Editorials

In defense of the stethoscope and the bedside

Respiratory sounds heard through the stethoscope lend useful information for diagnostic purposes. However, the accuracy and efficiency of clinical diagnosis are constrained by subjective interpretations and the level of auscultation expertise of the physician. In this work, Fourier-based signal processing approaches and uniform manifold projection (UMAP) for data visualization, are combined for tackling the computerized analysis of respiratory sounds. The results show that differences and similarities between the signals can be identified trough patterns emerging from the information embedded in stationary and dynamical spectral features from the pulmonary acoustic recordings. The outcomes of these different perspectives evince discriminative ability between the recording devices, the chronic and non-chronic condition of patients, and adventitious sounds. In a contrasting view to the analysis based on machine learning or deep learning, whose implementation is profusely reported in scientific literature, this paper shows that the proposed approach renders an effective analysis of pulmonary sounds, with clinical correlations. Furthermore, the information visualization achieved by means of UMAP can be an attractive tool for assisting physicians during patients auscultation.

Cardiac auscultation, long considered the centerpiece of the cardiac clinical examination, is rapidly becoming a lost art. Inadequate emphasis on the essentials of cardiac auscultation has resulted from the widespread availability of more elaborate and expensive “high-tech” diagnostic and therapeutic methods, particularly Doppler echocardiography. However, sophisticated high technology is not a substitute for a solid foundation in clinical cardiology including cardiac auscultation. When used properly, the stethoscope remains a valuable and cost-effective clinical tool that often enables many well-trained and experienced cardiac auscultators to make a rapid and accurate cardiac diagnosis with fewer, if any, additional studies. Not every patient needs every test.

Accordingly, this monograph reviews the fundamental principles of the art of cardiac auscultation. Emphasis is placed on the proper use of the stethoscope and the diagnostic and prognostic significance of the myriad heart sounds and murmurs present in patients with and without symptomatic heart disease. A practical clinical overview of the common auscultatory findings encountered in a variety of cardiac disease states and conditions will also be discussed. This monograph will inspire many practitioners to pick up their stethoscope, practice their cardiac examination, perfect their auscultatory skills, and reap the rewards of rediscovering this time-honored method of evaluating the cardiovascular system.

To assess the cardiac auscultatory skills of health care professionals before and after an actual (not simulated) patient-centered cardiac auscultation conference and to determine the effectiveness of this clinical teaching method on improving diagnostic proficiency.

Seventy-eight participants at a conference on cardiac auscultation completed preconference and postconference examinations on their ability to diagnose a wide variety of heart sounds and murmurs. Among those tested, 46 (59%) were physicians: 17 (22%) were cardiologists, 19 (24%) were medical interns or residents, 7 (9%) were cardiology fellows, 2 (3%) were general practitioners, and 1 (1%) was a pediatrician. Thirty-two (41%) of this group of respondents were nonphysicians: 14 (18%) were nurse practitioners, 9 (12%) were nurses, 6 (8%) were physician assistants, 2 (3%) were medical students, and 1 (1%) was a nonmedical professional. All participants were tested on 14 clinically important cardiac auscultatory events directly recorded from actual (not simulated) patients and transmitted via wireless infrared stethophones. The auscultatory events tested were wide physiologic splitting of S₂ in right bundle branch block, fixed S₂ splitting and systolic murmur in atrial septal defect, midsystolic click and late systolic murmur of mitral valve prolapse, S₄ gallop, S₃ gallop, opening snap of mitral stenosis, innocent systolic murmur, systolic murmur of mitral regurgitation, systolic murmur of tricuspid regurgitation, systolic murmur of hypertrophic obstructive cardiomyopathy, continuous murmur of patent ductus arteriosus, pericardial friction rub, prosthetic valve sounds, and alternation of heart sounds, heart murmurs, and the S₃ gallop in congestive heart failure.

On the basis of the analysis of the 78 participants who completed preconference and postconference evaluations of the 14 selected cardiac auscultatory events, a preconference identification score of 26.3% and a postconference score of 44.7% were observed. This represents a statistically significant overall improvement in diagnostic proficiency (P>.001).

Cardiac auscultatory skills among today's health care professionals are extremely poor, regardless of the level and/or type of training of the professional. An actual (not simulated) patient-centered teaching conference is an effective clinical method of improving cardiac auscultatory skills and diagnostic proficiency of health care professionals.

As the works presented by Drs. Aida Falcón de Vargas, Oscar Solı́s, Alexis Bello and José Félix Oletta pointed out in the present Symposium “Medicine of the XXI Century” [1], [2], [3], [4], scientific and technological advances in medicine are by all means extremely relevant these times. All considerations predict that investigations shall increase much more in the century we are just initiating, a fact that will provide us with greater insight and an exceptional scope in the diagnose and treatment of diseases as well as in the systems of prevention and rehabilitation.