Needs tips/tricks to auscultate heart sounds

[Jabbed]

Specifically:

1. How should I best position the patient?
   
2. Short of rapid squatting, are there any easy bedside maneuvers to increase preload? I'm never certain whether or not I'm just hallucinating the 1/6 murmurs.
   
3. Ways to reduce factitious sounds.

Thanks

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[Pacna]

Say "I didn't hear anything", then when the attending has you do something different on the third attempt, say "oh I hear it now."

 

[CherryRedDracul]

It takes experience and practice, but here are a few tips

1. Don't listen over clothes. Listen on bare skin.
2. Keep the stethescope tubing from rubbing against other things, creating adventitious sounds. I use my thumb to hold the tubing back from touching the patient.
3. If you have difficulty hearing heart sounds on a large patient, turn them on their left side so the heart moves closer to the chest wall.
4. Check a pulse simultaneously if you have difficulty figuring out S1 vs S2 (or S3, S4), systolic vs. diastolic murmurs, etc.
5. Have everything be as silent as possible in the room. That sometimes includes reminding the patient to be as quiet as he/she can be so you can listen carefully. But if you're in a busy setting like an ED, tough luck. Nothing you can really do about that.

 

[Bacchus]

Having the patient inspire deeply and then hold it increases negative pressure in the chest, increasing venous return a.k.a. preload. You can also ask the patient to lift her legs or have someone lift their legs to increase the venous return much like if they were in shock or about to vasovagal.

 

[atomi]

Hold the stethoscope between your index and middle fingers so that your finger tips extend beyond it and touch the patient. Put the rest of your hand on the patient so that your hand has stabilized the stethoscope and it cannot move.
The rookie mistake is to hold the head of the stethoscope with your finger tips and not touch the patient at all with the hand holding the stethoscope, just the head of the stethoscope. If you do this, then the head will be able to move on the patient and you will hear the friction of the movement, which will be much louder than the heart sounds and totally obscure them.

 

[KinesiologyNerd]

I usually check the resident's note for what they heard, and later cry myself to sleep wondering how I'll ever make it as an intern.

 

[cbrons]

Don't you love it when the nurses (or medical assistants) don't tell patients we cant properly examine them when they have jeans and a winter jacket on?

 

[Jabbed]

Having the patient inspire deeply and then hold it increases negative pressure in the chest, increasing venous return a.k.a. preload. You can also ask the patient to lift her legs or have someone lift their legs to increase the venous return much like if they were in shock or about to vasovagal.

Increased venous return but also increased pulmonary vascular compliance → ?decreased LV preload. I suppose if they hold long enough though the pulmonary vasculature will constrict.

Thank you for the thoughts though. I'll try and give the leg maneuvers a shot too.

 

[Bacchus]

Increased venous return but also increased pulmonary vascular compliance → ?decreased LV preload. I suppose if they hold long enough though the pulmonary vasculature will constrict.

Thank you for the thoughts though. I'll try and give the leg maneuvers a shot too.

http://www.cvphysiology.com/Heart Failure/HF006.htm

It's recommended if you were going to do you maneuvers for HOCM murmur detection, you do the leg raise maneuver.

 

[Bacchus]

http://www.cvphysiology.com/Cardiac Function/CF018.htm

We are both correct. It depends what your end goal is. Questioning pathology of the tricuspid or pulmonic valve? Breathe in.

HOCM? Leg raise and follow what you said.

 

[themockjock]

Specifically:

1. How should I best position the patient?
   
2. Short of rapid squatting, are there any easy bedside maneuvers to increase preload? I'm never certain whether or not I'm just hallucinating the 1/6 murmurs.
   
3. Ways to reduce factitious sounds.

Thanks

1. Put your stethoscope back in your pocket
2. Walk out of the room and open your hospital's EMR
3. Order Echo
4. Wait for a minute
5. Look at results of echo, see that patient has moderate AS
6. On rounds, pontificate about the 3/6 crescendo-decrescendo murmur that is heard best in the 2RICS and radiates to the carotids
7. Profit

 

[Bacchus]

I need to work at your system. Our echoes take hours to days to get done.

 

[TooMuchResearch]

Don't push too hard.

 

[Jabbed]

Thought I'd report back on what's worked for me:
1. Patient sitting up and leaning forward.
2. Deep inspiration and hold for 5 seconds: seems to increase both right and left-sided systolic murmurs
3. Small earbuds and (what's honestly been the biggest improvement for me) looking at the horizon and unlocking my jaw so the ear piece can totally nestle into my ear.
4. Resting my palm against the chest with the stethoscope head between my index and second finger + making sure that the tubing is totally straight.

Definitely noticed a substantial improvement in sound quality.

 

[Tenk]

1. Buy an electronic stethoscope.

2. Enjoy actually being able to hear things.

 

[Crayola227]

closing your eyes can help actually

sorta like Marvel's Daredevil

 

[medicalenthusiast13]

Hand grip maneuver to help differentiate between an aortic stenosis/mitral regurg.

 

[badasshairday]

1. Listen on bare skin

2. Be able to recognize aortic stenosis. Be able to recognize whether there is a diastolic or systolic murmur. The rest of the specifics don't matter because it turns out nobody except dinosaur cardiologists can tell (and even they are wrong often)

3. Get echocardiogram.

 

[badasshairday]

1. Put your stethoscope back in your pocket
2. Walk out of the room and open your hospital's EMR
3. Order Echo
4. Wait for a minute
5. Look at results of echo, see that patient has moderate AS
6. On rounds, pontificate about the 3/6 crescendo-decrescendo murmur that is heard best in the 2RICS and radiates to the carotids
7. Profit

Truth. You will realize in real life practicing physicians don't bother with those fancy maneuvers.

 

[Temple2020]

practicalclinicalskills.com (ECG | EKG | Heart Sounds | Murmurs | Lung Sounds) and easyauscultation (Heart and Lung Sounds | Free Lessons and Quizzes | Easy Auscultation)

 

[CherryRedDracul]

1. Put your stethoscope back in your pocket
2. Walk out of the room and open your hospital's EMR
3. Order Echo
4. Wait for a minute
5. Look at results of echo, see that patient has moderate AS
6. On rounds, pontificate about the 3/6 crescendo-decrescendo murmur that is heard best in the 2RICS and radiates to the carotids
7. Profit

The bolded would be a dream at my hospital.

Anyway, for me, my favorite way of auscultating a patient is to hold the tubing between my fingers and "plop" the stethoscope head onto the patient. It's similar to this stock photo with my fingers maybe a little more proximal.

I don't know, but it feels like I dampen less of the resonance of the stethoscope head when I hold the tubing as opposed to the head. I used to suck at a murmurs when I was an MS3, but by intern year, I got to the point where I could out-hear most IM attendings and could almost be on par with a relatively new cardiology fellow.

Of course, if the murmur is significant, we'd just echo anyway. And since I'm now a radiology resident, the stethoscope is buried somewhere in my apartment.

 

[Temple2020]

When is it appropriate to use the bell? I've had preceptors tell me to use it on babies, the carotid artery/jugular vein, etc.