Doctor, Stethoscope, Patient: do the least, hear everythingYaroslav Shpak, MD

My first auscultation experience was dramatic

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

CONFUSION

What should we do?

The answer is simple:

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

It can be done in a variety of ways, but

it is desirable to do the least, while obtaining all of the information.

We need a system.

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

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

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

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

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

Surely, at first, it will require more time.

Echocardiography is not a quick procedure either

Why two mitral valves😨?

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

Thus, few minutes are worth spending…

…and not depend on echocardiography.

Patient, in his turn, will appreciate your attention

So, the system

The entire process of heart auscultation has two sides:

✤external

✤internal

External: what we do with a stethoscope and a patient. It is

visible to everyone.

Internal: what is happening in our heads at the same time. This side is

not visible to anyone.

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

A patient should be examined in the following positions:

✤ lying on the back

✤ lying on the left side

✤ sitting

✤ standing

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.

TOO DIFFICULT!

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.

And then real difficulties begin.

So, I’ll repeat:

A patient should be examined in the following positions:

✤ lying on the back

✤ lying on the left side

✤ sitting

✤ standing

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.

Beginning of auscultation:

✤ patient is supine

✤ stethoscope is applied to the Erb’s point (third left intercostal space near the sternal border)

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

Occasionally, this is sufficient to generate a diagnostic hypothesis.

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

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

For now we should adhere to the

system

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.

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.

Then, we move on to the suprasternal

notch.Hence, we won’t miss aortic stenosis.

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.

Then – under the left clavicle.

That way we won’t miss patent ductus arteriosus.

Now, on to epigastrium and

mesogastrium.This is significant for diagnosing stenosis

of branches of abdominal aorta.

Then, patient turns into the left lateral decubitus position

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

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

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

While auscultating in other positions and

areas, membrane only is sufficient

Next, patient sits down.

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.

Then, patient stands uP

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!)

Next, patient squats down.

Listen through membrane over the Erb’s point and at the apex of the heart. Look

for a systolic murmur.

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.

That is it. Whoever is observing us

won’t notice anything else.

Internal sideThis is what happens in your head while doing everything you’ve just read about

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

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

As a result, we obtain information about the structure and the functions of the heart we’ve been examining

all this time.

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

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

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

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

Then, on the second heart sound

Then, we search for extra sounds and murmurs during systole

Then, we search for extra sounds and murmurs during diastole

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?)

Don’t forget!

In each auscultation point we scan sound in complete diapason,

starting from low frequencies and moving on to the high frequencies

In the beginning, deep attention concentration

is required to perform all of that.

It may seem difficult (I understand)…

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

And nothing will be left out.

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

Graphic fixation will be described in the next chapter…