Synthesizing cardiac examination findings in infants and children with murmurs: Holosystolic murmur at the left lower sternal border

VSD: ventricular septal defect; LV: left ventricle; RV: right ventricle; S2: second heart sound; S3: third heart sound.
* Note that the intensity of the murmur is less helpful in characterizing VSDs than it is in characterizing many other lesions. Loud VSD murmurs (eg, grade 4) can be heard with large defects (due to large amount of left-to-right flow across the defect) and with small restrictive lesions (due to the large systolic pressure gradient between ventricles).
¶ Innocent Still murmur and tricuspid regurgitation can also be heard in this location and can be distinguished from VSD murmurs by the quality and timing of the murmur (VSD murmurs are harsh and holosystolic [although small muscular defects may produce early systolic murmurs]; Still murmur has a vibratory or musical quality and occurs in early systole; the murmur of tricuspid regurgitation has a blowing quality and increases in intensity during inspiration). Other murmurs that may be heard in this location include semilunar valve regurgitation or tricuspid stenosis; however, these produce diastolic murmurs.
Δ Small muscular defects may produce an early systolic murmur rather than a holosystolic murmur.