Murmurs

Question 1

Easy mnemonic for remembering systolic murmurs

Answer 1

MRS ASS
Mitral Regurgitation
Aortic Stenosis

Question 2

How do you accentuate murmurs depend on the side?

Answer 2

Left sided - expiration

Right sided - Inspiration

Question 3

How do you listen to mitral regurgitation?

Answer 3

Listen at axilla with diaphragm while the patient leans to the left
Much commoner than mitral stenosis

Question 4

Give five causes of mitral regurgitation

Answer 4

• Prolapsing mitral valve
• Rheumatic mitral regurgitation
• Papillary muscle rupture
• Cardiomyopathy
• Connective tissue disorders

Question 5

What happens to the signs in mitral regurgitation

Answer 5

More likely to be in sinus rhythm
Face -> Malar flush
Palpation -> Displaced Apex beat/palpable thrill

Question 6

What do you hear on auscultation in mitral regurgitation?

Answer 6

Pansystolic murmur raditating to axilla heard best in the apex with the diaphragm when the patient is leadning to the left.

Question 7

ECG findings in MR?

Answer 7

Bifid p waves

Left ventricular hypertrophy

Question 8

Where do you listen for aortic stenosis?

Answer 8

• Listen with diaphragm over aortic valve

- Also listen at base of neck

Question 9

Give three causes of aortic stenosis

Answer 9

• Calcification of the valve
• Bicuspid aortic valve
• Rheumatic fever

Question 10

Give the three main symptoms which come on with aortic stenosis

Answer 10

• Loss of consciousness
• Angina
• Shortness of breath (orthopnoea & PND)

Question 11

What is the pathology of syncope in aortic stenosis?

Answer 11

Syncope may be explained by aortic stenosis generating a fixed cardiac output which cannot compensate for decrease in vascular resistance which comes on in exercise. This reduces blood flow to brain and causes syncope.

Question 12

Give the pulse, volume and palpation of aortic stenosis

Answer 12

Pulse – Character is slow and rising
Volume – Low volume with narrow pulse pressure
Palpation – Forceful apex beat

Question 13

What can you hear in auscultation of aortic stenosis

Answer 13

Ejection systolic murmur radiating to carotids

Question 14

What will you see in aortic stenosis on x-ray?

Answer 14

Chest x-ray will show a relatively small heart with a prominent dilated, ascending aorta -> Post-stenotic dilatation.

Question 15

What is the aortic stenosis ECG?

Answer 15

ECG will show left ventricular hypertrophy and left ventricular strain pattern.

Question 16

Where do you listen for aortic regurgitation?

Answer 16

• Aortic area

Question 17

Give five causes of aortic regurgitation

Answer 17

• Rheumatic fever
• Bicuspid valve
• Infective endocarditis
• Marfan’s syndrome
• Tertiary syphilis

Question 18

What is the pathology of aortic regurgitation?

Answer 18

Reflux of blood from aorta to LV in diastole. For cardiac output to be maintained, the total stroke volume must be increased, and therefore LV size must increase.

Question 19

Name three eponymous signs associated with aortic regurgitation

Answer 19

Quicke’s sign
De Musset’s sign
Pistol shot femorale

Question 20

What is Quincke’s sign?

Answer 20

Capillary pulsation in teh nail beds with aortic regurgitation

Question 21

What is De Musset’s sign?

Answer 21

Head nodding in aortic regurgitation

Question 22

What is pistol shot femorale?

Answer 22

A sharp banging heard on auscultation over the femoral arteries in time with each heartbeat

Question 23

What is the pulse in aortic regurgitation?

Answer 23

Collapsing (wide pulse pressure)

Question 24

What is auscultation in aortic regurgitation?

Answer 24

High pitched early diastolic murmur best heard at the left sternal edge in the fourth intercostal space with the patient leaning forward and their breath held in expiration.

Question 25

What happens if aortic regurgitation happens suddenly?

Answer 25

Acutely rapid pulmonary oedema and heart failure. This is treated with immediate aortic valve replacement

Question 26

Where do you listen for mitral stenosis?

Answer 26

Listen at apex with bell and ask patient to lean to left

Question 27

What is a common condition that causes mitral stenosis?

Answer 27

Rheumatic fever or chorea occurs in 50% of cases with mitral stenosis

Question 28

What occurs after you develop mitral stenosis?

Answer 28

High left atrial pressure (loud S1 and AF) leads to pulmonary venous hypertension and subsequently pulmonary arterial pressure (septal lines, cough productive of blood-tinged frothy sputum). This pulmonary hypertension leads to right ventricular hypertrophy, tricuspid regurgitation and the right heart failure.

Question 29

Give four symptoms of mitral stenosis

Answer 29

Atrial fibrillation and thromboembolism, chest pain and symptoms of heart failure.

Question 30

Give three signs of mitral stenosis

Answer 30

Atrial fibrillation, malar flush, tapping apex beat due to palpable 1st heart sound.

Question 31

Gives three causes of mitral stenosis

Answer 31

Rheumatic heart disease, calcification, endocarditis

Question 32

What do you hear in mitral stenosis?

Answer 32

• Loud S1 (high LA pressure keeps valve pen until late in diastole then slams it shut)
• Opening snap (high pitched sound just after S2).

Question 33

Outline what happens with the opening S2 snape in Mitral stenosis with increasing severity

Answer 33

• Opening snap (high pitched sound just after S2). If the mitral stenosis is severe, pressure in the LA increases and the mitral valve opens earlier in ventricular diastole. This means that the more severe the mitral stenosis, the shorter the gap between S2 and the opening snap.
• Rumbling mid-diastolic murmur best heard with the bell of the stethoscope held lightly at the apex with the patient lying on the left side.

Question 34

Give the signs on chest x-ray of pulmonary oedema

Answer 34

o	The signs of pulmonary oedema 
	Cardiac size
	Bat wing pulmonary opacities
	Presence of peri-bronchial cuffing
	Septal lines
	Pleural effusions
	Upper lobe pulmonary venous diversions