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A HOW-TO UPDATE AND CLINICAL REVIEW OF PROCEDURES COMMONLY PERFORMED, IN THE PRIMARY CARE SETTING
* What is the single most important feature of a murmur that you must determine? Why?
The single most important feature of a murmur that you must determine is whether it is systolic or diastolic.The reason is simple: all diastolic murmurs are indicative of organic heart disease.While systolic murmurs may be caused by organic heart disease, many are benign, representing innocent murmurs or flow murmurs.
* What is the most important feature of a systolic murmur that you should determine? Why?
You should determine whether the systolic murmur is a midsystolic (systolic ejection) murmur (see Figure 44a), or whether it is a holosystolic (pansystolic) murmur (see Figure 44b).The reason is that all holosystolic murmurs are caused by organic heart disease, whereas systolic ejection murmurs may or may not be caused by cardiac disease. A third category of systolic murmur is the late systolic murmur (see Figure 44c) which is discussed below.
* How do you know whether or not a systolic murmur is pansystolic?
First determine whether the murmur extends through the second sound (see Figures 44b and c), or whether it stops before the second sound (see Figure 44a). Once that is understood, assess whether the loudness of the murmur is constant throughout its duration (see Figures 44b and c) or whether it is crescendo-decrescendo in nature (see Figure 44a).
The classical murmur of mitral insufficiency, for example, is a pansystolic or holosystolic murmur (see Figure 44b). If you auscultate at the apex, you will note that the murmur extends right through 52 and that the intensity of the murmur is constant throughout systole. In contrast, a midsystolic or systolic ejection murmur, such as one hears in patients with valvular aortic stenosis, starts after the first heart sound and stops before the second sound (see Figure 44a).A midsystolic murmur, unlike a pansystolic murmur; is diamond-shaped, starting out softly, peaking in loudness at midsystole, and then decreasing in loudness until it disappears prior to S2 (see Figure 44a).
One organically induced murmur that extends through the second sound, but which is not pansystolic (because it starts in mid or late systole), is the murmur of mitral valve prolapse (see...