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Overview
 

 
Auscultation Rules of Thumb
  • "All Physicians Take Money" (rule of thumb/mnemonic) 
    • aortic valve
      • upper right sternal border
        • aortic stenosis
        • flow murmur
        • aortic valve sclerosis
    • left ventricular outflow tract obstruction
      • lateral displacement of maximal impulse
      • S4 gallop
      • upper left sternal border (ULSB) harsh, crescendo-decrescendo systolic murmur
        • hypertrophic obstructive cardiomyopathy
    • pulmonic valve
      • ULSB
        • pulmonic stenosis
        • flow murmur (e.g., ASD)
    • tricuspid valve
      • lower left sternal border (LLSB)
        • pansystolic murmur (tricuspid regurgitation and VSD)
        • diastolic murmur (tricuspid stenosis and ASD)
    • mitral valve
      • apex 
        • systolic murmur (mitral regurgitation) 
        • diastolic murmur (mitral stenosis) 
Murmur Cheat Sheet
Crescendo/Decrescendo
Holosystolic
Systolic
  • AS (to neck)
  • MVP (click)
  • HOCM
  • MR (to axilla)
  • TR (inspiration increases)
  • VSD (harsh)
Diastolic
  • Aortic regurgitation
  • MS (opening snap)
  • NOTE: See chart below for abbreviations
Murmur Identification
 
Lesion
Shape
Location Heard
Altered by Characteristics
Systolic
Aortic stenosis (AS)
  • Crescendo-decrescendo
  • Radiates to neck (carotids) and apex

--

  • "Parvus et tardus" (pulses weak compared to heart sounds)
  • Follows ejection click (due to halting of valve leaflets)  
Hypertrophic cardiomyopathy (HOCM)
  • Crescendo-decrescendo
--
  • ↓ venous return (e.g., Valsalva) - increases murmur
--
Mitral valve prolapse (MVP) 
  • Late crescendo
--
  • ↑ TPR (e.g., squatting, hand grip) - decreases murmur
  • ↓ venous return (e.g., Valsalva) - increases murmur
  • Mid-systolic click (tensing of chordae tendinae)
  • Loudest at S2
  • Later with ↑ afterload (e.g., hand grip).
Mitral regurgitation (MR)
  • Holosystolic
  • Radiates to axilla
  • ↑ TPR (e.g., squatting, hand grip)
  • ↑ LA return (e.g., expiration)  
  • High-pitched, blowing
Tricuspid regurgitation (TR) 
  • Holosystolic
  • Radiates to right sternal border
  • ↑ RA return (e.g., inspiration)
  • High-pitched, blowing
Ventricular septal defect (VSD)
  • Holosystolic
-- --
  • Harsh-sounding
Diastolic
Aortic regurgitation (AR)
  • Early decrescendo
  • Left sternal border with patient leaning forward
--
  • High-pitched blowing heard at end of expiration
Mitral stenosis (MS)
  • Late rumble 
  • Heard in lateral left decubitus position
  • ↑ LA return (e.g., expiration)
  • Opening snap (tensing of chordae tendinae) in early diastole after A2
Other
Patent ductus arteriosus (PDA)
  • Continuous
  • ULSB
--
  • Machine-like, continuous/constant murmur heard through systole and diastole
Atrial septal defect (ASD)
  • Systolic and diastolic
  • Systolic: ULSB (pulmonic valve)
  • Diastolic: LLSB (tricuspid valve)
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