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PubMed2005

Diagnostic value of lung auscultation in an emergency room setting.

BACKGROUND: In daily routine, physicians use history, physical examination and technology-based information such as laboratory tests and imaging studies to diagnose the patients' disease. We determined the diagnostic value of lung auscultation in patients admitted to the Medical emergency room with chest symptoms. METHODS: Two-hundred-and forty-three consecutive patients (137 males), mean age 59.2 years were included. Internal Medicine registrars had to make a presumptive diagnosis, 1) after having taken the history and 2) after having auscultated the lungs. Thereafter, routine diagnostic procedures were performed. The estimated diagnosis was compared with the final diagnosis based on the written report to the Family Practitioner. RESULTS: Two-hundred-eighty-seven diagnoses were made. Eighteen percent of patients suffered from left heart failure, 13% from unexplained chest pain, 10.5% from chest wall pain, and 10.5% from pneumonia. Forty-one percent of the diagnoses were already correct when based only on the patient's history. Lung auscultation improved the diagnostic yield only in 1% and worsened it in another 3%. By multiple logistic regression, normal lung auscultation (OR 0.12 [95CI% 0.053-0.29]) was the independent predictor for not having a lung or heart disease. However, elevation of B-type natiuretic peptide (BNP) (OR 1.16 per 100 pg/ml (95CI% 1.004-1.35), wheezing (OR 0.023 [0.002-0.33]) and pCO2 (OR 0.25 (0.10-0.621) were independent predictors for having a heart disease, whereas wheezing (OR 7.41 [3.26-16.83]) and CRP (OR 1.008 per 10 units [1.003-1.014]) were risk factors for having a lung disease. CONCLUSION: In contrast to history taking, abnormal lung auscultation does not appear to contribute considerably to the final diagnosis in patients presenting with chest symptoms in an emergency room setting. However, normal lung auscultation is a valuable predictor for not having a lung or heart disease, whereas wheezing is a predictor for having a lung disease and not having a heart disease.

Adolescent↗
PubMed2002

[A new medical education using a lung sound auscultation simulator called "Mr. Lung"].

We developed a lung sound auscultation simulator "Mr. Lung" in 2001. To improve the auscultation skills of lung sounds, we utilized this new device in our educational training facility. From June 2001 to March 2002, we used "Mr. Lung" for our small group training in which one hundred of the fifth year medical students were divided into small groups from which one group was taught every other week. The class consisted of ninety-minute training periods for auscultation of lung sounds. At first, we explained the classification of lung sounds, and then auscultation tests were performed. Namely, students listened to three cases of abnormal or adventitious lung sounds on "Mr. Lung" through their stethoscopes. Next they answered questions corresponding to the portion and quality of the sounds. Then, we explained the correct answers and how to differentiate lung sounds on "Mr. Lung". Additionally, at the beginning and the end of the lecture, five degrees of self-assessment for the auscultation of the lung sounds were performed. The ratio of correct answers for lung sounds were 36.9% for differences between bilateral lung sounds, 52.5% for coarse crackles, 34.1% for fine crackles, 69.2% for wheezes, 62.1% for rhonchi and 22.2% for stridor. Self-assessment scores were significantly higher after the class than before. The ratio of correct lung sound answers was surprisingly low among medical students. We believe repetitive auscultation of the simulator to be extremely helpful for medical education.

Auscultation↗
PubMed1993

A randomized trial of intrapartum electronic fetal heart rate monitoring versus intermittent auscultation.

OBJECTIVE: To determine whether continuous intrapartum electronic fetal heart rate monitoring (EFM) is associated with decreased perinatal mortality and morbidity compared with intermittent auscultation. METHODS: The study was conducted simultaneously at two university hospitals in Athens, Greece (Alexandra and Marika Iliadi Hospitals) from October 1, 1990 to June 30, 1991. All patients with singleton living fetuses and gestational ages of 26 weeks or greater were eligible for inclusion. The participants were assigned to continuous EFM or intermittent auscultation based on the flip of a coin. Both groups were followed during labor according to the most recent ACOG guidelines. However, fetal scalp blood pH and crossover from one group to the other were not used. RESULTS: A total of 1428 patients were included, 746 in the EFM group and 682 in the auscultation group. There were no differences between the groups in terms of maternal age, gravidity, parity, gestational age, and number of antepartum high-risk factors. More patients monitored electronically received oxytocin for either augmentation (52.4 versus 38.1%; P = .0001) or induction (15.6 versus 7%; P = .0001). The length of labor was longer in the EFM group (first stage 6.1 +/- 4.3 versus 5.5 +/- 3.7 hours; P = .006; second stage 29.4 +/- 18.6 versus 26.9 +/- 16.9 minutes; P = .01). There was a higher incidence of nonreassuring fetal heart rate patterns in the EFM group (23.4 versus 10.7%; P = .0001) and a higher rate of surgical intervention (11.2 versus 4.8%; P = .0001). This difference pertained to both vacuum extraction (5.8 versus 2.4%; P = .002) and cesarean delivery for suspected fetal distress (5.3 versus 2.3%; P = .005). There were no differences in 1- and 5-minute Apgar scores, fetal acidosis at birth, need for neonatal resuscitation, neonatal intensive care unit admission, use of assisted ventilation, neonatal hospital stay, or any other neonatal complications. Two neonatal deaths occurred in the EFM group and nine perinatal deaths in the auscultation group (two intrapartum and seven neonatal deaths). The perinatal mortality rates were 2.6 per 1000 and 13 per 1000 total births, respectively (P = .04). The two deaths in the EFM group and three of the neonatal deaths in the auscultation group may not have been prevented by intrapartum monitoring; however, four neonatal deaths from the auscultation group occurred in depressed (5-minute Apgar scores less than 7), acidotic (cord artery pH at or below 7.13) infants. The perinatal death rate related to fetal hypoxia was significantly less in the EFM group (zero of 746 versus six of 682; P = .03). CONCLUSION: In this controlled trial, intrapartum EFM, as the primary and only method of intrapartum fetal surveillance, was associated with decreased perinatal mortality due to fetal hypoxia but also with higher rates of surgical intervention for suspected fetal distress.

Adult↗
PubMed2001

Auscultation of the Chest and Abdomen by Athletic Trainers.

OBJECTIVE: To present a practical overview of the methods and techniques of auscultation of the chest and abdomen for use during the physical examination of athletes. Our intent is to provide information on this clinical technique to assist athletic trainers in recognizing and referring athletes presenting with potentially serious internal organ conditions. BACKGROUND: Use of the stethoscope is a clinical skill increasingly necessary for athletic trainers. Given the expanding breadth of both the assessment techniques used by athletic trainers and the populations they care for and the fact that clinical instruction guidelines have changed in the newly adopted National Athletic Trainers' Association Educational Competencies, our goal is to provide a framework upon which future instruction can be based. DESCRIPTION: This review covers the use of a stethoscope for auscultation of the chest and abdomen. Auscultation of the heart is covered first, followed by techniques for auscultating the breath sounds. Lastly, auscultation of the abdomen describes techniques for listening for bowel sounds and arterial bruits. CLINICAL ADVANTAGES: During the assessment of injuries to and illnesses of athletes, knowledge of auscultatory techniques is valuable and of increasing importance to athletic trainers. Athletic trainers who do not know how to perform auscultation may fail to recognize, and therefore fail to refer for further evaluation, athletes with potentially serious pathologic conditions.

Journal Article↗
PubMed2003

Teaching of pulmonary auscultation in pediatrics: a nationwide survey of all U.S. accredited residencies.

Structured teaching of pulmonary auscultation is greatly underrepresented during internal medicine (IM) or family practice (FP) training. It is not known, however, whether this underrepresentation applies to the other major field of primary care, pediatrics. To answer this question, we surveyed all accredited U.S. residencies in pediatrics by mailing a 1-page questionnaire to 174 pediatrics program directors, and by comparing results to those previously gathered from internal medicine and family practice residencies. Pediatrics directors' response rate was 62%. More pediatrics than family practice residencies offered structured teaching of pulmonary auscultation (21.5% vs. 9.7%, P < 0.004). When compared to internal medicine programs, this difference showed a trend toward significance (21.5% for pediatrics and 14.1%, for internal medicine, P = 0.08). Teaching modalities included: lectures (91.2%); audiotapes (13%); seminars (8.3%); and miscellaneous (21.7%). University-affiliated residencies taught auscultation significantly more frequently than nonuniversity-affiliated programs (25.4% vs.10.5%, P = 0.07). Pediatrics directors gave great importance to pulmonary auscultation, and wished for more time devoted to its teaching (5.52 +/- 0.84 and 5.01 +/- 1.07, respectively, on a 1-6 scale, with 6 indicating the highest value). They also attributed great clinical importance to 13 commonly encountered pulmonary auscultatory events (all rated, on average, between 4-5.8 on a 1-6 scale, with 6 indicating highest importance). In summary, training programs in pediatrics offered significantly more structured teaching of pulmonary auscultation than IM or FP residencies. Whether this difference in teaching may have a beneficial impact on the auscultatory proficiency of pediatric residents, as compared to internal medicine and family practice trainees, needs to be determined.

Auscultation↗
PubMed2002

Classifying coronary dysfunction using neural networks through cardiovascular auscultation.

The paper applies artificial neural networks (ANNs) to the analysis of heart sound abnormalities through auscultation. Audio auscultation samples of 16 different coronary abnormalities were collected. Data pre-processing included down-sampling of the auscultated data and use of the fast Fourier transform (FFT) and the Levinson-Durbin autoregression algorithms for feature extraction and efficient data encoding. These data were used in the training of a multi-layer perceptron (MLP) and radial basis function (RBF) neural network to develop a classification mechanism capable of distinguishing between different heart sound abnormalities. The MLP and RBF networks attained classification accuracies of 84% and 88%, respectively. The application of ANNs to the analysis of respiratory auscultation and consequently the development of a combined cardio-respiratory analysis system using auscultated data could lead to faster and more efficient treatment.

Adult↗
PubMed2000

Intermittent auscultation of the fetal heart rate: a review of general principles.

Multiple randomized clinical trials have been unsuccessful in providing evidence of efficacy of electronic fetal monitoring; thus, there is renewed interest in intermittent auscultation during labor for women with low-risk pregnancies. Auscultation must be used with palpation or external or internal electronic monitoring of uterine contractions. Auscultation and palpation require education, experience, and competency validation at regular intervals. Institutional policies and standards of care are mandatory for intermittent auscultation. Concerns exist regarding the personnel costs for auscultation; however, these costs may ultimately be shown to be offset by significant benefits in improved outcomes and patient satisfaction.

Female↗
PubMed2006

Evaluation of gastrointestinal motility by computerized analysis of abdominal auscultation findings.

BACKGROUND AND AIMS: To evaluate gastrointestinal motility by abdominal auscultation. METHODS: Abdominal auscultated sounds of 20 healthy adults and 10 diabetes mellitus patients with delayed gastric emptying were digitally recorded and then analyzed by computer while simultaneously monitoring the motility of the antrum of the stomach by ultrasonography. The auscultated sound, when the stomach wall was moving, was regarded as the gastroduodenal (GD) sound and when not moving as the intestinal (I) sound. The sound index (SI; the sum of the amplitude) was calculated to indicate the power of sound. Sounds were recorded for 15 min under fasting conditions and 60 min after a liquid meal. In six healthy adults, the gastroduodenal pressure was recorded under abdominal auscultation to detect any correlation between the motility index (MI; the sum of the area under the curve) and SI. RESULTS: A definite increase in the SI of the GD sound was observed after the liquid meal in comparison with that of the I sound. A positive correlation (r = 0.678) was observed between the SI of the GD sound and MI, thus, it was considered that the GD sound reflected the motility of the gastroduodenal wall. In the diabetes mellitus patients, the SI of the GD sound was significantly lower after food intake than in healthy adults. CONCLUSION: The results of the present study indicate that the abdominal auscultation test could be used as a new diagnostic method to detect any abnormality in gastrointestinal motility.

Adult↗
PubMed1997

Intermittent auscultation for the intrapartum assessment of fetal well-being in Western Australia.

In May 1995, in response to a decision of the Perinatal and Infant Mortality Committee of Western Australia, a survey of Western Australian hospitals was performed to ascertain what policies were in use for the monitoring of the fetal heart rate in labour and what proportion of these hospitals had access to electronic monitoring by cardiotocography. A response was received from 96% of the surveyed hospitals. More than half the births in this State (13,950 of 25,238) were monitored in labour using intermittent auscultation as the primary test; 7.5% of Western Australian births each year occurred in hospitals in which electronic monitoring was not available. Fewer than 50% of hospitals had written protocols describing the method of auscultation of the fetal heart during labour, the indications to contact a doctor or the management of fetal distress. The protocols which did exist displayed considerable variation in the recommended frequency of intermittent auscultation. The lack of standard practice in this field probably results from uncertainties in the literature. Intermittent auscultation has not been subjected to rigorous scientific evaluation as a screening tool and guidelines documenting ideal auscultatory practices need to balance the precision of electronic monitoring and freedom from intervention. Based on this compromise and existing evidence, a protocol for intermittent auscultation in normal labour is proposed.

Cardiotocography↗
PubMedDate not supplied

Abdominal auscultation in the detection of experimentally induced gastrointestinal sand accumulation.

A blind study was designed to determine if abdominal auscultation is an effective method for detecting the presence of intestinal sand. Fifteen horses divided into two groups were used in the study. There were seven horses in Group 1 and eight horses in Group 2. All horses were auscultated and determined to be free of sand sounds before initiation of Trial 1. Group 1 horses were given 4.2 g/kg body weight of sand via nasogastric tube using carboxymethylcellulose (CMC) as a suspending agent at 9.0 ml/kg body weight. Group 2 horses were given CMC only. Horses remained in the same group through all trials. A total of five trails, each lasting 24 hours, was performed. Dosing with sand and CMC or CMC alone was repeated at the beginning of each trial. Abdominal auscultation was performed on each of the 15 horses beginning on Trial 2 by an investigator with no knowledge of the grouping of the horses. The ventral abdomen was auscultated for 5 minutes at 7 hours and 17 hours after trial initiation. When a horse was considered positive for intestinal sand by auscultation, the horse was eliminated from future trials. On Trial 2, no horses were positive; on Trial 3, one horse; on Trial 4, two horses, and on Trial 5, four horses. Sounds considered characteristic for sand in the intestinal tract were eventually identified in all Group 1 horses. No horses in Group 2 were ever identified as having sounds characteristic for intestinal sand at any point during this investigation.

Animals↗
PubMedDate not supplied

Comparisons of blood pressure measurements by auscultation and Physiometrics Infrasonde recording techniques.

The levels of blood pressures measured by a Physiometrics Infrasonde recorder (model SR-2) were compared with the levels simultaneously measured byt auscultation utilizing a standard mercury sphygmomanometer (Baumanometer). The measurements were made on 1530 adult women and their 1760 adolescent children 15-17 years old. Two sets of blood pressures were taken about 3 minutes apart, each with an occluding cuff connected to the Physiometrics recorder as well as to the mercury sphygmomanometer. The reproducibility of the Physiometrics method was similar to that of the auscultation method. The means of the systolic pressures measured by the Physiometrics method were virtually equal to those of the auscultation method for women and girls; for boys, the means of the former method surpassed those of the latter by about 3 mm. The mean diastolic pressures by the Physiometric method were very close to the Korotkoff sound 5 (K5) pressure by the auscultation method for all three groups. The correlation coefficients between both methods were 0.98 for the systolic and 0.93 for the diastolic pressure of the adult women, and 0.94 for the systolic pressure of the adolescents. The correlations between the two diastolic pressures of adolescents were much less (0.69). The Physiometrics measurements were consistent with the measurements by auscultation for systolic and diastolic pressures of women and systolic pressure of adolescents, but the consistency was low for diastolic pressure of adolescents. An effort has been made to relate differences between the two methods with other anthropometric variables, but the correlations with these variables were of low level.

Adolescent↗
PubMed2002

A remote auscultation tool for advanced home health-care.

We have developed an Internet-based tool for remote realtime auscultation. The device was based on a commercially available electronic stethoscope and a PC which digitized and transmitted the signals. A voice and video channel were also available. The remote auscultation tool was evaluated between two sites in Sweden separated by a distance of 500 km. A doctor at one of the sites performed cardiac and pulmonary auscultations on patients located at the other site. Four test patients were assisted by a nurse operating the electronic stethoscope. The auscultation sessions were performed with and without video support to assess the importance of visual contact between doctor and patient. Twenty sessions were conducted (excluding technical testing to solve problems with the equipment). Audio quality was sufficient, as judged subjectively by the doctors concerned. Video support improved the doctor s confidence that the stethoscope was being operated properly and greatly simplified the interaction. Moreover, it improved all participants subjective impression of the virtual meeting. Our work demonstrates the feasibility of performing remote auscultation sessions over the Internet.

Auscultation↗
PubMed2002

Carotid artery auscultation--anachronism or useful screening procedure?

Carotid bruits are supposed to indicate the presence of high-grade common carotid or extracranial internal carotid artery stenosis in a large proportion of patients. Using a stethoscope, we prospectively auscultated 273 carotid arteries of 145 patients blinded to the results of a complete extracranial and intracranial Doppler investigation including extracranial color-coded duplex ultrasound. Fifty-four arteries showed stenosis of > or = 50%-99%, or occlusion of the extracranial internal or the common carotid artery. In 25 of these arteries, a bruit was present. In 9 out of 16 patients with extracranial stenosis from 70%-99%, a bruit was detected. In one additional patient with a middle-grade external carotid artery stenosis, a bruit was also present. In seven additional patients, a bruit was present in the absence of any carotid artery stenosis, cardiac vitium or goiter. The sensitivity of carotid auscultation for the detection of a 70%-99% stenosis of the common or extracranial internal carotid artery was 56% and specificity was 91%. The positive predictive value of a bruit found during carotid auscultation was 27%, and the negative predictive value of a normal auscultation was 97%. Carotid auscultation is a useful screening procedure in the detection of carotid stenosis or occlusion, but requires confirmation by carotid ultrasound.

Adult↗
PubMed1993

The teaching and practice of cardiac auscultation during internal medicine and cardiology training. A nationwide survey.

OBJECTIVES: To assess the time and importance given to cardiac auscultation during internal medicine and cardiology training and to evaluate the auscultatory proficiency of medical students and physicians-in-training. STUDY DESIGN: A nationwide survey of internal medicine and cardiology program directors and a multicenter cross-sectional assessment of students' and housestaff's auscultatory proficiency. SETTING: All accredited U.S. internal medicine and cardiology programs and nine university-affiliated internal medicine and cardiology programs. PARTICIPANTS: Four hundred ninety-eight (75.6%) of all 659 directors surveyed; 203 physicians-in-training and 49 third-year medical students. INTERVENTIONS: Directors completed a 23-item questionnaire, and students and trainees were tested on 12 prerecorded cardiac events. MAIN OUTCOME MEASURES: The teaching and proficiency of cardiac auscultation at all levels of training. RESULTS: Directors attributed great importance to cardiac auscultation and thought that more time should be spent teaching it. However, only 27.1% of internal medicine and 37.1% of cardiology programs offered any structured teaching of auscultation (P = 0.02). Programs without teaching were more likely to be large, university affiliated, and located in the northeast. The trainees' accuracy ranged from 0 to 56.2% for cardiology fellows (median, 21.9%) and from 2% to 36.8% for medical residents (median, 19.3%). Residents improved little with year of training and were never better than third-year medical students. CONCLUSIONS: A low emphasis on cardiac auscultation appears to have affected the proficiency of medical trainees. Our study raises concern about the future of this time-honored art and, possibly, other bedside diagnostic skills.

Attitude of Health Personnel↗
PubMedDate not supplied

Auscultation in mild mitral regurgitation in dogs: observer variation, effects of physical maneuvers, and agreement with color Doppler echocardiography and phonocardiography.

Observer variation in diagnosing mild mitral regurgitation in dogs by cardiac auscultation was assessed by having 6 veterinarians with different levels of experience examine 57 Cavalier King Charles Spaniels. Comparisons with color Doppler echocardiography and phonocardiography were made, and the effects of 2 physical maneuvers on the auscultatory findings were evaluated. Using mildly diseased dogs, interobserver agreement in diagnosing the presence or absence of left-sided murmurs ranged from 63% to 88%. The agreement with phonocardiography (range, 53-91%) increased with the amount of observer experience. The 2 most experienced observers could discern soft ejection murmurs from regurgitant murmurs and were able to diagnose 89% of the dogs with regurgitant jets larger than 30% of the left atrial area. In general, less experienced observers diagnosed most jets larger than 50%. In many dogs with small jets, no murmur was found by auscultation and phonocardiography. The audibility of mild regurgitation was significantly reduced in dogs that were difficult to auscultate. Early systolic murmurs were typical of mild regurgitation, whereas holosystolic murmurs typified severe regurgitation. In a few dogs, late systolic murmurs alternated with holosystolic murmurs. Systolic clicks were found phonocardiographically in 18 dogs with mild to moderate regurgitation, but the audibility apparently was low. In many mildly affected dogs, physical maneuvers increased murmur intensity. Thus, some form of dynamic auscultation might facilitate the diagnosis of mild regurgitation. Auscultatory findings in mild regurgitation appear to depend on observer experience, circulatory status, and how difficult the dog is to auscultate.

Animals↗
PubMed2005

Factors influencing cardiac auscultation proficiency in physician trainees.

INTRODUCTION: We assessed the accuracy of physician trainees in identifying different cardiac sounds and examined the factors influencing their cardiac auscultation proficiency. METHODS: A total of 106 physicians in the Family Medicine Training Programme were asked to identify 10 cardiac sounds played sequentially on the Littmann electronic stethoscope, which functioned as a surrogate patient. Their auscultation accuracy was scored numerically out of a maximum of 10. Demographical data of the physicians was collected prospectively. RESULTS: The mean (+/-SD) auscultation proficiency score of the study population was 4.0 +/- 1.7. Physicians who graduated in 1994 or earlier fared significantly poorer than those who obtained their Bachelor of Medicine and Bachelor of Surgery degrees between 1995 and 2000 (p-value equals 0.02). Auscultation proficiency was not related to current practice, previous years of primary care, cardiology, internal medicine or paediatric medicine postings, or cumulative years of postings. Normal heart sounds were most accurately identified. Prosthetic cardiac sounds were better identified than other extra-cardiac sounds while systolic murmurs were more accurately identified than diastolic murmurs. Tachycardia had the lowest identification rate. CONCLUSION: Our data suggest that cardiac auscultation skill declined with time, being significantly impaired eight years after graduation. We suggest that there is a need for retraining in the form of continuing medical education to address not only new knowledge and skills, but also basic skill competency.

Adult↗
PubMed2004

Reliability and validity of cervical auscultation: a controlled comparison using videofluoroscopy.

Cervical auscultation is experiencing a renaissance as an adjunct to the clinical swallowing assessment. It is a controversial technique with a small evidence base. We have aimed to establish whether cervical auscultation interpretation is based on the actual sounds heard or, in practice, influenced by information gleaned from other aspects of the clinical assessment, medical notes, or previous knowledge. We sought to determine (a) rater reliability and its impact on the clinical value of cervical auscultation and (b) how judgments compare with the "gold standard": videofluoroscopy. Swallow sounds were computer recorded via a Littmann stethoscope. Sounds were sampled from 10 healthy control swallows with no aspiration/penetration and 10 patient swallows with aspiration/penetration, all recorded during simultaneous videofluoroscopy. The system generated sound quality similar to "live" bedside listening, a feature rarely seen in cervical auscultation studies. The 20 sound clips were classified as "normal" or "abnormal" by 19 volunteer speech-language pathologists with experience in cervical auscultation. After at least four weeks, 11 of these judges rated the sounds rerandomized on a new CD. Intrarater reliability kappa ranged from -0.12 to 0.71. Individual reliability did not correlate with years of experience, practice pattern, or frequency of use. Interrater reliability kappa = 0.17. Comparison with radiologically defined aspiration/penetration yielded 66% specificity, 62% sensitivity, and majority consensus gave 90% specificity, 80% sensitivity. There was a significant relationship between individual reliability and true positive rate (r(s) = 0.623, p = 0.040). The reliability of individual judges varied widely and thus, inevitably, agreement between judges was poor. Validity is dependent upon reliability: Improving the poor raters would improve the overall accuracy of this technique in predicting abnormality in swallowing. The group consensus correctly identified 17 of the 20 clips so we may speculate that the swallow sound contains audible cues that should in principle permit reliable classification.

Aged↗
PubMed2006

Relationship between accurate auscultation of a clinically useful third heart sound and level of experience.

BACKGROUND: Poor performance by physicians-in-training and interobserver variability between physicians have diminished clinicians' confidence in the value of the third heart sound (S3). METHODS: To determine whether auscultation of a clinically useful S3 improves with advancing levels of experience, we performed a prospective, blinded, observational study of 100 patients undergoing left-sided heart catheterization. Patients underwent blinded auscultation by 4 physicians (each from 1 of 4 different levels of experience), phonocardiography, measurement of blood B-type natriuretic peptide levels, echocardiography for measurement of left ventricular ejection fraction, and cardiac catheterization for measurement of left ventricular end-diastolic pressure. RESULTS: Whereas residents' and interns' auscultatory findings demonstrated no significant agreement with phonocardiographic findings, an S3 auscultated by cardiology fellows (kappa = 0.37; P<.001) and cardiology attendings (kappa = 0.29; P = .003) agreed with phonocardiographic findings. Although the sensitivities of the S3 were low (13%-52%) for identifying patients with abnormal measures of left ventricular function, the specificities were high (85%-95%), with the best test characteristics exhibited by phonocardiography and more experienced physicians. The S3 detected by attendings and fellows was superior in distinguishing an elevated B-type natriuretic peptide level, a depressed left ventricular ejection fraction, or an elevated left ventricular end-diastolic pressure (P = .002-.02 for attendings and .02-.03 for fellows) compared with residents (P = .02-.47) or interns (P = .09-.64). CONCLUSIONS: The S3 auscultated by more experienced physicians demonstrated fair agreement with phonocardiographic findings. Although correlations were superior for phonocardiography, the associations between the S3 and abnormal markers of left ventricular function improved with each level of auscultator experience.

Adult↗