🤔 MEDIUM

 Test your knowledge of murmurs – but don’t worry, the video should help! 

Awaiting review

  • Discuss the basic science relevant to valvular heart disease 
  • Outine the common aetiology of systolic and diastolic murmur
  • Discuss the most common left and, and right, sided heart murmurs 

Approach to the Patient with Heart Murmur

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Question 1

STEM 1 OF 4

A 77YOM presents with recurrent episodes of self-described "faints" and shortness of breath on exertion.  His BP is 100/95 and his pulse feels slow to fill at the radial with some notable radio-radial delay.

Which sound is most likely to be absent on auscultation?
A
S1
B
S2
C
S3
D
S4
Question 2

STEM 2 OF 4

Select all the factors below that are most likely to have contributed to this patient's presentation
A
Group A streptococcus infection as a child
B
Cross-reactivity of myocytes to antibodies
C
Degeneration associated with age
D
Deposition of calcium within the leaflets
E
A connective tissue disorder
Question 3

STEM 3 OF 4

Which singular test would best confirm the diagnosis in this patient?
A
ECG
B
FBC
C
LFT
D
ECHO
E
CXR
Question 4

STEM 4 OF 4

Which is the first line management of this patient?  Select all that may apply. 
A
Furosemide
B
Amiloride
C
Indapamide
D
Isosorbide mononitrate
E
Balloon valvuloplasty
Question 5

STEM 1 OF 6

A middle-aged female presents with chronic cough, shortness of breath that is progressing and pain exacerbated with inhalation.  On examination, bilateral lung base crackles are heard and JVP is slightly raised.  A diastolic murmur is heard within the left axilla.

What is the most common cause of this patient's complaint?
A
Group A streptococcus
B
Group B streptococcus
C
Viridans streptococci
D
Staphylococcus aureus
E
Pseudomonas aeruginosa
Question 6

STEM 2 OF 6

The patient's pulmonary capillary wedge pressure is raised significantly.  What is the direct cause of this?
A
Right atrial hypertrophy
B
Right ventricular dilation
C
Left atrial hypertrophy
D
Left ventricular dilation
E
Right atrial dilation
Question 7

Stem 3 of 6

What is the best matched diagnosis in this patient?
A
Aortic stenosis
B
Aortic regurgitation
C
Infective endocarditis
D
Mitral stenosis
E
Mitral regurgitation
Question 8

STEM 4 OF 6

Given the diagnosis previously, what is the most common ECG finding you would expect?
A
Absent P wave
B
PR internval contraction
C
Saw-tooth phenomenon
D
Prolonged QTc
E
Tented T waves
Question 9

STEM 5 OF 6

When is the timing of the murmur best heard?
A
Pandiastolic
B
Early diastole
C
Mid diastole
D
Late diastolic
E
Ejection diastolic
Question 10

Stem 5 of 6

The patient is deemed to have severe symptomatic disease after echocardiography.  What is the first line management in this patient?
A
Surgical valvular replacement
B
Balloon valvuloplasty
C
Furosemide
D
Atenolol
E
Nifedipine
Question 11

BONUS QUESTION


Further information: The patient is known to be normotensive with no history of stroke or cardio-vascular disease.
Given this further information, what would you add to their long term management?
A
Propanolol
B
Ramapril
C
Warfarin
D
Tranexamic acid
E
Nothing
Question 11 Explanation: 
The patient may be at risk of AF and indeed, therefore, of a stroke. However, using CHA2DS2-VASc scoring, the patient scores a 1 due to sex. She is at low risk of thromboembolic events (1.3% per year without medication). You could consider warfarin, though this is at clinical discretion. NB: her ACPO is reversible with medication and surgery, thus she does not gain the point of CHF.
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