This mind map consists of murmurs arising from valvular lesions. Patient presentation for murmurs is most likely going to be in the form of a physical exam finding with or without accompanying symptoms. In some situations, patients report that their murmur was diagnosed by another clinician and they may or may not have had any further work up done on it yet. In any of the above situations, using the Epi-logical approach, it is important for a clinician to memorize all the differentials for cardiac murmurs, and chunking these based upon location makes memorization easy. In this clinical mind map, only valvular murmurs in adult populations are discussed. After determining the location of the murmur, the next high yield finding for a clinician to pursue is the timing of the murmur in relation to the cardiac cycle, such as systolic or diastolic.

An easy way to memorize these differentials is to pick one murmur, such as aortic stenosis, and commit to memory its location and timing characteristics. Murmurs of the same pathology and the same type of valves will have similar features. Aortic/pulmonic valves are similar to each other, aortic-ventricular valves are mitral, and tricuspid are similar to each other. In this case, murmur resembling aortic stenosis is a murmur of pulmonic stenosis. Murmurs arising from the same valve in relation to an opposite pathology will have opposite features. An example is an aortic stenosis murmur, which is a systolic murmur, versus aortic regurgitation, which is a diastolic murmur.

 

Systolic: Aortic Stenosis = Pulmonic Stenosis = Mitral Regurgitation = Tricuspid Regurgitation

Diastolic: Aortic Regurgitation = Pulmonic Regurgitation = Mitral Stenosis = Tricuspid Stenosis

 

In addition to the tips above, a helpful tip for a clinician to keep in mind when evaluating patients with murmurs is that generally pathology in right-sided valves produces symptoms of right-sided failure and pathology in left-sided valves produces symptoms of left-sided failure, but often times there is a significant amount of overlap, especially in the advanced stages of the disease.

Urgent and emergent situations include symptoms of class 3 or higher heart failure, and these are reflected in the patient’s vital signs, such as tachypnea, tachycardia and the appearance of distress. In addition, a quick physical exam may reveal crackles in the lungs, lower extremity edema, and/or altered mental status. Any valvular abnormality can give rise to an urgent/emergent situation if left untreated, but the most common culprits are the abnormalities with significant anatomic deformity and/or with underlying cardiac pathology. Weighing and removing anchor bias includes taking a complete history, performing a physical exam, and almost always performing a test, such as echocardiogram, to evaluate function and structure.