Distant murmurs

Q: Murmur heard over the back of the chest below or adjacent to the left scapula is most probably indicative of? (select one)

A) mitral regurgitation

B) mitral stenosis

C) aortic regurgitation

D) aortic stenosis

E) tricuspid regurgitation

F) tricuspid stenosis

Answer: A

One of the skills to acquire while listening to heart murmurs is to appreciate murmurs away from the heart. In this regard, two murmurs away from the heart can be a significant diagnosis.

• A systolic murmur of peripheral pulmonary stenosis can be audible over the anterior aspects of both lungs.
• A systolic murmur over the back of the chest below or adjacent to the left scapula can be appreciated as severe mitral regurgitation.

In this regard, it is interesting to know that in patients with End-Stage Renal Disease (ESRD), a continuous murmur in the apical region of the lung can be audible on the side of the arteriovenous fistula (AVF) created in the arm.

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#physical-exam

#nephrology

References:

1. Moss AJ. Murmurs heard at a distance from the patient: report of an unusual case. J Pediatr. 1976 Nov;89(5):852-3. doi: 10.1016/s0022-3476(76)80826-8. PMID: 978338.

2. Alpert MA. Systolic Murmurs. In: Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths; 1990. Chapter 26. Available from: https://www.ncbi.nlm.nih.gov/books/NBK345/