1. Virginia Joslin, PA-C, MPH
A Workshop: Review Your Knowledge and Build your Skills INTERPRETATION OF HEART SOUNDS
Virginia Joslin, PA-C, MPH
and
Karen Newell, PA-C, MMSc
Emory DFPM
Contact information:
Virginia Joslin, PA-C
Director, Emory University PA Program
(404)
Karen Newell, PA-C
Academic Coordinator
Emory University PA Program
(404)
Website:

2. Workshop Goals:
To enhance the learner’s knowledge and skills in heart sounds interpretation for improved clinical practice and performance on the Board Certification exam a) using physical exam techniques focusing on auscultation effectively and b) critically analyzing a narrative description of heart exam findings

3. Learner Objectives
By the end of the workshop, the learner will be able to:
Describe the critical cardiac anatomy and physiology as it relates to heart sounds.
Utilize the stethoscope properly to maximize your ability to pick-up subtle sounds.
Recognize the common causes of heart murmurs.
Interpret heart sounds based on timing, location, radiation, pitch, and changes in quality with specific exam techniques.
Provide a differential diagnosis for the etiology of extra heart sounds.
Identify the heart abnormality or diagnosis, given a classic description of case presentation with risk factors, history and physical exam findings.

4. Organize your critical thinking skills! Case Presentation
Mr. N. Trouble is a 64 y.o. homeless man with a history of worsening chest pain and DOE for the last 3 months. He has developed a nonproductive cough and orthopnea without fever. On exam of the heart you note:
an enlarged, hyperdynamic PMI displaced infero-laterally, a thrill over the apex, an S4, S3, and a grade IV/VI holosystolic murmur heard best with the diaphragm at the apex.

5. Case Presentation
What is the most likely diagnosis?
What is the likely cause of this condition in this patient?

6. Surface Anatomy: Key Landmarks
MCL
Sternal Angle 2
Erb’s Point
5 L. MCL
Bickley, Lynn S, Bate’s Guide to Physical Examination and History Taking. Lippincott Williams& Wilkens

7. Heart wall layers and pericardium
Other Relevant Cardiac Anatomy
Heart wall layers and pericardium
Inter-atrial and Inter-ventricular Septum
Valves
Chordae Tendineae and Papillary muscles
Cardiac conduction system
Three layers: Endocardium, Myocardium, Epicardium
Septum between atria, or between ventricles may have an opening ( ASD, VSD) which may cause a murmur
Normally heart valves open in one direction Valves allowing backward flow of blood are incompetent and cause regurgitant murmurs. Stiff, narrow valves cause valvular stenosis.
Chordae Tendinae act as ligaments between the papillary muscles and the A/V valves ( Tricuspid and Mitral).
Conduction System serves to organize the physiological events of the heart: Sinoatrial(SA) node to Atrioventricular(AV) node, to Bundle of His to Right and Left Bundle Branches and Perkinje Fibers. The Left Bundle Branch has septal, anterior and posterior fascicles.

8. Cardiac Conduction System
Organizer of the cardiac physiological events

9. Emory University Physician Assistant Program
A & P Valves Open M & T Valves Closed
Mitral Valve is closed
Tricuspid Valve is closed
Emory University Physician Assistant Program

10. Emory University Physician Assistant Program
M & T Valves Open P & A Valves Closed A P
Emory University Physician Assistant Program

11. 1 2 3 4 5 6 M & T close A & P open A & P close
#1 Left ventricular pressure exceeds left atrial pressure as the full ventricle begins to contract. The mitral valve is pushed closed = S1
#2 The left ventricular pressure exceeds that pressure in the aorta, pushing the aortic valve open. Normally no sound is heard. If the aortic valve is stiff, an ejection click may be heard.
#3 The pressure in the aorta exceeds the pressure in the left ventricle, pushing the aortic valve closed, causing S2
#4The pressure in the left atrium exceeds the pressure in the left ventricle, pushing the mitral valve open. Normally no sound is heard. If the mitral valve is stiff, an opening snap may be heard.
#5 Early in diastole the blood flows by gravity from the left atrium into the left ventricle. If the inferior septal wall of the ventricle is stiff, an early diastolic sound may be heard = an S3.
#6 At the end of diastole, the left atrium contracts, increasing the pressure in the left atrium. .
Bickley, Lynn S, Bate’s Guide to Physical Examination and History Taking. Lippincott Williams& Wilkens with permission 4 5 6
M & T open

12. A complete cycle of physiologic cardiac events
Aortic Pressure
Ventricular Pressure
Atrial Pressure S1
EjCl S4 S1
#7 At the end of diastole the left atrium contracts, ejecting the last bolus of blood into the left ventricle. . Normally no sound is heard. If the inferior septal wall of the left ventricle is stiff, and S4 gallop may be heard.
Bickley, Lynn S, Bate’s Guide to Physical Examination and History Taking. Lippincott Williams& Wilkens
A complete cycle of physiologic cardiac events

13. Quiz Which valves are normally closed during systole?
Aortic and Pulmonic
Tricuspid and Mitral
Aortic and Mitral
Tricuspid and Pulmonic

14. Answer: B T&M valves During Systole:
the Aortic and Pulmonic valves are OPEN
The Tricuspid and Mitral valves are CLOSED

15. Cardiac Exam Inspect Palpate Auscultate
The exam is inadequate, if the precordium is covered.
No more than one pulsation should be visible (PMI).
No more than one pulsation should be palpable:
Location: Normally in the MCL, 5th ICS or just medial
Pulse should be palpable no longer than 2/3 of systole as auscultated simultaneously
Size: No larger than 2.5 cm.
PMI that is enlarged, displaced, sustained suggests LVH
Auscultation should include, at a minimum, use of the bell and diaphragm in all four valve location

16. Normal Heart Sounds Valve Closure
S1 (closure of Mitral and Tricuspid valves)
S2 (closure of the Aortic and Pulmonic valves)
High pitched: heard best with the Diaphragm
Which is S1? S2? (location where best heard, rhythm, timing compared to the carotid pulse and JVP waves )
S1 due to closure of the Tricuspid and Mitral Valves
S2 due to closure of the Aortic and Pulmonic valves
Both are high pitched sounds, best heard with the diaphragm
Methods to differentiate S1 from S2:
1) Systole (between S1 and S2) is shorter than Diastole
2) S2 usually loudest at the base (Aortic and Pulmonic areas); S1 is usually loudest at the apex (Mitral area)
3) Carotid pulsation is palpable immediately after S1
4) S1 is audible immediately after the “a” wave of the JVP (the highest wave when looking at the JVP in profile) by observation
5) S2 occurs almost simultaneously with the “v” wave of the JVP

17. S2 = A P valves Base Apex S2 S2 S1 S1 = M T valves
S2 (A P) is loudest at the base of the heart, while S1(M T) is loudest at the apex. LET’s listen to Karen reproduce the normal Heart Sounds.
S1 = M T valves
Apex
Adapted from Bickley, Lynn S, Bate’s Guide to Physical Examination and History Taking. Lippincott Williams& Wilkens

18. Normal Splitting of S2 with Inspiration
Expiration
Inspiration
Physiologic splitting, the splitting of the Aortic and Pulmonic components of S2 with inspiration, is frequently present in healthy patients. Inspiration causes an increase in return of blood to the heart (right heart initially), slowing the timing of contraction of the right ventricle and closure of the pulmonic valve .
Think of inspiration as having a vacuum effect on blood in the venous system, increasing the amount of venous blood entering the right heart.
Split S2 with inspiration, heard best with diaphragm near 2nd and 3rd ICS at the LSB
Bickley, Lynn S, Bate’s Guide to Physical Examination and History Taking. Lippincott Williams & Wilkens

19. Quiz
Upon auscultation of heart sounds, where is S2 normally heard the loudest?
Base
Apex
Erb’s Point
2nd the LSB

20. **Answer: B
S2 is loudest at the base of the heart since this sound results from the closure of the Aortic and Pulmonic valves
The pressures on the left side of the heart are higher than on the right, thus the Aortic valve closure sound predominates ( A/P
Base S2 S2
S2= A&P valve closure S1
S2 (A P) is loudest at the base of the heart, while S1(M T) is loudest at the apex. LET’s listen to Karen reproduce the normal Heart Sounds.
S1 = M&T valve closure
Apex
Adapted from Bickley, Lynn S, Bate’s Guide to Physical Examination and History Taking. Lippincott Williams& Wilkens

21. Which of the following best describes the normal splitting of S2?
S2 is split into 2 components with expiration
S2 is split into 2 components with inspiration
Split S2 is heard best at the apex
Split S2 is heard best at the aortic valve region

22. Answer: B
If present, a split S2 is best heard near Erb’s Point (3rd LSB or over the Pulmonic valve area (2nd and
During Inspiration, venous return of blood to the right side of the heart, slows the right-sided physiologic events, causing a delay in the closure of the pulmonic valve.
A Split S2 during expiration is pathological !

23. Abnormal Heart Sounds Discrete sounds: Split S2 (pathological)
Gallops (S3 and S4)
Clicks (ejection)
Snaps (opening)
Continuous sounds:
Murmurs
Friction Rubs
PDA
The Symphony! Listen for just the violin! Just the drums!, Just the harp!
Be sure to take the time to listen in all four valve areas with both the diaphragm and bell, try to stay focused on each individual normal heart sound, listen for the normally quiet spaces between S1 and S2 (Systole), and S2 and S1(Diastole)

24. Paradoxical Splitting
Expiration
Inspiration
Inspiration S2
Expiration 1
Wide splitting 2
Fixed splitting 3
P2 A2
Pathologic Splitting of S2 means that there are two distinct audible components (A and P) during expiration. The split S2 in expiration may also occur in inspiration.
The A and P components of S2 may be due to:
delay of the pulmonic valve closure - Wide splitting (#1 illustration)
Pulmonic Stenosis
Right Bundle Branch Block
early closure of the aortic valve
Mitral Regurgitation
Atrial Septal Defect- Fixed splitting (#2 illustration)
delay in the closure of the aortic valve
Left Bundle Branch Block- Paradoxical splitting (#3 illustration)
S2 is usually a single sound in inspiration with LBBB
Note: S1 may be split in RBBB, and in normal healthy people
Paradoxical Splitting
Adapted from Bickley, Lynn S, Bate’s Guide to Physical Examination and History Taking. Lippincott Williams& Wilkens

25. Ejection Clicks Extra Sounds in Systole:
An Ejection Click is a high pitched, early systolic sound associated with the opening of an abnormal valve, sometimes followed by a murmur
Aortic Stenosis - 2nd R the SB
Pulmonic Stenosis- 2nd L the SB
What physiologic event normally occurs early in Systole?
Bickley, Lynn S, Bate’s Guide to Physical Examination and History Taking. Lippincott Williams& Wilkens

26. Extra Sounds in Diastole:
Snaps
An Opening Snap is a high-pitched diastolic sound associated with the opening of an abnormal valve, sometimes followed by a murmur
Tricuspid valve the LLSB
Mitral valve the apex
What physiologic events normally occur early in Diastole?
Bickley, Lynn S, Bate’s Guide to Physical Examination and History Taking. Lippincott Williams& Wilkens

27. Extra sounds in early in Diastole: Gallops
S3 and S4 are called Gallops, occur in diastole as a result of blood hitting a non-compliant, stiff ventricular wall. These are low-pitched sounds, heard best with the bell near the apex.
S3 is an early diastolic sound (blood passively entering the ventricle) associated with Heart Failure
heard at the LLSB or Apex with Left Heart Failure
heard over the lower sternum/ epigastric area with Right Heart Failure
Note: S3 can be heard normally in children
Early Diastolic Sound: S3
Heard best with the Bell
Bickley, Lynn S, Bate’s Guide to Physical Examination and History Taking. Lippincott Williams& Wilkens

28. Late Diastolic Sound: Gallop
S4 is a late diastolic sound associated with the active ejection of blood from the atria into the ventricles when the atria contract.
S4 may be normal with an enlarged healthy heart in an athletic, or abnormal with ventricular hypertrophy.
Late diastolic sound: S4
Best heard with the Bell
Summation Gallop ( S3+S4)
Bickley, Lynn S, Bate’s Guide to Physical Examination and History Taking. Lippincott Williams& Wilkens

29. Which of the following best describes an ejection click?
Quiz
Which of the following best describes an ejection click?
Occurs early in diastole and is best heard with the diaphragm
Occurs late in diastole and is best heard with the bell
Occurs early in systole and is a high pitched sound
Occurs early in systole and is a low pitched sound
A normal heard sound that occurs when the A&P valves open

30. Answer: C
An ejection click is an abnormal heart sound, classically described as high-pitched, which occurs early in systole, when a stiff aortic or pulmonic valve opens
Systole

31. Identify the Extra Heart Sound !
Is the extra sound continuous (murmur) or discrete(clicks, snaps, split S1or S2, Gallops, rubs)
Is the extra sound in systole or diastole?
Systole (between S1 and S2)
Carotid pulse quickly follows S1
“A” wave (atrial kick) in the JVP is quickly followed by S1
Systole is shorter than diastole
Which valve(A/P/T/M) location do you hear the sound best?
Do you hear it better with the bell or the diaphragm (high [click, snap, split S1 or split S2] or low pitched [S3,S4])?

32. Discrete Sounds A B A B
Which space between the heart sounds represents Systole ?
Which bars represent S1?

33. Extra Sounds Systolic vs. Diastolic
Diastole
Systole S2 S1 S2
“A” wave
Carotid pulse
“V” wave

34. Systolic Extra Sounds Diastole Systole S2  S1 S2
Where heard best? Bell or diaphragm?
Constant or varies with respiration?
Apex/ diaphragm = Split S1

35. Systolic Extra Sounds Diastole Systole S2 S1 S2 Where heard best?
Where heard best?
Bell or diaphragm?
Constant or varies with respiration?
Base / diaphragm = Ej. click (A or P)

36. Diastolic Extra Sounds
Diastole
Systole S2 S2 S1
Where heard best? Bell or diaphragm?
Constant or varies with respiration?
Opening snap (location/pitch) vs. split S2 (location/pitch/varies with respiration) vs. S3 vs. S4 (location/pitch)

37. Causes of Murmurs (turbulent flow)
Partial obstruction
Dilated chamber
Backward flow
Shunting
Increased output or increased stroke volume
Examples:
Partial Obstruction:
Valve Stenosis (AS, PS, MS, TS)
Valve Sclerosis, Bicuspid Aortic Valve
Idiopathic Hypertrophic Subaortic Stenosis
Patent Ductus Arteriosus
Dilated Chamber:
Cardiomyopathy
Backward Flow:
Incompetent valve - Regurgitation / Insufficiency (MR,TR,AR,PR)
Loose chordae tendinae / billowing leaflets (Mitral Valve Prolapse)
Shunting of Blood:
Atrial Septal Defect
Ventricular Septal Defect
Increased Cardiac Output
Hyperthyroidism • Pregnancy
Fever • Anemia

38. Assessment of Murmurs Timing of the murmur Systolic Events
Diastolic Events
S1 _________S2_______________ S1
Systolic Physiologic Events:
Normal Direction of Blood Flow
Ejection through the Aortic and Pulmonic Valves (AS, PS)
Through a septal defect flow from high pressure to lower pressure (ASD, VSD)
Flow against billowing mitral valve leaflets (MVP)
Abnormal Direction of Blood Flow:
Backwards flow through an incompetent valve (MR,TR)
Diastolic Physiologic Events:
flow through the Mitral and Tricuspid valves (MS,TS)
Abnormal Direction of Blood Flow
flow backwards through a leaking incompetent valve ( AR, PR)
Systole
Diastole

39. Location of the Murmur A P T M Best heard where ? Aortic Pulmonic
Tricuspid
Mitral (Apex)
Radiates to where?
R. Neck, L. Neck
L. Axilla
Back
Sound follows the
direction of flow A P T M
Aortic Valve murmurs are heard best at the 2nd R the SB.
Pulmonic Valve murmurs are heard best at the 2nd L SB.
Tricuspid Valve murmurs are heard best at the LLSB.
Mitral Valve murmurs are best heard at the apex ( PMI).
Radiation of the sound follows the path of the flow of blood:
Aortic Stenosis- murmur radiates to the right clavicle or neck.
Pulmonic Stenosis - murmur radiates to the left clavicle or neck.
Mitral Regurgitation - murmur radiates to the left axilla or left scapula
Aortic Regurgitation - murmur radiates downward toward the LLSB and apex

40. Other Qualities of Murmurs
Intensity (Grade I – VI)
Soft to loud (if thrill present, Grade is =/> IV)
Pitch (high, medium, low)
Musical Quality
Rumbling
Cooing
Blowing (Regurgitant murmurs)
Shape (change in intensity)
Crescendo
Decrescendo
Intensity: Graded on a scale of I - VI
Grade I - barely audible; examiner must concentrate to hear this
Grade II - soft, but audible
Grade III - loud
Grade IV - louder and associated with a thrill
Grade V - very loud, it can be heard with the stethoscope head 1/2 off the chest, and is associated with a thrill
Grade VI - so loud it can be heard without a stethoscope
Pitch: High, medium, low determined by which head of the stethoscope hears the murmur best ( low-pitched murmurs heard best with the bell).
In general, flow murmurs are low to medium pitched, regurgitant murmurs are high-pitched
Musical Quality:
Regurgitant murmurs usually described as “ blowing”
Mitral Stenosis- rumbling
MVP- cooing
PDA- machinery-like
Shape :
Crescendo- increasing in intensity
Decrescendo - decreasing in intensity
Crescendo- Decrescendo - increasing then decreasing.

41. Shape Crescendo Decrescendo Crescendo- decrescendo Plateau 1 2 3 4
#3 crescendo-decrescendo ( classic ejection murmur) Aortic and Pulmonic Stenosis
#4 plateau
Plateau
Bickley, Lynn S, Bate’s Guide to Physical Examination and History Taking. Lippincott Williams & Wilkens

42. Factors Changing Murmurs
Respiration (increase venous return with inspiration; ↑ in intensity of the murmurs of T.S. and P.S., but ↓ in intensity with T.R. and P.R.
Exercise (increase flow>>>> increased intensity)
Position
decubitus brings out mitral murmurs
leaning forward brings out the murmur of AR
Valsalva or Standing (decreases venous return)
Squatting (increases venous return)
Maneuvers are often used to differentiate murmurs:
Inspiration increases the intensity of right heart flow murmurs.
Exercise increases the intensity of most murmurs and may help to better assess a soft (low grade) murmur.
Position change
mitral valve murmurs are best heard or only heard in the left lateral decubitus position
the murmur of aortic regurgitation becomes more intense with the patients leaning forward with expiration
innocent murmurs are often heard only with the patient supine
Standing vs. Squatting
Squatting increases the venous return to the heart and increases left ventricular volume
increases the intensity of the murmur of Aortic Stenosis
decreases the intensity of the murmur of IHSS
decreases the intensity of the murmur of MVP, click is delayed, if present, and the murmur is shortened
Standing and the Valsalva maneuver decreases venous return and left ventricular volume
decreases the intensity of AS
increases the intensity of the murmur of IHSS
increases the intensity of the murmur of MVP and moves the click and murmur earlier (lengthens the murmur)

43. Emory University Physician Assistant Program
Physical Exam Pulses
Pulses: : slow and delayed carotid pulse with severe AS; bounding with AR;
Emory University Physician Assistant Program

44. Other PE Clues
Pulses:
bounding carotid pulse (AR)
decreased, delayed carotid pulse(AS)
decreased with outlet obstruction or weak(heart failure)
Pulsus alternans with L.Ventricular failure
Fundus: Roth spots, splinter hemorrhages (Endocarditis)
Lungs: crackles (heart failure)
General: Head bobbing: Severe Aortic Regurgitation
BP: Wide pulse pressure ( Systolic-Diastolic > 40 ): Aortic Regurgitation
Narrow pulse pressure ( Systolic- Diastolic < 40: Aortic Stenosis
JVP abnormalities:
Tricuspid Stenosis may be associated with a giant “a” wave
Tricuspid Regurgitation may be associated with a large “v” wave
JVP may be elevated with Pulmonic Stenosis
JVP elevated with Left Heart Failure, with some Cardiomyopathies, and with Constrictive Pericarditis
Pulses: delayed upstroke or diminished intensity of the Carotid pulse may be a clue to AS.
Bisferiens pulse (double systolic peak) is seen with Hypertrophic Cardiomyopathy, and AR.
Pulsus Alternans (pulse amplitude varies beat to beat) is seen with left ventricular failure.
Bounding, Corrigan’s or Water hammer carotid pulse: AR
Diminished femoral pulse or radial-femoral pulse delay and BP lower in the legs than in the arms may be seen with Coarctation of the aorta.
Paradoxical Pulse: Decrease in pulse amplitude on inspiration and/or decrease in systolic BP > 10 mm Hg with inspiration is seen in cardiac tamponade, constrictive pericarditis
Fundus: Only place to directly visualize blood vessels; Roth spots with endocarditis
Lungs: Crackles and wheezing with heart failure (Cardiomyopathy)
Skin and extremities: edema with heart failure, petechiae in the skin and nails, Janeway lesions and Osler nodes with Endocarditis
Abdomen: hepatomegaly and pulsatile liver may be due to Right Heart Failure

45. Emory University Physician Assistant Program
Physical Exam: Pulses
Paradoxical pulse with constrictive percarditis/tamponade
Femoral pulse delay and BP in legs < in arms (Coarctation of the aorta)
Rib notching
Emory University Physician Assistant Program

46. Emory University Physician Assistant Program
Physical Exam
Skin, Nails
Nail clubbing (chronic hypoxia)
Petechiae, splinter hemorrhages – Endocarditis
Osler’s nodes- finger tips - Endocarditis
Janeway lesions- palms and soles- Endocarditis
Pedal edema- Right heart failure
Janeway Lesion
Osler Node
aapredbook.aappublications.org
Emory University Physician Assistant Program

47. Other PE Clues General appearance: Vitals: Jugular veins:
Tall, thin with long limbs (Marfan’s);
Willowy, thin chest wall (Mitral Valve Prolapse)
Head bobbing (Severe AR)
Pale (Anemia)
Blue (anoxia with congenital heart defects)
Vitals:
Low BP with dehydration, Severe Heart Failure, MI
Pulse pressure wide (AR); narrow(AS)
Tachycardia with infection
Bradycardia with AV blocks
Jugular veins:
distended, elevated JVP (R heart failure, PericardialTamponade)
Giant A wave (TS)
Large v wave (TR)
Point of maximal intensity(PMI):
enlarged, displaced, hyperdynamic, sustained (L. Heart Failure, LVH, AS, AR, MR)
General: Head bobbing: Severe Aortic Regurgitation
BP: Wide pulse pressure ( Systolic-Diastolic > 40 ): Aortic Regurgitation
Narrow pulse pressure ( Systolic- Diastolic < 40: Aortic Stenosis
JVP abnormalities:
Tricuspid Stenosis may be associated with a giant “a” wave
Tricuspid Regurgitation may be associated with a large “v” wave
JVP may be elevated with Pulmonic Stenosis
JVP elevated with Left Heart Failure, with some Cardiomyopathies, and with Constrictive Pericarditis
Pulses: delayed upstroke or diminished intensity of the Carotid pulse may be a clue to AS.
Bisferiens pulse (double systolic peak) is seen with Hypertrophic Cardiomyopathy, and AR.
Pulsus Alternans (pulse amplitude varies beat to beat) is seen with left ventricular failure.
Bounding, Corrigan’s or Water hammer carotid pulse: AR
Diminished femoral pulse or radial-femoral pulse delay and BP lower in the legs than in the arms may be seen with Coarctation of the aorta.
Paradoxical Pulse: Decrease in pulse amplitude on inspiration and/or decrease in systolic BP > 10 mm Hg with inspiration is seen in cardiac tamponade, constrictive pericarditis
Fundus: Only place to directly visualize blood vessels; Roth spots with endocarditis
Lungs: Crackles and wheezing with heart failure (Cardiomyopathy)
Skin and extremities: edema with heart failure, petechiae in the skin and nails, Janeway lesions and Osler nodes with Endocarditis
Abdomen: hepatomegaly and pulsatile liver may be due to Right Heart Failure

48. Emory University Physician Assistant Program
Physical Exam JVP
JVP reflects RA pressure : ↑ JVP with R. Heart Failure, Constrictive Pericarditis, Cardiac Tamponade;
Large A wave-with Tricuspid Stenosis, large V wave with Tricuspid Regurgitation
Emory University Physician Assistant Program

49. Emory University Physician Assistant Program
Physical Exam
Abdomen
(ascites , pulsatile liver, hepatomegaly- R Heart Failure)
Extremities –
pedal/lower extremity edema(R heart failure), pale distally (Arterial Insufficiency)
Emory University Physician Assistant Program

50. Quiz Which of the following valve abnormalities may cause an enlarged displaced PMI
Mitral Stenosis
Pulmonic Stenosis
Aortic Stenosis
Tricuspid Stenosis
Ventricular Septal Defect

51. Answer: C
Aortic Stenosis will cause left ventricular hypertrophy, enlarging (>2.5 cm) and displacing the PMI leftward and inferiorly from the normal location (L. 5th ICS MCL)
Mitral Stenosis will enlarge the left atrium
Pulmonic Stenosis will enlarge the right ventricle (sternal lift)
Tricuspid Stenosis will enlarge the right atrium and cause abnormalities (elevated, giant “A” wave) of the JVP
VSD causes enlargement of the right ventricle due to the higher pressures in the left ventricle resulting in a left to right shunting of blood and eventually RVH. (sternal lift)

52. Systolic Murmurs Innocent and Physiological Murmurs
Anemia, Pregnancy, Fever, Hyperthyroidism
Normal Flow Direction through valves
Aortic and Pulmonic Stenosis
Idiopathic Hypertrophic Subaortic Stenosis
Holosystolic Murmurs
Backward Flow through incompetent valves or a Ventricular septal defect
Mitral and Tricuspid Regurgitation
Ventricular Septal Defect
Backward flow around billowing valve leaflets; but closed valve
Mitral Valve Prolapse
Try to Categorize the Murmur:
Systolic:
Normal flow direction (AS, PS, IHSS )- “ejection” murmur
Pansystolic (MR, TR, VSD) - heard through out systole
backwards flow against a flaccid, but competent valve (MVP)
- crescendo murmur
Diastolic:
Normal flow direction
Abnormal direction of flow

53. Systolic Murmurs Low-grade flow murmurs
Still’s murmur (innocent): child usually 3-6 years, mid-systolic, vibratory, heard at left sternal border to apex, disappears or ↓ with sitting/standing
Innocent Murmurs tend to be soft (low grade), ejection-type in shape, heard best along the left sternal border, and in the supine position, and should not be associated with any abnormal exam findings.
Physiologic Murmurs are ejection-type in shape. Look for other objective clues such as thyroidmegaly, pale conjunctiva, elevate temperature.
Adapted from: Bickley, Lynn S, Bate’s Guide to Physical Examination and History Taking. Lippincott Williams& Wilkens

54. Best heard at the Aortic area; Ejection shaped murmur,
radiates to the right clavicle/ neck;
May have EjCl, Narrowed Pulse Pressure, diminished delayed carotid upstroke, S4
PMI abnormalities
AS is classically:
a systolic ejection murmur, sometimes preceded by an Ejection click
best heard at the aortic region
described as harsh
radiates to the right neck
may be associated with a narrow pulse pressure
may be associated with a delayed upstroke of the carotid pulse, or diminished
may be associated with and enlarged, displaced PMI
may have an S4, if significant hypertrophy results
DDX:
IHSS- squatting may decrease the intensity of this murmur; valsalva and standing may increase the intensity of this murmur
Aortic Sclerosis - usually no other abnormal objective findings; more common in the elderly
Adapted from: Bickley, Lynn S, Bate’s Guide to Physical Examination and History Taking. Lippincott Williams& Wilkens

55. Split S2 with Inspiration
Best heard at the Pulmonic area, ejection type murmur, radiates to the left neck, ↑ in intensity with inspiration
Might have: Ej Cl over the pulmonic area, right-sided S4, sternal lift, JVP abnormalities
PS is classically:
a systolic ejection type murmur, sometimes proceeded by an Ejection click
heard best at the pulmonic region
described as harsh
radiates to the left neck
if severe, may be associated with a sternal lift and a right-sided S4
if severe, may be associated with an elevated JVP
murmur should increase in intensity with inspiration
Split S2 with Inspiration
Bickley, Lynn S, Bate’s Guide to Physical Examination and History Taking. Lippincott Williams& Wilkens

56. IHSS subaortic hypertrophy
Idiopathic Hypertrophic Subaortic Stenosis: An area of the ventricular septum located just beneath the aortic valve that can cause turbulent flow of blood and/or partial obstruction of blood flow out the aortic valve. The murmur is systolic and will vary in intensity with the volume of blood and the degree with which the septum is stretched.
From: Mosby’s Guide to Physical Examination Seidel H, Ball J.Dains J, Benedict GW

57. Other generalized Cardiomyopathies
Google images

58. The intensity of this murmur increases with the valsalva!
IHSS:
sounds like AS ( ejection-type, best heard near aortic region)
increases with Valsalva and standing ( hypertrophic area bulges with less blood volume, causing more obstruction) , decreases with squatting
The intensity of this murmur increases with the valsalva!
Bickley, Lynn S, Bate’s Guide to Physical Examination and History Taking. Lippincott Williams& Wilkens

59. Other Systolic Murmurs
mitral valve leaflets
Backward direction of flow at a competent mitral valve, but the mitral leaflets billow
Mitral valve prolapse
Click-murmur or
Click alone or
Murmur alone
Confirm by auscultating over the Mitral region while standing and squatting, or change with the valsalva maneuver
Valsalva/Standing lengthens the murmur;
Squatting shortens it
chordae tendinae
MVP classically:
is associated with a high pitched click, followed by a systolic, crescendo murmur, heard best in the mitral region.
Valsalva and standing moves the click or click/murmur earlier in systole, lengthening the murmur; squatting delays the click/murmur.

60. Holo/Pansystolic Murmurs
Mitral Regurgitation (Apex, radiates to the L. axilla or scapula)
Tricuspid Regurgitation (LLSB, JVP abnormalities)
Ventricular Septal Defect (lower sternum, Sternal lift)
Pansystolic = Holosystolic

61. radiation radiation Apex R sided
Mitral Regurgitation classically:
is a pansystolic murmur
heard best at the apex, sometimes only in the decubitus position
“blowing” in quality
radiates to the left axilla
may be associated with PMI abnormalities, +S4
may develop quickly S/P MI ( papillary muscle rupture)
R sided
M&T areas close together, Both are “blowing”! Radiation direction!
Bickley, Lynn S, Bate’s Guide to Physical Examination and History Taking. Lippincott Williams& Wilkens

62. +/- Sternal lift R-sided S4 Ventricular Septal Defect classically:
is a pansystolic murmur
heard best over the lower sternum
harsh in quality
radiates widely
may be associated with a sternal lift
may be associated with a right sided S4
intensity decreases with inspiration and squatting
Note: The intensity of the murmur and the size of the defect do not correlate!
R-sided S4
Bickley, Lynn S, Bate’s Guide to Physical Examination and History Taking. Lippincott Williams& Wilkens

63. Which of the following conditions would cause a holosystolic murmur?MS AS
ASD MR AR

64. Answer: D Holosystolic murmurs include: Tricuspid Regurgitation
Mitral Regurgitation
Ventricular Septal Defect

65. Diastolic Murmurs Possibilities during ventricular filling:
Normal direction of flow through narrowed valves
Mitral and Tricuspid Stenosis
Backward flow through incompetent valves
Aortic and Pulmonic Insufficiency M T P A

66. Compare to Tricuspid Stenosis!
Diastolic Decrescendo- Crescendo Murmur +/- Opening Snap
Mitral Stenosis classically:
is a decrescendo-crescendo diastolic murmur, sometimes preceded by an Opening Snap
murmur is low-pitched (heard best with the bell)
heard better in the left decubitus position, sometimes only heard in this position
Tricuspid Stenosis classically:
is a low-pitched murmur
heard best at the LLSB
intensity of the murmur increases with inspiration and squatting
may be associated with a giant “a” wave
Compare to Tricuspid Stenosis!
Both have low-pitched murmurs, may have an OS
TS: murmur ↑ with inspiration/squatting, +/- giant A wave
Bickley, Lynn S, Bate’s Guide to Physical Examination and History Taking. Lippincott Williams& Wilkens

67. Diastolic Decrescendo Murmur
Aortic Regurgitation classically:
is a decrescendo diastolic blowing murmur
best heard in the aortic region
radiates downward toward the apex
increases in intensity with leaning forward ( have patient exhale and hold their breath)
may be associated with an S4; may cause heart failure eventually (+S3)
PMI usually enlarged, displaced
associated with a wide pulse pressure
may be associated with a bounding “waterhammer” carotid pulse
in severe cases the patients head may bob
Pulmonic Regurgitation classically:
best heard in the pulmonic region
may have an associated sternal lift, left sided S4
decreases in intensity with inspiration
Blowing murmur, heard from Aortic area to the apex, S4,+/- S3, PMI abnormalities, wide pulse pressure, bounding or pulsus alterans of the carotid pulse, +/- head bobbing. Murmur may intensify as the patient leans forward and exhales
Bickley, Lynn S, Bate’s Guide to Physical Examination and History Taking. Lippincott Williams& Wilkens

68. Sounds heard in both Systole and Diastole
Pericardial Friction Rub
Patent Ductus Arteriosus
Venous Hum
Other auscultated precordial sounds may be misinterpreted as murmurs as they will be heard in systole and diastole

69. High pitched, scratchy, LLSB & apex, 3 components (2 in diastole), best heard with patient leaning forward
Pericardial Friction Rub:
is high-pitched (best heard with the diaphragm) and “scratchy”
usually heard along the left sternal border and apex
heard best with the patient leaning forward
characterized by 3 components occurring as the heart and pericardium come in contact
Bickley, Lynn S, Bate’s Guide to Physical Examination and History Taking. Lippincott Williams& Wilkens

70. PDA Machinery like, in neonates, S2 may be masked
Patent Ductus Arteriosus is:
usually found in neonates
has crescendo systolic and decrescendo diastolic components that mask S2
usually described as harsh and “machinery-like”
heard best in the pulmonic region
may radiate to the left clavicle
Bickley, Lynn S, Bate’s Guide to Physical Examination and History Taking. Lippincott William s& Wilkens

71. Continuous hum heard over the Jugular vein above the clavicle; sound disappears when the Jugular is compressed
A venous hum may initially be misinterpreted as a heart murmur thought to radiate to the neck, when the neck is auscultated before the heart.
is continuous
heard best above the clavicle over the jugular vein (could be bilateral)
disappears with pressure over the jugular vein
Bickley, Lynn S, Bate’s Guide to Physical Examination and History Taking. Lippincott Williams& Wilkens

72. Quiz
You hear this extra systolic sound clearly at the 2nd & 3rd left ICS with the diaphragm, but only with inspiration. ____
2. You hear this extra early diastolic sound only with bell at the apex in both inspiration and expiration in a healthy child._____
You auscultate an ejection murmur at the 2nd ICS RSB, which radiates to the right neck. What is the timing of the murmur ?
The intensity of a systolic murmur heard best at the 2nd ICS RSB seems to increase during the Valsalva maneuver. What is the likely heart abnormality? _____________

73. Answers
1. Physiologic Split S2 2. S3 3. Systole 4. IHSS Note: Aortic Stenosis is also best heard at the 2nd ICS of the RSB, radiates to the right neck. valsalva maneuver decreases the blood flow back to the heart including to the Left Ventricle, ↓ ing the intensity of the murmur of AS, but ↑ ing the murmur of IHSS (area of hypertrophy bulges into the outflow tract causing turbulence

74. Case Presentations 33 y. o. pregnant female with a new systolic murmur
Grade 2/6
mid-peaking ejection murmur
heard best at the left sternal border
unchanged during respiration
no other abnormal heart findings
KEY CLUES
The female accountant
PMI displaced leftward (big left ventricle)
paradoxical split (LBBB)
presystolic sound is low pitched (+S4)
harsh crescendo-decrescendo systolic murmur at the aortic region
radiates to the R neck
IV drug abuser
fever, skin petechiae
+ sternal lift (RVH)
blowing systolic murmur at LLSB (Tricuspid area)
decreases in intensity with inspiration (left heart problem,backward flow)
JVP abnormalities, large “v” wave

75. Physiological Murmur
Increase blood volume and flow through the aortic valve with pregnancy

76. 26 y.o. I.V. drug abuser with fever and a new systolic murmur
AS, PS
MR, TR (holosystolic), VSD
MVP
Fever suggests infection! Look for Roth spots, petechea, splinter hemorrhages, Osler nodes, Janeway lesions
Drug abuse most commonly effects Right heart valves ( T/P) ( forward or backward flow?)
The murmur increases with inspiration, is heard best at 2nd LICS at the SB, radiates to the Left clavicle/neck and is mid-peaking

77. Pulmonic Stenosis

78. 18 y.o. basketball “phenom” with episodes of C/P associated with palpitations, SOB. You auscultate a systolic murmur !
Systolic Murmur
AS, PS
MR, TR ( holosystolic), and MVP
You wisely auscultate at the apex and hear a click-murmur. You have the patient squat and the murmur decreases in intensity and shortens. Upon standing the murmurs gets louder and longer.
Q: Would you like to order any additional test?

79. Symptomatic Mitral Valve Prolapse

80. Neonate with a Holosystolic murmur
Three causes of Holosystolic/Pansystolic Murmurs
MR (Heard best at the Mitral valve(apex) area, radiates to __?; may have an S4 and enlarged PMI)
TR (Heard best at the Tricuspid area, decreases in intensity with inspiration) Check the JVP for elevation, large “v” wave
VSD (radiates widely across the sternum, may have a sternal lift)

81. In a Neonate, VSD is most common !
Note:
The size of the defect does not correlate with the intensity of the murmur

82. Mr. N. Trouble
S: 64 y.o. homeless man with a history of worsening chest pain and DOE for the last 3 months. He has developed a nonproductive cough and orthopnea without fever. O: On PE of the heart you note: an enlarged, hyperdynamic PMI displaced inferiorly and leftward, a thrill over the apex, an S4, S3,and a grade IV/VI holosystolic murmur, heard best with the diaphragm at the apex.
Mr. Runamuck
enlarged PMI
holosystolic/pansystolic, best heard at the apex DDX: MR, TR, VSD (all pansystolic)
TR and VSD would not enlarge the PMI .Check to see if the murmur radiates to the left axilla

83. Mr. N. Trouble A: D.Dx. MR, TR, VSD
Clues on history : homeless, C/P with DOE, orthopnea and nonproductive cough
Clues on physical exam: LVH, at least a Grade IV/VI holosystolic/pansystolic murmur heard best at the apex.
Which of the three valves abnormalities in your D.Dx is most likely, and what condition is the result of the valve problem?
Mr. Runamuck
enlarged PMI
holosystolic/pansystolic, best heard at the apex DDX: MR, TR, VSD (all pansystolic)
TR and VSD would not enlarge the PMI .Check to see if the murmur radiates to the left axilla

84. Auscultate at the axilla to confirm!
Mitral Regurgitation
Auscultate at the axilla to confirm!
He has developed CHF.

85. Helpful Web Resources
- Murmurs
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