Case 4 - Murmurs

Question 1

Clinical features of aortic stenosis

Answer 1

• Ejection systolic cresendo decresendo murmur
• Radiates to carotid
• Thrill palpation of aortic area
• Slow rising carotid pulse
• Narrow pulse pressure
• Exertional syncope

Question 2

Commonest differentials for systolic murmur

Answer 2

• Aortic stenosis
• Mitral regurgitation
• Tricusipid regurgitation
• Pulmonary stenosis

Question 3

Investigations for murmur

Answer 3

• Echocardiogram
• ECG
• CXR - calcified aorta? LVH?

Question 4

Commonest complications of severe aortic stenosis

Answer 4

• Heart failure
• LVH
• Arrhytmias eg AF
• Syncope
• Angina
• Cardiogenic shock
• Death - sudden

Question 5

Management aortic stenosis

Answer 5

• Valve replacement - open heart or TAVI (transcatheter aortic valve replacement via femoral artery)
• When symptomatic/LV dysfunction

Question 6

Common causes of valvular disease

Answer 6

• Senile calcification
• Congenital
• Rheumatic fever
• Cardiomyopathy
• Previous MI
• IE

Question 7

Clinical signs of aortic regurgitation

Answer 7

• Collapsing ‘water hammer’ pulse
• Wide pulse pressure
• High pitched, early diastolic murmur (heard best sitting forward on expiration)
• Displaced apex beat

Question 8

Weird signs of aortic regurgitation

Answer 8

• Corrigans sign - carotid pulsation dances, rapid rise and fall
• De Musset sign - head nod with pulse
• Quinckes sign - capillary pulsation in nailbed

Question 9

Clinical signs of mitral stenosis?

Answer 9

• Malar flush
• Low volume pulse
• AF common
• Tapping, non displaced apex
• Mid-diastolic murmur (best heard on expiration, rolled to left)

Question 10

Clinical signs of mitral regurgitation

Answer 10

• AF
• Displaced apex
• RV heave
• Soft S1, split S2 loud P2
• Pansystolic murmur at apex radiating to axilla

Question 11

Signs to look for in infective endocarditis

Answer 11

• Signs of IV drug use
• Janeway lesions (palms and soles, flat)
• Oslers nodes (raised)
• Splinter haemorrhages
• Roth spots
• Any new murmur/changed
• Splenomegaly
• Clubbing
• Petechiae

Question 12

Common pathogens causing infective endocarditis

Answer 12

• Streptococcus viridans
• Enterococci
• Staphylococcus aureus
• Staphylococcus epidermidis

Question 13

How to definitively diagnose IE?

Answer 13

• Transoesophageal echocardiagram usually needed
• Can sometimes see vegetations on TT echo but not always
• Blood cultures - 3x samples over 30-60 mins
• Duke criteria - major+3 minor or 5 minor

Question 14

Initial abx therapy for IE

Answer 14

• IV amoxicillin +/- gentamicin
• Vancomycin + gentamicin if penicillin allergic or severe

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