What graded level is described as a loud murmur with a thrill?

A loud murmur accompanied by a thrill is classified as a Grade 4 murmur. In the context of heart murmurs, grading is based on the intensity of the sound and the presence of additional physical findings. Grade 4 murmurs are characterized by their loudness, which is significant enough to be heard without amplification, and the vibration (or thrill) that can be palpated over the area where the murmur is heard.

For clarity on grading:

• A Grade 2 murmur is typically described as a faint murmur, which is barely audible.

• A Grade 5 murmur is very loud and can be heard with a stethoscope slightly off the chest, and while it may also have a thrill, it is at a higher grading level than what is described in the question.

• A Grade 6 murmur is the loudest, capable of being heard without a stethoscope at all, and also typically associated with a thrill.

Thus, a Grade 4 murmur accurately matches the description provided in the question.