Murmurs and lungs

[maygrl110]

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Does anyone know of a good website where we can listen to different heart sounds and murmurs? I understand it conceptually, but would really like to know what they sound like...totally something that still confuses me still. Similarly, anything with lung sounds-normals and abnormals would be great, too! I know Qbank had this, but my subscription's over!

Thanks!

Mei

 

[J-Rad]

http://www.blaufuss.org/

 

[Tiger26]

you can get the imurmur app for an iphone or itouch for only $0.99 on itunes--it's excellent

 

[jdh71]

The most important thing for the student to remember about murmurs is timing and location. I do my initial heart exam the same way every time, and it has made me more efficient and I'm less likely to miss anything. I know the "classic" way to approach the heart is inspection, palpation, percussion, auscultation, but for the purpose of being efficient, I normally go right to auscultation, and as long as you put your scope on the patient and not over their gown/t-shirt/blouse you will inspect at the same time. In a thin little dude you can often see the apical pulse through his chest wall.

I start at the apex with the diaphram - I identify s1 and s2, using the carotid pulse. Once I have s1 and s2, I know where systole and diastole happen, and I can now start listening to murmurs, clicks, and splits listening in the 5 main locations starting at the apex and working my way to 2nd RICS. If I hear a murmur, I identify (to the best of my ability) if the murmur happens in systole or diastole and in which location(s) it happens to be the loudest. And after having my ass handed to me by a cardiology attending, I now palpate any murmurs I find for thrills. Lastly I throw my bell onto the patient to check for gallops.

I always finish my heart exam with the radial pulses, making sure they match the monitor, are regular, and of similar strength.

I think its also important to remember that a heart sick enough to have a murmur will likely have more sounds than the idealized/stylized single murmur that you'll hear on "murmur sounds sites". At the end of the day even the cards attendings have to spend time with their scope on the patient's chest to get the correct murmurs and diagnosis. Your attendings will want to know that you are doing the right things to look for the murmurs and other sounds, picking up the rest takes time and experience.

 

[J-Rad]

...I start at the apex with the diaphram - I identify s1 and s2, using the carotid pulse. Once I have s1 and s2, I know where systole and diastole happen, and I can now start listening to murmurs, clicks, and splits listening in the 5 main locations starting at the apex and working my way to 2nd RICS. If I hear a murmur, I identify (to the best of my ability) if the murmur happens in systole or diastole and in which location(s) it happens to be the loudest. And after having my ass handed to me by a cardiology attending, I now palpate any murmurs I find for thrills. Lastly I throw my bell onto the patient to check for gallops.

I always finish my heart exam with the radial pulses, making sure they match the monitor, are regular, and of similar strength.

I think its also important to remember that a heart sick enough to have a murmur will likely have more sounds than the idealized/stylized single murmur that you'll hear on "murmur sounds sites". At the end of the day even the cards attendings have to spend time with their scope on the patient's chest to get the correct murmurs and diagnosis. Your attendings will want to know that you are doing the right things to look for the murmurs and other sounds, picking up the rest takes time and experience.

Nice advice. Remember positionality (supine, sitting/standing) and provocative maneuvers (valsalva, squatting, squat-->stand). A hint about valsalva esp for older toddlers to (less comprehending) adults: when supine telling them to push their belly out against your hand helps with this if they don't understand blowing out against a closed glottis. And since I mentioned kids and since this is a medical student forum I'd mention that murmurs in children and young adults quite often do not represent a sick heart.
And while the last bit of commentary is correct, there is data to support improvement in auscultatory skills using electronic resources in medical student and residents (in IM, FP, and Peds)

 

[howelljolly]

The most important thing for the student to remember about murmurs is timing and location. I do my initial heart exam the same way every time, and it has made me more efficient and I'm less likely to miss anything. I know the "classic" way to approach the heart is inspection, palpation, percussion, auscultation, but for the purpose of being efficient, I normally go right to auscultation, and as long as you put your scope on the patient and not over their gown/t-shirt/blouse you will inspect at the same time. In a thin little dude you can often see the apical pulse through his chest wall.

I start at the apex with the diaphram - I identify s1 and s2, using the carotid pulse. Once I have s1 and s2, I know where systole and diastole happen, and I can now start listening to murmurs, clicks, and splits listening in the 5 main locations starting at the apex and working my way to 2nd RICS. If I hear a murmur, I identify (to the best of my ability) if the murmur happens in systole or diastole and in which location(s) it happens to be the loudest. And after having my ass handed to me by a cardiology attending, I now palpate any murmurs I find for thrills. Lastly I throw my bell onto the patient to check for gallops.

I always finish my heart exam with the radial pulses, making sure they match the monitor, are regular, and of similar strength.

I think its also important to remember that a heart sick enough to have a murmur will likely have more sounds than the idealized/stylized single murmur that you'll hear on "murmur sounds sites". At the end of the day even the cards attendings have to spend time with their scope on the patient's chest to get the correct murmurs and diagnosis. Your attendings will want to know that you are doing the right things to look for the murmurs and other sounds, picking up the rest takes time and experience.

Good advice.

I'd also add, after literally being smacked upside the head by my cards attending when I forgot...

Palpate the PMI first, and listen over it (first) with the bell and diaphragm, then you can back-track to Ao, Pulm, Tri...

The most information is yielded over the PMI, and it might suggest what you should expect to hear in other locations, and what you should go hunting for on exam.

 

[jdh71]

Nice advice. Remember positionality (supine, sitting/standing) and provocative maneuvers (valsalva, squatting, squat-->stand). A hint about valsalva esp for older toddlers to (less comprehending) adults: when supine telling them to push their belly out against your hand helps with this if they don't understand blowing out against a closed glottis. And since I mentioned kids and since this is a medical student forum I'd mention that murmurs in children and young adults quite often do not represent a sick heart.
And while the last bit of commentary is correct, there is data to support improvement in auscultatory skills using electronic resources in medical student and residents (in IM, FP, and Peds)

I guess I don't worry about provacatives too much - most of my patients are too messed up or the process would be too time time consuming to attempt much of that (it's a modern world and for better or worse, the echo will take all the mystery out of it anyway). I imagine they are more helpful in the pediatric population - so I've got no comments on kids.

I'd like to see that data, because I have a hard time believing that electronic translates into practical clinical identification anymore than just listening to patients with murmurs. (Not being argumentative either)

 

[jdh71]

Good advice.

I'd also add, after literally being smacked upside the head by my cards attending when I forgot...

Palpate the PMI first, and listen over it (first) with the bell and diaphragm, then you can back-track to Ao, Pulm, Tri...

The most information is yielded over the PMI, and it might suggest what you should expect to hear in other locations, and what you should go hunting for on exam.

Good to remember of course. Unfortunately, in my patient population, finding a apical pulse is often an effort in futility.

 

[J-Rad]

I guess I don't worry about provacatives too much - most of my patients are too messed up or the process would be too time time consuming to attempt much of that (it's a modern world and for better or worse, the echo will take all the mystery out of it anyway). I imagine they are more helpful in the pediatric population - so I've got no comments on kids.

I'd like to see that data, because I have a hard time believing that electronic translates into practical clinical identification anymore than just listening to patients with murmurs. (Not being argumentative either)

"Cardiac auscultatory training among third year medical students during their medicine clerkship." Int J Cardiol. 2009 Feb 3 (Ostfeld, Robert et al)

"Helping Family Physicians Improve Their Cardiac Auscultation Skills with an Interactive CD-ROM" The Journal of Continuing Education in the Health Professions, Volume 22, pp. 152-159. (Roy, Douglas et al)

"Teaching Cardiac Auscultation: Effectiveness of a Patient-Centered Teaching Conference on Improving Cardiac Auscultatory Skills" Mayo Clin Proc. 2005 Nov;80(11):1443-8 (March, SK et al)

"The power of repetition in mastering cardiac auscultation." Am J Med. 2006 Jan;119(1):73-5 (Barrett MJ, et al)

"Effectiveness of Teaching Cardiac Auscultation to Residents During an Elective Pediatric Cardiology Rotation" Pediatr Cardiol. 2008 Nov;29(6):1095-100 (Mattioli, LF et al)

"Comparison of Two Educational Interventions on Pediatric Resident
Auscultation Skills" Pediatrics 2004;113;1331-1335 (Mahnke, CB et al)

"Teaching Cardiac Auscultation Using Simulated Heart Sounds and Small-group Discussion" Fam Med. 2001 Jan;33(1):39-44 (Horiszny JA.)

All found that electronic media could augment clinical/didactic teaching.
"A novel multimedia tool to improve bedside teaching of cardiac auscultation." Postgrad Med J. 2004 Jun;80(944):355-7 (Woywodt A) was a bit of a variant on the theme, but interesting nonetheless.

As for the provocative maneuvers, I don't do them on every (or even many) patients. However, the ones I am most concerned with are those that have a murmur that could be indicative of HOCM. Obviously a concerning family history, abnormal ekg, or concerning hx is going to earn an echo. But remember ~50% of kids will have a murmur (estimated 90% will have one in the totality of their childhood) yet congenital heart disease is <1% of the child population. And there isn't a pediatric cardiologist around every corner, so good PE skills in reassuring a benign (aortic systolic murmur vs. HOCM murmur in this case) is important from a practical standpoint.