Diastolic heart murmurs are heart murmurs heard during diastole ,    i. Many involve stenosis of the atrioventricular valves or regurgitation of the semilunar valves. From Wikipedia, the free encyclopedia. This article may be too technical for most readers to understand. Please help improve it to make it understandable to non-experts , without removing the technical details.
Compared with the murmur of aortic stenosis that extends up to the A2 heart sound, the murmur of pulmonic stenosis extends through the A2 sound up to the P2 heart sound. Accentuation Decrescendo blow the first sound tricuspid component and a tricuspid opening snap may also be present. Murmurs are described by Decrescendo blow timing in the cardiac cycle, intensity, shape, pitch, location, radiation and response to dynamic maneuvers. A patient with only mild to moderate aortic valve regurgitation due to rheumatic heart disease would not require cardiac surgery, but if aortic dissection is the etiology, emergent surgery may be necessary. Hand grip or squatting can be useful. For example, the murmur of Decrescenxo stenosis is best heard at the LUSB, but it may radiate to the apex. Even with mild stenosis, pulmonary edema may develop acutely with a rapid heart rate causing abbreviation of diastolic filling time. Hall RJ. The murmur of pulmonary valve regurgitation without associated pulmonary hypertension, as in pulmonary valve endocarditis or congenital abnormalities of the pulmonary valve, is of lower frequency and may be middiastolic with Decrescendo blow crescendo—decrescendo pattern of Dercescendo.
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Heart murmurs are discussed here. Two dimensional echocardiography in the diagnosis of carcinoid heart disease. How can I tell the difference Decrescendo blow music from the Baroque, Classical and Romance era. Thus, in severe mitral stenosis, Decrescendo blow opening snap occurs earlier — as does the initial decrescendo part of the murmur. Often, the S2 heart sound is difficult to detect. Pulmonary regurgitation Increases Decrescendo blow inspiration Aortic insufficiency Sometimes best Cheerleading shirts shorts if the patient is made to site up, lean forward and breathe out fully while the stethoscope at the left side of the lower part of the sternum. Anyone else in the same boat? Resting and exercise cardiac output is maintained until progressive left ventricular dilatation causes impairment of myocardial function. Electrocardiographic evidence of right atrial abnormality in a patient with mitral valve stenosis may also serve as a helpful clue to the presence of tricuspid valve stenosis. How to regain lost talents?
- Low-pitched, rumbling murmur heard throughout diastole: a whispered letter "r".
- These example sentences are selected automatically from various online news sources to reflect current usage of the word 'decrescendo.
- Related to decrescendo: decrescendo murmur.
- No tenor saxophone was present in this recording section, nor in "Crescendo in Blue," which was recorded the same day.
NCBI Bookshelf. Boston: Butterworths; A diastolic murmur is a sound of some duration occurring during diastole. All diastolic murmurs imply some alteration of anatomy or function of the cardiovascular structures. The four most commonly encountered diastolic murmurs include aortic and pulmonary valve regurgitation, and mitral and tricuspid valve rumbles Table Compared to most systolic murmurs, diastolic murmurs are usually more difficult to hear, and certain auscultatory techniques are essential for their detection.
The murmur of aortic regurgitation begins with the aortic component of the second sound and is decrescendo in intensity for a variable duration of diastole. It is usually a high-frequency, "blowing" sound, most often heard best along the left lower sternal border, although occasionally only in the second right intercostal space. It may be of maximum intensity along the right sternal border see discussion later in this chapter.
Rarely, the murmur may be isolated at the apex impulse. For detection, first think of a blowing, high-frequency sound coming from a distance to simulate it, purse your lips very tightly and blow. Place the diaphragm of the stethoscope along the left sternal border with very firm pressure, enough pressure to leave a slight indentation on the skin when removed. The fingers may be used to hold the stethoscope, but to avoid the extraneous noise from tremor of the finger muscles, the palm of the hand may be better.
The patient should be instructed "don"t breathe" at end expiration, or told to "take a deep breath, blow it all out then relax and don"t breathe. If the murmur is not heard at the left lower sternal border with the patient supine, auscultation in a similar fashion should be performed at the second right intercostal space and along the right sternal border.
The murmur may only be heard by listening in one of these areas with the patient sitting, leaning forward in relaxed expiratory apnea. Any bedside maneuver that transiently increases blood pressure may intensify or bring out the murmur. Hand grip or squatting can be useful. Proper timing of the cardiac cycle is essential. A heart rate of or greater abbreviates diastole so that systolic and diastolic duration are nearly equal.
In this situation even a loud murmur of aortic regurgitation may be mistaken for a systolic murmur. Simultaneous palpation of the carotid pulse is essential to avoid this error. The murmur of pulmonary valve regurgitation associated with pulmonary hypertension is an early diastolic, decrescendo murmur beginning with the pulmonary component of the second sound, best heard along the upper left sternal border.
Auscultatory techniques are like those for aortic regurgitation. The quality of pulmonary valve regurgitation is similar to that of aortic regurgitation, and differentiation may be difficult. The murmur of pulmonary valve regurgitation may increase in intensity with inspiration. In association with mitral regurgitation, intensity may actually decrease with inspiration.
The presence of bounding pulses and a wide pulse pressure support the diagnosis of aortic regurgitation. Pulmonary valve regurgitation frequently results from severe pulmonary hypertension. When the murmur is associated with mitral stenosis and pulmonary hypertension, it usually represents trivial aortic regurgitation simply because aortic regurgitation is more common than pulmonary valve regurgitation in this clinical setting. The murmur of pulmonary valve regurgitation without associated pulmonary hypertension, as in pulmonary valve endocarditis or congenital abnormalities of the pulmonary valve, is of lower frequency and may be middiastolic with a crescendo—decrescendo pattern of intensity.
It is frequently localized to a small area at the apex impulse. The patient should be relaxed in a left lateral decubitus position and the apex impulse localized. The bell of the stethoscope should be applied with very light pressure, just enough to make contact with the skin. Concentrate on diastole and move the bell over and just adjacent to the apex impulse. Listen in middiastole and just before the first sound.
If the murmur is due to mitral stenosis, there may be accentuation of the first sound and an opening snap. The opening snap is a high-frequency sound that introduces the middiastolic component of the rumble and occurs.
Maneuvers that transiently increase cardiac output, such as sit-ups, coughing, or squatting, may aid in detection. When the apex impulse is not easily located, scanning the area, listening for the point of maximum intensity of the heart sounds, can help identify the apex impulse and the area on which to concentrate for the mitral diastolic rumble. A tricuspid valve rumble has similar characteristics as the mitral rumble, but is localized along the left lower sternal border and increases in intensity with inspiration.
The bell should be placed, again with very light pressure, exploring from the third to the fifth interspaces, concentrating in diastole both during inspiration and expiration. Similar maneuvers to increase venous return may augment the murmur. The inspiratory accentuation aids in differentiation from the mitral rumble, although the latter does not usually radiate to the left sternal border. Accentuation of the first sound tricuspid component and a tricuspid opening snap may also be present.
The presystolic component of the tricuspid valve rumble is often crescendo—decrescendo, unlike the crescendo pattern of the mitral rumble. Aortic valve regurgitation is the result of a loss of perfect apposition of the aortic cusps in diastole. There may be deformity of the cusps or the supporting structures. The problem may develop gradually, as in rheumatic heart disease, or acutely, as in bacterial endocarditis.
The symptoms and physical findings depend on the severity of the regurgitation and the duration of its development. A minimal regurgitant volume causes no abnormalities other than the presence of the murmur. The regurgitant volume increases diastolic filling of the left ventricle, and as this gradually progresses, there is an increase in stroke volume, left ventricular dilatation, and hypertrophy. The peripheral pulses are hyperdynamic, and the pulse pressure is widened.
An apical diastolic rumble Austin-Flint may be heard at the apex. This is due to partial closure of the anterior leaflet of the mitral valve. The apex impulse becomes laterally displaced and sustained. Resting and exercise cardiac output is maintained until progressive left ventricular dilatation causes impairment of myocardial function. Easy fatigue and dyspnea ensue. Severe left ventricular dilatation causes inadequate apposition of the mitral leaflets, and a murmur of mitral regurgitation is heard.
As left ventricular diastolic pressure increases and is reflected into the left atrium and pulmonary veins, eventual pulmonary hypertension, right ventricular dilatation, tricuspid regurgitation, and elevated jugular venous pressure develop.
The presence of a widened pulse pressure, a murmur that continues throughout diastole, and an apical diastolic rumble Austin-Flint rumble imply significant aortic regurgitation even before the development of pulmonary hypertension and right heart failure.
Pulmonary valve regurgitation is the result of imperfect cusp apposition resulting from deformity of the cusps or the supporting structures. It is most frequently secondary to severe pulmonary hypertension with dilatation of the supporting structures. In such cases, the regurgitant volume is small and of no hemodynamic importance. Pulmonary valve regurgitation may also occur with normal pulmonary artery pressures.
In such cases, even a large regurgitation volume is usually well tolerated by the right ventricle. There is right ventricular dilatation and elevation of the jugular venous pressure. Rarely will severe right heart failure develop. The mitral valve rumble may be caused by normal or reduced blood flow through a stenotic valve, as in mitral stenosis.
Left atrial myxoma, cor triatriatum, and localized left atrioventricular groove pericardial constriction may also cause a left atrial left ventricular diastolic blood pressure gradient and a mitral valve rumble. Situations that cause an increase in diastolic mitral valve blood flow through a normal valve may also cause a rumble, as in mitral regurgitation, ventricular septal defect, patent ductus arteriosus, and complete heart block.
Mitral valve stenosis is most commonly the result of previous rheumatic fever that later causes leaflet scarification and fusion commissures. With only mild reduction in orifice size, a middiastolic or presystolic murmur is heard time of peak diastolic flow , and similarly, only a small pressure gradient is present.
As the anterior mitral leaflet stiffens, but is still mobile, its opening produces a sound, the opening snap, and its closure accentuates the intensity of the first heart sound.
As stenosis progresses, left atrial pressure rises in proportion to orifice reduction and flow cardiac output. Eventual rises in left atrial pressure are reflected into the pulmonary veins, capillary bed, and pulmonary arteries. Even with mild stenosis, pulmonary edema may develop acutely with a rapid heart rate causing abbreviation of diastolic filling time.
As left atrial pressure increases, the leaflets open more quickly in diastole, and the opening snap moves closer to the second sound. As pulmonary hypertension develops, the pulmonary component of the second sound is accentuated. Symptoms at rest may be minimal, but with exercise left atrial pressure increases further, and dyspnea is a prominent symptom.
With further progression, cardiac output does not increase appropriately with exercise, and easy fatigue occurs. Pulmonary hypertension initially results in right ventricular hypertrophy and a parasternal lift is felt; if pulmonary hypertension is of long standing, right ventricular dilatation, tricuspid regurgitation, and systemic venous hypertension develop.
Calcification of the mitral leaflets may produce immobility, and the opening snap and accentuated first sound are lost. As right ventricular dysfunction develops, even resting cardiac output is reduced; this reduction in mitral valve flow will soften the intensity of the rumble.
The tricuspid valve rumble, caused by valvular deformity and orifice stenosis, may be secondary to rheumatic heart disease, Ebstein's anomaly, or carcinoid heart disease.
Right atrial myxoma may also cause a diastolic tricuspid obstruction. The rumble may also result from increased flow across a normal valve as in atrial septal defect or tricuspid regurgitation. Tricuspid valve stenosis may be congenital in origin but is most commonly the result of rheumatic heart disease and is rarely an isolated valvular lesion. In such cases the manifestations may be subtle. The diastolic rumble and opening snap are similar to mitral stenosis. The location, left lower sternal border, and inspiratory accentuation aid in differentiation.
The jugular venous pulsations show attenuation of the "y" descent and prominence of the "a" wave. More severe tricuspid stenosis can cause hepatomegaly, ascites, peripheral edema, and exercise intolerance. Any of the diastolic murmurs may be present without any alteration of cardiac function. Their detection remains important for proper care of the patient.
The presence of any murmur that could be caused by an alteration in cardiac structures indicates the need for bacterial endocarditis prophylaxis. These patients should be evaluated on a regular basis for progression of the valvular problem. If prior rheumatic fever is a possible cause, prophylaxis for recurrence should be given. For these reasons, diastolic murmurs should be diligently sought in every patient who is examined.
Regarding the mitral and tricuspid valves, stenosis would result in a diastolic murmur and regurgitation a systolic murmur. Unusual clinical and echocardiographic features of severe isolated pulmonic insufficiency. Stenosis of the aortic or pulmonic valves will result in a systolic murmur as blood is ejected through the narrowed orifice. In general, a murmur will be the most intense over the listening post that corresponds to the diseased valve. Grading Systolic murmurs are graded on a scale of 6. Most important murmur is early diastolic murmur.
Decrescendo blow. Introduction
The classic murmur of aortic stenosis is a high-pitched, crescendo-decrescendo diamond shaped , midsystolic murmur located at the aortic listening post and radiating toward the neck. The radiation of the AS murmur is often mistaken for a carotid bruit. The AS murmur is also known to radiate to the cardiac apex on occasion, making it difficult to distinguish if mitral regurgitation is also present.
The intensity of the murmur of AS is not a good indicator as to the severity of disease. As AS worsens, the LV begins to fail, and the ejection fraction declines to the point where sufficient force to create turbulent flow is no longer produced, resulting in a decrease in the intensity of the murmur. While the intensity of the murmur may not be an accurate determinant of aortic stenosis severity, the shape of the murmur can be very helpful. As aortic stenosis worsens, it takes longer for blood to eject through the valve, so the peak of the crescendo-decrescendo murmur moves to later in systole.
Therefore, mild aortic stenosis would have a murmur that peaks early in systole, whereas the murmur of severe aortic stenosis would peak later. Remember from the Heart Sounds Topic Review that the delay in aortic valve closure can cause a paradoxically split S2 heart sound and, as the aortic valve becomes more heavily calcified, the intensity of the S2 heart sound declines.
Also, in patients with bicuspid aortic valves, an ejection click may be heard just before the murmur begins. The murmur of pulmonic stenosis is very similar to that of aortic stenosis. It is a midsystolic, high-pitched, crescendo-decrescendo murmur heard best at the pulmonic listening post and radiating slightly toward the neck; however, the murmur of pulmonic stenosis does not radiate as widely as that of aortic stenosis.
The murmur of pulmonic stenosis peaks early if the disease is mild and peaks later as the disease progresses. Also, this murmur demonstrates increased intensity during inspiration due to the increased venous return to the right heart, resulting in greater flow across the pulmonic valve.
Compared with the murmur of aortic stenosis that extends up to the A2 heart sound, the murmur of pulmonic stenosis extends through the A2 sound up to the P2 heart sound. Severe PS results in decreased mobility of the pulmonic valve leaflets, and thus a softer P2 sound. Also, as the PS worsens, the closure of the pulmonic valve is delayed, because more time is required to eject blood through the stenotic valve; this results in a widely split S2 heart sound that still exhibits inspiratory delay.
Note that the murmur of an ASD, discussed below, is also midsystolic; however, it has a fixed split S2. The murmur produced by an atrial septal defect is due to increased flow through the pulmonic valve, making it remarkably similar to that of PS. The difference lies in the intensity and splitting pattern of the S2 heart sound. The intensity of S2 should remain unchanged and may, in fact, be accentuated if pulmonary hypertension develops.
The S2 is fixed-split in a patient with an ASD. This differs from the widened split S2, seen in severe PS. Also, the murmur of an ASD does not increase in intensity with inspiration.
The murmur of hypertrophic obstructive cardiomyopathy is important to detect due to its clinical implications; see Hypertrophic Obstructive Cardiomyopathy Topic Review. The murmur is high-pitched, crescendo-decrescendo, midsystolic murmur heard best at the left lower sternal border. The important auscultatory features of HOCM that distinguish it from AS relate to dynamic auscultation, discussed in the respective section below. Holotsystolic murmurs — also known as pansystolic — include the murmurs of mitral regurgitation, tricuspid regurgitation and ventricular septal defects.
Because the intensity of these murmurs is high immediately after the onset of S1, and extends to just before the S2, the S1 and S2 sounds are often overwhelmed by the murmur and may be difficult to hear.
Although the direction of radiation of the murmur depends on the nature of the mitral valve disease, it usually radiates to the axilla. The intensity of the murmur of MR does not increase with inspiration, helping to distinguish it from the murmur of tricuspid regurgitation. The murmur of tricuspid regurgitation is similar to that of MR in that it is high pitched and holosystolic; however, it is best heard at the left lower sternal border, and it radiates to the right lower sternal border.
The intensity significantly increases with inspiration, helping to distinguish it from MR. A ventricular septal defect produces yet another holosystolic murmur. The murmur of mitral or tricuspid valve prolapse is the only significant late systolic murmur.
Tricuspid valve prolapse is relatively rare and usually not clinically significant. Mitral valve prolapse produces a midsystolic click, typically followed by a uniform, high-pitched murmur. The murmur is actually due to MR that accompanies the mitral valve prolapse; thus, it is heard best at the cardiac apex. Mitral valve prolapse responds to dynamic auscultation. Diastolic murmurs include aortic and pulmonic regurgitation early diastolic and mitral or tricuspid stenosis mid- to late-diastolic.
Tricuspid stenosis is very rare and is discussed further in the Tricuspid Stenosis Topic Review. As AR worsens in severity, the pressure between the LV and the aorta equalize much faster, and the murmur becomes significantly shorter.
In patients with AR, an early diastolic rumble may also be heard at the apex due to the regurgitant jet striking the anterior leaflet of the mitral valve and causing it to vibrate. This murmur is termed the Austin-Flint murmur. In addition to the above two murmurs, a systolic ejection murmur may be present in patients with severe aortic regurgitation at the right upper sternal border simply due to the large stroke volume passing through the aortic valve with each systolic contraction of the LV.
Pulmonic regurgitation produces a murmur that is often indistinguishable from that of AR. PR produces a soft, high-pitched, early diastolic decrescendo murmur heard best at the pulmonic listening post LUSB. The murmur of PR increases in intensity during inspiration, unlike that of AR. The murmur of PR is classically referred to as the Graham-Steele murmur , after the experts that initially described the sound. Mitral stenosis results in a uniquely-shaped, low-pitched, diastolic murmur best heard at the cardiac apex.
Immediately before the S1 sound, active left ventricular filling occurs when the LA contracts and forces more blood through the stenosed mitral valve, creating a late diastolic, crescendo murmur. In the presence of atrial fibrillation, the active left ventricular filling phase does not take place, and the latter part of the mitral stenosis murmur disappears.
As mitral stenosis worsens, left atrial pressure increases, forcing the mitral valve open earlier in diastole. Thus, in severe mitral stenosis, the opening snap occurs earlier — as does the initial decrescendo part of the murmur. The opening snap and murmur of mitral stenosis also respond to dynamic auscultation. The murmur of a patent ductus arteriosus, or PDA, is continuous throughout systole and diastole. Often, the S2 heart sound is difficult to detect. The murmur begins just after S1 and crescendos, peaking at S2, then decrescendos to S1.
Dynamic auscultation refers to using maneuvers to alter hemodynamic parameters during cardiac auscultation in order to diagnose the etiology of a heart sound or murmur. The hemodynamic changes that occur are complex; however, the ultimate result is a decrease in left ventricular preload.
The most important use of the Valsalva maneuver is to distinguish the murmur of aortic stenosis from hypertrophic obstructive cardiomyopathy — or simply to bring forth the murmur of HOCM. Aortic stenosis will soften or not change, whereas the murmur of HOCM becomes quite loud with Valsalva.
The Valsalva maneuver is also performed during routine echocardiographic examinations to see if a patient with grade II or worse diastolic function can decrease his or her left ventricular filling pressures adequately.
If the Valsalva maneuver fails to reduce the left ventricular pressure in the setting of diastolic heart failure, then grade IV diastolic dysfunction is said to be present — indicating a poor prognosis. Squatting forces the blood volume that was stored in the legs to return to the heart, increasing preload and thus increasing left ventricular filling. This maneuver will decrease the murmur of HOCM, as the increased left ventricular volume helps displace the hypertrophied interventricular septum, causing less outflow tract obstruction.
Standing quickly from a squatting position causes blood to move from the central body to the legs, resulting in less blood returning to the heart and decreasing left ventricular preload — similar to the effect seen with the Valsalva maneuver.
Passive leg raising is done simply by raising the legs high in a patient lying supine. This results in blood that was pooled in the legs returning to the heart, increasing left ventricular filling and preload — similar to the effect seen with squatting from a standing position.
Isometric handgrip exercises are performed by having a patient squeeze hard repetitively. This results in increased blood pressure, similar to exercise, and thus increased afterload. Elderly individuals may have a hard time with this maneuver, and transient arterial occlusion described below can be used instead. This maneuver will increase the intensity of left-sided regurgitant murmurs including MR and AR.
However, handgrip exercises will have no effect on the murmur of AS, which helps distinguish the presence of coexistent MR from Galliverdin phenomenon. This maneuver is performed by placing a blood pressure cuff on both arms and inflating it to 20 to 40 mmHg above the systolic blood pressure for 20 seconds — effectively resulting in increased afterload.
This maneuver will increase the intensity of left-sided regurgitant murmurs including MR and AR and is especially useful in elderly individuals who are unable to perform adequate handgrip exercises.
Amyl nitrate decreases left ventricular afterload by dilating the peripheral arteries and would decrease the murmur of MR. When the afterload is decreased, there is less resistance to blood flow from the LV through the aortic valve; this means less blood regurgitates through the mitral valve, thereby decreasing the intensity of the murmur.
Amyl nitrate can be given via inhalation to reduce afterload for diagnostic purposes in the cardiac catheterization laboratory to invoke a LV outflow tract gradient in patients with HOCM or as a diagnostic tool during cardiac physical examination.
Due to the advancement of echocardiography, it is not commonly used any longer. Tell us what you think about Healio. Patient Information What is Hypertension? What is Atrial Fibrillation? Visit Healio. There are four major causes of cardiac murmurs. Valvular stenosis: If blood is forced through a tight area, turbulent blood flow ensues, as is the case in valvular stenosis.
The radiation is typically toward the apex. The configuration is usually decrescendo and has a blowing character. The presence of this murmur is a good positive predictor for AR and the absence of this murmur strongly suggests the absence of AR. An Austin Flint murmur is usually associated with significant aortic regurgitation. Pulmonary regurgitation.
Pulmonary regurgitation is most commonly due to pulmonary hypertension Graham-Steell murmur. It is a high-pitched and blowing murmur with a decrescendo configuration. It may increase in intensity during inspiration and best heard over left second and third intercostal spaces.
The murmur usually does not extend to S1. Left anterior descending artery stenosis. This murmur, also known as Dock's murmur , is similar to that of aortic regurgitation and is heard at the left second or third intercostal space. A Coronary artery bypass surgery can eliminate the murmur. This murmur sounds similar to aortic insufficiency , but does not have a decrescendo. It is often heard in untreated anemia , and is best heard at the left sternal border. This murmur has a rumbling character and is best heard with the bell of the stethoscope in the left ventricular impulse area with the patient in the lateral decubitus position.
It usually starts with an opening snap. In general, the shorter the duration S2 to Opening Snap , the more severe the mitral stenosis. However, this rule can be misleading in situations where the stenosis is so severe that the flow becomes reduced, or during high-output situations such as pregnancy where a less severe stenosis may still produce a strong murmur.
In mitral stenosis, tapping apical impulse is present. Tricuspid stenosis. Best heard over the left sternal border with rumbling character and tricuspid opening snap with wide splitting S1. May increase in intensity with inspiration Carvallo's sign. Tricuspid stenosis often occurs in association with mitral stenosis.
The bell is used to hear low-pitched sounds. Use for mid-diastolic murmur of mitral stenosis or S3 in heart failure. The diaphragm , by filtering out low-pitched sounds, highlights high-pitched sounds. Use for analyzing the second heart sound, ejection and midsystolic clicks and for the soft but high-pitched early diastolic murmur of aortic regurgitation.
You can relate the auscultatory findings to the cardiac cycle by simultaneously palpating the carotid artery while listening to the heart:. If anything abnormal is found, move the stethoscope around until the abnormality is heard most clearly. Earpieces should be angled forwards to match the direction of the practitioner's external auditory meati. Pericardial sounds are sometime best heard with the patient on hands and knees. Auscultate the heart at various sites At the apex.
At the base the part of the heart between the apex and the sternum In the aortic and pulmonary areas to the right and left of the sternum, respectively Listen for normal heart sounds: The 1 st heart sound, S1 lub , marks the beginning of systole end of systole.
Related to the closure of the mitral and tricuspid valves. Loudest at the apex. The 2 nd hear sound, S2 dub , marks the end of systole beginning of diastole. Related to the closure of the aortic and pulmonic valves. Loudest at the base. You can relate the auscultatory findings to the cardiac cycle by simultaneously palpating the carotid artery while listening to the heart: S1 S2 Just precedes carotid pulse Follows carotid pulse Louder at apex Louder at base Lower pitch and longer than S 2 Higher pitch and shorter than S 2 Because systole is shorter than diastole: First of two grouped beats Second of 2 grouped beats If anything abnormal is found, move the stethoscope around until the abnormality is heard most clearly.
Analyze each category individually and then put it together to diagnosis the problem Category Definition Audio examples Aortic stenosis: Murmur: Harsh late-peaking crescendo-decrescendo systolic murmur Heard best- left 2nd ICS Radiation to the carotids. Possible associated findings: Abnormal carotid pulse Diminished and delayed "pulsus parvus and tardus" Sustained Apical impulse Calcified aortic valve on CXR Mitral Regurgitation: Murmur: Blowing holosystolic murmur Heard best at the apex Radiation to the axilla and inferior edge of left scapula.
Neck Veins. You can relate the auscultatory findings to the cardiac cycle by simultaneously palpating the carotid artery while listening to the heart: S1 S2 Just precedes carotid pulse. Possible associated findings: Abnormal carotid pulse Diminished and delayed "pulsus parvus and tardus" Sustained Apical impulse Calcified aortic valve on CXR.
Murmur: Blowing holosystolic murmur Heard best at the apex Radiation to the axilla and inferior edge of left scapula. Possible associated findings: S 2 : wide physiologic splitting S 3. Murmur: Soft blowing early diastolic decrescendo murmur Heard best at the left 2nd ICS without radiation May also hear systolic flow murmur and diastolic rumble Austin Flint Possible associated findings: Dilated apical impulse Abnormal and collapsing arterial pulses.
Murmur: Soft holosystolic murmur Heard best at the LLSB without radiation Intensity increases with inspiration or pressure over liver Possible associated findings: Elevated neck veins Systolic regurgitant neck vein Systolic retraction of apical pulse Edema, Ascites or both.
Murmur: High frequency early diastolic decrescendo murmur Heard best at 2nd-3rd ICS Increases with inspiration Associated findings: Abnormal S 2 splitting Sustained pulmonary hypertension. Murmur: Harsh crescendo-decrescendo systolic murmur Heard best sternal border bat 2nd or 3rd intercostal spaces Increases with inspiration Associated findings: Ejection sounds heard at sternal edge, 2nd or 3rd intercostal space Wide physiological splitting of S 2 Prominent A wave of the jugular venous pulse.
Murmur: Low frequency rumbling mid-diastolic murmur, with presystolic component possible Heard best at apex Accentuated in left lateral decubitus position Associated findings: Apical impulse absent or small Irregular pulse atrial fibrillation Loud S 1 Elevated neck veins with exaggerated A wave.