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go ahead and put your headphones for
second because I really want you get the
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full effect of these members
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here you go
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you you you you
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you you
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wall
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cool
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way
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what what what what what what what what
what what
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what
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d
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you
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you
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so it's pretty much a whirlwind a 5
pretty common murmurs
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00:01:06,026 --> 00:01:09,885

and some extra hard sounds and so if
that really confused you
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that's okay we can go through all the
mechanisms of these members
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and I'm have you understanding it no
time so is a quick review
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we have s1 ns2 and I'm gonna rape
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as one over here again because remember
this is a cycle
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and so in between s1 and s2 we have
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sisterly and between s2 and s1
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we have I S tully and if you remember
the s1 in the s2 are actually caused by
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closing
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the valves for s1 specifically the
closing up the mitral and tricuspid
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for as to specifically the closing above
the your dick
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and paul monette valves and these are
all abbreviated here
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no murmurs can occur between s1 and s2
and these would be systolic murmurs

28
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and these would be things like a or text
NoCs
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or poem on extra recess mitral
regurgitation
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or tricuspid regurgitation and one other
thing that doesn't necessarily cause a
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murmur
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but can be accompanied by mitral
regurgitation would be something like
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mitral valve prolapse
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and so the ones that we're going to talk
about today are going to be the
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left-sided
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valvular conditions so the aortic
stenosis and the mitral regurgitation
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as well as the mitral valve prolapse
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just realize that I made that pearl ape
and so we're gonna
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fix that ever done to start members
meeting they occur between
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s2 and s1 these are gonna be a or dick
regurgitation

41
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or Paul Monica regurgitation and mitral
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stenosis and try cuz been stenosis
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and remember the only way I'm arriving
at these names and when these murders
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occur
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is based on which valves should be open
or what role should be closed
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during Sisley and I S tully and so the
ones that we're going to really discuss
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here
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are gonna be your dick regurgitation and
mitral stenosis and again you'll notice
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these are the left side about
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we're doing this because the left side
valve problems are generally much more
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common in the right side about problems
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so now we've kind of categorize these
into
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systolic or diastolic murmurs to
questions that are gonna become

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important
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are where do you hear the murder most
loudly
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and what's the shape the murder
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and we're gonna explain it as we go
through each murmur since location is a
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pretty big concept
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wanna go over the four places that we
possible T or listen with our service go
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so one of them is here you'll see on
calling this an
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and this is in the second space in
between ribs also known as the second
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intercostal space
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and this is the a or dick area this is
also called
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the right upper sternal border on the
other side in the same
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inner costal space or spacing between
reps we have
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the poll Monique area and this is also
called

67
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the left upper sternal border then in
the fourth intercostal space
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we have the try cuz bit area and finally
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in the fifth intercostal space but in
what's called the
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made it clear victor line meaning if you
drew a line
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in the middle of the clavicle all the
way down to it intersect with this point
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in the fifth intercostal space
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this is the mitral area and the mitral
area
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is also called
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the apex and the reason why we listened
in these different positions
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is because we're actually listening
where the blood is expected to travel
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as it goes through the valve in question
so let's talk about
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New York stenosis I'm gonna do with them
to take you through the progression this
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murmur
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from s1 to s2 in terms of what's
actually happening with the valves with
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the heart muscle contracting
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and so we're gonna start of with s1 and
so if you remember
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s1 is the closing this mitral valve and
so let's say
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this is closed and so that closing
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is gonna cause what we hear as s one
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when it closes the heart actually begins
to you contract
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but its contracting against a closed
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New York valve and so this valve at this
point is closed
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and so that's the reason that in aortic
stenosis murmur
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actually doesn't start with s1 there's
actually a small
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time period small meeting like
milliseconds in between the closing of
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the mitral valve

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and when the york-bound actually opens
and remember what gives us that murmur
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is turbulent flow through the aortic
valve and so in the heart starts
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contracting a build up enough pressure
to open up this valve
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the leaflets have developed will kinda
excelerate upwards
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and when they finally pop open remember
they're not opening all the way because
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the bell for some reason eastern Arctic
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then this will first give you what's
called in dejection sound
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or an ejection click and that's here and
we're gonna label that
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EC for ejection click and that's caused
by these valve leaflets moving
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up really quick and then stopping really
quick and shooting open
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and so when the bell first opens you're
going to get a little bit a blood flow
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through this valve and as the heart
continues to contract more and more

105
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as shown by these errors squeezing out
more and more more forcefully
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you get more and more flow and then
eventually
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as the heart starts to relax a little
bit we're gonna get ready these errors
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you're gonna get less and less flow
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and so the way that this member actually
looks the shape with a member
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is that like we said as a contract more
forcefully
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you get more and more flow the member
becomes more and more intense
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and that is the ventricle starts
relaxing it becomes less and less
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intense and so we call this a crescendo
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d crescendo
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murmur you also hear people call this
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or refer to this as the a diamond-shaped
member you can kinda see that
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around here if you were to outline this

and so a or text i kno sis

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is called 8 systolic ejection murmur and
that makes sense because you're
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objecting blood
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have the aorta any can often have in
dejection click
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and it's usually heard most loudly at
the aortic
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area and the last thing I want to tell
you about this is that commonly
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this member can actually radiate to
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the neck or the karate kids the reason
for that is that this murder
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is occurring in the aorta and if you
remember summer the first branches of
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the aorta
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are actually karate arteries and so you
can hear the murmurs
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resonating up through the crowded
arteries in the neck no quick note and
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you'll notice this for all the other
members that we go through
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pulmonic stenosis which is really just
the same thing as a or text nurses but
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on the other side of the heart the right
side is virtually the same murmur
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it's a systolic ejection murmur
crescendo d crescendo
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and you can have been dejection click
but this one's not going to radiate to
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the nectar The Karate Kid
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and instead have been heard in the a
Orrick area
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it's normally heard in the Paul monic
area
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so the next member that I want to talk
about is mitral regurgitation
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and remember we're still on systolic
murmurs
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to mitral regurgitation is going to be
best heard
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in the mitral area or apex
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its members actually what we call a
hollow systolic
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or a pay n systolic murmur

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and all that means is that it last
throughout the entirety
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up sisterly so let's start it s1 in a
normal heart as one is caused by the
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closing
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the mitral valve and that closing occurs
because
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the pressure in the venture call is P
here
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is greater than the pressure in the
atrium the smoky here
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and so normally this valve
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would close and that would give you your
s1
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in addition you have your closed a word
about here
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but instead of closing remember we're
talking about mitral regurgitation
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and so this is a closing problem
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and so as the pressure starts to build
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in this left ventricle but still with

the aortic valve closed

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blood is actually getting through this
about
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and so that's gonna cause a murmur right
when
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s1 occurs so right
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as that Valve tries to close a dozen
close fully
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because the pressures higher the left
ventricle then left atrium you actually
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start that McBride
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s1 now as soon as the heart begins to
eject blood
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this aortic valve opens right up and
blood comes out this way
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because the pressure remains higher in
this venture call
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in the atrium the whole time you
actually get flow
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through this regurgitate valve
throughout the entire cycle
167
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and you would think naturally that is
the heart contracts harder

168
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that maybe this pressure would become
bigger
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and the truth is that the pressure
actually does become bigger
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but in chronic mitral regurgitation
which is what we're talking about the
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atrium actually
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gets bigger or dilates and so by doing
this becomes more compliant and what
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that means
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is that can accept the blood that's
coming back into it
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at a lower pressure so you can accept
more volume
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at a lower pressure and as a result that
pressure in the atrium
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does not go up so much but because the
pressure difference between the left
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ventricle
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which is really high remember that's the
workforce in the body
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and the left atrium which is pretty low

because just receiving

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blood from the lungs which is a low
pressure system the Jets have blood that
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actually come through here
183
00:11:03,319 --> 00:11:07,220
make a sound that to our years doesn't
change in intensity
184
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and it occurs all the way into the
second heart sound
185
00:11:10,093 --> 00:11:13,110
when this aortic valve closes and at
that point in time
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millisecond or so later the mitral valve
will open again
187
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and start a new diastolic cycle so as
I've written here we actually
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call this a hollow or pain systolic
murmur
189
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in addition it's also referred to as a
flat
190
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murmur because the intensity does not
change
191
00:11:30,085 --> 00:11:33,304
in this member will actually Radi
192
00:11:34,069 --> 00:11:37,250
to the AGS ila and so if you picture
this valve

193
00:11:37,025 --> 00:11:41,064
kind of sitting in this general area
somewhere
194
00:11:41,064 --> 00:11:44,493
when blood flow goes back the other way
its gonna kinda be forced
195
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in the direction of the skies are paid
over here now again just to mention the
196
00:11:48,319 --> 00:11:49,100
right-sided
197
00:11:49,001 --> 00:11:52,066
valve problem try cuz been regurgitation
you have the same armor
198
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8 hollow systolic flat murmur by it
199
00:11:56,029 --> 00:11:59,078
in that case you hear it in the
tricuspid area
200
00:11:59,519 --> 00:12:01,601
and that murmur wooden radiate to the
excellent because the valve is in a
201
00:12:02,339 --> 00:12:02,720
different position