Murmurs

Question 1

Area for auscultating the Aortic

Answer 1

Aortic: 2nd I.C.S right sternal border

Question 2

Area for auscultating the Pulmonary

Answer 2

Pulmonary: 2nd I.C.S left sternal border

Question 3

Area for auscultating the Tricuspid

Answer 3

Tricuspid: 5th I.C.S left sternal border

Question 4

Area for auscultating the Mitral

Answer 4

Mitral: 5th I.C.S mid clavicular line (apex area)

Question 5

The first heart sound (S1) is caused by

Answer 5

closure of mitral and tricuspid valves

Question 6

soft first heart sound is caused by

Answer 6

soft if long PR or mitral regurgitation

Question 7

loud first heart sound is caused by

Answer 7

loud in mitral stenosis

Question 8

The second heart sound (S2) is caused by

Answer 8

closure of aortic and pulmonary valves

Question 9

second heart sound (S2) soft in

Answer 9

soft in aortic stenosis

Question 10

second heart sound (S2) splitting due to

Answer 10

splitting during inspiration is normal

Question 11

S3 (third heart sound) is always pathological

Answer 11

false

considered normal if < 30 years old

Question 12

S3 (third heart sound) may persist in who?

Answer 12

(may persist in women up to 50 years old)

Question 13

S3 caused by

Answer 13

caused by diastolic filling of the ventricle

Question 14

S3 is heard in which conditions?

Answer 14

heard in left ventricular failure (e.g. dilated cardiomyopathy)
constrictive pericarditis (called a pericardial knock) mitral regurgitation

Question 15

What is pericardial knock?

Answer 15

S3 sound in constrictive pericarditis

Question 16

S4 is always normal

Answer 16

false

Question 17

S4 is caused by ventricular contraction against a stiff ventricle

Answer 17

false

caused by atrial contraction against a stiff ventricle

Question 18

S4 coincides with which part of the ECG

Answer 18

p waves

Question 19

S4 is heard in which conditions?

Answer 19

aortic stenosis, hypertension & HOCM

Question 20

(in HOCM a double apical impulse may be felt as a result of

Answer 20

palpable S4

Question 21

Aortic stenosis Clinical features of symptomatic disease?

Answer 21

chest pain
dyspnoea
syncope

Question 22

What type of murmur do you get in aortic stenosis?

Answer 22

delayed ejection systolic murmur

classically radiates to the carotids

Question 23

aortic stenosis radiating to a carotids is decreased following the Valsalva manoeuvre

Answer 23

true

Question 24

Pulse in aortic stenosis

Answer 24

narrow pulse pressure & slow rising pulse

Question 25

Which heart sounds are soft/absent in aortic stenosis

Answer 25

soft/absent S2, S4

Question 26

Aortic stenosis complications

Answer 26

left ventricular hypertrophy or failure

Question 27

Causes of aortic stenosis

Answer 27

degenerative calcification (most common cause in older patients > 65 years) bicuspid aortic valve (most common cause in younger patients < 65 years) William's syndrome (supravalvular aortic stenosis) post-rheumatic disease subvalvular: HOCM

Question 28

Management of aortic stenosis if asymptomatic

Answer 28

if asymptomatic then observe the patient is general rule

Question 29

Management of aortic stenosis if symptomatic

Answer 29

if symptomatic then valve replacement

Question 30

Management of aortic stenosis and asymptomatic - when is surgery considered?

Answer 30

valvular gradient > 40 mmHg and with features such as left ventricular systolic dysfunction then consider surgery

Question 31

Why is angiogram important prior to surgery in aortic stenosis?

Answer 31

Cardiovascular disease may coexist. ``` For this reason an angiogram is often done prior to surgery so that the procedures can be combined balloon valvuloplasty (limited to patients with critical aortic stenosis who are not fit for valve replacement) ```

Question 32

What murmur do you get in Aortic regurgitation

Answer 32

early diastolic murmur:

Question 33

Aortic regurgitation intesnity of murmur increased by

Answer 33

intensity of the murmur is increased by the handgrip manoeuvre

Question 34

Aortic regurgitation pulses?

Answer 34

collapsing pulse & wide pulse pressure

Question 35

Quincke's sign

Answer 35

(nailbed pulsation) in aortic regurgitation

Question 36

De Musset's sign

Answer 36

(head bobbing) in aortic regurgitation

Question 37

Causes of aortic regurgitation (due to valve disease)

Answer 37

rheumatic fever infective endocarditis connective tissue diseases e.g. RA/SLE bicuspid aortic valve

Question 38

Causes of aortic regurgitation (due to aortic root disease)

Answer 38

``` aortic dissection spondylarthropathies (e.g. ankylosing spondylitis) hypertension syphilis Marfan's, Ehler-Danlos syndrome ```

Question 39

Atrial flutter is a features of mitral stenosis

Answer 39

false | atrial fibrillation

Question 40

Mitral stenosis murmur

Answer 40

mid-late diastolic murmur (best heard in expiration) | loud S1, opening snap

Question 41

mitral stenosis can cause malar flush

Answer 41

true

Question 42

mitral stenosis pulse

Answer 42

low volume pulse

Question 43

causes of mitral stenosis?

Answer 43

rheumatic fever, rheumatic fever and rheumatic fever. Rarer causes that may be seen in the exam include mucopolysaccharidoses, carcinoid and endocardial fibroelastosis

Question 44

Features of severe MS?

Answer 44

length of murmur increases | opening snap becomes closer to S2

Question 45

CXR & MS?

Answer 45

left atrial enlargement may be seen

Question 46

Echo & MS?

Answer 46

the normal cross sectional area of the mitral valve is 4-6 sq cm. A 'tight' mitral stenosis implies a cross sectional area of < 1 sq cm

Question 47

What is Mitral regurgitation

Answer 47

``` mitral regurgitation (MR) occurs when blood leaks back through the mitral valve on systole mitral valve is located between the left atrium and ventricle, and regurgitation leads to a less efficient heart as less blood is pumped through the body with each contraction. ```

Question 48

second most common valve disease after aortic stenosis.

Answer 48

mitral regurgitation

Question 49

MR is common in otherwise healthy patients to a trivial degree and does not need treatment.

Answer 49

true

Question 50

Risk factors for MR?

Answer 50

``` Female sex Lower body mass Age Renal dysfunction Prior myocardial infarction Prior mitral stenosis or valve prolapse Collagen disorders e.g. Marfan's Syndrome and Ehlers-Danlos syndrome ```

Question 51

Causes of MR?

Answer 51

Post MI Infective endocarditis Rheumatic fever Congenital

Question 52

Most patients with MR are asymptomatic

Answer 52

True Most patients with MR are asymptomatic, and patients suffering from mild to moderate MR may stay largely asymptomatic indefinitely.

Question 53

MR Symptoms tend to be due to

Answer 53

failure of the left ventricle, arrhythmias or pulmonary hypertension. This may present as fatigue, shortness of breath and oedema.

Question 54

MR ECG

Answer 54

ECG may show a broad P wave, indicative of atrial enlargement

Question 55

MR CXR

Answer 55

Cardiomegaly may be seen on chest x-ray, with an enlarged left atrium and ventricle

Question 56

MR Echo

Answer 56

Echocardiography is crucial to diagnosis and to assess severity

Question 57

MR acute mx

Answer 57

Medical management in acute cases involves nitrates, diuretics, positive inotropes and an intra-aortic balloon pump to increase cardiac output severe- surgery

Question 58

MR mx dditional drugs for heart failure

Answer 58

If patients are in heart failure, ACE inhibitors may be considered along with beta-blockers and spironolactone

Question 59

A systolic murmur heard best in the 5th intercostal space is most consistent with?

Answer 59

mitral regurgitation

Question 60

ascending aortic dissection may cause

Answer 60

aortic regurgitation

Question 61

Tricuspid regurgitation murmur is systolic/diastolic

Answer 61

systolic

Question 62

Tricuspid regurgitation murmir is pan systolic

Answer 62

true

Question 63

Which valve disease presents with left parasternal heave

Answer 63

tricuspid regurgitation

Question 64

Tricuspid regurgitation presents with which liver symmptom?

Answer 64

pulsatile hepatomegaly

Question 65

Tricuspid regurgitation causes?

Answer 65

``` right ventricular infarction pulmonary hypertension e.g. COPD rheumatic heart disease infective endocarditis (especially intravenous drug users) Ebstein's anomaly carcinoid syndrome ```

Question 66

A 75-year-old man presents with difficulty breathing at night, occasional palpitations and tight chest pain. On examination, he has a collapsing pulse and a laterally shifted apex beat. You also notice his head bobs in time with his pulse. This is ?

Answer 66

Aortic regurgitation