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Opening snap in which OS is the mitral opening snap, and DM is the diastolic murmur. The ''aaaalve'' is the presystolic accentuation heard when a patient with mitral stenosis is in normal sinus rhythm. Figure 14-38 illustrates a diastolic atrioventricular murmur.

Diastolic semilunar murmurs begin immediately after S2, as heard in aortic or pulmonic regurgitation. In contrast to the diastolic atrioventricular murmurs, there is no delay after S2 to the beginning of the murmur. The high-pitched murmur is decrescendo in shape and is best heard with the diaphragm of the stethoscope while the patient is sitting up and leaning forward. A diastolic semilunar murmur is a sign of low sensitivity but high specificity. Figure 14-39 illustrates the pressure curves responsible for the generation of a diastolic semilunar murmur.

Table 14-8 lists important cardiac sounds according to the cardiac cycle. Figure 14-40 lists important characteristics of the systolic murmurs of aortic stenosis and mitral regurgitation. Table 14-9 summarizes the differentiation of some additional systolic murmurs. Figure 14-41 lists important characteristics of the diastolic murmurs of mitral stenosis and aortic regurgitation.

Figure 14-39 A diastolic semilunar murmur such as that occurring in aortic regurgitation. Note the systolic ejection murmur, which is related to the increased volume and flow.

Aorta

Left atrium

Left ventricle

Aorta

Left atrium

Left ventricle

Physical Clinical Diagnosis
(A2) S2

Table 14-8 Cardiac Sounds Cardiac Cycle

Early systolic Ejection click

Aortic prosthetic valve opening sound*

Midsystolic to late systolic Midsystolic click

Early diastolic Opening snap

Mitral prosthetic valve opening sound{ Tumor plop{

Mid-diastolic S3

Summation gallop§

Late diastolic (sometimes S4

called presystolic) Pacemaker sound

•Opening and closure of the prosthetic aortic valve are heard with many prosthetic valves. The opening is comparable to an ejection click; the closing is a "prosthetic" S2. ^Opening and closure of the prosthetic mitral valve are heard with many prosthetic valves. The opening is comparable to an opening snap; the closing is a "prosthetic" S^ {A left atrial myxoma that is pedunculated may "plop" in and out of the mitral annulus, simulating the auscultatory signs of mitral stenosis.

§At fast heart rates, the diastolic period shortens. If an S3 and S4 are present, the sounds may be summated into a single sound called a summation gallop.

Systolic Murmurs Differentiating AS from MR

Feature Aortic Stenosis Mitral Regurgitation

Location Aortic area Apex

Radiation Neck Axilla

Shape

Diamond

Holosystolic

Pitch

Medium

High

Quality

Harsh

Blowing

Associated signs

Decreased A2 Ejection click S4

Narrow pulse pressure Slow rising and delayed pulse

Decreased S-| S3

Laterally displaced diffuse PMI

PMI, point of maximum impulse.

PMI, point of maximum impulse.

S1 S2 S3

Figure 14-40 Systolic murmurs. A, Pathophysiology of aortic stenosis. Note the paradoxical splitting of the second heart sound (S2), the S4, and the ejection click. B, Mitral regurgitation. Note that the murmur ends after S2, and note the presence of the S3.

S1 S2 S3

Figure 14-40 Systolic murmurs. A, Pathophysiology of aortic stenosis. Note the paradoxical splitting of the second heart sound (S2), the S4, and the ejection click. B, Mitral regurgitation. Note that the murmur ends after S2, and note the presence of the S3.

Table 14-9 Differentiation of Other Systolic Murmurs

Pulmonic

Tricuspid

Ventricular

Innocent

Feature

Stenosis

Regurgitation

Septal Defect

Venous Hum

Murmur

Location

Pulmonic area

Tricuspid area

Tricuspid area

Above clavicle

Widespread

Radiation

Neck

Right of sternum

Right of sternum

Right neck

Minimal

Shape

Diamond

Holosystolic

Holosystolic

Continuous

Diamond

Pitch

Medium

High

High

High

Medium

Quality

Harsh

Blowing

Harsh

Roaring; humming

Twanging; vibratory

•Usually between the apex and the left lower sternal border.

•Usually between the apex and the left lower sternal border.

Diastolic Murmurs Differentiating MS from AR Feature Mitral Stenosis

Location Apex

Radiation No

Shape

Pitch

Quality

Associated signs

Decrescendo Low

Rumbling

Increased St Opening snap RV rock*

Presystolic accentuation

Aortic Regurgitation

Aortic area No

Decrescendo High Blowing S3

Laterally displaced PMI Wide pulse pressure{ Bounding pulses Austin Flint murmur{ Systolic ejection murmur§

PMI, point of maximum impulse; RV, right ventricular. •Right ventricular impulse at lower left sternal border.

{The wide pulse pressure is the cause of the many physical signs of aortic regurgitation: Quincke's pulse, De Musset's sign, Duroziez's sign, Corrigan's pulse, and so forth.

{An apical diastolic murmur heard in association with aortic regurgitation, mimicking that of mitral stenosis. §A flow murmur across a valve that is relatively narrow for the increased blood volume as a result of aortic regurgitation. It is relatively stenotic and need not be anatomically stenotic, as in true aortic stenosis.

S1 S2 Opening snap

Figure 14-41 Diastolic murmurs. A, Pathophysiology of mitral stenosis. Note the intensity of St and the accentuation of the diastolic murmur in late diastole. B, Aortic regurgitation. Note the systolic flow murmur.

S1 S2 Opening snap

Figure 14-41 Diastolic murmurs. A, Pathophysiology of mitral stenosis. Note the intensity of St and the accentuation of the diastolic murmur in late diastole. B, Aortic regurgitation. Note the systolic flow murmur.

Useful Vocabulary

Listed here are the specific roots that are important for understanding the terminology related to cardiac disease.

Root

Pertaining to

Example

Definition

brady-

slow

bradycardia

Slow heart rate

-cardio-

heart

cardiomegaly

Enlargement of the heart

sphygmo-

pulse

sphygmomanometer

Instrument for measuring blood pressure

supra-

above

supraventricular

Above the level of the ventricles

tachy-

fast

tachycardia

Rapid heart rate

Herbal Remedies For Acid Reflux

Herbal Remedies For Acid Reflux

Gastroesophageal reflux disease is the medical term for what we know as acid reflux. Acid reflux occurs when the stomach releases its liquid back into the esophagus, causing inflammation and damage to the esophageal lining. The regurgitated acid most often consists of a few compoundsbr acid, bile, and pepsin.

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