questions 12

Heart Murmurs

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Topic updated on 08/30/17 10:04pm

Overview
 

 
Auscultation Rules of Thumb
  • "All Physicians Take Money" (rule of thumb/mnemonic) 
    • aortic valve
      • upper right sternal border
        • aortic stenosis
        • flow murmur
        • aortic valve sclerosis
    • left ventricular outflow tract obstruction
      • lateral displacement of maximal impulse
      • S4 gallop
      • upper left sternal border (ULSB) harsh, crescendo-decrescendo systolic murmur
        • hypertrophic obstructive cardiomyopathy
    • pulmonic valve
      • ULSB
        • pulmonic stenosis
        • flow murmur (e.g., ASD)
    • tricuspid valve
      • lower left sternal border (LLSB)
        • pansystolic murmur (tricuspid regurgitation and VSD)
        • diastolic murmur (tricuspid stenosis and ASD)
    • mitral valve
      • apex 
        • systolic murmur (mitral regurgitation) 
        • diastolic murmur (mitral stenosis) 
Murmur Cheat Sheet
Crescendo/Decrescendo
Holosystolic
Systolic
  • AS (to neck)
  • MVP (click)
  • HOCM
  • MR (to axilla)
  • TR (inspiration increases)
  • VSD (harsh)
Diastolic
  • Aortic regurgitation
  • MS (opening snap)
  • NOTE: See chart below for abbreviations
Murmur Identification
 
Lesion
Shape
Location Heard
Altered by Characteristics
Systolic
Aortic stenosis (AS)
  • Crescendo-decrescendo
  • Radiates to neck (carotids) and apex

--

  • "Parvus et tardus" (pulses weak compared to heart sounds)
  • Follows ejection click (due to halting of valve leaflets)  
Hypertrophic cardiomyopathy (HOCM)
  • Crescendo-decrescendo
--
  • ↓ venous return (e.g., Valsalva) - increases murmur
--
Mitral valve prolapse (MVP) 
  • Late crescendo
--
  • ↑ TPR (e.g., squatting, hand grip) - decreases murmur
  • ↓ venous return (e.g., Valsalva) - increases murmur
  • Mid-systolic click (tensing of chordae tendinae)
  • Loudest at S2
  • Later with ↑ afterload (e.g., hand grip).
Mitral regurgitation (MR)
  • Holosystolic
  • Radiates to axilla
  • ↑ TPR (e.g., squatting, hand grip)
  • ↑ LA return (e.g., expiration)  
  • High-pitched, blowing
Tricuspid regurgitation (TR) 
  • Holosystolic
  • Radiates to right sternal border
  • ↑ RA return (e.g., inspiration)
  • High-pitched, blowing
Ventricular septal defect (VSD)
  • Holosystolic
-- --
  • Harsh-sounding
Diastolic
Aortic regurgitation (AR)
  • Early decrescendo
  • Left sternal border with patient leaning forward
--
  • High-pitched blowing heard at end of expiration
Mitral stenosis (MS)
  • Late rumble 
  • Heard in lateral left decubitus position
  • ↑ LA return (e.g., expiration)
  • Opening snap (tensing of chordae tendinae) in early diastole after A2
Other
Patent ductus arteriosus (PDA)
  • Continuous
  • ULSB
--
  • Machine-like, continuous/constant murmur heard through systole and diastole
Atrial septal defect (ASD)
  • Systolic and diastolic
  • Systolic: ULSB (pulmonic valve)
  • Diastolic: LLSB (tricuspid valve)
-- --


  RATE CONTENT
4.0
AVERAGE 4.0 of 11 RATINGS

Qbank (9 Questions)

TAG
(M1.CV.26) A 65-year-old male presents to his cardiologist to discuss increasing episodes of dyspnea after climbing stairs. He also now needs three pillows at night to sleep. Physical examination reveals an early diastolic murmur best appreciated at the left sternal border with bounding peripheral pulses. The cardiologist is very concerned and immediately refers the patient for a surgical workup. What is the most likely diagnosis? Topic Review Topic

1. Mitral valve insufficiency
2. Aortic regurgitation
3. Mitral stenosis
4. Aortic stenosis
5. Atrial myxoma

PREFERRED RESPONSE ▶
TAG
(M1.CV.28) A 64-year-old woman with a history of rheumatic fever presents to her primary care clinician complaining of excessive fatigue with walking and difficulty lying flat. She had no prior physical limitations, but recently has been unable to walk more than 3 blocks without needing to stop and rest. Her cardiac exam is notable for a late diastolic murmur heard best at the apex in the left lateral decubitus position with no radiation. What is the most likely diagnosis? Topic Review Topic

1. Mitral Regurgitation
2. Aortic Stenosis
3. MItral Stenosis
4. Aortic Regurgitation
5. Tricuspid Regurgitation

PREFERRED RESPONSE ▶
TAG
(M1.CV.41) A 27-year-old woman presents to her primary care physician complaining that she has recently been experiencing vague chest discomfort. Physical examination reveals a mid-systolic click that is thought to be due to sudden tensing of chorda tendinae. How would this murmur be enhanced while listening on examination and what confirmatory test should be done? Topic Review Topic

1. Inspiration; EKG
2. Inspiration; Echocardiogram
3. Squatting; Echocardiogram
4. Valsalva; Echocardiogram
5. Hand Grip; EKG

PREFERRED RESPONSE ▶
TAG
(M1.CV.75) A 65-year-old male with a history of coronary artery disease and myocardial infarction status post coronary artery bypass graft (CABG) surgery presents to his cardiologist for a routine appointment. On physical exam, the cardiologist appreciates a holosystolic, high-pitched blowing murmur heard loudest at the apex and radiating towards the axilla. Which of the following is the best predictor of the severity of this patient's murmur? Topic Review Topic

1. Enhancement with hand grip maneuver
2. Enhancement with expiration
3. Presence of audible S3
4. Enhancement with inspiration
5. Presence of audible S4

PREFERRED RESPONSE ▶
TAG
(M1.CV.117) A 37-year-old woman presents to clinic for routine checkup. She has no complaints with the exception of occasional "shortness of breath." Her physical examination is unremarkable with the exception of a "snap"-like sound after S2, followed by a rumbling murmur. You notice that this murmur is heard best at the cardiac apex. A history of which of the following are you most likely to elicit upon further questioning of this patient? Topic Review Topic

1. Family history of aortic valve replacement at a young age
2. Hyperflexibility, vision problems, and pneumothorax
3. Systolic click auscultated on physical exam 10 years prior
4. Repeated episodes of streptococcal pharyngitis as a child
5. Cutaneous flushing, diarrhea, and bronchospasm

PREFERRED RESPONSE ▶
TAG
(M1.CV.121) A 33-year-old Honduran woman presents to your clinic with shortness of breath. She reports that her symptoms have progressed over the past several months and are now impacting her quality of life because she cannot complete her usual exercise routine. She recalls "normal" childhood illnesses, including sore throats and fevers, but never required hospitalization. Vital signs are temperature 37 degrees Celsius, blood pressure 110/70 mm Hg, heart rate 109/min, respiratory rate 22/min, and oxygen saturation 98% on room air. Physical exam reveals a holosystolic, high-pitched, blowing murmur at the cardiac apex. One would expect that this murmur would also: Topic Review Topic

1. Radiate to the neck
2. Increase with squatting or handgrip
3. Increase with inspiration
4. Also have a mid-systolic click loudest at S2
5. Have a characteristic machine-like sound

PREFERRED RESPONSE ▶
TAG
(M1.CV.130) A 79-year-old man presents to the emergency room after a syncopal event. The patient has a history of hyperlipidemia for which he is taking atorvastatin. On physical examination, his vital signs are stable, but on cardiac auscultation, you detect a crescendo-decrescendo systolic murmur loudest on the right upper sternal border radiating to the neck. On physical exam, one would also expect: Topic Review Topic

1. That the murmur would best be heard in the lateral left decubitus position
2. The character of the murmur would be machine-like
3. The murmur would also have a mid-systolic click loudest at S2
4. The murmur would also have an opening snap
5. Palpation of the carotid pulse would be weak and late relative to the patient’s heart sounds

PREFERRED RESPONSE ▶
TAG
(M1.CV.141) A 73-year-old man presents to your clinic for a routine checkup. He states that he has not seen a doctor in "many years". He has no complaints. When you auscultate over the cardiac apex with the bell of your stethoscope, you notice an additional sound immediately preceding S1. This extra heart sound is most likely indicative of which of the following processes? Topic Review Topic

1. Increased left ventricular compliance
2. Decreased left ventricular compliance
3. Increased left ventricular filling volume
4. Decreased left ventricular filling volume
5. Increased pulmonary compliance

PREFERRED RESPONSE ▶
TAG
(M1.CV.142) A 48-year-old homeless man presents to clinic complaining of fatigue and fevers that "began recently." Cardiac exam reveals a holosystolic murmur, heard best over the left lower sternal border. The murmur increases on inspiration. He also has track marks on his arms bilaterally. This presentation is consistent with which defect? Topic Review Topic

1. Ventricular septal defect
2. Tricuspid regurgitation
3. Mitral regurgitation
4. Aortic stenosis
5. Pulmonary stenosis

PREFERRED RESPONSE ▶
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