Welcome to episode 97 of the Audio PANCE and PANRE PA board review podcast.

Today is a bonus episode rounding out this fabulous five-part podcast series with Joe Gilboy PA-C, all about cardiac murmurs. In this week’s episode, we continue our discussion of cardiac murmurs with ten PANCE and PANRE murmur questions.

We’ll cover the ins and outs of all the NCCPA content blueprint valvular disorders and learn how to identify and differentiate them from one another.

If you haven’t already, make sure to listen to our previous podcast episodes where we covered tricuspid stenosis, aortic valve murmurs, mitral valve murmurs, pulmonic valve murmurs, and HOCM and MVP.

Podcast Episode 97: Murmurs Made Incredibly Easy – 10 PANCE and PANRE Murmur Questions

Below is a transcription of this podcast episode edited for clarity.

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[00:00:00 ] Welcome back, everybody. This is Joe Gilboy. I work with Stephen Pasquini over there at Smarty PANCE. And today is the most dreaded podcast of all because you know what I’m going to do. That’s right. I’m going to ask cardiac murmur questions.

And I know it’s the most dreaded thing in the world. Let’s do this together because what I want to try to do here is make sense of it all. So, let’s just kind of recap some basic rules before we start going down this thing. You know, the previous lectures, what have I been barking about? What’s Joe been saying? First – inspiration, right? Expiration left.

[00:00:40 ] Inspiration, right? Expiration left. So, with inspiration, the right-sided murmurs sound louder. So that’s the tricuspid and the pulmonic valve regardless of if it’s stenosis or regurgitation. Expiration – left. What am I saying? Everything on the left side sounds louder with expiration, whether it’s aortic or mitral – your call.

[00:01:01 ] It can be stenotic or regurgitation, it doesn’t matter, but it’ll sound louder. What is squatting? Squatting is a party. So, what are you doing? You’re bringing it all the blood flow back home. And so, if I bring all the blood flow back home, just from a laminar flow physics point of view, I bring more blood flow back home to the heart, more blood flow over a valve specifically with a diseased disease valve, it sounds louder.

[00:01:29 ] So, right off the bat, squatting will do what? It’s going to make all my murmurs sound louder. That’s the whole point to decrease venous return. In other words, take blood flow away from the heart. What do I do? Well, those are going to be Valsalva and standing. So, what am I doing when I do Valsalva and standing?

[00:01:56 ] Taking blood flow away from the heart. So, what’s going to happen to all my murmurs when I stand and perform Valsalva? It takes blood flow away from the heart. Exactly. And then hand grip. What did handgrip do? So, in school, what’d you learn about hand grip? Well, it increases afterload, right? So, what they’re really saying to you is this, and this is how I want you to visualize it.

[00:02:18 ] When I do hand grip, what I’m really doing is this. You’re right. I’m increasing the afterload. But you must stop and think this one out for a second, folks. What’s really in the heart? Which valve must fight afterload?

[00:02:39 ] Say you increase the peripheral vascular resistance for whatever reason. So, you increase the afterload, who fights it? And your answer will be… oh, wait for a second, Joe, that’s the aortic valve in the left ventricle. Exactly. So, when I perform handgrip, who am I really challenging? Oh, I’m challenging the aortic valve and everything behind it.

[00:03:00 ] Exactly. So that’s the point I need inside your head? Then remember our last podcast was about our low-volume lovers. Who were our low-volume lovers? Who were the special needs murmurs that really like low volume? They’re like, hey, I like low volume, not high volume. I like low volume. Who was that?

[00:03:19 ] That was HOCM and mitral valve prolapse. What did they both like? They both like low volume. So, they’re the opposite of all my regular murmurs. They go in the opposite direction. All right, everybody got that? I am not going to give you a list of answers. So, what I’m going to do is I want you to listen to what I’m going to say. I’m going to say the test question twice.

[00:03:47 ] And then I want you to pause the podcast. Just put it on pause and think about your answer before I explain it. All right. Is everybody with me? Because that’s the best thing to do. All right, here we go.

Murmur Question #1:

[00:04:11 ] You have a 76-year-old gentleman that presents to your emergency room and comes in complaining of shortness of breath and chest pain on physical exam. You notice an upper sternal murmur that sounds louder with squatting and goes away with hand grip—one more time. Upper sternal border, sounds louder with squatting, and goes away with hand grip. Who am I?

[00:04:45 ] So upper sternal border. This will be my aortic and pulmonic area. Well, it goes away with handgrip. So, who’s that going to be? So, what happens with hand grip? I increase my afterload. Which valve fights the afterload? The aortic valve. It’s not pulmonic because the pulmonic valve is not fighting the afterload; it is fighting the lung. So, this has to be aortic stenosis, which makes sense for the syncope and the shortness of breath. So aortic stenosis is going to do what? Well, squatting, that’s a party. Of course, it will sound louder. We could actually throw expiration in here as well, couldn’t we? We sure could, but it’s the handgrip. That differentiates it, doesn’t it? Because the handgrip made the murmur go away. And what did the handgrip do? I keep telling you I want you to view handgrip like sitting on your aortic valve, and you can barely open up squeak, squeak, squeak, squeak.

[00:05:47 ] You can barely open up. Now imagine sitting on that valve. Can it open up now? And you’re like, no, it goes away. Exactly. And that’s the point I’m trying to make. The answer is aortic stenosis.

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Murmur Question # 2

[00:06:21 ] I have a 45-year-old gentleman who comes in with shortness of breath and chest pain. The murmur sounds louder with inspiration. It’s located at the upper sternal border. And I am also noticing that the patient has right ventricular hypertrophy and right bundle branch block on EKG. Who am I?

[00:06:44 ] Upper sternal border. Well, who are we talking about? The aortic valve or the pulmonic va