Heart Exam

My interest at a young age led me to become a physician assistant today. Auscultation of the heart is an often overlooked component of the physical exam. I use a triple head stethoscope when doing exams. It is important to listen to the heart in a number of different positions to rule out a heart murmur. Does anyone else feel that auscultation of the heart is overlooked.

I think women especially are less likely to have their hearts thoroughly auscultated (for two obvious reasons) and doctors not wanting to expose the breasts and lift the left breast. Several women I have stethed have commented on me being more thorough than their real doctors.

I also question everyone’s ability to discern what they hear - and even sometimes whether they DO hear - what is happening in heart and lungs. It could be attributed to a sub-par stethoscope, lack of exposure/training to real-live problem sounds, and/or even impaired hearing.

Today I have my migraine. Years ago, I had a migraine during a physical and my MD questioned whether, because I get migraines, I had a murmur. He could not hear one, so he scheduled me for an echocardiogram. So I went. The tech couldn’t hear a murmur either, but she did have me do something similar to a valsalva maneuver, which actually DID trigger a murmur that is repeatable. I could feel it, she could hear it, and it showed up on the echo.... though I also question the validity of the link between the migraine and the murmur - which may suggest something chronic or even congenital or comorbid vs. a link between the maneuver and a normal heart’s reaction....

So he had apparently read some studies. But no other MD/NP has ever validated that I have one, or the correlation, etc.

So I would add lack of knowledge to the list of reasons why perhaps the auscultation is relied upon less than we think.

That said, every nurse I know and work with very much knows the value of one stethoscope brand over another and holds his/her scope close at hand.... and the doctors get to know who among us is accurate with not only hearing something that is actually there but also when to ask for what follow up. And I have been privileged to work with both knowledgeable doctors and nurses who, when something less common is heard, will invite the less-exposed nurses to come listen along.

I have a heart murmur that I have had since childhood. My current GP cannot hear it, even though I can. All she checked was the Aortic and Pulmonary valves. I don't think she's ever checked the others. Even when I had general anesthetic last year, all the anesthesiologist did was listen to my lungs. Back in 2000, I had three surgeries in a year and at the first one's pre-op, the resident caught it where the anesthesiologist missed it.

It really does seem to be quicker and more cursory these days. My GP now just listens to my lungs over my top, but she has a new stethoscope so maybe the new ones can hear better through clothing? Not good for us stethophiles!

Regarding real exams: I'm in my mid-30s, so my exams are fairly quick, cut, and dried as is. That said, I think my heart/lungs get the most attention out of everything--if only because the stethoscope is used on my chest and on my back. It's always done on bare skin. (I was a little surprised to read some people had it done over their clothing!) When I was going to a pediatrician, I'd be stripped down to underwear, so my doctor could start listening to my heart and lungs whenever he was ready to start that portion of the exam. At my current PCP, I'm nude under a gown and I pull down the top of the gown come that time of the exam.

Regarding role play exams: I'd say this part of the exam gets played up a fair bit. There's something about a cold stethoscope on warm skin that works well to make the patient mildly uncomfortable and build some healthy tension as the doc listens up and down my body.

All that said, I've never had the pleasure of having a three-headed stethoscope used on me in either a real or fantasy setting. @physical68 : What are each of the heads used to listen for?

Do hear a lot of innocent heart murmurs. mostly S3 and S4 heart sounds. the majority of these murmurs do not require follow up but some do.

Some medical professionals seem to like the "cheaper" steths because that's all they need. My doctor is an internist and uses the Littmann Lightweight II SE. Which, to me, is disappointing. But he has hearing aids in both ears, so he doesn't need a particularly loud stethoscope. The hearing aids do the work of amplifying

Stethoscope choice is kinda like car choice. It's different for different people.

Re: steth

I agree with your statement, and it's the #1 reason so many women die from heart related issues! Also doctors assume women's hearts are the same as mens, womens heart symptoms are totally different and mimic stress almost 90% of the time. You may not even have any pain. Just in general not feeling up to par, back of neck and shoulder pain, pain in your back where your bra sits, feelings of doom, sweating, all are signs your heart is in stress. Stress tests, echo is first tests, but really the only way to really see how a heart is doing is a angiogram, because I'm a prime example, went two years ago because I could not mow the lawn without stopping, so knew something was up, had stress test, showed everything was fine, nope! I knew it wasn't but trusted the test. That was end of July, November 30 woke with chest pain! Off to the ER and doc says angiogram, showed my RCA coronary artery was collapsing, ( I have huge arteries) so I went from your fine to your gonna die in 4 months! Don't wait ever! Go to the ER and bitch till you get someone to listen, your life might depend on it.

I have to agree that a heart exam ... which is my favorite ... is mostly overlooked. The only time that I am thoroughly examined in different positions is during my yearly visit to my cardiologist. He has me sitting upright ... flat in my back ... and then leaning on my left side while auscultating me. My favorite part is when he auscultates my femoral pulses with me clad in underwear only. He will pull down each side of my underwear ... which exposes my pubic hair ... before placing the stethoscope over the artery area itself. Needless to say, this has usually caused me to bone up although my genitals remain covered. An extra bonus for me is having an electrocardiogram which the doctor himself conducts.

Like you Charlie, my favourite part of a cardio exam is when they check the femoral pulse. Lying on the bed in underwear only, having my boxers lowered slightly and exposing the top of my trimmed pubes, while they reach in and feel my femoral pulse and then push the stethoscope in and listen. Like you also, I get a boner and on the side it's on they sometimes have to push it out of the way.

A cardio exam isn't completed without checking all areas, not just palpating and listening to your chest and back. Checking also your sides, underarms, neck, abdominal aorta, femoral pulses, and pulses in your lower leg and feet.