murmur of pulmonic stenosis

Q: The murmur of pulmonic stenosis can be best heard at? - select one

A) left upper sternal border

B) right upper sternal border

Answer: A

The murmur of pulmonic stenosis is a systolic ejection murmur and is best heard at the left upper sternal border. If the murmur varies with respiration, it is still considered mild. It radiates to the back, in the posterior lung fields. 

In severe cases, there is a prominent left parasternal lift, along with splitting of the second heart sound. As expected, there is a right-sided fourth heart sound over the left sternal border if pulmonic stenosis leads to right ventricular hypertrophy with diminished compliance. 

Cyanosis occurs only later in the most severe cases.

In Jugular Venous Pressure (JVP), there is a prominent "A" wave, but overall JVP remains in the normal range.

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References:

1. Marchini F, Meossi S, Passarini G, Campo G, Pavasini R. Pulmonary Valve Stenosis: From Diagnosis to Current Management Techniques and Future Prospects. Vasc Health Risk Manag. 2023 Jun 30;19:379-390. doi: 10.2147/VHRM.S380240. PMID: 37416511; PMCID: PMC10320808.

2. Heaton J, Horenstein MS, Kyriakopoulos C. Pulmonary Stenosis. 2024 Oct 6. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2026 Jan–. PMID: 32809585.

3. Atiq M, Akhter S, Abdul Sattar S, Mohsin S, Aslam N. Murmur and Doppler alternans in critical pulmonary stenosis. Pediatr Cardiol. 2011 Oct;32(7):1004-7. doi: 10.1007/s00246-011-0033-6. Epub 2011 Jul 7. PMID: 21748495.