Murmurs DDx

Overview

• Heart murmurs are abnormal heart sounds believed to be caused by turbulent flow across heart valves or vascular abnormalities.
• When assessing a murmur, determine 6 characteristics: position at which it is loudest, grade, timing, duration, presence of a thrill, radiation and changes during respiration or with dynamic manoeuvers.

Causes

Continuous murmur

• Patent ductus arteriosus
• Arteriovenous fistula (coronary artery, pulmonary, systemic)
• Aortopulmonary connection (e.g. congenital, Blalock shunt)
• Venous hum (usually best heard over right supraclavicular fossa and abolished by ipsilateral internal jugular vein compression)
• Rupture of sinus of Valsalva into right ventricle or atrium
• ‘Mammary souffle’ (in late pregnancy or early postpartum period)

Mid-systolic murmur

• Aortic stenosis
• Pulmonary stenosis
• Hypertrophic cardiomyopathy
• Pulmonary flow murmur of an atrial septal defect

Pansystolic murmur

• Mitral regurgitation
• Tricuspid regurgitation
• Ventricular septal defect
• Aortopulmonary shunts

Early diastolic murmur

• Aortic regurgitation
• Pulmonary regurgitation

Mid-diastolic murmur

• Mitral stenosis
• Tricuspid stenosis
• Atrial myxoma
• Austin Flint murmur of aortic regurgitation
• Carey Coombs murmur of acute rheumatic fever

Presystolic murmur

• Mitral stenosis
• Tricuspid stenosis
• Atrial myxoma

References and Links

LITFL

• CCC – Murmurs and Valve Lesions

Journal Articles and Textbooks

• Talley NJ, O’Connor S. Clinical Examination: A Systematic Guide to Physical Diagnosis. MacLennan and Petty. 3rd edition, 1998.

CCC Differential Diagnosis Series
NEURO	Anosmia, Ataxia, Blepharospasm, Bulbar and Pseudobulbar palsy, Central Pontine Myelinosis, Cerebellar Disease, Chorea, Cranial nerve lesions, Dementia, Dystonia, Exophthalmos, Eye trauma, Facial twitches, Fixed dilated pupil, Horner syndrome, Loss of vision, Meningism, Movement disorders, Optic disc abnormality, Parkinsonism, Peripheral neuropathy, Radiculopathy, Red eye, Retinal Haemorrhage, Seizures, Sudden severe headache, Tremor, Tunnel vision
RESP	Bronchial breath sounds, Bronchiectasis, High airway pressures, Massive haemoptysis, Sore throat, Tracheal displacement
CVS	Atrial Fibrillation, Bradycardia, Cardiac Failure, Chest Pain, Murmurs, Post-resuscitation syndrome, Pulseless Electrical Activity (PEA), Pulsus Paradoxus, Shock, Supraventricular tachycardia (SVT), Tachycardia, VT and VF, SVC Obstruction
GIT	Abdominal distension, Abdominal mass, Abdominal pain, Asterixis, Dysphagia, Hepatomegaly, Hepatosplenomegaly, Large bowel obstruction, Liver palpation abnormalities, Lower GI haemorrhage, Malabsorption, Medical causes of abdominal pain, Rectal mass, Small bowel obstruction, Upper GI Haemorrhage
GUT	Genital ulcers, Groin lump, Scrotal mass, Urine colour, Urine Odour, Urine transparency,
MSK	Arthritis, Shoulder pain, Wasting of the small muscles of the hand
DERM	Palmar erythema, Serious skin signs in sick patients, Thickened Tethered Skin, Leg ulcers, Skin Tumour, Acanthosis Nigricans
ENDO	Diabetes Insipidus, Diffuse Goitre, Gynaecomastia, Hirsutism, Hypoglycaemia, SIADH, Weight Loss
HAEM	Splenomegaly
PAEDS	Floppy infant
MISC	Anaphylaxis, Autoimmune associated diseases, Clubbing, Parotid Swelling, Splinter haemorrhages, Toxic agents and abnormal vitals, Toxicological causes of cardiac arrest
IMAGING	CHEST: Atelectasis, Hilar adenopathy, Hilar enlargement on CXR, Honeycomb lung, Increased interstitial markings, Mediastinal widening on mobile CXR, Pulmonary fibrosis, Pseudoinfiltrates on CXR, Pulmonary opacities on CXR, ABDO: Gas on abdominal X-ray, Kidney mass, BRAIN: Intracranial calcification, Intracranial structures with contrast, Ventriculomegaly, OTHER: Pseudofracture on X-Ray,
LABS	LOW: Anaemia, Hypocalcaemia, hypochloraemia, Hypomagnesaemia,  HIGH: Bilirubin and Jaundice, Hyperammonaemia, Hypercalcaemia, Hyperchloraemia, Hyperkalaemia, Hypermagnesaemia,  ACID BASE: Acid base disorders, Resp. acidosis, Resp. alkalosis, Creatinine, CRP, Dipstick Urinalysis, Laboratory Urinalysis, Liver function tests (LFTs), Pleural fluid analysis, Urea, Urea Creatinine Ratio, Uric acid, Urinalysis, Urine Electrolytes

[cite]