Freeman and Levine in 1933 introduced the grading of murmurs up to 6 . However, they did not describe either how to tell grade 3 from grade 4 or the psychological approach to grade 1 murmurs.
Grading 1 to 6 is now generally accepted according to the following criteria, which serve for heart sounds as well as murmurs.
Grade 1 So soft that you must "tune in" to hear it. Tuning in means that you must know what to expect before you can hear it. Then you can eliminate room noise psychologically and try to hear something that you can already picture in your mind. A grade 1 murmur or heart sound has been defined as one that a medical student cannot hear. There is some truth in this, because a student often does not know what a soft blowing regurgitant murmur sounds like. You cannot "tune in" to nothing.
Grade 2 Grade 3 Grade 4
Grade 5 Grade 6
A soft murmur or sound that anyone can hear.
A loud murmur or sound that is palpable. When you feel a murmur, you are said to be feeling a "thrill." When you feel a heart sound, you are said to be feeling a "tap," or simply a "palpable sound."
A loud murmur that can be felt with the edge of the stethoscope, preferably with the diaphragm chest piece.
A murmur loud enough to be heard with the stethoscope slightly off the chest.
Although small localized movements are best perceived by the distal finger pads, thrills are best felt with the distal palm.
Note: Thrills and heart sounds are best perceived with the distal palm. One hand may be more sensitive than the other, so test each hand on any patient with a faint thrill or palpable sound to find your better hand.
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