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1. Done By: Dalal F. Alanazi
Medical student at KFU

2. Objective
1. The anatomy of the heart?
2. What does parasternal mean?
3. What is a murmur ?
4. Types and digress of murmurs & same disease
related to them?
5. Normal & murmur heart sound ?
6. Classification of cardiac murmurs?
7. what causes of murmur?
8. Diagnosis of murmur?
9. The Final diagnosis for the case

3. Summary for the case ..
During a routine sports examination, 14-year-old
Elisabeth is found to have a fairly loud, systolic
murmur in the 2th/3rd parasternal intercostal
space. Physical examination shows no further
abnormalities. Elisabeth experiences no restrictions
during exercise. A chest X-ray shows the right
atrium to be slightly enlarged and the pulmonary
arteries dilated .

5. Parasternal intercostal space ..
Parasternal: beside the sternum (adjacent to it).
The parasternal window is located next to the sternum,
between the 2rd and 5th intercostal spaces..

6. Definition of Murmur ..
Murmurs are pathologic and abnormal heart
sounds during heartbeat cycle -such as
whooshing or swishing- made by turbulent
blood in or near the heart. These sounds can
be heard with a stethoscope.
• Present at birthCongenital
• Develop later in lifeAcquired

7. Types and digress of murmurs ..
1- Systolic murmur: a heart murmur that occurs
during a heart muscle contraction which occur
between S1 and S2 .
2- Diastolic murmur: a heart murmur that
occurs during heart muscle relaxation between
beats which occur between S2 and S1.

8. Normal heart sounds ..
1. Between the first and the second heart sounds there is
systole.
2. Between the second and the next one there is diastole.

9. Cont .. Normal heart sounds
Normally, there are two heart sounds:
• First heart sound means exposure to
the A-V valve.
• Second heart sound means exposure to
the semilunar valves.

10. Name of disease What is it ?
Coronary artery disease or
heart attack
Blockages in your coronary arteries that
limit blood flow to your heart muscle
High blood pressure Elevated pressure in your arteries
Aortic stenosis Opening of aortic valve is narrowed,
impairing blood flow
Arrhythmia Irregular heart rhythm
Causes of systolic heart failure ..

11. Name of disease What is it?
Coronary artery disease
(CAD)
Blockage of the arteries that supply
blood to the heart.
High blood pressure Elevated pressure in your arteries.
Aortic stenosis Narrowed opening of the aortic valve.
Pericardial disease Abnormality of the sac that surrounds
the heart (pericardium).
Causes of Diastolic heart failure ..

12. Cardiac cycle

13. Cont.. Heart sounds

14. Classification of cardiac murmurs ..
murmurs helps to identify functional from
pathological murmurs and to distinguish
between the different types of pathological
murmur..

15. Cont ..
Grade 1:
• A quiet murmur that can be heard only after careful auscultation over
a localized area.
Grade 2:
• A quiet murmur that is heard immediately once the stethoscope is
placed over its localized PMI.
Grade 3:
• A moderately loud murmur.
Grade 4:
• A loud murmur heard over a widespread area, with no thrill palpable.
Grade 5:
• A loud murmur with an associated pericardial thrill.
Grade 6:
• A murmur sufficiently loud that it can be heard with the stethoscope raised
just off the chest surface.

16. Causes of murmur in heart ..
1. Most heart murmurs are innocent: They are
caused by blood flowing through healthy
valves in a healthy heart and do not require
treatment.
• However, heart murmurs can be caused by
blood flowing through a damaged or
overworked heart valve.

17. Cont.. Cause
FeverPregnancyanemiaPhysical activity
or exercise
An excessive amount
of thyroid hormone in
body hyperthyroidism

18. may result from a heart problem..
Heart valve
abnormalities
Holes in the
heart ASD or
cardiac shunts
Rheumatic
fever.
EndocarditisMitral valve
prolapse

19. How can we diagnose this case ?

20. Chest X-ray:
An X-ray image helps your doctor see the condition of your heart and
lungs.
Echocardiogram:
This is a commonly used test.In echocardiography, sound waves produce a
video image of the heart. It allows your doctor to see your heart's
chambers and measure their pumping strength..
This test also checks heart valves and looks for any signs of heart defects*

21. Electrocardiogram (ECG). This test records
the electrical activity of your heart and
helps identify heart rhythm problems..
Cardiac catheterization. In this test, a thin,
flexible tube (catheter) is inserted into a
blood vessel at the groin or arm and
guided to your heart. Through
catheterization, doctors can diagnose
congenital heart defects, test how well
your heart is pumping and check the
function of your heart valves.

23. Magnetic resonance imaging (MRI): is a technique that uses a
magnetic field and radio waves to create 3-D images of all organs
and tissues within your body.
Pulse oximetry: This painless test measures how well oxygen is
reaching your tissues.
It helps detect whether oxygenated blood is mixing with
deoxygenated blood*

24. Final diagnosis is
Arterial septal defect
• Normally, the right and left atria are separated by a septum
called the interatrial septum. If this septum is defective or
absent, then oxygen-rich blood can flow directly from the left
side of the heart to mix with the oxygen-poor blood in the right
side of the heart.
• The right ventricle will be forced to generate higher pressures
to try to overcome the pulmonary hypertension. This may lead
to right ventricular failure ..
(dilatation and decreased systolic function of the right ventricle)*

26. The deoxygenated (blue) blood will by pass the lungs and circulate
throughout the systemic circulation resulting in blue coloration
of the skin (right photo).
Blue Baby Syndrome
“Cyanotic heart problems” ..

27. Cont ..
The symptoms based on the diameter of the opening
(small or large) and, there is more than one opening..
1. Chest pain.
2. Shortness of breath.
3. vomiting.
4. Rapid or irregular heartbeats.
5. Swelling of legs, feet or abdomen.
6. Stroke.
7. Bluish skin color.

28. Summary
1. Anatomy of the heart?
2. What’s the parasternal & murmur means?
3. What the murmur?
• Types with same diseases related to
them..
• Digress..
• Classification..
• Causes..
• Diagnosis..
4. The Final diagnosis for the case?

29. Reference ..
• http://www.nlm.nih.gov/medlineplus/ency/article/000157.htm
• https://www.google.com.sa/url?sa=t&source=web&rct=j&ei=qP8MU8
HOIfOZ0AXAj4FQ&url=http://www.nytimes.com/health/guides/disease
/cyanotic-heart-
disease/overview.html&cd=1&ved=0CCYQFjAA&usg=AFQjCNGZ5GnYF
Bp6c_Hgo846dkAALSzaAg
• http://www.blaufuss.org/arrow/Systole.html
• http://www.medicinenet.com/heart_disease_pictures_slideshow_visu
al_guide/article.htm
• http://www.webmd.com/heart-disease/heart-failure/tc/systolic-heart-
failure-topic-overview
• http://www.webmd.com/heart-disease/heart-failure/tc/diastolic-
heart-failure-topic-overview