Murmurs

Question 1

VSD

Answer 1

holosystolic, LLSB, mid-diastolic murmur if large shunt; usually maintly early systolic if small; MC pathologic murmur; normal S2; precordial radiation

Question 2

MR

Answer 2

holosystolic, apex, higher pitched than VSD, radiates to axilla and back, blowing

Question 3

ASD

Answer 3

systolic ejection, LUSB, persistent/fixed S2 split from RVOL, soft; can be crescendo-decrescendo

Question 4

PDA

Answer 4

continuous diamond (crescendo-decrescendo), LUSB & L infraclavicular, bounding pulses, machine-like/rumbling; wide pulse pressure; associated with congenital rubella

Question 5

AV stenosis

Answer 5

mid systolic ejection, RUSB, early systolic ejection click at apex, harsh, radiates to carotids, systolic thrill at suprasternal notch

Question 6

supravalvular aortic stenosis

Answer 6

systolic ejection, ML-RUSB, no click

Question 7

HOCM

Answer 7

systolic ejection, LLSB/apex, PMI laterally displaced; often grade 3 or 4 crescendo-decrescendo at ML-RUSB; may have thrill over precordium (not suprasternal), may have gallops

Question 8

coarctation

Answer 8

systolic ejection, LUSB-left back mid-scap, pulse disparity

Question 9

PV stenosis

Answer 9

mid systolic ejection, LUSB, ejection click, harsh but less so than ASD, wide S2 split but not fixed - varies with respiration, positive thrill

Question 10

ToF

Answer 10

systolic ejection, MLSB, cyanosis

Question 11

what gives ejection clicks?

Answer 11

PVS (early systole, L base, varies with respiration), aortic (apex, doesn’t vary), systolic (AS, bicuspid AV, ToF, or truncus arteriosis)

Question 12

what gives non-ejection clicks?

Answer 12

[late systole at LLSB or apex] MVP

Question 13

what causes a paradoxical split in S2? [AV after PV]

Answer 13

severe AS or LLSB causing delay in LV emptying

Question 14

what causes a fixed split of S2? [AV then PV}

Answer 14

delayed RV emptying; ASD, RBBB, severe PS

Question 15

when do you hear an S4?

Answer 15

atrial contraction fills the ventricle; always abnormal; AS, MR, HOCM, HTN causing LVH

Question 16

maneuvers that increase VR?

Answer 16

passive SLR, squats {preload decrease > afterload increase]

Question 17

maneuvers that decrease VR?

Answer 17

valsava, squat to stand

Question 18

maneuvers that increase SVR?

Answer 18

squats, handgrip, transient artery occlusion

Question 19

HOCM murmur changes with maneuvers?

Answer 19

valsava and squat>stand increases; decreases with PSLR, squatting, and handgrip

Question 20

MVP murmur changes with maneuvers?

Answer 20

click earlier (and longer) if valsava and stand, click later if handgrip and transient arterial occlusion; volume increase with being supine or doing squat makes the prolapse less

Question 21

AS murmur changes with maneuvers?

Answer 21

transient art occlusion and handgrip decrease the murmur

Question 22

VSD murmur changes with maneuvers?

Answer 22

decreased with valsava and stand, increased with handgrip and transient arterial occlusion

Question 23

features of innocent murmurs?

Answer 23

otherwise normal exam, asymptomatic, no history of infection, no other abnormal heart sounds; usually musical, short and soft, louder when supine/exercise/anxiety/anemia/fever, decrease with valsava

Question 24

features of venous hum?

Answer 24

innocent murmur; continuous; from blood draining down collapsed jugular veins into dilated intrathoracic veins; absent when supine, decreased in valsava/turn head/JV compression

Question 25

features of supraclavicular artery bruit?

Answer 25

innocent murmur; turbulence in subclavicular and carotid arteries in early systole; short, supraclavicular

Question 26

features of peripheral pulmonic stenosis?

Answer 26

innocent murmur; functional at birth; common; RUSB with radiation to back and axilla, 2/2 turbulence; resolves by 6-12 mo

Question 27

features of TR murmur?

Answer 27

LLSB, pansystolic; at birth 2/2 transient papillary muscle dysfunction or with Ebstein anomaly; may have edema, JVP, hepatomegaly; systolic; has RLSB radiation

Question 28

sound of pericarditis?

Answer 28

friction rub in systole and diastole, sandpaper

Question 29

MV stenosis?

Answer 29

loud pulm part of S2, apical diastolic murmur with no opening snap (too thick)

Question 30

4 components of ToF?

Answer 30

PV stenosis causing subvalvular RVOT, RV and RAD, overriding aorta, and VSD

Question 31

ToF murmur?

Answer 31

2/2 RVOT so hear LUSB systolic ejection; may have click from aortic dilation; can disappear as flow decreases

Question 32

AR murmur?

Answer 32

high-pitched early diastolic murmur after aortic S2; wide pulse pressure

Question 33

PR murmur?

Answer 33

early low-pitched diastolic decrescendo starting with pulm part of S2