So, you know, thinking about the physical exam and how you as a cardiologist use your stethoscope, I was wondering if you could walk us through your exam and then point out some of the characteristics that might help distinguish an innocent murmur f- from a pathologic one.

Definitely.

So as I'm, as I'm putting the stethoscope on the chest and listening to the murmur, I'm trying to picture the murmur in my head.

I'm, I'm listening to the first and second heart sounds, S1 being the closure of those atrioventricular valves, the AV valves between the top and bottom chambers of the heart, and at the same time, the opening of the semilunar valves, the aortic and pulmonary valves going out, uh, to the body and the, and the lungs.

So S1 is the start of the systolic phase, and S2, that's the end of systolic phase, when those semilunar valves, uh, snap shut and the atrioventricular valves open up.

So as I'm listening, I'm trying to determine, first of all, where am I hearing this murmur? Am I hearing it at the right upper sternal border, which might be closer to the aortic valve, or the left upper sternal bor- border, which might be closer to the pulmonary valve? Am I hearing it at the left lower sternal border, close to the tricuspid valve, or, or out near the apex, where it might be closer to the mitral valve? Uh, in addition to the location on the chest, I'm listening to wit- what is the timing? Where in the cardiac cycle is this murmur happening? Is it during that systolic phase between S1 and S2, or is it between S2 and S1? That can be a challenge for some, uh, for some folks trying to determine which part of the cardiac cycle they're hearing the sound.

So, uh, you can put your finger on a pulse and feel the pulsation, and that will tell you during the pulse, that's the systolic phase.

So how often are patients getting echocardiograms when, for a murmur evaluation? Is that pretty standard, uh, s- is that standard of care in 2026?