Heart Murmurs

Question 1

Mitral regurgitation

Answer 1

Loud pansystolic murmur at the apex radiating into the axilla. Best heard in the left lateral position.

• displaced apex beat with thrusting.
• may be systolic thrill over apex.
• soft S1

Question 2

Mitral valve prolapse (Barlow Syndrome)

Answer 2

Mid-systolic click, followed by a late systolic murmur heard best at the apex. Squatting delays the click, standing increases the murmur.

Question 3

Mitral Stenosis

Answer 3

Rumbling mid-diastolic murmur heard at the apex and radiationg to the axilla. heard best in in the left lateral position - accentuated by excercise

• Tapping undisplaced apex beat
• Loud S1 and S2
• Left parasternal heave

(As mitral stenosis worsens, left atrial pressure increases forcing the mitral valve open earlier in diastole. Thus, in severe mitral stenosis, the opening snap occurs earlier as does the initial decrescendo part of the murmur.)

Question 4

Aortic regurgitation

Answer 4

High pitched early diastolic murmur audible in the aortic area and at the left sternal edge. Best heard leaning forward on end expiration

• Wide pulse pressure which is collapsing
• Apex beat is thrusting and displaced to 6th intercostal space in the anterior axillary line (volume overload)

Question 5

Aortic stenosis

Answer 5

Harsh ejection systolic murmur heard best at the left sternal edge (2nd ICS) . loudest leaning forward on end expiration and may radiate to carotids.

• Narrow pulse pressure and slow rising pulse
• aortic thrill
• Apex is forceful but usually undisplaced

Question 6

Tricuspid regurgitation

Answer 6

Pansystolic murmur heard loudest at lower left sternal edge during inspiration

• AF common
• JVP raised with giant v waves
• Tender pulsatile hepatomegaly

Question 7

Mechanical mitral valve replacement

Answer 7

Click on first heart sound (closure of valve)

Possible mid-diastolic murmur (more common with old ball-and-cage valve)

Pansystolic murmur? (leaking of prosthetic valve)

Question 8

Mechanical aortic valve replacement

Answer 8

Normal first heart sound

Ejection click (opening of prosthetic valve)

Soft ejection systolic murmur

Click on second heart sound (closing of valve)

Early diastolic murmur? (leaking - also wide pulse pressure and collapsing pulse)

Question 9

Heart Sounds

S1

S2

S3

S4

Answer 9

S1: Closure of the atrioventricular valves (AV) TRICUSPID AND MITRAL VALVES. This sounds like “LUB”.

S2: closure of the semilunar valves (SL) AORTIC AND PULMONIC VALVES. This sounds like “DUB”.

S3: heard after S2 and sounds like “LUB-DUB-TA”. Caused by vibrations of ventricle filling from a resistant ventricle due to fluid volume overload or heart failure.

S4: heard before S1 and sounds like “TA-LUB-DUB”. Caused by ventricle resistance from an atrial “kick” during presystole (hypertrophic left ventricle)