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Heart Sounds


Systolic murmurs include: AS, PS, MR, TR, MVP
Diastolic murmurs include: AR, PR, MS, TS
Aortic stenosis harsh midsystolic crescendo-decrescendo SEM best at RUSB 2nd R ICS, radiates to carotids.
AS: changes with squatting vs standing or Valsalva Louder w/squatting, quieter w/standing or Valsalva;
Aortic regurgitation soft, high pitched decrescendo diastolic blowing murmur, LSB at 2nd-3rd ICS
Mitral stenosis murmur low-pitched, decrescendo, mid-diastolic rumble best at apex in LLD, loud opening snap after S2
Mitral regurgitation Split S2, S3 gallop; high blowing holosystolic at apex radiating to axilla
Mitral valve prolapse (MVP) murmur: Late systolic murmur at apex, mid-systolic click (louder squatting)
Harsh midsystolic crescendo-decrescendo SEM best at RUSB 2nd R ICS, radiates to carotids Aortic stenosis
soft, high pitched decrescendo diastolic blowing murmur, LSB at 2nd-3rd ICS Aortic regurgitation
low-pitched, decrescendo, mid-diastolic rumble best at apex in LLD, loud opening snap after S2 Mitral stenosis
Mid-systolic click Mitral valve prolapse (MVP)
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 Aortic stenosis
Low pitched, diastolic rumble near apex with opening snap, best in LLD position 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 at apex preceded by click without radiation Mitral valve prolapse
High holosystolic murmur heard best at apex with radiation to left axilla, 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, and 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).
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 (but squatting makes MVP click accentuated & earlier)
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
80% of patients with this condition have A-fib and diastolic opening snap of S1 Mitral stenosis
Murmur that may cause cardiac dilatation, weakened cardiac muscles, pulmonary HTN due to increased blood flow: VSD (>ASD)
Aortic murmurs: pulse pressures AS: narrow pulse pressure. AR: wide pulse pressure
Auscultate this murmur with bell Mitral stenosis
MS vs TS: louder with expiration or squatting? MS louder with expiration or squatting; TS quieter with expiration
MR louder with: squatting or in LLD
MVP increases with: standing /Valsalva or handgrip (increased afterload)
Created by: Abarnard
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