Murmurs

Question 1

Bedside maneuver: inspiration

Answer 1

• increases intensity of right heart sounds

Question 2

Bedside maneuver: expiration

Answer 2

• increases intensity of left heart sounds

Question 3

Bedside maneuver: hand grip (increased systemic vascular resistance)

Answer 3

• increases intensity of MR, AR, VSD, MVP

- decreases intensity of AS, hypertrophic cardiomyopathy murmurs

Question 4

Bedside maneuver: valsalva (decreased venous return)

Answer 4

• decreases intensity of most murmurs

- increases intensity of MVP, hypertrophic cardiomyopathy murmurs

Question 5

Bedside maneuver: rapid squatting (increased venous return, increased preload, increased afterload with prolonged squatting)

Answer 5

• decreases intensity of MVP, hypertrophic cardiomyopathy murmurs

Question 6

Description of MR

Answer 6

• holosystolic, high-pitched “blowing murmur” that radiates towards axilla
• systolic murmur

Question 7

Maneuvers that can increase intensity of MR

Answer 7

• increased TPR (squatting) or LA return (expiration)

Question 8

Description of TR

Answer 8

• holosystolic, high pitched murmur that radiates towards right sternal border
• systolic murmur

Question 9

Maneuvers that can increase intensity of TR

Answer 9

• increased RA return (inspiration)

Question 10

Description of AS

Answer 10

• crescendo-decrescendo systolic murmur following ejection click
• radiates towards carotids/heart base
• systolic murmur

Question 11

Description of VSD

Answer 11

• holosystolic, harsh-sounding murmur

Question 12

Maneuvers that increase VSD

Answer 12

• hand grip due to increased afterload

- systolic murmur

Question 13

Description of MVP

Answer 13

• late systolic crescendo murmur with midsystolic click

Question 14

Maneuvers that increase MVP

Answer 14

• decreased venous return (standing or Valsalva)

- systolic murmur

Question 15

Description of AR

Answer 15

• high pitched “blowing” decrescendo murmur
• bounding pulses, and head bobbing
• diastolic murmur

Question 16

Maneuvers that increase or decrease AR

Answer 16

• increase: hand grip

- decrease: vasodilators

Question 17

Description of MS

Answer 17

• follows opening snap
• delayed rumbling
• best heard in left lateral decubitus
• diastolic murmur

Question 18

Description of PDA

Answer 18

• continuous machine-like murmur

Question 19

Description of normal splitting

Answer 19

• delayed closure of pulmonic valve during inspiration

Question 20

Description of wide splitting

Answer 20

• delayed closure of pulmonic valve regardless of breath

- an exaggeration of normal splitting

Question 21

Conditions that can cause wide splitting

Answer 21

• any condition that delays RV emptying such as pulmonic stenosis or RBBB

Question 22

Description of fixed splitting

Answer 22

• pulmonic closure is greatly delayed

Question 23

Conditions that can cause fixed splitting

Answer 23

• ASD (left to right shunt)

Question 24

Description of paradoxical splitting

Answer 24

• P2 sound occurs before delayed A2 sound

Question 25

Conditions that can cause paradoxical splitting

Answer 25

- any condition that delays LV emptying such as aortic stenosis or LBBB