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Heart Sounds


Aortic stenosis murmur: harsh midsystolic crescendo-decrescendo SEM best at RUSB 2nd R ICS, radiates to carotids. Louder w/squatting, quieter w/standing or Valsalva; pt sits forward & exhales. Narrow pulse pressure
Aortic regurgitation murmur: soft, high pitched decrescendo diastolic murmur, localized to left sternal border at 2nd-3rd ICS; diastolic blowing murmur; pt sits forward & exhales. Wide pulse pressure
Mitral stenosis murmur: low-pitched, decrescendo, early/middiastolic rumble best at apex (auscult w/bell) in LLD, loud opening snap after S2, all louder with expiration (vs tricuspid stenosis) or squatting
Mitral regurgitation murmur: Quiet S1, split S2, S3 gallop; high-frequency blowing holosystolic at apex with radiation to axilla & back; louder w/squatting or in LLD; visible & palpable LV heave at apex; JVD/edema if severe
Mitral valve prolapse (MVP) murmur: Late systolic at apex; increases (& occurs earlier) with standing / Valsalva or handgrip (inc afterload); mid or late systolic click +/- MR
Harsh midsystolic crescendo-decrescendo SEM best at RUSB 2nd R ICS, radiates to carotids. Louder w/squatting, quieter w/standing or Valsalva; patient sits forward & exhales = Aortic stenosis
Soft, high pitched blowing decrescendo diastolic murmur, localized to LSB = Aortic regurgitation
Low pitched, diastolic rumble near apex with high pitched, opening snap after S2; heard best in LLD position, especially with exercise Mitral stenosis
Mid-systolic click with or without MR Mitral valve prolapse (MVP)
Murmur: SEM at pulmonic, fixed split S2 ASD
Elderly w/ systolic murmur Aortic stenosis:due to calcifications (age related) or bicuspid valve (congenital)
Diamond shaped, blowing holosystolic murmur, best at RUSB, 2nd interspace; Pulsus parvus et tardus; possibly angina, syncope, CHF Aortic stenosis; TTE, then surg (AVR) or balloon
Low pitched, diastolic rumble near apex with opening snap, without radiation; best in LLD posn Mitral stenosis (ARMS are BAD); echo, balloon or MVR for sxs
Systolic ejection murmur heard best at base with radiation to left clavicle Pulmonary stenosis
Female or Post MI, systolic murmur best @ apex preceded by click without radiation Mitral valve prolapse
High holosystolic murmur heard best at apex with radiation to left axilla (apical systolic); JVD; visible, palpable LV heave at apex Mitral regurgitation
New murmur (often apical systolic) after MI = Mitral regurgitation (caused by papillary muscle rupture)
Murmur & Hx rheumatic heart disease Mitral stenosis
Continuous harsh, machine-like murmur at 2nd ICS = PDA (wide pulse pressure and loud S2)
Cyanotic infant with systolic thrill at LSB, systolic ejection murmur +/- click, & S2: Tetralogy of Fallot
High pitched holosystolic murmur at LSB (L-to-R), may have diastolic murmur of pulmonic regurgitation: VSD
Infant w/ dyspnea, difficulty feeding. Holosystolic murmur at LSB, 3rd ICS. LVH & RVH VSD
Auscultate when pt is squatting: what effect? Increases aortic stenosis; decreases HCM (increases preload; more blood separates anterior leaflet from septum -> quieter murmur)
Austin Flint murmur = mid-diastolic apical murmur when pt leans forward holding breath on expiration (aortic regurgitation)
Aortic area = RIGHT 2nd ICS (aortic stenosis, aortic regurgitation, HCM
Pulmonic area = LEFT 2nd ICS (PDA)
Erb's point = Left 3rd ICS (aortic or pulmonic valve dz
Aortic regurgitation is best heard here: Erb's point
Tricuspid area = LEFT 4th ICS
Mitral area = LEFT 5th ICS (cardiac apex)
pulsus paradoxus = >10mm Hg SBP decline on inspiration; 2/2 pericardial effusion/tamponade, pericarditis, asthma attack, tension PTX, SVC obstruction
Valsalva or pt standing, has what effect: decreases aortic stenosis murmur; increases HCM murmur (decreased venous return & preload -> less blood to separate leaflet from enlarged septum: louder murmur); may also enhance MVP click (& occurs earlier)
Put pt in LLD to auscultate: MS at apex, or S3, S4
Auscultate w/pt sitting, holding breath in expiration and leaning forward: Aortic regurgitation at LSB
HCM auscultation: Loud S4 at LSB; murmur similar to aortic stenosis, at LSB & apex
Graham Steell murmur = high pitched decrescendo diastolic murmur at LSB = miral stenosis +/- severe pHTN. Heard in mitral stenosis & pulmonic regurg (2/2 pHTN)
Pulmonic stenosis murmur = Harsh midsystolic crescendo-decrescendo SEM at LUSB & radiates to back/neck; inc with inspiration; wide split S2. Longer murmur = more severe dz
Pulmonic regurg (2/2 CHD) murmur = Lower-pitched Graham Steell-type murmur; late diastolic at 3rd-4th left ICS; RV heave
Tricuspid stenosis murmur = Low mid-diastolic / presystolic rumbling at 4th & 5th ICS, LSB, or below xiphoid; Carvallo sign
Carvallo sign = murmur intensified by inspiration (eg, TS)
Murmur of ASD: fixed wide split S2; early: systolic flow murmur at left 2nd-3rd ICS & SEM at pulmonic valve; later: low diastolic murmur at LUSB
Murmur in a patent ductus arteriosus: L to R shunt: continuous precordial murmur (machinery), thrill; R to L shunt: diastolic Graham Steell murmur
Tricuspid regurgitation murmur = high pitched pansystolic murmur (4th ICS in parasternal region); increases on inspiration & decreases on expiration & standing/Valsalva
Murmurs radiate in the direction of: blood flow
Inspiration causes: increased venous return to right ventricle; decreased venous return to left ventricle & reduced LV volume
Expiration allows which cardiac vessels to re-expand? pulmonary vessels & aorta
Which murmurs are accentuated by inspiration & expiration? Inspiration: accentuate Right heart murmurs. Expiration: accentuate Left heart murmurs.
Squatting (increasing preload) intensifies all murmurs EXCEPT: HCM & MVP
Handgrip increases systemic arterial pressure / HR and increases which murmurs (3)? MS, MR, AR, MVP. Decreases AS and HCM
Drug that mimics the effect of standing / Valsalva: amyl nitrate
Murmur in coarctation of aorta Ejection murmur at aortic area & LSB, radiates into left axilla & left back
VSD murmur: High pitched holosystolic murmur at LSB (L-to-R); small defects have diamond shaped murmur; may have diastolic murmur of pulmonic regurgitation
Created by: Adam Barnard Adam Barnard