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How to perform heart auscultation: do minimum, hear everything

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:

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How to perform heart auscultation: do minimum, hear everything

  1. 1. Doctor, Stethoscope, Patient: do the least, hear everything Yaroslav Shpak, MD
  2. 2. My first auscultation experience was dramatic
  3. 3. And everyoneapproaching a patient for an auscultation for the first time in their career is destined to end up the same way:
  5. 5. What should we do?
  6. 6. The answer is simple:
  7. 7. during auscultation, we need to acquire certain information by performing certain actions
  8. 8. It can be done in a variety of ways, but
  9. 9. it is desirable to do the least, while obtaining allof the information.
  10. 10. We need a system.
  11. 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. 12. Of course you are free to auscultate in a way that is convenient for you,
  13. 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. 14. It may seem that the actions, suggested by the system, will take too much time.
  15. 15. But the entire process described here takes 3 to 5 minutes per patient for most cases.
  16. 16. Surely, at first, it will require more time.
  17. 17. Echocardiography is not a quick procedure either Why two mitral valves 😨?
  18. 18. Auscultation is comparable to echocardiography in terms of its diagnostic power. Even today.
  19. 19. Thus, few minutes are worth spending…
  20. 20. …and not depend on echocardiography.
  21. 21. Patient, in his turn, will appreciate your attention
  22. 22. So, the system
  23. 23. The entire process of heart auscultation has two sides: ✤external ✤internal
  24. 24. External: what we do with a stethoscope and a patient. It is visible to everyone.
  25. 25. Internal: what is happening in our heads at the same time. This side is not visible to anyone.
  26. 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. 27. A patient should be examined in the following positions: ✤ lying on the back ✤ lying on the left side ✤ sitting ✤ standing
  28. 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. 29. TOO DIFFICULT!
  30. 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. 31. And then real difficulties begin.
  32. 32. So, I’ll repeat:
  33. 33. A patient should be examined in the following positions: ✤ lying on the back ✤ lying on the left side ✤ sitting ✤ standing
  34. 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. 35. Beginning of auscultation: ✤ patient is supine ✤ stethoscope is applied to the Erb’s point (third left intercostal space near the sternal border)
  36. 36. Major share of the heart-generated sound flow can be heard in the Erb’s point
  37. 37. Occasionally, this is sufficient to generate a diagnostic hypothesis.
  38. 38. In that case we can conduct auscultation in abbreviated format, by searching for symptoms confirming or refuting our hypothesis.
  39. 39. But, this is not possible until we gain some experience.
  40. 40. For now we should adhere to the system
  41. 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. 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. 43. Then, we move on to the suprasternal notch. Hence, we won’t miss aortic stenosis.
  44. 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. 45. Then – under the left clavicle. That way we won’t miss patent ductus arteriosus.
  46. 46. Now, on to epigastrium and mesogastrium. This is significant for diagnosing stenosis of branches of abdominal aorta.
  47. 47. Then, patient turns into the left lateral decubitus position
  48. 48. Do not fail to find a place, where apical imPulse is palpable, and then conduct auscultation there.
  49. 49. Auscultate in the Erb’s point and at the left fifth intercostal space
  50. 50. Only at the left lateral decubitus position we must use both - the bell and the membrane in each point
  51. 51. While auscultating in other positions and areas, membrane only is sufficient
  52. 52. Next, patient sits down.
  53. 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. 54. Then, patient stands uP
  55. 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. 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. 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. 58. That is it. Whoever is observing us won’t notice anything else.
  59. 59. Internal side This is what happens in your head while doing everything you’ve just read about
  60. 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. 61. Now, you need to analyze this sound flow by splitting it in components and then interpret the data.
  62. 62. As a result, we obtain information about the structure and the functions of the heart we’ve been examining all this time.
  63. 63. But we will understand nothing by perceiving heart sound in general.
  64. 64. Each component of the sonic flow should be picked out and analyzed
  65. 65. While analyzing specific sound, we must concentrate on it and exclude everything else from our attention.
  66. 66. No matter what area we put stethoscope on, we should sequentially concentrate our attention on the first heart sound initially
  67. 67. Then, on the second heart sound
  68. 68. Then, we search for extra sounds and murmurs during systole
  69. 69. Then, we search for extra sounds and murmurs during diastole
  70. 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. 71. Don’t forget!
  72. 72. In each auscultation point we scan sound in complete diapason, starting from low frequencies and moving on to the highfrequencies
  73. 73. In the beginning, deep attention concentration is required to perform all of that.
  74. 74. It may seem difficult (I understand)…
  75. 75. But a little practice makes this process automatic and qu i c k
  76. 76. And nothing will be left out.
  77. 77. Do not neglect graphic fixation of what you hear. This will significantly increase your auscultation efficiency.
  78. 78. Graphic fixation will be described in the next chapter…