Cardio - Heart Murmurs And Their Clinical Signs

Question 1

AS- name 4 symptoms

Answer 1

• Triad: angina (LV concentric hypertrophy), dyspnea and syncope
• LVF: PND, orthopnea, frothy sputum
• Systemic emboli if endocarditis
• Sudden death

Question 2

AS- general appearance, pulse rate and rhythm, pulse volume and character

Answer 2

• General appearance: pale and sweaty
• Pulse rate and rhythm: sinus, raised HR and low BP (fixed SV)
• Pulse volume and character: slow rising (anachronism), low volume

Question 3

AS - Apex beat, palpation, auscultation and internal jugular sign

Answer 3

• Apex beat: no displacement, pressure loaded
• Palpation: thrill aortic area
• Auscultation: systolic murmur, diamond shaped, 2nd HS gets quieter as AS worsens
◦ Right 2nd ICS, sitting forward in end-expiration, radiating to carotids
• Internal jugular sign: none

Question 4

Aortic stenosis vs aortic sclerosis

Answer 4

• Aortic Stenosis: 
	◦ Valve narrowing due to fusion of the    commissures 
	◦ Narrow PP, slow rising pulse
	◦ Forceful apex
	◦ ESM radiating → carotids
	◦ ECG: LVF
• Aortic Sclerosis: 
	◦ Valve thickening 
	◦ ESM with no radiation

Question 5

Aortic regurgitation: signs visible in general appearance

Answer 5

• General appearance: Corrigan’s sign (visible carotid pulsation), de Musset’s sign (head bobbing in time with carotid pulsation) and Quincke’s sign (nail bed pulsation).

Question 6

Aortic regurgitation: pulse rhythm and BP, pulse volume and character and whether there is a internal jugular sign

Answer 6

• Pulse rhythm and BP: sinus, high BP, normal HR
• Pulse volume and character: collapsing pulse and high volume
• Internal jugular: normal

Question 7

Aortic regurgitation: Apex, signs on palpation, murmur

Answer 7

• Apex: displaced (volume overload)
• Palpation: none
• Murmur
◦ EDM: soft or absent S2 +/- S3, mild disease (short murmur), moderate disease (longer) - Decrescendo

Question 8

Mitral stenosis - causes

Answer 8

• Rheumatic fever
• Prosthetic heart valve
• congenital
• Carcinoid tumours

Question 9

Mitral stenosis - General appearance, pulse rate and rhythm and pulse volume and character

Answer 9

• General appearance: Malar flush (↓CO → backpressure + vasoconstriction)
• Pulse rate and rhythm: AF, tachycardic
• Pulse volume and character: normal, no effect on LV

Question 10

Mitral stenosis - Apex beat, JVP, palpation

Answer 10

• Apex beat: non displaced, tapping (palpable S1)
• JVP may be raised
• Left parasternal heave (RVH secondary to PHT)

Question 11

Mitral stenosis - heart sounds and murmurs

Answer 11

• Murmur: rumbling MDM in apex, left lateral position in end expiration, radiates to axilla
*May also rarely get Graham Steell murmur (EDM 2O to PR) - high velocity flow back across the pulmonary valve; consequence of PHT 2nd to mitral valve stenosis.

Question 12

Mitral regurgitation - causes

Answer 12

• Mitral valve prolapse
• LV dilatation: AR, AS, HTN
• Annular calcification → contraction (elderly)
• Post-MI: papillary muscle dysfunction/rupture
• Rheumatic fever
• Connective tissue: Marfan’s, Ehlers-Danlos

Question 13

Mitral regurgitation - symptoms

Answer 13

• Dyspnoea, fatigue
• AF → palpitations + emboli
• Pulmonary congestion → HTN + oedema

Question 14

Mitral regurgitation - general appearance, pulse rate and rhythm, pulse volume and character + apex + JVP

Answer 14

• General appearance: normal
• Pulse rate and rhythm: normal
• Pulse volume and character: normal
• Apex: displaced
• JVP: normal

Question 15

Mitral regurgitation: palpation, auscultation and murmur

Answer 15

• Palpation: Left parasternal heave ( if have RVH) or thrill in apex area (rare)
• Auscultation: soft S1, S2 not heard separately from murmur or loud P2 (if PHT)
• Murmur: Blowing PSM in apex, Left lateral position in end expiration and radiates to the axilla, accelerates into diastole

Question 16

Tricuspid regurgitation- causes

Answer 16

• Functional: RV dilatation
• Rheumatic fever
• Infective endocarditis
• Carcinoid syndrome

Question 17

Tricuspid regurgitation - symptoms

Answer 17

• Fatigue
• Hepatic pain on exertion
• Ascites, oedema

Question 18

Tricuspid regurgitation - general appearance, pulse rhythm/BP/volume and character + internal jugular

Answer 18

• General appearance - COPD, elephant ears
• Pulse rhythm and BP - normal
• Pulse volume and character - normal
• Internal jugular - V waves and S waves

Question 19

Tricuspid regurgitation- apex, palpation, auscultation/murmur

Answer 19

• Apex beat - normal
• Palpation - possibly a right ventricular heave
• Auscultation - loud pansystolic murmur
◦ PSM (most TR don’t give murmurs)
◦ Pansystolic murmur becomes louder in inspiration (Carvallo’s sign)- allows us to distinguish it from mitral regurgitation

Question 20

VSD: general appearance, pulse rhythm/BP/volume/character, internal jugular and apex beat

Answer 20

• General appearance - normal
• Pulse rhythm and BP - normal
• Pulse volume and character - normal
• Internal jugular - normal
• Apex beat - normal

Question 21

VSD: palpation, auscultation

Answer 21

• Palpation - very commonly a thrill will be felt on the left parasternal edge.
• Auscultation - very loud pansystolic murmur