Murmur

Characteristics:
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Innocent - normal murmur

a. TIMING? EARLY in systole
b. GRADE? 1 or 2
Aortic Stenosis (AS)
a. TIMING? Systolic
b. CHARACTERISTICS? Ejection murmur, crescendo/decrescendo murmur, diamond shaped
nd
c. HEARD BEST LOCATION? 2 right intercostal space (aortic area), when patient leans forward. higher pitched - diaphragm
d. MANEUVERS? Increases with squatting and murmur decreases when patient stands fast or with hand grip
e. RADIATION? This radiates to the carotid
f. CAROTID UPSTROKE ASSOCIATIONS? Pulsus parvus et tardus
g. PULSE PRESSURE ASSOCIATION? Narrow pulse pressure with patients w aortic stenosis (they have decreases systolic BP)
Pulmonic Stenosis (PS)
a. TIMING? Systolic
b. CHARACTERISTICS? Ejection murmur, usually occurs LATE systole
c. MANEUVERS? It gets louder when the patient inspires (important)
Mitral Regurgitation (MR)
a. TIMING? Systolic (left ventricle contraction & blood is regurg from incompetent mitral valve)
b. CHARACTERISTICS? heard throughout systole, plateau holo-systolic murmur
c. HEARD BEST LOCATION? Mitral area (at the apex) , its higher pitched ! heard best with the diaphragm
d. RADIATION? Radiates to the axilla
e. MANEUVERS? This increases with hand grip
Tricuspid Regurgitation (TR)
a. TIMING? Systolic
b. CHARACTERISTICS? Plateau shaped, also holo-systolic murmur (TR not as common)
c. MANEUVERS? Gets louder when the patient inspires
Mitral Valve Prolapse (MVP)
a. TIMING? LATE systolic murmur (VERY common)
b. CHARACTERISTICS? Connective tissue degeneration of mitral valve. Its a prolapse in mitral valve that causes MID-
SYSTOLIC CLICK ! prolapsing of mitral valve causes it.
c. HEARD BEST LOCATION? Apex
Atrial Septal Defect (ASD)
a. TIMING? Systolic
b. CHARACTERISTICS? Low pitched. Shunting of blood from left side to the right side of atrium (left side has higher
pressure). The flow across pulmonic valve causes this sound
c. EXTRA HEART SOUND? Fixed S2 splitting (present when the patient inspires or expires) : left to right shunting delays the
closure of pulmonic valve bc of constant volume @ right side of heart.
nd
d. HEARD BEST LOCATION? 2 left intercostal space
Ventricular Septal Defect (VSD)
a. TIMING? Systolic Holo-systolic
b. CHARACTERISTICS? VSD does not radiate to the axilla and does NOT get louder as the patient inspires unlike TR
c. MANEUVERS? Increases with hand grip
d. EXTRA HEART SOUND? Fixed split S2
th
th
e. HEARD BEST LOCATION? Left sternum 4 and 5 intercostal space, also called ERBS point

ASD is higher up. VSD has that classic holo-systolic murmur that doesnt radiate to axilla/increase w inspiration. ASD is more EJECTION type
murmur its not heard throughout the systole. Differentiate by location and type of murmur
9)

Hypertrophic Cardiomyopathy (HCM)

a. TIMING? Systole. Harsh systolic murmur
b. CHARACTERISTICS? Heard throughout the entire precordium. Does NOT radiate anywhere


c.
d.

th

HEARD BEST LOCATION? ? 4 left intercostal space

MANEUVERS? Decreases with squatting and hand grip. Increases with Valsalva

Diastolic Murmurs: ARMS PITS: Aortic Regurg, Mitral Stenosis, Pulmonic Insufficiency (regurg), Tricuspid Stenosis
Murmur Characteristics:
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Aortic Regurgitation (AR)

a. TIMING? Diastolic (blood leaking from aorta back into left ventricle creating whooshing sound)
b. CHARACTERISTICS? High pitched sound (use diaphragm)
th
c. HEARD BEST LOCATION? 4 intercostal space with patient leaning forward and expiring Tricuspid area
d. MANEUVERS? Increases with hand grip and squatting
e. PULSE PRESSURE ASSOCIATION? Very wide pulse pressure
f. CAROTID UPSTROKE ASSOCIATION? Bounding pulses (blood is regurg into left vent, it pushes blood back up)
Pulmonic Regurgitation (PR)
a. TIMING? Diastolic (less common)
b. CHARACTERISTICS? Increases with inspiration
Mitral Stenosis (MS)
a. TIMING? Diastolic
b. CHARACTERISTICS? Low-pitched rumbling sound (heard best with the bell)
c. EXTRA SOUND? Opening snap is heard right before the diastolic murmur (from the thickened mitral valve)
d. HEARD BEST LOCATION & POSITION? Apex at the left lateral position with the bell
Tricuspid Stenosis (TS)
a. TIMING? Diastolic murmur with opening sound
b. CHARACTERISTICS? Increases with inspiration

Murmur Characteristics:
1)

Patent Ductus Arteriosus (PDA) (blood flow from the aorta!pulmonary artery)
a. TIMING? Heard in systole AND diastole
b. CHARACTERISTICS? Also called a machinery type murmur (continuous murmur)

EXTRA HEART SOUNDS KNOW SOUND AND EVERYTHING ABOUT THEM

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Physiologic Split S2 (lub dub dub) its very short

a. TIMING? Diastole
b. DESCRIPTION? It only occurs with INSPIRATION
c. NORMAL? YES
Fixed Split S2 (lub dub dub) . fixed split mean it occurs with Ins AND Exp. S1 S1 S2
a. TIMING? Diastole
b. DESCRIPTION? Occurs with Inspiration AND Expiration (no variation)
c. CAUSES? NOT NORMAL if you have ASD, you have constant shunting from left to the right side causing fixed split of S2.
S3
a. TIMING? EARLY Diastole
b. CHARACTERISTICS? Low pitched (heart best with the bell)
c. HEART BEST LOCATION? Apex (when patient is in left lateral decubitus)
d. CAUSES? Volume overload - Rapid ventricular filling in early diastole. sloshing-IN Can indicate Mitral regurgitation,
CHF. Volume overload can be a normal finding in children
S4
a. TIMING? LATE diastole
b. CHARACTERISTICS? Low pitched (use bell)
c. HEARD BEST LOCATION? Apex (at left lateral decubitus)
d. CAUSES? Results from atrial contraction against a non-compliant stiff ventricle. S4, S1, S2 = A STIFF wall