Means–Lerman scratch

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The Means–Lerman scratch is an uncommon type of heart murmur which occurs in patients with hyperthyroidism. It is a mid-systolic scratching sound best heard over the upper part of the sternum or second left intercostal space at the end of expiration.[1] The murmur results from the rubbing of the pericardium against the pleura in the context of hyperdynamic circulation and tachycardia,[2] and may mimic the sound of a pericardial rub.[3]

The sign was described by J. Lerman M.D. and J. H. Means M.D. of Massachusetts General Hospital in 1932.[4]


  1. ^ Williams, Mark E (2007). "15. The Cardiovascular System". Geriatric physical diagnosis: a guide to observation and assessment (illustrated ed.). McFarland. p. 175. ISBN 978-0-7864-3009-3. 
  2. ^ Recognizing Thyroid Storm in the Neurologically Impaired Patient: Pathophysiology at Medscape
  3. ^ Fadel BM, Ellahham S, Ringel MD, Lindsay J, Wartofsky L, Burman KD (June 2000). "Hyperthyroid heart disease" (PDF). Clin Cardiol. 23 (6): 402–8. doi:10.1002/clc.4960230605. PMID 10875028. 
  4. ^ J. Lerman M.D.; J. H. Means M.D. (October 1932). "Cardiovascular symptomatology in exophthalmic goiter". Am Heart J. 8 (1): 55–65. doi:10.1016/S0002-8703(32)90027-1.