Physical Finding |
Associated cardiac condition(s) |
Timing |
|
Early systolic |
Ventricular septal defect, acute mitral regurgitation, acute tricuspid regurgitation |
Holosystolic (pansystolic) |
Mitral regurgitation, tricuspid regurgitation, ventricular septal defect |
Midsystolic (ejection systolic) |
Aortic stenosis, pulmonary stenosis, hypertrophic obstructive cardiomyopathy, atrial septal defect, aortic coarctation, pregnancy, mammary soufflé, innocent murmur |
Late systolic |
Myocardial infarction, ischemia, diffuse myocardial disease, mitral regurgitation from mitral valve prolapse |
Early diastolic |
Aortic regurgitation, pulmonary regurgitation (± Graham Steell murmur) |
Middiastolic |
Mitral stenosis, tricuspid stenosis, atrial myxoma (right or left), acute severe aortic regurgitation (Austin-Flint murmur), acute rheumatic fever (Carey Coombs murmur) |
Presystolic (Late diastolic) |
Tricuspid stenosis, mitral stenosis, atrial myxoma (right or left), acute severe aortic regurgitation (Austin-Flint murmur) |
Continuous |
Patent ductusarteriosus, cervical venous hum, mammary soufflé, congenital or acquired arteriovenous shunt (e.g. coronary arteriovenous fistula, ruptured aneurysm of aortic sinus of valsalva into a right heart chamber, anomalous left coronary artery, intercostal arteriovenous fistula), small atrial septal defect with a high left atrial pressure, proximal coronary artery stenosis, pulmonary artery branch stenosis, bronchial collateral circulation, aortic coarctation |
Modulation (shape) |
|
Diamond (crescendo-decrescendo) |
Aortic stenosis, pulmonary stenosis, hypertrophic obstructive cardiomyopathy |
Decrescendo |
Aortic regurgitation, pulmonary regurgitation |
Plateau |
Mitral regurgitation, tricuspid regurgitation |
Location |
|
5th intercostal space mid-clavicular line / apical |
Mitral stenosis/regurgitation, hypertrophic obstructive cardiomyopathy |
Right 5th interspace |
Tricuspid stenosis/regurgitation |
Right 2nd interspace / base |
Aortic stenosis/regurgitation |
Right 1st interspace or higher |
Supravalvular aortic stenosis |
Right supraclavicular fossa |
Cervical venous hum |
Left 2nd interspace / upper sternal border |
Pulmonic stenosis/regurgitation, patent ductusarteriosus |
Left 3rd-4th interspace |
Tricuspid regurgitation, hypertrophic obstructive cardiomyopathy |
Left & Right of sternum, 4th-6th interspace |
Ventricular septal defect |
Back/ interscapular |
Patent ductusarteriosus, aortic coarctation |
Intensity |
|
1 |
Faint, must tune in |
2 |
Easily heard |
3 |
Moderately loud |
4 |
Palpable thrill and loud |
5 |
Very loud |
6 |
Heard with stethoscope off chest |
Frequency (pitch) |
|
High |
Mitral regurgitation, acquired pulmonary regurgitation, aortic regurgitation |
Low |
Mitral stenosis (rumble), tricuspid stenosis, congenital pulmonary regurgitation, acute severe aortic regurgitation |
Radiation |
|
Axillary |
Mitral regurgitation (anterior or laterally directed jet) |
Back / Subscapular |
Mitral regurgitation (posteriorly directed jet), patent ductusarteriosus, aortic coarctation |
Neck (Carotids) |
Aortic stenosis, hypertrophic obstructive cardiomyopathy, supravalvular aortic stenosis (louder in right neck) |
Quality |
|
Blowing |
Mitral regurgitation |
Varying throughout cycle |
Pericarditis (Pericardial friction rub) |
Maneuver |
Murmur that becomes louder |
Squatting, raising legs i.e. increase venous return (left ventricular volume) |
Aortic stenosis, aortic regurgitation, mitral stenosis, mitral regurgitation, ventricular septal defect, patent ductusarteriosus |
Valsalva, inhalation of amyl nitrate, sitting up, standing i.e. decrease left ventricular volume |
Mitral valve prolapse (& lengthens murmur), hypertrophic obstructive cardiomyopathy |
Handgrip, phenylephrine, or transient arterial occlusion by inflation of bilateral arm cuffs to 20mmHg above systolic blood pressure for 5 seconds (increases systemic arterial resistance) |
Mitral regurgitation, aortic regurgitation, ventricular septal defect |
Holosystolic louder in inspiration |
Tricuspid regurgitation (Carvallo's sign), Pulmonary stenosis, pulmonary regurgitation |
Following a premature beat or a long RR interval |
Aortic stenosis, pulmonary stenosis |
Extra signs |
|
Other physical findings to support your diagnosis |
Blood pressure, jugular venous pulse, thrill, apex beat, peripheral pulse characteristics, changes in first or second heart sound, presence of third or fourth heart sound |
Pleural effusion |
Left heart failure |
Inspiratory rales |
Left heart failure |
Pulsatile mass below umbilicus |
Abdominal aortic aneurysm |
Abdominal bruit (lateral) |
Renovascular hypertension |