Heart Murmurs - Improving care in ED

FACEM Part II Notes

Valve Disease

Symptoms & Signs

MS

Dyspnea

Orthopnea

PND

Hemoptysis

Mitral facies AF PHT

MR

Dyspnea

AF common

MVP

N/A

Heart Murmurs

Eunicia Tan

Murmur and Apex

Dynamic auscultation

Low-pitched rumbling DM Best in left lateral Opening snap Loud S1

with expiration

Apex ? Tapping

PSM Max at apex Rad to axilla

Apex ? Displaced ? Diffuse ? Hyperkinetic

Louder ? Expiration ? Squatting ? Leg raise ? Hand grip

Softer ? Valsalva

Systolic click Usu. Midsystolic High-pitched late systolic murmur

Longer, click earlier ? Valsalva

Shorter ? Handgrip ? Squatting ? Leg raise

Causes / Associations

Signs of Severity

ECG

Rheumatic Congenital (v rare)

Chronic ? Degenerative ? MVP ? Rheumatic ? Papillary m dysfxn ? Cardiomyopathy ? CTD - RA, ank spond ? Congenital Acute ? IE ? MI ? Surgery ? Trauma

Myxomatous degen Associations ? Marfans syndrome ? Secundum ASD ? HCM ? Anorexia nervosa

Small pulse pressure

Early opening snap

Longer mid-diastolic murmur

Signs of pulmonary HT

? Prominent a wave ? RV impulse ? Loud P2 ? PR and TR Valve are < 1cm

P mitrale AF RV strain RAD

Enlarged LV S3 Soft S1 Early diastolic rumble Pulmonary HT (late) Small volume pulse (severe) LVF

P mitrale AF LV overload RAD

Valve area 1.5 to 1

LVH

pulm

More than trivial

vasculature

shunt

Duct

calcification

Enlarged LV

LVH

Enlarged LV and N/A

L subclavian

Dilated asc

aorta

Aortic

indentation

Aortic pre- and

post-stenotic

dilation

Rib notching

(2nd-6th ribs)

RVH P pulmonale

Enlarged RA

N/A

Enlareged RV

Prominent PA

hilar markings

periph vessels

NOT boot

shaped

FACEM Part II Notes

Valve Disease

Symptoms & Signs

ToF

Cyanosis, clubbing,

polycythemia

RV heave

Thrill at LSE

Murmur and Apex

Dynamic auscultation

Short pulm ESM

N/A

Adult

? PR ? TR

Causes / Associations

Signs of Severity

Four features:

N/A

1. VSD

2. RV outflow

obstruction

3. Overriding aorta

4. RVH

TGA

Palpitations

TR murmur

N/A

N/A

N/A

Dizziness

MR murmur

Dyspnea

Gallop rhythm

SVC baffle obstruction

Scar Flushing Edema Cyanosis

ECG

CXR

Eunicia Tan

Surgery

RVH RAD

N/A

Boot-shaped

N/A

RV enlargement

lung

vascularity

Right sided

aortic knob,

arch, desc aorta

N/A

N/A

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