Page 105 - Clinical Pearls in Cardiology

Auscultation of the Precordium 93

13. What are the important characteristics of a functional
murmur?
The important characteristics of a functional murmur
that help to distinguish it from an organic murmur are
the following:
• Usually loudest at the base of the heart (aortic or
pulmonary area)
• Usually are midsystolic in timing
• Usually are soft (up to grade 3)
• Usually do not radiate
• Usually varies with the position of the person (softens
or disappears on standing)
• Usually S2 is well-preserved (normal split and
intensity)
• Usually do not keep ‘bad company’ like abnormal
pulse, abnormal apical impulse or other sounds like
S3, S4, opening snap, ejection clicks, etc.
14. What positions should the patient assume for
accentuating the audibility of various heart sounds
and murmurs?
To accentuate the audibility of sounds and murmurs in
the aortic area, the patient should be in the sitting up
and leaning forward position with his breath held in
expiration. Similarly, for the pulmonary and tricuspid
areas, he should be in the sitting up and leaning forward
position with his breath held in inspiration. For the
mitral area, he should be in the left lateral decubitus
position with his breath held in expiration. All valvular
murmurs, except the murmurs of mitral or tricuspid
stenosis, should be auscultated with the diaphragm of
the stethoscope.