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so today's session is ah is very different from other sessions. Okay with me, in previous weeks, we've been doing sort of specialty type of stations. Today is going to be a bit more in depth off a particular specialty. Okay, so we're going to be talking about heart murmurs specifically, uh, heart murmurs knowledge that's relevant for skis, eh? So we're not going to cover all aspects of heart murmurs knowledge where I'm going to try and specifically terror to the stuff that is relevant is clinically relevant and important for you guys to know if you all see exams. But I know that we have a lot of different years of medical school medical students and talk it come in. And I'm not too sure about the level of knowledge a lot of you might have. So I decided to sort of teach hot moments from basic principle. So there will be initiating a lot of physiology, you know, cardiac cycle stuff, basic principles of auscultation, which hopefully a lot of you will be familiar with. But I think it's important to get all that basic knowledge really clear and everyone's heads before we start talking about all the hard core clinical stuff. So let's get into it. So it says one hour, 30 minutes, I'll probably be the full two hours. Uh, just just be aware of that. So let's get into it. So the stage of hair is we've been asked to examine Mr Boss and 53 year old male is presented with shortness of breath. We've been asked to do a focus cardiovascular examination on the patient on. Then we'll we'll be asked to summarize our findings and present a differential diagnosis. So if you were, if you came to our cardiology station part to the cardiology station, part two of the Oscar station, part to a couple of weeks ago, you'll hopefully be very familiar with this light. This is like taken from that session. This is the Run three off the cardiovascular examination, which we talked to her in detail during that session. So today we're primarily talking about a specific aspect off that examination. We're talking about the auscultation aspect and, uh, relevant maneuvers that you guys going to do. So this is This is one of the major aspects off the cardiovascular examination, so it's important you have this bit of knowledge really nailed down and really confident. So I've got a lot of moments and simply as well, So it will be very interactive. There's a lot of spot diagnosis, lot of actual murmur sounds. So listen to the first one. I hope the moment sounds play okay? And let me know what you guys think. That again. What do you think of these? I'm sorry. They're sounds quite alot. I know them soon the sound can get it distorted that they have one more time. Okay, so I love you said getting right. So this is normal heart sounds. Okay, so? Well, hopefully the other sounds are a bit harder, but he's a member played here. That was just normal heart sounds okay. I really want you guys to be very familiar with what normal heart sounds sound like. Okay, so, um, your normal 1st and 2nd heart sounds. That's what they should sound like. Okay on. So just always just I recommend just trying auscultation many people as you can. Okay? Auscultate. Your parents are school at your house mates, and then just be really familiar with what the normal heart sounds are. Okay, Your s one s two heart sounds because because if you're confident what they sound like, you'll be much for you. You won't be able to pick up moments that much easier. Okay, but we're talking about normal heart sounds, so it's very important. We have the basic cardiovascular, and that's me. Physiology nailed down before we start understanding valvular pathologies and different features of different moments. So we got this is the basic schematic diagram I've made that. And I'm going to use this diagram to basically explain a lot of the bubble pathologies. So we're going to label this diagram in terms of the different balls. Can you guys tell me? What about is this? I rub this point it to that tricuspid valve gets is gonna be quite quite quick. Okay, I'm sure you guys look very familiar with this. How about this one here? Mitral valve gets How about this one? Pony valve gets on last one. This is your aortic. Well, okay. I'm very bread and butter of medicine. Okay. Get your heart and ask me if the heart's okay, but make sure you absolutely no where all these different balls are. So you have a mitral valve the aortic valve revolves and your TriCor Okay, remember, Mitral valve is also called Colby bicuspid valve as well. So, guys, can you not drawn screen, please? Asana. Can you move the imitation? Yeah. Sorry. Uh, this is gonna mess up the float out of it. Okay, so we talked about the, uh, anatomy of the heart's okay. Different be labeled. The heart's okay. Now, we don't need to explain. I go through how the valves actually function okay, in the normal person. So this is probably probably gonna be very basic for you guys. Not gonna like. It's been a while since I'm talking to myself. But this is an absolute the crucial bit of physiology to go through quickly before we start talking about the pathophysiology of a lot of these different murmurs. So cardiac cycle is bit missed. A day of the cardiac cycle you talk about is the been trickling feeling face. Okay, this is our ventricular dastardly. So this where blood is being possibly being filled on the Atria into the ventricles once the pressure and the ventricles is high enough. Okay, Once it's greater than the pressure in the atria. Then you're 80 vials will close. Okay. Your mitral valve tricuspid valve above close. Once I go, BP rises above your atrial pressure. And then at this stage, this is where you get you have ventricular systole. Okay, So initially, Cicely, it means that's when your ventricles start contracting. So initially, it will contract with both balls closed. Okay? And this is known as isovolumetric contraction. Okay, contracting until the pressure in the ventricles is greater than the pressure in the aorta. So, once depression, the ventricles is greater than the pressure in the aorta. Then your bowels will open. Okay, you're guilty about and your revolver both open. And then because eventually, still contracting. Okay, this is what blood is going to be injected out. Okay? And remember, this is still part of been triple A systole. So you're getting injection of blood into your aorta and pony arteries on. Then once the eventually assistant will come to a stock, okay. And your pressure in the aorta will be greater than your pressure in your ventricles once that happens. Um, your bowels are closed. Okay? You're volatile. Close. So it's available. Probably about close. Once D pressure in your aorta is higher than the pressure and the ventricles. And then the cycle basically start again. Okay, so that when the But so before that, when develops close, you bench, go start relaxing. Okay? And this is known as isovolumetric. Relax a shin. And then once the pressure in your ventricles lows enough below the pressure in the atria, that's when the cycle starts again. Okay, so, atria, your age you're feeling will start again. And that's the beginning off. Then trickle a vastly. Okay, so that's a quick run through of the cardiac cyclo. Okay, I hope that something you guys are very familiar with it is the basic kind of ask you physiology. But we're gonna basically gonna be The fundamentals are explaining all of the different murmurs. So again, I quickly reviewing that. So inserted some pictures. So this is where we haven't atrial feeling. Then after that blood flowing, you two ventricles bench will start contracting, and then we're going to get, uh, blood getting ejected from the ventricles. Okay, So once the ventricles become filled with blood and involves close and your blood will get injected into the aorta and then the cycle will be your systole and Then after that, you'll have your desk. Okay? Where you're ventricle. Start relaxing and the stop cycle starts again. So that's your cardiac cycle. I'm going through this in a bit of detail because that's this is gonna help us explain the normal heart. Sounds okay. It's very important that you guys are very familiar with how normal heart sounds are produced. Your s one s two. So until they are normal heart sounds, we have two heart sounds. Okay? Your s one heart sound and your s two heart sound. Okay. Can you tell me what is the s one hot sun? Which sound is that? Representative? What is s one represent? Yes. Closing off your, um A develops. Okay. Your mitral valve and your tricuspid valve. Okay, So as one is closing off the mitral and tricuspid valve, so that's just before the ventricle starts contracting. Okay, that's when you're so when your mitral valve and tricuspid valve close, that's when that's the beginning off. Then trickle a systole ST What is Stu represent? Yeah. So it's the closing off your pulmonary valve and your aortic. Okay, so that's representing the end of Cicely, right? When your opponent about in your aortic valve. Close. Okay. Remember, hot sounds normal. Heart sounds are produced by the closing about. Okay, you know, and a normal person opening of above doesn't make noise. Okay, It's the closing off the valve that generates normal heart sounds. So as one is closer closure off be 80 valves as to is the closed closure off your aortic valve in your pulmonary valve. Okay, so if you clear on that, can you guys tell me what does the face between s one and s to represent what is happening in the ventricles between s one and less too systole good on day after s two. And before your next start, Some. What is that? Representing fastly. Okay, so this is very important to be very clear. And when systole when Cicely is on one dose, please. So, between your first heart sound and your second heart sound, that's systole. Okay. And then after your second heart sound And before the first heart sound off the next cardiac cycle that starts slowly. Okay. Please. Week. Make sure you're very clear on when you're in systole and when you're industrially okay. Um good. So hopefully you guys are very clear on what normal heart sounds are. So it's still some of that basic anatomy. Okay, Because this is gonna help us explain the different bother. Pathologies. Remember, your bowels are composed of costs, Okay? There's different number of customers. Each valve leaflets your anything about come revolve and your tricuspid valve. Or in a long person, they all have three costs. Okay, but microvalve shown here it only has two costs in a normal person again. A normal, healthy person. Much above is the only valve which has to costs. Okay, remember that because it's, ah clinically, clinically relevant. Good. And so we're still talking about auscultation enough. So I'm wearing my steps to go pay it just, uh, mostly for flash, but I'll try and demonstrate some stuff with the stethoscope is well, so with your status, you up there's two bits to it. Okay, so you see here there's the bit in the front here this year. Die from, and we have the bit on the other side. That's your bell. Okay. So again, the bell is the smaller end of it. Smaller circle? Yes. Died from Is the bigger circle on your steps. Okay, Uh, yes, something. What's the difference between your diaphragm and the belt? Well, what's the one day when you're using the dye? From what about using the bell? What's the key difference in the way your diaphragm works And you're Bell works? Yeah. It's the pitch. Okay. Say it's depending on which side of the stats scope using. It's gonna help you pick up certain pictures off. Murmurs better. Okay, So, essentially, the diaphragm is good for certain members, and your belly is better for the certain members. Okay? Most murmurs are better. Best auscultated with your diaphragm. Okay, because most murmurs are generally higher pitched. Sounds okay, but the bell is useful for certain low pitched sounds. Okay, Uh, just out of interest. Can yes. Tell me which sounds are generally better auscultated with the bell. Okay. Which ones you would you associate with the bell? We'll go through this later on, but what? What, you guys think it's better also rotated with the belt. Ruiz. Yeah. So if you're also dating like a carotid bruit, definitely the fellas pretty good. My trolls. Stenosis? Yep. Mitral stenosis. Gentlease better heard with the bell. Cool. Yeah. Bruisies mitral stenosis. The common members that are better auscultated with the bell. But for the other ones Thebe, I from is generally the best to also take them. So we're still on the principles of auscultation. We're gonna talk through the different auscultation areas. Can you tell me where do you also take the They'll take a little about what is this area here? What is this location I'm pointing to hear? Yes, SGLT. Well, this is the Remember this is where your auscultated Okay, this isn't where the above actually, Yes. Okay, anatomically, this is the These are the locations where the or best going to hear the members of the sounds produced from the salty bulk. Okay, so it involves best auscultation point is thesis intercostal space, right? Personal border, uh, about your opponent about here. That's your left? Nothing, because the space have personal border. Ah, I just got a It's a tricuspid valve. So that is your fourth intercostal space left sternal border and your mitral valve here. So that's representing thie. 15 deposit space within the midclavicular line. Okay, so these are all sensation points for the bowel. For the different balls. Okay. Do you know any other auscultation points on the chest. Which other point gets auscultated commonly? Yeah. You might hear about another point called herbs Points. Okay, so that's between the upon revolve location and the tricuspid valve auscultation parts. Okay, It's called the Herbs point. Uh, he has no Wendy. What is explained? Good. For what? When would you auscultate with using the X point here? Yes. Ah, point generally, cardiologist, call up spine like the average your gas, and it's the average of all four valves. It's basically the best point. Best location to auscultate your heart sounds okay. Your normal heart sounds your s one s two because it's basically like a summary of the entire heart. Oscal, Titian and certain members do get auscultated a bit better in the office point as well. But yes, that's what helps point is if you get us about it. But these are your four major auscultation locations. Okay? Remember, these are where you're auscultate them is not where you're valves actually are. Okay? It's just where they're being auscultated the best. Uh, okay, so and another key tip for when you're also taking is to always palpate the carotid artery When your auscultated in these different locations. Can you tell me why am I palpating the carotid artery? What? I'm auscultated You might use the radial artery as well. What's the port? We'll see purpose of out of palpating while auscultated. Yeah, yeah. Corresponds with systole. Okay, so, big thing when you're when When people when people auscultate big struggle people often have is knowing which sounds they're listening to, as in which one is the first outside and which one is your second heart Sound okay? A lot of people struggle with determining which where which sounds which okay. And if you're struggling with knowing which sounds which you're gonna have trouble determining if the memory is a systolic murmur or a diastolic murmur. Okay, So the reason to also to palpate the croutons is because when you feel your carotid pulse that corresponds with trickle a systole. Okay, so if you're if you're also taking and palpating the prostate pills, you can feel with your hand when Cicely is happening, and that's gonna help you correlate with when your first heart sound is happening. And when your second heart sound is happening. Okay, that's a big thing. When your auscultated always palpate the carotid artery or O R peripheral artery when you also take cool. So we just talked about auscultation. Now, Now gonna quickly cover maneuver is, um can you tell me what maneuvers do we do during a cardiovascular examination in a lost feet? What do is do we ask the patient to do? Yes. It is generally two different types of maneuvers, Right? One maneuver is is to do with your respiration. Okay, inspiration expiration and the other maneuvers were doing is to do with the position off the patient. Okay, so in terms of the breathing, we're going, Some movements are better. Gonna be better auscultated with the patient breathing in. Okay, during inspiration on some murmurs are gonna be better auscultated during expiration when the patient is breathing out. Okay, So little bit physiology again. Okay, this is ah, bit of pathophysiology, but generally during inspiration. What's happening? Is that your right side of my numbers? Get louder. Okay. And during expiration, when you have the patient, breathe out fully and you also take your left side of members. Get louder. Okay. Now, terms of the physiology generally, what's happening during inspiration is that your intra thoracic pressure is decreasing. Okay, Onda, if your internal intrathoracic pressure decreases, that's gonna cause increased venous return to the right side. Okay? Because as being drawn up through your veins into the right side of the heart. So that's going to lead to increase billing off the right side of the heart. Okay, on, if you have increased feeling on the right side of the heart, that's gonna increase the intense intensity off any murmur in the right side of the heart. Okay. Quick point. What is a murmur? Did anyone tell me what is what What is what is the cause of a murmur? What is that, General cause of any heart murmur. What's happening inside the heart that's causing a member? Yeah. Turbulent blood flow. Okay, that's the That's the cause of a murmur generally. Okay, blood's not flowing linearly. Okay, There's blood's just it's moving in a tablet manner. Okay? And that's and that's causing a sound. Okay, because when it's moving in, a tablet manner is producing vibrations, and that's causing the sound to be auscultated. Okay, so if you're doing a maneuver that's increasing blood to a particular side of the hot, that means that there's gonna be more blood that's going to be moving tablet, Lee. That's gonna increase the sound of the member. Okay, so someone has a murmur associated with the right side of the hot. Okay, that's gonna increase with inspiration. Okay. When I say right sided murmurs, I'm talking about the actual bulbs. Okay. So murmurs affecting the TriCor above and movements affecting the pulmonary. Both. Okay, your right side and bowels. Okay. So murmurs of affecting the tricuspid valve and your pulmonary valve, they get louder on inspiration. And it's basically the vice versa for your expression. Okay, so during expiration, there's an increase in intra thoracic pressure as you breathe out. Okay, to breathe to help push air out of your mouth. But if there's an increase in in intra thoracic pressure, that's gonna squeeze blood over into the left side of the heart from the lungs. Okay, so you get increased venous return to the left side of the heart. And so same principle. If you have increased venous return to the left of the heart, that's going to lead to increase blood flow to the left side of hearts. Okay. Increased left sided filling. And that's gonna increase the intensity of any left sided murmurs. Okay. And again, left sided members I'm talking about the actual involves. Okay, So, members affecting the aortic valve and the mitral valve. Okay, so things like aortic regurgitation, a little stenosis, mitral regurgitation, Michael stenosis is they all get allowed on expiration. Okay, Because during expiration, um, the murders get louder on the last set of the hot. Okay, so that's what's happening during breathing. Okay? And if you don't want to remember any of this physiology, okay, you don't have to, But you saw on your monitor, remember, is the pneumonic of inspiration and lax relation. Okay, So your inspiration, right? Sided moments get louder on inspiration. Expiration Left side of moments get louder on expiration. Okay, That's beating in terms of positioning. Uh, there's two different positions we ask patients to take during the examination. One of them is that we ask them to lean forward and by asking them to lean forward. That's basically bringing the aortic valve closer to the chest wall. Okay, so if you bring the little ball closer to the chest wall, if there's any movements associated with the aortic Well, like a like stenosis. You'll take regurgitation. Uh, we'll make it easier for us to auscultate. Okay, so that's leading forward. Another one is that we ask the patient to go into the left lateral decubitus position, Okay? Leaning onto lying on the left side. And the reason tube to do that is it brings the mitral valve closer to the chest wall. Okay, so when you auscultated over the mitral valve in the left lateral position that increases. That helps us auscultated the any murmurs better. Okay, technically, it doesn't have to increase the intensity of the movements. Okay, It makes it easier for us to actually pick up the sounds because it's bringing the valves, close it in the chest wall. Okay, so that's the sort of physiology behind the maneuvers we do in the examination. Okay. Um, so again, if you don't want to remember the physiology, you don't have to, but this is the main. That's the sort of mechanism behind why we do it. Okay, Okay. Also still on the principles of ostentation. When you hear a murmur, you need to be able to grade it. Okay? In terms off, uh, grading how louder this you need to be able to sort of objectively quantify how loud and memories and this the classic grading scale we use particularly four systolic murmur. This is the grading score we used of a grade one murmurs. This basically means that it's very, very quiet. Okay, it takes a lot to auscultate them and only they can only generally be here heard by very experienced clinicians. Okay, great to means it's a bit louder again. Most people should be able to hear it. It is a great three months, for this is why you most of your members and Oskar's will be okay. That's why that very easily heard. But there's no palpable thrill. Okay, Can I? Don't tell me what is a political thrill. What is it? Thrill me? What? What? Do what I mean by a palpable thrill. What is it? Thrill me. Yeah, it's a vibration. Okay, So, basically, if the murmur is loud enough that you can actually put your hands over it and feel the vibrations. Okay? That's a thrill. Okay, that's a palpable. Thrilled. So if anyone has a palpable thrill associated with a murmur, that makes a murmur a minimum off a great for Okay, so? So if someone has a palpable thrill, that's a minimum of a great for murmur. And then above great four. It's if it's really loud and you can hear it with the step scope partially on the just. Okay, Barely on the chest. Uh, then that's a great five. Okay. And if you can hear it even without a stethoscope placed on the chest. Okay, if you're just hovering the stethoscope over the area and you can hear it, that's a great sex. Okay, so it's a super loud murmur, so that's the sort of grading scale for moments. Okay, um, in your skis, most of the members you'll hear will probably be great. Three or grade for okay, They'll be alive. A have a thrill, or they won't, but they will usually be pretty well audible. Um, yeah, that's the grading scale. Okay. No, this is a big thing for all ski. So Okay, if you hear a murmur in all skis, you need to be able to systematically describe the characteristics off the murmur. Onda, um, just presented in a present it systematically. Okay, let's talk through how we systematically present murmurs. Yeah, Same whenever you present murmurs. What's the first thing you should talk about? In terms of the actual heart sounds in general, What's the think you're examining will want? You will want you to comment on initially systolic and diastolic before that. What would you do even before we comment on systolic Diastolic? Yeah, Patient info. Okay. We've sort of sort of skipped pasta. The patient information bit. What else is important to talk about with the heart sounds? Yeah, s one s two. Okay, The big thing to think about first is it Does the patient have normal? First, the second heart, sons. Okay. In a normal patient, you should say heart sounds one and two are present. Okay, that's the first thing I would recommend you comment on. Okay, if you can hear both s one s two, and if they're sounding normal, other thing out coming down is if there are any additional heart sounds. Okay, we're not going to go through this today, okay? Just for the sake of time. Things like third heart sounds, four part sounds or things like pericardial rubs, splitting of heart sounds of things, All that sort of fun stuff. If you can auscultated you can comment on. But most of the patients are not gonna have any of this stuff. Yeah, but you can comment on any additional sounds. Then I would talk about the timing of the member. Okay. Is it a systolic murmur for a diastolic number? Okay. And we'll we'll go through the different types of just solid and diastolic murmur. But that's where in Poland things that comment on comments on the volume off the member. Okay. And we talked about the grading scale. So how loud is the murmur? Is it a great three? Great. For murmur. Is there a palpable true. Okay, then I would talk mentioned where it was auscultated best. Okay, remember that. Remember when you were talking about all those different ostentation points? That's where we're saying the murmurs heard loudest. Okay, that doesn't mean that it's the only point where a murmur can be hurt. Okay. For example, if someone has a little stenosis, just because you hear it in the aortic valve area doesn't mean you won't be able to auscultate it in your mitral valve area or your pulmonary area. Okay? It's just the areas where the murmurs heard Loudest. Okay, so common and where it's heard loudest common. On if there's any radiation. Okay, we'll talk about which movements have associated radiation. Okay, if it radiates the crossroads, it's radiating to the Exelon comment on anybody Asian and comment on any maneuvers that you do. Okay, Is the murmur louder on inspiration or expiration? Okay. On held inspiration or held expiration, Or if it's louder on a particular maneuver. Okay, that's louder. Um, Meaning forward. Louder. Ah, on the left lateral position. Okay. And finally, can anyone finish this off? What else could I comment on? What else would be useful to comment on? Yeah, differential. So you can offer differential sperm. Other things to comment on. If someone has valvular heart disease is what What? What would be a good thing to comment on process. Okay, so I put here just relevant negative findings. Okay? I'm so we talked about relevant active findings in history, taking okay. Things that rule out other differentials in your examination. Relevant negative findings basically means things that point towards certain diagnosis which the patient doesn't have Okay on. Basically, the key thing with the relevant active finding is that it's something you point away from closes off a moment. That's very worried. Okay, So what would be worrying Causes off moments in our cardiovascular station? What would be good to say that you've ruled out heart failure gets infective undercardia In fact, of endocarditis, I always like to say it put in a good sentence at the end, saying this patient does not have any evidence off infected and the card itis or heart failure as a cause off the moment. Okay, that's just a quick state statement. I like to add in a DNA when presenting murmurs. So just your relevant any negative findings which you picked up Okay, there's realistically, they're unlikely to have any patients with active infective endocarditis in your osteo okay or would significantly decompensated heart failure. So that's why it's a good statement to have that that can apply to most patients. Okay, there's no features off and the colitis know features of heart failure, okay? Or rheumatic heart disease, or someone said, where we talk about rheumatic heart disease and good beat up to that door. Cool. So let's take a break for a couple of minutes, so we basically just talk through some principles of ostentation talked about the physiology behind the cardiac cycle, and hopefully you guys are very confident in what normal heart sounds are. Now we're gonna move in to talk about those a different pathologies and talk through different heart murmurs. If you want to take a break for, let's say, two minutes. And if you guys have any questions about basically sculpt a shin, let me know you're supposed to report that recording guys love, so let's get into it. So, ideally, before we start talking about auscultated different moments, we got some. I got some written scenarios for you, so we're going to start off by talking about systolic murmur, and then we'll take a break. And then after that, we will talk about different the ast alk moments. First up, we're going to talk about really systolic members. Okay, different differentials. Foreign, really. Systolic murmur, so haven't read. So we haven't 85 year old man who has a crescendo decrescendo ejection, systolic murmur heard loudest in the aortic area, member radiates across did. She has a history of heart failure, also complains of chest pain and syncope. Cross the pulses are the late and diminished, and the apex feet is sustained, so it's quite a bit of a longer one. Good. Um, mostly we're getting this. This is a little stenosis. Can you tell me what is the likely cause off the aortic stenosis in this patient? There's there's there's different causes for it takes the nurses right in. This patient was still like, he goes calcification. Good. Okay, so we'll go through this, that this is likely that case off specifically severe aortic stenosis. I can. It's likely due to degenerative calcification. Okay, so you're also is important to not to be as specific as possible. Okay, As detailed as possible in your ancestor. So this is likely severe aortic stenosis on, but likely cause of the attack Stenosis is degenerative calcification. Okay, so let's break this down. So you have an elderly man. There's a crescendo. Decrescendo ejection, systolic murmur, loudest in the aortic area. Okay, This is a classic features for a lot of murmurs. Inject a lot of early systolic movements. Okay, but it's 16 OSIs classically will cause a crescendo. Decrescendo moment. Okay. As time is, I'll get louder initially and then quieter. Passively aortic stenosis. One of the key features is that it will radiates to the cross. It's okay. Uh, what's the relevance off? The heart failure, the chest pain and the syncope. What's the relevance of that? Well, I haven't needed that. Yes. This is this sentence here. Okay, this is the these two cents and said that basically tells you that this is severe aortic stenosis. Okay, so when we think about city yeah, aortic stenosis, we classically think of three symptoms. Okay, We think of syncope. Think of angina. Okay, so chest pain and we think of soreness of breath, okay? And this patient has a history of heart failure. And is that indicating that this is severe aortic stenosis? Okay, not just a standard aortic stenosis. This is severe. Quoted pulses are delayed and diminished. Okay, again, classical. A little stenosis. Is anyone? No. Well, Steve, fancy name for this feature here. Yeah, pulses polys at tautness. Okay. It's ah, if you want to be really specific, really fancy and call it that you can essentially with aortic stenosis, you get a slow rising post, okay? And take the actual carotid pulse. It's it feels a lot softer, and it's the bit delayed in 16 OSIs and also with Apex Beach. When you're palpating the apex beated someone who has aortic stenosis, It will continue to be sustained. Okay. She'll be, um, not necessarily displaced. That'll be sustained. Okay, um because then aortic stenosis is you get a pressure overloaded ventricle. Uh, can you tell me why is that likely? Cause of attacks, Telesis, Degenerative constipation in this patient. What indicates that this is degenerative calcification? Yeah, H Okay, so they're very elderly, man. Is that depend? It'd calcification is the most common cause of aortic stenosis and generally elderly patients. Okay, so the age is really important to pick up on with 16 doses patients. Okay, so hopefully you guys ah, have a reasonable understanding of some key features. Off. Take stenosis. We'll go through it in a bit more detail in a bit. How about this one? So you have a 17 year old boy, but the Jackson start murmur heard loudest in the left lung border history of syncope. When playing basketball member gets quiet, then when he squats, and he also has a murmur that corresponds with the P wave on an E. C G. It's a very interesting case. Uh, not quite ah, tetralogy. I could see what you mean. This isn't This isn't pulmonary stenosis first, but I think I think we have a couple of different answers. There's a couple of features here. That's it's very tricky. You need to have a I think, really broadly to put the features together. Come. They got a hawk. Um, so hypertrophic obstructive cardiomyopathy. Okay, um, so this is another differential for early systolic murmur. Okay. If someone has hypertrophic obstructive cardiomyopathy, Uh, the key thing here, this patient also has a dejection systolic murmur. But this is auscultated in the left sternal border. Okay, So, commonly, this is where you also take the pulmonary. Both, um, history of syncope when playing basketball. So this is a classic feature of anyone with hypertrophic cardiomyopathy. Okay. Placidly. Yeah. One of the big things with hypertrophic obstructive cardiomyopathy is that it's of the major major causes of sudden cardiac death and young people. Okay, so history of syncope even think basketball in keeping with, uh, how come this is the key statement. Okay. This is the thing that tells you this is how come the movement gets quieter when he squats. Okay. Sorry. Have spelt quiet around here. This is a quiet, um, Why? Why is that important? The moment gets quiet when he squats. What does that indicate? Yeah. Excludes a lot. It's the nurses. Okay, Someone's got it. So, basically, any other type of murmur when you squat, the memory gets, um, bladder. Okay, because of increased the nystatin, but with hypertrophic obstructive cardiomyopathy gets quiet. Okay, I'll talk through the physiology on a bit. Okay. But this is one of the major reasons why it's not why it's hawk. Um And what about this last statement? Hear the sound heard? There's also sound her that corresponds with the P wave on any CD. What do you think about that? This Is this a very difficult case? I'm not going. He might try. Uh, not quite. What's what is the p wave correlate with What is the p wave in a sed indicate? What is that? Basically indicating in a left atrial hyper to me? Not quite so if you were in the city is indicating atrial contraction, right? Basically it. So there's a moment that's happening when the atria is contracting. Okay, there's a sound produced by eight you're conducting. Yeah, good. Full top sound. Okay, so if someone has a full thoughts on, uh, classically seen in someone with hypertrophic obstructive cardiomyopathy? Okay, Someone who has very stiff ventricles. You can get a four spots on. Okay. And so you have four parts on four Heart sound is produced by a choke contracting. Okay, Sorry. Can you take this guy eso? That's why the pew. That's why the sound is produced That is correlating with the P wave because the sound is correlating with the atrial contraction. Okay, so s for, um, is this is a very tricky case. Okay, I will go through hypertrophic obstructive cardiomyopathy. Bit more detail they drawn. But that's why this was talking. Next one. Here we have a 25 year old woman who has an ejection systolic murmur heard loudest in the aortic area. Murmur radiates the crowds. She has a web neck and has not had a first period yet, but I think tennis and goodbye. What's the cause of the member? I just been able to both Okay, so this is still a little stenosis. Okay? They've got a jet systolic murmur, just like in the first one. It it's a injection. Systolic murmur radiating to the cross. It's but in this patient, the likely causes a bicuspid aortic valve. Can anyone tell me why is it bicuspid aortic valve in this patient? What? It's the justice patient actually has a bicuspid. Aortic? Yeah. So those two things, they have one. This is a young patient. Okay, remember, in older patients, most common cause of a lot expenses degenerative calcification in younger patients, generally bicuspid aortic valve is the most common cause of a lot external assist. And also, this patient has features off a genetic syndrome called Turner syndrome. Um, and this patient has peaches of Turner syndrome. Okay, Web neck. Um, know how the first period I get so primary amenorrhea another feature of Turner syndrome Onda congenital bicuspid aortic valves are a common feature of Turner syndrome as well. Okay on. But that's what that's a bicuspid. Aortic. No. Next one last one here, eight month old boy with Down syndrome has a Christian Decrescendo ejection systolic murmur heard loudest in the pulmonary area. There's no radiation. There's a systolic thrill and a heave on the left sternal border. He turns blue when he cries or feeds and there is digital clubbing. What do you think? So this is, Ah, know something necessary. You're seeing your Osco. Okay, but I'm trying to be complete with the differential sport. Early systolic members. So we got a lot of difference on says, what's the cause off the murmur? What's the cause of the ejection? Systolic moment of common area. Yeah. So this is primary stenosis, okay? And as I say, a lot of ancestor, This is likely a patient. A baby. You as you know, baby boy as tetralogy. Awful. Oh, Okay. So we talked about tetralogy a fellow in our pediatrics for final session. Okay, so if you want to learn more about estrogen below, it's you make sure to check out the pediatrics of finals open up. But this is what controls your follow. You get different defects. Okay. Uh, one of the defects you can get is pulmonary stenosis. So why is upon restenosis? So we got a crescendo. Decrescendo murmur Classic for probably stenosis has heard Let best and the pulmonary area. Okay, so just like it takes, the nose is best in the area. This is pulmonary stenosis. Best sit in the pulmonary area and um, restenosis doesn't really radiate. There's a systolic thrill. Okay, so it's indicating this is a great for murmur at the minimum. And there's also a heave on the left sternal border. Why is it why does this boy have a heave? It was the relevance of the heath on the left center border. Right. Ventricular hypertrophy gets Okay. So again, one of the other features off tetralogy follows. You get right. Ventricular hypertrophy. Yeah. He turns blue when he cries a beats. What is that called? What do you call that when maybe is get cyanotic during crying. A feeding? Yeah, it's called a tat spell. Okay, So babies who have tetralogy pillow, they can get these tests. Helps with me, get cyanotic. And if you remember from our cardiology station part too, we have many causes off digital clubbing. One of the causes off one of the cardiovascular causes of digital clubbing is sign Arctic heart disease. Okay. And technology, a fellow is one of the causes off a cyanotic heart disease. Okay, so that's one of the causes. A pulmonary stenosis. Okay. Obviously, as you can imagine published the nose. This is very rare. Okay, compared to things like a lot of stresses and hokum, but it's in the differential sprint. Really systolic member. Okay, so hopefully you guys have some reasonable understanding of some differential for really systolic murmur. Let's talk through some of the common ones and a bit more detail. Have a listening and tell me what you guys think. Yeah, that's one. That's one moment. I'm gonna pay the same murmur, but it's a different patient, so I'm listening. Good. So, no, not everyone's committed to saying it takes stenosis. Okay, we got we can't definitively say this is a little stenosis just yet, but if you can describe the moment properly, I'm sure a lot of people can say this was a really systolic murmur. Okay, so it's like a stop stop. So it's an early systolic murmur, okay? And as some people say, it was a crescendo decrescendo in quality. So it was getting louder initially and then quieter on, as I showed you from this diagram, it's best heard in the aortic area as best heard on health expiration. Okay, I'm gonna add in another statements. Um, so let's say I forgot to animate this probably, but we get out tell you that the moment radiates to the croutons as well. And I've got a sound to play as well. For that, you get the standard, so have a listen. So this is the same murmur. Okay, so this a patient has it takes 10 OSIs, and it's radiating to the carotid. So have a listen to what it sounds like over the carotid artery. Oh, Oh, Okay. So hopefully you can appreciate that's what he sort of radiation sounds like of aortic stenosis. Okay, so again, if you listen closely Ah, the murmur. It was a nearly systolic murmur, crescendo, decrescendo. And it was best in the l tick area. And I told you it's best heard in the the best heard on expiration. And there was radiation to the cross. It's okay. So that's a latex tennis. This So that's about cirrhosis and a bit more detail in terms of the actual pathology. So we come back to the diagram here. Okay, So it it'll take stenosis. What's happening is that we're getting a stenotic aortic valve. Okay, so if we look at the pathology, so during systole when the ventricles are contracting, involve a stenotic. So remember we said earlier a moment is produced by the blood flowing in a tablet manner. Okay, because of your blood blood flow. So during systole, when blood is being injected out because of the stenosis, there's a murmur happening here, Okay? And, um, because it is doing systole. So it's a systolic murmur. So here, in terms of the causes of a lytic stenosis, So in terms of a cause of actually stenotic aortic valve, that's generally to maintenance. Okay, Degenerative calcification. Most common in the elderly patients, which we said, and the congenital bicuspid, aortic valve comedy young people and also associated with turner syndrome. Rheumatic heart disease is, as you will come to see is basically can cause any type of valvular defect. Okay, rheumatic heart disease is is in the differential for any murmurs affecting the heart. Uh, can you tell me which valve is most commonly affected in rheumatic heart disease? Yeah. It's usually the might football, which gets affected the most in rheumatic heart disease. About matter, disease. It can affect any bulk. Okay, um, in terms of the clinical features off aortic stenosis before that. So we got a picture here off degenerative calcification. so you could see what? What a calcified aortic valves Bob looks like in terms of the clinical beaches, so most patients will actually often be asymptomatic. Okay? And it's often picked up, incidentally, but severe aortic stenosis, the three important symptoms to remember syncope, angina and dyspnea. Okay, three major symptoms to think about that indicates how severe someone's texting assist. So let's talk about the actual murmur now. So he said it was a systolic murmur. Okay, it's specifically this is how we could, uh, configure the murmur. Okay, so it is specifically it's a crescendo. Decrease tender member. Okay, we say it's an ejection systolic moment because the murmur is happening because off the ejection of blood during systole. Okay, so it's an ejection Systolic murmur. And yes, it's crescendo decrescendo. That's classic for allergic stenosis. Okay, so again, it's an ejection. Systolic murmur. Classically, it'll radiate to the carotid. It's best heard an expiration like any left side of Burma, and it's made louder with the patient's sitting forward because the because sitting forward brings the aortic valve closer to the chest wall. And often some patients might also have a click. Okay, at the start, of the murmur on Because sometimes when the moment opens, you get a click, son, when the When the of suddenly opens. Okay. While being stenotic, um, but this is the main movement features to be thinking about. Okay, Um, can you tell me what? What what else might you get in a patient with a lot extensive? What are the other features? Are a lot explosive that might be seen on examination. Yep. Someone they might have. Soft s to sun across in radiations. We said there might be radiation. Slow rising pulse. Okay, like we talked about. Cool. So these are some other features. Okay, We know we don't have time to talk about all of them. Okay, but key things. Things like a slow rising pulse. Okay, I sustained apex beats, which we talked about because you've got a pressure overloaded ventricle can get a thrill over the aortic valve. Now a post pressure. So, uh, the difference between your systolic BP and your diastolic BP can be very narrow and a lot of other features which we don't really have time to talk about. Today you get a soft s to sound. So the second outside because the valve has become very calcified. It doesn't actually close as close properly. Okay, close with the right amount of impact. So the actual sound becomes very soft. Okay, but this indicates very severe stenosis where the valves become so calcified that it's not closing with much force on there, Some other peaches that you can have a way we can talk about some other day. Um, but yeah. Go. So we're still talking about features off, uh, take stenosis. And I got this PCG for you guys, which and examine it might show you. And, yes, tell me what's happening in this CCD. Yeah. So we got so left. Ventricular hypertrophy. Okay, so if you to tune into Sahan as SED session the other day, you you might you might be familiar with some of the features off ventricular hypertrophy. I guess the key things quickly is these huge are ways it. Okay, these two, you two negative deflections Here, you can see the negative deflection that's coming off the E C d. Here. Okay, this is huge on the left axis. Deviation as well. So this is a CT showing left ventricular hypertrophy important sign off and extent OSIs. Okay, but the aortic stenosis you get left ventricular strain patterns such a trickle hypertrophy. So make sure you're able to recognize the CCD. Cool. So, in terms of the investigations for a recheck stenosis in your ski, can you tell me what would you What would you tell the exam? That you would do what different investigations And give me a reason for why you would do them as well. Yes. Obviously the echocardiogram is the gold standard to look generally assessed valve function. Okay, Other before the echocardiogram. What else do you need? ECD? Definitely. Okay, so I showed you in the CT. Just X rays useful. Any blood tests? What blood tests might be useful to do. BMP is a good one. So troponin. Um, yeah, I didn't put in the MPs I good one to mention as well. So again, in terms of investigations as we talk about all our ski sessions, general approach is divided into bedside investigations, blood tests, and any imaging and special tests. Okay. In terms of bedside tests, generally things to mention are things like basic observations and e c g. Okay. To look for things like ventricular hypertrophy. Urine, dipstick. What? What can a urine dipstick tell you and about? Disorders in general. What might be useful for? Yeah, he material. Okay, if someone has infective endocarditis that might present with hematuria. Okay, I say you and dipsticks a useful one blood test so you can mention a couple of times a full blood count might be useful to look for anemia. Okay. As a cause of a murmur you need. So look at renal function's. It's in case you need to do surgery and things. It's always useful to get a renal function. Lipid profile. Always useful if you think about cardiovascular disease in general plotting profile If you need to give things like a metallic valve replacement, you need to know what the patient's clotting level profile generally is. CRP e s s. Also, if someone has infection said infections like and the colitis, You want to check the inflammatory profile and blood cultures as well again thinking about undercard endocarditis as a cause off, um, valve problems. Okay. Uh, good. And it seems about imaging a special test of chest secretary. Always useful thing. You might pick up certain features on chest X rays for certain bobble a heart disorders echocardiogram is the gold standard. Okay for assessing the assessing any valvular pathology way? Don't it's not. I don't think it's time pulling for you guys to know which type of echocardiogram generally to go for. Okay. There's different types like transthoracic echocardiogram, transesophageal echocardiogram. Okay, there's different types, but echocardiogram is generally the gold standard for assessing the, um, valvular heart is orders on finally coronary angiography. Can you tell me, why would I consider doing corn area and er graffiti? What I what? I want to know what the coronary vessels are like. Yeah. So it's a good thing, too. It's always important to exclude any coronary artery disease. Okay, if I need Valium, Lipitor 80 is always important to do corn. You on directly. So, actually, you're gonna do major surgery as well. Okay. If they have evidence off coronary artery disease, you might Ah, it might be an indication to do a bypass at the same time I was doing a valve replacement. Okay, um, so that's why it's very useful to do corny angiography, if you know you need if a patient needs to have above replacement done you can just save rehooked resource is be a lot more Be very convenient for the patient is low. Okay. To do a bypass graft at the same time. Okay, so those are the investigations, okay? And I'll tell, you know, these are the investigations for any valve disorder. Okay, you can apply all of these different investigations for any valvular pathology. Okay, So investigations for all the other moments are is the exact same. Okay, So, again, it's all about being able to justify them. Okay. As long as he able to justify them, you can include them in your presentation of the answers. Okay, So I got a question for you guys. Can you guys tell me some indications for a valve replacement in a text? N OSIs? Yes, that is a common. Examine a question. So someone said severe aortic stenosis. Can it'll tell me what the severe aortic stenosis actually mean? The yes, if someone has those symptoms. Okay. What about if they're asymptomatic? What else might be done? What might you do that about a place in in They don't have any symptoms. Yeah, Tec the bowel barrier. Okay, so there's a lot of different features to look on echocardiography. Okay, um, ejection from you yet, so I'll just go through some of the key one. So if they have symptomatic disease with severe stenosis, So any of these numbers that's an indication to do the valve replacement. Okay, if they have any of these numbers, okay. If they have a significantly low valve area, okay, A really, really low ejection fraction. That is also an indication to do it if they need to have a CABG done at the same time. Okay, So, as I said before, if they need to have a bypass done at the same time is above the basement. That's an indication to to do that surgery on if there's evidence off systolic dysfunction. Okay, So low ejection fraction is basically part of that, that one as well on. But lastly, if they have features off in front of endocarditis and they're not responding to any medical therapies, that's also an indication to do um uh, about replacement. Okay, surgical valve replacement. So this is these are something he wants to make Sure you're able to list some of these because they do get tested relatively commonly in osteo and another viable question for you guys. Can you send me some complications off explosives, Pop a day? Yep. Hoping is a big one. Okay, this is the big major worry off exercise. Any other more niece complications. So syncope is a symptom of takes. The nurses. What else might cause? Okay, I'll go through it. So I've got a new monitor for you guys, so Oh, no, I forgot Teo. I forgot to put the letters in. So, uh, the actual pneumonic is leak. Okay, l e a p uh, You know, the lettuce. It should say l e a piece so helpful. Left ventricular failure. Evil and a card itis. Okay, um, A for anemia. Okay, so patients with aortic stenosis can get a hemolytic anemia on D s story. No p for pulmonary hypertension again. So if someone has severe aortic stenosis that can potentially lead to back pressure and lead to pulmonary hypertension. Okay. Remember endocarditis If anyone has any sort of damaged balls, Okay. Any type of damage about that is a risk factor for endocarditis generally, Okay, but yeah, these are some of the major complications of it. Extend Asus and in terms of the management in our politics. Know, sister, how you present management and Aussies remember, always talk about conservative aspects, medical aspects and surgical aspect. Um, in terms of conservative aspects, always mention MDT approach. Manage any co morbidities always mentioned charities and your presentation for the presentation of answers. Okay, things like heart foundation reduce strenuous exercise and you're good dental health. Okay. To reduce the risk off endocarditis and always insured patients have regular follow up. Okay, with regular examination and echocardiograms done in terms of medical and surgical therapies, so optimize any risk factors they have okay for cardiovascular disease. Okay, if they have any and high cholesterol, high lipid levels optimize that. And in terms of the key procedure, so the main one, it's the main thing thing about about the basement. Okay, surgical about replacement. And this might be done with a bypass procedure. And the other one that's being more commonly performed these days is this procedure called tabby? So this isn't a surgical procedure. This is a and O vascular procedure where they put in a catheter and then intervascularly repair the valve. This isn't This is done. If they're not suitable for surgery. Okay? So there's a very elderly. There's not much good outcomes to do a major operation. Uh, then you can do it, Todd. Okay. Yeah. Those are the key things to talk about. When you present management for a little stenosis. Let's go through some other differentials for systolic members. So have a read of this one. So we have a 55 year old man with cardiaca see artery disease. There's a high pitched holosystolic murmur at the apex that radiates to the exit Auscultation off the lungs reveals crackles in both long basis. And the CD last week showed ST elevation and leads to three and a V F. What do you think? Uh, this isn't Michael stenosis. My this is much took. That mitral stenosis causes a diastolic murmur. Yeah. So this is Michael regurgitation. Okay on. So we're talking about other causes of a systolic murmur. Okay. We talked about earlier. Systolic murmur is initially now we're talking about different other types of systolic moments. Specifically, this is a hollow systolic, miller and classically, that's gonna be caused by much regurgitation. Because we'll talk about why. But my trigger station, classically, because they Holliston systolic murmur best heard at the apex, and classically mitral regurgitation radiates to the exit auscultation of the lungs. Rubio's crackles in both lungs basis. So that's indicative of pulmonary edema. So because of my trigger education, blood leaking back into the lungs the last week showed ST Elevation in 23, maybe four days. I indicate yeah, inferior as stemi. Okay, so it's inferior wall myocardial infarction. Um, what's the relevance of the timeline of? Why is it why is it why is it relevant? That was last week. Yes. Um, I triggered station classically. It's It's one of the complications off, um, off my card infection. Okay. Off. And if you have my card infection, you have different complications. Okay. Mitral regurgitation is one of the complications off. Um, I say, Okay. It's one of the very worrying complications off my card infections. Classically mitral regurgitation. If it happens, it takes usually happens after a week or more than that. Okay. It doesn't usually happen within the first acute stage of infection. Okay, Usually takes a couple of days, but yeah, that's why this is mitral regurgitation. Classically, it's in terms of my card and functions. It's usually an inferior and my, which can cause mitral regurgitation. Okay, But it's not a standard. OK, is usually the inferior stem is the next one. 30 year old tall woman has a midsystolic click at the apex and a late, astomic moment that radiates to the exit. She has a history of arachnodactyly and reduced visual acuity. Intricate. You're getting a lot of ma finds. What's the cause of the memory? So yeah, this is Michael valve prolapse. Okay, so we'll talk about what might have our prolapses so classically much about prolapse. You get a midsystolic click. Okay, that's the key feature off. Okay, Michael Bob prolapse. But if you might have, I was prolapsing. Okay, so it's it's not touching each other properly. It's prolapsing into the atria. Then what can happen is that you have blood starting to re go today into the atria. Okay, so you can get a late systolic murmur from mitral regurgitation. Basically, after the midst of solid clay, I'll talk to you about the why you get this specific member. Uh, the people said history of are conducting and with juice visual acuity. So these are features off, um, Marfan syndrome. Okay. Uh, doctor, Doctor Lee can never tell me. What's the reduced visual acuity indicating? What does that indicate in Marfan syndrome? Yeah, Lens desiccation. Okay. Another important feature of Marfan's is dislocated lens. Okay, Um, so that can cause problems with vision. So Marfan syndrome is one of the key risk factors for mitral valve prolapse. Okay. Um, so yeah, that's MBP. Next one here. 15. Your boy has a pansystolic murmur. Palpable, Thrilled. At the lower left side of border, there's no radiation and the murmur is bury order portable JVP, X rays. Any complaints of recent worsening exertion or dyspnea? There are a candle folds and flat nasal bridge. Sorry. If you want to send the feedback, can you send the feedback form out now? Because I think we are running slightly behind us. Need to Yeah. What do you think? Yeah, it's a ventricular septal defect. Very good. Okay, um so again, talking about systolic members now, so the VSD So if you have a hole between your ventricle and your between your ventricles, you get what you get a pansystolic murmur. Okay. We'll talk through the mechanism in a bit. Now, this patient also has a palpable thrill at the lower left sternal border. Okay, so again, Ah, future. It indicates this is at least a grade four murmur. There's no radiation, classically with ventricular septal defects. And I'm sorry. The moment is barely audible. I think I forgot to change this. So, um, had it might seem a bit contradicting that the patient is a popular thrill and the murmur barely audible. Let's ignore the palpable drove. And I did make a mistake here. Can you tell me, what's the significance off the murmur being barely audible and a bit anticulataion little defect. What does that mean? If the murmur is barely audible? Yeah, means that this is a big pen trickle a septal defect. Okay, so, classically, if you think about it, ah, if you think about a hole between the ventricles, if the hole is really small, that's going to make the murmur really loud, Okay? Because the blood is trying to go through a really small defect, so you get a lot of terrible in blood flow. But if the actual defect is bigger, that means there's more space for the blood to actually move into the move between the ventricles. Okay, so that means there's less turbulent blood flow, so the moment actually is a bit quieter. Okay, so then trickle a septal defect if their moments quieter. That means that the actual defect is a lot bigger. Okay, so remember, if you are also taking someone with a B S t and the moments very loud, Uh, the allergy isn't that working? Okay? It probably means the VSD is quite a lot smaller, but if it's quieter, that's more worry. Okay. Means the defect is a lot bigger. Um, JB's raised complains of recent worsening exertion or dyspnea. Uh, what could this indicates in ventricular septal defects if someone's having, um, continuous left to right shunting, Yeah, pulmonary hypertension. Okay, so someone's getting blood constantly being shown. Chanted from the left ventricle to the right ventricle. That could lead to ventric. Right? Right sided heart failure. Okay. On existing this near that could indicate pulmonary hypertension. Okay, because of the continuous shunting of blood, finally, every count all falls on flat nasal bridge walker. That indicates yeah, yeah, down syndrome. Okay. Remember, in your osteo is always try and be as formal. It's possible when you talk about conditions. Okay? So try and say a recommending trisomy 21. Okay. Especially if you're talking in front of a patient as well. Okay. I think it just sounds better if you say trisomy 21 instead of saying the patient has down syndrome. Okay, but Down syndrome, one of the key risk factors for is another one of the key risk factors for ventricular septal defects. Good. Last one. 24 year old man has a pansystolic member. Okay, Someone else. What's the difference between Pansystolic moment? Hollis? The stomach moment. It's the same thing. Okay, I just I just change it up. But is a plant systolic murmur lower last time. The border, little clubbing and high grade fever Peoples are pinpoints and there are needle marks on his forearms. The murmurs louder on inspiration. And there is pulse. It'll help out. Um, actually, what do you think? Yeah, this is in fact, of under contract. It's okay. Specifically, it's causing tricuspid regurgitation. Okay, so tricuspid regurgitation again. Just like mitral regurgitation. It will cause a pansystolic murmur specifically in lower left sternal border where the tricuspid valve is located. Uh, this patient has features of effective and the card itis Okay, so a additional clubbing. Hi, Greg. Feet. Okay, so remember any patient who has a new fever and a new murmur that's indicative of endocarditis. Okay, so this patient has a new murmur, You fever coming is also caused by an endocarditis. Uh, what's the significance off? Pinpoint people's needle marks on his forearms. Opioids. Okay, so this patient is likely an IV IV drug user. Okay, on this is important because intravenous drug use is an important risk factor for in fact, of endocarditis. Okay, particularly off the tricuspid valve, just like in this case. Because if you think about the not to me, when you feel injecting on if you're injecting. Okay, any bugs that come in the veins is gonna land on the right husband. Both okay, Because that's the first bottle that's going to be That's the bugs going to come in contact with. Uh so IBD is a key risk factor for and look right at, uh, which again is, um, is, like, the likely cause off. And the colitis in this patient, based on the fact is an IV. Do you? Yeah. It's like a staph aureus is a common culprit in intravenous drug users. for undercard itis on. Lastly, So movement is louder on inspiration to remember at the start, we said right sided members are louder on inspiration. The Tricuspid valve is a right sided, so Tricuspid regurgitation gets louder on inspiration. And there's Pulsatile Hepatomegaly again. That's a sign of tricuspid regurgitation, commonly, because it's if they have huge Fatima ugly, and it's possible that indicates there's backflow from the heart. Okay, so that's those are some other differences for systolic minutes. Okay, let's talk through them quickly. Have a listen. Yes, on systolic murmur. Good. Have a listen to another one. It's the same murmur, but a different patients. Okay, I don't know how well it's playing, but this is the patient like the as I write about prolapse. Okay, sorry there wasn't a pansystolic members. If I played again, there's actually a click in the middle. Okay, I'm not sure I would be able to hear it, but if you listen closely, there's a click sound between in the middle of Cicely. And then there's a murmur. Okay, so I played again. Haven't trying. Listen to the midsystolic click off a much about prolapse. So listen, there's like a click sound in the middle again. Then there's a systolic murmur. Okay, that's classic for mitral valve prolapse. Okay, Uh, wasn't best it on expression. Sorry, I made a mistake. Yeah, I made a lot of mistakes on this one, so it should say expiration. Okay. Sorry about that. I'll change it when I send the slides. So this is mitral valve prolapse. Okay. So, again, in terms of the murmur, it was a midsystolic click. Okay, on there was some regurgitation with the murmur Is what? Okay, so let's talk about mitral valve prolapse. So what's happening in a mitral valve prolapse is that there is a prolactin mitral valve. Okay, so if they played again So what's happening is mitral valve is prolapsing into the atria. Okay, remember, you have these structures called court attend any attached to your mitral valve leaflets? So what's happening is this valve is prolapsing into the Atria Onda. You're getting a second because these quarter tendon er tensing okay to try and pull it back to its normal position and that tensing off the quarter tendon e is what produces the sound. Okay, you get a click sound because these quarter tendon e trying to pull the mitral prolapse invite above back to its original position. Okay, so that that's where you get the click sound with my MBP. So terms of the causes of a mitral valve prolapse it's usually the idiopathic. Okay, it's actually relatively common in the general population. Marfan's syndrome is also a common cause for it, as you talk about in the spot diagnosis and other things. Rheumatic disease and the card. It's as common causes for many defects, and it seems that clinical features most patients are asymptomatic on. But the key thing here is that when did the mitral valve is prolapsing That gives an opportunity for blood to regurgitate. Okay, because when it prolapses that there's opportunity for blood to regard state into the atria and when the blood regurgitates, you can get a murmur associated with it. Okay, if there's no rupture of the quarter tenderly okay, these if these court a tendency do not rupture when it prolapses, you don't get significant regurgitation. Okay, because the Kordech tendon he can pull it back to its original position. But if the court a tendency, do rupture a case of these, these things hanging these things anchoring the much above to its original position. If they rupture, then you can get significant blood regurgitating. Okay, it's again know rupture. Know much repeated station. If there is rupture, you get significant regurgitation. Okay, and then, if there's significant regurgitation, you'll get a systolic murmur associated with the clip. So let's talk about the the actual murmur again quickly. So in terms of the murmur for mitral valve prolapse, so you get a midsystolic click. Okay, because the quarter tendon the are tensing. So again it's a midsystolic click on. If there's regurgitation associated with it, you'll get the associated murmur case. You get a late systolic murmur because off the mitral regurgitation Okay, so that's the murmur for a mitral valve prolapse. Okay, next one. Here. So we have a murmur. Best auscultated in the mitral valve area, and it's radiating to the, um, exhilarate. Okay, so hopefully that you already have an idea of where to you, um, about the memory. But I have a listen to these different moments. They're they're offering the same. They're all the same murmur. But just in different patients, have a listen. A lot of you getting the diagnosis but just just have a listen and try and appreciate it so again that if you hurt your probably it was a pansystolic murmur. Okay, Was a murmur for the entirety of systole on Dad as this the best auscultated the mitral area, and it was radiating to deep Sillers. Well, so this is like, this is definitely mitral regurgitation, but have a listen to the other ones. Yeah, so that's still that's mitral regurgitation. Okay, I hope we keep trying to appreciate the pan systolic murmur. Okay, There's literally between the first outside and the second outside, there's no gap. Okay? It's in entirety of Cicely is a murmur. Have a listen again. Thank you. You can hear the patient breathing as well at the same time, but try and really holding on that pansystolic moment. Okay, that's a mitral regurgitation. Okay, that's what cool that's my trigger gets. So what's happening in my two big education is that it's in the name blood is regurgitation through the mitral, but Okay, so you have the mitral valve here. So what's happening is that the valves are not closing properly. Okay, for some reason, the bottoms aren't closing properly, so when the ventricles are contracting. Okay. During systole, that's gonna be for there's gonna be Ford flow of blood. Okay? Blood's just gonna be moving in this general direction. No, because they might above They haven't shots. Okay, at the end of ghastly the mitral valve to be closed. Okay, but here they haven't closed. When the ventricles are contracting, when the aortic valve opens, blood will be flowing this way. But because in mitral valve hasn't closed yet, blood will also be regurgitating through the Michael buff. Okay, because this is happening. This is because the Atria is a very low pressure system. Blood is always gonna be regurgitating through the about, okay, because the pressure in the ventricle is always gonna be higher than the pressure in the atria. Okay, for the entirety or systole. So that's why you get a pansystolic moment. Okay, Because whenever that, if the ventricles contracting blood is always going to be regurgitating through the mitral valve to the low pressure too low pressure atria. Okay, so that's why my trick education is a plant systolic murmur. And also because you're getting turbulent blood flow here. Okay, if you think about the anatomy of the heart. The the left side of the heart is close to the exit. So when you get that tube of blood flow that turbulent blood flow, it's turbulence that the vibration produced by that trembling it radiates to the exit. Okay, that's why you got the radiation With Michael Leakage. It's in terms of the actual closes off my freak education as we can divide them into the acute causes on the chronic courses. Okay, acute causes are things like if someone's had an M, I Okay, so we talked about it. But if you're ever in, am I looking my college infection that can make the papillary muscles anchoring the mitral valve to become a schematic and that can lead to failure off the mitral, but okay. Called Attended A can also rupture. Okay. And did it. Different causes of that and endocarditis can also cause acute mitral regurgitation, other chronic causes. So if someone has a prolapsing mitral valve Okay, we talked about before. That can also cause the vegetation, other causes, rheumatic heart disease. Some patients can get a functional dilation, so because the left ventricle gets very dilated, even if the valves are functioning properly. They're too far apart. So I she touch each other. Okay, So blood could just be good state through the opening. And sitting congenital abnormality is a swell. It might cause regurgitation. Okay, So the clinical features so again, depending on if it's acute. Um, are are chronic. Um, are acute. Um, if you're getting acute mitral regurgitation, that's a big emergency. Okay, It's a big worry, because you're gonna get acute heart failure, acute country and Dema type symptoms. That's in a big medical emergency. Chronic mitral regurgitation is you can get. It's typically happens in features. Can lead to chronic are fairly symptoms. Pulmonary hypertension, atrial fibrillation's. The common feature for most popular heart disease is okay, but yeah, that's mitral regurgitation. Okay, I got this slide repeated, so I forgot to delete the others of slide. This presented the same causes off management. Okay, but this is the, um this is a different way of thinking about it. Okay? You can divide it into my primary. My true good station, or secondly, much. We're good station. Okay, Um, but it's all the same. Cause is okay. You can either divided into acute or chronic. Um, are or you can divide it into primary mitral regurgitation or secondary primary mitral regurgitation. Okay, Sorry. I'm a quite a few mistakes on this side, but try fix them up when I send them up. So terms of the moment for mitral regurgitation. So it's typically, as you said, it's a plant. Systolic murmur. Uh, and he said, Why pansystolic murmur radiating to the Exelon? Okay, best turning expiration because it's a left sided moamer. And it's best tell in the left lateral position because, uh, when they're in the left lateral position, um, that's where that brings the mitral valve closer to the chest wall. And in terms of other examination findings, when I go not going through this but things like a soft s one, okay? Because the mitral valves don't touch each other properly, so the actual first heart sound becomes soft. And there's other features as well that you can have read about Cool. Get it will tell me. Well, this just extra tissues. Yes. Cardiomegaly. Okay. It doesn't matter if this is an A p V o R a p A view. Okay. This is called You might be okay because you got called him back in here because you're getting my foot with mitral regurgitation. You get been trickling enlargement. Okay, As well as left. Atrial enlargement. Okay, so cardiomegaly is a key test extra feature for mitral regurgitation. Uh, got this sed happy, You guys. What do you guys think about this? The CD? You're dishonest. ECD talk. You'll be very familiar with this. Yeah, he literally just Just look at the rhythm strip and tell me what you guys think. Yes, this is atrial fibulation. Okay, again in your skied. Go through it properly. Okay. Patient information. HCG details go through a systematically. Okay, but quickly here, if you look at the, um, rhythm. Okay. This is an irregularly irregular river. Okay? And it's a tachycardia. So? So there's a a trip population. Specifically, It's fast here again. Forget important feature off many valvular pathologies. Okay, but particularly mitral regurgitation. Age of ablation is very commonly caused by my troop vegetation. Okay, cool. And it is investigating. Much regret. Manifestation. It's the same as the age of stenosis. Okay? You congested by all of these investigations the same way we just vital the aortic stenosis ones. Um, but yet investigations are valvular pathologies. I've just kept it as a universal presentation. Okay? You can just say these things to justify for any valvular heart, doctor. Okay, Cool. And this is taken from a cardiology station pot one like I just put this in for a reference. So remember, with mitral regurgitation, acute mitral regurgitation. Uh, one of the big concerns is acute pulmonary edema. Okay, on again, we talked through the management of Acute. Call me a demon in your, um in the in your in the cardiology station. About one. Okay, Yeah. This decide is just for your reference. Cool. Let's move on to another, um, heart murmur. Okay. Still talking about systolic movies now? Yeah, I think I bet against the context this moment best heard in the tricuspid area. Okay, but the patient has also had a recent stemi. I didn't reset tricuspid areas best heard in the lower left sternal border. Okay, Specifically, So have a listen again. Yeah. Okay, right. The I think if you start it and try and describe the moment for me day, so it's basically it's basically the same murmur as the as the previous one. Yeah, yeah, but think about it. So It's if I don't use a pansystolic member. Okay. Best heard in the lower left sternal border patient Had a recent stemi. Okay, if I say, is that a recent stemi? What do you think? So the triggers from the radio station? Definitely based on the murmur, but where it's best located definitely could be. But because of the recent stemi want us, we said my trigger stations. One complication of stem is what else? What other complication of stem It can cause a pansystolic murmur best in the lower left sternal border. You have been trickling septal defects. So if I tell you, there's no radiation as well. So this is likely about trickle a septal defect. Okay, so let's talk about Bs D's. But VSD is classically get pansystolic murmur Best certainly lower left sternal border. It won't radiate. Okay, commonly it can be a complication off recent stemi. Okay, so then trickle a septal defects. What's happening in a V A s t is It's in the name. You getting a defect in the septum. Okay. And because of the defect, blood is able to shunt from the left side of the heart to the right side. of the heart. Okay, So if we think about the pathology here, whenever the ventricle is contracting, blood is gonna be moving to the right side of the hut. Okay, because the pressure in your left ventricle is always gonna be higher than the pressure in your right. Okay. So because the pressure is always higher whenever the ventricle is contracting, you're always your headache pansystolic member. Okay, because blood is always gonna be shunting, and you'll always be getting turbulent blood flow during systole. Okay, so with the STD's, you get a pansystolic moment. It's again pansystolic member, just like in my trunk education. But keeping it's, it's you have different auscultation points, and there's no radiation with, typically with a ventricular septal defect, you don't get radiation. Um, so then the cause is of a ventricular septal defect. It can be congenital again. If it's congenital, it could be associated with certain chromosomal abnormalities like trisomy is as such as down syndrome. Well, you get a quiet defect like an acquired ventricular septal defect. For example, after my carpal infection. Okay, it's one of the early. It's one of the earlier complications. Start. It can happen with a um, Michael infection. So other things, so don't have the actual moment again. It's a pansystolic murmur, best heard in the lower left sternal border. And again, we mentioned at the start. If it's a big defect, um, it's a It's a small defect of the actual ventricular septal defect is small. You get much more turbulent blood flow so that the moment he becomes louder. Okay, so if it's a smaller than trickle septal defect, the murmur is louder because you have more trouble in blood flow. It's that big defect. The moment is quieter because there's more space for blood to move, so there's less sibling blood flow. So the members quite a week a. So remember, if someone has a quieter, ventricular septal defect murmur, that's very worrying because it means the murder, the actual defect is bigger, okay? And also it doesn't typically radiate. Okay, we ask that you bring behind in time, but we're probably finished around 20 plus quarter past 20 past nine British standard time. That's funny. I just this so we're gonna talk about diastolic movements now, so we have a 25 year old man who has an early diastolic decrescendo murmur. Bastard In the able to Gary, those complains off. No back pain and stiffness. For the past five months, he has reduced lumbar flexion and reduced chest expansion. What do you think? Yeah, aortic regurgitation. That's the core. That's the murmur. Okay, so a little realization. Classically, you get early diastolic decrescendo murmur. Okay, there's no crescendo. And it'll be good to get decrescendo murmur That's in the area is Well, what about this low back pain and stiffness for the past five months? What does that indicate? Here? Ankle is expand the lights of skipped. Okay, so, um, we'll talk about this in the spine station. Mobile ankylosing spondylitis characterized by low back pain and stiffness. Okay, reduce lumbar flexion is one of the hallmarks of ankylosing spondylitis. And, uh, one of the extra articular manifestations of ankylosing spondylitis is you get a a tick regurgitation. Okay. It can be one of the manifestations of ankylosing spondylitis you get, uh, it's a good station. Reduced. Just expansion. What? What could that suggestion? And in a patient with ankylosing spondylitis? Yeah. Restrictive lung disease. So patients with, um, patients with ankylosing spondylitis in addition to a degree. Good station Another problem they can get is home early fibrosis. Okay, particularly at the top of the lungs. That might definitely to reduce chest expansion as well. Okay, we'll talk about ankylosing spondylitis doing these fine station. Yeah. This is a little bigger station. Next 14 year old woman has allowed first out, sound low pitched. I started rumble at the apex, recalls frequent sore throat as a child and upset of prolonged illness is a team with fever, migratory arthritis and chest pains. What do you think? Yep. Mitral stenosis. Because it's a classic moment for Michael stenosis. What's the cause of the mitral stenosis? Yeah. Rheumatic, rheumatic heart disease. Okay, so my feel stenosis. Uh, classically, you get a loud s one began a low pitch diastolic sound. Best it at the mitral area. Okay. And this description off sore throats as a child. Absolutely prolonged illness, fever, migratory arthritis, chest pains. This is classic story off rheumatic fever. Okay, so rheumatic fever. Basically, it happens. Which Which organ? It? Which organism causes rheumatic fever? Which bug? Yeah. Group A beat a little gas, beat a medic. Stop the caucus. Okay. We'll step pyogenes so patients get a usually typically as a young at a young age to get strep infection. Onda. In some patients, they get an autoimmune reaction to the infection and that can present with features of rheumatic fever. Okay. And some of these, like this patient, has features of rheumatic fever. Okay, she has a fever. Migrate to arthritis. Very classic feature of rheumatic fever and chest pains as well, because you can get different types of, um, kind of called itises. You get pericarditis on my card itis or endocarditis with rheumatic fever. Anything is that the most common cause of Michael stenosis is rheumatic heart disease. Okay, eso matter. Disease is the major cause of Michael stenosis. Next 1 42 year old woman has a personal heave and an early diastolic murmur of the left upper sternal border. She had corrective surgery for a sign. Arctic congenital heart disease at the age off three. Do you think about this system cause a murmur? Eso It's not probably stenosis. Maurice Nurses is a systolic murmur. What's because of the move? Yeah, pulmonary regurgitation. Okay. This is probably the vegetation. Um, opponent gives it this is bad and put this scenario off. Correct surgery for a sign out. A congenital heart disease. So, for example, or someone with tetralogy follow a common complication off corrective surgery for patients with, uh, Petrolia fellow. Okay. Where they correct the pollen restenosis. His patients could get pulmonary gravitation. Look at a relatively common complication of that surgery. Uh, other than this scenario, what else is a more common cause of pulmonary regurgitation? Really? What's the most that way? Cool. Pulmonology. Okay. Specifically, patients who have pulmonary hypertension. Okay, so it has pulmonary hypertension that can lead to probably get station. Okay, but it's a lot rarer compared to other valvular defects. Okay, so have a listen to this one. So we have a listen to it. Sounds Yeah. Have a listen. This one. Oh, yeah. Okay. What do you think about that? Those members there. So it was best heard in the Arctic area. Tested on expiration. Okay, I'm not sure how well you could hear it, but if you could, there was definitely a diastolic murmur, but yes. Yeah, that was a big vegetation. Okay, if you listen outplayed again, the key thing when your auscultated diastolic moments, it can be very difficult. Okay, the key trick I like to use is to listen for the absence off silence. Okay, so the allergy irritation you get an early diastolic murmur. Specifically, you get the murmurs straight after the second heart sound. So if you listen again after the dub after the second outside, listen for the absence off silence, Okay? Normally would be silent. Here. There's a still a sound coming up after the second heart sound. Okay, listen. Yeah, Okay. If you listen closely was like I loved up loved up. Okay? There was an absence of silence after the dub sat aortic regurgitation. So that's about, um, getting station. So with a little regurgitation, what's happening is blood is regurgitating after after systole. Okay, So, normally at the end of Sicily, devoted close shut, okay. To prevent backflow of blood at the end of Cicely. But with the integrated station, the bowels bowels not closing properly. So blood is regurgitating through the aortic bath. Okay, so it's happening after when the bowels should close again. So it's happening after systole. So it's an early diastolic sound. That's a big vegetation. Okay, so this is what's happening. Aortic regurgitation. Blood is we regurgitating through the aortic both so in terms of the causes, you can divide it into valvular causes. So problems with the actual valve itself, like endocarditis, rheumatic heart disease. Or you can divide it into causes off a little to Groot dilation. Okay, So if you have conditions which dilate the aortic roots, Okay, so there's nothing wrong with the valves, but because the route is dilated, the valves can't touch each other. And that's easy to read your station. That's what these causes conduce. Okay, so the aortic dissection you can get dilation of the aortic route again because off the, um intimal air because blood leaking the intimal air and you get dilation there totally syphilis again, you get syphilitic aortitis, which can dilate the aortic route. Make it to make the valve leaflets too far apart to touch each other again. And you get regurgitation happening there. And in terms of the clinical features again, you can divide it into acute a little bit better station and chronic. A particular station acute aortic regurgitation, classically will cause acute heart failure. Patient type symptoms. Okay, it's an emergency. Your degree decision might be a bit less significant. Okay, so in terms of the member for lt regard station again. We said it's an early diastolic murmur, so it's happening just after the s to sound so normally at the S to the aortic valve would be closed and they won't be a murmur, but to regurgitation because at s to the valves on up closing shut blood is regurgitating. So you're getting an early diastolic murmur. Okay, so and it's a decrescendo murmur. Okay, gets quieter. As, um, there's not that much blood, actually regurgitate is actually gets quieter. Um, so the d present a moment. So terms of the features classically, it gets described as a blowing murmur. Okay, that's the word that you that's used to describe it best heard an expiration because it's a left sided murmur and best heard, um, leading forward. Okay, because it brings the aortic valve closer to the chest wall and in terms of other examination finding So there's a bunch of them. Okay, classically in your osteo have big thing to look out for with a little regular station. Is the collapsing pulse your case you are still in. If they have shoulder pain, mister, arm up and feel for that collapsing pulse. Okay. And we talked about this doing our cardiology station part, too. Okay, There's a couple of other things you can look up for us. Well, okay, have a watching this video. So we're talking about signs off aortic regurgitation. So I have a look at the nail beds for this patient. Yeah, I think you look really closely. Quickly sign yet. So this is quickie Sign gets the quickest circular closely. Those ah visible pulsations and the nail, but okay, so if you look closely, there's actual nail bed is pulsating. Okay. Again, that's a sign of a legitimate vegetation and still talking about signs of allergic manifestation. Have a look at this one. Dancing carotid. It's was the more technical temper. Uh, the muscle. It is the head bobbing again. Not this one. Corrigan. Sign the Corrigan spots. Okay, said Corrigan sign. So you see these dancing karate? It's because of the bigger stating blood. That's classical aortic regurgitation. Okay, so there's a bunch of eponymous signs of the aortic station. Okay, We talked about quickie sign. Look, we talk about Corrigan sign, okay? There's a couple of other ones like the mustard sign. Like the head bobbing on. There's other ones, like probe signed the rosy. A sign. This is stuff that sort of comes up, boy in your single best answer type questions. Okay, but it's important to just having awareness of some of these other economist signs and investigations. Again, we talked about investigations. For all these problems, heart disease is is the same. Okay, you can just as long as he able to justify doing all of them. It's reasonable to mention any of these investigations. Okay, Okay. With on the last diastolic murmur know, So have a listen to this. A murmur vested in the mitral area. Best heard on expiration. So I have a listen. Yeah, I have to send to this. Place it again. What do you think? So what? How do you describe the movements? A diastolic murmur again, Right? And they're as mostly saying this was a this's This is Michael synopsis. Okay, do you listen closely? So with mitral stenosis, you get a mid diastolic. That sound okay? You get if you can hear, Probably. You got a opening snap. Okay. When the 12 opens suddenly does that do? Okay, so it's ah, opening snap and then you get the rumble sunk. Okay, that low pitch rumble after the snap. And again, it's happening during diastole. Okay, We'll talk about why it's a diastolic sound. That's Michael. Stiffness is out. Some can never tell me. What is this? Feature indicates it for talking about mitral stenosis. Yeah, a lot flush. Okay. Mail or flushing? Classic feature of my Christian assists. Okay. Looks a little bit like the rash you get with Lupus, but this is mail a flushing classically seen in the mitral stenosis. So that's about mitral stenosis. So what's happening in module stenosis is you're getting a did not take much about. Okay, so if you're typically blood should be easily able to pass through the mitral valve during diastole. Okay, so we're talking about gastric area when the mitral valve is normally open, blood flows from the atria to filled eventual. But because he might about is not IQ. You're getting turbulent blood flow here, and that's causing the diastolic murmur. Okay, So because of the stenosis is going to bring blood flow to a diastolic murmur. Okay. Um, South mitral stenosis. So this is what a picture of my customers so you have a base to not take mitral valve. The most important cause of mitral stenosis to remember as you talk about is dramatic heart disease. Okay, Definitely the most important one. The major one. Okay, Other ones are much more rare compared to the's Matic. Our disease in general is very red these days. It's okay because of, um, effective antibiotic therapies available but still take our disease is the most common cause off mitral stenosis. And there's a couple of teachers are classic features we we talked about before. Dyspnea mops is just pain atrial fibrilation. But mitral valve disease in general is a key feature. We talked about me laugh flushing. Okay, we should I showed you that picture. Very hypertension because, uh, back pressure. Okay, because left atrium is having a difficult time. Um, pushing blood through. Okay, So you're getting back pressure on defied, have some signs of rheumatic fever. Okay, Like we talked about joint pain. Um, for polio. Arthritis, Okay, fever, different features of rheumatic fever. So that the member for mitral stenosis again, it's a mid diastolic sound. So this is what the moment looks like again. Passively. You can get a snap. Okay, one, the mitral valve suddenly opened when blood comes in on. Do you get the murmur because of turbulent blood flow? Okay. And at the end, you get the moment actually increases at the end of ghastly. Can anyone explain why? This way we have the same mid diastolic rumbo. But just before the end of at the end of vastly, the moment gets louder. Can't even tell me why. Yeah, atrial contraction. Okay, so at at this point, this is when the eight years Okay, at the end of vastly. So when the age of contract is more pressure okay, that blood being eject being forced, dropping the atrium to the van score. So you're getting more to bring blood flow, so the moment actually gets louder at the end of ghastly. Okay, so you get an opening snack with mitral stenosis, a mid diastolic rumble, blood sewing. Uh, probably on the age of contract. When the h A contract at the end of vastly, the member gets louder. So in terms of feature is it's an opening snap followed by Diastolic rumble again, best in an expiration like all left sided murmurs and made louder in the left natural position because that brings the market Tobar off closer to the chest wall. Other examination finding is classically, you get a loud s one. Okay? And also, you get a ride metric. Like IV. Um, those of examination findings for a marshal stenosis. Well, can anyone describe this easy for me? What is this? You see GI pattern showing here. What do you think about this? The wave benefit, peewee. It's osteo that he my Charlie. Okay. And what is the mitral? Yes, I know. Yeah. Left atrial enlargement. Okay, this is probably plastic we seen in mitral stenosis. Okay, where you get left Atrial enlargement. So you get these benefit pee weeks, okay? That's what he might Well, he looks like so And still, what do you guys think about this? Chest X ray thinking about Michael stenosis. What you think? Yeah, and large left a chimp. Okay, There's definitely large left atrium. What about one of my here? Well, one of these contacts on pointing with my hair. Oh, it's a double. Right. Hard double, right. Heart border. Okay, double cardiac. Chad. Oh, okay. There's two contacts on the right side of the heart. Okay, again Classically with left atrium large when you get this double right heart, right heart. Okay, me. And again, this is classic chest sexual feature of mitral stenosis. Cool again. And investigations. Same for mitral stenosis. Okay, just just to be able to just by doing all of them, it's always the same for about the heart disease is in general. Okay, if you can come up with other one, that's fine. As long as you're able to justify them. Okay. Cool on blast one Here. Uh, we don't We're moving on to metallic valve. Okay, Finished our diastolic murmur. So Okay. We talked about a little station. Talk about, uh, Michael stenosis. Okay, Weight on two prosthetic heart valve sounds. And I also have a listen and tell me what you guys think. What do you think? It again? Anyone have an idea if I say there's a click sound, but is it corresponding with the aortic valve or the okay? Play one more time. This is an aortic valve replacement. Okay, some of you said yes. So the click is our first. It's it's best side of the aortic valve area. Okay, that's one thing. If you listen closely. The clink was corresponding with the second heart. Sound Okay, I would be dubbed on if you think about it. If someone has a prosthetic, both if the click is corresponding with the second heart sound, the second heart pound is produced by the aortic valve closing mainly. Okay, so the click is happening in the second heart sound. That means that it's the aortic valve that's been replaced. Okay, so that's a key thing. That's that's why it's an aortic valve replacement. There was also a small flow murmur as well. If you could hear, it's okay because of blood flowing over the prosthetic bath. But the key thing there is to be able to determine that the patient had a valve replacement and it'll take about replacement. Have a look at this one. So we just won't talk about multiple replacements. You can see him. That is a mitral valve replacement. Okay, but just have a listen. So again, try and appreciate the click with a mitral valve replacement. It's gonna be corresponding with the first heart, son. Have a listen. I was, like, clicked like click stop. Okay, that's a mitral button placement. Okay. Oh, so We're gonna finish off talking about valve replacements now, Okay? We talked about this during our cardiology station, but what do you think about this picture here? If you saw this in your osteodin be thinking about Yep. So this is a sternotomy. Scott. Well, what what would you think about with it? What's the next thing to do? If you see a midline stenotic the spine you're asking, Check the legs. Okay. Check the legs to see if they've got a graph. Scott. Okay, that's the first thing. Okay, so you should check the legs of days if they if there's a venous crafts other. Because if there is a scar that indicates that the they have a midline small risk are because they've had a CABG. If there's no graft scar there and they have a midline sternotomies card that actually is very suggestive that they've had a valve replacement. Okay, Valve replaced is a very common procedure where they need to make a midline Samata me incision? I guess so. That's why that's a midline snotty Stop. What do you think about this image here? If you think about Prosthetic Bob's? Yeah. Popara. Okay, So this is that put cooked, uric rush again. But I think that prosthetic well, so we're thinking about anti coagulation. Okay, so, chin to have metallic heart boss. Commonly, they'll have Popara okay, as in sort of easily bruisable skin. Okay, so they have easy bruising because they have a metallic valve. Although you need to be on lifelong warfarin so they'll have this purpura. Okay, that's the key. Those are some key signs to pick up on general inspection for patients who are prosthetic puffs. Let's talk about prosthetic valve. So when we talk about prosthetic valves generally two types Okay, there's metallic balls and tissue. Baseball's cheeky advantages off metallic balls is that they lost a lot longer. Okay, They're very long lasting tissue valves. They only last typically up to 10 years. Metallic balls. Problem is, that patient need to be on life long anticoagulation get typically with warfarin where I stick your house. They don't need to be on long term anticoagulation. Okay, The only meter you know, information for months and then they can stop metallic valve is because they need to be on lifelong and to aggravation generally preferred in younger patients. Okay? Or if patients are already on warfarin. Okay? They've already been established on warfarin therapy. Metallica's a general preferred tissue valves because, because it doesn't need long term anticoagulation. Generally preferred in elderly patients. Okay. As well as women off childbearing age. Can't tell me why. Why is tissue valves preferred in woman of childbearing age? What's the problem of giving metallic walls and women of child with baggage? Yeah, Well, friend is a big, big, big, big No, no in woman of childbearing age. Okay, well, friend is teratogenic. Okay, so you don't want to give warfarin generally as a tissue valve that generally preferred. That's the key differences in consideration in considering who gets a metallic valve who gets a tissue about and in terms of metallic valve replacements, Okay, in terms of which involves actually replaced. So key differences with an a little valve replacement do the s to sound will be metallic. Okay, you'll hear the click during s two, whereas with a mitral valve replacement will get a metallic exam doing s one. Uh, you might get an opening click in systole with an aortic valve replacement. Okay. When the metallic valve opens, whereas with mitral valve replacements will be during diastole. Um, you might get flow moments with both of them. Okay. On also key thing is, regurgitation is generally abnormal. Okay, if you have allergic regurgitation and then if the bottom of this one okay, that could indicate the valve is failing. Okay. Similarly, if you have mitral regurgitation with a much of our replacement that could indicate develop is failing. So that's the sort of keep principles between differentiating the aortic valve replacement from the mitral valve replacement. Okay. Okay. Couple. It's got some Viagra questions. You can ask any asked me some complications off metallic valve replacements. Very common osteo in effective endocarditis. Kids. What else? Leading So, uh, side effects from violation. Good. Bowel failure is big one. Hemolytic anemia is a big one. Okay. Yeah. Plots. Okay, that's about another big one. Um, good. So I have a new Monica. So the monarchy has hate said so. Page for hemolysis. So you get a Humalog came allergic anemia. Okay. Specifically, do you want to be very technical? It's a macro angiopathic human lytic anemia. Okay, so it's a different to the microangiopathic humility years. Okay, um, because the prosthetic valve is an obstruction and red blood cells could get sheared off it. I can get damaged. So you get he hemolysis because of it. Okay. For anticoagulation side effects. Okay, so if someone said bleeding, that's a big side effect off things like warfarin, chief of thromboembolism. Okay, so you get clots because of eat a big methodology object in your body. Okay, so get that definitely can induce clots. Even the slightest prosthetic bodies big. So, in fact, even colitis and finally default dysfunction. Okay, so the valve could just fail. Okay, that's a big problem with metallic votes. Okay. Big problem we worried about with and the topic about with basements in general. Okay, that's pretty much it. You guys, this is a little summary off all the murmurs, the common murmurs that sure been lost. It's okay. Uh, in terms of the key features, the maneuvers, the key location where their best heard. And we're the radio too. Okay, the three much of summary table off the common ones. You guys need to know in detail for your osteo, but yeah, that's it. Thank you, Guys, for unity is Ah, we did