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The differential stethoscope is a unique instrument that assists in rapid evaluation of pulmonary problems in the acutely ill patient. Simultaneous auscultation of homologous lung segments eliminates the problem of variability of breathing rate and pattern that must be confronted in conventional auscultation.
Clinicians should not minimize or overlook the importance of percussion of the liver and the spleen and of auscultation over the liver as routine parts of abdominal examination. Splenic percussion can be used to detect splenomegaly even before the spleen becomes palpable. The span of liver dullness on percussion can be compared with established normal standards to detect hepatomegaly or alterations caused by cirrhosis. A systolic bruit, a friction rub, or a venous hum detected by auscultation over the liver is an important sign of liver disease.
BACKGROUND: Abdominal auscultation has an important position in the physical examination of the abdomen. Little is known about rater agreement. The aim of this study was to describe rater agreement and thus, indirectly, the value of the examination. METHODS: In a semi-virtual setup 12 recordings of the intestinal sounds from 8 patients with acute abdominal pain and 4 healthy volunteers were presented to 100 physicians. The physicians were asked to characterize the intestinal sounds as normal or pathologic. Fisher's exact test was used for comparison between groups of physicians. RESULTS: Overall, 72% of the answers with regard to healthy volunteers concluded that the sounds were normal (equalling agreement), whereas 64% of answers with regard to intestinal obstruction concluded that the sounds were pathologic (but agreement was higher due to agreement on wrong diagnosis in one case). Bowel sounds from colonic obstruction were diagnosed as pathologic in 94 of 100 answers. In peritonitis disagreement dominated. Specialists in gastrointestinal medicine diagnosed bowel obstruction significantly more poorly than non-specialists in gastrointestinal surgery (P < 0.05). CONCLUSION: Rater agreement in normal subjects and in patients with intestinal obstruction was acceptable for a clinical examination. Abdominal auscultation is a helpful clinical examination in patients with acute abdominal pain.
Cardiac auscultation is suffering from declining interest, caused by competing diagnostic technology and inadequate training of doctors. Computer-assisted instruction (CAI) supporting graphics and digitized sound could be ideally suited for teaching and sharpening this skill. To evaluate this premise we randomized 35 third-year medical students to 3 hours of seminar teaching plus the use of audiotapes (group 1), the self-use of a MacIntosh-based CAI (group 2), or both (group 3). All students took a pre- and post-test consisting of eight pre-recorded cardiac events and were also assessed for computer anxiety. Although there were no significant differences between pre- and post-tests for each group and among groups, group 1 had a 4.5% deterioration in its diagnostic score compared to the 7.2% and 3.2% improvements of groups 2 and 3 respectively. Group 2 used the CAI significantly more than group 3. We conclude that CAI is at least as effective as seminars in teaching cardiac auscultation to third-year medical students.
Although most bruits heard over the skull in children are innocent, they might represent the sign of a treatable intracranial vascular pathology. Nevertheless, cranial auscultation is not routinely carried out during physical examination at a young age. Two children with vascular malformations are described in whom a cranial murmur was an early sign of intracranial vascular pathology. Routine cranial auscultation during physical examination of children is recommended.
OBJECTIVE: To assess the effectiveness of the labour admission test in preventing adverse outcomes, compared with auscultation only, and to assess the test's prognostic value in predicting adverse outcomes. DESIGN: Systematic review. SETTING: Labour wards in hospitals. POPULATION: Pregnant women in labour. Three randomised controlled trials including 11,259 women and 11 observational studies including 5831 women. METHODS: Literature searches in Medline, EMBASE, CINAHL, SweMed, The Cochrane Central Register of Controlled Trials, reference lists from identified studies and contact with experts. MAIN OUTCOME MEASURES: Obstetric interventions (augmentation of labour, continuous electronic fetal monitoring, epidural analgesia, fetal blood sampling and operative deliveries) and neonatal outcomes (perinatal mortality, Apgar score, seizures, resuscitation and admission to neonatal unit). RESULTS: Meta-analyses of the controlled trials found that women randomised to the labour admission test were more likely to have minor obstetric interventions like epidural analgesia [relative risk (RR) 1.2, 95% confidence interval (95% CI) 1.1-1.4], continuous electronic fetal monitoring (RR 1.3, 95% CI 1.2-1.5) and fetal blood sampling (RR 1.3, 95% CI 1.1-1.5) compared with women randomised to auscultation on admission. There were no significant differences in any of the other outcomes. From the observational studies, prognostic value for various outcomes was found to be generally poor. Likelihood ratio (LR) for a positive test was above 10 in 2 of 28 single outcomes and between 5 and 10 in six outcomes. CONCLUSIONS: There is no evidence supporting that the labour admission test is beneficial in low risk women.
Review of the history of auscultation of the lung reveals few scientific investigations. The majority of these have led to inconclusive results. The mechanism of production of normal breath sounds remains uncertain. Hypotheses for the generation of adventitious sounds are unproven. Advances in instrumentation for lung sound recording and analysis have provided little of clinical value. There has been a recent resurgence of interest in lung sounds. Space-age technology has improved methodology for sonic analysis significantly. Lung sounds are complex signals that probably reflect regional lung pathophysiology. If they were understood more clearly important non-invasive diagnostic tools could be devised and the value of clinical auscultation could be improved. A multidisciplinary effort will be required to achieve this.
Cardiac auscultation remains an important part of clinical medicine. The standard acoustic stethoscope, which has been useful for more than a century, cannot process, store, and play back sounds or provide visual display, and teaching is hindered because there is no means to distribute the same sounds simultaneously to more than one listener. Modern portable and inexpensive tools are now available to provide, through digital electronic means, better sound quality with visual display and the ability to replay sounds of interest at either full or half speed with no loss of frequency representation or sound quality. Visual display is possible in both standard waveform and spectral formats. The latter format is readily available and provides certain advantages over the time-honored waveform (phonocardiographic) method. Both methods, however, can and should be used simultaneously. Sound signals obtained electronically may then be subjected to objective visual and numerical analysis, transmitted to distant sites, and stored in medical records. Signal analysis shows early promise for clinical application, such as in the assessment of severity of aortic stenosis and in the separation of innocent from organic murmurs. In addition to their clinical value, these methods provide a critical vehicle for the teaching of cardiac auscultation, a method that can and should be preserved for future generations.
The reliability of auscultation, continuous wave (CW) Doppler imaging, and intravenous digital subtraction angiography (IV DSA) in the assessment of carotid artery disease has been evaluated in comparison with conventional angiography in 30 patients. With auscultation, specificity and sensitivity for internal carotid artery (ICA) stenosis of 50% or more were 81% and 67% respectively. CW Doppler imaging detected ICA stenosis of 50% or more with a sensitivity of 83% and a specificity of 92% and ICA occlusion with a sensitivity of 60%. The specificity of IV DSA was 95% and the sensitivity for ICA stenosis of 50% or more and ICA occlusion were 75% and 100% respectively. Combining CW Doppler and IV DSA findings raised sensitivity for ICA stenosis of 50% or more and ICA occlusion to 89% and 100% respectively and specificity to 95%. The combination of CW Doppler and IV DSA is a safe and accurate test battery in the detection and categorization of carotid disease.
Auscultation of neonates by means of conventional techniques is subject to many errors. Consequently, pediatricians rely on radiographs for much of their information regarding ventilation abnormalities. We report a method of simultaneous differential auscultation, using a double-headed stethoscope, which allows better auscultatory evaluation of neonates. The technique is simple and easily learned. The equipment used is inexpensive and easily constructed. The technique is most useful in emergency and transport situations when radiographs are not readily available.
OBJECTIVE: The aim of this study is to determine the level of clinical auscultation skills in pediatric residents at Duke University Medical Center. METHODS: Forty-seven residents from pediatrics and joint medicine/pediatrics training programs at Duke University Medical Center were enrolled in this study. They were asked to examine the cardiovascular patient simulator, Harvey, and report their findings. Five common conditions seen in the pediatric population were presented: ventricular septal defect, atrial septal defect, pulmonary valve stenosis, combined aortic valve stenosis and insufficiency, and innocent systolic ejection murmur. The responses were scored by the number of features and diagnoses accurately reported. Five pediatric cardiologists and cardiologists in training were also asked to participate in a manner similar to the trainees. RESULTS: The mean score of features identified for the resident group was 11.4 +/- 2.6 of a possible 19. The diagnostic accuracy was 33%. There was no significant difference between residents by year of training or by type of residency program, although there was a trend toward improved performance with more training. The difference in performance between the pediatric cardiology group and the residents group was striking. The condition that was most frequently misdiagnosed was the innocent systolic ejection murmur. CONCLUSIONS: The clinical auscultation skills of pediatric residents in this study were suboptimal. There was a trend toward improvement as training progressed, although not statistically significant. These skills are likely to improve further with increased exposure to patients with cardiovascular disease especially in the ambulatory care setting.
OBJECTIVES: To assess the cardiac auscultatory skills of health care professionals before and after an actual (not simulated) patient-centered cardiac auscultation conference and to determine the effectiveness of this clinical teaching method on Improving diagnostic proficiency. SUBJECTS AND METHODS: Seventy-eight participants at a conference on cardiac auscultation completed preconference and postconference examinations on their ability to diagnose a wide variety of heart sounds and murmurs. Among those tested, 46 (59%) were physicians: 17 (22%) were cardiologists, 19 (24%) were medical Interns or residents, 7 (9%) were cardiology fellows, 2 (3%) were general practitioners, and 1 (1%) was a pediatrician. Thirty-two (41%) of this group of respondents were nonphysicians: 14 (18%) were nurse practitioners, 9 (12%) were nurses, 6 (8%) were physician assistants, 2 (3%) were medical students, and 1 (1%) was a nonmedical professional. All participants were tested on 14 clinically Important cardiac auscultatory events directly recorded from actual (not simulated) patients and transmitted via wireless Infrared stethophones. The auscultatory events tested were wide physiologic splitting of S2 in right bundle branch block, fixed S2 splitting and systolic murmur in atrial septal defect, midsystolic click and late systolic murmur of mitral valve prolapse, S4 gallop, S3 gallop, opening snap of mitral stenosis, innocent systolic murmur, systolic murmur of mitral regurgitation, systolic murmur of tricuspid regurgitation, systolic murmur of hypertrophic obstructive cardiomyopathy, continuous murmur of patent ductus arteriosus, pericardial friction rub, prosthetic valve sounds, and alternation of heart sounds, heart murmurs, and the S3 gallop in congestive heart failure. RESULTS: On the basis of the analysis of the 78 participants who completed preconference and postconference evaluations of the 14 selected cardiac auscultatory events, a preconference Identification score of 26.3% and a postconference score of 44.7% were observed. This represents a statistically significant overall Improvement in diagnostic proficiency (P < .001). CONCLUSIONS: Cardiac auscultatory skills among today's health care professionals are extremely poor, regardless of the level and/or type of training of the professional. An actual (not simulated) patient-centered teaching conference is an effective clinical method of improving cardiac auscultatory skills and diagnostic proficiency of health care professionals.
A non-experimental survey was conducted to determine if the factors such as years of practice, how physical assessment skills were learnt and how often these skills were utilised, influenced nurses' reluctance to implement physical assessment. A sample of 150 registered nurses was surveyed. Analysis indicated that the majority of respondents has been taught to listen to chest sounds (auscultation) but did not implement this skill on a daily basis. Chi square analysis indicated that younger nurses with less years of experience were more keen to learn chest auscultation skills than nurses who were older and had more years of nursing experience.
This study investigated the accuracy and inter-rater reliability of 'specialized' physical therapists in the auscultation of tape-recorded lung sounds. In addition, a correlation was investigated between accuracy of interpretation and the number of years of specialization in the field of cardiorespiratory physical therapy. This research follows an earlier study which investigated the accuracy and inter-rater reliability of auscultating tape-recorded lung sounds in a 'non-specialized' cohort of physical therapists. The subjects were 26 'specialized' cardiorespiratory physical therapists working in acute urban teaching hospitals. These individuals were required to have been practising currently and exclusively for at least one year in the area of cardiorespiratory physical therapy. Participants listened with a stethoscope to five different sounds and identified them from a standardized list of terms. One of three tapes with the same lung sounds in different order was randomly selected for each physical therapist. The percentage of correct answers for all subjects was calculated. An accurate response in the detection of lung sounds was arbitrarily defined as a percentage of correct answers of 70% or greater. The difference between the pooled correct response rate of 50% and the arbitrarily set value of 70% was statistically significant (z = 2.23, p < 0.05), indicating that the 'specialized' physical therapists were not accurate in identifying lung sounds. There was no relationship evident between the accuracy and the number of years of cardiorespiratory 'specialization' (r = 0.08). Analysis of inter-rater reliability revealed 'fair agreement' (kappa = 0.26) among subjects. These results were similar to those found in the previous study.(ABSTRACT TRUNCATED AT 250 WORDS)
Auscultation or recording of foetal heart tones is possible throughout pregnancy. In the first trimester, the presence of heart activity proves a vital pregnancy and reduces the probability of spontaneous abortion. From the end of the second and during the whole of the third trimester foetal heart activity can be used to asses the foetal condition. The introduction of cardiotocography failed to reduce serious perinatal morbidity or mortality as compared with intermittent auscultation, but did increase the number of obstetrical interventions.
Percussional auscultation of the frontal sinuses is used for diagnosis of frontal sinusitides. Phonendoscope placed by the sinus walls auscultates sounds forming as a result of comparative percussion of the anterior sinus walls. Three main percussional tones are singled out. This method was employed for diagnosis in 48 patients with frontal sinusitis. The technique is easy to perform, safe and precise (90%). The trend in frontal sinusitides development can be followed up.
The aim of the study was to analyze the auscultatory findings and its variability in 84 patients (pts) with mitral valve prolapse syndrome (MVPS) who were examined in the different body positions. All the pts underwent the echocardiographical examination and in 32 subjects (38%) prolapse of the anterior mitral leaflet was found, in 40 pts (48%) prolapse of the posterior mitral leaflet and in 12 (14%) pts prolapse of the both mitral leaflets. The auscultation of the heart was done in the supine position, in the lying position on the left side and in the upright position of the patient's body. Characteristic for the mitral valve prolapse (MVP) auscultatory findings (midsystolic murmur, late-systolic murmur and/or mid-systolic "non ejection" click) were demonstrated by 43 pts (51%) in the supine position. During the auscultation in the lying position of the pts on the left side, the auscultatory findings were found in 57 pts (68%) while in the upright position in 64 pts with MVPS (76%). The study showed that the auscultatory findings in pts with MVPS were demonstrated more frequently in the lying position of the body on the left side or in the upright position compared with the supine position. Moreover we found that 20 pts with MVPS (24%) did not demonstrate the characteristic auscultatory findings of MVP.
Auscultation of the lungs has been a central element in clinical examination since the early part of the nineteenth century. However, the role of the stethoscope in our diagnostic work-up has more and more been challenged by newer diagnostic equipment. Research carried out over the last 30 years has given us new knowledge about the physical basis of lung sounds and the meaning of the sounds. Electronic stethoscopes and computer-based analysis of digital lung sounds are now available. Lungs auscultation findings should be interpreted with caution and be related to the case history and other clinical findings.