2025 – PAGE 126 – CARDIOLOGY
PULMONARY STENOSIS (PS)
Pulmonary stenosis rarely progresses and is much more benign than aortic stenosis. The exam reveals a harsh LUSB murmur, a single S1, a widely split S2 (since when A2-P2 happens, the P2 is delayed even more), and possibly a thrill or a click. (The P2 is also softer than normal and may be missed, causing the S2 to sound single.) There is a low risk of sudden death.
MITRAL STENOSIS (MS)
Mitral stenosis is a mid-DIASTOLIC murmur heard at the APEX. It is associated with chronic rheumatic heart disease.
TRICUSPID STENOSIS (TS)
Tricuspid stenosis is a mid-DIASTOLIC murmur heard at the LLSB.
AORTIC STENOSIS (AS)
Aortic stenosis is a progressive condition that is associated with a significant risk of sudden death, exertional chest pain, and syncope. Physical exam findings may include a mid-systolic murmur at the RUSB (right 2nd intercostal space), a thrill at the suprasternal notch, and a click or a paradoxical split (S2 is single on inspiration and splits on expiration). The EKG shows LEFT VENTRICULAR HYPERTROPHY (LVH). Patients should NOT be allowed to play sports until cleared by a cardiologist. Treat with balloon dilation.
MITRAL REGURGITATION (MR)
Mitral regurgitation is a holosystolic, blowing apical murmur that may radiate to the axilla.
- It is associated with MARFAN SYNDROME and EHLERS-DANLOS SYNDROME.
MITRAL VALVE PROLAPSE (MVP)
In mitral valve prolapse, there is a mid-systolic click followed by the mid-late systolic murmur. Note that although this is kind of a regurgitant type of murmur, it is not a holosystolic murmur like the others.
- PEARLS: The murmurs of MVP and HYPERTROPHIC CARDIOMYOPATHY (HCM or HOCM) are both murmurs that increase with standing or Valsalva and decrease with squatting. There are two ways to differentiate these murmurs. First, only MVP murmurs are preceded by a CLICK. Second, the HAND GRIP MANEUVER increases the MVP murmur and diminishes the HOCM murmur.
- MNEMONIC: (DOUBLE TAKE) “Baseball’s MVP (most valuable player) is a pitcher. You hear a CLICK when you take his picture. Whenever he’s STANDING on the mound and HOCing loogies/spit, the crowd gets extremely LOUD to see him in action! If he gets hurt and has to SQUAT, the noise from the crowd suddenly DIMINISHES.” This should help you remember the key exam findings for MVP and HOCM.
- KEY: GRIP = Increased noise for MVP only: “When the MVP gets his trophy, he stands at a podium and GRIPS the trophy tightly over his head, and the stadium erupts in LOUD cheer.”