Question 27

Created on Fri, 05/29/2015 - 06:06
Last updated on Sat, 03/10/2018 - 21:29
Pass rate: 54%
Highest mark: ?

Topic

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Other SAQs on this topic

Clinical examination of a 35 year old man who is short of breath reveals a pansystolic murmur.  Outline  the salient  clinical features and  investigations  which will help you distinguish  between  mitral  regurgitation, tricuspid regurgitation and  a  ventricular septal defect in this setting.

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College Answer

This question lends itself to answering with table. An example of the sort of information that could
be provided is included in the following example table:

MR

TR

VSD

Symptoms

Paroxysmal
Nocturnal Dyspnoea, orthopnea, palpitations, Chest Pain

Pedal oedema,
Chest Pain, Short
Of Breath

Chest Pain, Short
Of Breath

Pulse

Commonly AF

May be AF

Usually Sinus
Rhythm

JVP

May be raised

V waves

Prominent a waves
because of pulmonary hypertension

Precordium

Systolic Thrill +/-
Parasternal lift +/-

Systolic Thrill +/-
Parasternal lift +/-

Systolic Thrill +/-
Parasternal lift +/-

Murmur

Apical to axilla

Left Sternal Border,
increases with inspiration

Left Sternal
Border, occasionally concomitant Atrial Regurgitation

Other systemic
signs

Basal crepitations

Pulsatile liver

Other congenital
abnormalities +/-

Chest X-Ray

Straight Left heart
border, pulmonary oedema

Enlarged Right
Atrium

Nil specific

Echocardiogram

Classic features

Classic features

Classic features

Pulmonary Artery
Catheter

Pulmonary
hypertension

Pulmonary
hypertension, V waves on Central Venous Pressure

Step up in O2
saturation at
ventricular level

Discussion

To answer this, I have referred again to my own tabulated summary of heart murmurs.

One can do little to improve on the table presented in the college answer.

The MR and TR are easy to tell apart. TR gets louder on inspiration, and causes a pulsatile liver.

MR gets louder on expiration, and causes pulmonary oedema.

The VSD is a little more tricky, and apart from occasionally causing pulmonary hypertension its murmur is difficult to distinguish from the others.

Both VSD and MR will be loudest on expiration, but VSD will be most audible at the left sternal border, whereas the MR is best heard near the apex.

References

Clinical Examination of the Critically Ill Patient, 3rd edition by L.I.G. Worthley - which can be ordered from our college here.

Clinical Examination: whatever edition, by Talley and O'Connor. Can be acquired anywhere.