Murmurs & Pulses

Question 1

What are the sounds S1 and S2 representing?

Answer 1

S1 represents mitral and tricuspid valve closing

S2 represents aortic and pulmonary valve closing

Question 2

Pathophysiology:
Regurgitation
Stenosis

What are left heart murmurs and right heart murmurs?

Answer 2

Closing problem - regurg
Opening problem - stenosis

Left heart murmurs are systolic murmurs
Right heart murmurs are diastolic murmurs

Question 3

Systolic murmurs [5]

Answer 3

Aortic stenosis
Pulmonary stenosis
Mitral regurgitation
Tricuspid regurgitation
MVP

Question 4

Diastolic murmurs [4]

Answer 4

Aortic regurgitation
Pulmonary regurgitation
Mitral stenosis
Tricuspid stenosis

Question 5

Extra heart sounds

Answer 5

Systolic clicks
Opening snap
S3
S4

Question 6

Aortic stenosis
Murmur
Explanation
Character
Radiation

Answer 6

"Systolic ejection murmur"
Ejection click
When turbulent blood flows through stenotic aortic valve
Crescendo-decrescendo murmur
Radiation to carotid artery in the neck

Question 7

Pulmonary stenosis
Murmur character [3]
Explanation
Radiation

Answer 7

“Systolic ejection murmur”
Ejection click
Crescendo-decrescendo murmur

When turbulent blood flows through stenotic pulmonary valve
Location: pulmonary area
Radiation: none

Question 8

Mitral regurgitation
Murmur character
Explanation [2]
Radiation

Answer 8

“Holosystolic or pansystolic murmur”
Mitral valve doesn’t close and some flow to atrium occurs throughout the cycle
So murmur intensity doesn’t change throughout cycle
Radiation: axilla

Question 9

Tricuspid regurgitation
Murmur character
Radiation
Location

Answer 9

Same as MR
Pansystolic murmur
Location: tricuspid area

Question 10

Mitral valve prolapse
Murmur character [2]
Cause
Radiation
Location

Answer 10

Late systolic murmur
Non-ejection click or mid-late systolic click
Cause: loose chord tendinae
Associated with MR so after non-ejection click, its an MR murmur
Location: apex

Question 11

Aortic regurgitation
Murmur character [2]
Location
Explanation [2]

Answer 11

“Early diastolic murmur”
Descrescendo murmur
Location: left sternal border
As ventricle fills up with blood, turbulent blood flow becomes less turbulent

Question 12

Pulmonary regurgitation
Murmur character
Location

Answer 12

Same as AR

Location: upper left sternal border

Question 13

Mitral stenosis
Character [2]
Explanation [3]

Answer 13

Opening snap then mid-diastolic rumble with sloping appearance

1. Rapid filling occurs at the beginning of diastole (after s2) as this is when the pressure difference is highest. This is the most intense part of the murmur
2. As pressures equalise the intensity of the murmur reaches lowest point
3. Atrium contracts to push leftover blood into ventricle (pre-systolic accentuation) causing slight increase in intensity towards S1

Question 14

Tricuspid stenosis
Murmur character
Location

Answer 14

Same as MS

Location: tricuspid area

Question 15

In which conditions are the following systolic clicks heard?
Ejection click
Non-ejection click
Opening snap

Answer 15

Ejection click: Aortic stenosis
Non-ejection click: Mitral valve prolapse
Opening snap: mitral stenosis

Question 16

S3 and S4 heart sounds

Where are they typically heard?

Answer 16

S3 and S4 are not murmurs

Location: mitral, lying in decubitus position

Question 17

S3

• is also known as…
• Diastolic or systolic?
• Explanation [3]

Answer 17

Ventricular gallop
Early diastole, occuring just after S2
1. Volume overload as in CHF
2. Rapid filling phase, ventricles fill up quicker
3. Chordae tendinae tense producing S3 sound

Question 18

S4

• Explanation [3]
• When does it occur in the cycle?

Answer 18

Pressure overload as in high blood pressure
LVH strain, concentric hypertrophy
Heart has to contract against increased pressure
Occurs end-diastolic

Question 19

Pulsus paradoxes [3]

Answer 19

• greater than the normal (10 mmHg) fall in systolic blood pressure during inspiration
  → faint or absent pulse in inspiration
• severe asthma, cardiac tamponade

Question 20

Slow-rising/plateau pulse - what’s the clinical significance

Answer 20

Aortic stenosis
• in this condition the rate of ejection of blood into theaortais decreased so that the duration of the ejection is prolonged. The amplitude of thepulseis diminished as a consequence.

Question 21

Collapsing pulse

Clinical significance [3]

Answer 21

describes a pulse that is bounding and forceful, rapidly increasing and subsequently collapsing (sound of a hammer hitting water)

• aortic regurgitation
• patent ductus arteriosus
• hyperkinetic states (anaemia, thyrotoxic, fever, exercise/pregnancy)

Question 22

Pulsus alternans [2]

Answer 22

regular alternation of the force of the arterial pulse

severe LVF

Question 23

Bisferiens pulse: description and clinical significance [2]

Answer 23

‘double pulse’ - two systolic peaks

mixed aortic valve disease

Question 24

Jerky pulse is indicative of…

Answer 24

hypertrophic obstructive cardiomyopathy

*HOCM may occasionally be associated with a bisferiens pulse

Question 25

Eponymous signs of aortic regurgitation [5]

Answer 25

Corrigan's - exaggerated carotid pulse
Quinke's - nailbed pulsation
De Musset's - head nodding
Duroziez's - diastolic femoral murmur
Traube's - 'pistol shot' femorals