split, simple. Let us take a look at our
chest and how important
is this? Really important. So take a deep
breath. Stick with me and I am going to walk you
through this. Alright, now as we go through this, I would
like for you to point to your own chest where
we are. By looking at this, well remember a mirror
image. So we have aorta. The aortic valve
would be right parasternal second intercostal
space. Are you pointing to it? That is where it is,
why? Do this for me. Here is your left ventricle and you have
your aortic arch, anatomy. So where is my aortic
valve? Right second intercostal space. What
about the pulmonic valve? Second intercostal
space, left parasternal. Where is your right
ventricle? Down by the parasternal on the
left side and so, therefore, pulmonic valve
will be here. Are we clear? That is normal.
We are not doing any pathology right now.
I want you to go into the fourth intercosal
space now. We are still on the right side
of the heart. Picture that, conceptualize
that for me. Good. And fourth intercostal space left
parasternal, that's your tricuspid, T. Then we have
our mitral. All these you talked about in
anatomy, physio. Now we are going to put these
together and put some pathology studies. Your
mitral is going to be where please? Apex. Where
is your apex located in normal heart? Fifth
intercostal space, midclavicular, right about
here. How many times have we talked about
midaxillary? A few times. There will be a
lateral displacement. Automatically gives
you what? You are thinking about cardiomegaly
or whatever reason. But fifth intercostal
space midclavicular is your mitral. Alright, normal.
Let us put in some pathologies. So begin with
the systolic murmur here, right aortic side.
With an aortic side, who is your patient?
I'm just going to give you one little clue clinically
for each one of these major murmurs and then
we will get into these in greater detail as
we get into valvular pathology. Okay.
Not to worry.
Aortic stenosis. "Hey doc, 32-year-old and
feeling tired at walking a few blocks, may or
may not have chest pain. When I walk with
my dog and after a few blocks, I feel tired and
I feel little dizzy, chest pain. But then I
stopped and it goes away." Or the patient may
not have chest pain. But does he feel fatigue?
Maybe a little bit of dizziness. Next, upon
cardiac auscultation, you hear a murmur second
intercostal space right parasternal and you hear
the murmur radiating up into carotid. Diagnosis,
right off the bat, aortic stenosis. Tell me
about this patient. Wow! Walking the dog
felt tired, maybe perhaps chest pain maybe
not. What is all that about? If you have aortic
stenosis, tell me about stenosis, rigid aortic
valve. It doesn't want to open. So what happen
to cardiac output? We have decreased cardiac
output. How are you going to feel? Not too
great. You may find a little tired or maybe
perhaps there might be angina. We will talk
about this and tell me about the murmur. Where
was it radiating to? Radiating up into the
carotid. Not the blood. Your patient wasn't
doing this. Yes sir. The patient wasn't doing that.
That's aortic regurg.
We will come to that later okay. Right now,
aortic stenosis. Don’t worry all I am
doing is introduction. You expect to hear
that where? Right second intercostal. What
about some of these others? Aortic valve sclerosis
as the differential and a flow murmur with
increased amount of blood passing through
Let us move on to another one. Another area
here would be your pulmonic area. Where am
I? Second intercostal left parasternal.
Here you might be thinking about pulmonic
stenosis. Differential? Maybe something like tetralogy
of Fallot, pulmonic stenosis or maybe it was
an infection. Really? What kind? Tell me a virus
that may result in pulmonic stenosis. You're
telling me. Rubella. Let's continue, and then we have in the
tricuspid area, we are going to divide this as
and you want to do the same please so that
you keep your thoughts organized, systolic
and diastolic, and I want to walk through the
easy one first.
Let us do systolic first. First where am I?
Fifth intercostal and left parasternal. Stick
with me. Lot of information, this will be
repetitious and I will keep reinforcing it
but it begins with understanding where you
are as integrate. That is the name of the game. So here
let us begin with tricuspid regurg. How do
that occur? Maybe it is due to an IV drug
abuser or maybe there was issues with the carcinoid.
Okay anyhow, you are on the right side of the
heart, left parasternal fifth intercostal
and it is a systolic murmur. What does that
mean to you? That means that the tricuspid valve
does not want to close. Which way does it
normally close? The tricuspid valve, here
is my right ventricle and here is my tricuspid
valve and here is my right atrium. And the
valve was supposed to close this way, but
it does not close properly and it just opens
up during systole. What does that mean to
you in terms of your murmur? Between S1 and
S2, you can hear all the systolic murmur.
We will be spending time with that. Not to worry.
Where am I? Left parasternal fifth intercostal.
VSD, very common. One of the most common congenital
heart diseases is the ventricular septal defect
and that will be a systolic murmur. What kind
of shunt is this please? It is a left to right
shunt. "But Dr. Raj, why did you say in tetralogy
of Fallot, that there is a right to left shunt
when that patient had a ventricular septal
defect?" In tetralogy of Fallot, did you
have a VSD? Yes, you do. Why is there a right
to left shunting and here you're telling me it is left
to right? Because, in tetralogy of Fallot,
you had number 1 pulmonic stenosis resulted in right
ventricular hypertrophy. You did have a VSD
and the blood was rushing from the right ventricle
into left ventricle. There is a right to left
shunt. Here it is a left to right shunt.
This is not tetralogy. I am just strictly
saying VSD. Well with diastolic murmur, a
tricuspid stenosis. So here once again it
was IVDA meaning to say intravenous drug
abuser, staph auerus. I am injecting along
with my drug, staph. There it goes into my
vein. Fantastic. And my staph ends up on my
tricuspid valve. What is it going to do? It
causes complete stenosis. When is this supposed
to open, your tricuspid valve? During diastole,
but it is not. So, therefore, if you hear
a diastolic murmur after S2 and you are at
the fifth intercostal space, left parasternal,
welcome to tricuspid stenosis. Okay. Now let
us integrate atrial septal defect. We are going
to have fun here. Ready? Atrial septal defect.
What heart sound are you paying attention to? S2. With
S2, what kind of split is this? A physiologic
splt, a widened split or a fixed split? You
tell me. Fixed split. Blood was always rushing
from your left atrium into right atrium and,
therefore, S2, A2, P2 was always fixed between
your inspiration, expiration. It didn't change.
But that is a fixed split. How can you then
bring this into a diastolic murmur? Listen.
So now the blood is rushing into where? Into the right
atrium. Fantastic. When is the tricuspid valve
supposed to open? During systole or diastole?
Diastole. What is the definition
of a murmur? Increased turbulence across a
valve. With all this blood in the right atrium
and passing across a tricuspid valve, are
you not increasing your turbulence? Of course,
you are. Could you result in a diastolic murmur
at the fifth intercostal space, left parasternal?
Are you pointing to it? Please do it now.
At the atrial septal defect, now clinically
you can go one step further, that mean to
say that eventually you might find issues up by
the pulmonic area as well. That must be understood.
But go step by step, builds upon a foundation
so that you never crumble. If your foundation
is never strong like a building, what is going
to happen? Have a tornado. What have you and
then the building is gone. Because the foundation
was weak. Your foundation is strong, no matter
what they throw at you, the attending, licensing
board, you are guaranteed to get that question
right because your foundation is solid.
And that's what we're going to build here together.
Let's continue. And finally, we have our mitral area. Where are
you? Fifth intercostal space and you're at the
midclavicular. Pretty straightforward, but
these will be a mitral valvular issues and
we will get into greater detail. You all know
about mitral regurg, take your time. The mitral
valve is supposed to close from the left ventricle
towards left atrium and if it doesn't close
properly, you have a holosystolic murmur between
S1 and S2, don't you? And where would you hear
this? By the fifth intercostal space and by
the midclavicular or mitral stenosis. If
you have mitral stenosis, let's say chronic rheumatic
heart disease. Chronic rheumatic heart disease
may result in mitral stenosis. The mitral
valve doesn't want to open, even opening snap,
it's a middiastolic murmur and then you have
this particular murmur taking place at the
same location. Fifth intercostal space, midclavicular.
I sound like a broken record but
it is okay. Keeps saying this over and
over again so my voice haunts you whenever
you might be posed with the question.
And then finally we have PDA, patent ductus arteriosus. What happened
here? The ductus arteriosus is sitting closed
and so, therefore, close your eyes. Tell me
about this ductus arteriosus. What are you
connecting? You are connecting the aorta to
the pulmonary artery. You with me? The aorta with the pulmonary
artery is what you are connecting. And upon
birth, you have the ductus arteriosus still
open, then where is this blood going? The
blood is going from the aorta into the pulmonary
artery because you should know the systemic
pressure is quite high when compared to pulmonic.
So, therefore, what kind of murmur you are
going to have. What did I just do? That is
a machine murmur and at no point with my particular
rendition. Let us make an album called "Dr. Raj's
valvular heart sounds". At no point
in my rendition of your PDA, could you differentiate
between S1 and S2, could you? You couldn't.
Welcome to PDA. We will be spending time, not
to worry, with the pathophys of every single
one in the valvular heart diseases and the
question that you might get would be one in
which you go on and there is the computer. You
have to put on headphones. You listen to the
heart sounds and they will ask you and they'll put
a chest on your screen. A, B, C, D, E so forth
and then they will ask you, well where exactly
on this chest would you expect to heart this
particular valvular heart sound?
Last few points here with our location of
a couple of important valvular heart diseases
and it could be a little tricky if you are
not paying attention so I really want you to look
at me and pay attention to what I am saying.
First and foremost, we are on the left parasternal,
approximate the third intercostal space, that
would be the best location. Let us talk about
the first one. This patient here is the one
that would be perhaps presenting with yes
sir. Head bobbing. I feel my radial pulse
in it, wow I can really feel it. It's bounding.
It is a bounding pulse. Aortic regurg is what
we're referring to. Now if there is aortic
regurg, give me some differentials of aortic
regurg. Maybe consgestive heart failure. Aortic
root is becoming dilated. Maybe this patient
has ankylosing spondylitis. Look at me. I
am pretty stiff as this, but when I bend over,
my back and my vertebrae have a proper curvature.
Okay if I was half my age and I was 20, I
just give way my age whatever. So if I was
20 and I was bending over and I didn't have
a proper curvature my vertebrae, what is my
diagnosis most likely? Ankylosing spondylitis.
Why am I bringing this up? Because with ankylosing
spondylitis what might be its associated
valvular heart disease? Aortic regurg. Do
not forget that. Please ever. My point is this.
Now I want you to think about that anatomy again,
of the aorta. So we have left ventricle, aorta.
If you have regurg, then blood is rushing
from the aorta, back into the left ventricle,
is it not? Of course it is. And this is occurring
when? During diastole, isn't it? Because during
diastole is the one that aortic valve should
close. Don’t worry we will go through all
this again, but I am just putting all this
together for you because this is how good
you need to be. So now you have after S2,
early diastolic murmur moving towards the
apex so, therefore, aortic regurg would be
expected to be heard best at the third intercostal
space, left parasternal. So what kind of question
might you get? While you walk in and you have
your headphones and they give you a chest on the
screen and the chest on the screen will have
A, B, C, D, E. And then you'll have to listen
to the heart sound and then you would have
to locate where exactly on the chest you would
hear aortic regurg in this or where it would
be? A diastolic. Now if it was pulmonic
regurg, pretty straightforward.
Pulmonic regurg, you had the second intercostal
space left parasternal and you are going to
regurg back into right ventricle so that you
would expect to hear it around here as well.
Third intercostal space, left parasternal.
Then we have this patient. If this was a young
patient, not obese, no rheumatic heart disease,
no bicuspid aortic valve, none of those issues,
but was an athlete. Maybe a volley ball player,
maybe a tennis player and when they are going
for their volley either for the ball, well
they fall. And when they fall, they will never
get back again. They will never get back up,
sudden death. That is sad. This then brings
us to an unfortunate pathology called hypertrophic
obstructive cardiomyopathy. What does that
mean? What obstructed the outflow tract of
what? Close your eyes. What's obstructed
is the outflow tract from the left ventricle
towards the aorta. You with me? So, therefore,
where would you expect to hear this murmur,
the systolic murmur when the blood is trying
to be ejected? Once again third intercostal
space approximally left peristernal. Hope that
is clear. Last point here brings us to rapid squatting.