Generate a flowchart for examination of patient for heart murmurs

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Here is a comprehensive two-part answer: the original Harrison's flowchart and an enhanced generated version covering the full examination approach.

Approach to Examination of a Patient with Heart Murmur

Official Diagnostic Flowchart (Harrison's Principles of Internal Medicine, 22nd Ed.)

Figure 243-1 — Approach to the evaluation of a heart murmur. (Harrison's, 2025)

Enhanced Clinical Flowchart

Examination of a Patient with Heart Murmur — full flowchart

Key Clinical Framework

Step 1 — Characterize the Murmur

Assess all of the following attributes at auscultation:

Attribute	What to Assess
Timing	Systolic, diastolic, or continuous
Duration	Ejection (crescendo-decrescendo), holosystolic, early/mid/late
Intensity	Grade I–VI (Levine scale)
Quality	Harsh, blowing, rumbling, musical
Frequency	High, medium, low pitched
Location	Apex, LLSB, RUSB, LUSB
Radiation	Axilla (MR), carotids (AS), back (PR/AS)

Step 2 — Systolic vs. Diastolic/Continuous

Systolic Murmur:

Grade I–II, midsystolic in an asymptomatic child or young adult with no other cardiac findings → likely benign (innocent) → ECG + CXR; if normal, no further workup needed
Grade ≥III, holosystolic, or late systolic → Echocardiography indicated
Any systolic murmur with other signs/symptoms of cardiac disease (dyspnea, syncope, chest pain, thrills, abnormal S2) → Echocardiography
Abnormal ECG or CXR → Echocardiography → Cardiology referral

Diastolic or Continuous Murmur:

Always pathological — Echocardiography indicated in all cases → Cardiology consult

Step 3 — Dynamic Auscultation Maneuvers

Maneuver	Effect	Interpretation
Inspiration	↑ right-sided murmurs	Tricuspid/pulmonary lesions louder
Valsalva (strain)	↓ most murmurs; ↑ MVP & HOCM	Identifies MVP, HOCM
Squatting	↑ preload/afterload → MVP click moves later	HOCM murmur softer
Rapid standing	↓ preload → MVP click moves earlier	HOCM murmur louder
Hand grip	↑ LV afterload → ↑ MR, VSD, AR	Distinguishes MR from AS
Post-PVC beat	↑ AS murmur, no change in MR	Gallavardin differentiation

Step 4 — Grading (Levine Scale)

Grade	Description
I	Barely audible, requires concentration
II	Soft but easily heard
III	Moderately loud, no thrill
IV	Loud + thrill present
V	Very loud, heard with stethoscope partially off chest
VI	Audible without stethoscope

A murmur accompanied by a thrill = Grade IV or higher and is always pathological.

Sources: Harrison's Principles of Internal Medicine, 22nd Ed. (2025), Chapter 243 & 246; Medical Physiology (Boron & Boulpaep)

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