22 Heart Murmurs

  • LSB: Erb's point, no specific for one valve, aortic regurge
  • Apex: 5th intercostal space, mid clavicular line

  • Apex: PMI. If not at mid clavicular: enlarged
  • hyperdynamic: pushing very hard against finger, sympathetic driving

  • laminar: slow rate, no murmurs
  • turbulent: fast speed, very loud. Creates heart murmurs

  • closer together: S1 - S2. Farther apart: S2 - S1

  • in real life, 2 or 3
  • on exam, maybe up to 4, 5

  • hypertrophic cardiomyopathy: heart contracting, sound created by thick septum blood has to flow around
  • VSD: blood pushed through a hole

  • stills: heard in children, all normal murmurs

Aortic Stenosis

  • crescendo-decrescendo: ejection
  • pulsus parvus (weak) et tardus (late): put finger on pulse, sluggish/weak upstroke of carotid compared to normal vigorous pulse

Aortic Regurgitation

Mitral Regurgitation

Mitral Stenosis

  • opening snap after S2, like S3, occurs because stiff mitral valve leaflets has to open in diastole, followed by holo diastolic murmur
  • left sided S3/S4 both caused by rapid filling of ventricle, doesn't happen in stenosis
  • more severe stenosis, quicker opening snap occur: LA pressure rises with severe stenosis. When very high, OS happen quicker

Tricuspid and Pulmonic

  • inspiration: increased venous return to right side, right murmurs louder
  • inspiration: dilate veins in lungs, drops venous return to left side of heart, quieter
  • like sucking blood into lungs, pull blood away from left and pool in right

  • pulmonic stenosis very rare
  • tricuspid: very uncommon, occur in conjunction with mitral stenosis
  • pregnancy: women with asymptomatic rheumatic heart disease become sympatomatic when blood volume goes up
  • PHTN: high pressure in lungs push blood back through pulmonic valve
  • tricuspid: first place seeds

  • Mitral hat: Endocarditis: affects mitral valve; M protein molecular mimicry with muscle myosins. Mitral stenosis in conjunction with tricuspid stenosis

  • Running camel and mortar/pestel: acute rapid onset tricuspid endocarditis in IV drug users

Carcinoid

  • only if met to liver to not be metabolized

VSD

  • loud murmur = sick people, severe problem, severe symptoms, HF
  • very loud murmur and asymptomatic: rare, VSD (mitral, tricuspid regurg very sick with loud murmurs)

PDA

  • continuous: blood flows through in all phases of cardiac cycle

Maneuvers

  • inspire: diaphragm moves down, compresses veins in abdomen. Thorax also dilate
  • inspire: dilate veins in lungs

  • Tetralogy of fallot squat: increase afterload, feels better, different physiology

  • MVP: mitral valve bellow up into LA (bottom pic) and snap up to cause mitral regurge.
  • more preload: tightens leaflets, don't bellow quite as much, come together more firmly (top), less regurge
  • HCM: thick septum gets in way of blood flowing out of LV = murmur
  • more preload: septum pushed more towards right, less obstruction, less murmur

  • amyl nitrate not used anymore
  • AR, MR, VSD: blood flowing in wrong direction
  • forward: harder for blood to flow in foward direction
  • MVP, HCM: increased afterload increases LV cavity size, softer murmur

  • important