Dr Tejal Parekh, Dr Sarah Kolb.

Countdown2Finals 1
CARDIOLOGY OSCE HANDOUT Cardiac Murmurs Once you have mastered the key concepts of cardiac murmurs, recognising murmurs in your OSCE exam is simple! Remember, a full assessment consists of six main components 1. Timing : n relation to the cardiac cycle, always time with the CAROTID pulse as peripherals can be delayed. 2. Site: where can you hear the murmur the LOUDEST? 3. Character 4. Radiation 5. Murmur enhancing manoeuvre 6. Grade

Systolic

Diastolic

Ejection Systolic Aortic Stenosis Pulmonary Stenosis Pansystolic VSD Mitral Regurgitation Tricuspid Regurgitation Systolic Click Mitral Valve Prolapse Aortic valve replacement

Early Diastolic Aortic Regurgitation Mid-diastolic Mitral/tricuspid stenosis Opening snap/diastolic rumble Mitral Stenosis

Continuous (overlaps both heart sounds, hence not confined to diastole/systole) PDA ASD AV Malformation Venous Hum

Table 1.1. Brief overview of Timing of Murmurs within the Cardiac Cycle Aortic Stenosis: Site: Aortic, upper right sternal edge Timing: Ejection systolic. Can usually hear HS2. Character: harsh, high pitched Radiation: Carotids Murmur enhancing Manoeuvre: Ask patient to take a breath in and hold listen over carotids with diaphragm. Can also listen for aortic bruits at same time but with bell Peripheral Signs Slow rising pulse Narrow pulse pressure LVH: heaving apex beat JVP- raised if element of heart failure Note: If AS is due to a very severe aortic valve calcification, the murmur can actually echo off the calcified aortic valve and is heard loudest in the mitral area can be confusing!

Mitral Regurgitation: Site: Apex Timing: Pan systolic. HS2 inaudible if severe. Character: Radiation: Axilla (into the left atrium) Murmur-enhancing Manoeuvre: Left Lateral position, expiration Peripheral Signs: Can often be in Atrial Fibrillation Tachycardic LVH: heaving, displaced apex beat JVP: raised if element of Heart Failure Aortic Regurgitation: Site: Lower Left Sternal edge, loudest over 3rd or 4th intercostal space Timing : Early diastolic. Character : Radiation: no particular radiation Murmur-enhancing manoeuvre: Louder on end expiration reduced venous return into the right side of heart so left sided murmurs louder. Peripheral signs Collapsing pulse AKA water hammer pulse Wide pulse pressure Many others eg Corrgians sign, Quinkes sign, DuRoziez femoral murmur, De-Mussets etc. ***Do not need to recognize these in the OSCE but know for the written.*** Mitral Stenosis: Site: Apex Timing: Mid-diastolic Character: Low-pitched, rumbling Radiation: Left from apex. Murmur-enhancing Manoeuvre: Use bell of stethoscope and roll patient onto left side Peripheral signs Small pulse, which may be in irregularly irregular JVP is only raised if there is an element of Heart Failure Malar flush due to pulmonary HTN Grading ***Do not need to recognize this in OSCE but know for the written paper*** Grade 1 2 3 4 5 6 Auscultation Barely audible Medium Intensity Loud but no thrill Loud with thrill Very loud but still requires stethoscope to be on chest So loud, can heard with stethoscope off chest