Differential Diagnosis for a Low-Pitched, Rough, Rasping Murmur at the Right Second Intercostal Space

• Single Most Likely Diagnosis
  • Aortic stenosis: This condition is characterized by the narrowing of the aortic valve opening, which can cause a low-pitched, rough, rasping murmur heard at the right second intercostal space. The murmur is typically most intense at the point of maximal impulse and may radiate to the carotid arteries.
• Other Likely Diagnoses
  • Hypertrophic cardiomyopathy: Although more commonly associated with a murmur best heard at the left sternal border, hypertrophic cardiomyopathy can sometimes produce a murmur similar to aortic stenosis, especially if there is significant outflow tract obstruction.
  • Aortic sclerosis: This condition involves thickening or calcification of the aortic valve without significant stenosis. It can produce a similar murmur to aortic stenosis but is generally less intense.
• Do Not Miss Diagnoses
  • Aortic dissection: Although the primary presentation of an aortic dissection is severe, tearing chest pain, a new murmur due to involvement of the aortic valve or disruption of the aortic root can occur. Missing this diagnosis can be fatal.
  • Endocarditis: Infective endocarditis can cause valve dysfunction leading to new murmurs. The presence of fever, embolic phenomena, or other systemic signs of infection should raise suspicion for this condition.
• Rare Diagnoses
  • Subvalvular aortic stenosis: A congenital condition where the narrowing is below the aortic valve. It's less common than valvular aortic stenosis and might present similarly.
  • Supravalvular aortic stenosis: A rare congenital condition where the narrowing is above the aortic valve. It can present with a similar murmur but is much less common than other forms of aortic stenosis.