this is where we would need to actually comment on those murmurs and JVP findings, if we haven't already memorized everything about them (I know I haven't.)
murmurs
murmurs are reported according to their 4 main properties.
- timing
- site and radiation
- loudness and pitch (grading if possible)
- relationship to posture and respiration
the 4 characteristics will help us in determining just what kind of problem (usually valvular) are there, in the heart.
how do we know what is a systolic and diastolic murmur?
we palpate the carotid, for the pulsation. the heart sound that corresponds / occurs simulataneously with the pulsation is the S1, and any murmur that occurs between S1 and S2, is a systolic murmur.
now that we know what is systolic and what is diastolic, lets say the patient has a systolic murmur.
let us come up with a DD of a systolic murmur.
- pansystolic
- VSD
- Tricuspid regurgitation
- mitral regurgitation
- ejection systolic
- pulmonary stenosis
- aortic stenosis
- HOCM
- fever / fit, young adults
- late systolic
- tricuspid regurgitation
- mitral regurge
- prolapsed valve
- mitral Valve Prolapse
so how do we narrow this down?
is is through the other maneuvers you could do, and also radiation.
systolic murmur
systolic murmur
- pansystolic murmur (1st and 2nd heart sounds cannot be heard separately in all areas)
- is it left side (mitral regurge) or right (pulmonary regurge)? how to determine that?
- ask patient to breath in and out deeply
- a left-sided murmur (MR) will INCREASE in intensity with EXPIRATION as the venous return is reduced (as we breathe out, the intrathoracic pressure go down - making it easier for the left heart to pump blood)
- confirmed with M shaped P wave on ECG, and Echo.
- a right sided murmur (PR) will INCREASE in intensity with INSPIRATION as the venous return is increased (as we breathe in, intrathoracic pressure rises - pushing more blood into right heart)
- VSD will have no radiation - the murmur is heard throughout the precordium.
- confirmed by Echo and ECG - Right axis deviation & RBBB
- mid-systolic murmur (between S1 and S2, but both heart sounds heard clearly apart)
- Aortic stenosis
- cold extermities
- slow-rising pulse
- low BP
- low Pulse pressure
- HOCM
- JVP has high a wave,
- thrillss and murmur at left sternal edge
- Aortic sclerosis
- more common in elderly with Atherosclerosis
- plumonary high flow
- typical in young women
- benign if no pulmonary hypertension
- ASD
- pulmonary stenosis
- low pulse
- increased JVP
- left parasternal heave
diastolic murmur
- mitral stenosis
- tapping apex
- rumbling in character
- mireal stenosis with pliable valve
- opening snap
- aortic regurgitation
- increased BP
- increased pulse pressure
- collapsing pulse
- displaced apex
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