Auscultation and Heart Murmurs Lecture

Key Auscultation Locations

• Mnemonic: APTM (Apartment M)
  • Aortic area: Right second intercostal space
  • Pulmonic area: Left second intercostal space
  • Tricuspid area: Left fourth intercostal space
  • Mitral area (Apex): Apex of the heart

Analyzing Heart Murmurs

Example Case

• Patient: 78-year-old male with dyspnea on exertion, exertional angina
• Murmur: 2/6 systolic murmur in apical area
• Diagnosis Approach:
  • Determine if murmur is systolic or diastolic
  • Identify the location (e.g., mitral area) to determine the likely heart valve issue

Mitral Valve Murmurs

• Mitral Regurgitation: Systolic murmur at the mitral area
• Mitral Stenosis: Diastolic murmur at the mitral area
• Key Concept: If murmur occurs during systole, it’s likely regurgitation; during diastole, likely stenosis

Effects of Respiratory Phases and Preload/Afterload on Murmurs

Respiratory Effects

• Inspiration: Right-sided murmurs get louder
• Expiration: Left-sided murmurs get louder
• Memorization Tip: "Inspiration and expiration – left gets louder with expiration, right with inspiration"

Preload and Afterload

• Increased Preload:
  • Louder murmurs (more blood over valves)
  • Exceptions: Hypertrophic Obstructive Cardiomyopathy (HOCM) and Mitral Valve Prolapse (MVP)
• Decreased Preload:
  • Softer murmurs (less blood over valves)
  • Exceptions: HOCM and MVP
• Increased Afterload:
  • Louder regurgitant murmurs
  • Softer HOCM and MVP
• Decreased Afterload:
  • Louder HOCM and MVP

Murmur Characteristics and Mnemonics

Aortic Stenosis

• Characteristics: Crescendo-decrescendo murmur, radiates to carotids
• Mnemonic: Old and SAD (Syncope, Angina, Dyspnea)

Mitral Regurgitation

• Characteristics: Holosystolic murmur, radiates to axilla
• Mnemonic: Rue-mitral (for patients with rheumatic fever history)

Tricuspid Regurgitation

• Characteristics: Holosystolic murmur
• Mnemonic: "Do you want to try some drugs?" (For IV drug users)

Mitral Stenosis

• Characteristics: Opening snap
• Mnemonic: "Operating System is Microsoft" (OS is MS)

Hypertrophic Obstructive Cardiomyopathy (HOCM)

• Characteristics: Family history of sudden cardiac death
• Mnemonic: Changes with preload and afterload; louder with decreased preload and afterload

Mitral Valve Prolapse (MVP)

• Characteristics: Mid-systolic click
• Mnemonic: Young women with psychiatric history; "to win MVP, your team has to click"

Additional Notes

• Mnemonics and Patterns: Aid in recognizing murmur types
• Conceptual Understanding: Essential for exams and clinical practice
• Left Out Murmurs: PDA, VSD, ASD (not covered extensively in the lecture)