70M presents with SOB. You're asked examine the cardiovascular system.
As you auscultate the heart you hear a murmur. What would you do next?
Open this thread and I'll share my approach.
#MedEd #Tweetorial
#MedTwitter #MedStudentTwitter
@grepmeded @AndreMansoor @medrants
As you auscultate the heart you hear a murmur. What would you do next?
Open this thread and I'll share my approach.
#MedEd #Tweetorial
#MedTwitter #MedStudentTwitter
@grepmeded @AndreMansoor @medrants
Here’s my four step approach to auscultation when there’s a murmur:
1. Time the murmur
2. Listen for the character
3. Perform dynamic manoeuvres
4. Auscultate in all areas
1. Time the murmur
2. Listen for the character
3. Perform dynamic manoeuvres
4. Auscultate in all areas
Step 1. Time the murmur
Is it systolic or diastolic?
Palpating the carotid pulse while auscultating. This pulse corresponds with the start of systolic.
(Avoid the radial pulse which is more delayed and complicates your assessment.)
Is it systolic or diastolic?
Palpating the carotid pulse while auscultating. This pulse corresponds with the start of systolic.
(Avoid the radial pulse which is more delayed and complicates your assessment.)
Tip: If the murmur is immediately heard it’s likely to be systolic.
Diastolic murmurs often require dynamic manoeuvres to be heard.
- e.g. listen will bell at apex and roll for MS
- e.g. maximum expiration at left upper sternal border for AR
Diastolic murmurs often require dynamic manoeuvres to be heard.
- e.g. listen will bell at apex and roll for MS
- e.g. maximum expiration at left upper sternal border for AR
Step 2. Listen for the character
Ejection systolic murmur
“Crescendo-decrescendo”
WOOSHWOOSHWOOSH
Holosytolic
“Blowing”
SHSHSHSH SHSHSHSHSHSHSHSH
Ejection systolic murmur
“Crescendo-decrescendo”
WOOSHWOOSHWOOSH
Holosytolic
“Blowing”
SHSHSHSH SHSHSHSHSHSHSHSH
Step 3. Perform dynamic manoeuvres
Respiratory variation
- Louder on inspiration - right-sided murmur
- Louder on expiration - left-sided murmur
Handgrip -> makes MR louder
Valsalva -> makes HCM louder
Respiratory variation
- Louder on inspiration - right-sided murmur
- Louder on expiration - left-sided murmur
Handgrip -> makes MR louder
Valsalva -> makes HCM louder
Step 4. Auscultate in all areas
At each area listen individually for:
- Heart sounds (S1 at apex, S2 at base)
- Added sounds (S2, S3)
- Murmur
Radiation to neck (AS) axilla (MR)
Where is it loudest? Is the character the same everywhere, or are there multiple murmurs?
At each area listen individually for:
- Heart sounds (S1 at apex, S2 at base)
- Added sounds (S2, S3)
- Murmur
Radiation to neck (AS) axilla (MR)
Where is it loudest? Is the character the same everywhere, or are there multiple murmurs?
In summary when you hear a murmur:
1. Time the murmur
2. Listen for the character
3. Perform dynamic manoeuvres
4. Auscultate in all areas
1. Time the murmur
2. Listen for the character
3. Perform dynamic manoeuvres
4. Auscultate in all areas
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Until then, I’d like to hear from you. Is my approach similar to yours? Is there anything you do differently? What did I miss?
Let me know by commenting below.
Let me know by commenting below.
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