Every doctor, advanced practice nurse, or medical assistant has his or her own approach to listening to the chest. Achieving patient comfort and obtaining a thorough examination are more of an art than a skill. The room certainly must be quiet and the patient at ease to truly appreciate some speciﬁcs of heart murmurs. The murmur must accurately be described in terms of its loudness, site of maximal intensity and timing. Murmurs are graded from 1 to 6
Practically speaking, murmurs are considered either loud or soft because despite the accurate gradation of murmurs there is still controversy. The site of maximal intensity at ﬁrst listen could be misjudged, but with careful reevaluation can be accurately described to help decipher innocent versus pathologic murmurs. Most murmurs are heard along the sternal border. Upper sternal borders can be on the right side or on the left. Lower sternal borders are typically on the left side with variable gradation. Systematic auscultation of all areas of the chest and reassessment are imperative to ﬁnding the maximal intensity of murmurs. The timing of a murmur is also important. All diastolic murmurs are pathologic. However, most murmurs are systolic and can accompany a short period of systole or an entire period of systole. Continuous murmurs despite their name are not heard throughout the entire cardiac cycle. Continuous murmurs start in systole and continue without a pause into diastole.
In addition to the loudness, site of maximal intensity and timing, multiple adjectives can be used to describe some of the classic tones and qualities of heart murmurs. A twangy, musical vibratory murmur that is soft and at the left lower sternal border can almost universally be diagnosed as an innocent Still’s murmur. A harsh machinery continuous murmur at the high left sternal border, subclavicular area is not innocent and consistent with a PDA (patent ductus arteriosus). Most harsh holosystolic murmurs at the lower left sternal border are VSDs (ventricular septal defect). Pediatricians should not be afraid to use multiple adjectives to describe murmurs, as these can be useful for follow-up referrals and cross coverage.
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