Yeq

Aj P2

Turbulence due to a temporary increase in blood flow causes this murmur. Predisposing conditions include anemia, pregnancy, fever, and hyperthyroidism.

Stenosis of the pulmonic valve impairs flow across the valve, increasing afterload on the right ventricle. It is congenital and most often found in children. Pathologically increased flow across the pulmonic valve may mimic the murmur of pulmonic stenosis. The systolic murmur of an atrial septal defect originates from this flow, not the defect itself.

murs tend to peak near midsystole and usually stop before St. The crescendo-decrescendo or "diamond" shape is not always audible, but the gap between the murmur and S2 helps to distinguish midsystolic from pansystolic murmurs.

Murmur

Associated Findings

Location. 2nd to 4th left interspaces between the left sternal border and the apex

Radiation. Little

Intensity. Grade 1 to 2, possibly 3

Pitch. Medium

Quality. Variable

Aids. Usually decreases or disappears on sitting

None: normal splitting, no ejection sounds, no diastolic murmurs, and no palpable evidence of ventricular enlargement. Occasionally, a patient has both an innocent murmur and another kind of murmur.

Similar to innocent murmurs

Possible signs of a likely cause

Location. 2nd and 3rd left interspaces

Radiation. If loud, toward the left shoulder and neck

Intensity. Soft to loud; if loud, associated with a thrill

Pitch. Medium

Quality. Often harsh

In severe stenosis, S2 is widely split and P2 is diminished. When P2 is inaudible, no splitting is heard.

An early pulmonic ejection sound is common.

A right-sided S4 may be present. The right ventricular impulse is often increased in amplitude and may be prolonged.

(table continues on next page)

TABLE 7-6 ■ Midsystolic Murmurs (Continued)

Mechanism

Aortic Stenosis

May be decreased

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