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Approach to murmurs
This document provides an overview of how to approach heart murmurs. It discusses the basics of heart sounds and cardiac cycle timing. It describes the locations used to auscultate heart sounds. Murmurs are defined as audible vibrations caused by increased turbulence in blood flow. Pathological murmurs have distinguishing characteristics like timing within the cardiac cycle. The document outlines how to describe murmurs and provides examples of different types of murmurs heard in various locations based on their timing within the cardiac cycle. It also discusses classifications of murmurs and potential causes.
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Introduction to heart murmurs including basic cardiac sounds (S1, S2), phases of blood flow, and auscultatory areas.
Definition of heart murmurs, their significance, and the turbulence that causes them.
Clues for identifying pathological murmurs with characteristics such as timing, duration, and shape.
Details on murmur intensity classification, pitch, and how factors like respiration affect sound.
Overview of heart murmur classification and its significance.
Early systolic murmurs with examples including acute severe mitral regurgitation and their characteristics.
Descriptions of mid systolic murmurs and conditions like aortic stenosis with examples.
Characteristics of late systolic murmurs, primarily linked to mitral valve prolapse.
Definition and examples of holosystolic murmurs, including chronic mitral and tricuspid regurgitation.
Description of early and mid diastolic murmurs, with examples such as chronic aortic regurgitation.
Definition and examples of continuous murmurs, notably patent ductus arteriosus (PDA).
References used in the presentation regarding cardiac physical diagnosis and internal medicine.
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Approach to murmurs
- 1. APPROACH TO MURMURS DRKIRAN D YADAV 1ST YEAR PG DEPARTMENT OF GENERAL MEDICINE
- 2. BASICS • S1 :CLOSURE OF AV VALVES • S2 : CLOSURE OF SEMILUNAR VALVES • SYSTOLE : PERIOD BETWEEN S1 AND S2 BLOOD FLOWS ACROSS AORTIC AND PULMONARY VALVE • DIASTOLE : PERIOD BETWEEN S2 AND S1 BLOOD FLOWS ACROSS MITRAL AND TRICUSPID VALVE
- 3. CARDIAC VALVES ANDASSOCIATED AUSCULTATORY AREAS Erb’s area : 3rd L IC space close to sternum Gibson’s area : 1st L IC space close to sternum
- 4. • HEART MURMURSARE AUDIBLE VIBRATIONS CAUSED BY INCREASED TURBULENCE IN BLOOD FLOW AND ARE DEFINED BY THEIR TIMING WITHIN THE CARDIAC CYCLE. • TURBULENCE IS CAUSED BY INCREASE IN VELOCITY OF BLOOD FLOW INCREASE IN PRESSURE GRADIENT BLOOD MOVES FROM SMALL LARGE CHAMBER LOW BLOOD VISCOSITY • SIGNIFICANCE OF A MURMUR : WHETHER PHYSIOLOGICAL OR PATHOLOGICAL
- 5. Clues to identifypathologic murmurs • All diastolic murmurs • All pansystolic and late systolic murmurs • Continuous murmurs • Very loud murmurs (grade 4 or higher) • Associated cardiac abnormalities
- 6. Describing a murmur •Timing - systolic, diastolic, continuous further categorised into early mid late can be done by simultaneously feeling for the carotid pulse in tachycardia • Duration – Short, long or pansystolic/pandiastolic murmurs • Shape – crescendo, decrescendo, crescendo-decrescendo, plateau • Location of maximum intensity – depends on the site of origin • Radiation – reflects the intensity of the murmur and direction of blood flow • is determined by the site where the murmur originates • e.g. A, P, T, M listening areas
- 7. • Intensity –Graded on intensity scale at the site of maximal intensity grade 1 – very soft heard with great effort grade 2 – easily heard grade 3 – loud but without thrill grade 4 – loud with thrill grade 5 – heard with stethoscope edge touching the chest grade 6 – heard with stethoscope slightly off the chest Grade 3 or more indicates a structural heart disease, intensity decreases as distance between cardiac structure and stethoscope decreases • Pitch – high manifested as whistling low manifested as rumbling V
- 8. • Other characteristics Respiration-inspiration right heart murmurs increase in intensity expiration left heart murmurs increase in intensity Postural changes – supine to standing intensity of all murmurs decrease except murmurs of hocm and mvp standing to squatting intensity of right heart murmurs increase, MR and AS increase Cardiac cycle length – longer increase intensity of ejection murmurs regurgitant murmurs do not change Valsalva strain phase – heart sound and murmurs decrease in intensity Valsalva release phase- murmurs of right side return to baseline within 2-3 heart beats, left side murmurs after 5-10 heart beats Isometric Hand grip increases murmurs of left side MR,AR,VSD,MS
- 9.
- 10. Early systolic murmurs •Begin with S1 and end well before S2 • Eg : 1 Acute severe MR - decrescendo, apex causes MI, MVP, IE,Blunt chest wall trauma 2 small muscular VSD – left sternal border, grade 4 or 5 3 Acute severe TR – left sternal border, grade 1 or 2, increase in intensity with respiration( carvallo sign)
- 11. Mid Systolic Murmurs •Begin a short interval after S1 and end before S2 • Crescendo-decrescendo in configuration • Eg : 1 Aortic stenosis – Aortic area, radiates to carotids, Gallavardin Effect 2 HOCM – lower left sternal border 3 PS – pulmonary area 4 AV Sclerosis - aortic area grade1 or grade 2 5 Physiological murmur – lower left sternal border 6 Stills murmur
- 12. Late Systolic Murmurs •Best heard at left ventricular apex • Mostly due to MVP – introduced by ejection click post leaflet radiates to the base ant leaflet radiates to axilla or left infrascapular region
- 13. Holosystolic murmurs • Beginwith S1 continue through systole to S2 • Eg : 1 Chronic MR – left ventricular apex, high pitched, plateau radiates to the axilla Causes of chronic MR : Rheumatic scarring, Mitral annular calcification, Severe LV enlargement 2 Chronic TR – lower left sternal border, increase with inspiration Causes of chronic TR : Endocarditis, RHD, Carcinoid, Ebsteins Anomaly 3 VSD – mid to lower left sternal border, radiates widely, thrill present
- 15. Early Diastolic Murmurs •Begin immediately after S2 and end well before S1, Decrescendo in configuration • Eg : 1 Chronic AR – high pitched, blowing , second right space, auscultated with patient leaning forward causes – Marfans syndrome, ankylosing spondylitis, aortic dissection 2 PR – begins after p2, second left space, radiates along left sternal border, mostly due to pulmonary hypertension
- 16. Mid Diastolic Murmurs •Produced due to obstruction/augmented flow at mitral or tricuspid valve • Eg : 1 Mitral stenosis – opening snap f/b low pitched murmur best heard at LV apex patient in lateral decubitus position, presystolic accentuation present only in sinus rhythm 2 Tricuspid stenosis – lower left sternal border increase in intensity with inspiration, prolonged y descent in jvp waveform 3 Atrial Myxoma – prolapse across Mitral valve 4 carey coombs murmur – short mid diastolic murmur in arf
- 18. Continuous murmur • Beginin systole, peak near the second heart sound and continue into all or part of a diastole • Eg : PDA – Upper left sternal border Ruptured sinus of Valsalva – upper right sternal border coronary arteriovenousfistula, cervical bruit, venous hum, mammary souffle
- 19. References • Essential ofcardiac physical diagnosis – Jonathan Abrams • Harrisons principles of internal medicine • Manual of Practical Medicine – R Alagappan
- 20.