I myself faced lots of problems in auscultation. I never paid attention to wards in second prof and used to argue that there is nothing called murmur, all is hallucination!!! But after entering final prof, I realised that I also got tuned to those hallucinations. I would tell you how I got tuned to that!! My biggest problem was that I did not know what actually murmur is, the saying that if mind does not know ears dont listen, was absolutely true for me.
First of all I had to become very confident of theory. It is really simple concept. A little Anatomy , a little Physiology and a little Pathology . I read about using the stethoscope. I never knew why bell of stetho is important or why diaphragm is important. You surely would be knowing all these, but just to add for the ignorant ones that the diaphragm basically comes in more intimate contact with chest and helps transferring high frequency sounds better, and periphery alone (bell) helps in transmitting lower frequency better. In litmann there is said to be some springy action in the periphery of steth, such that if you dont press hard then diaphragm does not come in contact but if you push it a bit, then diaphragm touches the SKIN . So all low pitched sounds like mitral steosis murmur are better audible by bell and higher frequency by diaphragm.
Then comes the need to get acquainted to the heart sounds, first... second...first... second. This should be practiced on normal people or with people with slow heart sounds. I used to sleep listening to my own heart sound. The rythm of heart is something which should be firmly rooted in mind before attempting any murmur. Learning of course comes by palpating brachial or carotid along with but slowly we appreciate that diastole is longer and systole is smaller. Once this is appreciable, the sense of touch is relieved from effort and you need not palpate anymore. After mastering this rythm then comes quality of first and second sounds. Listen to stetho as often as possible, never leave a patient before listening heart and breath sounds. To catch abnormal the ears should be so familiar with normal that abnormal stands up on its own.
Now after mastering the normal sounds, catch hold of a good clinician, or request a house physician, or request a teacher or easiest is to go to wards and see the already diagnosed heart patients. Follow the book for auscultation and master the techniques of murmur appreciation before going to the patient. If your ear is trained for normal then you would definitely find the abnormal. dont start with MS, start with aortic stenosis or mitral regrugitation. These are very harsh murmurs. Then slowly let your experience flow to MS and AR. The day you have appreciated the MS murmur, you should gain confidence that you are above many now. Start concentrating on the first sound, opening snap and the presysytolic accentuation. They are all true "halluncinations"
Thereafter start seeing patients blindly. See the diagnosis only after you have reached a diagnosis yourself. One tip that I used most was that I took the history first, it helped me to concentrate on area of interest. Syncope will tell you to concentrate on aortic and breathlessness on mitral valve. I do not want to stress on this, but you need a good teacher. After learning all this you would feel S3, S4 and other murmurs to be so obvious. Now with diagnostic imaging becoming more common the art of listening is getting lost among younger generation but mastering steth, I feel is must. The last part and most difficult part that I learnt was learning absence of sounds. Like others, I used to work hard for resuscitating a patient. If that patient died, I could not believe my ears that there is no sound. Silence has its own sound. But slowly things changed at that front also. While working in Govt hospital, I had to declare lots of death. Slowly I became accustomed to that silence also....
I hope all this helps!!!!! if you have any queries then please do write, there are many here to help you!!
Note: discussion thread where soniadr25 originally posted her experience in learning heart sounds is at http://www.rxpgonline.com/postt41606.html
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