Heart Murmurs: Examination

A comprehensive clinical examination is the basis for selecting further diagnostic steps:

• General physical examination – including blood pressure, pulse, body weight, height; further:
  • Inspection (viewing).
    • Skin, mucous membranes, and sclerae (white part of the eye) [cyanosis (bluish discoloration of the skin and/or central mucous membranes caused by a lack of oxygen)]
    • Neck vein congestion? [heart failure (cardiac insufficiency)]
    • Edema/water retention? [heart failure (cardiac insufficiency)]
      • Lower leg: pretibial/pre-shin, ankle.
      • In the recumbent patient: presacral/pretibial, sacrum.
    • Peripheral cyanosis, generalized? – In valvular vitiation (heart defects)]
    • Central cyanosis (bluish discoloration of skin and central mucous membranes, e.g., tongue)? [in vitia (heart defect) with right-to-left shunt (in this disorder, deoxygenated venous blood enters the systemic circulation directly, bypassing the pulmonary circulation); heart failure (cardiac insufficiency)]
  • Auscultation (listening) of the heart* [due todifferential diagnoses:diseases that cause systolic heart murmurs:
    • Accidental systolic murmur – murmur occurring primarily in children and adolescents with no underlying pathologic change.
    • Aortic valve (auscultation point: 2nd intercostal space, abbreviated ICR, right parsternal).
      • Aortic valve stenosis (narrowing of the aortic valve) – spindle-shaped rough systolic p.m. 2nd ICR (intercostal space/intercostal rib space) right parasternal (next to the sternum), continued into the carotids (carotid arteries)
      • Aortic stenosis – narrowing of the descending portion of the aorta.
    • Functional systolic murmur – heart murmur without pathological change, which occurs, for example, in fever, pregnancy or hyperthyroidism (hyperthyroidism).
    • Hypertrophic obstructive cardiomyopathy (HOCM) – heart muscle disease that may present with the following symptoms and complications: Dyspnea (shortness of breath), angina (“chest tightness”; sudden onset of pain in the heart area), arrhythmias, syncope (brief loss of consciousness), and sudden cardiac death (PHT).
    • Mitral valve (auscultation point: 5th ICR on the left in the midclavicular line).
      • Mitral valve regurgitation (inability of the mitral valve to close) – high-frequency, banded systolic murmur (systolic murmur) p.m. (punctum maximum) above the apex of the heart, carried away into the axilla (armpit).
    • Tricuspid valve insufficiency (inability of the tricuspid valve to close) – (auscultation point: 5th ICR right parasternal).
    • Ventricular septal defect – congenital or acquired defect of the septum of the ventricles.

    Diseases that cause diastolic heart murmurs:

    • Aortic valve regurgitation (inability of the aortic valve to close) – diastolic decrengeal murmur after the 2nd heart sound p.m. over the aorta or Erb (auscultation point corresponding approximately to the middle of the heart figure; it is located in the 3 ICR on the left, about two QF (transverse fingers) parasternal (next to the sternum)); spindle-shaped systolic (in relative aortic stenosis).
    • Mitral valve stenosis (narrowing of the mitral valve) – tympanic first heart sound, mitral opening sound, diastolic decrescendo murmur (a heart sound continuously decreasing in intensity), transitioning to a presystolic crescendo murmur (a heart sound continuously increasing in intensity)
    • Pulmonary valve regurgitation (inability of the pulmonary valve to close) (auscultation point: 2nd ICR left parasternal).
    • Tricuspid valve stenosis (narrowing of the tricuspid valve) (auscultation point: 5th ICR right parasternal)

    Diseases leading to systolic-diastolic heart murmurs:

    • Arteriovenous fistula – short-circuit connection between the arterial and venous systems, may be due to pulmonary angioma or injury
    • Coronary fistula – pathological connection between a coronary vessel and a cardiac cavity.
    • Open ductus botalli – short circuit between the high and low pressure systems, which is usually interrupted immediately after birth
    • Ruptured sinus valsalva aneurysm – bulging located in the heart, the rupture (rupture) of which can lead to a short circuit]
  • Auscultation of the lungs [wg.possible secondary diseases: Pulmonary edema (accumulation of water in lung tissue); congestive bronchitis (chronic bronchitis with constant coughing)]

Square brackets [ ] are used to indicate possible pathological (pathological) physical findings. * Cardiac murmurs are characterized as follows:

• Loudness (loudness differentiation using a sixths scale):
  • 1/6 – audible only with difficulty during auscultation (listening).
  • 2/6 – quiet, but always audible during auscultation.
  • 3/6 – loud, but without buzzing.
  • 4/6 – loud noise with buzzing
  • 5/6 – audible sound even without full application of the stethoscope (medical examination instrument for the assessment of sound phenomena]
  • 6/6 – without stethoscope audible maximum loud noise.
• Noise generation is described as follows:
  • Ribbon-like – the volume of the noise is the same throughout.
  • Spindle-shaped – noise starts quietly, reaches a maximum and becomes quieter towards the end
  • Crescendoform – an initially quieter noise becomes louder
  • Decrescendoform – an initially louder sound becomes quieter
• Conduction (e.g., in aortic stenosis, the murmur is carried away into the common carotid artery).
• Punctum maximum (site where a heart murmur is heard loudest and most clearly).

Other clues

• During routine auscultation, two-thirds of all children may be found to have heart murmurs, most of which are harmless. Only about.l 1% of those affected actually have a cardiac problem.