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RxPG :: View topic - How to master heart sounds?  
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Author Message

vic01
Aim AIIMS

FAQ: How to master heart sounds?
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

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medico_mahesh
Aim USMLE Step 1

hope this may helpful to u
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take other advice too.
gud luck


vic01
Aim AIIMS

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


soniadr25
Aim NEET PG

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!!! icon_lol.gif

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" icon_biggrin.gif

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.... icon_cry.gif

I hope all this helps!!!!! if you have any queries then please do write, there are many here to help you!!


barun


thanks for such a little but very basic lecture.


soniadr25
Aim NEET PG

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
Aim AIIMS

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
Aim NEET PG

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 icon_wink.gif


vic01
Aim AIIMS

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


soniadr25
Aim NEET PG

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!! icon_biggrin.gif

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
Aim AIIMS

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
Aim DM Cardiology

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


superashdoc
Aim DNB Part 2

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


AshB


hey dr sonia, thanks for sharing ur experiences!! icon_smile.gif


legolassildarin
Aim Maharashtra PG

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
Aim Canada

wow,soniadr u r gr8 n very helpful hope to get accustomed v heart sounds after ur educating tips icon_smile.gif n thanx medico_mahesh,wonderful site indeed icon_smile.gif


simba7ligo


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


thanx for such a nice guideline to diagnose murmurs.


vintu
Aim AIIMS

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
Aim MRCP Part 1

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


arpatil
Aim NEET PG

thanks.its very good.


drnirrag
Aim MS Othopaedics

i d just like 2 add a small point...

auscultate with the same steth every time ... and a decent quality one at that


sheshukumar
Aim DM Neurology

gone thru ur communications ............... nw can i share my queries with you.


vic01
Aim AIIMS

sure sheshu...
go ahead and put in all your doubts


drkk007
Aim DM Cardiology

reg listening to cardiac sounds
hello vic! First of all to master cardiac sounds, try to listen to each and every patient present in your ward so as to differentiate normal one from abnormal one.. ok?
Then, to differentiate systolic frm diastolic murmurs, take help of carotid pulse. The cardiac sound coinciding with carotid is S1. So u can understand the murmur if it precedes the S1 as diastolic and if it succeeds carotid as Systolic .. Ok

Hope this helps you!!!!!!!!!!!!

Bye


drkk007
Aim DM Cardiology

helo soniadr! i think u got very wel experienced in listening 2 heart sounds... Hope u grow beter n beter so as to reach the heights of eugene braunwald!!!!!!!!!!!
al da best


mann_comp
Aim USMLE Step 1

hi guys t really was an enriching experience reading this thread thanks a lot


rmh


Interesting thread!!!!!!!


sayedsileem


It is very simple, just concentrate, prolong the time of listening at each site and imagine the motion of valves and blood that is passing through them.


vivekvjay
Aim Other

GRT WORK SONOA DR....
TATS WAS SUPERB SITE...
TANX ALOT ....


mohammed2351
Aim UPSC

soniadr25 wrote:
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!!! icon_lol.gif

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" icon_biggrin.gif

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.... icon_cry.gif

I hope all this helps!!!!! if you have any queries then please do write, there are many here to help you!!



excellent post...for the first time i felt i need to not just know abt a thng but need to master it fully..coz it would help serve the patients in need of care....


contactKhans
Aim AIIMS

Hi All ,
We are having MD/MS/PG-DIPLOMA/MBBS/MDS/BDS Management quota seats in Karnataka,
If interested Kindly call on 81..47..83..81..29....


arunsbn94


Thanks dr. vic for starting such a nice and useful thread


rajeevsharma
Aim DM Gastroenterology

U can hear audio cassettes and and CDs of Dr Ghanshyam Vaidhya Clinical Cases


arunsbn94


thanx. soniadr25 & medico_mahesh.....
The Auscultation Assistant is really a nice and useful site....

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