Primer 11- Diastolic Murmers

Question 1

Identify the drug category associated with each the following endings:

• azepam
• azole
• caine
• cycline
• navir

Answer 1

1. benzodiazepines
2. antifungals
3. local anesthetics
4. tetracyclines
5. protease inhibitors

Question 2

How does hemicholinium inhibit the transport of choline to the nerve terminal?

Answer 2

Hemicholinium –> INHIBITS Na+/choline cotransport into cell

Question 3

Identify the derivatives of each of the following aortic arches: 
3rd? 
Lt  4th? 
Rt. 4th? 
6th?

Answer 3

3rd–> common carotid artery
Lt 4th–> Aortic Arch
Rt 4th–> proximal rt. subclavian
6th–> proximal pulmonary aa’s, ductus arteriosis

Question 4

List the 4 heart sounds that are BENIGN when there is no evidence of disease processes:

Answer 4

1. Split S1
2. Split S2 on inspiration (pulm valve closes later)
3. S3 in patient UNDER 40yoa
4. Early, quiet, systolic murmur

Question 5

What will you think of when you have a patient OVER 40 with an S3 murmur?

Answer 5

Heart failure post MI, ischemic heart disease

Question 6

During diastole, which heart valves are closed and which are open?
Which murmurs might be heard in these valves?

Answer 6

Closed: aortic, pulm–> STENOSIS @ DIASTOLE
Open: tricuspid, mitral–> REGURG @ DIASTOLE

Question 7

3 important points to take into account when you get a question about a heart murmur:

Answer 7

1. clinical scenario
2. Location (APTM)
3. Systole/ Diastole?

Question 8

Describe what happens in the thorax during inspiration.

Which two murmurs will get LOUDER with inspiration?

Answer 8

Inspiration–> DECREASE Intrathoracic pressure–> ^ IVC return to RA

1. LOUDER TRICUSPID murmurs (rIght = Inspire)
2. LOUDER SPLIT S2 ( vs mitral stenosis)

Question 9

Describe what happens in the thorax during expiration.

Which murmur will get LOUDER with expiration?

Answer 9

Expiration–> ^ Intrathoracic pressure

1. LOUDER MITRAL murmur (LEft = Expire)

Question 10

Describe what happens physiologically to the heart with hand grip.
Which murmur gets LOUDER with hand grip?

Answer 10

Grip hands–> ^ SVR –> ^ Afterload

1. LOUDER MITRAL REGURG

Question 11

Describe what happens in the thorax with the valsalva maneuver.
Which murmur gets LOUDER with this maneuver?

Answer 11

Valsalva–> ^ Intrathroacic pressure–> ^ Preload + ^Afterload

1. MOST murmurs get SOFTER
2. LOUDER HYPERTROPHIC CARDIOMYOPATHY MURMUR

Question 12

Which murmurs are louder in the lateral decubitus position?

Answer 12

1. Mitral murmurs (stenosis + regrug)

2. LEFT S3, S4

Question 13

3 causes of aortic regurgitation murmur:

Answer 13

1. dilated aortic root (syphilis, Marfan)
2. bicuspid aortic valve
3. rheumatic fever

Question 14

When is aortic regurgitation murmur heard?
Where is it loudest?
3 associated clinical findings?

Answer 14

Immediately after S2 in diastole
Loudest @ Lt sternal boarder
1. Wide use pressure (Decrease systemic diastolic pressure)
2. Strong peripheral pulse (water hammer)
3. Head bobbing

Question 15

What is one common cause of mitral stenosis?

Answer 15

Rheumatic heart disease

Question 16

What is one clinical outcome of prolonged mitral stenosis?

Answer 16

Left atrial dilation

Question 17

When is mitral stenosis murmur heard?

Where is it loudest?

Answer 17

Pause between S2 and start of murmur
- Listen for “opening snap”

Loudest @ APEX in lateral decubitus position
Louder with EXPIRATION

Question 18

Describe a PDA murmur.
When is it heard: systole or diastole?
What keeps the DA open?
What closes the DA?

Answer 18

Continuous, machine like murmur through diastole + systole
Open: PGE
Close: Indomethacin (NSAIDS)