22 Heart Murmurs

• LSB: Erb's point, no specific for one valve, aortic regurge
• Apex: 5th intercostal space, mid clavicular line

• Apex: PMI. If not at mid clavicular: enlarged
• hyperdynamic: pushing very hard against finger, sympathetic driving

• laminar: slow rate, no murmurs
• turbulent: fast speed, very loud. Creates heart murmurs

• closer together: S1 - S2. Farther apart: S2 - S1

• in real life, 2 or 3
• on exam, maybe up to 4, 5

• hypertrophic cardiomyopathy: heart contracting, sound created by thick septum blood has to flow around
• VSD: blood pushed through a hole

• stills: heard in children, all normal murmurs

Aortic Stenosis

• crescendo-decrescendo: ejection
• pulsus parvus (weak) et tardus (late): put finger on pulse, sluggish/weak upstroke of carotid compared to normal vigorous pulse

Aortic Regurgitation

Mitral Regurgitation

Mitral Stenosis

• opening snap after S2, like S3, occurs because stiff mitral valve leaflets has to open in diastole, followed by holo diastolic murmur
• left sided S3/S4 both caused by rapid filling of ventricle, doesn't happen in stenosis
• more severe stenosis, quicker opening snap occur: LA pressure rises with severe stenosis. When very high, OS happen quicker

Tricuspid and Pulmonic

• inspiration: increased venous return to right side, right murmurs louder
• inspiration: dilate veins in lungs, drops venous return to left side of heart, quieter
• like sucking blood into lungs, pull blood away from left and pool in right

• pulmonic stenosis very rare
• tricuspid: very uncommon, occur in conjunction with mitral stenosis
• pregnancy: women with asymptomatic rheumatic heart disease become sympatomatic when blood volume goes up
• PHTN: high pressure in lungs push blood back through pulmonic valve
• tricuspid: first place seeds

• Mitral hat: Endocarditis: affects mitral valve; M protein molecular mimicry with muscle myosins. Mitral stenosis in conjunction with tricuspid stenosis

• Running camel and mortar/pestel: acute rapid onset tricuspid endocarditis in IV drug users

Carcinoid

• only if met to liver to not be metabolized

VSD

• loud murmur = sick people, severe problem, severe symptoms, HF
• very loud murmur and asymptomatic: rare, VSD (mitral, tricuspid regurg very sick with loud murmurs)

PDA

• continuous: blood flows through in all phases of cardiac cycle

Maneuvers

• inspire: diaphragm moves down, compresses veins in abdomen. Thorax also dilate
• inspire: dilate veins in lungs

• Tetralogy of fallot squat: increase afterload, feels better, different physiology

• MVP: mitral valve bellow up into LA (bottom pic) and snap up to cause mitral regurge.
• more preload: tightens leaflets, don't bellow quite as much, come together more firmly (top), less regurge
• HCM: thick septum gets in way of blood flowing out of LV = murmur
• more preload: septum pushed more towards right, less obstruction, less murmur

• amyl nitrate not used anymore
• AR, MR, VSD: blood flowing in wrong direction
• forward: harder for blood to flow in foward direction
• MVP, HCM: increased afterload increases LV cavity size, softer murmur

• important