Murmur Madness: The Audio PANCE and PANRE Episode 45

Welcome to episode 45 of the FREE Audio PANCE and PANRE Physician Assistant Board Review Podcast.

Today we are going to take a brief detour away from 10 daily questions and instead cover the murmurs you need to know for your PANCE and PANRE exam.

I have still included an 11 question exam at the end of this post so make sure you scroll down after you listen to the podcast.

There are a total of 17 cardiac conditions that may present on exam day in the form of a descriptive sound/murmur.

You will often be given supporting evidence such as the location of auscultation or radiation which you can use to narrow down your options.

There are total of 51 cardiac topics in the NCCPA™ Cardiology PANCE and PANRE Content Blueprint which represents 16% of the PANCE and PANRE exam.

(click here to download the FREE NCCPA Content Blueprint cheat sheet)

These cardiac conditions and their associated murmurs cover a whopping 33% of the cardiology section of the PANCE and PANRE exam!

Take a listen to this week's podcast episode

If you can't see the audio player click here to listen to the full episode.

Let's break this all down:

Each of the links below opens the corresponding lesson on SmartyPANCE and is available to members (you must be logged in or join now)

There are 9 valvular disorders associated with murmurs:

Valvular Disorders (PEARLS and Flashcards)

Five congenital heart diseases that have corresponding murmurs

Congenital Heart Diseases (PEARLS)

One murmur associated with cardiomyopathy

Hypertrophic cardiomyopathy

And a pair of conditions nested under the label of "other forms of heart disease" that have associated murmurs/heart sounds worth mentioning

Other Forms of Heart Disease (PEARLS)

Making Sense of Murmurs

Let's start with the valvular disorders:

You have 4 heart valves with two main conditions - half are diastolic murmurs and half are systolic murmurs. Here is a helpful mnemonic:

Recalling Common Systolic Heart Murmurs: MR PASS

M itral
R egurgitation
P hysiologic (also known as functional, systolic flow murmur, a heart murmur heard in the absence of cardiac abnormality)
A ortic
S tenosis
S ystolic - All the above murmurs are heard during systole.

MR PASS wins the Most Valuable Player award.

M itral
V alve
P rolapse - Add MVP as another systolic murmur.

MR PASS often hangs around with MS ARD.

M itral
S tenosis
A ortic
R egurgitation
D iastolic - All the above murmurs are heard during diastole.

**Here are the nine valvular murmurs and their associated descriptions**

Remember which are systolic and diastolic this can be very helpful at ruling out or ruling in a condition come exam day.

Aortic Stenosis - Systolic harsh ejection crescendo decrescendo murmur at RUSB (aortic area) with radiation to the neck and apex
Aortic Regurgitation - diastolic - soft high pitched blowing at LSB with patient sitting leaning forward and exhaling
Mitral stenosis - diastolic - low pitched decrescendo rumbling with opening snap at the APEX (the mitral area) enhanced by expiration
Mitral regurgitation - blowing holosystolic murmur loudest at the APEX (the mitral area) with a split S2 that radiates to the axilla and is increased by squatting, handgrip and expiration
Tricuspid Stenosis - diastolic - mid diastolic rumbling at LLSB (tricuspid area) with opening snap
Tricuspid regurgitation - High pitched holosystolic blowing murmur that radiates to the LSB (tricuspid area)
Pulmonic stenosis - harsh midsystolic ejection crescendo-decrescendo murmur with widely split s2 at LSB that radiates to the left shoulder and neck
Pulmonic regurgitation - diastolic - high pitched, decrescendo murmur at LUSB increase with inspiration
Mitral valve prolapse - Midsystolic ejection click head best at the APEX (the mitral area)

With these valvular murmurs you have 4 auscultation points which can be easily remembered using the mnemonic APT Ment watch this amazing video so you never forget!

Another helpful mnemonic: Aortic Pulmonic Tricuspid Mitral - A ll P hysicians T ake M oney!

Aortic area: right 2nd interspace (Right upper sternal border RUSB)
Pulmonic area: 2nd left interspace (Left upper sternal border LUSB)
Tricuspid area: Left lower sternal border LLSB
Mitral area: APEX

You can use the auscultation point to successfully narrow down your murmur and use the designation of systolic or diastolic to narrow down even further.

Five congenital heart diseases that have corresponding murmurs

Congenital Heart Diseases (PEARLS)

Atrial septal defect - Systolic ejection murmur at 2nd left intercostal space with an early to mid-systolic rumble and fixed splitting of the 2nd heart sound (s2) and CXR will show pulmonary vascular markings.
Coarctation of the aorta - Late systolic ejection murmur-posterior or continuous murmur if collateral flow. Will have absent or weak femoral pulses with a delay of palpable femoral pulse and HTN in arms but low or normal blood pressure in the legs
Patent ductus arteriosus - Continuous, rough, machinery-like murmur, heard best in the first interspaces of the LSB
Tetralogy of Fallot - Harsh systolic ejection murmur heard best at the left sternal border. Associated with bluish skin, trouble gaining weight, and sudden loss of consciousness during crying or feeding
Ventricular septal defect - Harsh high pitched holosystolic murmur heard best at the LSB with ride radiation and a fixed split S2

One murmur associated with cardiomyopathy

Hypertrophic cardiomyopathy - Medium-pitched, mid-systolic murmur that decreases with squatting and increases with straining. S4 gallop and apical lift with thick, stiff left ventricle. HCM is the leading cause of sudden death in athletes and may cause angina.

Several of these conditions have a "tell" that make it easy to identify the condition and they are usually always part of the question stem

HOCM Sudden death in athlete
Atrial Septal Defect Fixed wide splitting of S2
Coarctation of Aorta X-Ray, Rib notching, absent or weak femoral pulses with a delay of palpable femoral pulse and HTN in arms but low or normal blood pressure in the legs.
PDA Machine like murmur
Tetralogy of Fallot Cyanosis with crying or feeding
VSD Holosystolic Murmur

And a pair of conditions nested under the label of "other forms of heart disease" that have associated murmurs/heart sounds worth mentioning

Other Forms of Heart Disease (PEARLS)

Acute and subacute bacterial endocarditis - A new mitral regurgitant murmur in a patient with a history of IVDA, fever (39.0º C),* and a blood culture that reveals 2 out of 2 positive growth
Acute pericarditis - Although this is not a murmur, it is important to identify a pericardial friction rub heard best with patient upright and leaning forward. Chest pain is also relieved by sitting and/or leaning forward

You can listen to all these murmurs and see their associated waveforms at www.smartypance.com/courses/cardiology

Here is a wonderful video from the Khan Academy of how to approach murmurs video of murmurs

Murmur Flash Cards

Episode 45 PANCE and PANRE Murmur Quiz

You will see from these questions on the PANCE and PANRE things aren't always so straightforward.

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Congratulations - you have completed Murmur Madness. You scored %%SCORE%% out of %%TOTAL%%. Your performance has been rated as %%RATING%%

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Question 1

An elderly female presents for evaluation of exertional syncope, dyspnea, and angina. She admits that previous to these symptoms she had insidious progression of fatigue that caused her to curtail her activities. Which of the following is the most likely diagnosis?

A	Aortic stenosis
B	Aortic regurgitation Hint: Patients with aortic regurgitation are likely to complain of an uncomfortable awareness of their heart, especially when lying down. These patients develop sinus tachycardia with exertion and complain of palpitations and head pounding with activity.
C	Mitral stenosis Hint: The symptoms related to mitral stenosis are related to increased pulmonary pressure after the left atrium can no longer overcome the outflow obstruction.
D	Mitral valve prolapse Hint: Patients with mitral valve prolapse are typically asymptomatic throughout their lives, although a wide range of symptoms is possible. When symptoms do occur, palpitations from arrhythmias are most common along with lightheadedness. Syncope is not part of this disease process.

Question 1 Explanation:

The major symptoms of aortic stenosis are exertional syncope, dyspnea, and angina. Symptoms do not become apparent for a number of years and usually are not present until the valve is narrowed to less than 0.5 cm to 2 cm of valve surface area.

Question 2

A 37 year-old female with history of Turner's syndrome and coarctation of the aorta repaired at the age of 3 presents for routine examination. The patient is without complaints of chest pain, dyspnea, palpitations, or syncope. On examination vitals signs reveal a BP of 130/76, HR 70, regular, RR 16. On cardiac examination you note a grade II/VI systolic ejection murmur at the left sternal border and a grade III/VI blowing diastolic murmur. Which of the following does this patient require?

A	Antibiotic prophylaxis
B	Beta blocker therapy Hint: Beta blocker therapy may increase the amount of regurgitation because of increased diastolic time and is not indicated in this patient.
C	Chest CT Hint: This patient should undergo serial echocardiograms, chest CT will not give information regarding any changes in the aortic regurgitation or ejection fraction.
D	Exercise Stress Test Hint: This patient is without any complaints; exercise stress test is not indicated.

Question 2 Explanation:

This patient has a history of congenital heart disease and presently has a murmur consistent with aortic regurgitation. This patient requires antibiotic prophylaxis against infective endocarditis.

Question 3

A patient had an acute inferior, transmural myocardial infarction 4 days ago. A new murmur raises the suspicion of mitral regurgitation due to papillary muscle rupture. Which of the following murmur descriptions describes this condition?

A	A grade III/VI diastolic murmur heard best at the apex without radiation. Hint: This is a classic description for mitral valve prolapse.
B	A grade IV/VI systolic ejection murmur heard best at the base with radiation to the left clavicle. Hint: This is a classic description for mitral valve prolapse.
C	A grade II/VI systolic murmur heard best at the apex preceded by a click and without radiation. Hint: This is a classic description for mitral valve prolapse.
D	A grade IV/VI systolic murmur heard best at the apex with radiation to the left axilla.

Question 3 Explanation:

This is a classic description of mitral regurgitation. The papillary muscle rupture is a complication of an acute inferior transmural myocardial infarction, and results in a failure of the mitral valve leaflets to close. The direction of regurgitant flow of blood is toward the left axilla.

Question 4

A 24 y/o waitress complains of generalized, sub-sternal chest pain that is worsened with exertion. She appears anxious; she denies ETOH, tobacco and illicit drug use. You auscultate her heart and diagnose mitral valve prolapse. What did you hear to make this diagnosis?

A	A diastolic rumble
B	A holosystolic click
C	A midsystolic click
D	An opening snap Hint: An opening snap is associated with tricuspid valve and mitral valve stenosis

Question 4 Explanation:

The murmur of mitral valve prolapse is described as a MIDSYSTOLIC EJECTION CLICK heard best at APEX

Question 5

A 23 year-old male presents with syncope. On physical examination you note a medium-pitched, mid-systolic murmur that decreases with squatting and increases with straining. Which of the following is the most likely diagnosis?

A	Hypertrophic cardiomyopathy
B	Aortic stenosis Hint: Straining decreases the intensity of the murmur associated with aortic stenosis and squatting increases the intensity.
C	Mitral regurgitation Hint: Mitral regurgitation is characterized by a blowing systolic murmur that radiates to the axilla, it is not often associated with syncope.
D	Pulmonic stenosis Hint: Pulmonic stenosis is a harsh systolic murmur with a widely split S2, and no change with maneuvers.

Question 5 Explanation:

Hypertrophic cardiomyopathy is characterized by a medium- pitched, mid-systolic murmur that decreases with squatting and increases with straining.

Question 6

Which of the following physical findings is suggestive of atrial septal defect?

A	Fixed split S2
B	Increased pulse pressure Hint: Pulse pressures reflect the difference in aortic and left ventricular volumes that occur during ventricular systole Increased pulse pressures are seen in aortic regurgitation which is a different entity than atrial septal defect.
C	Continuous mechanical murmur Hint: Continuous mechanical murmurs are noted in patients with patent ductus arteriosus.
D	Difference in blood pressure between the left and right arm Hint: Differences in blood pressure between the left and right arms are seen in conditions such as coarctation of the aorta.

Question 6 Explanation:

An atrial septal defect will cause a shunt of blood from the left to the right atrium. This will result in an equalization in the amount of blood entering both the left and right ventricles which effectively eliminates the normally wide splitting that inspiration typically causes in hearts without an atrial septal defect.

Question 7

A 12 year-old boy presents to the office with pain in his legs with activity gradually becoming worse over the past month. He is unable to ride a bicycle with his friends due to the pain in his legs. Examination of the heart reveals an ejection click and accentuation of the second heart sound. Femoral pulses are weak and delayed compared to the brachial pulses. Blood pressure obtained in both arms is elevated. Chest x-ray reveals rib notching. Which of the following is the most likely diagnosis?

A	abdominal aortic aneurysm Hint: Abdominal aortic aneurysm is usually asymptomatic until the patient has dissection or rupture. It is uncommon in a child.
B	pheochromocytoma Hint: Pheochromocytoma classically causes paroxysms of hypertension due to catecholamine release from the adrenal medulla, but does not cause variations in blood pressure in the upper and lower extremities.
C	coarctation of the aorta
D	thoracic outlet syndrome Hint: Thoracic outlet syndrome occurs when the brachial plexus, subclavian artery, or subclavian vein becomes compressed in the region of the thoracic outlet. It is the most common cause of acute arterial occlusion in the upper extremity of adults under 40 years old.

Question 7 Explanation:

Coarctation is a discrete or long segment of narrowing adjacent to the left subclavian artery. As a result of the coarctation, systemic collaterals develop. X-ray findings occur from the dilated and pulsatile intercostal arteries and the "3" is due to the coarctation site with proximal and distal dilations.

Question 8

You are asked to evaluate a term infant in the delivery room. He was born a few minutes earlier by spontaneous vaginal delivery with Apgar scores of 9 and 9. The mother had good prenatal care and a normal pregnancy. No significant family history is noted. On physical examination, the infant appears alert and is active and crying. Acrocyanosis is noted on extremities. A grade 2/6 soft, systolic murmur is audible at the left upper sternal border. Otherwise, the examination is completely normal. What should be your next step in the management of this patient?

A	order an echocardiogram Hint: See B for explanation
B	perform a second detailed physical exam at 24 hours
C	order an ECG and chest radiograph Hint: See B for explanation
D	get a cardiology consultation Hint: See B for explanation

Question 8 Explanation:

This is the transient systolic murmur of patent ductus arteriosus. It is audible at the upper left sternal border and in the left infraclavicular area on the first day, and it usually disappears soon thereafter. As in older infants and children, not all heart murmurs in neonates are pathologic. More than 50% of term-born infants are found to have innocent systolic murmurs at some time during the first week of life. The prevalence is even higher in premature infants. The incidence of structural congenital heart disease is estimated to be less than 1% of all live births. The infant should have a detailed examination at 24 hours and again before discharge before any further decisions are made. Acrocyanosis, a normal phenomenon, should also be distinguished from central cyanosis.

Question 9

A 10-month-old girl was admitted to the hospital for cardiac catheterization. Her history included cyanosis noted at about 6 weeks of age, increasing over the last 7 months and becoming more severe with crying or physical activity. The chest x-ray demonstrates a "boot shaped heart" A presumptive diagnosis of tetralogy of Fallot (TOF) was made on admission. TOF has 4 components, which of the following below is not part of the diagnosis?

A	Pulmonary valve stenosis
B	VSD
C	Overriding aorta
D	Right ventricular hypertrophy
E	ASD

Question 9 Explanation:

In 1888, Fallot described a congenital heart defect composed of four characteristics (a) large ventricular septal defect (VSD) (b) right ventricular outflow obstruction (pulmonary valve stenosis) (c) overriding aorta (d) right ventricular hypertrophy. The main characteristic of TOF is cyanosis. Hypercyanotic spells or "tet spells" are paroxysmal episodes in which the cyanosis acutely worsens. Crying, feeding, or defecating can bring on these episodes.

Question 10

Which of the following medications is indicated in the treatment of patent ductus arteriosus?

A	prednisolone Hint: steroids such as prednisolone and dexamethasone are not used in the treatment of PDA
B	dexamethasone Hint: See A for explanation
C	indomethacin
D	cyanoacrylate tissue adhesive Hint: another name for this is "dermabond" and it is not indicated in the treatment of PDA

Question 10 Explanation:

Give premature infants a prostaglandin inhibitor (eg, indomethacin) to close the PDA; surgical closure has not been shown to improve outcomes. Prostaglandin inhibitors are usually ineffective in full-term infants, but catheter-delivered occlusion devices or surgery is typically beneficial.

Question 11

A 2-week-old infant is brought to your office by his mother for a checkup and establishment of care. They have just moved into the area, and you have not seen the baby before. The mother states that the baby was born at term and she had a normal pregnancy. On examination, the infant has a grade 3/6 harsh pansystolic heart murmur heard along the lower left sternal edge. There is no radiation of the murmur. The heart rate is 82 beats/minute and regular. There is no thrill. The blood pressure is 80/60 mm Hg. No other abnormalities are found on examination. The infant is in the 50th percentile for height and weight. What is the most likely cardiac diagnosis in this infant?

A	ventricular septal defect (VSD)
B	innocent cardiac murmur
C	tetralogy of Fallot
D	pulmonary atresia
E	coarctation of the aorta

Question 11 Explanation:

This infant most likely has a small VSD. Most commonly, the murmur is detected at 2 to 6 weeks of age when the infant returns for the initial checkup after hospital discharge. The typical heart murmur associated with a VSD is harsh, pansystolic, and best heard at the lower left sternal edge. Even as the VSD becomes smaller, it maintains its regurgitant characteristic of starting off with the first heart sound (holosystolic timing). As a VSD closes and becomes smaller, the murmur can actually become louder until the VSD is closed. Infants with small VSDs are well developed and acyanotic. Infants with large VSDs may have poor weight gain or show signs of congestive heart failure before 2 or 3 months of age.

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