Auscultation

[posr]

Hello.

I am a pre-med and have a question on cardiac auscultation. When I looked cardiac auscultation exam report, usually documented as: Regular rate and rhythm, normal S1,S2, no MGR

My question is how do we know the heart rate and rhythm are regular or not by auscultation only without looking EKG? So,I was wondering what information we normally get only by auscultation using stethoscope only during physical examination.
Also, when I read some literature murmur and gallop(extra sounds) are normally best heared in left lateral position. So, is it correct to write no murmur/gallop/rub only by ausculating in a sitting position?

In short, please tell me what information are we expected to find by auscultation only using stethoscope only in a sitting position and what is the correct way to document the result assuming the exam is normal.
RRR, normal S1,S2, no murmur/gallop/rub sitting
or
Regular S1, S2
or
Normal S1, S2
or
Regular S1, S2, no murmur/gallop/rub?

What about taking radial pulse during auscultation-is it helpful?

Thank you

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[ROBINHO]

Run very fast...maybe 100m...and then hold your pulse to see if u can tell if your heart is beating faster or slower(that is rate). What u feel at your pulse is same thing one hears when your heart is listened to. So yes, somebody who listens to the heart everyday(experience) will be able to tell if the heart rate is normal or not.

And as u wrote...literature says...''Best heard at left lateral position''. That doesnt mean that you should listen to only that position. Routinely doctors auscultate 4-5 spots depending on what the patient came in for. And the position depends on what u are suspecting.could be sitting could be lying down with your belly up, could be lying on your left side.

With experience u can tell if Rate Normal,Rhythm Normal, and when there is no murmurs,Gallops, or Rubs

Yes it helps to palpate pulse at the same time becos sometimes u able to figure out some pathologies whose specific signs are felt in the pulse.

Good Luck

 

[NDESTRUKT]

Great questions...

Once you're doing clinical rotations in medical school and as a resident you'll realize these things come naturally and you'll be able to differentiate what use to be difficult to grasp issues very easily. Even the mediocre resident with enough practice can realize if someone's rate and rhythm are regular are not. Murmurs are sometimes subtle so it's not always that easy but if you didn't hear it you didn't hear it.

No need to specify what position you heard it. If it's going to be significant, you'll likely suspect it by history and go from there.

 

[posr]

Oh! I didn't know that doctors can tell heart rate and rhythm are regular or not by auscultation only without looking EKG. Thank you very much, I understand it now.

So, if the exam is normal(using auscultation only with stethoscope)- which one is correct to document the result?

Do we need to document both RRR, and regular or normal S1,S2 together as:

Regular rate and rhythm, regular S1, S2?

or

Regular rate and rhythm

or

Regular S1, S2

or

Normal S1, S2


Thank you again

 

[ROBINHO]

Keeping it simple (assuming you are a Pre MEd) as in your profile.

Normal Heart Sounds(S1,S2)
regular Rhythm, regular rate
No murmurs/gallops/ rubs (this isnt so important for you...I dont think you would be expected to know that)


and again about the Rate. By experience a Doctor can tell if the rate is normal...very fast or slow. However to document the exact rate 80, 120 etc the physician can feel the pulse or sometimes auscultate the heart and look at his watch to count.

Same applies to rhythm. by listening a doctor can tell the that there is something wrong. A very experienced doctor can tell you what kind of arrhythmia by listening. But for documentation purposes u order an EKG.

however if you are very sure they are normal...u can write it down as regular rate and rhythm.
then say if it is normal Heart Sound
and optional...no murmurs,no gallops no rubs


Hope I helped
Good luck

 

[azq]

If your exam is normal in auscultation with stethoscope, you can document your report as: RRR, no murmur, gallop, or rub. You can also document as: Regular S1, S2 without murmur, gallop(= S3, S4), or rub
Offcourse some people write as: RRR, normal S1, S2 and without murmur, gallop, or rub but in my perspective if you write RRR, I didn't see the reason why you include normal S1, S2. Similarly, if you write regular S1, S2, I don't see the need to include RRR.. both mean the same thing but either way is fine for me.
offcourse this my opinion..others can correct me if I am wrong

 

[Myostatin]

You raise a vaild point - i.e. can you tell that the rhythm is regular without looking at an EKG, just based on auscultation - the answer is yes, but for the most part you can only say that its regular, not that it is a normal rhythm.

For example,

VT, accelerated junctional rhythm, complete heart block with ventricular or junctional escape, and any number of supra ventricular tachycardias can all sound completely regular by ascultation (of course the rate will be discernably abnormally fast or slow in most of these cases, but not all).

In the exam, you're only stating that the rhythm is regular, not that it is normal - you can only definitively tell that the rhythm is normal with an EKG.

There are exam findings that can tip you off to some of the abnormal rhythms, that are not directly related to auscultation - cannon a-waves in the case of complete heart block, for example.

 

[J-Rad]

Offcourse some people write as: RRR, normal S1, S2 and without murmur, gallop, or rub but in my perspective if you write RRR, I didn't see the reason why you include normal S1, S2. Similarly, if you write regular S1, S2, I don't see the need to include RRR.. both mean the same thing but either way is fine for me.
offcourse this my opinion..others can correct me if I am wrong

No. Abnormalities of S1 and/or S2 can and frequently do occur the the setting of a regular rate and rhythm. The single S2 of a baby with HLHS is abnormal, but does not affect rhythm/rate. The split S2 heard in the setting of an ASD, likewise, do not affect rate/rhythm. S1 and S2 tell you about closure of the AV and semilunar valves. Different conditions can affect them without affecting rate/rhythm. Ebstein's, other AV valve abnormalities, bundle branch blocks, ASDs, etc. Abnormalities of rhythm won't necessarily affect S1 and S2 either. The RRR and the S1/S2 are assessments of different things.

 

[azq]

You are right. I was in the impression that rhythm will cover S1 and S2. I agree with you. But, if that is the case
the correct documentation is RRR, normal S1, S2 or RRR, regular S1, S2 assuming that there is no abnormality on S1 & S2?

As per your info. I think normal S1, S2 may describe it better than Regular S1, S2, I think.

 

[J-Rad]

I typically use the term "normal" or describe the abnormality if appropriate. Because a large portion of my patient population (children) can have a prominent normal splitting of S2, I may document "prominent physiological splitting of S2"instead of normal S2, just so a PCP less comfotable with heart sounds doesn't get freaked out.