole and inspiration

Harsh, diamond-shaped, crescendo-decrescendo systolic ejection murmur

Aortic stenosis

Where is an aortic stenosis murmur best heard?

RUSB radiating to neck/carotid

What are the 3 symptoms associated with AS?

Exertional dyspnea, angina, syncope

What test is used to diagnose an AS murmur?

TEE

What 2 other physical exam findings are associated with AS?

- Paradoxical split S2
- Pulsus parvus et tardus

High pitched decrescendo diastolic murmur

Aortic regurgitation

What murmur may result in a Austin Flint murmur?

Aortic regurgitation

Where is aortic regurgitation best heard?

Along LLSB (valve) or RLSB (aortic root)

What accentuates an aortic regurgitation murmur?

Sitting up and leaning forward

What abnormal pulse is associated with aortic regurgitation?

Pulsus alternans & Bisferens pulse

What abnormal pulse is associated with an Austin-Flint murmur?

Pulsus alternans & Bisferens pulse

Mid late diastolic rumble at the apex secondary to retrograde regurgitant jet competing with antegrade flow from the LA to the LV

Austin-Flint murmur

Wide pulse pressure presentation with forceful arterial pulse upswing with rapid falloff

Water-Hammer pulse

Pistol-shot bruit over femoral pulse

Traube's sign

Unusually large carotid pulsation

Corrigan's pulse

Pulsatile blanching and reddening of fingernails upon light pressure

Quincke's sign

Head bobbing caused by carotid pulsations

De Musset's sign

Pulsatile bobbing of the uvula

Muller's sign

To & fro murmur over femoral artery heard best with mild pressure applied to the artery

Duroziez's sign

What is the most important testing used to diagnose aortic regurgitation?

TEE

What will an EKG show in a patient with aortic regurgitation?

LVH

What is the medical treatment for aortic regurgitation?

Reduce afterload- CCBs (nifedipine), ACEI, ARBs, hydralazine

What is the most common cause of mitral stenosis?

Rheumatic fever

What symptoms are associated with mitral stenosis?

Palpitations, HF, dyspnea, A fib, Ortner's syndrome

What murmur may be associated with Ortner's syndrome?

Mitral stenosis

Hoarseness due to recurrent laryngeal nerve compression

Ortner's syndrome

Opening snap, low-pitched diastolic rumble, Loud (crisp) S1, Increased P2

Mitral stenosis

Where is mitral stenosis best heard?

Apex in the left lateral decubitus position

What accentuates mitral stenosis?

Squatting, leg raise, left lateral decubitus

What decreases the intensity of mitral stenosis?

Valsalva, standing, inspiration

Mitral stenosis may present for the first time in __________

Pregnancy

What can be seen on a CXR of a patient with mitral stenosis?

LAE, possible pulmonary edema

What can be seen on a TEE of a patient with mitral stenosis?

Doming of mitral valve, LAE, turbulent inflow (pressure gradient measured by Doppler)

What is the treatment for mitral stenosis?

Percutaneous balloon valvuloplasty

Holosystolic murmur, high-pitched and loud

Mitral regurgitation

What is the most common cause of mitral regurgitation?

Mitral valve prolapse

Where is mitral regurgitation best heard?

Apex radiating to the left axilla

What symptoms are associated with mitral regurgitation?

Dyspnea, fatigue, PND, orthopnea

What is the best testing for diagnosis of mitral regurgitation?

TEE & color Doppler echo

What can be seen on an EKG of a person with mitral regurgitation?

LVH and LAE

What is the treatment for chronic mitral regurgitation?

Percutaneous MV repair with catheter based clip

What is the most common patient demo for mitral valve prolapse?

Slender, tall females

"Barlow's syndrome"

Mitral valve prolapse

"Click murmur syndrome"

Mitral valve prolapse

What symptoms are rare with mitral valve prolapse?

Edema and HF

Mid systolic click, followed by a late systolic murmur

Mitral valve prolapse

Where is mitral valve prolapse best heard?

Apex

What is the effect of Valsalva on mitral valve prolapse?

More holosystolic, louder, earlier click

What is the effect of squatting on mitral valve prolapse?

Shorter, delayed click

What is the best testing for diagnosis of mitral valve prolapse?

TEE

Is endocarditis prophylaxis recommended for patients with mitral valve prolapse?

No

What is the symptomatic treatment for mitral valve prolapse?

Beta blockers

Systolic crescendo-descrescendo ejection murmur in the left upper sternal border that increases with inspiration and radiates diffusely

Pulmonic stenosis

What testing is used to confirm the diagnosis of pulmonic stenosis?

Echo

What symptoms associated with pulmonic stenosis may develop?

RVH, JVD, RV ischemia

When is pulmonic stenosis usually detected?

Childhood- congenital

What is the most common cause of primary pulmonic regurgitation?

Congenital abnormality

What are causes of secondary pulmonic regurgitation?

Pulmonary HTN, Dilated cardiomyopathy

Crescendo-decrescendo early diastolic murmur heard at the LUSB

Pulmonic regurgitation

What causes a louder pulmonic regurgitation?

Squatting, inspiration

What causes a softer pulmonic regurgitation?

Valsalva, expiration

What condition is associated with a Graham Steell murmur?

Pulmonic regurgitation

High-pitched early diastolic descrescendo murmur heard over the LUSB, a result of high-velocity regurgitant flow across an incompetent pulmonic valve

Graham Steell murmur

What symptoms may be associated with pulmonary regurgitation?

RHF symptoms

Retrograde flow from the pulmonary artery into the right ventricle during diastole

Pulmonic regurgitation

Dysfunction of the valve leaflets, papillary muscles or the mitral valve annulus to properly close

Tricuspid regurgitation

When tricuspid regurgitation is due to rheumatic heart disease, it generally occurs in combination with __________

Tricuspid stenosis

What is the most common congenital form of tricuspid regurgitation?

Ebstein anomaly

Why is tricuspid regurgitation seen in IVDA?

IVDA --> Bacterial endocarditis --> S. aureus --> Osler nodes, Janeway lesions, Roth spots

High pitch blowing pansystolic murmur at the 4th ICS LSB

Tricuspid regurgitation

What testing is done for the diagnosis of tricuspid regurgitation?

Echo

What makes tricuspid regurgitation louder?

Inspiration

What makes tricuspid regurgitation reduced?

Standing, Valsalva

What symptoms are associated with tricuspid regurgitation?

Symptoms of RHF

harsh mid systolic crescendo-decrescendo murmur

HOM

where is HCOM best heard?

3rd ICS LSB (didn't say explicitly in her powperpoint)

what is the most common cause of sudden death in young athlete's?

HCOM

what makes HCOM louder?

valsalva and standing

what makes HCOM softer?

squatting and trendelenberg

what symptoms are associated with HCOM?

exertion syncope and DOE

what do you see on an EKG with HCOM?

large amplitude QRS complexes with deep Q waves and tall R waves

treatment for HCOM?

BB and CCBs
- they decrease obstruction

what medications should be avoided with HCOM?

positive ionotropes and nitrates

opening click; mid-systolic high-pitched crescendo-decrescendo heard @ LUSB

pulmonic stenosis

fixed split S2

mid-systolic murmur heard @ LUSB

ASD

holosystolic left parasternal murmur with thrill heard @ LLSB

VSD

loud continuous machinery-like murmur heard @ left infraclavicular region

PDA