Sandbox:Nuha

• • Holosystolic (pansystolic) murmurs:
    • chronic MR.
    • chronic TR.
    • VSD
    • PDA with pulmonary hypertension
  • Midsystolic (systolic ejection) murmurs
    • Innocent murmur (still's murmur)
    • AS
    • PS
    • HOCM
    • Functional:
      • ASD
      • VSD
      • Straight back syndrome
      • Aortic root dilation
      • Pulmonary artery dilation
      • pulmonary hypertension
      • Hyper-kinetic status:
        • pregnancy
        • Anemia
        • hyperthyroidism
        • exercise
        • A-V fistula
  • Early systolic murmurs
    • Acute MR
    • Acute TR
    • Small VSD
  • Mid to late systolic murmurs

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Maximum intensity over apex Radiation to axilla or base A2 not heard over apex Decreased intensity with amyl nitrate

 

 

Maximum intensity over left sternal border Radiation to epigastrium and right sternal border Increased intensity during inspiration Prominent c-v wave with sharp y descent in jugular venous pulse

 

 

Maximum intensity over lower left third and fourth interspace Widespread radiation, palpable thrill Decreased intensity with amyl nitrate No change in intensity during inspiration Wide splitting of S2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mitral regurgitation

 

 

Tricuspid regurgitation

 

 

Favors ventricular septal defect; often difficult to differentiate from mitral regurgitant murmur

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hyperdynamic left ventricular impulse
Wide splitting of S2

 

Sustained left ventricular impulse
Single S2 or narrow splitting of S2

 

 

 

Prominent left parasternal diastolic impulse
Normal brief left parasternal systolic impulse
Normal P2, Rarely paradoxical S2

 

Primary

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sustained systolic left parasternal impulse Narrow splitting of S2 with marked increase in intensity of P2

 

Secondary to pulmonary hypertension

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Primary mitral regurgitation

 

Secondary mitral regurgitation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SYSTOLIC MURMUR	DIASTOLIC MURMUR	Continuous Murmur
❑ STEMI / LBBB ❑ NSTEMI / Unstable angina ❑ Stable angina ❑ Pericarditis ❑ Aortic dissection ❑ Aortic stenosis ❑ Prinzmetal's angina ❑ PCI-induced coronary vasospasm ❑ Cocaine induced coronary vasospasm	❑ Pulmonary embolism ❑ Pneumothorax ❑ Asthma exacerbation ❑ Pulmonary hypertension ❑ Pneumonia ❑ Pleuritis	❑ Pancreatitis ❑ Acute cholecystitis ❑ GERD ❑ Peptic ulcer ❑ Esophageal spasm ❑ Mallory-Weiss syndrome	❑ Musculoskeletal pain: ❑ Costochondritis ❑ Rheumatoid arthritis ❑ Rib fracture ❑ Herpes zoster ❑ Anxiety ❑ Panic disorder