Murmur

Description

Location

• Aortic valve: second intercostal space at the right sternal border
• Pulmonary valve: second intercostal space at the left sternal border
• Tricuspid valve: fourth intercostal space at the left sternal border
• Mitral valve: fifth intercostal space at the left midclavicular line
• Radiation: Murmurs may radiate, allowing auscultation at remote locations

Intensity

Grade	Description
Grade 1	Faintest sound that can be detected
Grade 2	Soft murmur that is readily detectable
Grade 3	Louder than grade 2 but not associated with a palpable thrill
Grade 4	Associated with a palpable thrill
Grade 5	Audible with stethoscope placed lightly on the chest
Grade 6	Audible with stethoscope off the chest

Quality

• High or low frequency
• Blowing, harsh, musical, rumbling, squeaky

Profile

• Crescendo, decrescendo, crescendo-decrescendo, or plateau

Timing

• Systolic, diastolic
• Early, mid, or late
• Holosystolic

Interpretation

Valvulopathy	Location	Radiation	Timing	Quality	Profile	Inspiration	Isometric Handgrip (↑ Afterload)	Squatting (↑ Preload)	Valsalva (↓ Preload)	Release Valsalva
Flow murmur			mid-systolic
Aortic regurgitation	LLSB		diastolic	blowing	D	↓	↑	↑		↑
Aortic regurgitation, Austin Flint	PMI		mid-diastolic	rumble
Aortic stenosis	RUSB	±carotids	systolic		C-D	↓		↑	↓	↑
Mitral regurgitation	PMI	±axillae	systolic			↓	↑	↑	↓
Mitral valve prolapse			early systolic	click		↓	↓	↓	↑
Mitral stenosis	PMI		diastolic			↓		↑	↓
Pulmonic regurgitation						↑				↑
Pulmonic stenosis	LUSB		systolic		C-D	↑				↑
Tricuspid regurgitation	LLSB		systolic			↑
Tricuspid stenosis	LLSB		diastolic			↑			↓	↓
Atrial septal defect	LUSB			may be harsh; fixed split S2
Ventricular septal defect	PMI						↑		↓
Hypertrophic obstructive cardiomyopathy	PMI to LLSB		systolic				↓	↓	↑
Patent ductus arteriosus	LUSB		continuous	machine-like