❤️ Heart Murmurs · Innocent vs Pathologic · VSD · PDA · Aortic Stenosis · Still’s

Schwartz Clinical Handbook — Chapter 53 · Still murmur (innocent) · VSD (holosystolic) · PDA (continuous) · Aortic stenosis (crescendo‑decrescendo) · Coarctation

Select timing (systolic, diastolic, continuous), quality (vibratory, harsh), location (LLSB, LUSB, axilla), grade, thrill, S2 splitting, and associated symptoms (dyspnea, cyanosis, exercise intolerance) → differentiate innocent murmurs (Still, physiologic, venous hum) from pathologic (VSD, ASD, PDA, aortic/pulmonic stenosis, coarctation).
⚠️ Red flags: diastolic murmur, continuous murmur, thrill, cyanosis, abnormal S2, exercise intolerance, decreased femoral pulses → cardiology referral/echocardiogram.

📋 Step 1 — Murmur characteristics & exam
📌 Diagnostic impressions
📖 Schwartz Ch 53

Select timing (systolic, diastolic, continuous), quality (vibratory, harsh, musical), location (LLSB, LUSB, apex, axilla), grade (1‑6, thrill), S2 splitting, and symptoms (dyspnea, cyanosis, failure to thrive) → differentiate innocent murmurs (Still murmur, venous hum, pulmonary flow) from pathologic (VSD, ASD, PDA, aortic stenosis, pulmonic stenosis, coarctation).

✔️ Still murmur (innocent): vibratory, LLSB, grade II‑III, no thrill, normal S2.
✔️ VSD: holosystolic, LLSB, ± thrill, pulmonary flow murmur if large.
✔️ PDA: continuous “machinery” murmur at LUSB, bounding pulses.
✔️ Aortic stenosis: crescendo‑decrescendo, RSB, radiation to carotids, ejection click.
✔️ Coarctation: systolic murmur in back, delayed/ diminished femoral pulses.
📘 Schwartz pearls (Chapter 53)
• Innocent murmurs: grade ≤III, systolic, no thrill, normal S2, normal ECG/CXR.
• VSD: large defects → louder murmur, smaller defects → may still have thrill.
• PDA: indomethacin for prematurity; surgical/device closure.
• Aortic stenosis: ECG LVH if severe; echocardiogram for gradient.
• Coarctation: four‑limb BP, echo, treat hypertension.