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Questions and Answers
A 65-year-old patient presents with a blowing murmur that radiates to the left axilla during systole. What is the most likely classification of this murmur?
A 65-year-old patient presents with a blowing murmur that radiates to the left axilla during systole. What is the most likely classification of this murmur?
- Innocent Systolic Murmur
- Aortic Stenosis
- Mitral Regurgitation (correct)
- Mitral Valve Prolapse
What type of murmur is associated with a crescendo-decrescendo intensity pattern?
What type of murmur is associated with a crescendo-decrescendo intensity pattern?
- Aortic Stenosis (correct)
- Mitral Stenosis
- Pansystolic Murmur
- Functional Murmur
A 30-year-old athlete is found to have a normal physiological heart murmur during a sports physical. Which characteristic of this murmur should be expected?
A 30-year-old athlete is found to have a normal physiological heart murmur during a sports physical. Which characteristic of this murmur should be expected?
- Uniform Intensity (correct)
- High Pitch
- Pansystolic Configuration
- Mid Diastolic Timing
An elderly patient exhibits a high-pitched early diastolic murmur. Which condition is most likely causing this abnormal heart sound?
An elderly patient exhibits a high-pitched early diastolic murmur. Which condition is most likely causing this abnormal heart sound?
A patient is diagnosed with mitral valve prolapse. Which audible sound would you likely hear during auscultation?
A patient is diagnosed with mitral valve prolapse. Which audible sound would you likely hear during auscultation?
A murmur is described as decrescendo in intensity after an initial crescendo. What is the likely classification of this murmur?
A murmur is described as decrescendo in intensity after an initial crescendo. What is the likely classification of this murmur?
In assessing a patient's heart sounds, a late systolic click is noted. What condition is most likely indicated by this finding?
In assessing a patient's heart sounds, a late systolic click is noted. What condition is most likely indicated by this finding?
A murmur is heard best at the left second intercostal space and is described as a harsh sound. What is the most likely cause of this murmur?
A murmur is heard best at the left second intercostal space and is described as a harsh sound. What is the most likely cause of this murmur?
A patient presents with a murmur best heard at the second right intercostal space. Which condition is most likely indicated by this location?
A patient presents with a murmur best heard at the second right intercostal space. Which condition is most likely indicated by this location?
A patient exhibits a late diastolic murmur with a presystolic accentuation. Which of the following is the most likely diagnosis?
A patient exhibits a late diastolic murmur with a presystolic accentuation. Which of the following is the most likely diagnosis?
The murmur indicating mitral valve prolapse is often described as which of the following?
The murmur indicating mitral valve prolapse is often described as which of the following?
When evaluating a young adult with a continuous murmur best heard at the second left intercostal space, which condition should be suspected?
When evaluating a young adult with a continuous murmur best heard at the second left intercostal space, which condition should be suspected?
What is the characteristic acoustic feature of an ejection murmur associated with aortic stenosis?
What is the characteristic acoustic feature of an ejection murmur associated with aortic stenosis?
A heart murmur is identified as a systolic, pansystolic murmur. Which pathology is most likely to cause this murmur?
A heart murmur is identified as a systolic, pansystolic murmur. Which pathology is most likely to cause this murmur?
Which type of murmur is characterized by a diamond shape on examination?
Which type of murmur is characterized by a diamond shape on examination?
Which location is associated with a mid-diastolic murmur?
Which location is associated with a mid-diastolic murmur?
A 60-year-old man presents with a systolic murmur that radiates to his neck. What is the likely diagnosis associated with this type of murmur?
A 60-year-old man presents with a systolic murmur that radiates to his neck. What is the likely diagnosis associated with this type of murmur?
A 45-year-old female patient has a murmur that you can hear best at the left shoulder. What type of murmur does she likely have?
A 45-year-old female patient has a murmur that you can hear best at the left shoulder. What type of murmur does she likely have?
What is the grading of a murmur that is easily audible and accompanied by a thrill?
What is the grading of a murmur that is easily audible and accompanied by a thrill?
While examining a patient, you find a loud diastolic murmur that is Grade 5. What does this indicate?
While examining a patient, you find a loud diastolic murmur that is Grade 5. What does this indicate?
In a patient with a murmur that shows no increase during the Valsalva maneuver, how would you classify this murmur?
In a patient with a murmur that shows no increase during the Valsalva maneuver, how would you classify this murmur?
A patient presents with a systolic murmur best heard between the scapulae. What is the most likely situation?
A patient presents with a systolic murmur best heard between the scapulae. What is the most likely situation?
What maneuver should be performed to best listen for mitral murmurs and S3 heart sounds?
What maneuver should be performed to best listen for mitral murmurs and S3 heart sounds?
A clinical evaluation reveals a patient with a fixed split second heart sound and a diastolic murmur. What does this suggest?
A clinical evaluation reveals a patient with a fixed split second heart sound and a diastolic murmur. What does this suggest?
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Study Notes
Murmurs
- A sound made by blood flowing through a normal valve or an abnormal valve.
- Murmurs are described by:
- Timing
- Loudness (intensity)
- Configuration (shape)
- Frequency (pitch)
- Location
- Radiation
- Response to dynamic maneuvers
- Types:
- Systolic:
- Ejection murmurs: associated with aortic stenosis or pulmonary stenosis
- Pansystolic (holosystolic): associated with mitral or tricuspid regurgitation
- Late systolic: associated with mitral valve prolapse
- Diastolic:
- Early diastolic: associated with aortic regurgitation
- Diastolic rumble: associated with mitral stenosis
- Systolic:
- Common Maneuvers:
- Left side position: Bring out S3 and mitral murmurs
- Lean forward position: Bring out aortic murmurs
- Valsalva maneuver:
- Phase 1: Straining (increased intrathoracic pressure)
- Phase 2: Release (blood rushes back to heart)
Extrasounds
- Systolic Click: associated with innocent/physiologic murmurs, mitral/tricuspid regurgitation, and mitral valve prolapse
- Opening Snap: associated with mitral stenosis
- Ejection Sound: associated with aortic valve disease
- S3: normal in children, associated with heart failure
- S4: associated with various diseases
Grading of Murmurs
- Grade 1: Just audible
- Grade 2: Audible but faint
- Grade 3: Readily audible
- Grade 4: Easily audible, accompanied by a thrill
- Grade 5: Very loud, audible with stethoscope partially off chest
- Grade 6: Loud enough to be heard without stethoscope, only need to put ear close to chest
Functional vs Pathological Murmurs
- Functional murmurs:
- Common in asymptomatic adults
- Grade I – II @ LSB
- Systolic ejection pattern
- Normal precordium, apex, S1
- Normal intensity & splitting of second sound (S2)
- No other abnormal sounds or murmurs
- No evidence of LVH
- Pathologic murmurs:
- Diastolic murmur
- Loud murmur - grade 4 or above
- Regurgitant murmur
- Murmurs associated with a click
- Murmurs associated with other signs or symptoms e.g. cyanosis
- Abnormal 2nd heart sound – fixed split, paradoxical split or single
Additional Tips
- JVP inspection: Jugular vein distention
- Ejection systolic murmurs:
- Aortic stenosis: Radiates to neck
- Pulmonary stenosis: Radiates to left shoulder
- Mitral regurgitation: Radiates to left axilla and lower left chest at the back
Maneuvers
- Valsalva maneuver: A special maneuver used to evaluate the heart, especially for murmurs and extra heart sounds.
- Stages:
- Strain phase: Increased intrathoracic pressure
- Release phase: Blood rushes back to the heart
- The maneuver is divided into four phases:
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