Murmurs - Johns

Question 1

What is the grade of most murmurs?

Answer 1

III

Question 2

When does diastole occur?

Answer 2

After S2

Question 3

Describe an aortic stenosis murmur:

Answer 3

• Early to mid-systolic
• Heard best over base and tends to radiate to carotids
• Crescendo-decresendo
• Late stages may have decreased systolic pressure and slow carotid upstroke (rather than a tapping pulsation)

Question 4

What is the etiology of Aortic Stenosis?

Answer 4

Degenerative calcific, rheumatic, bicuspid

Question 5

What is the pathophysiology of aortic stenosis?

Answer 5

Pressure gradient over 50 mm or valve area represents critical obstruction (1/3 of normal valve area)

Question 6

What are the symptoms of Aortic Stenosis?

Answer 6

Angina, syncope, dyspnea on exertion

Question 7

What is the treatment for Aortic Stenosis?

Answer 7

• Valve replacement

- Balloon valvuloplasty in children and young adults

Question 8

Describe a mitral insufficiency (regurgitation):

Answer 8

• Even, blowing murmur
• Holosystolic murmur
• Heard best at apex, tends to radiate to the axilla (putting stethoscope on axilla to hear it)

Question 9

What is the etiology for Mitral Insufficiency?

Answer 9

RHD, congenital, acute MI with papillary muscle dysfunction, endocarditis, calcification with age

Question 10

What is the pathophysiology of Mitral Insufficiency?

Answer 10

Decreased forward flow
Acute - little enlargement of left atrium, pulmonary edema
Chronic - large left atrium

Question 11

What are the symptoms of Mitral Insufficiency?

Answer 11

Acute - pulmonary edema

Chronic - Severe fatigue, atrial fibrillation

Question 12

What are the treatments of Mitral Insufficiency?

Answer 12

• Medical treatment for CHF, atrial fibrillation

- Surgery: patients with severe MR with limitations of work or routine household tasks

Question 13

Describe Mitral Stenosis:

Answer 13

• Diastolic murmur best heard at apex with patient in left lateral recumbent position
• Low pitched (rumble)
• Opening snap precedes murmur

Question 14

What is a typical mitral stenosis case?

Answer 14

Women from Nigeria, pregnant in 2nd trimester with pulmonary edema - has mitral stenosis

Question 15

What is the etiology of mitral stenosis?

Answer 15

Most are rheumatic, rarely congenital

-Decreased incidence since strep treatment

Question 16

What is the pathophysiology of mitral stenosis?

Answer 16

• Normal valve orifice is 4-5 cm2, left atrial pressure rises with 2 cm2
• Pulmonary hypertension
• Resultant right ventricular failure

Question 17

What symptoms are associated with mitral stenosis?

Answer 17

• Dyspnea with exertion and cough
• Hemoptysis
• Arterial embolism

Question 18

What is the treatment for mitral stenosis?

Answer 18

• Antibiotic prophylaxis

- CHF, Atrial fibrillation - Valve replacement if valve area less than 1.0 cm2

Question 19

Describe Aortic Insufficiency (regurgitation):

Answer 19

-High pitched diastolic murmur heard best at base of heart

Question 20

When is aortic insufficiency best heard?

Answer 20

With patient sitting

• Louder with inc. severity
• “water-hammer” pulse, increased pulse pressure

Question 21

What is the etiology of aortic insufficiency?

Answer 21

2/3 are rheumatic - Endocarditis, trauma (car accidents), congenital

Question 22

What is the pathophysiology of aortic insufficiency?

Answer 22

Increased SV

-Deterioration of left ventricular function precedes symptoms

Question 23

What are the symptoms of aortic insufficiency?

Answer 23

• May be asymptomatic for years
• Uncomfortable awareness of heartbeat when lying down, exertion dyspnea first symptom followed by orthropnea and PND - Angina, CHF

Question 24

How do you treat aortic insufficiency?

Answer 24

Difficult to time: Patients asymptomatic until myocardial dysfunction develops
-Myocardial dysfunction does not return after surgery

Question 25

Describe Mitral Valve Prolapse:

Answer 25

- Click-murmur syndrome - Mid or late systolic click - May be followed by a high pitched late systolic murmur - Heard best at the apex

Question 26

What is the etiology of mitral valve prolapse?

Answer 26

Congenital or genetic, very common, females between 14-30

Question 27

What is the pathophysiology of mitral valve prolapse?

Answer 27

Myxomatous degeneration of posterior leaflet | -Usually benign but may trigger arrhythmias

Question 28

How do you treat mitral valve prolapse?

Answer 28

Reassure

Question 29

What are innocent murmurs?

Answer 29

- Always systolic ejection in nature - Occur without evidence of physiologic abnormalities - Grade I or II intensity - No thrills or radiation - End well before S2 - Found in 30-50% of children

Question 30

What are three right sided murmurs?

Answer 30

1. Tricuspid stenosis 2. Tricuspid regurgitation 3. Pulmonic stenosis

Question 31

What is Tricuspid stenosis?

Answer 31

Rare in developed countries, rheumatic, associated with mitral stenosis, giant A wave in neck, diastolic murmur best heard along lower left sternal border and xiphoid (right ventricular failure --> most often caused by left sided failure)

Question 32

What is tricuspid regurgitation?

Answer 32

Functional from right ventricular dilation, signs of right sided heart failure, holosystolic murmur at LLSB, prominent v waves in neck

Question 33

What is pulmonic stenosis?

Answer 33

-Usually preceded by ejection click, mid systolic murmur like this is probably benign.