Heart Murmurs and extra sounds

Murmur Grading:
- - Grade I/VI: Very faint, heard only after the listener has "tuned in" may not be heard in all positions.
  - Grade II/VI: Quiet but heard immediately upon placing the stethoscope on the chest.
  - Grade III/VI: Moderately loud
  - Grade IV/VI: Loud with a palpable thrill
  - Grade V/VI: Very loud. May be heard with a stethoscope partly off the chest.
  - Grade VI/VI: Heard best with the stethoscope entirely off the chest

- AS: medium pitched. heard best at 2nd RICS. Systolic crescendo-decrescendo murmur with transmission to the carotid arteries. A2 decreased, ejection click and S4 often heard at apex. Paradoxical splitting of S2. Narrow pluse pressure and delayed carotid upstroke. LVH with lift at apex.
- AR: Heard best at LLSB, 3rd, and 4th ICS. Soft diastolic decrescendo murmur. Often with LVH. Widened pulse pressure, Corrigan's pulse, Traube's sign, Quincke's sign, and Duroziez's sign may be seen with chronic AI. S3 and pulsus alternans often present with acute AI.
  - e.g.: medium pitched, grade 2/6 diastolic, blowing decrescendo murmur, heard best in the 4th L. ICS, with radiation to the apex.
- HOCM: Bifid carotid pulse, S4 heart sound (diastolic dyfunction), harsh systolic crescendo-decrescendo murmur located at the apex and LSB. Increases with Valsalva maneuver and standing erect, and amyl nitrite. It decreases with sudden squatting, leg raising, and handgrip exercises.
- PS: Heard best at L 2nd ICS. Systolic crescendo-decrescendo murmur. Loud with inspiration. Click often present. A2 delayed and soft if severe. RVH with parasternal lift.
- PR: Heard best at L 2nd ICS. Diastolic decrescendo or crescendo-decrescendo murmur. Louder with inspiration. RVH usually present.
- MS: Localized apex in the Left Lat. decubitus position. Heard best with bell (low rumbling). Diastolic murmur with presystolic accentuation contributed by atrial systole - kick, ending with lound S1 when the valve slams shut. Opening snap soon after S2 and often precedes the murmur heard best at apex with diaphragm. Increased P2, R. sided S4, L. sided S3 often present. RVH with parasternal lift may be present. In atrial fibrillation the presystolic accentuation is not heard, as the atrial systole is not present.
- MR: High pitched. Heard best at apex. Holosystolic murmur with transmission to axilla. Soft S1, may be masked by murmur. S3 and LVH often present. Midsystolic click suggests MVP.
- TRI: High pitched. Heard best at LLSB. Holosystolic murmur. Increases with inspiration. R. sided S3 often present. Large V wave in JVP.
- ASD: Medium pitched. Heard best at LUSB. Systolic murmur. Fixed splitting of S2 and RVH, often with L and right-sided S4.
- VSD: Most frequent congenital heart disease. Harsh holosytolic murmur with midsystolic peak, heard best at LLSB. Usually associated with thrill. S1 and S2 may be soft.
- Patent Ductus: Medium pitched. Heard best at L. 1st and 2nd ICS. Continuous, machinery murmur. Increased P2 and ejection click may be present.
- S3: Early diastolic sound caused by rapid ventricular filling. Heard best with bell. L. sided S3 heard best at apex. R. sided S3 heard best at LLSB. L. sided S3 seen normally in young people, also pregnancy, thyrotoxicosis, MR, and CHF.
- S4: Late diastolic sound caused by a noncompliant ventricle. Heard best with bell. L. sided S4 heard at apex, R. sided S4 heard at LLSB. L. sided S4 may be normal (young, well-trained athelete) and with HTN, AS, and MI. R. sided S4 seen with PS and pulmonary HTN.

Systolic murmurs:

- Holosystolic: MR, TR, VSD, AP shunts
- SEM (MSM): AS, PS, ASD, MR, TR, HCM (LLSB)
- ESM: VSD with pulm HTN, TR without pulm HTN
- LSM: MVP with assoc. block

Diastolic murmurs:

- EDM: AR
- MDM: MS, TS, AR - severe (Austin-Flint), L. atrial myxoma.

http://depts.washington.edu/physdx/heart/demo.html

Above is the link for HS

MVP can be asymptomatic and can also present with symptoms of atypical chest pain, palpitations, dyspnea on exertion, and exercise intolerance. Other symptoms, such as anxiety, low blood pressure, and syncope, suggest autonomic nervous system dysfunction. Occasionally, supraventricular arrhythmias are seen, suggesting an increased parasympathetic tone.

In MVP, the mid-systolic click is followed by a late systolic murmur. This finding is commonly heard at the apex. The murmur of MVP varies with position. The murmur is accentuated when the patient is standing and in the Valsalva maneuver (systolic click comes earlier, and the murmur is longer) and diminishes when the patient is squatting (systolic click comes later, and the murmur is shorter).

Murmur and maneuvers:

- Squatting and raising legs ▲ venous retur to heart, ▲ preload, ▲ PVR, ▲ BP, ▲ LV volume, ▲ SV:
  - ▲ intensity of murmur of AS
  - ▼ intensity of murumur of HOCM as LVOT obstruction is decreased
  - ▼ intensity of murmur of mitral valve prolapse.
- Standing, valsalva, amyl nitirite ▼ venous return to heart, ▼ PVR, ▼ BP, ▼ LV volume, ▼ SV:
  - ▲ intensity of murmur of mitral valve prolapse
  - ▲ and HOCM (LVOT is increased)