Cardio: murmurs

Question 1

S3 gallop

Answer 1

dilated cardiomyopathy

Question 2

harsh systolic murmur best heard at LSB

Answer 2

hypertrophic cardiomyopathy HOCM

Question 3

hypertrophic cardiomyopathy (HOCM)

Answer 3

harsh systolic murmur best heard at LSB

Question 4

Dilated cardiomyopathy

Answer 4

S3 gallop

Question 5

similarities with aortic stenosis + HOCM

-differences?

Answer 5

• angina
• systolic murmur
• both murmurs go in the same direction with afterload maneuvers– both increase with Amyl nitrate and both decrease with handgrip

DIFFERENCES

• HOCM
• preload maneurvers that decrese LV volume (valsava, standing) will WORSEN the murmur—->these manuecers decrease intensity of aortic stenosis murmur
• increased volume (squatting, leg raise) will decrease the murmur of HOCM—-vs will increase intensity of AS

Question 6

sitting up and leaning forward

Answer 6

accentuates Aortic murmurs

Question 7

lying on the left side

Answer 7

accentuates mitral murmurs

Question 8

increased venous return

Answer 8

inreases ALL murmurs/opening snap (left and right side)

EX of incr venous return=squatting, leg raise, lying down,

Question 9

decreased venous return

Answer 9

*valsalva
*standing
*decreases all murmurs/opening snap (left and right)
EXCEPT: increase murmurs of HOCM and increased ejection click of MVP

Question 10

Inspiration

Answer 10

increases venous return on the right side
inncreasesd all murmurs/opening snap on the RIGHT side only
decreased ejection click right side
**RIGHT SIDED MURMURS HEARD BEST WITH INSPIRATION

decreased venous return on the left side
*all murmurs/opening snap on the left side are decr

Question 11

right sided murmurs heard best wth

Answer 11

inspiration

Question 12

expiration

Answer 12

incrs venous return on the lft side
-incrs murmurs on left side—delyes ejection click on L side

decrs venous rreturn to the right sife

Question 13

left sided murmurs heard best?

Answer 13

after maximal expiration

Question 14

handgrip

Answer 14

increased afterload by compression the arteries of the upper extremityy–>leading to decreaed LV emptying
-decreased forward flow and increased backward flow

• **outflow murmurs (AS, HOCM, MVP) are decr with handgrip
• incr in afterload prevents blood from being ejected from ventriles–lessening the blood flowing through stenosed aortic valvue and less blood ejected in HOCM

**regurg murmurs (AR, MR) incr with handgrip due to backward flow

*MS increased due to incr afterload

Question 15

what are the only two things that affect AS and HOCM

Answer 15

handgrip (decrs) and amyl nitrate (incrs)

Question 16

amyl nitrate

Answer 16

decreases afterload–direct arteriolar vasodilator leading to increased LV emptying—increases flow and decreases backward flow of blood

• AS, MVP, HOCM incrs
• regurg murmurs (AR, MR) decr
• **why afterload reducers like ACEI are used in tx of AR and MR

Question 17

Aortic Stenosis

• quick patho
• etiologies (3 basic categories)
• CM– mc?
• PE
• what incrs murmur

Answer 17

PATHO

• LV outflow obstruction leads to fixed CO, incr AL, LVH and eventual LV failure
• etiologies:
  1. Degenerative: calcifications*****, wear/tear, over 70yO
  2. congenital and bicuspid valve common in <70
  3. rheumatic HD: isolated or accomp with AR

CM

• Once symptomatic—lifespan dramatically reduced
• dyspnea MC s/s
• ***ANGINA: MC symptom—one this happens–5 year mean survival
• *syncope=3 yr survival
• *CHF=2 yr survival

PE

• harsh ejection systolic crescendo-decrescendo murmur
• best heard at RUSB
• split S2
• radiating to the carotid
• weak + delayed carotid pulse– pulsus parvus et tardus
• narow pulse pressure

INCRS:

• sitting while leaning forward
• incr venous return–sqautting supine, leg raise
• expiration

DECRS:

• decr venous return–valsalva, standing
• inspiration
• handgrip

Question 18

harsh systolic crescendo-decrescendo murmur heard at RUSB

Answer 18

AS

Question 19

Aortic Regurg

• quick patho
• etiologies
• pe
• cm
• incrs
• decrs

Answer 19

*incomplete aortic valvue closure leads to LV volume overload with eventual LV dilation and HF

ETIOLOGIES

1. acute: AMI, aortic dissection, encoarditis—-all can lead to pulmonary edema
2. chronic: aortic dilation–Marfan syndrome, inflamm disordres, Rheumatic fever, syphilis, HTN

PE
*high pitched diastolic blowing decrescendo murmur best heard at the LUSB

INCRS

• sitting while leaning forward
• incr venous return–supine ,squatting, leg raise
• expiration
• hand grip

DECRS

• decr venous return–valsalva, standing,
• inspiration
• amyl nitrate

CM

• austin flint murmur–>mid-late diastolic rumble at the apex secondary to retrograde regurg
• BOUNDING PULSES–due to incr SV
• pulses bisferiens
• widened pulse pressure
• water hammer pulse

Question 20

water hammer pulse

Answer 20

AR

Question 21

high pitched diastolic blowing decrescendo murmur best heard at the ULSB

Answer 21

AR

Question 22

opening snap

Answer 22

MS

Question 23

Mitral Stenosis

• patho
• etiologies—-MC?
• cm
• decrs
• incrs

Answer 23

*obstruction of flow from LA–LV secondary to narrowed mitral oriface–>blood backs up in the LA–>incrs LA pressure/volume overload–>pulmonary congestion–>pulmonary HTN–>CHF

ETIOLOGIES

• RHEUMATIC FEVER is almost always the cause—3 or 4 decade of lief
• congenital, myxoma LA, thrombus, valvulities (SLE, amyloidosis, carcinoid)

CM

• PULM
• dyspnea (MC s/s)
• pulm edema
• hemoptysis
• pulm HTN
• AFIB
• secondary to atrial enlargement
• Right HF
• Mitral Faces–>ruddy/flushed cheeks with facial pallor—chronic hypoxia

*signs of LA enlargement–dysphagia (esoph compression), Ortner’s syndrome (recurrent layngeal nerve palsy)–hoarsnensss

PE

• prominent S1 opening snap
• low-ptiched mid-diastolic rumbling murmur best heard at the apex

INCRS
*left lateral decubitus

DECRS
*decr venous retunr— valsalva, standing

Question 24

Diastolic low pitched decrescendo rumbling murmur with opening snap heard best at the apex

Answer 24

Mitral stenosis

Question 25

Mitral regurg - patho - etiolgies-- mcc in us and devlop countries - cm - pe

Answer 25

PAHTO *abnm retrograde flow from LV into LA-- leading to leeft atrial dilation and increaed pulmonary pressure ETIOLOGIES * MVP MC cause in US * rheumatic fever MCC in devlop countries CM * chronic: HF--dyspnea MC s/s, afib, HTN, hemoptysis * acute: pulm edema, hypotension PE *blowing high pitched holosystolic murmur best heard at the apex with radiation to the axilla INCRS: left lateral decubitus, expiration, isometric exercise, incr venous return (squatting, leg raise, lying supine), handgrip DECRS: decr venous return--valsalva, standing, inspirtion, amyl nitrate *widely split s2, laterally displaced PMI, S3, soft S1 for severe cases

Question 26

blowing high pitched holosystolic murmur best heard at the apex with radiation to the axilla

Answer 26

mitral regurg

Question 27

mitral valve prolapse - quick patho - mcc of? - mc in w or m - %of population etiologies cm pe

Answer 27

leaflefts of MV bulge into left atrium during systole MVP MCC of mtiral regurg in US ************ MC in young women (15-30yO) 2-5% of population ETIOLOGIES * Myxomatous degeneration of mitral valvue * CT dz--- marfans CM * most asympto * autonomic dysfunction-->anxiety, atypical CP, panic attacks, palpitations from arrhythmias, syncope, dizzines, fatigue PE * Mid-late systolic ejection click best heard at the apex. * EARLIER CLIKC + LONGER MURMUR DURATION: anything that makes LV smaller aka decrs preload-->valsalva, standing due to iincrs prolapse * DELAYED CLICK + SHORTER MURMUR DURATION: anything that makes LV bigger (incrs preload) due to decr prolapse--- handgrip

Question 28

Mid-late systolic ejection click best heard at the apex

Answer 28

MVP

Question 29

Pumonic stenosis | -mc etiology

Answer 29

right ventric outflow obstruction of blood across the PV -almost always congenital and a dz of young------ PE *harsh mid-systolic ejection crescendo-decrescnedo murmur that radiates to the neck *maximal at the LUSB INCRS: inspiration

Question 30

harsh mid-systolic ejection crescendo-decrescnedo murmur that radiates to the neck

Answer 30

pulmonic stenosis

Question 31

Pulm regurg - etiologies - pahto - cm - pe

Answer 31

almost always congenital***** others: pulm htn, tetraology of fallot, endocarditis, rheumatic HD patho *retrograde flow from pulmonary artery into RV-->right sided overload CM - most clinically insignificant - sympotmatic=right sided HF PE *Graham Steell murmur--> brief decrescendo early diastolic murmur @ LUSB (2nd L ICS) with full inspiration INCRS: incr venous return--sqautting supine inspiration DECRS: dcr venous return--valsalva, standing, expiration

Question 32

brief decrescendo early diastolic murmur @ LUSB (2nd L ICS) with full inspiration

Answer 32

pulm regurg

Question 33

Tricuspid Stenosis

Answer 33

blood backs up into right atrium-->incrs right atrial anlargement-->right sided HF PE *mid-diastolic murmur at LLSB (xyphoid, 4th ICS) *low frequency INCRS: incr venous return--squatting, supine, inspiration, leg raise, +opening snap but occurs later than the one for MS

Question 34

* mid-diastolic murmur at LLSB (xyphoid, 4th ICS) | * low frequency

Answer 34

tricuspid stenosis

Question 35

Tricuspid Regurg

Answer 35

holosytolics blowing high pitched murmur at the subxyphoid are (left mid-sternal brorder) -little to no radiation -INCRS: invr venous return--- squatting, supine, inspiration, leg raise -Carvallo's sign: incr murmur intensity with inspiration--due to incr right isded vlood flow during inspiration------helps to distinguish TS from MR +/- pulsatile liver

Question 36

holosytolics blowing high pitched murmur at the subxyphoid are (left mid-sternal brorder)

Answer 36

tricuspid regurg