Abnormal heart sounds and murmurs

Rationale

Murmurs and abnormal heart sounds may be detected on physical examination. Although systolic murmurs are often “innocent” or physiologic, diastolic murmurs are virtually always pathologic. A thorough history and physical examination almost always identify which patient cases require further investigation and management.

Causal Conditions

(list not exhaustive)

1. Abnormal heart sounds
   1. S₁ (e.g., mitral stenosis, atrial fibrillation)
   2. S₂ (e.g., hypertension, aortic stenosis)
   3. S₃ (e.g., heart failure)
   4. S₄ (e.g., hypertension)
   5. Abnormal splitting (e.g., atrial septal defect)
2. Systolic murmurs
   1. Ejection murmurs (e.g., physiologic, aortic stenosis)
   2. Pansystolic murmurs (e.g., mitral regurgitation)
3. Diastolic murmurs
   1. Early (e.g., aortic regurgitation)
   2. Mid-diastolic (e.g., mitral stenosis)
4. Pericardial friction rubs

Key Objectives

Given a patient with a murmur or abnormal heart sounds, the candidate will differentiate innocent from pathologic conditions; diagnose the cause, severity, and complications; and initiate an appropriate management plan.

Enabling Objectives

Given a patient with a murmur or abnormal heart sounds, the candidate will

1. list and interpret critical clinical findings, including
   1. the origin of the abnormal sound and/or murmur; and
   2. results of an appropriate history and physical examination aimed at determining the underlying pathological condition, including severity and complications (e.g., heart failure, endocarditis);
2. list and interpret critical investigations, including
   1. diagnostic screening for cardiac arrhythmia by means of clinical findings and electrocardiogram; and
   2. appropriate diagnostic imaging, including echocardiography, for further investigation of the murmur or abnormal heart sounds; and
3. construct an effective initial management plan, including
   1. initiating management for the underlying condition and its complications (e.g., heart failure, atrial fibrillation, endocarditis);
   2. recommending endocarditis prophylaxis if indicated; and
   3. determining whether the patient requires specialized care.