PART 2: Cardinal Manifestations and Presentation of Diseases
SECTION 5 Alterations in Circulatory and Respiratory Functions
e13 Approach to the Patient With a Heart Murmur
 | Figure e13-1 Diagram depicting principal heart murmurs. A. Presystolic murmur of mitral or tricuspid stenosis. B. Holosystolic (pansystolic) murmur of mitral or tricuspid regurgitation or of ventricular septal defect. |
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 | Figure e13-2 Maximal intensity and radiation of six isolated systolic murmurs. HOCM, hypertrophic obstructive cardiomyopathy; MR, mitral regurgitation; Pulm, pulmonary stenosis; Aortic, aortic stenosis; VSD, ventricular septal defect. (From JB Barlow, Perspectives on the Mitral Valve. Philadelphia, FA Davis, 1987, p... |
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 | Figure e13-3 A mid-systolic nonejection sound (C) occurs in mitral valve prolapse and is followed by a late systolic murmur that crescendos to the second heart sound (S2). Standing decreases venous return; the heart becomes smaller; C moves closer to the first heart sound (S1), and the mitral regurgitant murmur has an... |
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 | Figure e13-4 Left. In valvular pulmonic stenosis with intact ventricular septum, right ventricular systolic ejection becomes progressively longer, with increasing obstruction to flow. As a result, the murmur becomes longer and louder, enveloping the aortic component of the second heart sound (A2). The... |
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 | Figure e13-5 Differential diagnosis of a holosystolic murmur. |
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 | Figure e13-6 Diastolic filling murmur (rumble) in mitral stenosis. In mild mitral stenosis, the diastolic gradient across the valve is limited to the phases of rapid ventricular filling in early diastole and presystole. The rumble may occur during either or both periods. As the stenotic process becomes severe, a large pressure gradient... |
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 | Figure e13-7 Comparison of the continuous murmur and the to-fro murmur. During abnormal communication between high-pressure and low-pressure systems, a large pressure gradient exists throughout the cardiac cycle, producing a continuous murmur. A classic example is patent ductus arteriosus. At times, this type of murmur can be confused with a... |
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 | Figure e13-8 Top. Normal physiologic splitting. During expiration, the aortic (A2) and pulmonic (P2) components of the second heart sound are separated by <30 ms and are appreciated as a single sound. During inspiration, the splitting interval widens, and A2 and P2 are clearly... |
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 | Figure e13-9 Strategy for evaluating heart murmurs.*If an electrocardiogram or chest x-ray has been obtained and is abnormal, echocardiography is indicated. TTE, transthoracic echocardiography; TEE, transesophageal echocardiography; MR, magnetic resonance. (Adapted from RO Bonow et al: J Am Coll Cardiol 32:1486,... |
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