1

UKRAINIAN MINISTRY OF PUBLIC HEALTH

Vinnytsya National Medical University n.a. M.I. Pyrogov

«APPROVED»
At the methodological meeting of the internal
medicine propedeutics department
Chief of the department
____________ prof. Mostovoy Y.M.
«______»_______________ 2017 y.

Guidelines
for Third-year Students of the Medical Department

Subject Propedeutics of internal medicine

Module № 1
Enclosure module № 1
Topic Auscultation of the heart:heart murmurs
Course 3
Faculty Medical № 1

Methodical recommendations are made in accordance with educationally-qualifying descriptions

and educationally-professional programs of preparation of the specialists ratified by Order MES of
Ukraine from 16.05 2003 years № 239 and experimentally - curriculum, that is developed on
principles of the European credit-transfer system (ECTS) and Ukraine ratified by the order of MPH
of Ukraine from 31.01.2005 year № 52.

Vinnytsya – 2017
 2

1/\. Importance of the topic

Auscultation of a heart is the most valuable method of its analyses. With the help of
auscultation one can diagnose pathologic rates of a heart’s activity and give a diagnostic assessment
of a clinical pattern of a disease. Murmurs usually appear at the different pathologic conditions that
can be related with heart and blood circulation. Revealing murmurs and distinguishing their reasons
have a great diagnostic importance.

2. Concrete aims:
- Study of classification of the cardiac murmurs
- Study characteristics of the systolic murmurs in different clinic situation
- Study characteristics of the diastolic murmurs in different clinic situation
- Study feature and causes of functional cardiac murmurs
- Study feature and causes of pleuropericardial and pericardial friction rubs
3. Basic training level

Previous subject Obtained skill

Normal anatomy Anatomy of the heart and vessels
Normal physiology Mechanics of heart working and blood circulation
Histology Ontogenesis of the cardiovascular system, histological structure of the
heart and vessels
Biomedical physics Principles of liquid flow in a tube

4. Task for self-depending preparation to practical training

4.1. List of the main terms that should know student preparing practical training

Diastolic murmur Mitral stenosis

Systolic murmur Aortic stenosis
Functional murmur Mitral regurgitation
Pericardial friction rub Aortic regurgitation

4.2.Theoretical questions:
1. Definition and physical base of murmur appearance.
2. Classification of cardiac murmurs.
3. Systolic cardiac murmurs, their characteristics at the different clinical situation.
4. Diastolic cardiac murmurs, their characteristics at the different clinical situation.
5. Functional cardiac murmurs, their characteristics at the different clinical situation.
6. How functional cardiac murmurs can be distinguished from organic?
7. Pericardial friction rub, its characteristics and causes.
8. Pleuropericardial friction rub, its characteristics and causes.

4.3. Practical task that should be performed during practical training

1. Auscultation of the heart
2. Auscultation of the heart in a norm and pathology.
3. Auscultation of the cardiac murmur.
4. Assessment of the heart auscultation

5. Topic content
Cardiac murmurs
In addition to the normal heart sounds, abnormal sounds known as murmurs may be heard in
auscultation. Cardiac murmurs may both endocardiac and exocardiac. Endocardiac murmurs occur
 3

in dysfunction of the intact valves - functional murmurs or in anatomical changes in the structure of
the heart valves - organic murmurs.
Organic cardiac murmurs.
When a valve is stenotic or damaged, the abnormal turbulent flow of blood produces a
murmur, which can be heard during the normally quiet times of systole or diastole.
The mechanisms of cardiac murmurs can be explained by the physics laws concerning the
flow of liquids in tubes.
Such condition as liquid flowing through a partially narrowed portion of the tube can cause
turbulent flow. The intensity of noise depends on the extent of narrowing: the narrower lumen of
the tube, the more intense noise. In significant narrowing of the tube, noise may weaken or even
disappears. Liquid flowing from a smaller portion of the tube to a larger one can also cause vortex
movement. Murmur can be caused by blood flow in the vascular lumen partially obstructed by
atherosclerotic plaque or thrombus.
Following characteristics used to describe cardiac murmurs are timing, intensity, pitch,
quality, configuration, duration, location and radiation.
Murmurs are defined in terms of their timing within the cardiac cycle.
Systolic murmur terminates between S1 and S2 or begins instead of significantly decreased
S1.
Diastolic murmur begins with or after S2 and terminates at or before the subsequent S1.
The intensity of the murmurs is graded according to the Levine scale:
• Grade I - Lowest intensity, difficult to hear even by expert listeners
• Grade II - Low intensity, but usually audible by all listeners
• Grade III - Medium intensity, easy to hear even be inexperienced listeners, but without a
palpable thrill
• Grade IV - Medium intensity with a palpable thrill
• Grade V - Loud intensity with a palpable thrill. Audible even with the stethoscope
placed on the chest with the edge of the diaphragm
• Grade VI - Loudest intensity with a palpable thrill. Audible even with stethoscope raised
above the chest.
A cardiac murmur's pitch varies from high to low.
Common descriptive terms of a murmur's quality include rumbling, blowing, machinery,
scratchy, harsh, rough, squeaky, or musical.
The configuration of murmur is defined by changes in their intensity during systole and
diastole as recorded on a phonocardiogram.
A decrescendo murmur gradually decreases in intensity, a crescendo murmur gradually
increases in intensity, a crescendo-decrescendo murmur (a diamond-shaped) first increases in
intensity, and then decreases in intensity, and a plateau murmur is equal in intensity throughout the
murmur.
A murmur's duration can be of different length.
Location. Cardiac murmurs may not be not audible over all areas of the chest, and it is
important to note where it is heard best and where it radiate to. The location on the chest wall where
the murmur is best heard and the areas to which it radiates can be helpful in identifying the cardiac
structure from which the murmur originates.

Best auscultatory areas of a cardiac murmurs. Topographic classification of murmurs.

Auscultatory areas Murmur Heart valvular disease
Heart apex Systolic Mitral regurgitation
Diastolic Mitral stenosis
Second intercostal Systolic Aortic stenosis
space at the right Diastolic Aortic regurgitation
sternal edge
 4

Second intercostal Systolic Pulmonary stenosis

space at the left sternal Diastolic Pulmonary regurgitation
edge
Base of the ziphoid Systolic Tricuspid regurgitation
Diastolic Tricuspid stenosis
Radiation. Some cardiac murmurs may be heard not only in standard auscultatory areas but
also transmitted in the direction of blood flow. This phenomenon is known as radiation.
Murmurs radiate in either a forward (ejection murmurs) or backward direction
(regurgitation murmurs).

Auscultatory areas and radiation of murmurs in heart valvular diseases.

Heart valvular Auscultatory
Murmur Radiation areas
disease areas
Mitral Systolic Heart apex Axillary region
regurgitation
Mitral stenosis Diastolic Heart apex No radiation
Aortic Diastolic Second intercostals Botkin-Erb's
regurgitation space at the right point, sometimes
sternal edge heart apex
Aortic stenosis Systolic Second intercostal Subclavian,
space at the right carotid arteries,
sternal edge interscapular
region
SYSTOLIC MURMURS
Aortic stenosis.
One of the most frequent pathologic systolic murmurs is due to aortic stenosis. The murmur
of aortic stenosis heard best over "aortic area", second intercostal space along right sterna border,
with radiation into the neck, along carotid arteries, into the interscapular region (ejection murmur).
The intensity of murmur varies directly with the cardiac output. It has a harsh quality, are usually
crescendo-decrescendo in configuration (as the velocity of ejection increases, the murmur gets
stronger, and as ejection declines, its diminished), is typically midsystolic murmur (starts shortly
after S1, when the left ventricular pressure becomes enough to open aortic valve; ends before left
ventricular pressure falls enough to permit closure of the aortic leaflets).
Pulmonary stenosis.
The murmur of pulmonary stenosis is heard best in the "pulmonic area", second intercostal
space along the left sternal border. The murmur can be heard radiating into the neck or the back
(ejection murmur), has a harsh quality, a crescendo-decrescendo shape, and midsystolic duration.

Mitral regurgitation.
Systolic murmur in mitral regurgitation is best heard at the heart apex, with radiation into
the axilla (regurgitant murmur). The quality of murmur is usually described as blowing, frequency -
as high-pitched, the configuration of murmur may vary considerably, and its duration is
holosystolic.
Tricuspid regurgitation.
The holosystolic murmur of tricuspid regurgitation is best heard at the base of the sternum,
generally softer than that of mitral regurgitation, and frequently increases during inspiration.
DIASTOLIC MURMURS
Aortic regurgitation.
The murmur of aortic regurgitation best heard in the second intercostal space along left
sternal edge, it widely radiates along the left sternal border (Botkin-Erb's point) and to be well
transmitted to the heart apex (regurgitant murmur). This murmur is usually characterized as
blowing, generally high-pitched, decrescendo (since there is progressive decline in the volume of
 5

regurgitationduring diastole), and early diastolic murmur. In severe regurgitation, it may be

holodiastolic. The soft, rumbling, low-pitched, mid- to late diastolic murmur at the heart apex
(Austin Flint murmur) may be detected in severe aortic regurgitation. It is thought to be due to a
functional mitral stenosis, as the backflow blood from the aorta presses on the mitral valve, slightly
occluding the flow from the left atrium.
Pulmonary regurgitation.
The murmur of pulmonary regurgitation is best heard in the second intercostal space to the
left of the sternum, with radiation along left sternal edge (regurgitant murmur), high-pitched,
decrescendo, early diastolic murmur. The diastolic murmur of pulmonary regurgitation without
pulmonary hypertension is softer, and low- to medium-pitched.
In mitral stenosis functional early diastolic, high-pitched, with a decrescendo quality
murmur is heard over the pulmonic area. This murmur, known as Graham Steel murmur, begins
with accentuated S2, and is caused by dilation of the pulmonary artery due to significant pulmonary
hypertension.
Mitral stenosis.
The murmur of mitral stenosis is best heard at the heart apex with a little radiation. It is
usually described as low-pitched, rumbling, characteristically follows OS, and can be heard best
with the patient in the left lateral decubitus position. The murmur is nearly holodiastolic with
presystolic accentuation, or presystolic crescendo, or early diastolic (protodiastolic) decrescendo.
Tricuspid stenosis.
The diastolic murmur associated with tricuspid stenosis is localized to a relatively limited
area over the ziphoid, low-pitched, rumbling, and like most right-sided events, may be stronger
during inspiration.
Extracardiac murmurs: pleuropericardial friction rub and pericardial friction rub
Pericardial friction rub may be heard when the pericardial sac becomes inflamed. The
surface of pericardium becomes shaggy due to fibrin over its.
Pericardial friction rub is heard:
1. Dry pericarditis
2. At the beginning or at the end of exudative pericarditis
3. Uremia
4. Myocardial infarction (Dressler syndrome)
5. Polyserositis (autoimmunity diseases)

Signs of pericardial friction rub

1. Is heard during systole and diastole
2. Character – may be soft or rough, like snow crunches
3. The best place for listening – area of absolute dullness of heart
4. Not radiation
5. Increases if patient band front or if the funeral of the stethoscope is pressed to the
chest
Pleuropericardial friction rub may be heard when the pleura near the heart is inflamed.

Signs of the pleuropericardial friction rub:

1. Associated with breathing
2. Increases during deep inspiration
3. The best place for listening is the left edge of the relative cardiac dullness

6. MATERIALS FOR SELF-CONTROL

TESTS
1. What heart diseases listed below can you find organic systolic cardiac murmurs at?
A. mitral stenosis
B. *Aortic stenosis
 6

C. Aortic regurgitation
D. Pulmonary regurgitation
E. Tricuspid stenosis
2. What heart diseases listed below can you find organic diastolic cardiac murmurs at?
A. *Stenosis of mitral foramen
B. Stenosis of orifice of aorta
C. Mitral valve deficiency
D. Stenosis of lung arteries orifice
E. Threecaspid valve deficiency
3. The best point for hearing the systolic murmurs at aortic stenosis is
A. The heart apex
B. The Botkin – Erb point
C. *The second intercostal space, to the right from the breastbone
D. The second intercostal space, to the left from the breastbone
E. On the middle of the breastbone on the level of third rib
4. The best point for hearing the diastolic murmurs at aortic regurgitation is
A. The heart apex
B. The Botkin – Erb point
C. *The second intercostal space, to the right from the breastbone
D. The second intercostal space, to the left from the breastbone
E. On the middle of the breastbone on the level of third rib
5. Anaemic functional murmur is more often:
A. *Systolic
B. Diastolic
C. Protodiastolic
D. Presystolic
E. Systola-diastolic
6. Anaemic murmur is heard better
A. *Above the lung artery
B. At Bodkin’s point
C. Above all valve orifices
D. On the apex of the heart
E. Above the aorta
7. Haemodinamical functional murmurs can be auscultated at
A. *Thyrotoxicosis
B. Mitral stenosis
C. Myocarditis
D. Cardiosclerosis
E. Hypertension disease
8. How is functional systolic murmur differed from organic one?
A. It is not ruled by periods of breathing
B. Loud, harsh, prolonged
C. Do not change during exercises
D. *Do not have irradiative zones
E. Often supported by feeling of systolic “cat purr”
9. The pericardial friction rub is better heard
A. On the heart apex
B. on the Botkin-Erb point
C. *Above the absolute heart’s dullness zone
D. On heart’s base
E. Near the xiphoid process
10. The pericardial friction rub usually appears at
A. *Uremia
 7

B. Hydropericardium
C. Cardiomegaly
D. Angina pectoris
E. Adhesion of pericardium and pleura
11. The pericardial friction rub differs from organic murmurs in that it is
A. More delicate
B. Heard like far away
C. *Heard near the ear
D. Always coincide with systole
E. Well radiate to other auscultatic zones
12. The pericardial friction rub differs from organic in that it is
A. Become stronger during pressing the chest
B. *Becomes weaker if patient bends forward
C. Heard above zones, projections and places of the best auscultation of heart’s vavles
D. Do not coincidance with cardiac periods
E. Never gives tactile sings
13. The pericardial friction rub differs from organic in that it is
A. Never gives any tactile fillings
B. *Becomes stronger if patient bends forward
C. Coincidance with systola and diastola
D. Well irradiate to other auscultatic zones
E. Loud
14. Which organic murmur gives the filling of “cat purr” on the heart apex?
A. Systolic murmur of mitral regurgitation
B. *Diastolic murmur of mitral stenosis
C. Systolic murmur of aortic stenosis
D. Diastolic murmur of aortic regurgitation
E. Systolic murmur of tricuspid regurgitation
15 Which organic murmur gives the filling of “cat purr” in the second intercostal space right
from the breastbone?
A. Systolic murmur of mitral regurgitation
B. Diastolic murmur of mitral stenosis
C. *Systolic murmur of aortic stenosis
D. Diastolic murmur of aortic regurgitation
E. Systolic murmur of tricuspid regurgitation
16. Which cardiac murmur gives tactile filling above absolute cardiac dullness that becomes
stronger while bending the body forward?
A. Systolic murmur of mitral regurgitation
B. Diastolic murmur of mitral stenosis
C. Systolic murmur of aortic stenosis
D. Diastolic murmur of aortic regurgitation
E. *Systole-diastolic pericardial friction rub.
17. Which functional murmur can be heard at aortic regurgitation?
A. Systolic hydremic
B. Systolic hemodynamic
C. *Flint’s murmur
D. Coombs’ murmur
E. Graham-Steel murmur
18. Systolic murmur of aortic stenosis irradiates
A. To the heart apex and to Botkin’s point
B. To the left axillary region
C. To the second left intercostal space
D. To the area of xiphoid process
 8

E. *To the carotid and subclavical arteries

19. What are the reasons for Flint’s murmur in aorta valve deficiency
A. Relative mitral regurgitation
B. *Relative mitral stenosis
C. Relative aortic stenosis
D. Relative tricuspid regurgitation
E. Relative pulmonary stenosis
20. Which functional murmur can be heard at mitral stenosis?
A. Systolic hydremic
B. Systolic hemodynamic
C. Systolic muscular
D. Kumbs’ murmur
E. *Graham-Steel murmur

Situation tasks
Situation task 1. The boy, 16 years old, has short systolic murmur above the lung artery, which don’t
irradiate. Heart’s tones don’t change
1. Are such processes typical for organic or functional murmur?
2. What process helps to find the difference in organic and functional murmurs?
3. What conditions promote the formation of functional murmur?

Situation task 2. During the auscultation of the patient it was found that, the first tone is weaken
and the sharp systolic murmur which irradiates to the arteries of neck is heard in the second
intercostal space to the right from breast-bone
1. During what heart disease such systolic murmur is heard?
2. What is the mechanism of its origin?
3. What symptoms during palpation this patient have?

Situation task 3. During the patient’s auscultation the louder firs tone and presystolic murmur is
heard above the top of the heart
1. For which pathology this murmur is typical?
2. How to explain its origin?
3. Does this murmur irradiate?

Situation task 4. During the auscultation of the heart the murmur which takes systole and diastole
is heard in the fourth intercostal space to the right from the breast-bone
1. How is it named
2. For which pathology this murmur is typical?
3. What are the typical features of this murmur?

Control questions:
1. Definition and physical base of murmur appearance.
2. Classification of cardiac murmurs.
3. Systolic cardiac murmurs, their characteristics at the different clinical situation.
4. Diastolic cardiac murmurs, their characteristics at the different clinical situation.
5. Functional cardiac murmurs, their characteristics at the different clinical situation.
6. How functional cardiac murmurs can be distinguished from organic?
7. Pericardial friction rub, its characteristics and causes.
8. Pleuropericardial friction rub, its characteristics and causes.

Practical task
1. Auscultation of the heart
 9

2. Auscultation of the heart in a norm and pathology.

3. Auscultation of the cardiac murmur.
4. Assessment of the heart auscultation

7. Reference source
 Olga Kovalyova, Tetyana Ashcheulova Propedeutics to internal medicine, Part 1. –
Vinnytsya: NOVA KNYHA, 2006. – p. 200-208.
 V. Vasilenko, A. Grebenev. Internal disease. An Introductory Course. – English translation,
Mir Publishers. – Moscow, 1987 – P. 215-220.
 Barbara Bates. A guide to Physical Examination and History Taking. – J. B. Lippincott
Company, Philadelphia, 1995. – P. 265-266, 300-313.
 Oxford Handbook of Clinical Medicine. –6th edition / Murray Longmore, Ian B. Wilkinson,
Supraj Rajagopalan. – OXFORD University Press, 2004. – P. 92-94.
 V.T. Ivashkin, A.V. Okhlobystin Internal Diseases Propedeutics. – M: ГЕОТАР – Медіа,
2014. –p. 176 (Chapter II).
 Harrison’s principles of internal medicine.-.16th ed.- McGraw-Hill, Medical Publishing
Division, 2005. – Vol. 2. - P. 1304-1346.
 Guide to case report writing, history taking and physical examination of the therapeutical
patient / Textbook for the medical students by Ukrainian, English or Russian / 2 nd editional
with correction and added/ Y. M. Mostovoy, A. V. Demchuk, T. V. Konstantynovych, T. D.
Danilevych, V. L. Poberezhets. – Vinnytsia: Center DZK, 2016. – 120 p.

Professor Konstantynovych T.V.

Professor assistant Tsymbaliuk N.V.