Murmurs

In clinical schools (in Malaysia, at least) you will actually get to hear lots of murmurs, and you will see (if you take some time to look at them) lots of changes in the JVP

this is where we would need to actually comment on those murmurs and JVP findings, if we haven't already memorized everything about them (I know I haven't.)

murmurs


murmurs are reported according to their 4 main properties.

1. timing
2. site and radiation
3. loudness and pitch (grading if possible)
4. relationship to posture and respiration

the 4 characteristics will help us in determining just what kind of problem (usually valvular) are there, in the heart.

how do we know what is a systolic and diastolic murmur?

we palpate the carotid, for the pulsation. the heart sound that corresponds / occurs simulataneously with the pulsation is the S1, and any murmur that occurs between S1 and S2, is a systolic murmur.

now that we know what is systolic and what is diastolic, lets say the patient has a systolic murmur.

let us come up with a DD of a systolic murmur. 

• pansystolic
• VSD
• Tricuspid regurgitation
• mitral regurgitation
• ejection systolic
• pulmonary stenosis
• aortic stenosis
• HOCM
• fever / fit, young adults
• late systolic
• tricuspid regurgitation
• mitral regurge 
• prolapsed valve
• mitral Valve Prolapse

so how do we narrow this down? 

is is through the other maneuvers you could do, and also radiation.

systolic murmur

• pansystolic murmur (1st and 2nd heart sounds cannot be heard separately in all areas)
• is it left side (mitral regurge) or right (pulmonary regurge)? how to determine that?
• ask patient to breath in and out deeply
• a left-sided murmur (MR) will INCREASE in intensity with EXPIRATION as the venous return is reduced (as we breathe out, the intrathoracic pressure go down - making it easier for the left heart to pump blood)
• confirmed with M shaped P wave on ECG, and Echo.
• a right sided murmur (PR) will INCREASE in intensity with INSPIRATION as the venous return is increased (as we breathe in, intrathoracic pressure rises - pushing more blood into right heart)
• VSD will have no radiation - the murmur is heard throughout the precordium.
• confirmed by Echo and ECG - Right axis deviation & RBBB
  
• mid-systolic murmur (between S1 and S2, but both heart sounds heard clearly apart)
• Aortic stenosis
• cold extermities
• slow-rising pulse
• low BP
• low Pulse pressure
• HOCM
• JVP has high a wave, 
• thrillss and murmur at left sternal edge
• Aortic sclerosis
• more common in elderly with Atherosclerosis
• plumonary high flow
• typical in young women
• benign if no pulmonary hypertension
• ASD
• pulmonary stenosis
• low pulse
• increased JVP
• left parasternal heave

diastolic murmur

• mitral stenosis
• tapping apex
• rumbling in character
• mireal stenosis with pliable valve
• opening snap
• aortic regurgitation
• increased BP
• increased pulse pressure
• collapsing pulse
• displaced apex