Murmurs

Question 1

What causes the first heart sound (S1)?

Answer 1

Closing of the atrioventricular valves (tricuspid and mitral valves)

Question 2

What causes the second heart sound (S2)?

Answer 2

Closing of the semilunar valves (pulmonary and aortic valves)

Question 3

When is the third heart sound (S3) heard?

Answer 3

0.1 seconds after the second heart sound

Question 4

In what patient is a third heart sound normal in?

Answer 4

A patient aged between 15 - 40 years

Question 5

What causes the sound of S3?

Answer 5

The pulling of the chordae tendinae to their full length

Question 6

What may an S3 indicate in an older patient?

Answer 6

Heart failure

Question 7

When is the fourth heart sound (S4) heard?

Answer 7

Directly before S1

Question 8

When is the fourth heart sound (S4) normal?

Answer 8

NEVER

Question 9

What causes a fourth heart sound (S4)?

Answer 9

Turbulent flow of the atria contracting against a non-compliant ventricle.

This indicates a stiff or hypertrophic ventricle.

Question 10

Which side of the stethoscope is optimal for low-pitched sounds?

Answer 10

Bell

Question 11

Which side of the stethoscope is optimal for high-pitched sounds?

Answer 11

Diaphragm

Question 12

Where is the pulmonary area anatomically located?

Answer 12

2nd intercostal space on left sternal border

Question 13

Where is the aortic area anatomically located?

Answer 13

2nd intercostal space on right sternal border

Question 14

Where is the tricuspid area anatomically located?

Answer 14

5th intercostal space on left sternal border

Question 15

Where is the mitral area anatomically located?

Answer 15

5th intercostal space mid-clavicular line

Question 16

Where is Erb’s point?

Answer 16

3rd intercostal space on left sternal border

Question 17

What is Erb’s point used for?

Answer 17

This is the best area for listening to the heart sounds S1 and S2

Question 18

What manoeuvres can be performed to accentuate murmurs?

Answer 18

Putting patient on to left-hand side can help to accentuate mitral stenosis

Sitting the patient up with breath-holding can help to accentuate aortic regurgitation.

Question 19

How do you describe a murmur?

Answer 19

Site (where is it loudest)
Character (soft, blowing, crescendo, decrescendo)
Radiation (carotids, axilla)
Intensity (graded 1-6)
Pitch (high/low)
Timing (systolic/diastolic)

Question 20

What is the grading system for murmurs?

Answer 20

Grade 1 - difficult to hear
Grade 2 - quiet
Grade 3 - easy to hear
Grade 4 - easy to hear + palpable thrill
Grade 5 - audible with stethoscope barely touching chest
Grade 6 - audible with stethoscope completely off the chest

Question 21

Stenosis of which valve would cause left atrial hypertrophy?

Answer 21

Mitral valve

Question 22

Stenosis of which valve would cause left ventricular hypertrophy?

Answer 22

Aortic valve

Question 23

What valvular disease results in left atrial dilatation?

Answer 23

Mitral regurgitation

Question 24

What valvular disease results in left ventricular dilatation?

Answer 24

Aortic regurgitation

Question 25

What are the causes of mitral stenosis?

Answer 25

Rheumatic heart disease | Infective endocarditis

Question 26

What murmur would mitral stenosis present with?

Answer 26

``` Mid-diastolic Low-pitched Rumbling Loud S1 Palpable tapping apex beat ``` Associated with a 'malar flush' and atrial fibrillation

Question 27

What murmur would mitral regurgitation present with?

Answer 27

``` Pan-systolic High-pitched Whistling Radiates to the left axilla May have S3 ``` Results in congestive cardiac failure

Question 28

What are the causes of mitral regurgitation?

Answer 28

``` Idiopathic weakening with age Ischaemic heart disease Infective endocarditis Rheumatic heart disease Connective tissue disorders ```

Question 29

What murmur would aortic stenosis present with?

Answer 29

``` Ejection-systolic High-pitched Crescendo-decrescendo Radiates to the carotids Slow-rising pulse Narrow pulse pressure Exertional syncope ```

Question 30

What are the causes of aortic stenosis?

Answer 30

Idiopathic age-related calcification | Rheumatic heart disease

Question 31

What murmur would aortic regurgitation present with?

Answer 31

Early-diastolic Soft Corrigan's pulse (collapsing pulse) Can result in an Austin-Flint murmur

Question 32

What is an Austin-Flint murmur?

Answer 32

Heard at the apex Early-diastolic Rumbling This is caused by blood flowing back through the aortic valve and over the mitral valve, causing the mitral valve to vibrate.

Question 33

What are the causes of aortic regurgitation?

Answer 33

Idiopathic age-related weakness | Connective tissue disorders