Music of the heart

Last year, during one of our "preclinical clinical experiences," I presented a patient who happened to have an interesting heart murmur.  I was excited because heart murmurs can range from being very difficult to hear to being palpable with your hands.  Since this murmur was a normal variant and rather unnoticeable to anyone doing a quick head-to-toe (and therefore undocumented on the patient's history), the precepting physician double-checked my finding.

Sure enough, the doctor agreed.  It was more of a good teaching point than an interesting clinical finding, but nonetheless, it was a shining moment.  I had pointed it out to my fellow medical student earlier (heart murmurs I can do, but neurologic exams are another story, so this is not meant to sound immodest).  She asked the physician how to logically approach listening for murmurs, a question many of us have.

The physician started off by asking me if I had played an instrument.  I played flute for 10 years (competitively, to a ridiculous extent).  Normally, this is a topic I avoid, having heard enough American Pie jokes for a lifetime. The other student had not.

He described heart sounds as being like an orchestra; there's not just one melody.  There are many melodies and harmonies superimposed, creating a piece of music.  To a medical student, listening to the heart sounds like  a non-musician listening to music: you get the overall effect.  If one instrument is grossly out of tune, or grossly out of rhythm, it's obvious that something isn't right.

Listening to this could be daunting!

The trick to listening to heart sounds is to break it down.  Can you pick out the trombone playing the counter-melody?  Can you hear the tympani, the clarinet, the french horn?  You have to start with the core of the sound- for the heart, the "lub dub," the baseline in music. Then you can listen for other murmurs, clicks or snaps.  So much can be gained by knowing when in the cardiac cycle the extra sound occurs.  How can you describe it if you haven't even identified the basic parts?

Aha! Early systolic decrescendo murmur with a mid-systolic click. Ok, it's an unlikely pair.

Listening to the heart is just like listening to music; it takes a skilled ear, but it can be learned.