1. DIASTOLIC MURMUR QUIZ Dr. S. Aswini Kumar. MD. 1. This 35 year-old woman with past history of polyarthritis of several weeks duration, eight years back, now presenting with dyspnoea; on examination showed a low volume pulse with raised jugular venous pressure and tapping apex. Cardiac auscultation in the left lateral decubitus position showed a grade 3/6 mid-diastolic murmur.2. This 55 year-old man presented with orthopnoea and paroxysmal nocturnal dyspnoea. Pulse was irregularly irregular with an apex pulse deficit of 24. Auscultation of the heart showed a variable first heart sound with an opening snap and a faint mid-diastolic murmur localized to the mitral area without pre-systolic accentuation.3. This 45 year-old woman presented with palpitations and syncope. Clinical examination showed a high volume pulse and wide pulse pressure. The apex was shifted down and out and there was a short ejection systolic murmur in the aortic area and a grade 2 early diastolic murmur in the second aortic area while sitting up & leaning forward.4. A 75 year-old man presented with severe palpitation and dyspnoea. His wife had recurrent abortions before giving birth to a male child. The first heart sound was normal and the second heart sound was loud and ringing in quality. An early diastolic murmur was best audible in the aortic area and conducted along the right sternal border. 5. The only symptoms in this patient were a fluttering discomfort in the neck and upper abdominal discomfort. The primary visible sign was a giant flickering ‘a’ wave with gradual ‘y’ descent in the jugular venous pulse. The mid-diastolic murmur was localized to a small area in the left lower sternal edge with increase during inspiration.6. This 45 year-old man presented with excruciating pain in the precordial and inter-scapular region, which migrated from its original position. The S1 was normal but the A2 was loud. A diastolic murmur was audible along the right sternal border. The clue to the diagnosis was the asymmetry in the pulses and presence of a tracheal tug.7. In this 35 year-old lady with severe tiredness and palpitations, there were peripheral signs of severe aortic regurgitation. S1 was soft and S2 was obscured by a soft regurgitant early diastolic murmur and a louder mid-diastolic murmur which mimicked mitral stenosis but was not accompanied by any of its other clinical features8. In this 25 year-old man with acute onset of high grade fever, polyarthritis and choreiform movements, there appeared a new grade-2 mid-diastolic murmur. It was best heard in the mitral area and not conducted elsewhere. The first heart sound was not accentuated as expected in the case of mitral stenosis and there is no opening snap9. This 45 year-old woman who had recurrent respiratory infections on examination showed cardiomegaly and prominent pulmonary artery pulsations. The components of second sound were widely separated and not moving with respiration. A short systolic murmur in pulmonary and a mid-diastolic murmur in tricuspid area were heard.10. This 15 year-old child with respiratory infection was found to have a grade 2 intensity pan-systolic murmur in the left lower sternal edge, with a prominent thrill but with out any radiation. There was a short mid-diastolic rumble heard in mitral area with out any opening snap or pre-systolic accentuation as in case of mitral stenosis. 11. This diastolic murmur in a 35-year-old woman is best heard in the second left intercostal space close to the sternum and is associated with a very loud pulmonary second sound. The murmur is heard immediately following this sound and radiates along the left sternal edge. The murmur increases in intensity during deep inspiration12. This 15 year-old child originally had a systolo-diastolic murmur in the pulmonary area. Later when he developed severe PAH, the diastolic component of the murmur disappeared. But soon another diastolic murmur appeared. But this time, it was in the early part of diastole and soft when compared to the original murmur.13. The mid-diastolic murmur heard in this 35 year-old lady was surprising that it appeared to become dynamic in nature, appearing at times when the patient was sitting up and disappearing when the patient was lying down. Then it would appear again, when the patient was lying in lateral decubitus position. She also had low grade fever.14. This 45 year-old man was always leaning forward and was unable to sit upright when attempting auscultation. A diastolic murmur was present in the second aortic area and conducted along the left sternal border. There was also evidence of polyarthritis involving various larger joints of the axial skeleton.15. This 55 year-old man was trying to unload a heavy log of wood from a truck, when he was hit on the chest by the log. There after he felt severe chest pain and dyspnoea. There was no evidence in the ECG to suggest an acute myocardial infarction. But then appeared a new grade 3 diastolic murmur in the aortic area and evidence of LVF.16. This 35 year-old man has an uncomfortable flushing, typically of the head and neck, often precipitated by ingestion of food or hot beverages. Striking skin color changes occurred ranging from pallor and erythema to a violaceous hue. Abdominal cramps with recurrent diarrhea also occurred. He also had a mid-diastolic murmur.17. This 05 year-old boy had a systolic murmur in the aortic area and conducted to the carotids. The he developed low grade fever and clubbing. A new diastolic murmur appeared in the second aortic area, which was also conducted along he left sternal edge. But these were not really associated peripheral signs of aortic insufficiency.