heart sounds

[coconut lime]

i seem to have a lot of trouble hearing heart sounds clearly. i mean, i can hear the basic lub-dub, but i really can't tell if a rhythm sounds regular or not, i can't hear the S1 split, and i definitely can't hear a murmur! and i have a good steth too, i bought the Cardio III. does anybody else have problems differentiating heart sounds? any advice or web sites that i should check out? thanks!!!

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[tega]

i seem to have a lot of trouble hearing heart sounds clearly. i mean, i can hear the basic lub-dub, but i really can't tell if a rhythm sounds regular or not, i can't hear the S1 split, and i definitely can't hear a murmur! and i have a good steth too, i bought the Cardio III. does anybody else have problems differentiating heart sounds? any advice or web sites that i should check out? thanks!!!

i had a similar problem during PD (2nd yr).....and i was able to BS my way through it.....i couldnt hear anything...i was not taking this class that seriously anywayz........but i guess i'll have to remedy this quickly. But then again my steths was a generic crap!!!

 

[tega]

there is a really good website for heart sounds though.,...i dont have it on this pc....but when i have access to it, ill post it up. Was very helpfull, cuz even though i couldnt hear anything on an actual pt....when a sound was described..i was able to make some sense of it....

 

[b&ierstiefel]

Being more skilled at listening to heart sounds comes with lots of experience. When I first started my cardiology rotation, I was in the same situation. As the month progressed, I got a little better.

It also seems that some doctors will listen more carefully for certain heart sounds in a certain type of patient. For instance, people will listen very very carefully for a S4 and sometimes will hear a (fictitious or real) S4 in a patient with a long history of HTN with LVH seen on EKG.

 

[EctopicFetus]

yeah i just started my Medicine rotation and we have some PD with the CMRs and we went to this lady and he asked us to listen (i have the cardiac III too and neither I nor the other med student could hear the murmur. Then the CMR took the stethoscope and placed it in one spot and it was clear as day. I think this is just a matter of practice. Also, (in my own defense ) he said she had an ectopic SA so it makes it harder. anyway practice makes perfect.

 

[souljah1]

I'll take a look for this website I know of that has good examples of heart sounds.

In the meantime, I would just practice on as many people as you can. If you feel comfortable, ask a doc that you know to spend a few days listening to heart sounds in patients on the floor with real findings. I did that during first year and it was really helpful. I would go in, do a quick HPI and then do a focused cardiac exam. I'd present what I thought I found to him and then we would go back in and go over it together. It was really helpful.

Here are some basic things that he taught me: First things first, it is really important that you distinguish S1 and S2. Feeling the pulse can help you determine which is S1 for the upstoke of the pulse should occur just after S1. Assessing Rhythm is kind of hard to explain. It should, well, be in rhythm. The main thing is to determine, if things are not regular, if it is regularly irregular or irregularly irregular (Afib). Use the bell of your stethoscope to determine if there any gallops (S3/S4). With the diaphragm, listen to the four major quadrants. If you hear a diastolic murmur (occurs after S2) it is always (pretty sure anyway) pathologic. If you hear a systolic it will occur inbetween S1 and S2 and can differ in quality and timing. Note whether or not you hear associated clicks, does it crescendo then decrescendo, where it is loudest, does it radiate, etc. Bates actually has a pretty good chapter on cardiovascular exam and how to describe murmurs.

 

[KKay999]

This is a really good site.

http://www.blaufuss.org/tutorial/

 

[ak1978]

blaufuss is an exceptional site. It shows how important it is to correlate with other physical features (arterial pulsatations, jvd, etc). I'm only starting to get better after a year on the floors. Residents in general aren't any better than ms3's at auscultation (scary but true). Murmurs can really much more subtle than you think--listen carefully; they'll become more obvious with time. And use the bell! I've often heard certain sounds only with the bell (better for s1-s4, AS, PS, IHSS, MS, TS, and pericardial knocks).
if you're having trouble telling s1 from s2, remember that s2 will be louder at the base compared to at the apex...

physical diagnosis--a dying art

http://www.med.ucla.edu/wilkes/inex.htm is another decent site.

 

[ericdamiansean]

I have cassettes, CDs, computer programs...but at the end of the day..you have to develop your own technique.
I'll share mine with you:
When listening to heart sounds, palpating a faint thrill or even an apex, stop breathing, close your eyes and concentrate on the sense which you are using ie. touch or hearing..it really helps
WHy do I say stop breathing? That's because personally, when I'm trying to concentrate on listening to heart sounds etc, I suddenly become aware of my own breathing, and this disturbs my technique, and I'm hearing my own breath sound...sounds crazy..but you can give it a shot

 

[ericdamiansean]

if you're having trouble telling s1 from s2, remember that s2 will be louder at the base compared to at the apex...

physical diagnosis--a dying art

http://www.med.ucla.edu/wilkes/inex.htm is another decent site.

the S1 also correlates with the pulsation you feel at the carotid artery, it's a safer bet

 

[coconut lime]

oh crap....i always thought that the "lub" was s1 and the "dub" was s2.....i guess i was way wrong!

 

[Dr Alo]

I was taught that anytime you are listening to a heart palpate a pulse, either carotid or on teh wrist. The sound you hear when the pulse hits is S1. So S1 and the pulse coincide. Of course, carotid will be better than wrist, since it is more proximal to the heart.

 

[Seaglass]

Actually the S1 comes slightly before the pulse since it take time for the pulse to travel to where you are feeling it (most noticable at the wrist). I've seen lots of students make mistakes because they are hearing S2 just after the pulse hits, and they assume it is S1 because it came so near the pulse.

C

 

[ericdamiansean]

oh crap....i always thought that the "lub" was s1 and the "dub" was s2.....i guess i was way wrong!

they used to tell us this when we were freshmen...and in high school..haha, you can't fool me no more

 

[ericdamiansean]

Actually the S1 comes slightly before the pulse since it take time for the pulse to travel to where you are feeling it (most noticable at the wrist). I've seen lots of students make mistakes because they are hearing S2 just after the pulse hits, and they assume it is S1 because it came so near the pulse.

C

so, this means that the jugular pulse is still the best since it travels the nearest and fastest from the heart?

 

[Seaglass]

Well, hopefully your jugular isn't pulsating enough to feel it because if it is you have some serious heart failure problems. Now, watching for the A and V waves in the jugular can be helpful but for palpation I find the carotid to be best.

C

 

[coconut lime]

so if lub-dub doesn't correspond to s1-s2, what DOES it reflect??

 

[14022]

my tips on better auscultation

1) have the patient lie down, if possible...this is a given in the inpatient setting but have them lie down as an outpatient as well...

2) tell them to breath "normal"...i listen to the lungs before the heart so many patients will take it upon themselves to continue to breathe deeply for the heart exam as well...the deep breathing sounds often interfere with my ability to hear the heart...this is minimized if you tell them to breathe normally

3) start at the apex and identify one sound at a time and then focus on other sounds until you have the complete picture...palpate the carotid pulse...the sound before the pulse is s1, the one after is s2...if you dont hear 2 sounds, why not? is there a "swooshing" that blocks out the sound? if so, which sound is blocked? as a student, you cant just put the stethoscope on the body and hear "aortic stenosis"...over time this will be possible but for now you have to go through each step of the exam and put the pieces together


i hope this helps

 

[ericdamiansean]

get them to breathe via the mouth is better too

I think most people have a bigger problem with the JVP
The technique about casting a shadow, I haven't seen it being done yet..but for me..intense concentration helps me see it...but sometimes, staring at something so hard can fool your eyes..darn

 

[Mumpu]

It's practice and having a good stethoscope (wielding a Sprague-Rappaport with a Craddock/Pelham bell over here). But mostly practice.

Keep your eyes open and watch the patient breathe -- it will keep you from taking breath sounds for murmurs and eventually let you diagnose things like left vs right-sided S4 (LV S4 appears at the peak of expiration, RV at the peak of inspiration) and TR vs MR (TR gets louder with inspiration although this can be very subtle) and paradoxical splitting. You can often identify S2 because it splits with inspiration. I find palpating the pulse to be very confusing, particularly with tachycardic patients and with kids because of the lag, but experiment and find what works for you.

Something else that helps tremendously is a solid grasp of physiology of heart sounds. Many findings are subtle and you will not hear them unless you specifically listen for them. Work up to the point where you can name all findings in different heart conditions (i.e. the three components of the mitral stenosis murmur and the sequence in which they appear, the three components of pericardial rub, the two components of severe AS, etc.), in what phase of heart cycle they appear, and what is the underlying pathology and pathophysiology.

Don't get frustrated, keep at it. Find someone who is good at physical exam and ask them to see a few patients with findings -- most exam deities are more than happy to teach.