Does anyone else have problems hearing certain patient's hearts?

[3dee]

I just started my first rotation. Sometimes I have trouble hearing certain patients' heart sounds and lung sounds (while others have very clear audible heart sounds). What am I doing wrong?? I am listening in all the proper spots and move the steth around to try to locate them but no success.

Thanks!

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[Vigil]

If the patient can tolerate it, I generally bend them over at the waist so their heart moves more anterior. Or if they're in a bed, left lateral recumbency, works for me.

 

[Rothbard]

nm

 

[Bacchus]

Are you listening on skin? I know it sounds straight forward, but it truly is the best way to auscultate. Your stethoscope forms a much better seal on the skin than over fabric. I find it to be more problematic in females because they wear multiple layers, have a thick bra strap, etc. If you can auscultate on skin, try to.

 

[3dee]

I always auscultate on skin...however, bacchus is right, if the patient is obese, I cant hear ANYTHING!

 

[FunnyCurrent]

no I have a triple head

 

[thepoopologist]

I just started my first rotation. Sometimes I have trouble hearing certain patients' heart sounds and lung sounds (while others have very clear audible heart sounds). What am I doing wrong?? I am listening in all the proper spots and move the steth around to try to locate them but no success.

Thanks!

Are you pushing down? If so, don't. In summary

1. Listen on skin
2. Listen in a quiet area if possible
3. Don't push down. You should make the seal with the skin but nothing beyond that. Yes even with the fatties.
4. If they're fat, don't worry about it. They're dead anyway.

 

[VivaLaVida]

An attending once showed me a way of holding the stethoscope in the palm of my hand instead of with fingers on the diaphragm attachment. It reduced the noise made by rustling fingers on sensitive scopes that can disguise some sounds. It helped me in some patients.

 

[duckie99]

I was using a cheap stethoscope for a while because my better one broke and I could literally not hear a moderately overweight person's heart on the skin. I ended up just getting a new nice one and immediately no longer had any problems. A good one will cost at least $150. If you are having problems hearing sounds and otherwise doing everything right it is likely you just need a nicer stethoscope.

Also make sure you are wearing it correctly in your ears every time. Relax and ask the patient to be still and quiet when listening to the heart. Be sure to say "take big breaths through your mouth" when listening to the lungs. You should be able to heart and lung sounds even on BMI >40 no problem (though they will sound more distant obviously the greater the BMI). Lung sounds are iffy in general though because some people simply will not give a good effort.

 

[VenusinFurs]

Some COPDers have very distant heart sounds because there are blebs.

 

[umean2tellme]

Are you pushing down? If so, don't. In summary

1. Listen on skin
2. Listen in a quiet area if possible
3. Don't push down. You should make the seal with the skin but nothing beyond that. Yes even with the fatties.
4. If they're fat, don't worry about it. They're dead anyway.

Outstanding! 👍

 

[DrSnips]

A good electronic stethoscope with adjustable volume will let you hear auscultate any patient, even extremely obese patients in noisy environments. Why we are willing to use modern technology in virtually every aspect of patient care but still cling to old-fashioned devices for the physical exam is beyond me.

That said, I do use a traditional stethoscope myself, but I am considering making the switch after borrowing a colleague's electronic one and being suitably impressed.

 

[Alvarez13]

Are you pushing down? If so, don't. In summary

1. Listen on skin
2. Listen in a quiet area if possible
3. Don't push down. You should make the seal with the skin but nothing beyond that. Yes even with the fatties.
4. If they're fat, don't worry about it. They're dead anyway.

 

[Alvarez13]

A good electronic stethoscope with adjustable volume will let you hear auscultate any patient, even extremely obese patients in noisy environments. Why we are willing to use modern technology in virtually every aspect of patient care but still cling to old-fashioned devices for the physical exam is beyond me.

That said, I do use a traditional stethoscope myself, but I am considering making the switch after borrowing a colleague's electronic one and being suitably impressed.

Yes OP, ditch the $100 scope you bought last year and spend another $300 on an electronic one.You should also buy 2 otoscopes in case you lose one.

Like someone else said, make sure to make a good seal but don't press down hard. You could also tell the patient to hold their breath for a second are get them to walk around to get the heart moving a little more. A patient room is also better than a noisy ED.

 

[Aclamity]

Yes OP, ditch the $100 scope you bought last year and spend another $300 on an electronic one.You should also buy 2 otoscopes in case you lose one.

Like someone else said, make sure to make a good seal but don't press down hard. You could also tell the patient to hold their breath for a second are get them to walk around to get the heart moving a little more. A patient room is also better than a noisy ED.

Hmm are these electronic steths going to become the norm for our generation? Haven't seen any attendings using them, but def seen a fair amount of residents carrying the around

 

[Alvarez13]

Hmm are these electronic steths going to become the norm for our generation? Haven't seen any attendings using them, but def seen a fair amount of residents carrying the around

I want an electronic reflex hammer. No swinging. Just zaps the patient.

 

[DrSnips]

Yes OP, ditch the $100 scope you bought last year and spend another $300 on an electronic one.You should also buy 2 otoscopes in case you lose one.

Like someone else said, make sure to make a good seal but don't press down hard. You could also tell the patient to hold their breath for a second are get them to walk around to get the heart moving a little more. A patient room is also better than a noisy ED.

Yeah Alvarez is right, making a $300 investment in a piece of equipment you will be using everyday you go to work for the rest of your life is silly. As long as we're saving as much money as possible, a cardboard tube with an exam glove stretched over one end can make an impromptu stethoscope.

I also like the suggestion to get the patient walking around. A lot of hospital patients are in terrible physical condition. You're going to make them tachy by doing this and then hearing murmurs will become difficult no matter what stethoscope you use.

 

[duckie99]

Yeah Alvarez is right, making a $300 investment in a piece of equipment you will be using everyday you go to work for the rest of your life is silly. As long as we're saving as much money as possible, a cardboard tube with an exam glove stretched over one end can make an impromptu stethoscope.

I also like the suggestion to get the patient walking around. A lot of hospital patients are in terrible physical condition. You're going to make them tachy by doing this and then hearing murmurs will become difficult no matter what stethoscope you use.

Electronic stethoscopes are pretty much unnecessary unless you are hearing-impaired. The work-up for any particular murmur is the same whether you used an electronic or normal steth. And I have not heard of a study that electronic steths are better at picking up a murmur.

Yeah you use a steth day in and day out but its importance is really dependent on your field. And by the time a resident decides cardiology they are good at picking up murmurs without an electronic one.

I want an electronic reflex hammer. No swinging. Just zaps the patient.

lol that would be awesome!

 

[DrSnips]

Electronic stethoscopes are pretty much unnecessary unless you are hearing-impaired. The work-up for any particular murmur is the same whether you used an electronic or normal steth. And I have not heard of a study that electronic steths are better at picking up a murmur.

Yeah you use a steth day in and day out but its importance is really dependent on your field. And by the time a resident decides cardiology they are good at picking up murmurs without an electronic one.



lol that would be awesome!

Well obviously you won't have heard of a study if you don't look at the literature...

http://www.ncbi.nlm.nih.gov/pubmed/8965622
http://www.ncbi.nlm.nih.gov/pubmed/3746368
http://www.ncbi.nlm.nih.gov/pubmed/21549289

I don't think anyone will argue that the electronic stethoscope doesn't amplify the sound (that is all it does). The question therefore is this: Is every significant pathologic murmur audible at the sound levels you are likely to hear with a standard stethoscope in an average exam environment?

I don't know the answer to this question, but I have been given no reason to believe it is yes.

 

[duckie99]

Is every significant pathologic murmur audible at the sound levels you are likely to hear with a standard stethoscope in an average exam environment?

my ultimate point in the statement you bolded was that I have not heard of any comparison research proving better health outcomes with an electronic steth. Sure you can hear a murmur better but what's the point of spending $500 when you could spend $150 for the same outcome? Thus my reasoning for saying they are likely only useful for the hearing-impaired physician and perhaps in certain cardiology clinics.

I have not seen a single physician use one. A med student walking around with one = dorky loser.

 

[DrSnips]

my ultimate point in the statement you bolded was that I have not heard of any comparison research proving better health outcomes with an electronic steth. Sure you can hear a murmur better but what's the point of spending $500 when you could spend $150 for the same outcome? Thus my reasoning for saying they are likely only useful for the hearing-impaired physician and perhaps in certain cardiology clinics.

I have not seen a single physician use one. A med student walking around with one = dorky loser.

The only people I have seen use them were residents. In any case, anecdotal evidence about who we have seen use them is irrelevant. That is the entire point of evidence-based medicine, only the evidence matters. You also seem to misunderstand that my point is about hearing murmurs you would otherwise miss, not "hearing them better."

Research on better outcomes in such a case is impossible. You can't compare the outcome of treatment in a case where the murmur wasn't heard with one where it was, because how would you find cases of murmurs that weren't heard? The research that can be done is of the type I presented to you, which points toward auscultation being easier with the electronic.

 

[Charles_Carmichael]

Well obviously you won't have heard of a study if you don't look at the literature...

http://www.ncbi.nlm.nih.gov/pubmed/8965622
http://www.ncbi.nlm.nih.gov/pubmed/3746368
http://www.ncbi.nlm.nih.gov/pubmed/21549289

I don't think anyone will argue that the electronic stethoscope doesn't amplify the sound (that is all it does). The question therefore is this: Is every significant pathologic murmur audible at the sound levels you are likely to hear with a standard stethoscope in an average exam environment?

I don't know the answer to this question, but I have been given no reason to believe it is yes.

I don't have access to the two older studies you linked, but none of the 3 are compelling enough to suggest that electronic stethoscopes are better than normal stethoscopes for everyday use. The two older studies seem to essentially be surveys of what (a relatively few) clinicians prefer and the 2011 one is comparing electronic vs. normal with regards to air transport, where background noise is much higher than in a hospital/clinic.

With that being said, I've also never seen anyone actually use an electronic one. Pretty much all the cardio fellows/attendings I've seen have been rocking the Littman III or a Welch-Allyn.