Term
| You hear a midsystolic click and a late systolic murmer when auscultating your patient. You have them stand up and the click happens sooner, the murmur lasts longer. They squat down, and the click happens later and the murmur is shorter. What is the most likely cause of the murmur? |
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Definition
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Term
| With mitral valve prolapse, why do standing and squatting change the timing of the click and the duration of the murmur? (Generally) |
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Definition
| The valve confirmation changes in these different positions. |
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Term
| What is the effect on preload of standing up? Of squatting? |
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Definition
Standing up: decreased preload
Squatting: increased preload |
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Term
| Your patient has a pansystolic murmur that is louder on INspiration. IN addition, they have a pulsatile liver and pulsatile JVD. What is the most likely cause of the murmur? |
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Definition
Tricuspid Regurgitation (severe)
-This triad is easily testable but RARELY seen in its entirety |
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Term
Your patient has a pansystolic murmur. It is not effected by respiration.
It could be described as HARSH. What is the likely cause of the murmur? |
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Definition
| Ventricular Septal Defect |
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Term
| How would you distinguish between the murmur of a ventricular septal defect and that of mitral valve regurgitation? |
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Definition
| The murmur of a VSD is HARSH |
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Term
| Your patient has an early diastolic murmur that is high-pitched and blowing. You note that the murmur starts loud and quiets down. What is the likely cause of the murmur? |
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Definition
| Aortic insufficiency (aortic valve regurgitation) |
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Term
| What is the cause of the systolic ejection murmur that is sometimes found in patients with aortic insufficiency? |
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Definition
| During diastole, the LV is now filling from two sources: the LA, and the regurgitating aorta. As a result, there is higher flow, creating a systolic murmur |
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Term
| Your patient has a diastolic, LOW pitched rumble that you hear at the apex of the heart. What is the most likely cause of this murmur, and why does it happen? |
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Definition
Aortic Insufficiency- AUSTIN FLINT MURMUR
-the jet of regurgitated blood from the aortic valve is hitting the anterior mitral leaflet |
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Term
| You place your stethoscope on the patients femoral artery. When you tilt the distal part of the scope off, you hear a systolic murmur. When you tilt the proximal part of the scope off, you hear a diastolic murmur. What is the cause of the murmur? |
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Definition
| Aortic insufficiency- DUROZIEZ SIGN- this is caused by to and fro movement of blood in the femoral artery because of the incompetent aortic valve |
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Term
| Your patient presents with a BP of 140/70. You happen to notice that the blood flow to their nailbeds changes with their heartbeat. If you checked their popliteal blood pressure, what would you likely find? |
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Definition
Widened pulse pressure- aortic insuffic.
Phasic nail blanching- Quincke's Pulse
SO, the Hill Sign is when the popliteal systolic BP exceeds the brachial by more than >60mm Hg.
(gotcha!) |
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Term
| Your patient has known pulmonary hypertension without known valve deformity. Name the murmur you are most likely to hear? |
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Definition
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Term
| Your patient has a mid diastolic murmur that begins after P2. It is a low-pitched crescendo-decrescendo murmur. It gets LOUDER during INSPIRATION. What is the cause of this murmur? |
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Definition
Pulmonic insufficiency via deformity of the pulmonic valve
(Very Uncommon) |
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Term
| Your patient has an early diastolic murmur beginning with a loud pulmonic component of S2. The murmur is HIGH pitched, decrescendo, and blowing. It gets LOUDER during INSPIRATION. What is the cause of this murmur and what is it called? |
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Definition
Pulmonic insufficiency NOT due to valve deformity
Graham Steell Murmur |
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Term
| Your middle-aged patient presents with a mid-diastolic murmur that is Low-pitched, rumbling, and you notice it is best heard when they are lying on their left side. What pertinent piece of their medical history would it be reasonable to conclude from these findings? |
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Definition
History of Rheumatic Fever
MITRAL STENOSIS |
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Term
| Your patient has a complicated medical history not well described because they are from India. They have a history of smoking, HTN, and DM. On exam, you hear an opening snap and an accentuated S1 sound. What is the likely cause? |
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Definition
| Mitral Stenosis- secondary to Rheumatic Fever |
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Term
| In mild mitral stenosis, why do we hear a louder S1 sound? |
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Definition
| The stenosis causes the pressure gradient between LA and LV to remain longer, meaning the valves close from a greater distance and make a louder noise |
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Term
| What will be the effect on the S1 heart sound of a lengthened PR interval? |
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Definition
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Term
| How do we distinguish the murmur of aortic regurgitation (Austin-Flint) from mitral stenosis? |
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Definition
| Aortic regurg. has no opening snap |
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Term
| What causes the Carey Coombs murmur? |
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Definition
| ACUTE rheumatic fever- inflammation of the mitral valve |
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Term
| How would you differentiate mitral stenosis and tricuspid stenosis on exam? |
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Definition
| In tricuspid stenosis, the murmur gets louder on INSPIRATION. |
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Term
| Your patient has a remote history of having taken diet pills in the 1970s. She presents to you with a murmur at the left sternal border that gets louder on inspiration. What is the cause of this murmur? |
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Definition
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Term
| Name a situation where a non-continuous murmur can mimic a continuous murmur: |
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Definition
This would be a to-and-fro murmur-
Combination of Aortic Stenosis and Aortic Insufficiency- actually two separate murmurs that occur during systole AND diastole |
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Term
| What type of murmur would you expect to hear to confirm a diagnosis of Patent Ductus Areteriosus? |
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Definition
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Term
| Your patient presents with a blood pressure of 87/50. You can't really hear their heart, and they have jugular venous distention. What is the MOST likely diagnosis? |
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Definition
Pericardial Tamponade
This is called Beck's triad, and can be found in only a minority of cases, but is specific |
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Term
| You decide to do an extensive blood pressure experiment on your patient and find that their systolic arterial pressure declines 25 mmHg during inspiration. What is this called, and what is a LIKELY cause? |
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Definition
This is Exaggerated Pulsus Paradoxus
A likely cause is pericardial tamponade, but this test is not specific |
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Term
| You notice that your patient has jugular venous distention. You also notice that it gets more prominent on inspiration. What is this called? |
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Definition
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Term
| What is the HALLMARK sign of acute pericarditis on auscultation? |
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Definition
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Term
| Describe Virchow's triad. What does it mean? |
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Definition
-Vascular Injury
-Venous Stasis
-Hypercoagulability
Big risk for venous thrombosis, venous thromboembolism |
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Term
| What is the most common cause of congenital aortic stenosis, and what is the hallmark sing on auscultation? |
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Definition
| Bicuspid Aortic Valve- aortic ejection sound (also called click, but Carmine likes to say "sound") |
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Term
| What is the most common cause of ACQUIRED aortic stenosis? |
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Definition
| Senile fibrocalcific processes |
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Term
| Your 65 year old patient presents with a crescendo-decrescendo murmur that peaks in early systole and radiates to the carotids. What is the likely cause of the murmur? |
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Definition
| Senile Fibrocalcific Aortic Stenosis |
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Term
| You feel your patient's pulse while listening to their heart. You normally expect to feel the carotid upstroke very quickly after the S1 sound, but it is delayed in this patient. What is this called, and what is your diagnosis? |
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Definition
Pulsus Parvus et tardus
Likely aortic stenosis |
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Term
| What is the effect of aortic stenosis on aortic pressure during systole? |
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Definition
| The valve doesn't open well, so the aortic peak pressure never makes it as high as ventricular pressure. This maintains a flow gradient that explains the aortic stenosis murmur. |
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Term
| Your patient has suspected aortic stenosis. On looking at their EKG, you notice they occasionally have PVCs. You listen to their murmur during a PVC and note that it gets LOUDER after the PVC. Is this aortic stenosis? |
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Definition
| Yes, the premature beat caused a reduced preload with less contraction. There is then a compensatory pause which allows for greater filling, so the NEXT beat has an INCREASED preload, with a large effect on the Aortic Stenosis Murmur |
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Term
| When a hypertrophic heart contracts during systole, happens to the anterior mitral leaflet, and what does this explain? |
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Definition
| The thickened septum pulls the ant. mitral leaflet out of its usual position- it sucks it into the ventricular outflow tract. This causes a systolic ejection murmur. |
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Term
| How does a patients volume status effect preload and a systolic ejection murmur due to hypertrophic cardiomyopathy? |
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Definition
| If the patient is "dry" or preload is reduced, the ventricle is not as full during systole. The IV septum is closer to the ant. leaflet of the mitral valve, obstruction is even greater, and the murmur is LOUDER. |
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Term
| Your patient has a crescendo-decrescendo murmur that you attribute to hypertrophic cardiomyopathy. What bedside would accentuate the murmur (make it louder) to confirm your suspicion? |
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Definition
REDUCE PRELOAD: gets louder during
-Valsalva
-standing from sitting or lying down
-Amyl nitrite |
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Term
| To differentiate between the crescendo-decrescendo systolic murmur of hypertrophic cardiomyopathy and an aortic stenosis murmur, you have your patient squat down. The murmur gets louder when they do. Which type of murmur do they have? |
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Definition
| They have Aortic Stenosis- note that the beside exam maneuvers (valsalva, squatting) yield opposite results between these two types of murmurs |
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Term
| You have a patient with hypertrophic cardiomyopathy do an isometric handgrip maneuver. What is this doing to flow to the heart, and what will the effect be on their HOCM murmur? |
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Definition
Isometric handgrip increases preload
The murmur of hypertrophic cardiomyopathy will get SOFTER |
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Term
| Your patient has a systolic crescendo-decrescendo murmur that increases during INSPIRATION. It does NOT radiate to the carotids. What is the likely cause of this systolic murmur? |
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Definition
Pulmonic Stenosis-
***Remember, though, that in congenital pulmonic stenosis, the murmur gets SOFTER during inspiration*** |
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Term
| What valve issue causes an exhaggerated v-wave on the jugular venous waveform and why? |
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Definition
| Tricuspid regurgitation- the physiological v-wave is a rise in RA pressure during systole. If you add blood by a regurgitating tricuspid valve, that pressure will increase even more |
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Term
| Your patient has Atrial Fibrillation. You decide to evaluate their jugular venous waveform because you, like Dr. Jones, are obsessed with the Wigger Diagram. Do you expect to find an a-wave in this patient? |
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Definition
No- no a-wave because there is no right atrial contraction to speak of
(it is just vibrating but not truly contracting) |
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Term
| You are listening to your patients heart and you notice that the S2 sound is unified on inspiration but split on expiration. What is this called, and what is are some possible causes? |
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Definition
| This is PARADOXICAL splitting of the S2 sound. Causes are LBBB, LV outflow obstruction, RV pacemaker, RV ectopic beats, systemic hypertension (rarely) |
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Term
| When auscultating your patient, you notice that their second heart sound never comes together on inspiration or expiration. You also note a mid-systolic murmur. What is your diagnosis? |
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Definition
Atrial Septal Defect
Note- there are other potential causes of FIXED splitting of the S2 sound, but ASD is always what you think of first and the mid-systolic murmur clinches it |
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Term
| What is the cause of the S3 sound? |
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Definition
| Tensing of the chordae tendinae or sudden limitation of the ventricular expansion during early rapid filling |
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Term
| You are listening at the apex of the heart and you hear a low-pitched heart sound after S2. What are you hearing? |
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Definition
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Term
| What is the cause of the S4 heart sound? |
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Definition
| The atrium contracting against a stiffened ventricle. Results from reduced ventricular compliance |
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Term
| Would you expect to hear an S4 sound in a patient with Afib or Aflutter? |
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Definition
Nope.
Because they are not doing the old atrial kick, which is the cause of the S4 heart sound. In Afib/Aflutter, there is no contraction of the atrium. |
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Term
| What happens to the length of diastole when the heart rate speeds up? |
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Definition
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Term
Most right-sided pathological auscultatory findings increase in intensity when the patient does what?
What is the exception? |
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Definition
| INSPIRATION increases Right Sided pathological sounds EXCEPT pulmonic ejection click |
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Term
| What does inspiration do to venous return to the right side of the heart? |
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Definition
| Inspiration INCREASES venous return to the right side of the heart, thus increasing volume and flow |
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Term
| What is the effect of the valsalva maneuver on venous return and preload? |
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Definition
| VALSALVA- decreases venous return AND decreases preload |
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Term
| What is the Muller maneuver and what is its effect on venous return and preload? |
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Definition
| This is like a sustained hiccup, the opposite of valsalva- PULLING against a closed glottis. The Muller maneuver INCREASES venous return and INCREASES preload |
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Term
| You are evaluating a patient for a heart murmur. You give them amyl nitrite. What does this do to their heart rate and their systemic vascular resistance? |
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Definition
Amyl nitrite is a potent vasodilator. It REDUCES systemic resistance, decreasing arterial pressure, but causing reflex TACHYCARDIA after 30-60 seconds
(which increases cardiac output) |
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Term
| In what patients are vasopressors contraindicated? |
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Definition
| Patients with CHF or systemic hypertension |
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Term
| What is the effect of methoxamine or phenylephrine on blood pressure and afterload? |
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Definition
These drugs, vasopressors, are vasoconstrictors. They increase blood pressure and afterload.
They should NOT be used in patients with CHF or systemic hypertension. |
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Term
| REVIEW THE MURMUR SCALES FOR SYSTOLIC AND DIASTOLIC MURMURS |
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Definition
| REVIEW THE MURMUR SCALES FOR SYSTOLIC AND DIASTOLIC MURMURS |
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Term
| Your patient has a murmur that begins after the S1 sound and ends before the S2 sound. Is it systolic or diastolic? |
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Definition
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Term
| Your patient has a murmur that beings after the S2 sound and is gone before the S1 sound. Is it systolic or diastolic? |
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Definition
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Term
| Your patient has a murmur that begins in systole and continues after S2 into diastole. What is this TYPE of murmur called? |
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Definition
| Continuous murmur- sounds like a washing machine |
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Term
| Why can fever, anemia, hyperthyroid, pregnancy, and beriberi all cause systolic murmurs? |
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Definition
| They all cause high cardiac output, which causes turbulence on ventricular ejection |
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Term
| What are the three things that can cause a pansystolic murmur? |
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Definition
| Tricuspid Regurg, Mitral Regurg, and Ventricular Septal Defect |
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