Page 1 of 2: FAQ: How to master heart sounds?

vic01 · Credits: 3793 Preparing for: AIIMS My Scrapbook

haaai every1,
i face a lot of problem in recognizing and interpreting heart sounds and murmur..
can any1 pleez help me regarding wat exactly should i be doing?
lookin 4 ur advices and support
thank u all in anticipation

medico_mahesh · Credits: 1006 Preparing for: USMLE Step 1 My Scrapbook

hope this may helpful to u

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take other advice too.
gud luck

vic01 · Credits: 3793 Preparing for: AIIMS My Scrapbook

thanks a lot mahesh...
its really nice...
just got a glimpse of the site...

soniadr25 · Credits: 2078 Preparing for: AIPGE My Scrapbook

Yes indeed it is a wonderful site!! 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!!

barun · Credits: 218 Preparing for: DM - Cardiology My Scrapbook

thanks for such a little but very basic lecture.

soniadr25 · Credits: 2078 Preparing for: AIPGE My Scrapbook

You are welcome Barun!! If you have any questions on auscultation then please do post!!! There is a famous thread initiated by draditithegreat.

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Just browse through this and you would get good compilation of heart murmurs....

vic01 · Credits: 3793 Preparing for: AIIMS My Scrapbook

great work soniadr...
it indeed is proving v.helpful,goin step by step...
i too agree the art of auscultation is gettin lost...
but doesnt that feel great wen you find that diagnosis being labelled by echo wat u already had made by your stetho...
thanks again

soniadr25 · Credits: 2078 Preparing for: AIPGE My Scrapbook

You are welcome vic01!! It feels too good when you see the echo report matching with your diagnosis. I remember in my final year, the teacher who taught me, used to give list of cases (to auscultate) every Monday. It went on for 3-4 weeks and then I went to his OPD after my clinics class. There was a patient lying, with five-six stethos on his chest (you know it happens sometimes during classes). Sir asked me to go and see the case... With his training, I had grown lot more confident and it did not take more than a min (in that crowd) to diagnose it as mitral stenosis with pulmonary hypertension, and when I uttered these word to him, he showed me exact wording written on patient's echo report!! That doubled my blood volume instantly

vic01 · Credits: 3793 Preparing for: AIIMS My Scrapbook

so prompt in replying back!!!!!!
i think i really m impressed by u..
n will need to know a bit of heart sounds 4m u..
if i keep listening,i think kuch to samajh me aa jaana chahiye...

thanks 4 ur lovely guidance..
will need it more in future

soniadr25 · Credits: 2078 Preparing for: AIPGE My Scrapbook

Kya karein vic bhai, "is PG entrance ne nikkamma bana diya, varna bande hum bhi bade kaam ke they"!!... isi liye net pe hi baithe rehte hain!!

You are most welcome for your queries! But I would stress on clinical examination before starting auscultation. Just to show the importance of clinical examination, I would narrate you a story. I did not do my internship from my home institute. While in my new college, I came across a young male patient who was being treated for rheumatic heart disease without any history of rheumatic fever (sometimes it can not be elicited)!! One of my friends took me to the patient for learning heart sounds. I told her to see the patient first. And it was a coincidence that by little effort on clinical examination we could elicit features of Marfan's syndrome. I mean they are so obvious, of course, but only to those who wish them to be obvious. And instantly that MR murmur took a preponderance for mitral valve prolapse..... So that is why small things like splinter hemmorhages can steer the diagnosis and treatment instantly.... Never reach for stetho until you have made up a probable diagnosis!!!

All the best into the world of auscultation...!!

vic01 · Credits: 3793 Preparing for: AIIMS My Scrapbook

rxpg team...
do u have anything to add to this????????
coz heart sounds is a v.commonly encountered prblm
for both ugs and pgs

rick12 · Credits: 2844 Preparing for: Maharashtra PG My Scrapbook

great site man...
beautifully heard all the heart sounds
thanks
medico_ mahesh

superashdoc · Credits: 26179 Preparing for: DNB Part 2 My Scrapbook

Hey that 'bhai' thing was pretty suggestive.Does this now mean we are a part of a rakhee thread?hee hee.

AshB · Credits: 42606 My Scrapbook

hey dr sonia, thanks for sharing ur experiences!!

legolassildarin · Credits: 2428 Preparing for: Maharashtra PG My Scrapbook

hi there
gr8 reference site and thanx soniadr
anyways i'd like to add a small thing.make it a habit to put a thumb over the common carotid when u place ur stetho over any of the heart areas.the 1st heart sound corresponds with the aortic pulsation so when u want to know murmurs this becomes the best way to determine whether they are diastolic or systolic...........it was taught to us by an eminent cardiologist from AIIMS..........great physician.made it easy and convinient for us to understand

sd04 · Credits: 4337 Preparing for: Canada My Scrapbook

wow,soniadr u r gr8 n very helpful hope to get accustomed v heart sounds after ur educating tips

n thanx medico_mahesh,wonderful site indeed

simba7ligo · Credits: 305 My Scrapbook

i am sorry for what about to say... i think you might know it but for examining murmurs... there are steps to be followed

1) where is the murmur?
2) is it systolic or diastolic?
3) where can it be heard loudest?
4) does it radiate to axilla, carotid?
5) is it associated with a thrill?

i just want to give u a way to approach a murmur... it is nice to listen to a murmur and say what it is quickly but putting steps just might help anyone esp. me on not even diagnosing but talking about what i hear and can find on auscultation...

drsumit84 · Credits: 204 Preparing for: AIPGE My Scrapbook

thanx for such a nice guideline to diagnose murmurs.

vintu · Credits: 199 Preparing for: AIIMS My Scrapbook

hey thanx sonia.
dat was really informative.
i'll surely practice ur way.
i always had alot of trouble listening n appreciating murmurs.but,i think ur info wud make a difference.
byee

dr_idli · Credits: 2020 Preparing for: MRCP Part 1 My Scrapbook

as with all the others , this is a very interesting thread . thank you soniaji .
i'm begining to work in a cardiology unit . any more tips for a fresher like me

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