Valvular Heart Disease: Dynamic Auscultation

by Carlo Raj, MD

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    My students always ask me "Dr. Raj, an attending who asked me what it meant to clench one's fist, in the intensity of its murmur whether it is increased or decreased and I always got that question wrong and then I always went to the back of the class and I felt so that I could come up and answer me questions properly." So what we will do here as we go through dynamic auscultation as continued building up your confidence so that whatever environment that you are in that you are able to fill confident about your answer because you are walking through every aspect of the pathophys. So, up until now we have talked about inspiration, expiration, clenching of the fist and squatting and we've put that into different categories and diagnoses and it is kind of been plastered all over sporadically. So let us take all of these maneuvers and put them all together and organize it so that for one final time we have all of it in one place. Wouldn't that be nice? So, if it is respiration, and you are doing inspiration, the diaphragm is going to move downwards. It contracts. It causes then your thoracic portion to decrease and it becomes or behaves more like a vacuum. And so therefore, the sucking up blood into the right side and so, therefore, the murmurs on the right side will be increased in intensity, as simple as that. When you exercise, you are causing what? You are causing your aterials to vasodilate so that you increase amount of blood flow to the skeletal muscles that are also starving for oxygen. And then in the meantime causing venoconstriction resulting in increased venous return to the right side. And so, therefore, murmurs caused by blood flow across...

    About the Lecture

    The lecture Valvular Heart Disease: Dynamic Auscultation by Carlo Raj, MD is from the course Valvular Heart Disease. It contains the following chapters:

    • Overview of Dynamic Auscultation
    • Hypertrophic Obstructive Cardiomyopathy
    • Diagnosis
    • Overview of Changes in Murmurs
    • Summary of Dynamic Auscultation

    Included Quiz Questions

    1. Pulmonic stenosis.
    2. Aortic stenosis.
    3. Aortic regurgitation.
    4. Hypertrophic obstructive cardiomyopathy.
    5. Mitral stenosis.
    1. Exercise
    2. Standing
    3. Handgrip
    4. Squatting
    5. Amyl nitrate
    1. It often presents in obese patients.
    2. It is the result of an autosomal dominant gene in 60% of cases.
    3. It is due to an dynamic outflow tract obstruction.
    4. It is due to asymmetrical hypertrophy of the left intraventricular septum.
    5. It can be auscultated in the same area as aortic stenosis.
    1. Beta blockers - decreases chronotropy and decreases inotropy
    2. ACE inhibitors - decreases volume overload improves
    3. Digoxin - increases inotropy and decreases chronotropy
    4. Calcium channel blockers - decreases dromotropy, inotropy and chronotropy
    5. None of the above
    1. 3rd intercostal space, left parasternal border.
    2. 2nd intercostal space, right parasternal border.
    3. 2nd intercostal space, left parasternal border.
    4. 5th intercostal space, midclavicular line.
    5. None of the above.
    1. Both murmurs will increase in intensity with decreased venous return.
    2. Both involve obstruction of the aortic outflow tract from the left ventricle.
    3. Both are systolic murmurs.
    4. Both murmurs will decrease in intensity with isometric handgrip.
    5. Both can cause changes to pulse rhythms.
    1. Pulsus bigeminus
    2. Pulsus parvus et tardus
    3. Pulsus alternans
    4. Pulsus paradoxus
    5. Corrigan's pulses.
    1. Systolic ejection-type crescendo-decrescendo murmur.
    2. Diastolic decrescendo murmur
    3. Opening snap followed by diastolic low-pitched decrescendo murmur
    4. Blowing holosystolic murmur.
    5. Continuous machine-like murmur.
    1. Amyl nitrate increases afterload.
    2. Isometric handgrip increases afterload.
    3. Valsalva phase II decreases preload.
    4. Rapid squatting increases preload.
    5. Exercise increases preload and decreases afterload.
    1. Aortic stenosis
    2. Ventricular Septal Defect
    3. Aortic regurgitation
    4. Mitral regurgitation
    5. Patent ductus arteriosus
    1. Standing
    2. Handgrip
    3. Passive leg raising
    4. Rapid squatting
    5. Amyl nitrate
    1. Aortic regurgitation will decrease in intensity.
    2. Mitral valve regurgitation will increase in intensity.
    3. Ventricular septal defect will increase in intensity.
    4. Hypertrophic obstructive cardiomyopathy will decrease in intensity.
    5. Mitral valve prolapse will decrease in intensity.

    Author of lecture Valvular Heart Disease: Dynamic Auscultation

     Carlo Raj, MD

    Carlo Raj, MD

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    Thumbs up! Dr. Raj.
    By LAVON E. on 12. February 2017 for Valvular Heart Disease: Dynamic Auscultation

    Excellently presented and directly inline with my PDI course lectures...