Again, I always try to think of murmurs during the exam in terms of: location, timing, intensity, duration, radiation, quality and frequency (pitch).  Complex congenital heart disease may be associated with multiple individual heart lesions and shunts in which it may not be possible to evaluate each part individually by auscultation.  In addition, the location and radiation patterns of specific heart murmurs may be difficult to correlate with specific heart lesions in the presence of chamber or great artery inversion, transposition, malposition or atresia.  With that said, I believe that it is important to have a set routine of cardiac physical examination of which auscultation is a part.  The overall appearance of the child, color, pallor, perfusion, alertness, warmth, respiratory pattern, palpation of precordial activity, liver fullness, and venous and arterial pulses are as important as auscultation of the heart.   I start with the patient in the supine position by listening with my stethoscope diaphragm then the bell at the apex of the heart inferiorly and laterally.  Then I slowly work my way towards the left and right lower sternal border, the left and right middle and the upper sternal borders, then from the right upper sternal border to the left and right supra clavicular areas and then the supra-sternal notch and neck.  Then I move to listen to each axillae.  After the child sits up (or the infant's chest is held to the chest of the parent) I focus on radiation of the heart murmur to the left back, the middle back and then right back.  I then listen to the neck and right upper and left upper stenal borders again in this upright position.  I have the patient squat down and I listen to the patent after standing.  Finally, I listen over the fontonelle and liver in young children for evidence of bruit of arterial-venous connection.  In my mind I draw a line across the chest at about the second intercostal space which separates the listening areas into upper (superior basilar) and lower (inferior apical) broad categories.  Murmurs which are heard best above the line are likely to be of the systolic crescendo-decrescendo timing and usually are of semi-lunar valve or great artery (or great artery branch) origin.  The radiation pattern of these murmurs further helps to differentiate them.  Murmurs that heard best at the right upper sternal border and radiate to the supra-sternal notch and neck are likely to be of aortic origin.  Those that are heard best at the left upper sternal border and radiate through out the precordium and to the back (specifically the left back) are likely to be of pulmonary origin.  Radiation to the axillae suggests branched pulmonary artery turbulence or stenosis.  The higher the pitch of these murmurs of semi-lunar valve stenosis, the greater the velocity of the blood moving out of the ventricles and the higher the pressure gradient between the ventricle and the great artery and the more severe the degree of stenosis.  Semi-lunar valve stenosis with a low to medium pitch may correlate with mild to moderate aortic or pulmonary valve stenosis and a gradient less that 40mmHg.  Severe semilunar stenosis with a gradient greater than 60mmHg will likely have a medium to high pitch, be more loud and more harsh, be later to peak in systole.