Updated: 9/17/2018

Heart Murmurs

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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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Questions (13)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M1.CV.141) A 73-year-old man presents to your clinic for a routine checkup. He states that he has not seen a doctor in "many years". He has no complaints. When you auscultate over the cardiac apex with the bell of your stethoscope, you notice an additional sound immediately preceding S1. This extra heart sound is most likely indicative of which of the following processes? Review Topic

QID: 100657
1

Increased left ventricular compliance

6%

(1/16)

2

Decreased left ventricular compliance

62%

(10/16)

3

Increased left ventricular filling volume

12%

(2/16)

4

Decreased left ventricular filling volume

6%

(1/16)

5

Increased pulmonary compliance

6%

(1/16)

M1

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PREFERRED RESPONSE 2

(M1.CV.26) A 65-year-old male presents to his cardiologist to discuss increasing episodes of dyspnea after climbing stairs. He also now needs three pillows at night to sleep. Physical examination reveals an early diastolic murmur best appreciated at the left sternal border with bounding peripheral pulses. The cardiologist is very concerned and immediately refers the patient for a surgical workup. What is the most likely diagnosis? Review Topic

QID: 100542
1

Mitral valve insufficiency

7%

(10/149)

2

Aortic regurgitation

70%

(105/149)

3

Mitral stenosis

15%

(22/149)

4

Aortic stenosis

5%

(7/149)

5

Atrial myxoma

1%

(1/149)

M1

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PREFERRED RESPONSE 2

(M1.CV.121) A 33-year-old Honduran woman presents to your clinic with shortness of breath. She reports that her symptoms have progressed over the past several months and are now impacting her quality of life because she cannot complete her usual exercise routine. She recalls "normal" childhood illnesses, including sore throats and fevers, but never required hospitalization. Vital signs are temperature 37 degrees Celsius, blood pressure 110/70 mm Hg, heart rate 109/min, respiratory rate 22/min, and oxygen saturation 98% on room air. Physical exam reveals a holosystolic, high-pitched, blowing murmur at the cardiac apex. One would expect that this murmur would also: Review Topic

QID: 100637
1

Radiate to the neck

3%

(5/145)

2

Increase with squatting or handgrip

55%

(80/145)

3

Increase with inspiration

18%

(26/145)

4

Also have a mid-systolic click loudest at S2

19%

(27/145)

5

Have a characteristic machine-like sound

3%

(5/145)

M1

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PREFERRED RESPONSE 2
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(M1.CV.75) A 65-year-old male with a history of coronary artery disease and myocardial infarction status post coronary artery bypass graft (CABG) surgery presents to his cardiologist for a routine appointment. On physical exam, the cardiologist appreciates a holosystolic, high-pitched blowing murmur heard loudest at the apex and radiating towards the axilla. Which of the following is the best predictor of the severity of this patient's murmur? Review Topic

QID: 106799
1

Enhancement with hand grip maneuver

22%

(24/109)

2

Enhancement with expiration

13%

(14/109)

3

Presence of audible S3

50%

(55/109)

4

Enhancement with inspiration

6%

(6/109)

5

Presence of audible S4

7%

(8/109)

M1

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PREFERRED RESPONSE 3

(M1.CV.130) A 79-year-old man presents to the emergency room after a syncopal event. The patient has a history of hyperlipidemia for which he is taking atorvastatin. On physical examination, his vital signs are stable, but on cardiac auscultation, you detect a crescendo-decrescendo systolic murmur loudest on the right upper sternal border radiating to the neck. On physical exam, one would also expect: Review Topic

QID: 100646
1

That the murmur would best be heard in the lateral left decubitus position

10%

(1/10)

2

The character of the murmur would be machine-like

0%

(0/10)

3

The murmur would also have a mid-systolic click loudest at S2

0%

(0/10)

4

The murmur would also have an opening snap

10%

(1/10)

5

Palpation of the carotid pulse would be weak and late relative to the patient’s heart sounds

70%

(7/10)

M1

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(M1.CV.117) A 37-year-old woman presents to clinic for routine checkup. She has no complaints with the exception of occasional "shortness of breath." Her physical examination is unremarkable with the exception of a "snap"-like sound after S2, followed by a rumbling murmur. You notice that this murmur is heard best at the cardiac apex. A history of which of the following are you most likely to elicit upon further questioning of this patient? Review Topic

QID: 100633
1

Family history of aortic valve replacement at a young age

9%

(1/11)

2

Hyperflexibility, vision problems, and pneumothorax

0%

(0/11)

3

Systolic click auscultated on physical exam 10 years prior

9%

(1/11)

4

Repeated episodes of streptococcal pharyngitis as a child

73%

(8/11)

5

Cutaneous flushing, diarrhea, and bronchospasm

0%

(0/11)

M1

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PREFERRED RESPONSE 4

(M1.CV.41) A 27-year-old woman presents to her primary care physician complaining that she has recently been experiencing vague chest discomfort. Physical examination reveals a mid-systolic click that is thought to be due to sudden tensing of chorda tendinae. How would this murmur be enhanced while listening on examination and what confirmatory test should be done? Review Topic

QID: 106282
1

Inspiration; EKG

1%

(1/149)

2

Inspiration; Echocardiogram

16%

(24/149)

3

Squatting; Echocardiogram

26%

(38/149)

4

Valsalva; Echocardiogram

45%

(67/149)

5

Hand Grip; EKG

11%

(17/149)

M1

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PREFERRED RESPONSE 4

(M1.CV.142) A 48-year-old homeless man presents to clinic complaining of fatigue and fevers that "began recently." Cardiac exam reveals a holosystolic murmur, heard best over the left lower sternal border. The murmur increases on inspiration. He also has track marks on his arms bilaterally. This presentation is consistent with which defect? Review Topic

QID: 100658
1

Ventricular septal defect

0%

(0/7)

2

Tricuspid regurgitation

86%

(6/7)

3

Mitral regurgitation

0%

(0/7)

4

Aortic stenosis

0%

(0/7)

5

Pulmonary stenosis

0%

(0/7)

M1

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PREFERRED RESPONSE 2

(M1.CV.28) A 64-year-old woman with a history of rheumatic fever presents to her primary care clinician complaining of excessive fatigue with walking and difficulty lying flat. She had no prior physical limitations, but recently has been unable to walk more than 3 blocks without needing to stop and rest. Her cardiac exam is notable for a late diastolic murmur heard best at the apex in the left lateral decubitus position with no radiation. What is the most likely diagnosis? Review Topic

QID: 100544
1

Mitral Regurgitation

33%

(11/33)

2

Aortic Stenosis

0%

(0/33)

3

MItral Stenosis

61%

(20/33)

4

Aortic Regurgitation

0%

(0/33)

5

Tricuspid Regurgitation

3%

(1/33)

M1

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PREFERRED RESPONSE 3
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