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Differentiating between pathologic and innocent (physiologic or functional) murmurs is high yield for the USMLE exam.

Here's a list of features that distinguishes the pathologic murmur:

  • Murmur intensity or quality unchanged with change of position
  • Presence of symptoms such as dyspnea, chest pain, syncope
  • Presence of abnormal S2
  • Any pansystolic murmur
  • Any diastolic murmur (note that murmur throughout systole and diastole can still be physiologic)
  • Any murmur with grade equal to or over III/VI
  • Presence of palpable thrill
 

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Just wanted to add that they usually give some hint about the innocent murmur such as patient having fever or hyperthyroidism
 
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