1. CONTINUOUS MURMUR QUIZ Dr. S. Aswini Kumar. MD. 1. This 15 year-old girl admitted with dyspnoea has a continuous murmur which is best heard at the second left inter-costal space and conducted along the clavicle. This is accompanied by a constant thrill. There is a late systolic accentuation for the continuous murmur. Multiple clicks are also heard.2. This 45 year old man came with history of sudden onset of severe tearing type of chest pain along the left side of sternum following lifting up of a heavy log of wood. Clinical examination showed bounding pulses and a very superficial continuous thrill & murmur best elicited over the left sternal edge.3. A one year old infant was found to have a continuous murmur over the precordium. While investigating this, the ECG of the child surprisingly showed classical changes of acute anterior wall myocardial infarction. The child was subjected to a coronary artery bypass with internal mammary artery graft. 4. In this 45 year-old man a faint continuous murmur was heard along the left sternal edge and left ventricular apex. The diastolic component was louder. Subsequently the murmur disappeared and the ECG showed changes of myocardial infarction. Coronary angiography was diagnostic. 5. In this 35 year-old woman there is a pulsatile mass over the upper limb. A continuous bruit is heard over the swelling. There is edema, varicosity, and pigmentation of the skin distal to the swelling. Compression of the swelling caused reflux slowing of the heart rate.6. In this 75 year-old man with history of bone pains and vertigo, there is enlargement of the skull, bowing of the right tibia, which is warmer than the other and a continuous murmur is heard in the upper part of the thigh. There is also evidence of bounding pulses and high output cardiac failure. 7. This 35 year-old patient was admitted with clinical features of uremia and diagnosed to have chronic renal failure. He was subjected to a minor surgical procedure in the thigh and there after on auscultation a continuous murmur was heard over the upper part of the thigh.8. This 1 year-old infant was having a continuous murmur over the mid sternal region which was maximally heard during late systole. The pulmonary component of the second sound was accentuated and the diastolic part of the murmur was brief. Central cyanosis was evident.9. This 15 year-old boy has a grade V/VI pansystolic murmur, continuing as an early diastolic murmur was heard in the third and fourth intercostal space along the left sternal edge. The wide pulse pressure due to very high systolic and very low diastolic blood pressure was highly suggestive of diagnosis. 10. This patient has evidence of a continuous murmur over the left side of precordium. At the same time he has a wide and fixed split second sound and a opening snap heard in early diastole, mid-diastolic rumbling murmur best heard in the mitral area with presystolic accentuation. 11. This 35 year-old woman has cardiomegaly, outward and downward shift of the apex, which is forceful in character and a murmur over the aortic areas which appear to be continuous in the sitting up and leaning forward position. The systolic part of the murmur is also conducted to the carotids.12. A 25 year-old man has continuous murmurs heard over the lateral walls of the chest. Tortuous blood vessels are seen over back and sides of chest. Weak and delayed lower limb pulses and isolated upper extremity hypertension are present. Upper limbs were better developed than the lower.13. This 5 year-old child has breathlessness and cyanosis on exertion which is relieved to some extent by squatting. Examination shows a prominent LPH, single component second sound and a short ESM in the pulmonary area. In addition the child has continuous murmurs over the sides of chest.14. This 15 year-old child underwent a cardiac surgery at the age of five for complaints of severe breathlessness & central cyanosis. On examination there are weak left upper limb pulses, LPH, systolic thrill and an ESM in pulmonary area. There is a continuous murmur heard over the left side of chest.15. This 25 year-old lactating mother was complaining of severe chest pain and was detected to have a continuous heart murmur over the left of precordium. Firm pressure with the diaphragm of the stethoscope eliminated the diastolic portion of the murmur.16. In this young man aged 25 years, a continuous murmur is audible in the medial part of right supra-clavicular fossa especially in the upright posture. It is abolished instantaneously by digital compression of the internal jugular vein. The murmur is reduced in intensity in the lying posture.17. In this 45 year-old chronic alcoholic patient a continuous murmur is heard only in the epigatrium and around the umbilicus. On examination there is edema, hepatomegaly, splenomegaly and ascites. There is palmar erythema and spider naevi over the upper chest.