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MURMURS
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Introduction
Def:
prolonged series of sounds or vibrations
of varying loudness , frequency , character ,
duration , configuration .
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Physics of murmurs:
Any fluid that crosses reynolds number morethan 2000 causes murmur because of turbulence
R=density of fluid *velocity * diameter divided byviscosity
There are two theories for production ofturbulence , turbulence theory and eddie or
vortex theory Turbulence is produced by high velocity ,
abnormal valve , narrow orifice , post stenoticdilatation
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some important points
1)all murmurs are not pathological
2)absence of murmur cant exclude pathology
of heart
3)murmurs can also be due to extra cardiacorigin
4)murmurs have different properties intensity, location ,pitch ,quality , radiation , shape ,timing of the murmur.
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continued
5)High and medium pitched sounds are bestheard with diaphragm
6)Low pitched heart sounds are best heard
with the bell 7)We cannot identify properly a murmur if the
heart is beating rapidly and irregularly
8)diastolic murmurs are always pathological
9) grade 3 or more systolic murmurs are canbe pathological
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Timing
Murmurs can be divided into systolic or
diastolic by inspection or palpation of the
carotid artery and apical impulse
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1)Systolic based on timing divided into
Early systolic
Mid systolic
Late systolic
Pan systolic or holosystolic 2)diastolic divided into
Early diastolic
Mid diastolic
Late diastolic or pre systolic 3)continous murmurs
4)double murmurs
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EARLY SYSTOLIC MURMUR
Due to acute severe mitral regurgitation
Tricuspid regurgitation
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Mid systolic murmur
Can be innocent or pathological
Most common
sometimes present in children and adults
without pathology Will be present high output states such as
anaemia , fever , pregnancy
Aortic stenosis
Pulmonary stenosis Hypertrophic cardiomyopathy (due to septal
enlargement)
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Late systolic
Mitral valve prolapse
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Pan systolic murmur
Mitral regurgitation
Tricuspid regurgitation
Ventricular septal defect
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Mid or Late diastolic
Mitral stenosis
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Double murmurs
Aortic stenosis with aortic regurgitation
Pulmonary stenosis with pulmonary
regurgitation
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Continuous murmurs
Venous hum
Patent ductus arteriosis
Mammary souffle
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Timing of the murmurs
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Shape of the murmur
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Shape of the murmur
It can be crescendo ascending
Decrescendo- descending
Crescendo-decresendo uniform
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Location of the murmur
Normally method of auscultation should be
inch to inch
Main areas of auscultation are mitral area or
apex , tricuspid area , aortic area and
pulmonary area
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Mitral area 5th intercostal space half inch medialto the mid clavicular line
Tricuspid area 5th intercostal space in the leftparasternal area
Pulmonary area 2nd intercostal space leftparasternal area
Aortic area 2nd intercostal space right parasternalarea
Neo aortic or erbs area 3rd and 4th intercostal leftparasternal areas
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Character or Quality
Can be described as blowing , musical,
rumbling or rolling , grating etc
Rumbling or rolling commonly used for mitral
stenosis
Blowing is soft murmurs for regurgitant
lesions
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Radation
To the axilla and back-mitral regurgitation
To carotids -aortic stenosis
Gallaverdin effect
to apex in aortic stenosis To the right parasternal area-vsd
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intensity
Grading of murmurs of systolic origin
Grade 1 heard with difficulty
Grade 2 faint but can be heard easily
Grade 3 moderately loud
Grade 4 loud with thrill
Grade 5 very loud
Grade 6 loud can be heard without astethascope
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Diastolic murmurs graded upto 4 only
Thrill always associated with pathological heartonly
Murmur grade 3 or more is always pathological Mitral stenosis , aortic stenosis and ventricular
septal defect as they progress the intensity oftheir murmur decreases
Heart failure as it progress decreases theintensity of murmur
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Pitch
High frequencies normally produce highpitched sounds
Low frequencies low pitched sounds
High pitch is normally due to high velocity offlow which can be due to high pressuregradient and a narrow orifice eg ( small aortic
regurgitation and a small vsd) Low pitch is normally due to low pressure
gradient and large orifice eg(mitral stenosis)
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Other procedures
Valsalva and standing decreases the flow to
the heart so they decrease the intensity of the
murmur
Squatting and exercise increases the flow so
increases the intensity of the murmur
There are two exceptions hocm and mvp
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location pitch quality radiatio
n
shape timing others
Mitral
regurgitation
Apical
Leftlateral
position
High
pitched
blowing To the
axillaand
back
From s1
to s2
Soft s1
bestheard
with
diaphgr
am
Mitral
stenosis
apex low Rumblin
g or
rolling
cresend
o
decresc
endo
and
From s2
to s1
Presysto
lic
accentu
ation
Loud s1
Opening
snap
Aorticstenosis
Aorticarea
low rough To thecarotids
Crescendo-
decresc
endo
Midsystolic
Diamond
shaped
EjectionClick,gall
avedin
effect
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location pitch quality radiation Shape timing others
Tricuspid
regurgita
tion
Tricuspi
d area
Low
pitch
blowing nil uniform pansyst
olic
May be
associat
ed with
diastolic
rumble
Raised
jvp
Pulmon
ary
stenosis
Pulmon
ary area
Low
pitch
rough Diamon
d
shaped
systolic Wide
split s2
Aortic
regurgit
ation
2nd and
3rd ics
and left
sternal
border
blowing decresc
endo
Early
diastolic
Can be
Associat
ed
With
ESM
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SOME EPONYMS
Stills murmur-innocent murmur in childhood
Graham steels murmur-pulmonary regurgitation
Austin flint murmur-aortic regurgitation
Rogers murmur-ventricular septal defect Machinary murmur-patent ductus arteriosus
Carey coombs murmur-mitral valve inflammationdue rheumatic fever mid diastoloic
Cabot locke murmur-anaemia diastolic Docks murmur-left anterior descending branch
stenosis (continuous)
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THANK YOU