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      Development of a Smartphone App for Visualizing Heart Sounds and Murmurs

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          Abstract

          Background: Auscultation is one of the basic techniques for the diagnosis of heart disease. However, the interpretation of heart sounds and murmurs is a highly subjective and difficult skill. Objectives: To assist the auscultation skill at the bedside, a handy phonocardiogram was developed using a smartphone (Samsung Galaxy J, Android OS 4.4.2) and an external microphone attached to a stethoscope. Methods and Results: The Android app used Java classes, “AudioRecord,” “AudioTrack,” and “View,” that recorded sounds, replayed sounds, and plotted sound waves, respectively. Sound waves were visualized in real-time, simultaneously replayed on the smartphone, and saved to WAV files. To confirm the availability of the app, 26 kinds of heart sounds and murmurs sounded on a human patient simulator were recorded using three different methods: a bell-type stethoscope, a diaphragm-type stethoscope, and a direct external microphone without a stethoscope. The recorded waveforms were subjectively confirmed and were found to be similar to the reference waveforms. Conclusions: The real-time visualization of the sound waves on the smartphone may help novices to readily recognize and learn to distinguish the various heart sounds and murmurs in real-time.

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          Most cited references27

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          Competency in cardiac examination skills in medical students, trainees, physicians, and faculty: a multicenter study.

          Cardiac examination is an essential aspect of the physical examination. Previous studies have shown poor diagnostic accuracy, but most used audio recordings, precluding correlation with visible observations. The training spectrum from medical students (MSs) to faculty has not been tested, to our knowledge. A validated 50-question, computer-based test was used to assess 4 aspects of cardiac examination competency: (1) cardiac physiology knowledge, (2) auditory skills, (3) visual skills, and (4) integration of auditory and visual skills using computer graphic animations and virtual patient examinations (actual patients filmed at the bedside). We tested 860 participants: 318 MSs, 289 residents (225 internal medicine and 64 family medicine), 85 cardiology fellows, 131 physicians (50 full-time faculty, 12 volunteer clinical faculty, and 69 private practitioners), and 37 others. Mean scores improved from MS1-2 to MS3-4 (P = .003) but did not improve or differ significantly among MS3, MS4, internal medicine residents, family medicine residents, full-time faculty, volunteer clinical faculty, and private practitioners. Only cardiology fellows tested significantly better (P<.001), and they were the best in all 4 subcategories of competency, whereas MS1-2 were the worst in the auditory and visual subcategories. Participants demonstrated low specificity for systolic murmurs (0.35) and low sensitivity for diastolic murmurs (0.49). Cardiac examination skills do not improve after MS3 and may decline after years in practice, which has important implications for medical decision making, patient safety, cost-effective care, and continuing medical education. Improvement in cardiac examination competency will require training in simultaneous audio and visual examination in faculty and trainees.
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            The teaching and practice of cardiac auscultation during internal medicine and cardiology training. A nationwide survey.

            To assess the time and importance given to cardiac auscultation during internal medicine and cardiology training and to evaluate the auscultatory proficiency of medical students and physicians-in-training. A nationwide survey of internal medicine and cardiology program directors and a multicenter cross-sectional assessment of students' and housestaff's auscultatory proficiency. All accredited U.S. internal medicine and cardiology programs and nine university-affiliated internal medicine and cardiology programs. Four hundred ninety-eight (75.6%) of all 659 directors surveyed; 203 physicians-in-training and 49 third-year medical students. Directors completed a 23-item questionnaire, and students and trainees were tested on 12 prerecorded cardiac events. The teaching and proficiency of cardiac auscultation at all levels of training. Directors attributed great importance to cardiac auscultation and thought that more time should be spent teaching it. However, only 27.1% of internal medicine and 37.1% of cardiology programs offered any structured teaching of auscultation (P = 0.02). Programs without teaching were more likely to be large, university affiliated, and located in the northeast. The trainees' accuracy ranged from 0 to 56.2% for cardiology fellows (median, 21.9%) and from 2% to 36.8% for medical residents (median, 19.3%). Residents improved little with year of training and were never better than third-year medical students. A low emphasis on cardiac auscultation appears to have affected the proficiency of medical trainees. Our study raises concern about the future of this time-honored art and, possibly, other bedside diagnostic skills.
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              Cardiac auscultation: rediscovering the lost art.

              M Chizner (2008)
              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.
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                Author and article information

                Journal
                CRD
                Cardiology
                10.1159/issn.0008-6312
                Cardiology
                S. Karger AG
                0008-6312
                1421-9751
                2017
                June 2017
                26 April 2017
                : 137
                : 3
                : 193-200
                Affiliations
                aDepartment of Medical Informatics, School of Allied Health Sciences, Kitasato University, bDepartment of Physiology, and cDepartment of Medical Informatics, Kitasato University School of Medicine, Sagamihara, Japan
                Author notes
                *Noritaka Mamorita, Department of Medical Informatics, School of Allied Health Sciences, Kitasato University, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa 252-0373 (Japan), E-Mail mamorita@kitasato-u.ac.jp
                Article
                466683 Cardiology 2017;137:193-200
                10.1159/000466683
                28441656
                c89f3234-0093-4947-a73f-edbaf3b5706d
                © 2017 S. Karger AG, Basel

                Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

                History
                : 13 October 2016
                : 28 February 2017
                Page count
                Figures: 6, References: 34, Pages: 8
                Categories
                Original Research

                General medicine,Neurology,Cardiovascular Medicine,Internal medicine,Nephrology
                Cardiac auscultation,Heart sounds,Smartphone phonocardiogram app,Murmurs,Real-time sound wave visualization

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