GP Teaching

8/3/2019 GP Teaching

http://slidepdf.com/reader/full/gp-teaching 1/42

Heart murmurs

Kiran Dhaliwal



Contents

• Introduction to heart murmurs• Normal heart sounds• Classification of murmurs

• Commonest types of valvular diseaseand associated heart murmurs

– Causes – Signs and symptoms

– Investigations and treatment• How to examine a patient with a

murmur• Quiz



What is murmur?

• An abnormal sound heard duringthe cardiac cycle.

(Mayo Clinic)

• Caused by turbulence of blood flowwhich occurs when the velocity of the blood is disproportionate to the

size of the orifice it is movingthrough

(Cardiology Crash Course)



Normal heart sound



Classification of murmurs



Classification of murmurs





Classicisation of murmurs

• Systolic

– Ejection systolic

– Pansystolic

• Diastolic

– Early distolic

– Mid-distolic

• Continuous

–



Grading heart murmurs





Ejection systolic murmurs

• Cresendo-decresendo systolicmurmur



Heart valve pathology

• Mitral valve disease

– Mitral stenosis

– Mitral regurgitation

• Aortic valve disease

– Aortic stenosis

– Aortic reurgitation

–



• Causes

• Signs and symptoms

•

Examination – Pulse

– Blood pressure

– Palpation (apex beat)

– Ausultation



Aortic stenosis

• What type of murmur does itproduce?

• What would it look like?

•



Causes of aortic stenosis

• Senile degeneration of aortic valve

• Rheumatic aortic stenosis

•

Calcification of bicuspid valve• Congenital



Signs and symptoms of aorticstenosis

Triad of symptoms

Dizziness

SOB

Chest pain

Symptoms

• Mild or moderateaortic stenosis is

usuallyasymptomatic

• Sudden death

•

Episodes of acutepulmonaryoedema

•



Examination

• Pulse

– Reduced volume

– Slow rising pulse

• Blood pressure

– Narrow pulse pressure

• Palpitation

– Heaving non-displaced apex beat



Ausculatation

• Ejection systolic murmur

• Loudest in aortic region

•

Radiates into the carotids•



Aortic regurgitation

Clinical features

• Collapsing pulse

• Wide pulse pressure

• Austin flint murmur

• Diastolic murmur

• High pitched

• Best heard with



Causes of aorticregurgitation



Signs and symptoms of aorticstenosis

• Fatigue

• Dyspnoea



Examination

• Pulse

– Large volume

– Collapsing pulse

• Blood pressure

– Wide pulse pressure

• Palpation

– Displaced, heaving apex beat



Auscultation

• Early diastolic murmur

• Blowing

•

High pitched (listen with diaphragm)• Loudest in left sternal edge of 4th

intercostal space)



Mitral stenosis

• Malar flush

• Atrial fibrilation (if severe)

• Tapping displaced apex beat

•



Causes of mitral stenosis



Mitral regurgitation



Causes of mitralregurgitation

• Rheumatic fever (50%)

• SLE

• Ischemic heart disease

• Drugs

– Appetite suppresants

• Fenfluramide

– dopamine agonists

• Cabergoline

•



Other types of murmurs

• Info included in handout



Examination

• Inspection – Scars

– Heave

–

Hands• Peripheral stigmata of infective

endocarditis

• Cardiovasular system examination –

Pulse – Blood pressure

– JVP

• Ausulatation



Auscultation



Examination

• Palpation

– Thrills



Examination of a patient

• Does the patient have any signs of valve disease

• Does the patient have a murmur

– Describe murmur

– Timing

– Radiation



Review of patient



10 minutes





1. What murmur is this?

• Audio clip



2.

• A patient reports SOB on exertion,which gradually becomes moresevere

• PMH: Rheumatic fever as a child

• On examination they have AF




• Audio clip



4.

• On examination a patient has a lowvolume pulse with a small pulsepressure

• A systolic thrill is palpable at theapex over the aortic area




• Audio clip




• Audio clip



Summary

Documents

GP Teaching