Littmann Cardiology III, and i STILL can't hear an S4!

[PowderHound]

OK, so I have the nice stethoscope they recommended, and I've been on cardiology for 4 days and I still cannot hear an S4 to save my life. My attending listens to every patient before me and says, "s/he has an S4" and I listen at the PMI with the bell and I can't hear it at all. Even the ones my attending says are loud! I've gotten online and listened the the auscultation tutorials so I know what I'm listening for, and I just don't hear it. Has anyone else encountered this, or have any advice on what I can do. I'll buy a different freakin' stethoscope if I have to....

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[mountainman123]

I have a DRG Echo amplified stethoscope and I hear murmurs that the doctor couldn't, and this has been the case with the last 4 doctors that I have been with. DRG makes some sweet stethoscopes and they are all better than any Littmann in my opinion. I had the same stethoscope you did before this one, but got this one as a present when I started med school and have never gone back. It has a 400% digital amplification feature that lets you hear EVERYTHING. I got mine on Ebay- just type in DRG stethoscope and see what comes up. Just my opinion...

 

[VFTW]

It's the fourth day of your rotation, you say? Well, that's not so long. Our cardiology guy at my school, who is truly, a brilliant and important physician who is an outstanding clinician, told us that he didn't truly hear an S4 and know what it was until he was a cardiology FELLOW. and this is the dude that all of the other Cards faculty talk about as being a talented, excellent old-school diagnostician who can diagnose pretty much any cardiac defect based on auscultatory exam because he trained in the days before echos did all the work. If the master of heart sounds didn't hear an S4 right away, I'm pretty sure it's okay that you haven't yet, either. So don't stress, they'll come when they come.

 

[Dr JPH]

So don't stress, they'll come when they come.

I agree.

Many heart sounds, not just S4s, are "Ah-HA!" moments.

One day you will hear one and wont forget it.

Then the problem becomes convincing yourself not every patient has MVP.

 

[ericdamiansean]

Don't worry, it comes with experience..forget about S4, some people can't even catch diatolic murmurs.

Heard of people who are so good that you can give them a crappy disposable stet and they can hear murmurs, clicks, snaps etc?

 

[ericdamiansean]

I have a DRG Echo amplified stethoscope and I hear murmurs that the doctor couldn't, and this has been the case with the last 4 doctors that I have been with. DRG makes some sweet stethoscopes and they are all better than any Littmann in my opinion. I had the same stethoscope you did before this one, but got this one as a present when I started med school and have never gone back. It has a 400% digital amplification feature that lets you hear EVERYTHING. I got mine on Ebay- just type in DRG stethoscope and see what comes up. Just my opinion...

Is it that good? I am using an ADC cardio, but sometimes I think Littmann cardio has a louder and clearer sound. Am planning to change once I finish med school so am on the lookout for something really good

But DRG echo is so expensive, the cheapest on ebay is close to $300..rich folks..

 

[mountainman123]

Is it that good? I am using an ADC cardio, but sometimes I think Littmann cardio has a louder and clearer sound. Am planning to change once I finish med school so am on the lookout for something really good

But DRG echo is so expensive, the cheapest on ebay is close to $300..rich folks..

I also have a Littmann cardio and have compared and I think the DRG is better and clearer. It is expensive, but if you are interested in Internal Medicine, FP, Cardio, etc.. I think it would be a wise investment to have what you believe will help you do your job better. But, if you are a surgeon- no need. I know that the FP I am working with now and who has been doing FP for 14 years is amazed with my stethoscope and looking for one himself after comparing with his Littmann.

 

[ericdamiansean]

I also have a Littmann cardio and have compared and I think the DRG is better and clearer. It is expensive, but if you are interested in Internal Medicine, FP, Cardio, etc.. I think it would be a wise investment to have what you believe will help you do your job better. But, if you are a surgeon- no need. I know that the FP I am working with now and who has been doing FP for 14 years is amazed with my stethoscope and looking for one himself after comparing with his Littmann.

People are still amazed with my one sided bell/dia ADC cardio , even those in IM.
The culture here is that you get pimped if you get something "out of the norm", for example pink tubing for stets...if I get an electronic, I'll bring a camera to capture one of these expressions

How about maintenance? Changing the batteries? I am sure you won't be leaving it hanging around in your car (heat, theft etc)

 

[mountainman123]

Actually noone can tell that it is electronic. It looks like a normal stethoscope and can be used even if the batteries go dead. Actually, I don't use the digital that often- only when i think I hear something and want to make sure. The head turns to either Bell, Digital, Diaphragm, or Off completely. On the regular diaphragm it is better than the Littmann cardio and that is what I was talking about when comparing it. The batteries are supposedly easy to change as you just order it online for like 10 dollars or so and they send you "the kit". I have not had to change mine yet and have had it over 2 years now. DRG uses solid metal tubing inside to transfer the sound better, the eartips are gel and way more comfortable. Just check it out and compare, they sell them both on Allheart.com I think.
As far as worrying about it- I don't think I worry more than I did with my old one, but like I said before- you really can't tell that it is digital like the Littmann does- being extremely different looking.

 

[ericdamiansean]

I've checked out allheart, it seems tat DRG is the only one that can function as an analog stet?
Any others?

 

[amyl]

i LOVE my amplified stethoscope! I think it was about 220 but worth every penny. i can hear everything even in the gomers and overweight.

 

[Purifyer]

Im crying on the inside for the medstudent who can't hear an S4 after 4 days of cardiology.. lol.

In the real world, if a patient has a previously undocumented murmur, they get an echo. If a patient is asymptomatic but that budding med student within hears an S4, who cares? If they are in new symptomatic right or left or C HF.. they'll get an echo more than likely anyway (ie. for more effective in demonstrating diastolic dysfunction than a subtle clinical sign).

The moral of the story is... ECHOs for all!

I dont remember the last time I heard a diastolic murmur either. NB Im an intern with 6 months experience (*GASP!* I hear you say), 3 months CCU and 3 months general medicine.

Don't get me wrong, I loved 'clinical medicine' and all the useless signs and crap that you get pimped on mercillessly in med school, not that anyone will care but I topped the class in terms of medical clinical examination distinction exams. There was a time when I actually gave a crap about extra heart sounds. But the fact of the matter is, they come in, we buff them, give them the frusejuice and if they are still too sick, ship them off to hospital level care, next please. Man that sounds pretty jaded.. Im not... haha.

 

[ChildNeuro]

If you listen to enough patients then you will get the murmurs, it just takes time. I have shyed away from getting an amplifying electronic stethoscope because I am afraid it will produce murmurs that aren't really there. A cardiologist in his 80's that I followed before medical school was hard of hearing, but with his stethoscope could diagnose heart murmurs very quickly and pull out subtle findings, so experience does help alot. On inpatient medicine it is easy to believe that echo is the end and begining of the cardiac evaluation, but it is important to be able to pick-up stuff on the ambulatory side as well. It should be easy to differentiate diastolic and systolic murmurs, just palpate the radial pulse if you are uncertain what phase it is happening in. S4 and S3 are a bit more trickier, but if you hear it enough then you will learn to appreciate it. Remember, hearing cardiac murmurs comes with much practice, which you will have, and is physical exam finding that will build with time, don't become distracted by pining down all of the cardiac murmurs in a patient, pay attention to the big picture and studying clinical medicine too.

 

[bivwack]

strangley enough, i read this thread last night, and during IM rounds today my resident, told me to listen for an S4 on a patient, i used my $26 knockoff- Littmann Cardiology III and heard it right away. First time i ever heard one, first time i ever tried.
i don't think the brand, model etc...of stethoscope matters that much, it has more to do with the # hearts you have listened to, the more normal hearts you ascultate the easier it is to identify something that doesn't belong or isnt right.

Now i am not saying that i would have picked it up, and know it was an S4, had my resident not pointed it out, but i probably would have picked up that something was not quite right about S1 on this pt, because i have a pretty good idea what a normal S1 should sounds like. And i will defiantly need to hear many more S4's before i can confidently pick one up w/o prompting

 

[ericdamiansean]

The moral of the story is... ECHOs for all!

Yup, ECHOs for all but I think that your clinical skills should be pretty good as well. You don't know where you might be working one day, maybe even for MSF, you don't have an ECHO at your disposal.

 

[TheRoach]

S4 ba duh................duh
S3 ba .............duh duh

More than 2 duh's and you either got an S3 or S4 then just listen for where 2 of the 3 are closest together at the beginning of the heart sounds or at the end.

 

[Bike on a Trek]

1) Listen to an audiotape (http://www.wilkes.med.ucla.edu/Rubintro.htm or http://www.sci.sdsu.edu/multimedia/heartsounds/ or the CD-ROM included with some textbooks) Note that you may have to install free plug-ins to get this to work. When you listen, you should first try to listen for the timing. Next, as you listen, "Zen out" and try to ignore the S1 so that the S4 will stand out. What you should try to do is pretend like you are listening for the sounds "behind" the S1. If this doesn't make sense, imagine you're sitting in at home in your studio theatre with surround sound, about 10 feet from your big screen tv with speakers to either side of you (nice imagery, huh?). Pretend that you are trying to block the sound out of the two side speakers (ie, S1 and S2) so that you can isolate the sound from the central speaker at front.

2) After the above, the next time you are on rounds, ask your instructor if they would hold their bell in place and allow you to listen through their stethoscope. Do exactly as you did with the audiotape. Concentrate on the timing and then "zen out" the S1 to listen for the background sound. I guarantee that if you concentrate, you'll hear it with this method (assuming your instructor heard the correct thing!). If you still can't hear it, ask your instructor to use your stethscope to see if she/he can still hear it.