Describe Any Murmurs Present

If a murmur is present, attention should be directed to the following features:

Timing in the cardiac cycle Location

• Radiation Duration Intensity Pitch

# Quality

Relationship to respiration Relationship to body position

Timing of murmurs as to systole and diastole is paramount. Does the systolic murmur begin with, or after, S1? Does it end before, with, or after S2? Does the murmur occupy the entire systolic period? Murmurs occurring throughout systole are termed holosystolic or pansystolic. These murmurs begin with S1 and end after S2. A systolic ejection murmur begins after S1 and ends before S2. Does the murmur occur only in early systole, midsystole, or late systole? Does

Table 14-7 Approach to Cardiac Auscultation




51 in all areas

52 in all areas

Systolic murmurs or sounds in all areas

Left lateral decubitus

Diastolic events at apex with bell of stethoscope


51 in all areas

52 in all areas

Systolic murmurs or sounds in all areas Diastolic murmurs or sounds in all areas

Upright, leaning forward Diastolic events at base with diaphragm of stethoscope the murmur persist throughout the entire diastolic period? Such murmurs are termed holodiastolic.

In which area is the murmur best heard?

The radiation of the murmur can provide a clue as to its cause. Does it radiate to the axilla? the neck? the back?

The intensity of a murmur is graded from I to VI, based on increasing loudness. The following grading system, although antiquated, serves as a means of communicating the intensity of the murmur:

I: Lowest intensity, often not heard by inexperienced listeners II: Low intensity, usually audible by inexperienced listeners III: Medium intensity without a thrill IV: Medium intensity with a thrill

V: Loudest murmur that is audible when the stethoscope is placed on the chest; associated with a thrill VI: Loudest intensity: audible when stethoscope is removed from chest; associated with a thrill

Murmurs can be described, for example, as ''grade II/VI," ''grade IV/VI,'' or ''grade II-III/ VI.'' Any murmur associated with a thrill must be at least a grade IV/VI. A grade IV/VI murmur is louder than a grade II/VI murmur only because there is more turbulence; both or neither may have clinical significance. The ''/VI'' is used because there is another, less popular, grading system involving only four categories. An important axiom to remember is the following:

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