Help with heart sounds...

[sebsvenmdc]

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Ok, so I'm so completely pathetic at getting heart sounds. Can past step 1 takers indicate what fraction of heart sounds they could answer just based upon the stem...and without the audio?

 

[Zweisamkeit]

I think I had 3 heart sound questions and the stems for all of them did not help me out so I had to listen to the audio. Bummer.

 

[sebsvenmdc]

I think I had 3 heart sound questions and the stems for all of them did not help me out so I had to listen to the audio. Bummer.

That sucks. What resources did you use? The UCLA heart sound website? Did your heart sounds sound like them?

 

[Zweisamkeit]

That sucks. What resources did you use? The UCLA heart sound website? Did your heart sounds sound like them?

Yeah, I used that website and reviewed media questions in Qbank, but I still had difficulty during the actual test. Oh well.

 

[kdburton]

My microbiology/pharm professor is on the NBME and writes micro questions.. In one of our reviews (not talking about heart sounds), he mentioned that there is a decent number of experimental questions on each test and the thing is that it takes at least two years for those questions to be statistically validated in order to be counted toward your score. Since multimedia questions are only recently available (not even this year for some people who are still taking it at centers that still use Fred v1), it seems to me that it is likely that all these "hard" heart sounds questions that people keep talking about may actually be experimental just because they are such recent additions. Anyone else think that sounds reasonable?

 

[Noeljan]

My microbiology/pharm professor is on the NBME and writes micro questions.. In one of our reviews (not talking about heart sounds), he mentioned that there is a decent number of experimental questions on each test and the thing is that it takes at least two years for those questions to be statistically validated in order to be counted toward your score. Since multimedia questions are only recently available (not even this year for some people who are still taking it at centers that still use Fred v1), it seems to me that it is likely that all these "hard" heart sounds questions that people keep talking about may actually be experimental just because they are such recent additions. Anyone else think that sounds reasonable?

I sure hope so!!! One of my preceptors told me it took him till 1st year of residency to really be able to properly pick up abnormal heart sounds and timing just via ascultation. Also, what about schools that dont even have clinicals 1st two years

 

[ZagDoc]

I found the heart sound ones pretty easy to reason out. The murmurs I got were classic murmurs and pretty obvious from the audio, but each question also had enough info in the stem to reason it out.

Since they always list the point the murmur is heard loudest in the stem, here's how I would reason them out.
-You MUST know the points associated with each murmur. I learned "Al Pacino, The Man" but there's several mnemonics out there. Upper Right Sternal Border = Aortic. Upper Left Sternal Border = Pulmonic. Lower Left Sternal Border = Tricupid. Left 5th intercostal space at midclavicular line = Mitral. They are not trying to trick you, they will ALWAYS list the point the murmur is heard in its classic point of auscultation. So if they say the point the murmur is heard loudest is at the midclavicular line, you KNOW its a mitral murmur.
-Once you've determined which valve it is from that, your only job is to determine if its a systolic or diastolic murmur. You don't need to be able to tell if the murmur is descrendo, crescendo-descrendo, "blowing", anything. If the murmur is at the upper right sternal border, it MUST be an aortic murmur. Is it systolic? Stenosis. Diastolic? Regurg.
-There are a couple places they can trick you. Mitral Regurg/Prolapse. You need to be able to pick up a click if there is one. Is there a click? Prolapse. If there's a click and its a diastolic murmur, it CAN'T be prolapse, it has to be stenosis. They will also try to trick you with hypertrophic cardiomyopathy, since its ejection murmur mimics aortic stenosis. But go back to the history in the stem, since its often is a dead giveaway from HCM. If it isn't, they have to give you something about how the murmur changes on held breath/valsalve/squatting/etc. Just remember, increased preload makes aortic stenosis louder (more blood through a small hole increases turbulence) and HCM ejection murmur softer (more blood in outflow tract keeps the mitral leaflet from collapsing against the hypertrophic ventricular septum).

They're also big on classic associations.
If its a mitral prolapse, its almost always in a Marfan's or adult polycystic kidney disease patient.
PDAs and ASDs are almost always in newborns.
Aortic stenosis is almost always in a 60 year old man.
If its a tricuspid murmur, its almost always in an IVDU.
Mitral murmurs almost always with rheumatic fever.

 

[sebsvenmdc]

Wow, thanks for the help, dude! 🙂

I found the heart sound ones pretty easy to reason out. The murmurs I got were classic murmurs and pretty obvious from the audio, but each question also had enough info in the stem to reason it out.

Since they always list the point the murmur is heard loudest in the stem, here's how I would reason them out.
-You MUST know the points associated with each murmur. I learned "Al Pacino, The Man" but there's several mnemonics out there. Upper Right Sternal Border = Aortic. Upper Left Sternal Border = Pulmonic. Lower Left Sternal Border = Tricupid. Left 5th intercostal space at midclavicular line = Mitral. They are not trying to trick you, they will ALWAYS list the point the murmur is heard in its classic point of auscultation. So if they say the point the murmur is heard loudest is at the midclavicular line, you KNOW its a mitral murmur.
-Once you've determined which valve it is from that, your only job is to determine if its a systolic or diastolic murmur. You don't need to be able to tell if the murmur is descrendo, crescendo-descrendo, "blowing", anything. If the murmur is at the upper right sternal border, it MUST be an aortic murmur. Is it systolic? Stenosis. Diastolic? Regurg.
-There are a couple places they can trick you. Mitral Regurg/Prolapse. You need to be able to pick up a click if there is one. Is there a click? Prolapse. If there's a click and its a diastolic murmur, it CAN'T be prolapse, it has to be stenosis. They will also try to trick you with hypertrophic cardiomyopathy, since its ejection murmur mimics aortic stenosis. But go back to the history in the stem, since its often is a dead giveaway from HCM. If it isn't, they have to give you something about how the murmur changes on held breath/valsalve/squatting/etc. Just remember, increased preload makes aortic stenosis louder (more blood through a small hole increases turbulence) and HCM ejection murmur softer (more blood in outflow tract keeps the mitral leaflet from collapsing against the hypertrophic ventricular septum).

They're also big on classic associations.
If its a mitral prolapse, its almost always in a Marfan's or adult polycystic kidney disease patient.
PDAs and ASDs are almost always in newborns.
Aortic stenosis is almost always in a 60 year old man.
If its a tricuspid murmur, its almost always in an IVDU.
Mitral murmurs almost always with rheumatic fever.

 

[metallo]

EXTREMELY helpful... thanks, ZagDoc!

 

[512TA]

I found the heart sound ones pretty easy to reason out. The murmurs I got were classic murmurs and pretty obvious from the audio, but each question also had enough info in the stem to reason it out.

Since they always list the point the murmur is heard loudest in the stem, here's how I would reason them out.
-You MUST know the points associated with each murmur. I learned "Al Pacino, The Man" but there's several mnemonics out there. Upper Right Sternal Border = Aortic. Upper Left Sternal Border = Pulmonic. Lower Left Sternal Border = Tricupid. Left 5th intercostal space at midclavicular line = Mitral. They are not trying to trick you, they will ALWAYS list the point the murmur is heard in its classic point of auscultation. So if they say the point the murmur is heard loudest is at the midclavicular line, you KNOW its a mitral murmur.
-Once you've determined which valve it is from that, your only job is to determine if its a systolic or diastolic murmur. You don't need to be able to tell if the murmur is descrendo, crescendo-descrendo, "blowing", anything. If the murmur is at the upper right sternal border, it MUST be an aortic murmur. Is it systolic? Stenosis. Diastolic? Regurg.
-There are a couple places they can trick you. Mitral Regurg/Prolapse. You need to be able to pick up a click if there is one. Is there a click? Prolapse. If there's a click and its a diastolic murmur, it CAN'T be prolapse, it has to be stenosis. They will also try to trick you with hypertrophic cardiomyopathy, since its ejection murmur mimics aortic stenosis. But go back to the history in the stem, since its often is a dead giveaway from HCM. If it isn't, they have to give you something about how the murmur changes on held breath/valsalve/squatting/etc. Just remember, increased preload makes aortic stenosis louder (more blood through a small hole increases turbulence) and HCM ejection murmur softer (more blood in outflow tract keeps the mitral leaflet from collapsing against the hypertrophic ventricular septum).

They're also big on classic associations.
If its a mitral prolapse, its almost always in a Marfan's or adult polycystic kidney disease patient.
PDAs and ASDs are almost always in newborns.
Aortic stenosis is almost always in a 60 year old man.
If its a tricuspid murmur, its almost always in an IVDU.
Mitral murmurs almost always with rheumatic fever.

Nice!

 

[sswang00]

does anyone know a site where I can listen to heart sounds for practice? Because I do not have the kaplan Q bank

Murmurs are covered well in Goljan and FA, but I had some trouble understanding s3/s4.
If anyone is having trouble understanding s3 and s4 sounds, i found a great description over here: http://www.prep4usmle.com/forum/thread/53109/

 

[deleted103644]

Auscultation Assistant

S3: "Kentucky" Ken (S1) Tuck (S2) EEE (S3)

Happens early in diastole, blood sloshing into a chamber with blood in it already.

S4: "Tennessee" Ten (S4) Ess (S1) EEE (S2)

Happens late in diastole, blood getting pushed into a noncompliant chamber.


For most heart sounds, you can reason your way through them (or at least really narrow it down).

Diastolic murmur: stenotic atrial valve or insufficiency of a ventricular valve.

Systolic murmur: stenotic ventricular valve or insufficient atrial valve.

Increase on inspiration: Right side.

Increase on expiration: Left side.

That alone is enough to narrow you down to 1-2 choices on most questions.

If you can get a good grasp of S2 splitting, even better (increased volume delays that side's S2 sound, splitting independent of breathing is due to blood bypassing the lungs --> ASD).

Throw in a couple of extra bits of trivia (valsava increases HOCM, machinery murmur, click in MVP, holosystolic murmur in VSD) and you've got most of your bases covered.


Personally I'm awful at actually hearing the sounds, so I mainly focus on these key points and then try to get the rest from the clinical scenario. Auscultation would be so much easier with one of these... ThinkLabs

 

[PokerDoc]

here's the site I used in cardio theme: http://www.blaufuss.org/

it in itself was enough for me to learn everything, but now you have more than enough resources in this thread.

 

[radiodoc99]

http://depts.washington.edu/physdx/heart/demo.html