> For the complete documentation index, see [llms.txt](https://thisispiggy.gitbook.io/my-wiki/llms.txt). Markdown versions of documentation pages are available by appending `.md` to page URLs; this page is available as [Markdown](https://thisispiggy.gitbook.io/my-wiki/01-step-1/cardiology/22-heart-murmurs.md).

# 22 Heart Murmurs

## Overview

[\_](https://github.com/thisispiggy/my-wiki/tree/601ff771dc2fac1318ae8b59435ac8485628fd81/01%20Step%201/Cardiology/heart%20auscultation%20locations%20and%20murmurs%20overview.%20Heart%20base%20and%20apex)..

![](https://f001.backblazeb2.com/file/wikiFiles/TI8l8Nt.jpg)

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

![](https://f001.backblazeb2.com/file/wikiFiles/WfnXvpZ.jpg)

![](https://f001.backblazeb2.com/file/wikiFiles/55AC82F8-254A-4528-B383-1BF0CF35F697.jpg)

![](https://f001.backblazeb2.com/file/wikiFiles/PTGSauU.jpg)

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

[\_](https://github.com/thisispiggy/my-wiki/tree/601ff771dc2fac1318ae8b59435ac8485628fd81/01%20Step%201/Cardiology/laminar%20vs%20turbulent%20flow%20areas,%20speed/README.md)..

![](https://f001.backblazeb2.com/file/wikiFiles/hLnrSdf.jpg)

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

[\_](https://github.com/thisispiggy/my-wiki/tree/601ff771dc2fac1318ae8b59435ac8485628fd81/01%20Step%201/Cardiology/murmur%20types%20and%20grades/README.md)..

![](https://f001.backblazeb2.com/file/wikiFiles/4acfpX1.jpg)

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

![](https://f001.backblazeb2.com/file/wikiFiles/WfnXvpZ.jpg)

![](https://f001.backblazeb2.com/file/wikiFiles/pn32BEy.jpg)

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

[\_](https://github.com/thisispiggy/my-wiki/tree/601ff771dc2fac1318ae8b59435ac8485628fd81/01%20Step%201/Cardiology/systolic%20and%20diastolic%20murmur%20causes/README.md)..

![](https://f001.backblazeb2.com/file/wikiFiles/3JQaxk9.jpg)

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

![](https://f001.backblazeb2.com/file/wikiFiles/xob2d98.jpg)

![](https://f001.backblazeb2.com/file/wikiFiles/WfnXvpZ.jpg)

[\_](https://github.com/thisispiggy/my-wiki/tree/601ff771dc2fac1318ae8b59435ac8485628fd81/01%20Step%201/Cardiology/functional%20murmur%20are,%20causes/README.md)..

![](https://f001.backblazeb2.com/file/wikiFiles/qooJig0.jpg)

* stills: heard in children, all normal murmurs

## Aortic Stenosis

[\_](https://github.com/thisispiggy/my-wiki/tree/601ff771dc2fac1318ae8b59435ac8485628fd81/01%20Step%201/Cardiology/aortic%20stenosis%20murmur%20characteristics/README.md)..

![](https://f001.backblazeb2.com/file/wikiFiles/xTnruji.jpg)

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

![](https://f001.backblazeb2.com/file/wikiFiles/7013AD5F-A84E-4A01-A18D-D700470B8540.jpg)

![](https://f001.backblazeb2.com/file/wikiFiles/E24F6B18-E698-4A91-8393-6A3D50186A04.jpg)

## Aortic Regurgitation

[\_](https://github.com/thisispiggy/my-wiki/tree/601ff771dc2fac1318ae8b59435ac8485628fd81/01%20Step%201/Cardiology/aortic%20regurg%20characteristics/README.md)..

![](https://f001.backblazeb2.com/file/wikiFiles/8MoyXbc.jpg)

![](https://f001.backblazeb2.com/file/wikiFiles/f0G3j3U.jpg)

## Mitral Regurgitation

[\_](https://github.com/thisispiggy/my-wiki/tree/601ff771dc2fac1318ae8b59435ac8485628fd81/01%20Step%201/Cardiology/mitral%20regurg%20characteristics/README.md)..

![](https://f001.backblazeb2.com/file/wikiFiles/zV5yawm.jpg)

## Mitral Stenosis

[\_](https://github.com/thisispiggy/my-wiki/tree/601ff771dc2fac1318ae8b59435ac8485628fd81/01%20Step%201/Cardiology/mitral%20stenosis%20characteristics/README.md)..

![](https://f001.backblazeb2.com/file/wikiFiles/r5fiQxJ.jpg)

* 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

[\_](https://github.com/thisispiggy/my-wiki/tree/601ff771dc2fac1318ae8b59435ac8485628fd81/01%20Step%201/Cardiology/tricuspid,%20pulmonic%20murmurs%20characteristics,%20differences%20from%20left%20side,%20causes/README.md)..

![](https://f001.backblazeb2.com/file/wikiFiles/ti5utmU.jpg)

* 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

![](https://f001.backblazeb2.com/file/wikiFiles/oCe24HY.jpg)

* 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

![](https://f001.backblazeb2.com/file/wikiFiles/icnP76H.jpg)

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

![](https://f001.backblazeb2.com/file/wikiFiles/EgzwBgs.jpg)

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

### Carcinoid

[\_](https://github.com/thisispiggy/my-wiki/tree/601ff771dc2fac1318ae8b59435ac8485628fd81/01%20Step%201/Cardiology/carcinoid%20heart%20disease%20pathogenesis,%20diagnosis,%20symptoms/README.md)..

![](https://f001.backblazeb2.com/file/wikiFiles/KsrOT5H.jpg)

![](https://f001.backblazeb2.com/file/wikiFiles/KpDvcTP.jpg)

* only if met to liver to not be metabolized

![](https://f001.backblazeb2.com/file/wikiFiles/BKoJj5Z.jpg)

## VSD

[\_](https://github.com/thisispiggy/my-wiki/tree/601ff771dc2fac1318ae8b59435ac8485628fd81/01%20Step%201/Cardiology/VSD%20murmur%20cause,%20symptoms,%20characteristics/README.md)..

![](https://f001.backblazeb2.com/file/wikiFiles/sleNxCY.jpg)

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

![](https://f001.backblazeb2.com/file/wikiFiles/WfnXvpZ.jpg)

[\_](https://github.com/thisispiggy/my-wiki/tree/601ff771dc2fac1318ae8b59435ac8485628fd81/01%20Step%201/Cardiology/3%20causes%20of%20holocystolic%20murmurs/README.md)..

![](https://f001.backblazeb2.com/file/wikiFiles/BTFqlJh.jpg)

![](https://f001.backblazeb2.com/file/wikiFiles/WfnXvpZ.jpg)

## PDA

[\_](https://github.com/thisispiggy/my-wiki/tree/601ff771dc2fac1318ae8b59435ac8485628fd81/01%20Step%201/Cardiology/PDA%20characteristics/README.md)..

![](https://f001.backblazeb2.com/file/wikiFiles/RrJ9OV4.jpg)

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

![](https://f001.backblazeb2.com/file/wikiFiles/WfnXvpZ.jpg)

## Maneuvers

[\_](https://github.com/thisispiggy/my-wiki/tree/601ff771dc2fac1318ae8b59435ac8485628fd81/01%20Step%201/Cardiology/inspiration,%20expiration%20and%20murmurs/README.md)..

![](https://f001.backblazeb2.com/file/wikiFiles/rufovAA.jpg)

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

[\_](https://github.com/thisispiggy/my-wiki/tree/601ff771dc2fac1318ae8b59435ac8485628fd81/01%20Step%201/Cardiology/different%20maneuvers%20with%20murmurs/README.md)..

![](https://f001.backblazeb2.com/file/wikiFiles/5zsskT8.jpg)

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

![](https://f001.backblazeb2.com/file/wikiFiles/VhX1PWM.jpg)

* 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

![](https://f001.backblazeb2.com/file/wikiFiles/JZxQGqs.jpg)

* 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

![](https://f001.backblazeb2.com/file/wikiFiles/gm4JAv8.jpg)

![](https://f001.backblazeb2.com/file/wikiFiles/1BFFB59A-DEB9-42E0-A560-2E5E6301FB62.jpg)

![img](http://www.uworld.com/media/L22506.jpg)

[\_](https://github.com/thisispiggy/my-wiki/tree/601ff771dc2fac1318ae8b59435ac8485628fd81/01%20Step%201/Cardiology/clues%20to%20diagnosing%20murmurs/README.md)..

![](https://f001.backblazeb2.com/file/wikiFiles/GCgtXR8.jpg)

* important