Heart Murmurs

Question 1

Mid-systolic, crescendo-decrescendo heard best in the RUSB; radiating to R clavicle/carotid/apex associated with enlarged, nondisplaced apical impulse; S4

Answer 1

Aortic stenosis

Note: Bicuspid valve without calcification will have systolic ejection click followed by the murmur

Question 2

What does S3 indicate?

Answer 2

S3 can be normal in young people but otherwise, can indicate LV dysfunction/volume overload. Anything that would cause increased volume load the in ventricle like mitral regurgitation or aortic stenosis

Question 3

Diastolic decrescendo, heard best LLSB (valvular) or RLSB (dilated aorta) with sitting and leaning forward; no radiation associated with enlarged, displaced apical impulse S3/S4, increased pulse pressure, bounding carotid and peripheral pulses

Answer 3

Aortic regurgitation

Question 4

Diastolic decrescendo, low-pitched heard best in the apex without radiation; associated with loud S1, opening snap after S2, tapping apex beat, P2 can be loud if pHTN present

Answer 4

Mitral stenosis

Question 5

Is the interval between S2 and the opening snap (in diastole) longer or shorter in severe stenosis?

Answer 5

Shorter

Question 6

Systolic (holo-, mid-, or late-) heard best in the apex with radiation to the axilla or back (occasionally anteriorly to precordium); associated with S3, apical impulse hyperdynamic, changes with valsalva and handgrip

Answer 6

Mitral regurgitation

Question 7

How does mitral regurgitation change with valsalva?

Answer 7

Moves onset of click and murmur closer to S1 (systolic murmur)

Valsalva will DECREASE preload. Since increased venous return and diastolic filling (squatting) enhance the ventricular volume, it helps to maintain tension along the chordae and to keep the valve shut.

Question 8

How does valsalva decrease preload?

Answer 8

It increases the intrathoracic pressure.

Question 9

Holosystolic heard best in LLSB with radiation to LUSB associated with an increase during inspiration and merged and c and v waves in jugular venous pulse

Answer 9

Tricuspid regurgitation

Inspiration, increase preload, more flow to create murmur

Question 10

Diastolic, low-pitched, decrescendo; increased intensity during inspiration best heard in the LLSB that is nonradiating and associated with elevated CVP with prominent a wave and signs of venous congestion

Answer 10

Tricuspid stenosis

Question 11

Systolic; crescendo-decrescendo heard best at the LUSB that radiates to L clavicle associated with pulmonic ejection click after S1 (diminishes with inspiration)

Answer 11

Pulmonary stenosis

Question 12

Diastolic, decrescendo best heard at the LLSB that does not radiate and is associated with Loud P2 if pulmonary hypertension is present

Answer 12

Pulmonary regurgitation

severe pulmonary hypertension can cause pulmonary regurgitation

Question 13

Midsystolic, grade 1-2/6 heard best in RUSB without radiation

Answer 13

Innocent flow murmur

Question 14

Systolic, crescendo-decrescendo heard best at LLSB without radiation and associated with enlarged, hyperdynamic apical impulse; bifid carotid impulse with delay and increase intensity during Valsalva or with squatting to standing (decreased preload)

Answer 14

Hypertrophic cardiomyopathy

Question 15

Systolic crescendo-decrescendo at the RUSB that does not radiate and associated with fixed split S2, RV heave

Answer 15

Atrial septal defect

Question 16

Holosystolic heard best at LLSV without (?)radiation, palpable thrill murmur that increases with hand-grip and decreases with amyl nitrite

Answer 16

Ventricular septal defect

Hand grip increases afterload which would increase the flow of blood going across the VSD into the RV

Question 17

What does hand-grip do to the heart?

Answer 17

Increases afterload

Question 18

How does hand-grip affect mitral regurgitation?

Answer 18

Increases murmur intensity (increase in afterload causing increase backward flow)