As a medical student and even in my earlier years as a teacher, almost 50 years back, I remember teaching almost a dozen points to differentiate a ‘functional’ from an ‘organic' murmur in the precordium.

The initial concept of differentiation was that these organic murmurs were due to a structural defect in the heart. But for a long time, some of the functional murmurs such as those due to severe anaemia were considered ‘organic’ because they were produced by dilatation of the heart (the valvular rings) and ‘flow changes’.

I remember the early years of my practice, when I used to demonstrate a systolic murmur in the precordium in a patient, and yet the patient had absolutely no evidence of any disease whatsoever in the body. Nor did he have any abnormality in the heart, based on evidence of clinical examination, X-ray chest and ECG in those days.

Then came the era of 2D Echo Cardiography (preceded by M mode Echocardiography), followed by Doppler and Duplex sonography of the heart. Additional imaging like MRI of the heart, which shows the structural anatomy of the organ (very vividly), is available only since the last few years. It has already been more than 10 years, since I remember diagnosing a functional murmur in an otherwise normal person with a normal chest and heart. So what happened to dozens of patients, in whom we used to diagnose a ‘functional’ murmur in the heart?

My advice to General Practitioners is to avoid diagnosing a ‘functional’ murmur. For example, in a normal person with a soft systolic murmur in precordium concentrate on second heart sound, which even if slightly abnormal will point to diagnosis of ASD (Atrial Septal Defect), which is quite often missed for years before it is picked up during a patient’s lifetime.

Every patient complaining of anginal pain is to be examined carefully. If such a patient has a systolic murmur in the precordium of whatever grade, do not miss the diagnosis of HOCM (Hypertrophic Obstructive Cardiomyopathy). Instead of asking for a stress test, ask for a 2D Echocardiography.

If a patient, who had an attack of myocardial infarction, develops dyspnoea or any other symptom, the systolic murmur heard at the apex of the precordium should warn you that most likely his papillary muscle is infarcted and he has developed papillary muscle dysfunction (PMD).

Finally in patients, who have a systolic murmur over the apex or in the precordium (especially over lower half) in absence of any disease whatsoever, exclude MVP (Mitral Valve Prolapse). The latter is extremely common in such patients.

Thus my advice will be that as far as examination of the heart is concerned, auscultate every patient over the precordium. If any murmur is detected, do not diagnose it as functional even if it is not loud and it is only of grade II or III.