Name: auscultation
Uploaded: 2023-04-30T06:42:17.000Z
Duration: 6 min 17 s
Channel: JoVE

K12 Standards

new-york-state-science-learning-standards

New York State Science Learning Standards

High School

Physical Science

HS. Energy

HS-PS3-2.

Auscultation

<ol>
	<li>Throughout the entirety of the patient encounter, use your un-aided sense of hearing to identify findings that may be diagnostically useful (e.g., hoarse voice or grunting with expiration).</li>
	<li>Before patient contact, decontaminate the stethoscope by wiping it with a 70% alcohol pledget, a standardly available antiseptic rinse used for hand hygiene, or a hospital surface disinfectant.3</li>
	<li>Positioning of the stethoscope
	<ol>
		<li>Place the stethoscope ear buds in your ears with the tips pointing forward in order to create a seal that drowns out ambient noise.</li>
		<li>Confirm which side of the chest piece (i.e., the bell or the diaphragm) is active by gently tapping on one side or the other.</li>
		<li>Rotate the chest piece until you hear and feel a click to switch between the bell and diaphragm as needed. Certain stethoscopes have only one side to the chest piece, which can be used as a diaphragm and a bell depending on the amount of pressure applied against the patient&#39;s skin. Firm pressure makes the chest piece a diaphragm, while light pressure makes it a bell.</li>
		<li>Hold the chest piece in your dominant hand. There are two commonly used handgrips for the chest piece:
		<ol>
			<li>Support the chest piece between the middle phalanges of your second and third fingers, with your thumb tucked under the tubing to keep it off of the patient&#39;s skin, which can potentially reduce noise artifacts.</li>
			<li>Support the chest piece between the distal phalanges of your thumb and second finger. When using this grip, tuck the remaining fingers under the tubing to keep it off the patient&#39;s skin, though in certain maneuvers, these fingers need to be held in slight extension to keep the fingers themselves off of the patient&#39;s skin (e.g., auscultation at the base of the heart).</li>
		</ol>
		</li>
		<li>Refer to the dedicated videos on the cardiac, pulmonary, abdominal, and vascular examinations for specific details on the techniques of auscultation for these areas.</li>
		<li>As you listen, especially to heart sounds, consider the physiology and mentally picture the anatomy which may help to parse the variety of sounds that are heard simultaneously.</li>
		<li>Train the mind to form a visual representation of the sounds being heard, as this may help to better clinically characterize the sounds. Certain electronic stethoscopes allow examiners to record sounds and actually create visual representations of the findings.</li>
	</ol>
	</li>
</ol>
<div class="chapter_text" id="script_0">
	Auscultation refers to the act of listening to the sounds produced by the body during a physical examination. 
	Historically, the term "auscultation" was synonymous with "immediate auscultation," in which the examiner's ear was placed directly against the patient's skin. Although this was standard practice for centuries, the method proved inadequate in nineteenth-century France, due to social norms and suboptimal diagnostic yield. Therefore, in 1816, Ren&eacute; La&euml;nnec invented the first stethoscope. This was a hollow wooden tube with a flat surface on one end-to be placed on the patient's skin, and an opening at the other end-to listen to the sounds transmitted. Since then, stethoscope has undergone many technologic advances, but it still remains a tool that is inseparable from clinical practice.
	This video will illustrate the parts of the stethoscope and demonstrate how to use this instrument during any physical examination. 
</div>
<div class="chapter_text" id="script_1">
	First, let's review what are the different parts of a stethoscope and what is their function. The basic parts include the ear buds, the tubing and the chest piece. Now-a-days commonly used stethoscopes have two flat surfaces on the chest piece-one is the diaphragm and other is the bell. 
	Usually, the diaphragm is applied firmly against the skin to listen to the high frequency sounds such as S1 and S2. The firm application is necessary as this allows the high frequency sounds from within the patient vibrate to the membrane of the diaphragm, which in turn results in propagation of sound through the column of air inside the stethoscope and into the examiner's ears. Conversely, when applied lightly, the bell transmits low frequency sounds such as S3 or S4. The open bell acts as a cup that directly transmits sounds from within the patient through the tubing. Pressing more firmly with the bell can stretch the underlying skin, essentially turning it into a diaphragm. Certain stethoscopes have only one side to the chest piece, which can be used as a diaphragm and a bell; firm pressure makes the chest piece a diaphragm, while light pressure makes it a bell.
</div>
<div class="chapter_text" id="script_2">
	Now, let's go over some important steps related to auscultation that can be applied to any physical examination. Throughout the entirety of the patient encounter, use your unaided sense of hearing to identify findings that may be diagnostically useful, like hoarse voice or grunting respirations. 
	Before patient contact, decontaminate the stethoscope with any of the standardly available agents. Place the stethoscope ear buds in your ears with the tips pointing forward in order to create a seal that drowns out ambient noise. By gently tapping on both surfaces, confirm which side of the chest piece is active. To switch between the two sides, rotate the piece until you hear a click, and then tap to confirm. 
	Hold the chest piece in your dominant hand. There are two commonly used handgrips for this. One way is to support the piece between the middle phalanges of your second and third fingers with your thumb tucked under the tubing to keep the tube off the patient's skin, which can potentially reduce some noise artifacts. Another way is to support it between the distal phalanges of your thumb and second finger. When using this grip, you should normally tuck the remaining fingers under the tubing. Except, in certain maneuvers where these fingers need to be held in slight extension to keep the fingers themselves off the patient's skin. For example, during auscultation at the base of the heart. 
	There are specific techniques of auscultation for pulmonary, cardiac, abdominal, and vascular examinations, which will be covered in the respective videos of these collections. As you listen, consider the physiology and mentally picture the anatomy, which may help to parse the variety of sounds that are heard simultaneously. Train the mind to form a visual representation of the sounds being heard, as this may help in better clinical characterization of the underlying pathology. Certain electronic stethoscopes allow examiners to record sounds and actually create visual representations of the findings. 
</div>
<div class="chapter_text" id="script_3">
	You've just watched JoVE's video on general approach to auscultation during a physical examination. You should now understand the different parts of a stethoscope, and how to use this instrument effectively. 
	Making meaning out of the variety of sounds that one appreciates with the stethoscope can seem daunting to the early learner. Through deliberate practice, with consideration of anatomy and physiology of the structures being examined, and possibly the use of visual representation of sound, auscultation becomes a powerful diagnostic tool for the clinician. As always, thanks for watching!
</div>

This video covered the general considerations related to auscultation during the physical examination. Auscultation is typically done with the aid of a stethoscope, though certain findings, especially on the respiratory examination, may be evident to the un-aided ear. While specific stethoscope techniques vary based on each individual portion of the exam, in all circumstances, the clinician must hold the stethoscope properly and recognize the difference between the bell and the diaphragm in order to optimize the diagnost...

auscultation

Source: <a href="https://www.jove.com/author/Jaideep+S._Talwalkar">Jaideep S. Talwalkar</a>, MD, Internal Medicine and Pediatrics, Yale School of Medicine, New Haven, CT
Through auscultation, the clinician is able "to eavesdrop on the workings of the body" to gain important diagnostic information.1 Historically, the term "auscultation" was synonymous with "immediate auscultation," in which the examiner's ear was placed directly against the patient's skin. Although this was standard practice for centuries, the method proved inadequate in nineteenth-century France, due to social norms and suboptimal diagnostic yield. This led René Laënnec to invent the first stethoscope in 1816 (Figure 1), a tool that has since become inseparable from auscultation in modern clinical practice, and patients hold it as a symbol of honor and trustworthiness among those who carry them.2
<img alt="Rotational symmetry diagram; wooden kaleidoscope construction, reflecting mirror alignment." src="/files/ftp_upload/10153/10153fig1.jpg" data-altupdatedat="1761830439000" data-alt="Figure 1"> 
Figure 1. A representative illustration of the first stethoscope invented by René Laënnec.
The stethoscope has undergone many technologic advances since Laënnec's initial hollow wooden tube. Practically speaking, the provider must understand the difference between the two sides of the modern stethoscope's chest piece: the diaphragm and the bell (Figure 2).
<img alt="Stethoscope diagram with labeled parts: ear buds, tubing, bell, diaphragm." src="/files/ftp_upload/10153/10153fig2.jpg" data-altupdatedat="1761830439000" data-alt="Figure 2"> 
Figure 2. Parts of a modern stethoscope.
When applied firmly against the patient's skin, the diaphragm transmits high frequency sounds. Sounds from within the patient vibrate the membrane of the diaphragm. These vibrations result in the propagation of sound through the column of air inside the stethoscope and into the examiner's ears. Conversely, when applied lightly, the bell transmits low frequency sounds. The bell acts as a cup that directly transmits sounds from within the patient through the tubing of the stethoscope. Pressing more firmly with the bell can stretch the underlying skin, essentially turning it into a diaphragm. Auscultation is used in a wide variety of clinical settings. It most commonly plays a role in the examination of the chest, heart, abdomen, and vasculature.

Source: Jaideep S. Talwalkar, MD, Internal Medicine and Pediatrics, Yale School of Medicine, New Haven, CT
Through auscultation, the clinician is able ...

Auscultation refers to the act of listening to the sounds produced by the body during a physical examination. Historically, the term "auscultation" was synonymous with "immediate auscultation," in which the examiner's ear was placed directly against the patient's skin. Although this was standard practice for centuries, the method proved inadequate in nineteenth-century France, due to social norms and suboptimal diagnostic yield. Therefore, in 1816, Ren? La?nnec invented the first stethoscope. This was a hollow wooden tube with a flat surface on one end-to be placed on the patient's skin, and an opening at the other end-to listen to the sounds transmitted. Since then, stethoscope has undergone many technologic advances, but it still remains a tool that is inseparable from clinical practice.This video will illustrate the parts of the stethoscope and demonstrate how to use this instrument during any physical examination. First, let's review what are the different parts of a stethoscope and what is their function. The basic parts include the ear buds, the tubing and the chest piece. Now-a-days commonly used stethoscopes have two flat surfaces on the chest piece-one is the diaphragm and other is the bell. Usually, the diaphragm is applied firmly against the skin to listen to the high frequency sounds such as S1 and S2. The firm application is necessary as this allows the high frequency sounds from within the patient vibrate to the membrane of the diaphragm, which in turn results in propagation of sound through the column of air inside the stethoscope and into the examiner's ears. Conversely, when applied lightly, the bell transmits low frequency sounds such as S3 or S4. The open bell acts as a cup that directly transmits sounds from within the patient through the tubing. Pressing more firmly with the bell can stretch the underlying skin, essentially turning it into a diaphragm. Certain stethoscopes have only one side to the chest piece, which can be used as a diaphragm and a bell; firm pressure makes the chest piece a diaphragm, while light pressure makes it a bell.Now, let's go over some important steps related to auscultation that can be applied to any physical examination. Throughout the entirety of the patient encounter, use your unaided sense of hearing to identify findings that may be diagnostically useful, like hoarse voice or grunting respirations. Before patient contact, decontaminate the stethoscope with any of the standardly available agents. Place the stethoscope ear buds in your ears with the tips pointing forward in order to create a seal that drowns out ambient noise. By gently tapping on both surfaces, confirm which side of the chest piece is active. To switch between the two sides, rotate the piece until you hear a click, and then tap to confirm. Hold the chest piece in your dominant hand. There are two commonly used handgrips for this. One way is to support the piece between the middle phalanges of your second and third fingers with your thumb tucked under the tubing to keep the tube off the patient's skin, which can potentially reduce some noise artifacts. Another way is to support it between the distal phalanges of your thumb and second finger. When using this grip, you should normally tuck the remaining fingers under the tubing. Except, in certain maneuvers where these fingers need to be held in slight extension to keep the fingers themselves off the patient's skin. For example, during auscultation at the base of the heart. There are specific techniques of auscultation for pulmonary, cardiac, abdominal, and vascular examinations, which will be covered in the respective videos of these collections. As you listen, consider the physiology and mentally picture the anatomy, which may help to parse the variety of sounds that are heard simultaneously. Train the mind to form a visual representation of the sounds being heard, as this may help in better clinical characterization of the underlying pathology. Certain electronic stethoscopes allow examiners to record sounds and actually create visual representations of the findings. You've just watched JoVE's video on general approach to auscultation during a physical examination. You should now understand the different parts of a stethoscope, and how to use this instrument effectively. Making meaning out of the variety of sounds that one appreciates with the stethoscope can seem daunting to the early learner. Through deliberate practice, with consideration of anatomy and physiology of the structures being examined, and possibly the use of visual representation of sound, auscultation becomes a powerful diagnostic tool for the clinician. As always, thanks for watching!

Education

JoVE Science Education

Clinical Skills

Physical Examinations I

general approach to the physical exam

Why Physical Exams Still Matter

Physical examination remains an important part of medicine. Doctors have used the body exam for centuries to connect changes in body function with disease. Even with modern imaging and lab tests, the bedside exam still helps clinicians understand what may be happening in the patient. Physical examination is not a replacement for tests, and it does not answer every question. Some maneuvers that were once highly valued may have limited usefulness. Still, many conditions can only be found through...

observation and inspection

Clinical Observation in Physical Exam

Clinical observation is the starting point of a physical examination and begins at the first contact with a patient. Observation is a broad term for using the senses carefully to gather information. Inspection is a narrower term. It refers to what can be seen with the eyes, especially on the surface of the body, rather than to behavior. Skilled clinicians use more than sight when they examine a patient. They also rely on touch, through palpation and percussion, and on hearing, through...

palpation

How Hand Position Guides Palpation

Palpation uses touch to collect diagnostic information during the physical exam. It is one of the ways a healthcare provider uses the senses to learn more about a patient. The part of the hand used for palpation changes depending on the body area being examined. Finger pads are best for fine detail. Their dense sensory nerves help the examiner feel small features, such as the borders of masses or lymph nodes. The back of the hand, also called the dorsal surface, gives a rough sense of relative...

percussion

Clinical Percussion and Body Sound

Clinical percussion uses tapping to create sound and help assess what lies beneath the body surface. It is a simple bedside technique that depends on the way sound changes when it travels through different tissues. The method began with Leopold Auenbrugger, an Austrian inn-keeper's son, who found that tapping beer barrels could help him take inventory. He later applied the same idea to patients in Vienna and published the first description of its diagnostic use in 1761. Jean-Nicolas Corvisart...

Stethoscope Sounds in Clinical Exam

Auscultation is a clinical exam method that lets a provider listen to sounds inside the body. Doctors use it to gather important diagnostic information from the chest, heart, abdomen, and blood vessels. For many years, auscultation meant immediate auscultation. In that method, the examiner placed an ear directly on the patient's skin. This approach was used for centuries, but it became less useful in nineteenth-century France because of social norms and poor diagnostic yield. René Laënnec...

proper adjustment of patient attire during the physical exam

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Draping for a Better Physical Exam

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blood pressure measurement

Manual Blood Pressure Reading Steps

Blood pressure reading uses an indirect method to measure the pressure of blood against vessel walls. Blood pressure, or BP, is a vital sign that is checked routinely in hospital and outpatient settings. It is one of the most common medical assessments performed around the world. The indirect method is non-invasive, safe, and easily reproducible, so it is used most often. BP can be measured automatically by oscillometry or manually by auscultation. Auscultation uses a sphygmomanometer, which...

measuring vital signs

Vital Sign Ranges and Patient Status

Vital signs are objective measurements that show a patient’s clinical status. The commonly accepted vital signs are blood pressure, heart rate, temperature, respiratory rate, and oxygen saturation. In many practices, pain is also treated as the sixth vital sign and is documented with the others. Pain is different from the other vital signs because it is a subjective measurement. That means the pain scale can vary from one patient to another. A vital signs assessment includes heart rate, blood...

respiratory exam i: inspection and palpation

respiratory-exam-i-inspection-and-palpation

Checking Breathing Distress by Exam

Respiratory exam starts with looking for breathing distress and feeling the chest. Shortness of breath is a common reason for both outpatient and inpatient evaluation. Early inspection can reveal fast breathing or cyanosis, which is a bluish color change that can signal low oxygen. If a patient shows respiratory distress, the situation needs urgent attention and oxygen therapy. In many cases, careful clinical examination can help identify lung problems without relying only on tests. This is...

respiratory exam ii: percussion and auscultation

respiratory-exam-ii-percussion-and-auscultation

Respiratory Exam: Lung Sounds and Percussion

Respiratory exam skills include percussion and auscultation of the lungs. These techniques help identify lung problems during a physical exam. Percussion uses tapping to assess the chest, and auscultation uses a stethoscope to listen for breath sounds. Percussion is a useful skill that is often skipped in routine clinical practice. When it is done correctly, it can help a physician detect underlying lung pathology. Auscultation can also give an almost immediate clue to several acute pulmonary...

cardiac exam i: inspection and palpation

Cardiac Exam I: Checking the Chest First

Cardiac exam inspection and palpation are the first steps in a careful heart assessment. These steps help a physician gather useful information before using a stethoscope. They are part of the core examination performed when a patient is first seen. Heart and circulatory disorders are common reasons for hospital admission. They can include conditions such as myocardial infarction and congestive heart failure. Because of this, learning a complete cardiac examination is important for any...

cardiac exam ii: auscultation

Listening for Normal and Abnormal Heart Sounds

Heart auscultation uses a stethoscope to listen to heart sounds and check for normal and abnormal patterns. For physicians, knowing how to hear these sounds and tell them apart is an essential skill. The sound heard at each spot on the chest relates to the closing of specific heart valves. The heart has two main sounds, called S1 and S2. S1 happens when the mitral and tricuspid valves, which are the atrioventricular valves, close after blood enters the ventricles. This marks the start of...

cardiac exam iii: abnormal heart sounds

Heart Murmurs and Gallop Sounds

Heart murmurs and gallop sounds are abnormal heart sounds that can be heard during auscultation, or listening to the heart with a stethoscope. A good understanding of normal heart sounds is the first step in telling normal sounds apart from abnormal ones. Murmurs usually have a swishing quality and point to turbulent blood flow across a heart valve. Murmurs can happen because a valve is too narrow, which is called stenosis, or because blood leaks backward across the valve, which is called...

peripheral vascular exam

Assessing PAD and Venous Signs

Peripheral vascular disease can affect blood flow in the arms and legs, and careful exam steps help reveal signs of disease. Peripheral artery disease (PAD) is linked to cardiovascular and cerebrovascular complications. Risk factors include diabetes, hyperlipidemia, hypertension, and tobacco use. Symptoms may appear as limb claudication, which is cramp-like muscle pain that gets worse with activity and better with rest. Chronic venous insufficiency (CVI) can cause lower extremity swelling,...

peripheral vascular exam using a continuous wave doppler

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Bedside Doppler for Leg Blood Flow Checks

Peripheral vascular disease affects the arteries and veins outside the heart, and it is common in older adults. History and physical exam can suggest the diagnosis, but Doppler ultrasound is now a routine part of the bedside vascular exam. This lesson focuses on bedside assessment of peripheral arterial disease and chronic venous insufficiency with a handheld continuous wave Doppler. A handheld Doppler is a simple tool that sends and receives ultrasound at the same time. It detects changes in...

physical examinations i

This collection provides a foundation for performing physical exams; with techniques ranging from measuring blood pressure or vital signs, to key pulmonary and cardiovascular physical examinations. 

Learn how auscultation works, why René Laënnec invented the stethoscope, and how the diaphragm and bell help clinicians hear body sounds.

Stethoscope Sounds in Clinical Exam | JoVE K12

HS. Waves and Electromagnetic Radiation

HS-PS4-5.

Life Science

Structure and Function

HS-LS1-3.

Jaideep Talwalkar

Internal Medicine

Yale School of Medicine

Overview

The Stethoscope

General Approach to Auscultation

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Auscultation

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