Techniques - Heart Sounds & Murmurs Exam - Physical Diagnosis Skills - University of Washington School of Medicine

[Heart Sounds & Murmurs]

Liver & Ascites

Neck Veins

Pulmonary

Thyroid

Examination

• Techniques

• 1st & 2nd Heart Sounds

• 2nd & 3rd Heart Sounds

• Clicks and Snaps

• Murmurs

• Rubs

• Demonstrations

Historical

Pathophysiology

Associated Evaluations

• Patient HX

• Physical Exam

• Laboratory & Imaging

Differential Dx

Evidence Base

• Accuracy in Diagnosis of Systolic Murmurs

• Accuracy in Diagnosis of Diastolic Murmurs

• Accuracy in Diagnosis of CHF

References

Teaching Tips

[Skill Modules >> Heart Sounds & Murmurs >> Techniques ]

Techniques: Heart Sounds & Murmurs

Murmurs (general) | Systolic | Diastolic

Systolic Murmurs

valvular murmurs


nonvalvular murmurs

Causes:

Blood flow through a structure normally closed during systole (mitral or tricuspid valves or the interventricular septum).
Blood flow through a valve normally open in systole but abnormally narrowed (e.g. aortic or pulmonary stenosis).
Increased blood flow through a normal valve (a flow murmur).

Analyze the murmur for

Intensity (Grade)
Where it occurs in systole
Where it is best heard and where it radiates to
What it sounds like
What happens during special maneuvers

Where murmurs occur in systole:

Systolic Murmurs are classified as:

Holosystolic

Holosystolic: Regurgitation across AV valves (mitral and tricuspid) or ventricular septal defect
Timing:	Similar intensity throughout the length of systole
Cause:	Blood flow through an incompetent valve
Examples:	Mitral or tricuspid valve or ventricular septal defect

Mid or late systolic

Timing:	Murmur starts in mid- or late systole
Cause:	Valve is competent at the start of systole but starts to leak 1/2 way through.
Examples:	Mitral valve prolapse.

Midsystolic

midsystolic

Midsystolic (crescendo-decrescendo): Aortic stenosis, aortic sclerosis, "flow murmurs," pulmonic stenosis
Timing:	Starts quietly at the beginning of systole, rise to a crescendo in midsystole and then become quiet again towards the end of systole
Cause:	Murmurs that are due to blood being forced through a narrowed
Examples:	Aortic stenosis, aortic sclerosis, "flow murmurs," pulmonic stenosis

Early Systolic

Timing			MR*
Early	shshssh	dub	MR when S₂heard at base but not apex
Mid	lub	shshsdub	Less likely MR
Late	lub	shshshs (obliterates S₂)	Less likely MR
Holosystolic	shshshshshhshshs (obliterates _S1 & S₂)

Where it is best heard and where it radiates to

Location of Maximal Intensity	Radiation	Typical for
2nd right intercostal space	Right carotid artery	Aortic stenosis
5th or 6th left intercostal space	Left anterior axillary line, left axilla	Mitral regurgitation (including mitral regurgitation due to mitral valve prolapse)
Left axilla Lower left sternal border	LRSB, Epigastrium, 5th ICS mid left thorax	Tricuspid regurgitation
5th left intercostal space mid- left thorax	Lower left sternal border	Hypertrophic cardiomyopathy

What it sounds like

Quality	Aortic stenosis	MR*	HCM#
Musical (honk or coo)	Usually aortic
Nonmusical
Blowing	Usually aortic
Harsh

What happens during special maneuvers

Murmur analysis with dynamic auscultation
Maneuvers
		Rt. sided	Lt. sided
		TR/PS	Aortic stenosis (AS)	MR*	HCM#
Change with respiration
	Inspiration		Decreases or no change
To decrease flow
	Valsalva maneuver
	Squat to stand			variable
To increase flow
	Leg elevation		No decrease	No decrease
	Handgrip
	Stand to squat			variable
*MR=mitral regurgitation #HCM=hypertrophic cardiomyopathy

*You can also distinguish between AS and MR by changes in intensity after changes in cycle length. Listen for a beat after a PVC. With a longer time between beats, there is increased filling, increased contractility and decreased afterload. This increases the flow across the mitral valve as more blood flows forward with the decrease in afterload, decreasing the intensity of the MR murmur.