Auscultation of the Heart

an on-line auscultation course

Objective: To observe and document heart sounds in preparation for diagnosis
Is the Stethoscope Obsolete?


There are about 280,000 Primary Care Physicians who do physical assessments on their patients each day; at some point, they have to make a decision on whether to treat a patient themselves or to seek the aid of a specialist.

The primary physician’s basic diagnostic tools are patient history, stethoscope, sphygmomanometer, ophthalmoscope, otoscope, and lab tests. That’s about it. Without auscultation skills in using their stethoscope, they could be sending some of their patients who have abnormal sounds home without the help of a cardiologist. Without a tested stethoscope and good auscultation skills, the primary physician can easily hear only the normal sounds and miss the abnormal sounds. This program, with about five hours of practice, can turn you into an excellent auscultator. You are already a good auscultator in many ways, you just need to know how to transfer those skills to heart and lung sounds.

Primary physicians need to be our best auscultator and they can be!!

You Are Already A Good Auscultator

Yes, you are—I ask you to close your eyes and then I go over and open and close a door. The door also gives a little rattle and I click the handle. I ask you to open your eyes and tell me what you heard.

Immediately I start getting correct answers from everyone. I ask, was it a metal or a wood door? Again correct answers. What other sounds did you hear?—“the handle clicked and it rattled.”  How did you know that? You had your eyes closed. You saw the door with your ears. Amazing! You told me a lot about the normal and abnormal anatomy of that door, by just listening. You successfully observe and then evaluate many sounds all day long.  Now all you have to do is let me show you how to apply those skills to heart and lung sounds. It’s the same thing, isn’t it?

I will summarize six steps of auscultation that will help you do the same thing with heart sounds that you did with the door. Then I will take you into more detail with each of the steps. At first, you will need to do these steps slowly; afterward, you will stop thinking and find yourself doing them very fast, as you did with the door. Just because you do it fast does not mean you skip any of these six steps.


A Six-Step Method


1) Observing - Because you usually get rewarded for being the first to get the right answer, you jump to a diagnosis too quickly (guessing). In this step, you will find joy in carefully observing the sounds the heart created and finding auscultation is simple. All you have to do is be patient with yourself (and with me).
2) Test Stethoscope Functionality - You assume your stethoscope is picking up all the sounds from your patient’s chest and delivering them to your ear without losing any of the sounds the heart is creating. Up to 55% leak! You must test your stethoscope every 60 days! I will show you how.
3) Starting Point - You are listening to a system that cycles, and you try to chase the sounds around the cycle. You need to find a STARTING POINT. Then you can listen to only one event at a time as long as you wish. At 60 bpm, you have eight events happening in one second!  One event a time makes it so simple.
4) Abnormal Sounds - Abnormal heart sounds are nothing but the sounds of normal heart structures whose anatomical structures have changed. You cannot memorize all abnormal sounds. You do need to know some simple parts of the normal anatomy of the heart that relates to the sounds you hear, just as you did with the door.  
5) Placement - If you put your stethoscope on your patient through their clothes, haphazardly at any place and complete observing in 10 seconds flat, you have to be kidding yourself!  I have had this happen to me so many times as a patient that it’s not funny anymore. In fact, it is an insult to the patient.
6) Documenting - You love to write a diagnosis, first learn to document graphically and with words what you hear. When you look at the documentation you will see the correct diagnosis. It’s as easy as a slam dunk.


Observing

Observing and analyzing of your patient’s heart sounds are two separate functions.

OBSERVE: Acquire data and experience the sounds, then, you have something to analyze, judge, diagnose.

Medical literature has well documented that the physician’s ability to auscultate is a disaster. Typically, those tested could not tell if a murmur was in systole or diastole. Yet that information is essential to a correct diagnosis. You have not been trained to observe (acquire the data).

Dr. Betty Edwards1 explains that you are well educated and rewarded in the use of left hemisphere skills:

Verbal: Using words to name, describe and define.
Analytical: Evaluating step by step and part by part.
Rationale: Drawing conclusions on reason and fact.

You use different skills to observe. You are seldom educated and rewarded for the skills of observation. Your senses are fed primarily to the right hemisphere of the brain, characterized as: 

Nonverbal: Awareness; ability to observe your environment without judging.
Synthesis:  Putting parts together to form wholes.
Non-rational:  No basis of reason or fact; willingness to suspend judgment.

You do use your right hemisphere in many ways but you are not aware of it that is the problem. Your educational skills have been centered mostly on memorization, which is an ability associated with the left hemisphere. In school, your right hemisphere and your ability to observe have been seriously alienated.

Dr. Jerre Levy2, an associate of Dr. Roger Sperry, stated only partly humorously that “American scientific training through graduate school may entirely destroy the right hemisphere.”  I seriously disagree with Dr. Levy---You can recover these sensibilities rather easily because they are part of your nature, you were born with them---Don’t let anyone tell you that you can’t.

In 1981, Dr. Roger Sperry3 received the Nobel Prize in Medicine for his study in this field. In a paper he published in 1973 called “Collateral Specialization of Cerebral Function in the Surgically Separated Hemispheres,” he stated that there appear to be two separate but interacting ways our minds operate. He discovered that the two modes of processing tend to interfere with each other; however, with your understanding of the skills (different functions) of the two hemispheres, you can have them complement each other.

Evidence has established that the right hemisphere of the brain is the one that perceives and observes sounds. You need to find a way to quiet the left hemisphere to keep it from interfering while you observe. You will then experience what Dr. Sperry refers to as the “two ways of knowing.”  

You hear of baseball pitchers who “freeze up,” golfers who are “not in the zone.”  These are great examples of the left hemisphere getting too busy; You start judging and guessing before the right hemisphere has a chance to function.  The first step is to only observe not diagnose.

You can’t be angry with the left hemisphere for doing things that it is designed to do. It is up to you to hush it, and then later coordinate the two sides of your brain. Just take a deep breath and exhale slowly and listen.


Test Stethoscope Functionality (click here for instructions)


Starting Point


You can only listen to one event at a time!

This may sound silly to you, but the biggest reason you are not able to hear each of your patient’s heart sounds is that you unconsciously try to listen to the entire cycle at one time. You can’t do it, but you try. With a normal heart at 60 bpm, you have eight events happening in one second of time. In order to actually hear them all, you will have to focus your ears on one event at a time, just as you would focus your eyes on one picture at a time on a museum wall. The difference is that heart sound events are in a cycle, and you have to find a STARTING POINT. This is critical; without knowing where you are in the cycle; you have absolutely no way of knowing which events you are listening to.

The heart cycle has two phases; at 60 bpm, ejection time (systole) is 0.40 seconds long. The filling time (diastole) is 0.60 seconds long. As the heart gets to the end of the ejection, you hear a slight pause while the heart refills with about 40cc of blood. At the end of that pause (filling), you have a STARTING POINT to focus your ears on. You know where you are, the beginning of the ejection phase. Then slowly move your ears to the next event, stopping and listening to that event for as many cycles as you wish. (As the heart rate increases, the time differential between ejection and filling becomes impossible to hear, so look or feel for a pulse in the neck or for the radial pulse for the beginning of ejection.)

If you do not acquire this skill you will never know what parts you are listening to and you will be totally lost. This skill is not that difficult and you can do it, with just a little practice. I am going to get you through this, so hang in there and be patient with yourself.


Abnormal Sounds


Abnormal sounds can be a slam dunk if you really know the way normal sounds are created by the heart and their relationships to other events. Abnormal sounds are nothing more than normal sounds that have been altered. If you don’t really understand the normal, hand up your stethoscope, you will only be guessing and believe me there is a lot of that going around.

The first sound event, at the beginning of systole --0.00 sec, is the mitral and tricuspid valves closing. Take yourself back to your anatomy class when you had normal heart valves in your hands, remember feeling the texture, etc. You know by its feel that it can only make certain kinds of sounds, unless its structure changes. Now, see with your mind’s eye these valves flopping as they open and close. You have just heard, felt and seen the mitral and tricuspid valves operating in a normal situation. Now imagine feeling and seeing a valve that is stenosed, and you have a good concept of the quality of the sound that would be created. If you hear that kind of sound, you know it is not normal. That’s fundamental to keep in mind.  This is not rocket science stuff. It’s fairly simple if you keep it to a few simple rules and don’t complicate it. Remember, you are already a good auscultator. Let's start listening to heart sounds.

Stop here and go to Setting Up For Auscultation Study (the last section) then return here.

























[cycle]
MC Mitral Closure TC Tricuspid Closure
PO Pulmonic Opening AO Aortic Opening
AC Aortic Closure PC Pulmonic Closure
TO Tricuspid Opening MO Mitral Opening


Go to Track #1, on your playback device, set it so it will repeat. Focus on one event at a time as I am describing it: Follow around the graph below keeping in mind at each point the relationships of timing, pressure, and sounds. Go to the STARTING POINT (0.00). Listen with your stethoscope for the end of the pause (filling). Listen to one event at a time, just focus on that one event and listen as long as you wish. Don’t hurry you are in control. Then move to the next event.

As the contraction of the ventricles starts increasing pressure, the first sound (S1) you hear is the necessary closure of the mitral and tricuspid valves. Take your time carefully listening to all the sounds around these two events.

As pressure continues to increase about 40cc of blood is ejected through the pulmonary and aortic valves forcing them to open. In a normal heart, these valves are quiet. You need to keep in mind that these valve openings are occurring because if there is a noise at that location you will want to know why.

The ventricle's pressure rises rapidly. As the ventricles stop contracting and start relaxing, the blood flow starts to reverse slightly. This causes the aortic and pulmonary valves to close. making a second sound (S2).

The pressure in the relaxed ventricles continues to fall, causing the tricuspid and mitral valves to open quietly as 40cc of blood flows out of each atrium to refill the ventricles. Again, be aware of this opening, because if you hear a noise at that timing you will want to know why. Take your time, don’t hurry. Get this down solid and you will have a slam dunk when you start listening to abnormals.


Placement


Now that you know how the normal heart sounds are created, you need to know where to put your stethoscope on the patient’s chest to find the sounds and get to the point of maximum intensity.

On each track of heart sounds the general areas of auscultation are identified. As you listen with your stethoscope on “The Patient,” (stethoscope listing pad) you can visualize the anatomical position the sounds are coming from.

Lines connect the location of the valve rings and outflow direction to the different general areas where you put your stethoscope. As you focus, your ears will take you into the heart and give you an idea of what is occurring. 

After you locate the general area, Dr. Proctor Harvey4 recommends you inch your stethoscope around until you get the point of maximum intensity. Sometimes the difference of one-half an inch makes a big difference.
Never listen through the patient’s clothes

 

A   Aortic Area

P    Pulmonary Area

M    Mitral Area

T    Tricuspid Area

                                                                                                     




Documenting

Example of diagramming and describing Aortic Regurgitation
                                                                                      
You need to document your observations, not just give an answer “aortic regurgitation.”  I may want to know how you arrived at your observations. For example, if you diagram and then describe what you are hearing such as; I am hearing a long, blowing, decrescendo diastolic murmur, then I know we hearing the same thing.

  

 

 

 

 

Five main characteristics are:
Duration: Is the sound short, medium, or long?
Quality: Is the sound blowing, harsh, cooing, mechanical, rumbling, or musical?
Shape: Is the sound crescendo, decrescendo, pan, or diamond?
Intensity: Is the sound grade 1 very soft, 2 audible, 3 moderately loud, 4 loud, 5 very loud or 6 heard without a stethoscope?

(or use Soft, Medium and Load)
Timing: Is the sound occurring in systole or diastole? With refinement, is it early, mid, or late systolic?


Setting Up For Auscultation Study


1.  On line training, open up the program section (Auscultation Study) and go to Track #1
2. Move the elastic to the side on the aPad (stethoscope listening pad) and unwind the cord. Plug it into the headset output on your computer. Put your stethoscope on the soft side of aPad and listen.You can use the elastic band to hold your stethoscope to the aPad. 
3  Set your volume control to about the level you would hear from your patient.
4. Set the mode control so that each individual track will keep repeating itself. You can then listen to each track as long as you want. Use the forward and reverse buttons to move from track to track.
5. Turn off any sound enhancement hardware or software (bass enhancement, room mimicking)











 




 Now you are ready to start listening to the Auscultation Study:

Congratulations! You are on your way to being an excellent auscultator. Go through the 42 heart sounds in the program at a very relaxed pace, using the 6 steps you have just studied. Only listen with your stethoscope for 15 minutes at a time, otherwise, your ears will become fatigued.