Proper auscultation requires a quiet area. Every attempt should be made to eliminate extraneous noise from radios, televisions, and so forth. The earpieces of the stethoscope are directed anteriorly or parallel to the direction of the external auditory canal. If the earpieces are put in backward, the openings of the earpieces impinge on the wall of the external canal and lower the intensity of the sounds. The earpieces should fit properly so as to be comfortable but tight enough to exclude external noises.
It is often useful for you to close your eyes when listening to the heart. Sounds that are more difficult to hear sound louder with your eyes closed, because the brain is flooded with all types of sensory input. The input from the eyes appears to be the most important. The next important sensory input is auditory, which is followed by tactile input. If you eliminate the distraction of visual stimuli, the brain concentrates more on the auditory input, and the sounds become more evident.
As indicated in Chapter 13, The Chest, the bell of the stethoscope should be applied lightly to the skin, whereas the diaphragm should be pressed tightly against the skin. High-pitched sounds, such as valve closure, systolic events, and regurgitant murmurs, are better heard with the diaphragm. Low-pitched sounds, such as gallop rhythms or the murmur of atrioventricular stenosis, are better heard with the bell.
It is common in many countries to examine patients through their clothing or a hospital gown. In the United States, however, never listen through any type of clothing.
There are several other pitfalls in auscultation. Make sure that the stethoscope is in good shape: Cracked tubing certainly interferes with good listening. Both the examiner and the patient must be comfortable for the best hearing. An examiner who is straining over the patient and is uncomfortable will want to finish the examination quickly without a proper assessment. Always inspect and palpate before auscultation. Accumulate as much information as possible before listening!
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