so let's get started with the auscultation so there are four very distinct locations where stethoscopes get placed and what might happen on your exam is that you'll be given the location of where they're auscultate immers so the mnemonic for remembering these positions is apartment M we filled that in here a PTM apartment M the right second intercostal space is known as the aortic area the left second intercostal space is known as known as the pulmonic area the left fourth is the tricuspid area and then you have the apex which is the mitral area so get this down and commit this to memory first this is good not only for exams but also for when you enter your clinical rotations and start to have to you know know where to place your stethoscope when you're actually listening to somebody's heart now let's I want to transition now and and kind of use an example to show you how to figure out what the murmur is simply based on a few clues in the description so here's an example a 78 year old male presents complaining of dis Nia on exertion and exertional angina for the past three months on exam you know tattoo out of six systolic murmur when you're set the scope is placed in the apical area which of the following is the correct murmur so this is much simpler than it needs to be people get really overwhelmed when they get murmur questions but let's simplify this basically you need to look for a few things one is the murmur systolic or diastolic and where's it occurring if you know those two pieces of information you can solve the murmur without any other clues you don't even have to listen to the audio file to see what the murmur sounds like in this question they told us that it's a systolic murmur and it's in the apical area so you can see in the top left here I included our diagram with our four different auscultation spots so we know that we're in the apical area so we know this has to be a mitral sound now the question is is it mitral stenosis or mitral regurgitation so starting from the ground up here if you knew of the apartment M mnemonic you would already know this has to be mitral so you've got part this question solved part two is is it mitral stenosis or mitral regurgitation and that's where the systolic versus diastolic part comes into play so now you have to ask yourself what happens at the valve during systole versus diastole so we're talking about the mitral valve and we know that during diastole blood is gonna flow from the left atrium into the left ventricle and fill during diastole but in systole blood is going to be ejected out of the left ventricle and it has the potential of going back across the mitral valve if it's going to regurgitate back into the left atrium so I've kind of already given it away here but basically we know that we're talking about a systolic murmur and the only time that a murmur occurs on the mitral valve during systole is during mitral regurgitation again if it was if it was mitral stenosis it would have to be a diastolic murmur because the only time that you hear mitral stenosis is when blood flows across the mitral valve when the left atrium is trying to throw blood into the ventricle as it fills that ventricle so I want to take a step back here and make sure that you're up to speed first you have to know the AP TM apartment M mnemonic that tells you where the murmur is located or what area were listening to then you have to ask yourself what happens at that valve during systole versus diastole and if you know all of that information you can solve what the murmur is based on just those two pieces you don't have to even listen to the audio file so it's a really nice trick if you can get that down and understand the basic physiology about what happens at the valve in systole versus diastole now with that in mind this is the basics the absolute basics that you need to know the systolic versus diastolic murmurs what I recommend is that you pause the video right now and ask yourself what happens at the aortic valve what happens at the pulmonic valve what happens at the tricuspid and what happens at the mitral during systole versus diastole if you can understand whether blood is going to be ejected or going to be filling a ventricle then you will be able to solve almost every question if you're ready to move on we're gonna now talk about what makes murmurs louder or softer and this is usually what people get tripped up on so it's very important that we get a few things down first is that during inspiration right-sided murmurs get louder and during expiration left-sided murmurs get louder this is just a general rule and I need you to memorize it because it's gonna go a long way for you so what I always remembered was inspiration and expiration left-sided gets louder during expiration and right-sided gets louder during inspiration this is something that you absolutely need to memorize I wouldn't even think about why just memorize it the more confusing topic is what happens with preload versus afterload so we're gonna spend quite a bit of time on this slide so I really want to make sure that you understand this when you increase preload basically what you're doing is pushing more blood back to the heart therefore as more blood flows over Valve's the murmurs become louder because more blood is going to flow over them so as an example if you usually have a mitral stenosis the more blood that flows across that mitral valve means that that murmur is going to be louder because more blood is gonna flow through an already stenotic valve so if your auscultate in it it will be louder aka worse the exception to this rule is hypertrophic obstructive cardiomyopathy and mitral valve prolapse this is a very high yield concept so I'm gonna explain this when you have hypertrophic obstructive cardiomyopathy or hocum for short the the heart becomes hypertrophied and the septum kind of bulges and blocks the outflow tract so normally more blood flowing across a valve ER into the heart makes murmurs louder but in the case of hokum and mitral valve prolapse which is you know lower yield but still we include it in this discussion more blood in the heart actually pushes that septum back into its normal physiologic position so in hokum if you can envision this diagram in your head the more blood or the more pressure on that septum pushes it back into its normal position and reopens that outflow tract so generally speaking any time you increase preload which you do be a squatting or leg raising more blood is gonna flow through the heart and anytime more blood flows over a valve whether it's stenotic or regurgitant you're gonna get louder murmurs the only exception to this rule is hokum and mitral valve prolapse in hokum it's because more blood pushes the septum back into its normal position which is the picture all the way on the left and in mitral valve prolapse it's because the mitral valve is literally prolapsing and it's blocking normal blood flow so I want to simplify this to the most basic level you don't need to understand what's happening with the mitral valve you'll never be asked that but just think of it as more blood going through the heart and returning the mitral valve leaflets back into their normal position that's all you need to know so again I'm gonna summarize more blood more preload every murmur gets louder the only exceptions are hokum and mitral valve prolapse hokum because you re open up the outflow tract obstruction and mitral valve prolapse because you returned the valves back into a relatively normal position or you don't hear the mid-systolic click that goes along with mitral valve prolapse that's increased preload now let's jump to the other side of the slide here if you decrease your preload your murmurs will get softer and it's the same exact reasoning right less blood going back to the heart means less blood is gonna flow across a stenotic or regurgitant valve therefore the murmurs will be softer aka better right they're not going to sound as loud they're not going to sound as bad because less blood is flowing over the abnormal valve again the exception is hokum and mitral valve prolapse again for the same reason so in hokum if you look at our picture on the left here you've got you see the normal position of the heart but then the the image just to the right shows the heart with hypertrophic cardiomyopathy if you have less blood flowing through the heart then less blood is there to push that septum back to its normal position so hokum sounds worse in mitral valve prolapse you have less blood to return the mitral valves back to their normal position when you decrease preload you do that via valsalva so you bear down if you it's like telling a patient I want you to bear down and pretend like you're having a bowel movement this prevents blood from returning to the heart aka it decreases your preload so that's everything you need to know about preload right think about preload as the amount of blood that gets loaded into the right atrium aka the amount of blood that is returning to the heart through the venous system now I want to talk about after load after load is basically the pressure against which the heart pumps so increase after load means more pressure is being exerted upon the left ventricle as it tries to eject blood out of the heart you can increase your after load by doing something called hand grip so when you're examining a patient if you ever want to have them do hand grip you're gonna tell them to squeeze their left hand and that hand grip is going to increase after load right it's going to increase the pressure against which the heart has to pump now usually when you increase the after load you get louder regurgitant murmurs now why is that well if the heart has to pump against a greater pressure that means there is more pressure forcing blood backwards right normally blood is going to pump out of the heart but if it's pumping against a greater pressure then you can think of it as more pressure being exerted upon the heart which is gonna try to force blood backwards and that's exactly what a regurgitant murmur is right blood is going to accidentally flow backwards in the wrong direction back over the valve so when you increase after load the regurgitant murmurs become louder likewise when you increase after load you're gonna get a softer hokum and a softer mitral valve prolapse and this is the same reasoning as before if we increase after load then hocum has more pressure propping septim back into its normal position the mitral valves have more pressure propping them back into their normal position those valve leaflets so again a softer hokum or a softer MVP is really saying that the murmur is getting better right it's getting softer you don't hear it as much because there's less of a mechanical issue since there's more pressure returning the heart to its physiologic position and that's really important to understand the last thing I want to talk about is decreasing after load you can decrease after load by using a drug called amyl nitrite II and this is probably the lowest yield of anything on this slide but I include it for completeness sake here if you decrease your afterload hokum gets louder right less pressure is forcing that septum back into its normal position so the outflow tract gets obstructed and the hokum murmur gets worse aka louder if you decrease your after load you get a louder MVP again same reason less pressure is being forced upon those mitral valve leaflets which means that the mitral valve is going to prolapse more and get worse or get louder so again this slide is talking about preload versus after load how we change preload how we change after load how we make it increase versus decrease how you do that with valsalva squatting leg raise all this stuff it's very high yield the reason that this is important on your exam is that they'll give you a murmur and they'll tell you what you know they'll say that the patient bears down what do you expect to happen something like that they want to make sure that you can understand the physiology of what's going on in the chambers of the heart and how that changes the the strength of the murmur that you're hearing the other thing that I want to point out is that hokum because it's such a high yield exception and again it's way more high yield than mitral valve prolapse hokum can sound like other murmurs but the way that you differentiate them is based on what it's doing with these maneuvers so if you want to distinguish hokum from something like a ventral ventricular septal defect they'll tell you what's happening with the murmurs so keep this in mind it's very high yield now what I want to get into is the last section of this video this is going to be a rapid room you of high-yield associations and buzzwords that can help you get the murmur right I've included a lot of my new monix here that helped me on my exam pretty extensively and I would say that I usually was getting between 90 and a hundred percent of the murmur questions correct just because I had these in my back pocket so up to this point you you should understand normal physiology you should understand the a PTM locations and systolic versus diastolic you know what's happening across that valve you should understand how maneuvers change those murmurs but if all else fails if all of that normal physiology that I just explained is not enough to get you the answer right well fear not guys I've got some pretty sick mnemonics for you so let's get into them the first is aortic stenosis and I would consider aortic stenosis to be probably the highest yield murmur that shows up on exams this is known as a crescendo decrescendo murmur which means that the murmur gets louder towards the middle and then softer so it kind of increases and then comes back down there are two presentations for aortic stenosis one is gonna just be an old patient if you have to take an absolute guess on your exam and you have a patient who's let's say seventy years or older it's most likely aortic stenosis because over time with all of the changes that happen as you age that valve just breaks down you know hypertensive hearts and remodeling of the heart really leads to a lot of pressure going through that valve and it causes an aortic stenosis and what they say is that patients are sad they get syncope angina and dyspnea right so dis Neah angina syncope remember that old patients are sad day or text enosis is sad the other thing that you should keep in mind is that it's possible to have a basically a functional aortic stenosis through a calcified valve so if any patient has really high calcium levels you can actually deposit little calcium crystals around the aortic valve and because crystals accumulate around the valve it's decreasing the space that blood has to pump through the aortic valve which creates a functional aortic stenosis so again a artx enosis two presentations anyone who's old and sad and the other person who has little calcification of their valve the other thing that I want you to remember about or text enosis is that it radiates to the carotid and the way that you can remember this is that I take the letter A for aortic stenosis and I draw the up arrow in the down arrow which reminds me that it's crescendo decrescendo the up arrow also reminds me that it radiates up to the carotid so if you remember where the aortic area is on our kind of ribcage diagram that up arrow points or right at the carotid so aortic stenosis old and sad crescendo decrescendo radiates to the carotid if you do have to listen to it on your exam and it sounds like it gets louder and then comes back down that that's a or text enosis that's crescendo decrescendo and what you see at the top here is just the kind of diagram of the murmur based on what it sounds like so again a or Texas enosis crescendo decrescendo mitral regurgitation is a holosystolic murmur so it's usually about the same volume throughout but it doesn't it doesn't stop it's holosystolic its present for all of systole so between s1 and that should say s2 you hear continuous murmur the mitral valve is usually implicated if the patient has a history of rheumatic fever so the mnemonic is room mitral anytime they have a history of rheumatic fever think about the mitral valve that is the number one valve that gets involved mitral regurgitation radiates to the axilla that's important and it's high-yield because sometimes they'll tell you about the murmur and say that it's radiating and they'll give you the direction of the axilla so again rue mitral very important that's mitral regurgitation tricuspid regurgitation is very similar it's also hauless holosystolic between s1 and again that should say s2 it's there the entire time the tricuspid valve is always damaged when you have patients who have a history of intravenous drug abuse so my new Monica is do you want to try some drugs I want you to think about the tricuspid murmurs whether it's regurgitation or stenosis whenever you have a patient who has any risk factors or history for IV da so you know patients with HIV hepatitis obvious intravenous drug abuse anything that points to them being a former drug abuser immediately think tricuspid valve the reason that this is because the first valve that blood flows across when it reaches the heart is the tricuspid valve so if you have blood that's littered with pathogens as a result of intravenous drug abuse the damage is going to be primarily concentrated at the tricuspid valve so want to try some drugs that's tricuspid regurgitation mitral stenosis is a very high yield murmur because of the description it has what's called an opening snap that's super high yield and we'll come back to that in one second but again we're talking about the mitral valve here so anytime a patient has a history of rheumatic fever think rue mitral it's always gonna be the mitral valve more often than not this opening snap is really high yield and my pneumonic for remembering this is that the operating system is Microsoft that is to say that the OS is ms the opening snap is mitral stenosis so anytime they describe an opening snap it's gonna be mitral stenosis and the reality of this is that it's really hard to hear an opening snap when you're actually listening to an audio file so if they want you to pick mitral stenosis they're usually gonna include the buzzword opening snap that could change but that's what I would remember so again the operating system is Microsoft aka the OS is ms aka the opening snap is mitral stenosis the next murmur we're gonna talk about is hokum hypertrophic obstructive cardiomyopathy and we already went through this pretty extensively on the slide about maneuvers and how they change murmurs but any time a patient has a family history of sudden cardiac death I want you to think about hokum so patients that are dying in their 20s or 30s while they're exercising the reason that that happens is that again in hokum/the the outlet is obstructed and you get functional heart failure because the heart is unable to pump blood to the rest of the body and one thing leads to another and patients die during exercise when increased demand is placed on their heart so just to go through this one more time hokum is going to be similar to other murmurs by the way that it sounds and the location in which you hear it but how it changes during maneuvers gives it away so it gets louder or worse with decreased preload so less blood going to the heart means that the septum can push over more and obstruct more which makes the murmur louder or worse it gets louder or worse with decrease after load so decrease after load means less pressure forcing that septum over which means the septum is going to block the outlet so the murmur gets louder or worse hokum gets softer aka better with increased preload so you want to increase your preload have the patient do some leg raising or some squatting get more blood going back to the heart more blood in the heart is gonna force that septum push it to the side and make the murmur better or softer and it lastly the murmur will get softer are better with increased afterload so have the patient use some hand grip squeeze their left hand you're gonna make the heart have to pump against a greater pressure which means more pressure is gonna force that septum back into its normal position which makes hocum sound softer or better the last murmur we're going to talk about is mitral valve prolapse MVP so mitral valve prolapse is high-yield for a few reasons one is that it has something called a mid-systolic click anytime you have a young woman with a psychiatric history I want you to think about MVP we're still trying to understand the relationship between psychiatry and cardiology and it's very very extensive however usually patients with MVP are young women who are anxious or depressed don't ask me why I cannot tell you i but that is the Association so keep that in the back of your mind MVP can be caused by myxoma this valve disease I'm throwing that in here because any time they talk about this I want you to think about the mitral valve think about MVP for myxoma tiss valve disease and my beautiful mnemonic to remember MVP is that to win MVP your team has to click so that mid-systolic click is found in MVP or mitral valve prolapse that's it for this video there are a few murmurs that I did not include because there's not much that you need to know about them those would include a PDA a VSD and an ASD if you're confused about those murmurs I recommend googling them and learning the few basics that you need to know but for the purpose of this discussion I left them out because there's not much that you need to know about them and there is one buzzword that can summarize most of them so I don't want to waste your precious brain space this has been heart murmurs that