Murmurs

Question 1

pathophysiology of aortic stenosis

Answer 1

LV outflow obstruction leads to a fixed cardiac output, increased after load, left ventricular hypertrophy, and eventually LV failure

Question 2

what is the most common valvular disease

Answer 2

aortic stenosis

Question 3

sx aortic stenosis

Answer 3

exertional dyspnea MC sx
decreased exercise tolerance
angina
syncope
CHF

Question 4

describe the sounds/quality for aortic stenosis

Answer 4

harsh, low pitched, mid-late peaking, systolic, crescendo-decrescendo murmur best heart at the right upper sternal border and radiates to the carotid arteries

Question 5

when does aortic stenosis increase

Answer 5

sitting while leaning forward
increased venous return (squatting, supine, leg raise)
expiration
decreased after load (inhalation of amyl nitrate)

Question 6

when does aortic stenosis decrease

Answer 6

decreased venous return (valsalva, standing)
inspiration
increased afterload (handgrip)

Question 7

PE aortic stenosis

Answer 7

weak, delayed carotid pulse
narrow pulse pressure
fourth heart sound (S4)

Question 8

Test of choice for aortic stenosis and what will it show

Answer 8

echocardiogram
small aortic orifice
LVH
thickened/calcified aortic valve

Question 9

what will you see on EKG for aortic stenosis

Answer 9

LVH

Question 10

definitive diagnosis for aortic stenosis

Answer 10

cardiac catheterization

Question 11

only effective tx for aortic stenosis

Answer 11

aortic valve replacement

Question 12

aortic regurgitation

Answer 12

incomplete aortic valve closure leading to regurgitation of blood through the aortic valve into the left ventricle during diastole

Question 13

two most common causes of aortic regurgitation

Answer 13

endocarditis
aortic dissection

Question 14

quality/sound of aortic regurgitation

Answer 14

high pitched, blowing, decrescendo or sustained, diastolic murmur best heard over Era’s point

Question 15

when does aortic regurgitation increase

Answer 15

sitting up while leaning forward
holding breath in end-expiration
increased venous return (squatting, supine, leg raise)
increased after load (handgrip)

Question 16

when does aortic regurgitation decrease

Answer 16

decreased venous return (valsalva, standing)
inspiration
decreased after load (amyl nitrate)

Question 17

what else will you see on PE for aortic regurgitation

Answer 17

bounding ulses
pulses bisferiense
wide pulse pressure (increased SBP and decreased DBP)

Question 18

tx for aortic regurgitation

Answer 18

after load reduction - ACEI, ARBs, Nifedipine, Hydralazine

surgery is definitive

aortic valve replacement for emergency

Question 19

mitral stenosis

Answer 19

narrowing of the mitral valve orifice leading to obstruction of flow from the left atrium to the left ventricle and back flow of blood into the left atrium

Question 20

pathophysiology of mitral stenosis

Answer 20

obstruction of flow from LA to LV –> blood backs up into left atrium –> pulmonary congestion –> pulmonary HTN –> CHF

Question 21

Sx mitral stenosis

Answer 21

exertion dyspnea (MC)
exercise intolerance
hemoptysis
cough
pulmonary HTN
Afib

Question 22

what are mitral facies commonly seen in mitral stenosis

Answer 22

ruddy (flushed) cheeks with facial pallor (chronic hypoxia)

Question 23

PE for mitral stenosis

Answer 23

prominent (loud) S1
opening snap
loud P2

Question 24

sounds/quality mitral stenosis

Answer 24

low-pitched, mid-diastolic, rumbling murmur best heard at the mitral area/apex (left fifth intercostal space at the mid-clavicular line)

Question 25

increase sound for mitral stenosis

Answer 25

left lateral decubitus position expiration increased venous return (squatting, leg raise, lying, supine)

Question 26

decreased sound mitral stenosis

Answer 26

decreased venous return (valsalva, standing) inspiration amyl nitrate

Question 27

what will EKG show for mitral stenosis

Answer 27

left atrial enlargement Afib pulmonary HTN (RVH, right axis deviation)

Question 28

tx for mitral stenosis

Answer 28

percutaneous balloon valvuloplasty

Question 29

what is almost always the cause of mitral stenosis

Answer 29

rheumatic heart disease

Question 30

mitral regurgitation

Answer 30

incomplete closure of mitral valve, leading to retrograde blood from from left ventricle to left atrium during systole

Question 31

compensatory consequences to mitral regurgitation

Answer 31

left atrial dilation left ventricular hypertrophy

Question 32

most common cause of mitral regurgitation

Answer 32

mitral valve prolapse

Question 33

sx mitral regurgitation

Answer 33

exertional dyspnea Afib dyspnea at rest pulmonary edema hypotension tachypnea hypoxemia cyanosis decreased cardiac output possible cardiogenic shock

Question 34

sounds/quality of mitral regurgitation

Answer 34

high-pitched, blowing, holosystolic murmur best heard at the apex, often with radiation to the left axilla, sub scapular region, or upper sternal borders

Question 35

increased mitral regurgitation

Answer 35

left lateral decubitus expiration increased venous return (squatting, leg raise, supine) increased afterload (handgrip)

Question 36

decreased mitral regurgitation

Answer 36

decreased venous return (valsalva, standing) inspiration decreased after load (amyl nitrate)

Question 37

Tx for mitral regurgitation

Answer 37

after load reducers (ACEI, ARBs, hydralazine, nitrates) repair is generally preferred over replacement

Question 38

in what population is mitral valve prolapse MC

Answer 38

young women (15-35 years old)

Question 39

causes of mitral valve prolapse

Answer 39

myxomatous degeneration - weakened and elongated chord tendineae, mitral annular dilation, thickened leaflet tissue connective tissue diseases - Marfan or Ehlers-Danlos syndromes, osteogenesis imperfecta

Question 40

sx for mitral valve prolapse

Answer 40

most asx if sx - atypical chest pain, palpitations, exertion dyspnea, dizziness, etc

Question 41

sounds/quality mitral valve prolapse

Answer 41

mid-late systolic click best heard at the apex

Question 42

earlier click and longer duration MVP

Answer 42

any maneuver that makes LV smaller or decreases preload (valsava, standing)

Question 43

later click and shorter duration MVP

Answer 43

any maneuver that increases preload (squatting, supine, leg raise) handgrip

Question 44

tx for asx MVP

Answer 44

reassurance

Question 45

tx for MVP w autonomic dysfunction

Answer 45

beta blockers

Question 46

MC cause of primary pulmonic regurgitation

Answer 46

almost always congenital

Question 47

Pathophysiology of pulmonary regurgitation

Answer 47

back flow of blood from pulmonary artery to RV --> right sided volume overload

Question 48

sx pulmonary regurgitation

Answer 48

insignificant if sx - associated w right sided HF --> hepatic congestion, ascites, jugular venous distention, lower extremity edema

Question 49

PE for pulmonic regurgitation

Answer 49

Graham steel murmur - brief high-pitched decrescendo early diastolic blowing murmur heard at left upper sternal border

Question 50

increased pulmonic regurgitation

Answer 50

inspiration increased venous return (squatting, supine, leg raise)

Question 51

decrease pulmonic regurgitation

Answer 51

expiration decreased venous return

Question 52

tricuspid stenosis

Answer 52

stenosed valve --> back flow of blood from RV to RA --> right sided heart failure

Question 53

sound/quality tricuspid stenosis

Answer 53

mid-diastolic murmur at left lower sternal border

Question 54

increased intensity tricuspid stenosis

Answer 54

increased venous return (squatting, supine, leg raise) inspiration

Question 55

PE tricuspid stenosis

Answer 55

opening snap

Question 56

tricuspid regurgitation