Murmurs

Question 1

What group of valves closing causes the S1 heart sound?

Answer 1

Atrioventricular valves

Question 2

What group of valves closing causes the S2 heart sound?

Answer 2

Semilunar valves

Question 3

What causes the S3 heart sound and when is it normal vs abnormal?

Answer 3

Caused by rapid ventricular filling causing the chordae tendinae to pull and “twang” like a guitar string.

Can be normal in 15-40 year olds

Abnormal in older people (indicates heart failure)

Question 4

What’s S4, what causes S4 and is it abnormal?

Answer 4

Yes, abnormal

S4 is directly before S1.

Indicates stiff or hypertrophic ventricle

Caused by turbulent flow from an atria contracting against a non compliant ventricle

Question 5

Where on the chest do you listen to hear the four valves?

Answer 5

Pulmonary: 2nd I.C.S left sternal border

Aortic: 2nd I.C.S right sternal border

Tricuspid: 5th I.C.S left sternal border

Mitral: 5th I.C.S mid clavicular line

Question 6

Where do you listen on the chest for S3 and what is the area called?

Answer 6

Erb’s point

3rd I.C.S left sternal border

Question 7

What murmur is best listened to with the patient lying on their left hand side?

Answer 7

Mitral stenosis

Question 8

What murmur is heard best with the patient sitting up leaning forward and holding exhalation?

Answer 8

Aortic regurgitation

Question 9

How do you assess a murmur?

Answer 9

SCRIPT

S- Site, where is the murmur it’s loudest
C- Character, soft/blowing/crescendo etc
R- Radiation 
I- Intensity, what grade is it
P- Pitch (pitch indicates velocity)
T- Timing, is it systolic or diastolic

When presenting a murmur, use C, I, T, P, S, R, then give your diagnosis of what murmur it is

Question 10

Explain the grading of murmurs from grade 1 to 6

Answer 10

1: Difficult to hear
2: Quiet
3: Easy to hear
4: Easy to hear with a palpable thrill
5: Can hear with stethoscope barely touching the chest
6: Can hear with stethoscope off chest

Question 11

What murmur results in left atrial hypertrophy?

Answer 11

Mitral stenosis

Question 12

What murmur results in left ventricular hypertrophy?

Answer 12

Aortic stenosis

Question 13

What murmur causes left atrial dilation?

Answer 13

Mitral regurgitation

Question 14

What murmur causes left ventricular dilation?

Answer 14

Aortic regurgitation

Question 15

What are the two common causes of mitral stenosis?

Answer 15

Rheumatic heart disease

Infective endocarditis

Question 16

What is the timing, pitch and character of mitral stenosis?

Answer 16

Mid-diastolic
Low pitched
Rumbling

Question 17

What heart sound is louder in mitral stenosis?

Answer 17

S1

Question 18

What symptom and heart problem is mitral stenosis associated with?

Answer 18

Malar flush
due to back pressure of blood into pulmonary system causing a rise in CO2 and vasodilation

Atrial fibrillation

Question 19

What is the timing, pitch and character of mitral regurgitation?

Answer 19

Pan systolic
High pitch
Whistling

Question 20

What murmur may you hear S3 in?

Answer 20

Mitral regurgitation

Question 21

What are the causes of mitral regurgitation?

Answer 21

Idiopathic weakening of valve with age

Ischaemic heart disease

Infective endocarditis

Rheumatic heart disease

Connective tissue disorders like ehler’s danlos and marfans

Question 22

What is the timing, pitch and character of aortic stenosis?

Answer 22

Ejection systolic, high pitched, crescendo-decrecendo (louder then quieter)

Question 23

Where do aortic stenosis murmurs radiate?

Answer 23

Carotids

Question 24

What are the causes of aortic stenosis?

Answer 24

Idiopathic age related calcification

Rheumatic heart disease

Question 25

What signs and common symptom do patients complain of in aortic stenosis?

Answer 25

Signs: Slow rising pulse Narrow pulse pressure Symptom: Exertional syncope

Question 26

What is the timing and character of aortic regurgitation?

Answer 26

Early diastolic, soft

Question 27

What sign is aortic regurgitation associated with on examination?

Answer 27

Collapsing/Corrigan’s pulse

Question 28

What other murmur can aortic regurgitation cause?

Answer 28

Austin flint murmur

Question 29

What are the causes of aortic regurgitation?

Answer 29

Idiopathic age related weakness Connective tissue disorders like ehler’s danlos or marfans

Question 30

What is the pitch, timing of tricuspid regurgitation and where does it radiate to?

Answer 30

High pitched, pan systolic, radiates to right lower sternal border

Question 31

Where on the chest is it best to listen to tricuspid regurgitation?

Answer 31

Left lower sternal border

Question 32

What are the causes of tricuspid regurgitation?

Answer 32

Infective endocarditis (common) Rheumatic heart disease (common) Congenital heart defect called ebstein anomaly Carcinoid tumours Rheumatoid arthritis Radiation therapy