Murmurs

Question 1

S1

Answer 1

• loudest at the apex
• sound of the tricuspid and mitral valves closing
• after S1 and before S2 is systole
• systole begins at #9: when LV pressure exceeds LA pressure
• systole ends at #17: when aortic and pulmonic valves close

Question 2

S2

Answer 2

• heard loudest at the base
• sound of pulmonic and aortic valves closing
• after S2 abd before the next S1 is diastole
• diastole beins at #17: when aortic and pulmonic valves close
• diastole ends at #9: when tricuspid and mitral valves close

Question 3

turbulent flow

Answer 3

• increased flow rate –> increased CO
• narrowing —> increased flow
• valve stenosis
• valve regurgitation
• other (VSD, HCM, PDA)

Question 4

Answer 4

Question 5

Grading a Murmur

Answer 5

Question 6

systolic murmurs

Answer 6

•closing of tricsupid and mitral valves

1) crescendo-decrescendo
- aortic stenosis
- pulmonic stenosis
- hypertrophic cardiac myopathy
2) holosysolic
- mitral regurgitation
- tricuspid regurgitation
- VSD

Question 7

Answer 7

• systolic - crescendo decrescendo
• aortic stenosis
• pulmonic stenosis
• hypertrophic cardiac myopathy

Question 8

Answer 8

• systolic - holosystolic
• mitral regeurgitation
• tricuspid regurgitation
• VSD

Question 9

diastolic murmurs

Answer 9

• closing of aorta and pulmonic valves
• decrescendo
• aortic regurgitation
• pulmonic regurgitation

•rumble

• mitral stenosis
• tricuspid stenosis

Question 10

Answer 10

• diastolic - decrescendo
• aortic regirgitation
• pulmonic regurgitation

Question 11

Answer 11

• diastolic - rumble
• mitral stenosis
• tricsupid stenosis

Question 12

aortic stenosis

Answer 12

• systolic murmur - left side
• crescendo decrescendo
• starts when aortic valve opens (#12) , stops when closes (#17)
• blood having a hard time pushing through
• syncope, angina, dyspnea

Question 13

mitral regurgitation

Answer 13

• systolic murmur - left side
• holosystolic
• begins when mitral valve closes (#9) and ends when mitral valve opens again (#21)
• starts as soon as systolic pressure is greater than atrial pressure, lasts as long as LV pressure exceeds LA pressure

Question 14

aortic regurgitation

Answer 14

• diastolic murmrur - left side
• decrescendo
• starts when aortic valve closes ( #17) and continues until aotic valve opens again (#12)
• heard better while pateint is sitting up, can cause head bobbing, murmur over femorals
• during diastole, blood leaks back
• high pulse pressure (systolic BP goes up a little, diastolic BP goes down)
• can cause a flow murmur during suystole due to extra blood

Question 15

mitral stenosis

Answer 15

• diastolic - left side
• rumble
• blood has a hard time pushing throuh
• starts when mitral valve opens (#21) and ends when mitral valve closes (#9)
• can end up causing a fib and pulmonary edema

Question 16

inspiration

Answer 16

• Increase right-sided murmurs
• Decrease left-sided murmurs (see exceptions below)

Question 17

expiration

Answer 17

• Decrease right-sided murmurs
• Increase left-sided murmurs (see exceptions below)

Question 18

Increase Preload—Leg Raise (increase venous return)

Answer 18

• Increase most murmurs
• Except decrease HCM

Question 19

Decrease Preload—Standing, Valsalva (decrease venous return)

bear down, increase pressure in chest

Answer 19

• Decrease most murmurs
• Except increase HCM

Question 20

Increase afterload (handgrip/phenylephrine)

Answer 20

• Increase backward flow
• Increase MR and VSD
• Decrease AS and MS
• Decrease HCM (more blood in ventricles, increases size of ventricle and opens up outlfow tract)

Question 21

Decrease afterload (vasodilator—amyl nitrate)

Answer 21

• decrease backward flow
• decrease MR and VSD
• increase AS and MS
• increase HCM

Question 22

continuous murmur

Answer 22

•patent ductus arteriosus

Question 23

S3

Answer 23

• early in diastole (after S2)
• hear failure with reduced EF
• more blood left in LV
• blood hits blood —> vibration of walls

•chronic mitral regurgitation

• bllod into atrium, whcih eventually gets back to lV
• bllod hits blood —> vibration of walls

•children and pregnant women - not pathologic

Question 24

S4

Answer 24

• late in diastole (before S1)
• contraction of atria pushes extra blood in
• anyone with stiff heart
• HTN
• HFpEF
• blood hits stiff wall
• with a fib, no S4 heard

Question 25

S2 splitting

Answer 25

•inspiration, physiologic -negative pressure, more blood comes in and pulmonic valve stays open longer •wide - RV failure (MI) - pulmonary hypertension - RBBB (late contraction) •fixed -atrial septal defect (more blood into right heart) •paradoxical - aortic closes after pulmonic - LBBB - LV failure