A Few Imp Points:
Pulse , BP and Apex beat should give us idea about the predominant or single valve lesions;
Weak pulse indicates stenotic lesion like MS, AS, Pulmonary stenosis etc, whereas good volume pulse usually indicates Regurgitant lesions like AR,MR unless these Regurgitant lesions are complicated by significant cardiac failure or more than one type of valve lesions are present like AR with MS etc.
BP/Pulse Pressure;
Low BP with narrow pulse pressure usually indicates stenotic lesions like MS, AS or significant heart failure.
Wide pulse pressure favours predominant regurgitation lesions.
Apex Beat;
Displaced Heaving apex best indicates chronic Regurgitant lesions like MR, AR. Whereas un displaced apex beat which is heaving means AS and un displaced apex beat which isn’t heaving usually favours MS.
So MS; weak pulse, low BP and undisplaced apex beat which isn’t heaving. Murmur is MDM which is sometime too faint that you have to search for it at apical area or sometime too loud and prolonged to be confused with MR but doesn’t radiate to axilla.
AS: weak low volume pulse, low BP with narrow pulse pressure and undisplaced HEAVING Apex beat.murmur is ESM which can be all over the precordium or just at aortic area with possible radiation to carotid s. soft A2.
AR: good volume collapsing pulse, wide pulse pressure and displaced heaving apex beat where you have to search for murmur. Peripheral signs are very helpful for AR. EDM which is not very prominent and need to be listened carefully. Absence of silence in diastole is imp clue.
MR: good volume pulse, good pulse pressure and displaced heaving apex beat where murmur is easily heard and pan systolic with usual radiation to axilla. If murmur isn’t radiating to axilla, it is less likely to be MR ( though possible but for exam keep it low). Sometime MS murmur is very loud and confused with MR but MS doesn’t radiate to axilla.
If JVP isn’t elevated or isn’t having prominent V wave, TR isn’t there. TR murmur is best at tricuspid area.
Loud P2 means pulmonary HTN and exclude PS.
VSD; THRILL is important clue here. if no thrill, it is less likely to be uncomplicated VSD. absent thrill would mean either no VSD or the one complicated with Eisenmrnger when murmur gets soft or absent as well. VSD is usually in young patients with thrill across the sternum and pan systolic murmur across the sternum,. VSD can be with or without signs of Pulmonary HTN ( loud P2) or signs Eisenmenger ( loud P2, clubbing and cyanosis). If there is VSD without loud P2 or with soft P2, always suspect TOF.
Suspect Eisenmenger if patient has clubbing with cyanosis and loud P2. When Eisenmrnger develops, underlying murmurs etc disappear due to almost equalisation of right and left pressures. In younger than 40,VSD is more likely. Above 40, ASD is most likely. Differential clubbing will be PDA. TOF is very similar and can be confused with Eisenmenger as clubbing ANC cyanosis are there but there will be no pulmonary HTN ( soft P2 due to PS).
Soft P2 with ESM at pulmonary area means PS, usually with RVH ( left parasternal heave).
Loud P2 with EDM at pulmonary area means secondary PR. Primary PR would have EDM at pulmonary area but soft P2.
Loud P2 is often confused with fixed split of ASD. So carefully listen for split if there is no apparent sign of Pulmonary HTN.
Murmurs which radiate or heard at more than one area are usually left sided murmurs.
Stenosis is almost always chronic whereas regurgitation can be acute (without significant LV dilatation, but usually in cardiogenic shock and not for for exam purpose.) or regurgitation can be chronic ( dilated LV with signs of fluid overload). Acute regurgitation is either traumatic, infective , rheumatic fever or ischemia of papillary muscles ( last one only for MR/TR).