Advanced Physical Diagnosis
  • Techniques
• 1st & 2nd Heart Sounds
• 2nd & 3rd Heart Sounds
• Clicks and Snaps
• Murmurs
• Rubs
  • Demonstrations
Associated Evaluations
  • Patient HX
  • Physical Exam
  • Laboratory & Imaging
Differential Dx
Evidence Base
• Accuracy in Diagnosis of Systolic Murmurs
• Accuracy in Diagnosis of Diastolic Murmurs
• Accuracy in Diagnosis of CHF
Teaching Tips
[Skill Modules >> Heart Sounds & Murmurs >> Teaching Tips ]

Teaching Tips: Heart Sounds & Murmurs

General Points

  • As with any physical sign, it is helpful to have the learner commit to an assessment before utilizing technology, such as radiography, ECG, or invasive monitoring.
  • Talk aloud to describe the maneuver as it is being performed.
  • To keep all participants interested, pose questions that learners can be thinking about until it is their turn to examine patients.
  • Ask the patient's permission before reviewing the sign as a group. Summarize to the patient when the exam is completed.
  • There are different way to approach the exam depending upon the level of the learner:
    • A finding may be simply demonstrated, or a brief patient history may be given and the learner asked to demonstrate appropriate exam maneuvers, or
    • Demonstrate various maneuvers to detect an abnormality (e.g., ascites), and ask learners about the value (sensitivity and specificity) of each exam maneuver.
  • Historical points are fun and enhance interest in the exam.

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Heart Sounds & Murmurs

Algorithm for using maneuvers and dynamic auscultation to diagnose a confusing systolic murmur:

Murmur Analysis with Dynamic Auscultation

Murmur Analysis with Dynamic Auscultation

You can also distinguish between AS and MR by changes in intensity after changes in cycle length. Listen for a beat after a PVC. With a longer time between beats, there is increased filling, increased contractility and decreased afterload. This increases the flow across the aortic valve leading to an increase in AS murmur intensity. It decreases the regurgitant flow across the mitral valve as more blood flows forward with the decrease in afterload, decreasing the intensity of the MR murmur.

Teaching Tip: It is easier to hear the different intensities of the normal beat and post PVC murmur by listening to the post PVC murmur and then the murmur associated with the subsequent normal beat. This is easier to hear than remembering the intensity of the murmur that occurred before the pause and comparing it to the post extra beat murmur.

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Engage Learners During Exam

QuickTime format S3 (1.5MB)
QuickTime format S3 & S4 (3.4MB)
Case Example
Example of evidence-based teaching case (aortic stenosis)
(Case adapted from presentation by Paul Sutton, MD, PhD.)
Friction Rubs

The traditional descriptions of friction rub used correlations such as "leather rubbing together" (examples such as a saddle and leather pants). Now these are irrelevant since most of us don't even know what leather sounds like!

Better examples to convey the sound are:

  • the crunching sound of walking on new snow with an icy top crust.
  • Ask the learner to rub his/her thumb and index finger together right nest to the ear; this reproduces a similar sound
  • Cover ear with hand and with fingernail of opposite hand, scratch along dorsal surface of hand that is covering the ear

The teacher can ask students and residents some of the following questions. Which may help them to understand pericardial rubs better:

Question 1: What are the timing of sounds in a pericardial rub?
Question 2: Why is the pericardial friction rub usually loudest during inspiration?

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