Welcome to episode 97 of the Audio PANCE and PANRE PA board review podcast.
Today is a bonus episode rounding out this incredible five-part podcast series with Joe Gilboy PA-C, all about cardiac murmurs. In this week's episode, we continue our discussion of cardiac murmurs with ten PANCE and PANRE board review murmur questions.
We'll cover the ins and outs of all the NCCPA content blueprint valvular disorders and learn how to identify and differentiate them from one another.
Podcast Episode 97: Murmurs Made Incredibly Easy - 10 PANCE and PANRE Murmur Questions
Below is a transcription of this podcast episode edited for clarity.
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[00:00:00] Welcome back, everybody. This is Joe Gilboy. I work with Stephen Pasquini over there at Smarty PANCE. And today is the most dreaded podcast of all because you know what I'm going to do. That's right. I'm going to ask cardiac murmur questions.
And I know it's the most dreaded thing in the world. Let's do this together because what I want to try to do here is make sense of it all. So, let's just kind of recap some basic rules before we start going down this thing. You know, the previous lectures, what have I been barking about? What's Joe been saying? First - inspiration, right? Expiration left.
[00:00:40] Inspiration, right? Expiration left. So, with inspiration, the right-sided murmurs sound louder. So that's the tricuspid and the pulmonic valve regardless of if it's stenosis or regurgitation. Expiration - left. What am I saying? Everything on the left side sounds louder with expiration, whether it’s aortic or mitral - your call.
[00:01:01] It can be stenotic or regurgitation, it doesn't matter, but it'll sound louder. What is squatting? Squatting is a party. So, what are you doing? You're bringing it all the blood flow back home. And so, if I bring all the blood flow back home, just from a laminar flow physics point of view, I bring more blood flow back home to the heart, more blood flow over a valve specifically with a diseased disease valve, it sounds louder.
[00:01:29] So, right off the bat, squatting will do what? It's going to make all my murmurs sound louder. That's the whole point to decrease venous return. In other words, take blood flow away from the heart. What do I do? Well, those are going to be Valsalva and standing. So, what am I doing when I do Valsalva and standing?
[00:01:56] Taking blood flow away from the heart. So, what's going to happen to all my murmurs when I stand and perform Valsalva? It takes blood flow away from the heart. Exactly. And then hand grip. What did handgrip do? So, in school, what'd you learn about hand grip? Well, it increases afterload, right? So, what they're really saying to you is this, and this is how I want you to visualize it.
[00:02:18] When I do hand grip, what I'm really doing is this. You're right. I'm increasing the afterload. But you must stop and think this one out for a second, folks. What’s really in the heart? Which valve must fight afterload?
[00:02:39] Say you increase the peripheral vascular resistance for whatever reason. So, you increase the afterload, who fights it? And your answer will be... oh, wait for a second, Joe, that's the aortic valve in the left ventricle. Exactly. So, when I perform handgrip, who am I really challenging? Oh, I'm challenging the aortic valve and everything behind it.
[00:03:00] Exactly. So that's the point I need inside your head? Then remember our last podcast was about our low-volume lovers. Who were our low-volume lovers? Who were the special needs murmurs that really like low volume? They're like, hey, I like low volume, not high volume. I like low volume. Who was that?
[00:03:19] That was HOCM and mitral valve prolapse. What did they both like? They both like low volume. So, they're the opposite of all my regular murmurs. They go in the opposite direction. All right, everybody got that? I am not going to give you a list of answers. So, what I'm going to do is I want you to listen to what I'm going to say. I'm going to say the test question twice.
[00:03:47] And then I want you to pause the podcast. Just put it on pause and think about your answer before I explain it. All right. Is everybody with me? Because that's the best thing to do. All right, here we go.
Murmur Question #1:
[00:04:11] You have a 76-year-old gentleman that presents to your emergency room and comes in complaining of shortness of breath and chest pain on physical exam. You notice an upper sternal murmur that sounds louder with squatting and goes away with hand grip—one more time. Upper sternal border, sounds louder with squatting, and goes away with hand grip. Who am I?
[00:04:45] So upper sternal border. This will be my aortic and pulmonic area. Well, it goes away with hand grip. So, who's that going to be? So, what happens with hand grip? I increase my afterload. Which valve fights the afterload? The aortic valve. It's not pulmonic because the pulmonic valve is not fighting the afterload; it is fighting the lung. So, this has to be aortic stenosis, which makes sense for the syncope and the shortness of breath. So aortic stenosis is going to do what? Well, squatting, that's a party. Of course, it will sound louder. We could actually throw expiration in here as well, couldn't we? We sure could, but it's the handgrip. That differentiates it, doesn't it? Because the handgrip made the murmur go away. And what did the handgrip do? I keep telling you I want you to view handgrip like sitting on your aortic valve, and you can barely open up squeak, squeak, squeak, squeak.
[00:05:47] You can barely open up. Now imagine sitting on that valve. Can it open up now? And you're like, no, it goes away. Exactly. And that's the point I'm trying to make. The answer is aortic stenosis.
Murmur Question # 2
[00:06:21] I have a 45-year-old gentleman who comes in with shortness of breath and chest pain. The murmur sounds louder with inspiration. It's located at the upper sternal border. And I am also noticing that the patient has right ventricular hypertrophy and right bundle branch block on EKG. Who am I?
[00:06:44] Upper sternal border. Well, who are we talking about? The aortic valve or the pulmonic valve. Inspiration → right and expiration → left. So, this murmur sounds louder with inspiration, so I know that this is on the right side. Then it's got to be the pulmonic valve. And now they're telling me I've got right ventricular hypertrophy and right bundle branch block. Then blood must be backing up into the right ventricle.
[00:07:10] In other words, something must be backing up, which means the valve must be stenotic. Oh, I see your point. It's stenotic, and the right ventricle is going to hypertrophy. Remember if you take right ventricular hypertrophy and let it go unopposed. You stretch, and you stretch, and you stretch, and you stretch, and you dilate, and you stretch, and you dilate and stretch that wall.
[00:07:28] What are you going to get? The wires are going to get busted. That's right bundle branch block. For those of you thinking outside the box, and you're telling me, Joe, if I dilate my left ventricle and just stretch it and stretch and a bust, the wires, I get left bundle branch? Exactly. No, that's exactly what you're going to get. So the answer to the question is pulmonic stenosis.
Murmur Question # 3
[00:07:45] You have a young 32-year-old female who recently immigrated to the United States from Indonesia and is currently working and has now been complaining of increasing shortness of breath at work. On exam, you hear a murmur at the left sternal border. It sounds louder with expiration and appears to be diastolic in nature. Who am I?
[00:08:38] So again, left sternal border. So that's just about everybody but the pulmonic valve. The murmur sounds louder with expiration, so you know it will be on the left (louder with inspiration → right and louder with expiration → left). So, based on these parameters, I know I'm dealing with either the aortic valve or the mitral valve, and I am a diastolic murmur. So now you have to stop and think. So, this seems to be in the neighborhood of the mitral area, and it's a diastolic murmur.
[00:09:00] So it can't be mitral regurgitation. It has mitral stenosis, and that's the correct answer. And then, of course, as I always say, you'll see the test questions, do this all the time. They'll talk about people who immigrated to the United States. And what they're really saying to you is this. So, this lady most likely has some form of rheumatic fever.
[00:09:16] Maybe she had strep when she was a younger child and just wasn't diagnosed. So, what they're really sharing with you is this. As soon as I see the word immigrant, what they are really saying is this: Listen, this person is at high risk for TB. All right. That's the one thing that we kind of worry about.
[00:09:29] The second thing is that their care is not as structured as ours. In other words, they slipped through the cracks. Could this patient have had a previous strep throat and had rheumatic fever, which led her to the mitral stenosis? Of course, she could.
[00:09:44] And that was the whole point to it. But again, it is expiration → left, left sternal border. Just about everybody is at the LSB, so that doesn't really help. But it was on the left side. So, I know this is either going to be aortic or mitral. And then you told me it was diastolic, so this will fit mitral stenosis.
[00:10:06] So, just trying to get you to look at these murmurs differently. That's all just more from a laminar flow physics point of view.
Murmur Question #4
[00:10:15] Next question. I have a 67-year-old female who comes in with an upper sternal border murmur. This murmur increases in intensity when she is squatting, and with handgrip, it decreases intensity with Valsalva and standing.
[00:10:41] One more time. This murmur increases in intensity with squatting and handgrip and decreases in intensity with Valsalva and standing. Who am I?
[00:10:54] So let's think about this upper sternal border. So, what are we talking about? Pulmonic or aortic. They didn't tell me what side right or left did they? However, they told me that this murmur increases in intensity with squatting - that's everybody. So that's not helping me, but they said it increases in intensity with hand grip. Stop. No stop right here.
[00:11:06] Handgrip, who's that challenging? Pulmonic or aortic? Oh, that's aortic, Joe. I see your point. That makes so much sense. It's not pulmonic. So, this is going to be either aortic stenosis or aortic regurgitation.
[00:11:28] Well, let me think about this. You're telling me that this murmur sounds louder with handgrip, and wait a second, it's not shutting it off. It's making it worse. This means that the valve is wide open. Oh, then this must be aortic regurgitation, and that's the correct answer. And of course, you know, my low volume maneuvers - Valsalva and standing, of course, will make it go away. The answer is aortic regurgitation.
[00:11:51] So does everybody see this? I'm just trying to get you ready for the PANCE. But does every see how we're looking at this now? This is what I keep hammering away at, approach this not from a memorization point of view but a laminar flow physics point. Stop memorizing!
[00:12:07] Start trying to make sense of this because once you make sense of this, it will flow so much easier for you. Ignore those things you memorized in PA school, those little four squares, the graphs, etc.. I've seen it all in my 30 years of teaching. You can't teach me one more trick. And I laugh when I'm sitting here in my studio saying this to you because I know students better than students know students. And I get it, but I'm just trying to teach you what will help you the most on the boards.
Murmur Question #5
[00:12:36] Next question. I have a patient who is a 72-year-old gentleman with hypertension, diabetes, and coronary artery disease, who also smokes. He comes in complaining of increasing shortness of breath and bilateral leg swelling. He's got a murmur noted on physical exam in the upper sternal border. The murmur sounds louder with inspiration. Squatting makes it sound louder. Standing and Valsalva make it go away. And this murmur appears to be diastolic in nature. Who am I?
[00:13:31] Upper sternal border (pulmonic and aortic area) and louder with inspiration. So, I'm on the right (inspiration → right and expiration → left). This has got to be pulmonic. So, it’s going to be pulmonic stenosis or pulmonic regurgitation. He's a smoker. So, he's got some pulmonary hypertension. I get it. And this is a diastolic murmur. So, what pulmonary valve disorder is diastolic?
[00:13:51] You're going to go, oh, this has got to be pulmonic regurgitation. Exactly and wait a second. Oh, that makes so much sense. All that pulmonary hypertension, with COPD and stuff like that. Oh, that makes so much sense. And then he's going to have to fight it. And, of course, everything is going to back up into the right ventricle and then go to his legs. The answer is pulmonic regurgitation.
Murmur Question #6
[00:14:27] Next question. I have a 37-year-old female with a previous history of mitral valve prolapse.
[00:14:33] However, recently, she's been coming in with increasing shortness of breath and was diagnosed with atrial fib. Physical exam shows a murmur that increases with squatting and sounds louder with handgrip. And this murmur increases in intensity in the left lateral decubitus position. This murmur also decreases in intensity with Valsalva and standing. Who am I?
[00:15:10] One more time. The murmur increases intensity with squatting. Also, hand grip, also left lateral decubitus position, and decreases in intensity with Valsalva and standing. Who am I?
[00:15:31] All right. So, let's think about this, she had a previous history of mitral valve prolapse. I got it. But now she's got increasing shortness of breath and a fib - oh something went wrong.
[00:15:41] Do people with mitral valve prolapse get a fib? No, not at all. And so now this murmur is going to increase in intensity with squatting so that's not helping me, but the hand grip, it increases with hand grip. So, wait a second. Let me think about this. So, there I am handgrip sitting on the aortic valve, which means the left ventricle has got to fill up with more blood and the left ventricle is going to contract with more blood.
[00:16:07] And then that mitral valve that should stay closed is actually blowing right on through. And if I put them in that left lateral decubitus position, that's bringing the mitral valve to the surface. So let me think about this for a second, Joe. Hold on here. So, you're telling me that the left lateral decubitus position brings the mitral valve to the right?
[00:16:31] So whether it be mitral stenosis or mitral regurgitation, that's the maneuver, it'll bring it closest to the chest. So, you hear it better. And we could argue expiration in this question, but this clue wasn't given to me here. And does everybody see the most common cause for mitral regurgitation is actually mitral valve prolapse that goes untreated?
[00:16:48] And that's how we get it. And then, of course, they start irritating the left atria, which is how they get the AFib. But now, does everybody understand how the handgrip made it worse? Again let's think about it. Your hand gripping. What are you doing? Increasing the pressure behind the aortic valve.
[00:17:05] What's the left ventricle going to do? Remember the Frank-Starling thing? What did Frank say? When you increase afterload, you're going to increase preload. What's the left ventricle going to do? Fill up with more blood. And there’s that mitral regurgitation valve - come and go as you please. Now that left ventricle goes to contract, what's it going to do?
[00:17:20] Oh, it will push more blood flow against my regurgitant mitral valve. Exactly. And that's the correct answer – mitral regurgitation.
Murmur Question #7
[00:17:31] Next question. I have this 67-year-old gentleman who comes in complaining of right-sided heart failure. He's also got some right atrial enlargement, and he also has bilateral lower extremity edema. During the exam you note a mid-diastolic murmur at the left lower sternal border that increases in intensity with inspiration, sounds louder with squatting, and goes away with standing and Valsalva. Who am I?
[00:18:09] Again, mid-diastolic murmur, left lower sternal border, increasing with intensity with squatting and inspiration, goes away with Valsalva and standing. Who am I?
[00:18:30] Let's think about it. So, what did we get in the question? Well, we got the word inspiration. So, what do we know? Oh, that's on the right. And then we said left sternal border.
[00:18:39] So who's that? Everybody. But it's not the pulmonic valve or the aortic valve. So, who are we talking about if it's on the right and not the pulmonic valve? The tricuspid valve. And then you told me that it was mid-diastolic. So, wait a second. The tricuspid valve, what's the diastolic murmur associated with the tricuspid valve? Is this regurgitation or stenosis? Oh, this is stenosis. The answer is tricuspid stenosis.
[00:18:59] What are your low volume maneuvers? Standing and Valsalva. Usually, with these maneuvers, all of the murmurs will go away. The low volume lovers are murmurs that sound louder with low volume. That’s HOCM and mitral valve prolapse.
Murmur Question #8
[00:19:13] Next question. I have a murmur that is holosystolic in nature that is located on the left midsternal border and sounds louder with squatting and inspiration. This murmur also goes away with Valsalva and standing. Who am I?
[00:19:40] One more time. I am a holosystolic blowing murmur. I'm located at the left midsternal border. I sound louder with inspiration and squatting, and I go away with standing and Valsalva. Who am I? So holosystolic means, it's probably most likely some type of regurgitation and now you're telling me that it's on the left midsternal border that's everybody. But the key piece of information you gave me is inspiration, which means this is right. Which means it's going to be the tricuspid valve. Now you're telling me it's holosystolic, so that can't be tricuspid stenosis because that is diastolic. So, this is going to be tricuspid regurgitation. The answer is tricuspid regurgitation.
[00:20:29] Then there's that thing about the Carvallo's sign. The increased murmur intensity with inspiration. And then sometimes we see that pulsatile liver. Because everything's backing up on the right side, so, all that blood flow is going to the liver, and it's causing it to kind of shake in a way. Sometimes we call it pulsatile.
So again, is everybody starting to understand this?
- Inspiration → right and expiration → left
- Squatting is not going to help you much
- And now you have to ask, where's the location of this murmur? And remember, when they say left, lower sternal border, they're saying, hey, this is everybody but the pulmonic and the aortic valve, which are located in the upper sternal border.
They're not going to be nice to you and say, oh, it's right or left because that gives you too much information.
So again, we're just going to pull back, and we're going to use Joe's basic rules.
Murmur Question #9
[00:21:17] Next question. You have a healthy 24-year-old female sitting on your exam table who comes in with mild lightheaded and dizziness with very little exertion. On physical exam, you notice that she has a murmur when she performs standing and Valsalva; however, this murmur also goes away with squatting. The rest of her physical exams is essentially unremarkable.
[00:21:57] And when you have her perform handgrip, the murmur disappears. Who am I?
[00:22:05] Remember this murmur sounded louder with standing and Valsalva. It went away with squatting, and it went away with handgrip. So, wait a second. You're going; it went away with squatting? Isn't squatting a party, Joe, doesn't that make everybody sound louder?
[00:22:22] It does. Wait a second. I'm back to my special needs murmurs, the ones that like low volume. So, this is either HOCM or mitral valve prolapse. Exactly! So, let me take this one step further. So, you're telling me if I squat, what do I do again? I'm pushing all the blood flow back home. So, you're taking the left ventricle and filling it with blood.
[00:22:47] So if I have HOCM, then all that blood will do what? It's going to push the walls apart. But wait a second, the murmur is going to go away. That makes sense. Wait a second. It went away with hand grip as well? So let me think about this again. Hold on. Handgrip. What'd you do? Oh, that's right, I increased my afterload. Joe said basically you're just sitting here on the aorta. What did Frank say? You increase afterload; you increase preload. So, what's the left ventricle going to do to fight that afterload? Fill it with more blood. And what are the walls going to do? Push apart. That's HOCM.
You see what you have to remember is that HOCM is not a valve problem. Say to yourself, HOCM is not a valve problem. And if you didn't get it the first two times, let's say it a third time, HOCM is not a valve problem. It's a wall problem. The left ventricle walls are hitting. And so now, does everybody understand, as they're at rest, what do you want to do to make the murmur louder? You know you want the walls to hit. Just lightly tap, and you want them to hit. So, what's in between the walls? Blood. So, what makes it sound louder? Oh, standing and Valsalva. Put blood in there, and what will we do with the walls? Push them apart. So how do you put blood in the left ventricle? Oh, I could squat, and I could do hand grip. Exactly. And that's the whole point I'm trying to make about HOCM. The answer is HOCM.
Murmur Question #10
[00:24:10] Last question. You have a young, healthy 31-year-old female who comes into your clinic, and she's been complaining of progressive, mild shortness of breath and palpitations. On physical exam, you notice a murmur that increases in intensity with Valsalva and standing. You also notice that this murmur goes away with squatting. You also note that this murmur sounds louder in mid-systole. Who am I?
[00:25:04] So, let's think about the information we were given. We were given information that this murmur sounds louder with Valsalva and standing (our low volume maneuvers).
[00:25:13] We also know that this murmur goes away with squatting (our high volume maneuver), and then they give us this mid-systole. So who am I?
[00:25:25] You're telling me that squatting makes it go away, which means it's quite the opposite of what we would expect, which means it's got to be a low volume lover, which is correct because it sounds louder with Valsalva and standing. Also, this murmur is a mid-systolic murmur.
[00:25:43] So wait a second, when I look at my “low volume lover” murmurs, you have to remember there's really only one low volume murmur. That's mitral valve prolapse because you remember HOCM has nothing to do with the valves. It has everything to do with the walls. So, you're like, oh, they're telling me that this thing sounds louder mid-systole.
[00:26:05] One more time, when is the left ventricular pressure highest? Mid systole. Then there is that redundant mitral valve that has prolapsed, and the valve can't hold. And then what does it do? The blood blows right on through. And that's the correct answer – this is mitral valve prolapse.
[00:26:24] All right, listen, I need you to replay this podcast until you get tired of me talking, OK?
[00:26:32] It's like, oh my gosh, someone put Joe out of his misery, right? Tell him to stop talking to me. And I want you to keep replaying this and replaying this. But most importantly, stop memorizing!
[00:26:46] So let's go over it again just as a recap.
- Upper sternal borders, who are they talking about? Aortic and pulmonic.
- Where's everybody else? The left lower sternal border.
- So left lower sternal border is not helping you out much.
- But if I say upper sternal border, I'm either pulmonic or aortic. If it's on the right upper sternal border, that's aortic. If it's on the left upper sternal border, that's pulmonic.
- Louder with inspiration → right and louder with expiration → left.
- What squatting? Party maneuver, who parties? Everybody, everyone's going to sound louder.
- Who are your low-volume maneuvers? That's standing and Valsalva. So, you have less blood flow in the heart, and most murmurs sound quieter.
- Who are your special needs murmurs? What were the two murmurs or two areas that like low volume? They like less blood in the ventricles. That is mitral valve prolapse, which is a valve problem, and HOCM, which is really a wall problem.
- Then inspiration → right and expiration → left. How do you take the mitral valve and put it close to the chest? The left lateral decubitus position. That's what I do. So, the left lateral decubitus position is best, whether it be mitral stenosis or mitral regurgitation.
- And one more time. What’s hand grip? Handgrip is me sitting on the aortic valve. If I have aortic stenosis, I can barely open up, and you sit on the aortic valve, and is it going to be able to open up? Heck no! But if I have aortic regurgitation and now all this blood flow is going back against the aortic valve. Is there anything to stop it? No. And remember if I have a normal aortic valve and perform hand grip, what will I do? Remember what Frank Starling's curve said, when I increase afterload, I increase preload, so what's the left ventricle going to do? It’s going to fill it with more blood.
- So if I have HOCM, what are you doing to the walls? Well, I'm filling it with more blood, but what am I doing with the walls? Pushing them apart.
[00:28:32] Hopefully, I've demystified the heart murmur issues for you, and I hope this makes more sense. Like I said, just replay this podcast episde.
Remember what I've been trying to teach about inspiration and expiration and squatting and handgrip and all these maneuvers we can do to make the murmur sound louder and disappear. And if you go with that approach, I promise you, no matter how the PANCE comes at you with a heart murmur question - You're going to nail it.
[00:28:57] If you go at it from the memorization point of view, you will be in a boatload of trouble. Because all the buzzwords are gone and all those kinds of stuff. So listen, it's been an honor. And it's always a pleasure to speak with you out there in podcast land. And so right now, I got pixie.
[00:29:13] My rescue dog whose lying on my bed, sitting here, and she's giving me that look like she wants to go outside for a walk. So it's time to take my rescue dog out for a walk. All the best, and please, as you're getting ready for the PANCE, like I said, in the previous podcast, make sure you take care of yourself, take care of your health and take care of your brain.
[00:29:32] All the best, Joe.
Resources and links from the show
- Join our brand-new Smarty PANCE Member's Community
- View all the episodes in this series Cardiac Murmurs Made Incredibly Easy
- View the NCCPA content blueprint valvular disorders
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- Check out my list of recommended PANCE and PANRE review books
- Sign up for the FREE Daily PANCE and PANRE email series
- Join the Smarty PANCE NCCPA Content Blueprint Website
- Get your free 8-week PANRE Blueprint study schedule and the 8-week PANCE study schedule
- Get your free Trello PANCE study planner
- Get 20% off any Picmonic membership by using this link, or if you are a Smarty PANCE member, get Picmonic for Smarty PANCE.
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