A patient presents with a systolic murmur. The differential is wide.  Let’s use augmentation maneuvers to narrow the differential diagnosis.


Inspiration – Inspiration was found to increase right-sided heart murmurs with 100% sensitivity and 88% specificity (Lembo, NEJM, 1988).


Transient arterial occlusion by blood pressure cuff inflation increases the regurgitant murmurs of aortic regurgitation, mitral regurgitation, and ventricular septal defect.  Hand grip is sometimes taught for this purpose, but to the extent that it represents exercise, it can increase flow murmurs as well.


Most of the skills in auscultation come from a combination of knowledge and experience.  A good website for learning basic heart sound pathologies is


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