🧠 STEP 10 — Student Memory Support
🃏 1️⃣ High-Yield Flashcards
What produces the first heart sound?
Closure of the mitral and tricuspid valves at the start of systole.
What produces the second heart sound?
Closure of the aortic and pulmonary valves at the end of systole.
What is the simplest rule for predicting murmur timing?
Stenosis murmurs when the valve should be open; regurgitation murmurs when it should be closed.
What are the characteristic findings of aortic stenosis?
Ejection systolic murmur, carotid radiation, slow-rising pulse and concentric left ventricular hypertrophy.
What are the characteristic findings of aortic regurgitation?
Early diastolic decrescendo murmur, bounding pulse, wide pulse pressure and left ventricular volume overload.
What are the characteristic findings of mitral stenosis?
Opening snap, low-pitched mid-diastolic apical murmur and left atrial enlargement.
What major complications follow mitral stenosis?
Atrial fibrillation, pulmonary hypertension, left atrial thrombus and systemic embolism.
What are the characteristic findings of mitral regurgitation?
Pansystolic apical murmur radiating to the axilla with left atrial and ventricular volume overload.
What causes acute rheumatic fever?
Cross-reactive immune injury following group A streptococcal pharyngitis.
What is the hallmark microscopic lesion of acute rheumatic carditis?
An Aschoff body containing Anitschkow cells.
What is the hallmark morphology of chronic rheumatic mitral stenosis?
Commissural fusion, chordal shortening and a fish-mouth valve opening.
Which tests support a preceding group A streptococcal infection?
Raised ASO titre, raised anti-DNase B, positive throat culture or rapid antigen test.
What are the major Duckett Jones manifestations?
Carditis, migratory polyarthritis, Sydenham chorea, erythema marginatum and subcutaneous nodules.
What is the typical morphology of infective endocarditis?
Bulky, friable, infected and destructive vegetations.
Which organisms classically cause acute and subacute infective endocarditis?
Acute: Staphylococcus aureus. Subacute: viridans-group streptococci.
What are the two major Modified Duke criteria?
Typical positive blood cultures and evidence of endocardial involvement.
What is nonbacterial thrombotic endocarditis associated with?
Malignancy or another hypercoagulable state with sterile embolic vegetations.
What is Libman–Sacks endocarditis associated with?
Systemic lupus erythematosus or antiphospholipid antibody syndrome.
What is primary prophylaxis of rheumatic fever?
Prompt and adequate treatment of group A streptococcal pharyngitis.
What is preferred secondary prophylaxis after rheumatic fever?
Regular intramuscular benzathine penicillin G to prevent recurrent attacks.
🧠 2️⃣ Mnemonics
Mnemonic Title: Duckett Jones Major Manifestations
Mnemonic Word: J♥NES
Meaning:
- J — Joints: migratory polyarthritis
- ♥ — Carditis
- N — Nodules
- E — Erythema marginatum
- S — Sydenham chorea
Mnemonic Title: Four Major Valve Murmurs
Mnemonic Word: AS–MR Systolic; MS–AR Diastolic
Meaning:
- AS — Aortic stenosis: systolic
- MR — Mitral regurgitation: systolic
- MS — Mitral stenosis: diastolic
- AR — Aortic regurgitation: diastolic
Mnemonic Title: Aortic Stenosis Symptom Triad
Mnemonic Word: SAD
Meaning:
- S — Syncope
- A — Angina
- D — Dyspnea
📋 3️⃣ Memory Tables
Table 1 — Four Major Valvular Lesions
| Lesion | Murmur | Hemodynamic effect | Key clue |
|---|---|---|---|
| Aortic stenosis | Ejection systolic | LV pressure overload | Carotid radiation |
| Aortic regurgitation | Early diastolic | LV volume overload | Wide pulse pressure |
| Mitral stenosis | Mid-diastolic | LA pressure overload | Opening snap |
| Mitral regurgitation | Pansystolic | LA and LV volume overload | Axillary radiation |
Table 2 — Types of Vegetations
| Type | Typical setting | Morphology | Major consequence |
| Rheumatic verrucae | Acute rheumatic fever | Small, sterile, closure lines | Later fibrosis |
| Infective vegetation | Bacteremia and valve risk | Bulky, friable, destructive | Emboli and valve failure |
| Nonbacterial thrombotic | Malignancy/hypercoagulability | Sterile platelet-fibrin deposits | Systemic embolism |
| Libman–Sacks | SLE/antiphospholipid syndrome | Sterile, either valve surface | Embolism or scarring |
⚡ 4️⃣ Rapid Revision Points
Must Remember
- S1 marks atrioventricular valve closure and the start of systole.
- S2 marks semilunar valve closure and the end of systole.
- Aortic stenosis causes pressure overload and concentric left ventricular hypertrophy.
- Aortic and mitral regurgitation cause volume overload and eccentric enlargement.
- Mitral stenosis primarily enlarges the left atrium, not the left ventricle.
- Rheumatic fever is immune-mediated after group A streptococcal infection.
- Raised ASO supports recent infection but does not independently diagnose carditis.
- Aschoff bodies are characteristic of acute rheumatic carditis.
- Fish-mouth mitral stenosis is characteristic of chronic rheumatic heart disease.
- Fever with a new murmur requires investigation for infective endocarditis.
- Obtain blood cultures before antibiotics when the patient is stable.
- Secondary benzathine penicillin prevents recurrence but does not reverse valve fibrosis.
🩺 5️⃣ Clinical Memory Hooks
Clinical Hook 1
Exertional syncope + carotid-radiating systolic murmur → Aortic stenosis
Clinical Hook 2
Opening snap + apical diastolic rumble + irregular pulse → Mitral stenosis with atrial fibrillation
Clinical Hook 3
Childhood sore throat + migratory arthritis + later valve disease → Rheumatic heart disease
Clinical Hook 4
Fever + new regurgitant murmur + positive blood cultures → Infective endocarditis
Clinical Hook 5
Malignancy + recurrent emboli + negative cultures → Nonbacterial thrombotic endocarditis
⭐ 6️⃣ Starred High-Yield Exam Points
⭐ High-Yield Points:
- ⭐ Stenosis murmurs when the valve should be open; regurgitation murmurs when it should be closed.
- ⭐ Short A2–opening snap interval indicates raised left atrial pressure and severe mitral stenosis.
- ⭐ Hallmark acute rheumatic lesion: Aschoff body with Anitschkow cells.
- ⭐ Hallmark chronic rheumatic morphology: fish-mouth mitral stenosis.
- ⭐ Staphylococcus aureus causes acute destructive infective endocarditis.
- ⭐ Draw multiple blood cultures before antibiotics when infective endocarditis is suspected and the patient is stable.
- ⭐ Regular benzathine penicillin G prevents recurrent rheumatic fever and additional valve damage.
- ⭐ A vegetation is not automatically infective—rheumatic, marantic and Libman–Sacks vegetations are sterile.