Auscultation in a Loud Environment

[MedStudent219]

---

Members don't see this ad.

Hi all,

I'm an MS2, and I've gotten a lot better at auscultating (although still a lot to learn and practice) compared to first year. One thing I've been having difficulty with is hearing when theres a lot of background noise, i.e. many people talking or shouting and what not. It makes it more difficult to figure out what I'm hearing and sometimes makes hearing any sounds impossible. Is there any way to improve hearing in a loud environment? Is this just due to my inexperience? Also, when listening to the aortic and pulmonary areas, S1 and S2 is pretty quiet, is that normal? I can very barely hear it and would wonder how I'd hear a murmur when listening to those areas. Thanks for all the assistance 😀

 

[longhaul3]

If you’re trying to auscultate in an environment where people are shouting, presumably it’s an ED during a code or trauma, and when a patient is in extremis you’re not trying to hear a grade I murmur. Does the patient have a heartbeat, is there reasonable air movement, is there florid pulmonary edema, is there tamponade, is there acute MR with a grade VI murmur, is there critical aortic stenosis, etc.

If those are absent, follow up in clinic or on the floor after the patient has been admitted and stabilized.

Otherwise, find a quieter place to auscultate. Or just order an echo and consult medicine (kidding, kidding).

 

[MedStudent219]

If you’re trying to auscultate in an environment where people are shouting, presumably it’s an ED during a code or trauma, and when a patient is in extremis you’re not trying to hear a grade I murmur. Does the patient have a heartbeat, is there reasonable air movement, is there florid pulmonary edema, is there tamponade, is there acute MR with a grade VI murmur, is there critical aortic stenosis, etc.

If those are absent, follow up in clinic or on the floor after the patient has been admitted and stabilized.

Otherwise, find a quieter place to auscultate. Or just order an echo and consult medicine (kidding, kidding).

Ah, right thanks! So being able to hear the find detail of auscultation isn't really necessary in those sorts of environments. Thanks! Also, perhaps a dumb question but are the pulmonary and aortic areas meant to be significantly quieter than the tricuspid and mitral areas?

 

[deleted407021]

In peds you frequently auscultation when siblings are running around hollering and being wrangled by parents and in the ED or ICU there are obviously lots of noises from staff and equipment. Just keep up the practice. Even knowing what normal sounds like really, really well helps a ton here because even in loud environments I’ve found those unusual findings start to jump out at me.

As for the sounds being relatively quieter over the A and P points, that’s interesting because you’re right over the heart there. Make sure you’re not listening through a rib. Try adjusting the *pressure* you apply with your diaphragm as well to get a sense of the tones.

 

[MedStudent219]

In peds you frequently auscultation when siblings are running around hollering and being wrangled by parents and in the ED or ICU there are obviously lots of noises from staff and equipment. Just keep up the practice. Even knowing what normal sounds like really, really well helps a ton here because even in loud environments I’ve found those unusual findings start to jump out at me.

As for the sounds being relatively quieter over the A and P points, that’s interesting because you’re right over the heart there. Make sure you’re not listening through a rib. Try adjusting the *pressure* you apply with your diaphragm as well to get a sense of the tones.

Ah thank you so much! In regards to your second point, that is what I thought too! However, it seems I might be listening through a rib. How does one ensure that they are not listening through a rib when auscultating? Do you manually palpate and find each intercostal space, that is what I used to do but I've never actually seen a doctor do that, they usually just know where to listen from, so how would they know they're know over a rib? Your help has been appreciated 😀

 

[deleted407021]

Ah thank you so much! In regards to your second point, that is what I thought too! However, it seems I might be listening through a rib. How does one ensure that they are not listening through a rib when auscultating? Do you manually palpate and find each intercostal space, that is what I used to do but I've never actually seen a doctor do that, they usually just know where to listen from, so how would they know they're know over a rib? Your help has been appreciated 😀

A lot of docs get sloppy 😉
Others know the patient in front of them and don’t expect to find anything new they didn’t find on the first ever exam.
Most attendings are good and can appreciate what they need by quickly listening over one point.

Our job is to do it the right way, every time in whatever style we prefer. I do palpate before placing the diaphragm. Bell held in whatever hand, I’ll make sure I’m feeling the intercostal space very quickly with a finger of that hand before placing the diaphragm all in one motion.

 

[Matthew9Thirtyfive]

Ah, right thanks! So being able to hear the find detail of auscultation isn't really necessary in those sorts of environments. Thanks! Also, perhaps a dumb question but are the pulmonary and aortic areas meant to be significantly quieter than the tricuspid and mitral areas?

Are you using a tunable stethoscope? Mine is tunable and will tune to lower frequencies with less pressure and higher frequencies with more pressure. If I push in, the heart sounds get much fainter since they are lower frequency mostly (except the click).

Also agree with using your finger to quickly check your positioning and to palpate first.

 

[RNthenDoc]

This will seem like common sense to 99% of you, but I’m going to say it in the off chance that someone needs to hear it:

Mute the patient’s TV if you are going to listen to them, or you will only hear the cast of Big Bang Theory.

Can’t count the times I’ve seen it.

 

[deleted407021]

This will seem like common sense to 99% of you, but I’m going to say it in the off chance that someone needs to hear it:

Mute the patient’s TV if you are going to listen to them, or you will only hear the cast of Big Bang Theory.

Can’t count the times I’ve seen it.

Same goes for the god awful tablets on the little stands that sell drugs to patients in exam rooms.

 

[MedStudent219]

A lot of docs get sloppy 😉
Others know the patient in front of them and don’t expect to find anything new they didn’t find on the first ever exam.
Most attendings are good and can appreciate what they need by quickly listening over one point.

Our job is to do it the right way, every time in whatever style we prefer. I do palpate before placing the diaphragm. Bell held in whatever hand, I’ll make sure I’m feeling the intercostal space very quickly with a finger of that hand before placing the diaphragm all in one motion.

Are you using a tunable stethoscope? Mine is tunable and will tune to lower frequencies with less pressure and higher frequencies with more pressure. If I push in, the heart sounds get much fainter since they are lower frequency mostly (except the click).

Also agree with using your finger to quickly check your positioning and to palpate first.

What kind of motion do you use to feel the intercostal space and then auscultate in one motion? I'm trying to implement this, but I'm being quite messy when it comes to this. Thanks for all your assistance 😀 !

 

[NVO]

Sometimes all it takes is using your free hand to clamp the steth into your ears more for a better seal

 

[deleted407021]

What kind of motion do you use to feel the intercostal space and then auscultate in one motion? I'm trying to implement this, but I'm being quite messy when it comes to this. Thanks for all your assistance 😀 !

It just takes practice. Hard to describe but be creative!

 

[Matthew9Thirtyfive]

What kind of motion do you use to feel the intercostal space and then auscultate in one motion? I'm trying to implement this, but I'm being quite messy when it comes to this. Thanks for all your assistance 😀 !

I palpate first for heaving, etc. So when I do that I find the sternal angle then. So I pretty much know where the intercostal space is. When I go to auscultate I just use my middle finger real quick to confirm. I hold the stethoscope with my thumb and index. I can control the tuning that way.

 

[MedStudent219]

It just takes practice. Hard to describe but be creative!

I palpate first for heaving, etc. So when I do that I find the sternal angle then. So I pretty much know where the intercostal space is. When I go to auscultate I just use my middle finger real quick to confirm. I hold the stethoscope with my thumb and index. I can control the tuning that way.

Practiced it a few times with a mate today, think I've got it and its really efficient!! 😀 Thank you so much, this forum is awesome!

 

[deleted407021]

Practiced it a few times with a mate today, think I've got it and its really efficient!! 😀 Thank you so much, this forum is awesome!

Woot!

 

[jdh71]

If auscultation were a lab test we’d never order it.

 

[deleted407021]

If auscultation were a lab test we’d never order it.

I’ve seen physicians across a variety of specialties place more or less emphasis on auscultation.

 

[jdh71]

I’ve seen physicians across a variety of specialties place more or less emphasis on auscultation.

Look it’s a data point. And murmurs especially the loud ones are perhaps hints, suggestions. But these days anything really important about the heart (and it’s valves) will be determined by an echo not a really really good physical exam. I’m not trying to be a cynical dick in here either. It’s just not that important-important.

 

[deleted407021]

Look it’s a data point. And murmurs especially the loud ones are perhaps hints, suggestions. But there days anything really important about the heart (and it’s valves) will be determined by an echo not a really really good physical exam. I’m not trying to be a cynical dick in here either. It’s just not that important-important.

Right, anytime we’ve had a question about the heart on my services the patient gets an echo.

Have you seen anything yet on the utility of those new handheld, portable ultrasound probes that fit into your smart phone?

 

[throwaway1000000]

Look it’s a data point. And murmurs especially the loud ones are perhaps hints, suggestions. But there days anything really important about the heart (and it’s valves) will be determined by an echo not a really really good physical exam. I’m not trying to be a cynical dick in here either. It’s just not that important-important.

Although I do not have much experience compared to you, I agree 100%. In the past yr, I probably used it for 4-5 scenarios: to pick up a loud aortic stenosis murmur, bowel sounds in ileus/obstruction, decreased breath sounds for pneumo, crackles for HF and possibly for pneumonia
Other than the aortic stenosis murmur everything else like pneumothorax, ileus, HF can all be picked up by hx and imaging

To be honest, I am not entirely sure why we listen to patients hearts especially the ones without any heart disease or lung disease every single day. It's almost ppl like to do it for billing and to say they did some sort of physical exam

 

[jdh71]

Right, anytime we’ve had a question about the heart on my services the patient gets an echo.

Have you seen anything yet on the utility of those new handheld, portable ultrasound probes that fit into your smart phone?

Those are very very cool. You do need too know what you are looking at however and still if you see something odd you will (currently) still need a formal echocardiogram. Maybe in five to ten years . . .

 

[aldol16]

It comes with time. It's hard in the preclinical years because you're just trying to get the technique down at that point, e.g. where to listen to, what certain sounds mean, etc. Once you get to clinical years and listen to heart sounds on everyone, you'll start to be able to pick them out from the background sound. And they seem louder once you're able to focus on them and know what you're listening for.

 

[aldol16]

To be honest, I am not entirely sure why we listen to patients hearts especially the ones without any heart disease or lung disease every single day. It's almost ppl like to do it for billing and to say they did some sort of physical exam

It's because you wouldn't want to miss a new murmur on someone. The physical exam is about what is pertinent and what is dangerous to miss. You wouldn't want to miss a new murmur in a patient because that could be very dangerous. Everyone who has heart disease started somewhere. You should probably care more about people who don't have heart disease in their history because they're the ones at risk for heart disease. Everyone who has heart disease already has heart disease.

 

[throwaway1000000]

It's because you wouldn't want to miss a new murmur on someone. The physical exam is about what is pertinent and what is dangerous to miss. You wouldn't want to miss a new murmur in a patient because that could be very dangerous. Everyone who has heart disease started somewhere. You should probably care more about people who don't have heart disease in their history because they're the ones at risk for heart disease. Everyone who has heart disease already has heart disease.

I mean they are not going to develop a new murmur in a day if they don't have it on your exam during admission
Of course, if this is someone admitted for chest pain, I would listen to their heart everyday.
But if they are admitted for a GI issue, I don't see that being particularly useful but I see internists listening every single day. Maybe out of habit. Maybe for documentation. I am not sure, but it does not seem useful

 

[jdh71]

I mean they are not going to develop a new murmur in a day if they don't have it on your exam during admission
Of course, if this is someone admitted for chest pain, I would listen to their heart everyday.
But if they are admitted for a GI issue, I don't see that being particularly useful but I see internists listening every single day. Maybe out of habit. Maybe for documentation. I am not sure, but it does not seem useful

Any new and important pathology that would manifest in part as a new murmur would also be symptomatic otherwise.

It’s not like patients are just sitting around ready to keel over (ded, dided!!) with a murmur you just HAVE TO (omg!!) pick up or else without symptoms.

Now where you may have to be a bit careful is in a patient with existing chronic disease also causing symptoms like COPD or obesity. And this is why I never blame being old or fat for the shortness until the lungs and heart have had a thorough work up into both. Hell they will usually get a CPET before I blame being fat and or old.

The loudest murmurs you usually hear are from clinically stable aortic stenosis.

 

[deleted407021]

Any new and important pathology that would manifest in part as a new murmur would also be symptomatic otherwise.

It’s not like patients are just sitting around ready to keel over (ded, dided!!) with a murmur you just HAVE TO (omg!!) pick up or else without symptoms.

Now where you may have to be a bit careful is in a patient with existing chronic disease also causing symptoms like COPD or obesity. And this is why I never blame being old or fat for the shortness until the lungs and heart have had a thorough work up into both. Hell they will usually get a CPET before I blame being fat and or old.

The loudest murmurs you usually hear are from clinically stable aortic stenosis.

If I recall, you're critical care right?

 

[jdh71]

If I recall, you're critical care right?

Pulmonary and critical care

 

[deleted407021]

Pulmonary and critical care

If you'll let me pick your brain for a min, how much do you think lung auscultation tells you? Is it still a very useful part of a PE?

Going into peds and interested in CC.

 

[jdh71]

If you'll let me pick your brain for a min, how much do you think lung auscultation tells you? Is it still a very useful part of a PE?

Going into peds and interested in CC.

We need pediatricians. Glad to hear you are seriously considering it.

Lung sounds are also fairly lacking in sensitivity and specificity. They add data points and evidence but rarely diagnose much especially in someone symptomatic enough to get an evaluation who will likely have chest imaging. But wheezing is helpful in deciding if your treatment for COPD or asthma is working or those disease processes are flaring. You can pick up prolonged expiratory phases. You will get a decrease in sounds with effusion and definitely with pneumo. Crackles fine and more Velcro like can help in cases of heart failure or fibrosis, respectively. Everything else just kind of sounds off or wrong. You need to listen to enough lungs. So the exam more supports and goes a long with rather than gives the diagnosis. It’s pretty hard to have lung specific pathology contributing to shortness of breath with normal sounding lungs. So it can help rule out the lungs as the bad guys if clear.

Not a huge role in PE.