Cardiology
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| Systolic murmurs include: | AS, PS, MR, TR, MVP
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| Diastolic murmurs include: | AR, PR, MS, TS
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| Aortic stenosis | harsh midsystolic crescendo-decrescendo SEM best at RUSB 2nd R ICS, radiates to carotids.
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| AS: changes with squatting vs standing or Valsalva | Louder w/squatting, quieter w/standing or Valsalva;
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| Aortic regurgitation | soft, high pitched decrescendo diastolic blowing murmur, LSB at 2nd-3rd ICS
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| Mitral stenosis murmur | low-pitched, decrescendo, mid-diastolic rumble best at apex in LLD, loud opening snap after S2
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| Mitral regurgitation | Split S2, S3 gallop; high blowing holosystolic at apex radiating to axilla
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| Mitral valve prolapse (MVP) murmur: | Late systolic murmur at apex, mid-systolic click (louder squatting)
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| Harsh midsystolic crescendo-decrescendo SEM best at RUSB 2nd R ICS, radiates to carotids | Aortic stenosis
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| soft, high pitched decrescendo diastolic blowing murmur, LSB at 2nd-3rd ICS | Aortic regurgitation
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| low-pitched, decrescendo, mid-diastolic rumble best at apex in LLD, loud opening snap after S2 | Mitral stenosis
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| Mid-systolic click | Mitral valve prolapse (MVP)
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| SEM at pulmonic, fixed split S2 | ASD
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| Elderly w/ systolic murmur | Aortic stenosis: due to calcifications (age related) or bicuspid valve (congenital)
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| Diamond shaped, blowing holosystolic murmur, best at RUSB, 2nd interspace; Pulsus parvus et tardus | Aortic stenosis
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| Low pitched, diastolic rumble near apex with opening snap, best in LLD position | Mitral stenosis (ARMS are BAD); echo, balloon or MVR for sxs
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| Systolic ejection murmur heard best at base with radiation to left clavicle | Pulmonary stenosis
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| Female or Post MI, systolic murmur best at apex preceded by click without radiation | Mitral valve prolapse
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| High holosystolic murmur heard best at apex with radiation to left axilla, palpable LV heave at apex | Mitral regurgitation
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| New murmur (often apical systolic) after MI = | Mitral regurgitation (caused by papillary muscle rupture)
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| Murmur & Hx rheumatic heart disease | Mitral stenosis
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| Continuous harsh, machine-like murmur at 2nd ICS = | PDA (wide pulse pressure and loud S2)
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| Cyanotic infant with systolic thrill at LSB, systolic ejection murmur +/- click, and S2: | Tetralogy of Fallot
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| High pitched holosystolic murmur at LSB (L-to-R), may have diastolic murmur of pulmonic regurgitation: | VSD
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| Infant w/ dyspnea, difficulty feeding. Holosystolic murmur at LSB, 3rd ICS. LVH & RVH | VSD
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| Auscultate when pt is squatting: what effect? | Increases aortic stenosis; decreases HCM (increases preload; more blood separates anterior leaflet from septum => quieter murmur)
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| Austin Flint murmur = | mid-diastolic apical murmur when pt leans forward holding breath on expiration (aortic regurgitation)
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| Aortic area = | RIGHT 2nd ICS (aortic stenosis, aortic regurgitation, HCM
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| Pulmonic area = | LEFT 2nd ICS (PDA)
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| Erb's point = | Left 3rd ICS (aortic or pulmonic valve dz
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| Aortic regurgitation is best heard here: | Erb's point
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| Tricuspid area = | LEFT 4th ICS
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| Mitral area = | LEFT 5th ICS (cardiac apex)
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| pulsus paradoxus = | >10mm Hg SBP decline on inspiration; 2/2 pericardial effusion/tamponade, pericarditis, asthma attack, tension PTX, SVC obstruction
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| 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).
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| Put pt in LLD to auscultate: | MS at apex, or S3, S4
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| Auscultate w/pt sitting, holding breath in expiration and leaning forward: | Aortic regurgitation at LSB
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| HCM auscultation: | Loud S4 at LSB; murmur similar to aortic stenosis, at LSB & apex
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| Graham Steell murmur = | high pitched decrescendo diastolic murmur at LSB = miral stenosis +/- severe pHTN. Heard in mitral stenosis & pulmonic regurg (2/2 pHTN)
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| 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
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| Pulmonic regurg (2/2 CHD) murmur = | Lower-pitched Graham Steell-type murmur; late diastolic at 3rd-4th left ICS; RV heave
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| Tricuspid stenosis murmur = | Low mid-diastolic / presystolic rumbling at 4th & 5th ICS, LSB, or below xiphoid; Carvallo sign
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| Carvallo sign = | murmur intensified by inspiration (eg, TS)
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| 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
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| Murmur in a patent ductus arteriosus: | L to R shunt: continuous precordial murmur (machinery), thrill; R to L shunt: diastolic Graham Steell murmur
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| Tricuspid regurgitation murmur = | high pitched pansystolic murmur (4th ICS in parasternal region); increases on inspiration & decreases on expiration & standing/Valsalva
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| Murmurs radiate in the direction of: | blood flow
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| Inspiration causes: | increased venous return to right ventricle; decreased venous return to left ventricle & reduced LV volume
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| Expiration allows which cardiac vessels to re-expand? | pulmonary vessels & aorta
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| Which murmurs are accentuated by inspiration & expiration? | Inspiration: accentuate Right heart murmurs. Expiration: accentuate Left heart murmurs.
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| Squatting (increasing preload) intensifies all murmurs EXCEPT: | HCM & MVP (but squatting makes MVP click accentuated & earlier)
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| Handgrip increases systemic arterial pressure / HR and increases which murmurs (3)? | MS, MR, AR, MVP. Decreases AS and HCM
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| Drug that mimics the effect of standing / Valsalva: | amyl nitrate
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| Murmur in coarctation of aorta | Ejection murmur at aortic area & LSB, radiates into left axilla & left back
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| VSD murmur: | High pitched holosystolic murmur at LSB (L-to-R); small defects have diamond shaped murmur; may have diastolic murmur of pulmonic regurgitation
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| 80% of patients with this condition have A-fib and diastolic opening snap of S1 | Mitral stenosis
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| Murmur that may cause cardiac dilatation, weakened cardiac muscles, pulmonary HTN due to increased blood flow: | VSD (>ASD)
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| Aortic murmurs: pulse pressures | AS: narrow pulse pressure. AR: wide pulse pressure
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| Auscultate this murmur with bell | Mitral stenosis
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| MS vs TS: louder with expiration or squatting? | MS louder with expiration or squatting; TS quieter with expiration
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| MR louder with: | squatting or in LLD
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| MVP increases with: | standing /Valsalva or handgrip (increased afterload)
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