Question 26.3

List 4 causes of a diastolic murmur over the apical area.

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College Answer

Mitral stenosis
Severe mitral regurgitation (flow murmur)
Significant left to right shunt (VSD)
Austin-Flint murmur of aortic regurgitation
Carey-Coombs murmur


This question interrogates one's knowledge of the highly regarded Talley and O'Connor manual of physical examination.

I have used this book to revisit the issue of physical examination in some detail.

In Talley and O'Connor, there is a particular table which this question references. To be precise, it is Table 3-9 in the 6th edition ("Cardiac murmurs").

The mitral stenosis, VSD and severe MR are well known and require little thought from the candidate.

Not so, for the other two.

Specifically, the Carey Coombs murmur is discussed. Not "Carey-Coombs" as the college puts it, but Carey Coombs, named after Dr C.F. Coombs from Bristol. Anyway, its a "short mid-diastolic rumble" which disappears with resolving valvular disease.

The Austin-Flint murmur is not hyphenated either - and it is named after Austin Flint, who was a damn genius and generally deserves to have his murmur spelled correctly in official college papers. Its a murmur of the aortic regurgitation jet hitting the apex of the left ventricle in diastole. The great man himself, with lucid clarity described the murmur in his seminal article:

"“Oftener rough than soft. The roughness is often peculiar. It is a blubbering sound, resembling that produced by throwing the lips or the tongue into vibration with the breath of respiration.” 

Its poetry. In fact, the whole article is awesome. It is peppered with terms like "amphoric resonance" and "puerile respiration", which have since become lost in this era of trans-thoracic echocardiography.



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 any damn where.

Flint, Austin. Compendium of Percussion & Auscultation, and of the Physical Diagnosis of Diseases Affecting the Lungs and Heart. W. Wood & Company, 1870.