Gen Med: Heart MurmursThe following article is specific to heart murmurs, for a basic template on the cardiac examination, click here.

Every patient you will ever come across should at some point have their heart checked, so you must know what the heart SHOULD sound like. To do this, there's nothing for it but to EXAMINE EVERY PATIENT you can get your hands on - when you know whats normal, you can determine what's abnormal.

Listen to the heart:After you've checked the position of the apex beat, you should start your examination there... The apex is also known as the MITRAL area. Then move to the lower left sternal edge (TRICUSPID area), to the upper left sternal edge (PULMONARY area) and finally to the upper right sternal edge (AORTIC area). A useful way to remember where each of these areas are is to think about where the murmur would be best heard based on the DIRECTION the blood flows through the valve. It would be good to sit down and work this out.

REMEMBER THIS MNEMONIC: MR AS's ARMS (pronounced mister asses arms)1. MR/TR - Pan-systolic murmur, radiate to axilla2. AS/PS - Ejection systolic murmur, AS: radiates to the carotids, PS: radiates to the back3. AR/PR - Early diastolic murmur, radiate along the sternal edge4. MS/TS - Mid-diastolic murmur

You should be able to decide what the murmur might be based on1. Location - where is it? Apex (Mitral), LLSE (Tricuspid), ULSE (Pulmonary) or URSE (Aortic)2. Timing of the murmur - time the murmur against the CAROTID pulse: is it systolic or diastolic?3. Where in the cycle does it come?/What does it sound like? I.e. is it pan systolic, ejection systolic etc4. What is the radiation of the murmur?5. What other signs is the murmur associated with?

Aortic Sclerosis

Ejection systolic murmur heard loudest over R USE. Differential for aortic stenosis, but aortic sclerosis should not radiate to the carotids.

Common in elderly patients, especially those who have hypertension and cardiomegaly. Due to calcification of the valve. Risk factors for incident aortic valve calcification include older age, male gender, a higher body

mass index, smoking and the use of lipid-lowering and antihypertensive medications

Severity of the murmur:1. What is the grade of the murmur?

Systolic murmurs are graded from 1-6, diastolic from 1-4. 1 - Soft, barely audible murmur 2 - Soft but murmur detected immediately 3 - Clearly audible murmur, no thrill 4 - Murmur with a palpable thrill 5 - Murmur heard with stethoscope only partially touching chest 6 - Murmur heard without stethoscope on the chest

Markers of   severe   aortic stenosis Triad of:1. Chest pain2. Syncope3. Heart failure (Symptoms: shortness of breath, creps on auscultation, pulmonary hypertension if severe)

Aortic regurgitationAortic regurgitation is characterised by a early diastolic murmur which is loudest over the right upper sternal edge and radiates along the sternal edge. It may be associated with a collapsing pulse, and several signs such as:Corrigan's sign (prominent carotid artery pulsations)Muller's sign (pulsations of the uvula)Quinkes sign (pulsations of the capillary bed seen at the nails)De-Musset's sign (bobbing of the head in time with pulsations)Traube's sign (pistol shot sound heard over the femoral pulse)Duroizez's sign (to and fro murmur heard over the femoral artery on slight compression)

A collapsing pulse may be due to:

Aortic regurgitation PDA Hyperdynamic states: pregnancy, thyrotoxicosis, anaemia, high fever Aortopulmonary window Ruptured aneurysm of the aortic sinus

Referenceshttp://www.uptodate.com/contents/aortic-valve-sclerosis?source=search_result&search=aortic+sclerosis&selectedTitle=1%7E15#H9