Heart murmurs

Question 1

When does physiological splitting of the second heart sound occur?

Answer 1

During inspiration in children/young adults

Question 2

Mitral stenosis is best heard…

Answer 2

With the bell at the apex, with the patient lying on left hand side, breath held in expiration

Question 3

Mitral regurgitation is best heard…

Answer 3

With the diaphragm, at apex, breath held in expiration

Question 4

Aortic regurgitation is best heard…

Answer 4

Patient sitting up, at the lower left sternal border

Question 5

When is a third heart sound considered pathological?

Answer 5

Over age of 30

Question 6

What is always an abnormal finding on auscultation of heart sounds?

Answer 6

S4 (just before S1). Represents atrial contraction against a stiff left ventricle

Question 7

Ejection systolic murmur

Answer 7

Aortic stenosis

Question 8

Pansytolic murmur

Answer 8

Mitral regurgitation

Question 9

Early diastolic murmur

Answer 9

Aortic regurgitation

Question 10

Mid-diastolic murmur

Answer 10

Mitral stenosis

Question 11

The ejection systolic murmur of aortic stenosis classically radiates to…

Answer 11

The carotids

Question 12

The pansystolic murmur of mitral regurgitation classically radiates to…

Answer 12

The axilla

Question 13

Ejection systolic murmurs may be innocent in what circumstances? (3)

Answer 13

Children
Pregnancy
Tachycardia

Question 14

Feature of aortic stenosis on examination

a) auscultation (3)
b) pulse
c) palpation

Answer 14

a) Ejection systolic murmur
Soft S2
S4
b) slow rising pulse
c) heaving apex; thrill

Question 15

Causes of aortic stenosis? (4)

Answer 15

Degenerative calcification
Bicuspid aortic valve
Post-rheumatic disease
HOCM

Question 16

Management of aortic stenosis?

Answer 16

Asymptomatic- observe

Symptomatic- if fit for surgery, replace valve; if unit, balloon valvuloplasty

Question 17

Presentation of aortic stenosis? (3)

Answer 17

Chest pain
SOBOE
Syncope

Question 18

What are the commonest valves in need of replacement?

Answer 18

Aortic and mitral

Question 19

What are the two main options for valve replacement?

Answer 19

Biological (bovine/porcine)

Mechanical (bi-leaflet)

Question 20

Advantage/disadvantage of mechanical valves?

Answer 20

Adv- low failure rate

Dis- require long term anticoagulation

Question 21

Target INR for a) aortic b) mitral mechanical valves?

Answer 21

a) 3.0

b) 3.5

Question 22

What type of valve do older/younger patients recieve?

Answer 22

Older usually bioprosthetic (tend to deteriorate/calcify over time)

Younger usually mechanical

Question 23

Loud first heart sound, tapping undisplaced apex beat, opening snap after 2nd heart sound and rumbling mid-diastolic murmur?

Answer 23

Mitral stenosis

Question 24

Causes of mitral stenosis? (3)

Answer 24

Rheumatic fever
Congenital
SLE
Left atrial myxoma

Question 25

Presentation of mitral stenosis?

Answer 25

Palpitations Dyspnoea Haemoptysis Malar flush

Question 26

Complications of mitral stenosis?

Answer 26

Left atrial hypertrophy (hoarseness, dysphagia, left main bronchus collapse) Pulmonary hypertension

Question 27

What heart arrythmia often develops in mitral stenosis and why?

Answer 27

Atrial fibrillation; due to left atrial hypertrophy

Question 28

CXR signs of mitral stenosis? (3)

Answer 28

Calcified mitral valve Left atrial enlargement (double shadow) Pulmonary oedema

Question 29

Management of mitral stenosis? (3)

Answer 29

AF rate control and anticoagulation Balloon valvuloplasty (non calcified valve) Valve replacement surgery

Question 30

What is Corrigans sign and what does it indicate?

Answer 30

Abrupt distension and collapse of the carotid arteries Aortic regurgitation