case presentations of cardiac murmers

1. Differential Diagnosis of
Cardiac Murmers
HAIFA ALSHWIKH

2. Heart murmurs are sounds during your
heartbeat made by turbulent blood in the
heart

4. Ejection systolic murmers
Aortic stenosis
Pulmonary stenosis
HOCM
Pansystolic murmers
Mitral regurgitation
Tricuspid regurgitation
VSD
Early diastolic murmers
Aortic regurgitation
Pulmonary regurgitation
Mid diastolic murmer
Mitral stenosis
Tricuspid stenosis

5. Case 1
You are seeing 76 yrs old patient in medical ward who is
complaining of dyspnea and anginal chest pain , on examination
his BP 120/100 ( narrow pulse pressure ), pulse rate 78 , regular
low volume with slow rising character , JVP is not raised ,
on examining precordium : the apex is undisplaced with a heaving
character , there is a palpable systolic thrill at the aortic area , on
ascultation the 1st heart sound was normal , the 2nd heart sound
was soft , there is a ejection systolic murmer which is loudest at
aortic area radiating to carotids.

6. ECG

7. Chest x ray

8. Whats the diagnosis ?
AORTIC STENOSIS
What are the causes of AS ?
Aging (degenerative changes )
Rehumatic HD
Congenital( Bicuspid AV)
What are the complication of AS ?
Syncope
Sudden death
LV failure
Infective endocarditis

9. What are the indication of aortic valve replacement ?
1-Symptomatic patient :
(angina , chest pain , dyspnea , syncope )
2-Aortic valve pressure gradiant > 50 mmhg

10. Case 2
your patient is 65 years adult who is having dyspnea , his pulse is 90
bpm regular , large volume with collapsing character , BP 160 60
( wide pulse pressure ) , there is visible carotid pulsation in the
neck ( corrigan sign ) , JVP is not elevated
on examining precordium , apex displaced and thrusting in charcter
, no heaves or thrill , on ascultation the 1st and 2nd heart sounds
were normal , there is an early diastolic murmer at left sternal
edge loudest when patient is sitting forward in expiration , lung
bases are clear , no lower limbs odema

11. Whats your diagnosis ?
AORTIC REGURGITATION
What are the causes of aortic regurgitation ?
Bicuspid AV
Rehumatic heart disease
Aortitis ( syphilis , ankylosing spondylitis , psoriatic aortitis )
Aortic dissection

12. management of aortic regurgitation ?
Asymptomatic
should be treated medically by diuretics , ACE and annual
echocardiography
Indication of aortic valve replacement :
1-Symptomatic patient
2-echocardiography criteria's :
EF < 60 %
End systolic LV diameter > 55 mm

13. Case 3
You have been asked to examine a 32 years old man in cardiology
department who admitted because of palpitation and
hemoptysis , his face looked flushed (malar flush ) , PR 84
irregular irregular with normal volume and character ,
on examine precordium the apex was undisplaced with tapping
character , no heaves or thrills , on ascultation the 1st heart
sound was loud , the 2nd heart sound was normal , there is an
opening snap in early diastole and a mid diastolic rumbling
murmur at the apex , heard best while the patient in left lateral
position

14. ECG

15. Chest x ray

16. What is the diagnosis ?
MITRAL STENOSIS
What are the causes of mitral stenosis ?
Rehumatic fever
Congenital
Connective tissue diseases
What are the complications of MS ?
Atrial fibrillation
Left atrial thrombus
Pulmonary hypertension
Right side heart failure

17. What are the indication for mitral valvoplasty ?
1-Symptomatic patient
2-Isolated mitral stenosis without mitral regurgitation
3-Moblie non calcified valve
4-Lt atrial thrombus
What are the indications for mitral valve replacement ?
Rigid calcified valve

18. Case 4
Your patient is 21 years old female who was admitted with dyspnea
and palpitation , her pulse is 76 bpm irregular irregular , JVP was
raised
on examining precordium : apex was displaced and thrusting in
character , there is a parasternal heave and apical thrill , on
ascultations 1st heart sound is soft , 2nd heart sound is normal ,
there is a pansystolic murmer at the apex radiating to the axilla ,
there is a basal lung crepitation and lower limb odema ?

19. Whats the diagnosis ?
MITRAL REGURGITATION
pulmonary hypertension
heart failure
What are the causes of MR ?
Rehumatic HD
Mitral valve prolapse
Myocardial infarction (Papillary muscle rupture )

20. Case 5
Your patient is 56 years old female with history of rheumatoid
arthritis with interstitial lung disease on regular follow-up in
rheumatology OPD , her pulse is 96 bpm regular with good
volume , no special character , her JVP is elevated at 12 cm .
On examining of her precordium the apex was undisplaced , there is
parasternal heave and parasternal thrill , on ascultation 1st heart
sound was soft , there is loud pulmonary component of the 2nd
sound , there is pansystolic murmer at left lower sternal edge
louder during inspiration , the lung bases were clear , but there
are sacral and lower limb odema

21. whats the Diagnosis ?:
-Pulmonary hypertension
-Functional tricuspid regurgitation
-Rt side heart failure
What are the cause of tricuspid regurgitation ?
-Functional :
Pulmonary hypertension
Right ventricular dilatation
-Rehmatic
-Ebstein anomaly
What do you expect the abonarmality in JVP in this
patient ?
CV waves fusion

22. JVP
A = Atrial contraction
C= Closure of tricuspid
X= atrial relaXation
V= Filling of atria
Y= opening of tricuspid
Prominent a waves = tricuspid
stenosis
CV wave fusion = tricuspid
regurgitation
Prominent y descent = constrictive
pericarditis

23. Mitral
regurgurtation
Tricuspid
regurgatation
Auscultation Pansystolic murmer
radiates to axilla ,
loudest in expiration
Pansystolic murmer not
radiating , loudest in
inspiration
palpation Apical thrill Parasternal thrill
hepatomegally -------- Pulsatile hepatomegally
JVP -------- V waves

24. Case 6
You are examining 18 yrs old girl in medical ward admitting as a case
of anemia , and with a previous heart surgery and taking
anticoagulant tablets daily , his PR are 94 irregular irregular ,
good volume , no specific character , an audible prosthetic click
can be heard with unaided ear
on examining precordium there is a mid sternotomy scar , apex
displaced with thrusting character , there is parasternal heave ,
on ascultation there is a prosthethic click concides with carotid
pulse ( 1st heart sound) , there is a pansystolic murmer at apex
radiates to axilla , there is bibasal lung crepitation and LL odema
.

26. Chest xray

27. Whats the diagnosis ?
Prosthetic cardiac valve ( mitral prosthesis )
Mitral regurgitation ( leaking )
Heart failure
What are the types of prosthethic valves ?
Mechanical :
Ball and cage
Single tilting disc
Double tiliting disc
Tissue valves:
Pregnant , elderly , contraindication to anticoagulant

28. Examining CVS
Observation
Hands
Clubbing (Cyanotic congential heart disease , Infective endocarditis )
Peripheral cyanosis
Splinter haemorrhages
Osler's nodes = tender lumps in pulp of fingertips
Janeway lesions = red macules on wrist and hand
Nicotine stains
Radial pulse -
RATE :
RHYTHM : Irregularly irregular = atrial fibrillation Regularly irregular = 2nd degree heart block
VOLUME : Small volume thready pulse = shock
Small volume - in low output states eg heart failure
CHARACTER :
Slow Rising pulse = aortic stenosis
Collapsing ( aortic regurgitation , AV fistula , PDA , fever , thyrotoxicosis , anemia , mitral regurgitation)
Bisferiens = (mixed aortic disease , HOCM )
Pulsus alternans - LVF
Pulsus Paradoxus - pulse weakens in inspiration - indicates tamponade or constrictive pericarditis

29. Face Malar flush (mitral stenosis) , Jaundice (poss. prosthetic valve causing mild haemolysis)
Eyes Xanthelasmata or corneal arcus = hyperlipidaemia
Mouth
Cyanosis
High arched palate of Marfan's -> aortic regurgitation
Back : Listen at lung bases for fine inspiratory creps of pulmonary oedema (LVF) , Sacral oedema
Abdomen
Hepatomegaly - RVF
Pulsatile hepatomegaly - tricuspid regurgitation
Splenomegaly - endocarditis
Pulsatile mass (not liver) - abdominal aneurysm
Femoral arteries, radio-femoral delay (coarctation of aorta) and femoral bruits
Also can listen for renal bruits
Peripherally (Peripheral pulses , Pitting oedema , Varicose veins )
Finally
BLOOD PRESSURE
narrow pulse pressure indicates aortic stenosis
wide pulse pressure indicates aortic regurgitation
drop of > 10mm Hg in inspiration indicates pulsus paradoxus and (tamponade or constrictive pericarditis )
Fundi
hypertensive changes
Roth' spots = retinal vasculitis indicative of endocarditis