ECR 2 Lab

Cardiac Exam-Murmurs

ECR 2 Lab-Cardiac Exam-Murmurs

This week, lab will be held in the IPEC small group rooms and will make use of software
and the Smart Boards as a way to learn the cardiac physical exam. Your objectives for
this lab session are:
1. Recognize phases of the cardiac cycle and their relation to the heart sounds.
2. Recognize arterial and venous pulsations in the neck
3. Describe the attributes of heart murmurs (timing, location, radiation,
intensity/grading, pitch, quality)
4. Describe history, physical exam, murmur description, and murmur changes with
maneuvers for the following valvular conditions: Aortic Stenosis, Hypertrophic
Obstructive Cardiomyopathy, Ventricular Septal Defect, Mitral Valve Prolapse,
Mitral Regurgitation, Tricuspid Regurgitation, Aortic Regurgitation, and Mitral
Stenosis.
In preparation for lab, please complete the questions related to each scenario as
instructed. Completion of the questions is mandatory and will count as Project #5.
In order to receive full credit, you must submit your project via the Drop box on
D2L by 11:59pm (CST) on Sunday, November 2, 2014.
The scenarios/questions will be used in the sessions to assist in learning of the materialyou may want to have access to the project during the session.
Bring your stethoscopes-you will listen to heart sounds, extra heart sounds and
murmurs.

Resources:
Bates 11th edition: pp. 376-385, Tables 9-7, 9-8, 9-9, 9-10, 9-11 (10th edition pp. 361370). (Copies on reserve in Boxer Library)
Symptom to Diagnosis, 2nd edition: pp. 423-424, 435-437. (Available through Access
Medicine in Boxer Library Electronic Resources)

ECR 2 Lab
Cardiac Exam-Murmurs

Project #5
Complete the questions for each scenario. Please refer to the Project grading rubric in the
syllabus posted on D2L.

1. A 74 year old man presents to the emergency room with an episode of syncope. He has
noticed exertional chest pain and dizziness while playing golf the past few months.
Today, he passed out while walking to the green on the 4th hole.
Physical examination: Temperature 98.6 F, RR 16. While supine, BP 120/80, HR 90 and
after standing for three minutes, BP 120/90, HR 90. Neurological and pulmonary
examinations are normal. Cardiac examination reveals a systolic murmur best heard at
the right upper sternal border radiating to the carotid arteries, an S4 heart sound, an
inaudible S2 heart sound, and a weak and delayed carotid impulse. Laboratory studies are
normal.
A. What is the most likely diagnosis?
B. Describe how both the history and physical exam findings (normal and abnormal)
support your diagnosis:
History:
Physical Exam:

2. A 16 year old boy with no significant past medical history presents to his primary care
physician for a physical exam prior to participating in high school soccer. He has no
physical complaints.
His blood pressure is 115/85, heart rate 80, respirations 12, and he is afebrile. His
physical examination reveals normal lung sounds, S1, S2 with no extra heart sounds and
normal jugular venous pressure. There is a V/VI holosystolic murmur with a thrill at the
left lower sternal border that does not change with inspiration.
A. What is the most likely cause of his heart murmur?
B. Describe how both the history and physical exam findings (normal and abnormal)
support your diagnosis:
History:
Physical Exam:

ECR 2 Lab
Cardiac Exam-Murmurs

3. A 17 year old male with no significant past medical history passes out while playing
basketball. He states that he was feeling a little dizzy prior to the event, but denies any
chest pains or palpitations. Nothing like this has ever happened before. His father died
suddenly at age 35 of what was thought to be an acute myocardial infarction.
On examination, his blood pressure is 115/85, heart rate 80, respirations 12, and he is
afebrile. His physical examination reveals normal lung sounds, S1, S2, and a II/VI midsystolic cresendo-decresendo murmur heard best near the sternum at the L 3rd and 4th
interspaces. He has a sustained point of maximal impulse and his carotid pulse has a
rapid upstroke.
A. What is the most likely diagnosis?
B. Describe how you would expect the murmur to change with the valsalva maneuver,
standing and squatting:
Valsalva (strain phase):
Standing:
Squatting:

4. A 36 year old woman with no past medical history presents to her primary care office
with a complaint of chest pains and palpitations for the past few months. The pain is
substernal, pressure-like, and radiating to her left arm. It can last for minutes or hours at a
time.
Her blood pressure is 120/80, heart rate 80, and respirations 20. Physical examination
reveals normal lung sounds, no murmurs, and a mid-systolic click at the left lower sternal
border and the mitral area. Her ECG is normal.
A. What is the most likely diagnosis?
B. Describe how you would expect the mid systolic click to change with standing and
squatting:
Standing:
Squatting:

5. A 60 year old woman presents with dyspnea, orthopnea, and lower extremity edema.
She has a history of coronary artery disease and was hospitalized 6 months ago with an
acute inferior wall myocardial infarction.
Examination reveals bibasilar crackles, regular rate and rhythm, normal S1 and a loud S2.
An S3 is present and jugular venous pressure is estimated at 10 cm (5 cm above the
3

ECR 2 Lab
Cardiac Exam-Murmurs

sternal angle). There is a IV/VI holosystolic murmur heard best at the apex that radiates
to the axilla. The murmur does not change with inspiration.
A. What is the most likely cause of her heart murmur?
B. Describe how both the history and physical exam findings support your diagnosis:
History:
Physical Exam:

6. A 25 year old woman who is 20 weeks pregnant presents with dyspnea and
hemoptysis. This is her first pregnancy. She denies chest pain, palpitations, fever, or leg
pain.
Her temperature is 37.0 C, blood pressure 110/60, heart rate 100, respirations 24, and
oxygen saturation 95% on room air. Cardiac examination reveals a loud S1 and an
opening snap followed by a mid-diastolic murmur heard best at the apex with the bell of
the stethoscope.
A. What is the most likely valvular disease?
B. What is the most common cause for her valvular disease?
C. Explain the loud S1