AM Report Pearls: Murmurs 101
Time to take it back to the bedside! For the exam, auscultation is key but palpation is also important! Important things to note when describing a murmur:
- Timing and Duration – occurs during diastole vs systole vs continuous through entire cardiac cycle. Is it early, mid, late, or throughout the cycle?
- Location and radiation –where on the chest wall is the murmur loudest (APTM) and in what direction does the sound radiate (upwards, apical, to the back?)
- Intensity of the murmur – as Yerem pointed out, know the difference between 3/6 and 4/6 = palpable thrill!
- Grade I is the faintest murmur that can be heard (with difficulty)
- Grade II murmur is also a faint murmur but can be identified immediately
- Grade III murmur is moderately loud
- Grade IV murmur is loud and is associated with a palpable thrill
- Grade V murmur is very loud but cannot be heard without the stethoscope.
- Grade VI murmur is the loudest and can be heard without a stethoscope
Other associated sounds – mid-systolic click, loud S2 (A2, P2 splitting), S3 or S4
RUSB Murmurs 102 (Advanced Maneuvers):
- If you hear a crescendo-decrescendo SEM at RUSB with no S2, think severe AS
- If you hear a crescendo-decrescendo SEM at RUSB with loud S2, think Pulmonary Hypertension PLUS AS
- If you hear a crescendo-decrescendo SEM at RUSB with paradoxical S2 (i.e. P2 before A2) think critical AS (note: paradoxical S2 can also be seen in LBBB)
- Normally, the split between A2 & P2 widens with inspiration, if the split narrows instead, think severe AS
- Standing up decreases preload, decreases LVEDP – no change in AS murmur (fixed obstruction) but increases HOCM murmur because it worsens LVOT obstruction
- Squatting increases preload, increases LVEDP – no change in AS murmur (fixed obstruction) but decreases HOCM murmur because it decreases LVOT obstruction
Check out this website from UW on murmurs with audio files to re-listen to murmurs over & over to burn them into your brain! http://depts.washington.edu/physdx/heart/demo.html