a concise table summarizing the murmur characteristics and special findings for each valve defect:
Valve Defect | Murmur Description | Location | Special Findings |
Mitral Regurgitation (MR) | High-pitched, blowing, pan-systolic murmur | Apex, radiating to left axilla | S3 heart sound, holosystolic murmur, constant intensity |
Mitral Stenosis (MS) | Low-pitched, rumbling diastolic murmur | Apex, best with bell in left lateral position | Opening snap after S2, loud S1, low-pitched rumble |
Aortic Stenosis (AS) | Harsh, systolic ejection murmur | Right 2nd intercostal space, radiates to carotids | Crescendo-decrescendo murmur, delayed carotid upstroke, S4 |
Aortic Regurgitation (AR) | High-pitched, blowing early diastolic murmur | Left sternal border, best leaning forward | Decrescendo murmur, water hammer pulse, Quincke’s sign, Austin Flint murmur |
Tricuspid Regurgitation (TR) | Pan-systolic murmur | Left lower sternal border, radiates to right | Increases with inspiration (Carvallo’s sign), JVD, pulsatile liver |
Tricuspid Stenosis (TS) | Low-pitched, rumbling diastolic murmur | Left lower sternal border, louder with inspiration | Elevated JVP, peripheral edema, louder with inspiration |
Pulmonary Regurgitation (PR) | High-pitched, blowing early diastolic murmur | Left upper sternal border | Graham Steell murmur (associated with pulmonary hypertension), right ventricular lift |
Pulmonary Stenosis (PS) | Systolic ejection murmur, crescendo-decrescendo | Left upper sternal border, radiates to left shoulder | Ejection click, right ventricular hypertrophy, widened split of S2 |
Patent Ductus Arteriosus (PDA) | Continuous machinery-like murmur | Left infraclavicular area | Bounding pulses, possible cyanosis, high pulse pressure |
Aortic Valve Sac Rupture | Harsh, continuous murmur | Over the heart, radiating widely | Sudden hemodynamic changes, requires urgent attention |
Mnemonic: "MR PAN MS RUM AS JECK AR BLOW" and Additional Valve Conditions
This mnemonic is a helpful tool to remember key characteristics of certain valve disorders, specifically Mitral Regurgitation, Mitral Stenosis, Aortic Stenosis, and Aortic Regurgitation. It can also be expanded and corrected to include Tricuspid and Pulmonic valve conditions.
Grading of Murmurs
Murmurs are graded on a scale from 1 to 6 based on intensity:
Grade 1: Barely audible, even under optimal conditions.
Grade 2: Faint but audible immediately after placing the stethoscope.
Grade 3: Moderately loud, easy to hear but without a thrill.
Grade 4: Loud with a palpable thrill (a vibration felt on the chest wall).
Grade 5: Very loud, with a thrill. It can be heard with only part of the stethoscope on the chest.
Grade 6: Extremely loud, can be heard with the stethoscope slightly off the chest wall, accompanied by a thrill.
Heaving and Thrills: A Refined Explanation
Positioning for Assessment:
The patient should be in a relaxed position, typically lying at a 45-degree angle or supine. The examiner places the hand or fingertips on the chest wall, focusing on appropriate areas to detect heaving and thrills.
Heaving:
A palpable, forceful lifting sensation of the chest wall that feels like a pushing or pounding against the palm, indicating increased cardiac effort.
Cause: Common in conditions like left or right ventricular hypertrophy.
Palpation: Place the palm on the left parasternal or apical region of the chest. If you feel a forceful, sustained lift under the palm, this indicates a heave.
Thrill:
A palpable vibration that feels like a buzzing or rippling sensation under the fingertips, caused by turbulent blood flow through the heart or great vessels.
Palpation: Place the pads of the fingers over areas of murmur auscultation (precordial area, apex, or along the sternal borders). If a vibration is felt, this indicates a thrill.
Mnemonic Breakdown:
MR PAN: Mitral Regurgitation and Pan-systolic
Mitral Regurgitation (MR):
Description: A high-pitched, blowing, pan-systolic murmur.
Location: Best heard at the apex, radiating towards the left axilla.
Special Signs:
Holosystolic murmur covering the entire systole.
S3 heart sound may be present due to volume overload in the left ventricle.
The murmur remains constant and does not vary with respiration.
MS RUM: Mitral Stenosis and Rumbling
Mitral Stenosis (MS):
Description: A low-pitched, rumbling diastolic murmur.
Location: Best heard at the apex with the bell of the stethoscope, especially in the left lateral decubitus position.
Special Signs:
Opening snap following S2.
Low-pitched rumble due to turbulent blood flow through the stenotic mitral valve.
Loud S1 is often heard due to the stiff valve leaflets.
AS JECK: Aortic Stenosis and Ejection Click
Aortic Stenosis (AS):
Description: A harsh, systolic ejection murmur.
Location: Best heard at the right second intercostal space, radiating to the carotids.
Special Signs:
Crescendo-decrescendo murmur due to the narrowing of the aortic valve during systole.
Ejection click (JECK) often heard in stiff valves.
Delayed carotid upstroke (pulsus parvus et tardus).
S4 sound due to left ventricular hypertrophy.
AR BLOW: Aortic Regurgitation and Blowing
Aortic Regurgitation (AR):
Description: A high-pitched, blowing early diastolic murmur.
Location: Best heard at the left sternal border, especially when the patient is leaning forward and at the end of expiration.
Special Signs:
Decrescendo murmur as the blood flows back into the left ventricle during diastole.
Water hammer pulse (Corrigan’s pulse).
Quincke's sign (nailbed pulsations), Müller’s sign (uvula pulsations), and Duroziez’s sign (murmur when compressing the femoral artery).
Austin Flint murmur: A rumbling diastolic murmur at the apex, mimicking mitral stenosis.
Additional Valve Conditions Mnemonic:
TR PAN: Tricuspid Regurgitation and Pan-systolic
Tricuspid Regurgitation (TR):
Description: A pan-systolic murmur.
Location: Best heard at the left lower sternal border, radiating to the right side of the sternum.
Special Signs:
The holosystolic murmur increases with inspiration (Carvallo's sign).
Jugular venous distention (JVD), hepatojugular reflux, and pulsatile liver due to systemic venous congestion.
TS RUM: Tricuspid Stenosis and Rumbling
Tricuspid Stenosis (TS):
Description: A low-pitched, rumbling diastolic murmur.
Location: Best heard at the left lower sternal border with the bell of the stethoscope, increasing with inspiration.
Special Signs:
Opening snap, louder with inspiration.
Elevated jugular venous pressure (JVP) and peripheral edema due to right-sided heart failure.
PR BLOW: Pulmonary Regurgitation and Blowing
Pulmonary Regurgitation (PR):
Description: A high-pitched, blowing early diastolic murmur.
Location: Best heard at the left upper sternal border.
Special Signs:
Graham Steell murmur: A high-pitched diastolic murmur, often associated with pulmonary hypertension.
May present with a right ventricular lift due to hypertrophy.
PS JECK: Pulmonary Stenosis and Ejection Click
Pulmonary Stenosis (PS):
Description: A systolic ejection murmur with a crescendo-decrescendo pattern.
Location: Best heard at the left upper sternal border, radiating to the left shoulder.
Special Signs:
Ejection click before the murmur.
Right ventricular hypertrophy leads to a palpable right ventricular heave.
Widened split of S2 due to delayed closure of the pulmonic valve.
Continuous Machinery Murmur in PDA and Aortic Valve Sac Rupture:
Patent Ductus Arteriosus (PDA):
Description: The most common cause of a continuous machinery-like murmur, which is a murmur heard throughout systole and diastole.
Location: Best heard at the left infraclavicular area or left upper sternal border.
Cause: PDA occurs due to a persistent communication between the aorta and the pulmonary artery, allowing abnormal blood flow after birth.
Associated Signs:
Bounding pulses due to the high pulse pressure.
Often accompanied by cyanosis if the PDA is large.
Differential diagnosis: PDA is the primary condition to consider when a continuous murmur is heard.
Aortic Valve Sac Rupture:
Description: Another potential cause of a continuous murmur, although much rarer than PDA.
Location: Typically presents with a harsh murmur over the heart, which can radiate widely.
Cause: Occurs when the aortic valve sac ruptures into a cardiac chamber or nearby structure, leading to abnormal communication.
Associated Signs:
This can lead to sudden hemodynamic changes and a loud murmur due to turbulent flow between the affected structures.
Clinical urgency: This is a rare but serious condition that requires immediate attention and intervention.
Summary:
The mnemonic "MR PAN MS RUM AS JECK AR BLOW" helps remember key features of valvular heart diseases. Mitral Regurgitation (MR) presents with a high-pitched, pan-systolic murmur at the apex, radiating to the axilla, often with an S3 sound. Mitral Stenosis (MS) is a low-pitched, rumbling diastolic murmur at the apex, heard best with the bell, often featuring an opening snap. Aortic Stenosis (AS) causes a harsh, systolic ejection murmur at the right 2nd intercostal space, with delayed carotid upstroke. Aortic Regurgitation (AR) is a high-pitched, blowing diastolic murmur at the left sternal border, associated with signs like a water hammer pulse and Quincke's sign. Additional valve conditions include Tricuspid Regurgitation (TR) with a pan-systolic murmur increasing on inspiration, Tricuspid Stenosis (TS) with a rumbling diastolic murmur louder on inspiration, Pulmonary Regurgitation (PR) with a blowing diastolic murmur, and Pulmonary Stenosis (PS) with a systolic ejection murmur and an ejection click. PDA causes a continuous machinery murmur, while aortic valve sac rupture can cause a harsh continuous murmur.
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