Make a master differentiating table between as ar ps pr ms mr ts tr
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heart murmurs AND auscultation
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Merck Manual cardiac murmurs aortic stenosis mitral regurgitation auscultation table
Master differentiation table: valvular lesions
Abbreviations: AS = aortic stenosis, AR = aortic regurgitation, PS = pulmonary stenosis, PR = pulmonary regurgitation, MS = mitral stenosis, MR = mitral regurgitation, TS = tricuspid stenosis, TR = tricuspid regurgitation.
| Lesion | Timing and murmur | Best heard | Radiation | Key auscultatory clues | Classic peripheral / examination findings |
|---|---|---|---|---|---|
| AS | Harsh ejection systolic, crescendo-decrescendo | Right 2nd intercostal space | Carotids | Soft/absent A2 in severe AS; delayed peak indicates severe obstruction; systolic thrill may be present | Slow-rising, low-volume pulse (pulsus parvus et tardus); narrow pulse pressure; sustained heaving apex |
| AR | High-pitched, blowing early diastolic decrescendo | Left sternal border, 3rd-4th intercostal spaces, sitting forward in end-expiration | Usually none | May have Austin Flint murmur: low-pitched mid-diastolic apical murmur from severe AR | Wide pulse pressure, bounding or collapsing pulse, head bobbing, Quincke nail-bed pulsation; displaced hyperdynamic apex |
| PS | Harsh ejection systolic, crescendo-decrescendo | Left upper sternal border, 2nd intercostal space | Left shoulder / neck, sometimes back | Ejection click that decreases with inspiration; wide split S2 with soft/delayed P2 in severe disease | RV heave; raised JVP if advanced RV failure |
| PR | High-pitched early diastolic decrescendo | Left upper sternal border | Usually none | Graham Steell murmur in pulmonary hypertension: high-pitched PR murmur that becomes louder on inspiration | Signs of pulmonary hypertension or RV failure, such as raised JVP and RV heave |
| MS | Low-pitched rumbling mid-diastolic murmur, often presystolic accentuation if sinus rhythm | Apex, with bell in left lateral position | Localized | Loud S1, opening snap after A2; shorter A2-OS interval suggests more severe MS; presystolic accentuation disappears in AF | Malar flush, tapping apex; AF and pulmonary hypertension features in later disease |
| MR | Blowing pansystolic murmur | Apex | Axilla and sometimes back | Soft S1; may have S3 from volume overload. Acute MR may be early decrescendo rather than pansystolic | Displaced, hyperdynamic apex; pulmonary edema if acute/severe |
| TS | Low-pitched rumbling mid-diastolic murmur | Lower left sternal border / xiphisternum | Localized | Opening snap may occur; murmur increases with inspiration | Raised JVP with prominent a waves, hepatomegaly, ascites, peripheral edema |
| TR | Blowing pansystolic murmur | Lower left sternal border | Right sternal border / epigastrium | Increases with inspiration: Carvallo sign; may have pulsatile liver | Raised JVP with prominent v waves, pulsatile hepatomegaly, ascites, edema |
Quick timing rule
| Systolic murmurs | Diastolic murmurs |
|---|---|
| AS, PS, MR, TR | AR, PR, MS, TS |
| Ejection systolic: AS, PS | Early diastolic: AR, PR |
| Pansystolic: MR, TR | Mid-diastolic: MS, TS |
A diastolic murmur is pathological until proven otherwise. The basic timing distinction between AS/MR in systole and AR/MS in diastole is described in Guyton and Hall Textbook of Medical Physiology under “Heart Murmurs Caused by Valvular Lesions.” The Merck auscultation guide provides supporting descriptions and maneuver effects.
Differentiation by respiration and bedside maneuvers
| Maneuver | Murmurs that become louder | Murmurs that become softer |
|---|---|---|
| Inspiration | Right-sided: PS, PR, TS, TR | Most left-sided murmurs relatively soften |
| Expiration | Left-sided: AS, AR, MS, MR | Right-sided murmurs relatively soften |
| Handgrip - increased afterload | MR, AR; may increase MS flow murmur | AS, PS; also HCM and MVP |
| Standing / strain phase of Valsalva - reduced preload | Most murmurs decrease | AS, AR, MR, MS, PS, PR, TS, TR all generally decrease |
| Squatting / passive leg raise - increased preload and afterload | AS, MR, AR and most flow-dependent murmurs | HCM and MVP become softer / later |
| Release of Valsalva | Right-sided murmurs rise first; left-sided murmurs rise a few beats later | - |
High-yield rule: right-sided lesions increase with inspiration, whereas left-sided lesions are louder during expiration. Handgrip particularly favors regurgitant murmurs, especially MR and AR. This is consistent with the maneuver table in the Merck reference.
Lesion-by-lesion rapid clinical differentiation
| Lesion | Typical cause | Chamber consequences | Main symptoms / complications |
|---|---|---|---|
| AS | Degenerative calcification, bicuspid valve, rheumatic disease | Pressure overload LVH | Exertional angina, syncope, dyspnea; late heart failure |
| AR | Aortic root dilatation, bicuspid valve, endocarditis, rheumatic disease | LV volume overload and eccentric LVH | Palpitations, exertional dyspnea, heart failure; acute AR causes pulmonary edema and shock |
| PS | Usually congenital | RV pressure overload, RVH | Often asymptomatic if mild; exertional dyspnea, syncope, RV failure if severe |
| PR | Pulmonary hypertension, repaired congenital heart disease, endocarditis | RV volume overload | Usually asymptomatic initially; severe PR causes RV failure |
| MS | Usually rheumatic heart disease | LA enlargement, pulmonary venous hypertension, later RV failure | Dyspnea, hemoptysis, AF, systemic embolism, pulmonary hypertension |
| MR | Degenerative prolapse, ischemia/papillary muscle dysfunction, dilated LV, endocarditis | LA and LV volume overload | Dyspnea, fatigue, AF, pulmonary hypertension, heart failure |
| TS | Usually rheumatic, often with MS | RA enlargement and systemic venous congestion | Fatigue, edema, ascites, hepatic congestion, AF |
| TR | Usually functional from RV dilatation/pulmonary hypertension; also endocarditis | RA/RV dilatation, systemic venous congestion | Pulsatile liver, ascites, peripheral edema, fatigue |
One-line memory anchors
- AS: “Ejection systolic to the carotids + slow-rising pulse.”
- AR: “Early blowing diastolic + wide pulse pressure.”
- PS: “Ejection systolic at pulmonary area + inspiration.”
- PR: “Early diastolic at pulmonary area + pulmonary hypertension.”
- MS: “Opening snap + apical rumbling diastolic murmur.”
- MR: “Pansystolic at apex to axilla.”
- TS: “Right-sided MS, rare, raised JVP with giant a waves.”
- TR: “Pansystolic LLSB murmur louder on inspiration + giant v waves.”
Exam caution: real patients can have mixed lesions, atrial fibrillation, pulmonary hypertension, prosthetic valves, or low cardiac output, all of which can alter the expected murmur intensity. Echocardiography confirms valve morphology, severity, chamber response, and pulmonary pressures.
Create a one-page PDF of this valvular lesion table
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Reading File
Browsing Directory
~/
Running Command
mkdir -p "/tmp/workspace/valvular-lesions-pdf/src" "/tmp/workspace/valvular-lesions-pdf/output"
Writing File
~/valvular-lesions-pdf/src/create_valvular_table.py
from reportlab.lib import colors
from reportlab.lib.pagesizes import A4, landscape
from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle
from reportlab.lib.enums import TA_CENTER
from reportlab.lib.units import mm
from reportlab.platypus import SimpleDocTemplate, Table, TableStyle, Paragraph, Spacer, KeepTogether
from reportlab.pdfbase.pdfmetrics import stringWidth
from pypdf import PdfReader
OUT = '/tmp/workspace/valvular-lesions-pdf/output/Valvular_Lesion_Differentiating_Table.pdf'
PAGE = landscape(A4)
W, H = PAGE
M = 9 * mm
styles = getSampleStyleSheet()
title = ParagraphStyle('TitleSmall', parent=styles['Title'], fontName='Helvetica-Bold', fontSize=15, leading=17, alignment=TA_CENTER, textColor=colors.HexColor('#17365D'), spaceAfter=2)
sub = ParagraphStyle('Sub', parent=styles['Normal'], fontName='Helvetica', fontSize=6.8, leading=8.1, alignment=TA_CENTER, textColor=colors.HexColor('#4F4F4F'), spaceAfter=5)
head = ParagraphStyle('Head', parent=styles['Normal'], fontName='Helvetica-Bold', fontSize=6.4, leading=7.3, alignment=TA_CENTER, textColor=colors.white)
cell = ParagraphStyle('Cell', parent=styles['Normal'], fontName='Helvetica', fontSize=6.0, leading=7.05, spaceAfter=0)
lesion = ParagraphStyle('Lesion', parent=cell, fontName='Helvetica-Bold', fontSize=7.0, leading=8.0, textColor=colors.HexColor('#17365D'))
small_head = ParagraphStyle('SmallHead', parent=styles['Normal'], fontName='Helvetica-Bold', fontSize=6.5, leading=7.4, textColor=colors.white, alignment=TA_CENTER)
small = ParagraphStyle('Small', parent=styles['Normal'], fontName='Helvetica', fontSize=6.0, leading=7.0)
foot = ParagraphStyle('Foot', parent=styles['Normal'], fontName='Helvetica-Oblique', fontSize=5.5, leading=6.2, alignment=TA_CENTER, textColor=colors.HexColor('#555555'))
def p(text, style=cell):
return Paragraph(text, style)
rows = [
['Lesion', 'Murmur timing and character', 'Best heard / radiation', 'Key auscultatory clues', 'Clinical findings and associations'],
['<b>AS</b><br/>Aortic stenosis', '<b>Harsh ejection systolic</b><br/>Crescendo-decrescendo', '<b>R 2nd ICS</b><br/>Radiates to carotids', 'Soft or absent A2; late peaking suggests severe disease; systolic thrill', '<b>Pulsus parvus et tardus</b>, narrow pulse pressure, heaving apex<br/>Degenerative, bicuspid, rheumatic'],
['<b>AR</b><br/>Aortic regurgitation', '<b>High-pitched early diastolic</b><br/>Blowing decrescendo', '<b>L sternal edge</b>, 3rd-4th ICS<br/>Sitting forward, end-expiration', 'Austin Flint murmur at apex in severe AR', '<b>Wide pulse pressure</b>, collapsing pulse, displaced hyperdynamic apex<br/>Aortic-root disease, endocarditis'],
['<b>PS</b><br/>Pulmonary stenosis', '<b>Harsh ejection systolic</b><br/>Crescendo-decrescendo', '<b>L upper sternal border</b><br/>May radiate to left shoulder/back', 'Ejection click decreases with inspiration; wide split S2, soft/delayed P2', 'RV heave; raised JVP if advanced<br/>Usually congenital'],
['<b>PR</b><br/>Pulmonary regurgitation', '<b>Early diastolic</b><br/>High-pitched decrescendo', '<b>L upper sternal border</b>', 'Graham Steell murmur in pulmonary hypertension; louder with inspiration', 'Pulmonary hypertension or RV failure signs<br/>Often secondary to pulmonary hypertension'],
['<b>MS</b><br/>Mitral stenosis', '<b>Low-pitched mid-diastolic</b><br/>Rumbling; presystolic accentuation in sinus rhythm', '<b>Apex</b>, bell<br/>Left lateral position', '<b>Loud S1 + opening snap</b>; shorter A2-OS interval = more severe; accentuation lost in AF', 'Malar flush, tapping apex<br/>AF, embolism, pulmonary hypertension<br/>Usually rheumatic'],
['<b>MR</b><br/>Mitral regurgitation', '<b>Blowing pansystolic</b>', '<b>Apex</b><br/>Radiates to axilla', 'Soft S1; S3 with volume overload; acute MR may be early decrescendo', 'Displaced hyperdynamic apex; pulmonary edema if acute<br/>MVP, ischemia, dilated LV, endocarditis'],
['<b>TS</b><br/>Tricuspid stenosis', '<b>Low-pitched mid-diastolic</b><br/>Rumbling', '<b>Lower L sternal border</b> / xiphisternum', 'May have opening snap; <b>increases with inspiration</b>', 'Raised JVP with giant <b>a</b> waves, hepatomegaly, ascites, edema<br/>Often rheumatic'],
['<b>TR</b><br/>Tricuspid regurgitation', '<b>Blowing pansystolic</b>', '<b>Lower L sternal border</b>', '<b>Carvallo sign:</b> louder with inspiration', 'Raised JVP with giant <b>v</b> waves, pulsatile liver, ascites, edema<br/>Often functional from RV dilatation'],
]
data = [[p(x, head) for x in rows[0]]]
for r in rows[1:]:
data.append([p(r[0], lesion)] + [p(x) for x in r[1:]])
main = Table(data, colWidths=[27*mm, 50*mm, 49*mm, 65*mm, 76*mm], repeatRows=1)
main.setStyle(TableStyle([
('BACKGROUND',(0,0),(-1,0),colors.HexColor('#17365D')),
('GRID',(0,0),(-1,-1),0.28,colors.HexColor('#B9C7D8')),
('VALIGN',(0,0),(-1,-1),'MIDDLE'),
('LEFTPADDING',(0,0),(-1,-1),2.5),('RIGHTPADDING',(0,0),(-1,-1),2.5),
('TOPPADDING',(0,0),(-1,-1),2.2),('BOTTOMPADDING',(0,0),(-1,-1),2.2),
('BACKGROUND',(0,1),(-1,-1),colors.white),
('ROWBACKGROUNDS',(0,1),(-1,-1),[colors.white,colors.HexColor('#F2F6FA')]),
]))
man = [
[p('Maneuver', small_head), p('Murmur response', small_head)],
[p('<b>Inspiration</b>', small), p('<b>Right-sided</b> murmurs increase: PS, PR, TS, TR.', small)],
[p('<b>Expiration</b>', small), p('<b>Left-sided</b> murmurs become more apparent: AS, AR, MS, MR.', small)],
[p('<b>Handgrip</b>', small), p('<b>Increases MR and AR</b>; decreases AS and PS.', small)],
[p('<b>Standing / Valsalva strain</b>', small), p('Decreases most murmurs. (Exception outside this table: HCM increases; MVP click occurs earlier.)', small)],
]
man_tbl = Table(man, colWidths=[49*mm, 218*mm])
man_tbl.setStyle(TableStyle([
('BACKGROUND',(0,0),(-1,0),colors.HexColor('#2F6B82')),
('GRID',(0,0),(-1,-1),0.28,colors.HexColor('#B9C7D8')),
('VALIGN',(0,0),(-1,-1),'MIDDLE'),
('ROWBACKGROUNDS',(0,1),(-1,-1),[colors.HexColor('#EDF5F7'), colors.white]),
('LEFTPADDING',(0,0),(-1,-1),3),('RIGHTPADDING',(0,0),(-1,-1),3),
('TOPPADDING',(0,0),(-1,-1),1.8),('BOTTOMPADDING',(0,0),(-1,-1),1.8),
]))
memory = Table([[p('<b>Fast pattern:</b> systolic = AS, PS, MR, TR. Diastolic = AR, PR, MS, TS. Ejection systolic = AS/PS. Pansystolic = MR/TR. Early diastolic = AR/PR. Mid-diastolic = MS/TS.', foot)]], colWidths=[267*mm])
memory.setStyle(TableStyle([('BACKGROUND',(0,0),(-1,-1),colors.HexColor('#FFF4D6')),('BOX',(0,0),(-1,-1),0.3,colors.HexColor('#E3C875')),('LEFTPADDING',(0,0),(-1,-1),3),('RIGHTPADDING',(0,0),(-1,-1),3),('TOPPADDING',(0,0),(-1,-1),2),('BOTTOMPADDING',(0,0),(-1,-1),2)]))
doc = SimpleDocTemplate(OUT, pagesize=PAGE, leftMargin=M, rightMargin=M, topMargin=7*mm, bottomMargin=7*mm, title='Valvular Lesion Differentiating Table', author='Orris')
story = [Paragraph('VALVULAR LESIONS: MASTER DIFFERENTIATING TABLE', title), Paragraph('Auscultation, key signs, and bedside maneuvers', sub), main, Spacer(1, 3.5*mm), man_tbl, Spacer(1, 2.3*mm), memory]
doc.build(story)
reader = PdfReader(OUT)
assert len(reader.pages) == 1, f'Expected 1 page, got {len(reader.pages)}'
text = reader.pages[0].extract_text()
assert 'VALVULAR LESIONS' in text and 'Carvallo' in text
print(f'Created {OUT} | pages={len(reader.pages)} | bytes={__import__("os").path.getsize(OUT)}')
Running Command
python "/tmp/workspace/valvular-lesions-pdf/src/create_valvular_table.py" && python -c "from pypdf import PdfReader; p='/tmp/workspace/valvular-lesions-pdf/output/Valvular_Lesion_Differentiating_Table.pdf'; r=PdfReader(p); print('verified_pages=',len(r.pages)); print('page_size=',float(r.pages[0].mediabox.width),float(r.pages[0].mediabox.height))"
Valvular Lesion Differentiating Table
PDF Document · PDF
Create a one-page PDF of this valvular lesion table
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Valvular Lesion Differentiating Table
PDF Document · PDF
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