So, here you are with stethoscope in your hands facing your first patient. Or maybe not the first? Auscultation has to be performed quickly but without any omissions. One more time: quickly and comprehensively. The rest is in the slideshow. More information about heart auscultation and cardiological diagnosis: http://cardiacauscultation.com

1. Doctor, Stethoscope, Patient: do the least, hear everything
Yaroslav Shpak, MD

2. My first auscultation experience was dramatic

3. And everyoneapproaching a patient for an auscultation for
the first time in their career is destined to end up the same way:

4. CONFUSION

5. What should we do?

6. The answer is simple:

7. during auscultation, we need to acquire
certain information by performing certain actions

8. It can be done in a variety of ways, but

9. it is desirable to do the least, while obtaining
allof the information.

10. We need a system.

11. How can you take the greatest possible advantage of your
capacities with the least possible strain? By cultivating the
system. I say cultivating advisedly, since some of you will
find the acquisition of systematic habits very hard.
Sir William Osler

12. Of course you are free to auscultate in
a way that is convenient for you,

13. but the systemguarantees (almost certainly;-)
that you will hear everything that can be heard
by spending the least amount of time and efforts.

14. It may seem that the actions, suggested
by the system, will take too much time.

15. But the entire process described here takes
3 to 5 minutes per patient for most cases.

16. Surely, at first, it will require more time.

17. Echocardiography is not
a quick procedure either
Why two mitral
valves 😨?

18. Auscultation is comparable to echocardiography
in terms of its diagnostic power. Even today.

19. Thus, few minutes are worth spending…

20. …and not depend on echocardiography.

21. Patient, in his turn, will appreciate your attention

22. So, the system

23. The entire process of heart auscultation
has two sides:
✤external
✤internal

24. External: what we do
with a stethoscope
and a patient. It is
visible to everyone.

25. Internal: what is
happening in our heads at
the same time. This side is
not visible to anyone.

26. External side is comprised of:
✤ Patient’s position during auscultation
✤ Position of the stethoscope and the way we use it (bell
vs. diaphragm)
✤ The optimal sequence of actions, leading to the best
result

27. A patient should be examined in the
following positions:
✤ lying on the back
✤ lying on the left side
✤ sitting
✤ standing

28. It is desirable to examine your patient in a squatted
position first, and then standing position immediately
after.
This is a valuable diagnostic technique for mitral valve prolapse and
hypertrophic obstructive cardiomyopathy.

29. TOO DIFFICULT!

30. Only at the beginning. In practice, it becomes difficult
when primary clinical data is not obtained in its entirety.
Such deficiency can never be compensated later.

31. And then real difficulties begin.

32. So, I’ll repeat:

33. A patient should be examined in the
following positions:
✤ lying on the back
✤ lying on the left side
✤ sitting
✤ standing

34. Cardiac exam in each position has its own
p E c u L i a r i t i e s.
The following information is easier to read and
understand than the word above.

35. Beginning of
auscultation:
✤ patient is supine
✤ stethoscope is applied to the
Erb’s point (third left
intercostal space near the
sternal border)

36. Major share of the heart-generated sound
flow can be heard in the Erb’s point

37. Occasionally, this is sufficient
to generate a diagnostic hypothesis.

38. In that case we can conduct auscultation in
abbreviated format, by searching for symptoms
confirming or refuting our hypothesis.

39. But, this is not possible
until we gain some experience.

40. For now we should adhere to the
system

41. After listening in the
Erb’s point,
stethoscope is placed
into aortic area.
Then we move it in small steps (3 to 4 cm)
through the following route: aortic area -
pulmonic area – back to Erb’s point – fifth
left intercostal space – and finally apex.

42. Then, stethoscope is placed
at the area symmetrical to
the Erb’s point on the right
side of the sternum.
This matters in diagnosing aneurysm of
ascending aorta.

43. Then, we move on
to the suprasternal
notch.
Hence, we won’t miss aortic stenosis.

44. After that – on to carotids
(no specific location, listen at
the point with the best
contact between stethoscope
and patient’s skin).
Hence we won’t miss stenosis of carotid
arteries or aortic stenosis.

45. Then – under the
left clavicle.
That way we won’t miss patent ductus
arteriosus.

46. Now, on to
epigastrium and
mesogastrium.
This is significant for diagnosing stenosis
of branches of abdominal aorta.

47. Then, patient turns
into the left lateral decubitus position

48. Do not fail to find a place, where apical imPulse is palpable,
and then conduct auscultation there.

49. Auscultate in the Erb’s point and at the left fifth intercostal space

50. Only at the left lateral decubitus position we must use both - the bell and
the membrane in each point

51. While auscultating in
other positions and
areas, membrane
only is sufficient

52. Next, patient sits down.

53. Along the left sternal
border search for a point,
where splitting of the
second heart sound is most
prominent.
This is a very important topic, but I will
not talk about it here.

54. Then, patient stands uP

55. Ask your patient to
exhale, hold the
breath and lean
forward.
Look for an early diastolic murmur of
aortic regurgitation at the Erb’s point and
in symmetrical area on the right of the
sternum. Press stethoscope’s membrane
firmly against the thorax. So firm, that
diaphragm’s imprint remains visible on
the skin (not forever!)

56. Next, patient
squats down.
Listen through membrane over the Erb’s
point and at the apex of the heart. Look
for a systolic murmur.

57. Then, patient
goes back into
vertical position.
Examine with a membrane in Erb’s point
and at the apex. Look for a systolic
murmur again.

58. That is it.
Whoever is observing us
won’t notice anything else.

59. Internal side
This is what happens in your head while
doing everything you’ve just read about

60. All this time you worked to obtain a disordered sonic flow encrypted to
contain surprisingly a lot of information about your patient’s heart.

61. Now, you need to analyze this sound flow by splitting it in components
and then interpret the data.

62. As a result, we obtain information about the structure
and the functions of the heart we’ve been examining
all this time.

63. But we will understand nothing by
perceiving heart sound in general.

64. Each component of the sonic flow should be picked out and analyzed

65. While analyzing specific sound, we must concentrate
on it and exclude everything else from our attention.

66. No matter what area we put stethoscope on, we should sequentially
concentrate our attention on the first heart sound initially

67. Then, on the second heart sound

68. Then, we search for extra sounds and murmurs during systole

69. Then, we search for extra sounds and murmurs during diastole

70. That’s how we scanned complete cardiac cycle without missing anything
By the way, this is a picture of mitral stenosis with
mitral opening snap in early diastole and low-
frequency diastolic murmur with the presystolic
accentuation
Loud first heart sound
And aortic systolic ejection
murmur (aortic stenosis?)

71. Don’t forget!

72. In each auscultation point we scan sound in complete diapason,
starting from low frequencies and moving on to the highfrequencies

73. In the beginning,
deep attention concentration
is required to perform all of that.

74. It may seem difficult (I understand)…

75. But a little practice makes this process
automatic and qu i c k

76. And nothing will be left out.

77. Do not neglect graphic fixation of what you hear.
This will significantly increase your auscultation
efficiency.

78. Graphic fixation
will be described in the next chapter…