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PubMed2004

Teaching cardiac auscultation to trainees in internal medicine and family practice: does it work?

BACKGROUND: The general proficiency in physical diagnostic skills seems to be declining in relation to the development of new technologies. The few studies that have examined this question have invariably used recordings of cardiac events obtained from patients. However, this type of evaluation may not correlate particularly well with bedside skills. Our objectives were 1) To compare the cardiac auscultatory skills of physicians in training with those of experienced cardiologists by using real patients to test bedside diagnostic skills. 2) To evaluate the impact of a five-month bedside cardiac auscultation training program. METHODS: 1) In an academic primary care center, 20 physicians (trainees in internal medicine and family practice) and two skilled academic cardiologists listened to 33 cardiac events in 13 patients directly at bedside and identified the cardiac events by completing an open questionnaire. Heart sounds, murmurs and diagnosis were determined beforehand by an independent skilled cardiologist and were validated by echocardiography. Thirteen primary cardiologic diagnoses were possible.2) Ten of the physicians agreed to participate in a course of 45-minute sessions once a week for 5 months. After the course they listened again to the same patients (pre/post-interventional study). RESULTS: 1) The experts were the most skillful, achieving 69% recognition of heart sounds and murmurs and correct diagnoses in 62% of cases. They also heard all of the diastolic murmurs. The residents heard only 40% of the extra heart sounds and made a correct diagnosis in 24% of cases. 2) After the weekly training sessions, their mean percentage for correct diagnosis was 35% [an increase of 66% (p < 0.05)]. CONCLUSIONS: The level of bedside diagnostic skills in this relatively small group of physicians in training is indeed low, but can be improved by a course focusing on realistic bedside teaching.

Adult↗
PubMed2002

Inter- and intra-rater reliability of cervical auscultation to detect aspiration in patients with dysphagia.

OBJECTIVE: To measure the inter- and intra-rater reliability of cervical auscultation used alone to detect aspiration in dysphagic patients. SETTING: A university teaching hospital. DESIGN: Comparison of the detection of aspiration in 16 recorded swallow sounds by five speech and language therapists on two occasions. Swallow sounds were recorded simultaneously with videofluoroscopy. SUBJECTS: Sixteen patients referred for assessment of dysphagia with videofluoroscopy. RESULTS: The kappa statistic for multiple raters showed fair agreement between raters (kappa = 0.28). There was high agreement when aspiration occurred but in non-aspirating swallows there was significant overdetection of aspiration (p < 0.001 McNemar's test). The intra-rater reliability within different individuals was widely variable (kappa = 0.55 (range 0.31-0.85)). CONCLUSIONS: Presented with the swallowing sounds in isolation speech and language therapists cannot reliably classify swallows into those with accompanying aspiration and those without. There appears to be a problem of over detection of aspiration. Even in this small study, however, some individual therapists achieve such high reliability (kappa = 0.85) that they must be using successful internal criteria to interpret the swallow sounds correctly and further qualitative research may identify these.

Adult↗
PubMed1994

Venous carbon dioxide embolism in pigs: an evaluation of end-tidal carbon dioxide, transesophageal echocardiography, pulmonary artery pressure, and precordial auscultation as monitoring modalities.

We evaluated the effects of CO2 embolism on end-tidal carbon dioxide (ETCO2) and compared four methods for detection of gas embolism. Fourteen pigs were monitored for CO2 embolism with transesophageal echocardiography (TEE), changes in ETCO2, changes in mean pulmonary artery pressure (MPAP), and precordial auscultation (AUSC). Serial injections of CO2 (ranging from 0.05 to 5.0 mL/kg) were performed in seven pigs (Group 1). In the other seven pigs, CO2 was infused at rates between 0.01 and 0.4 mL.kg-1.min-1 (Group 2). Positive responses were defined as an acute change in heart sounds (AUSC), visualization of gas bubbles in the right cardiac chambers on TEE, an increase in MPAP > or = 3 mm Hg, and an acute change (increase or decrease) in ETCO2 > or = 3 mm Hg. In both groups, positive responses to CO2 embolism were represented by an initial decrease in ETCO2. The frequency with which positive responses were observed revealed that TEE was the most sensitive method (P < 0.05), whereas no differences were found among the other methods. In conclusion, in this model, positive response to CO2 embolism was represented by a decrease in ETCO2. TEE was the most sensitive method of detection of CO2 embolism, and ETCO2, MPAP, and AUSC were equally sensitive.

Animals↗
PubMed1991

Auscultated forced expiratory time as a clinical and epidemiologic test of airway obstruction.

OBJECTIVE: Seeking an inexpensive, readily available, clinical, screening, and field surveillance test of airway obstruction, we determined the validity of current dogma that forced expiratory time (FET) is a good clinical test of airway obstruction yet is of no epidemiologic use given excessive intrasubject variability. SUBJECTS AND METHODS: Two hundred twenty-nine white male plumbers and pipefitters were evaluated by spirometry, chest roentgenography, and a standardized respiratory questionnaire during a union-sponsored asbestos screening program. Subjects were classified as having large airway obstruction (LAO), small airway obstruction (SAO) alone, or no obstruction, on the basis of standard spirometric prediction equations. Two physicians, blinded to clinical and spirometric data, independently measured FET while auscultating the trachea with a stethoscope. The FET was defined as the time taken for an individual to forcefully exhale through an open mouth from total lung capacity until airflow became inaudible. Five such times were recorded for each subject. The mean of the three times having the narrowest range was deemed the FET for calculating test sensitivity and specificity. Based on previous literature, an FET greater than or equal to 6 s was considered abnormally prolonged. RESULTS: Two hundred five subjects completed both spirometry and FET testing; 67 had LAO, 5 SAO, and 133 no obstruction. A total of 83 percent had three FETs reproducible within a range of less than or equal to 1 s. The sensitivity and specificity of FET for LAO were 92 and 43 percent, respectively, while for SAO alone, 60 and 44 percent, respectively. Overall, FET misclassified 56 percent of nonobstructed subjects. Adjusting the normal-abnormal cutoff points for both FET and SAO minimally improved the performance of FET. CONCLUSION: Although FET is a simple, inexpensive, sensitive, and fairly reproducible clinical test of LAO, it cannot be recommended as a clinical or an epidemiologic tool because of its extremely low specificity.

Asbestosis↗
PubMed1998

The accuracy and interobserver agreement in detecting the 'gallop sounds' by cardiac auscultation.

STUDY OBJECTIVES: To determine the observer accuracy and interobserver agreement in identifying S4 and S3 by cardiac auscultation and whether they improve with increasing observer experience. DESIGN: Prospective, blinded study. SETTING: Cardiology and general internal medicine wards in a university-affiliated teaching hospital. PATIENTS: Forty patients with a cardiac diagnosis and 6 patients without were studied. MEASUREMENTS AND RESULTS: Two cardiologists, one general internist, three senior and two junior postgraduate internal medicine trainees, blinded to the patients' characteristics, examined the patients and documented their findings on a questionnaire. Computerized phonocardiogram was obtained in all patients as a gold standard and was interpreted by a blinded, independent cardiologist. The mean positive predictive values for S4 and S3 were 51% (range, 24 to 100%) and 71% (range, 50 to 88%), respectively. The mean negative predictive values for S4 and S3 were 82% (range, 67 to 94%) and 64% (range, 56 to 85%), respectively. The overall interobserver agreements for detecting S4 was K = 0.05 (95% confidence interval [CI], 0.01 to 0.09) and S3 was K = 0.18 (95% CI, 0.13 to 0.24). There was no apparent trend in the accuracy or interobserver agreement with regard to the level of observer experience. CONCLUSION: The agreement between observers and the phonocardiographic gold standard in the correct identification of S4 and S3 was poor and the lack of agreement did not appear to be a function of the experience of the observers. The overall interobserver agreement for the detection of either S4 or S3 was little better than chance alone.

Adult↗
PubMedDate not supplied

Accuracy of heart rate obtained by auscultation in atrial fibrillation.

The accuracy of heart rate estimation by cardiac auscultation over a 15-second period, and the influence of clinical experience on accuracy were evaluated in a dog with chronic atrial fibrillation by test subjects of varying experience. Only 30% of all test subjects provided accurate heart rate estimates. Board-certified specialists, medicine residents, and experienced nurses were significantly more accurate in their estimates than surgery residents and students. Accurate estimates were provided by 12.5% of surgery residents and students, as opposed to 64% of the other test subjects. Auscultatory estimates of heart rate in atrial fibrillation may be significantly inaccurate, and under some circumstances they may not provide a sound basis for making clinical decisions.

Animals↗
PubMed1983

Aids to cardiac auscultation.

Despite the wide application of aids for cardiac auscultation, their diagnostic efficacy has not been comprehensively evaluated. The most commonly used auscultatory aids, including respiration (Carvallo's maneuver), Müller and Valsalva maneuvers, squatting, standing, handgrip, intrinsic cycle length changes, and amyl nitrite, are discussed. A review of the literature suggests that enthusiasm for these aids must be tempered because of limitations in sensitivity and specificity as well as weaknesses in the methods used in the validation studies.

Amyl Nitrite↗
PubMed1981

An audiosystem for teaching pulmonary auscultation.

We have developed and tested a portable audiosystem that will allow as many as 14 persons to listen simultaneously to pulmonary and cardiac sounds when an instructor places a central stethomicrophone on a patient's chest. This system facilitates the teaching and learning of chest auscultation on the clinical setting because it (1) helps to ensure that the student hears what the instructor intends, (2) minimizes patient discomfort by allowing everyone in the group to listen simultaneously rather than in groups of two or three in succession, and (3) provides a means of effectively recording sounds at the bedside for future educational purposes.

Audiovisual Aids↗
PubMed2001

Teaching cardiac auscultation using simulated heart sounds and small-group discussion.

BACKGROUND AND OBJECTIVES: Several educators have reported poor identification of abnormal cardiac sounds by primary care residents. Practice and review with cardiology patient simulators and prerecorded heart sounds has been shown to increase the accuracy of diagnosis by medical students and residents. METHODS: The participants were 15 members of an urban family practice residency. The residents were presented with simulated heart sounds and were asked to identify them in a pretest and posttest. Between the tests, participants were invited to three separate teaching sessions that involved a discussion of cardiac auscultatory findings and a review of audiotaped similar heart sounds. Residents who were unable to attend the teaching sessions formed a control group. RESULTS: The pretest identification rate was 36% for the heart sounds. This improved to 62% for all residents after the intervention. Higher rates of improvement were demonstrated by the residents who attended one or more teaching sessions, compared with the residents who attended no teaching sessions. CONCLUSIONS: Small-group discussion and repetitive auscultation of simulated heart sounds can improve the cardiac auscultatory proficiency of family practice residents.

Education, Medical, Undergraduate↗
PubMed1995

[The cardiac examinations in 19c. Poland (development of auscultation and percussion among Cracow and Warsaw physicians)].

The essay is a continuation of the subject touched upon in one of the last year issues. It starts with Józef Dietel's acceptance of a chair in Cracow. The ways of examining and describing of circulatory system by students at his clinic particularly percussion and auscultation are presented. Numerous exerts from descriptions of circulatory system examining methods for students from Antoni Kryszka and Józef K. Rose and Włodzimierz Dybek handbooks are quoted.

Auscultation↗
PubMed1994

[19 c. heart examination in Poland (the beginning of percussion and auscultation)].

Basing on the 19 c literature and health reports, the contemporary views upon the methods of circulatory tract examination were reconstructed. The differences in the choice and propagation of the new methods were pointed out at the most important centres of medicine in Poland: Warsaw, Cracow and Vilnius. It was also established that the methods of percussion and auscultation had reached Poland earlier that the research done so far seemed to have indicated.

Auscultation↗
PubMed2003

Echocardiography or auscultation? How to evaluate systolic murmurs.

OBJECTIVE: To compare cardiac physical examination with echocardiography for evaluating systolic murmurs. QUALITY OF EVIDENCE: Three databases were searched for studies comparing echocardiography and auscultation as to sensitivity and diagnostic accuracy: MEDLINE (Ovid Online), EMBASE, and Current Contexts. The quality of reported data is lowered by subjective interpretation of results of both cardiac physical examination and echocardiography, especially Doppler colour flow imaging. MAIN MESSAGE: In adults, functional systolic murmurs can usually be distinguished from organic murmurs. Pathologic murmurs frequently have one or more associated clinical abnormalities. If a clinician determines a murmur is benign, results of echocardiography are very likely to be normal, especially in young and middle-aged adults. According to current guidelines, echocardiography should not be ordered for "innocent" systolic murmurs in patients who are asymptomatic and have otherwise normal findings on examination. If patients with functional systolic murmurs could be identified and not routinely referred for echocardiography, great cost savings could be realized. CONCLUSION: Echocardiography is not required for all patients with systolic murmurs and should not replace cardiac physical examination.

Adult↗
PubMedDate not supplied

A comparison of the auscultated acceleration test and the nonstress test as predictors of perinatal outcomes.

In this prospective study, the predictive ability of the nonstress test (NST), the most widely used antepartum screening test to assess fetal well-being, was compared with that of the auscultated acceleration test (AAT) in predicting perinatal outcomes. The AAT is a more easily administered test than the NST, and, unlike the NST, does not use electronic fetal monitors. Study subjects were 205 women with singleton pregnancies greater than 34 weeks' gestation, whose delivery occurred within 7 days of receiving antepartum testing by NST at Johns Hopkins Hospital. The AAT yielded better prediction of poor perinatal outcomes than the NST. The NST, however, was a significantly better predictor of favorable outcomes than the AAT. The AAT has the potential to affect perinatal care if false positive results can be decreased through further research.

Adult↗
PubMed1990

Oscillometric finger blood pressure versus brachial auscultative blood pressure recording.

In this study, a recently marketed proprietary finger blood pressure monitor, the Marshall, Astro F-88, was compared with the standard auscultative brachial mercury sphygmomanometer on 125 subjects. Measurements were undertaken according to the standards set by the American Heart Association. Sensitivity of the finger blood pressure measurement was 76% for systolic and 75% for diastolic blood pressure in diagnosis of high blood pressure (systolic greater than 140 mm Hg and diastolic greater than 90 mm Hg). Specificity was 86% for systolic and 82% for diastolic blood pressure. Positive predictive values were 58% for systolic and 38% for diastolic blood pressure in the study population in which prevalence of hypertension was 12%. The correlation coefficient (Pearson) for systolic values between devices was 0.76 (P less than .0001) and 0.57 (P less than .0001) for diastolic pressure. Values obtained by the finger monitor were found to be higher than those obtained by the mercury sphygmomanometer. Mean differences and standard deviations (paired t test) for systolic and diastolic pressures between the two devices were 2.3 +/- 14.9 mm Hg (P less than .08) and 2.9 +/- 14.5 mm Hg (P less than .02), respectively. These values are not in accordance with the proposed national standards because only 48% of the systolic and 37% of the diastolic blood pressure measurements were within 5 mm Hg of the mercury sphygmomanometer measurements. Therefore, although these differences may well be due to different techniques of monitoring employed by the devices, this device is not recommended for evaluation of blood pressure.

Adolescent↗
PubMed1988

Correlation between left ventriculography, auscultation, and M-mode and two-dimensional echocardiography in mitral valve prolapse.

Mitral valve prolapse (MVP) is a common valvular abnormality which is observed in as many as 5% of the general population. Although invasive as well as noninvasive tools have been developed to determine the existence of this disorder, none is perfect and false negative as well as false positive diagnoses abound. Because MVP is a relatively benign disorder, it has also not been easy to make the usual clinical-pathological correlations. Left ventriculography is considered by many to be the gold standard, but this designation is probably not deserved. The angiographic criteria used by most do not permit unequivocal separation of normal mitral valve systolic bulging from pathologic MVP, and the interobserver and intraobserver variability of interpretation is high. However, false positive diagnoses can be eliminated if MVP is diagnosed only when para-annular displacement of mitral leaflet tissue is detected during systole rather than simple leaflet bulging. Although mid-systolic clicks and late systolic murmurs have proven to be the auscultatory hallmarks of this disorder, many patients have these signs without other diagnostic findings, consequently making it impossible to confirm the presence of MVP. Furthermore, the appearance of diagnostic echocardiographic abnormalities in patients with normal cardiac examinations implies that auscultation is not a sensitive marker of MVP. Both M-mode and two-dimensional echocardiography have technical limitations and the repeatability of interpretation of these tests is disappointingly low (80 to 90%). Because of these difficulties the angiographic-echocardiographic correlation is only fair. Nonetheless echocardiography has generally been accepted as the diagnostic modality of choice. Future technical improvements will likely enhance the diagnostic accuracy of this technique.

Echocardiography↗
PubMed1987

[Treatment of an asthmatic child becomes more effective when the mother is well informed, auscultates her child and keeps a diary].

The asthmatic child himself can do nothing against his illness. It is the task of the mother, assisted by the physician, to prevent the child suffering from his asthma. To achieve this purpose it is not sufficient to prescribe medicaments only. But a comprehensive information of the mother about asthma bronchiale, the auscultation of the child by his mother and a daily record of the symptoms make the medicaments effective.

Asthma↗
PubMed1984

Fetal heart rate pattern recognition by the method of auscultation.

The thesis that obstetric health care personnel can discriminate characteristics of baseline fetal heart rate (FHR) and FHR patterns by auscultation needs to be tested. For this study, audiotones of the FHR signals were recorded for eight representative FHR patterns. Each recording was for three minutes and included one uterine contraction. Physicians and nurses who use continuous electronic FHR monitoring on a regular basis listened to the eight recordings and attempted to identify the baseline rate, variability, and periodic patterns, and then matched their perceptions with the eight corresponding FHR tracings (not in order). Baseline FHR and FHR without periodic patterns were most frequently identified correctly. Late decelerations with and without good baseline variability were misdiagnosed 18.4 and 33% of the time, respectively. Although the FHR characteristics and periodic patterns were correctly identified most of the time, failure to recognize significant periodic patterns by as many as one-third of the participants is unacceptable in modern obstetrics.

Female↗
PubMed1983

The role of auscultation and registration of bowel sounds in the diagnosis of acute appendicitis.

The study described was designed to evaluate the role of auscultation and registration of bowel sounds in the diagnosis of acute appendicitis. In 37 patients with suspected acute appendicitis undergoing appendicectomy the bowel sounds were registered twice pre-operatively and once on the postoperative day. The results show that single registration of bowel sounds is rarely diagnostic, but repeated examinations with the method used in this study might provide an additional factor to reaching a diagnosis. However, the results are difficult to apply directly to the clinical situation, and further evaluation of this method, as well as an improvement of the technical equipment used, is essential.

Acute Disease↗