Auscultation Research Paper
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Areas of Auscultation - Learn How to Auscultate (Part 4)
They found that internal medicine and family practice doctors are not statistically superior to medical students. Only pulmonologists achieved statistically better results than others e. Furthermore, discrepancies also arise from the differing nomenclature and formal distinctions between sound classes used in the existing medical literature. This is a wide ranging problem of international magnitude, as has been shown by numerous authors [ 2 — 5 ]. Pasterkamp et al. However, there is still no uniformly standardized classification of the types of phenomena characteristic of the human respiratory system that is used by the medical community as a whole. Physicians often use words to describe perceived pathologies in the respiratory system that are associated with distinct semantic meanings in different handbooks or universities.
This leads to problems in preliminary auscultation courses, and more importantly during later professional work, when doctors exchange or consult diagnoses. They use different descriptions of the same sounds or semantically similar and sometimes even identical terms to describe distinct phenomena. This results in descriptions that are ambiguous at the very least or in extreme cases even incomprehensible to other doctors, which in turn may require repetition of examinations to resolve. A further technical point is that the sounds are not stored and there is no possibility to go back to the recordings or compare them to other sounds, so there is also no possibility to verify the description, which increases the ambiguity even further.
The main goal of this paper is to answer the following question: How correctly and consistently do physicians and medical students evaluate respiratory sounds, and do they categorize them identically? In this context, other aspects of the problem have also been analyzed in detail: Do pulmonologists perform better than other groups of physicians? How does the group of students fit into this community? These questions stem from the hypothesis that the reduction of pathological classes as proposed by Pasterkamp et al. Particularly it means that even though physicians use the class of crepitus and medium crackles see Table 1 for details they cannot distinguished those classes from other crackles while listening and thus these terms should not be used.
Moreover, we test the hypothesis that due to expert and daily practice, pulmonologists are likely to perform better than non-pulmonology medical providers and trainees. The investigated problem is especially crucial because most unwell patients, undergo examination by GPs and family doctors whose auscultation results are taken into account in more detailed diagnosis and further treatment [ 7 ]. Our test was anonymous and conducted online via the Internet using Questionpro Professional. This software was chosen because it enables the presentation of uncompressed and high quality audio to users. Moreover, before the experiment was made available to the participants, the quality of the signals in this software was subjectively verified by two experienced acousticians sound engineers independently without hearing loss for distortions and possible artifacts.
No difference was found between direct and online listening. In addition, to minimize the possibility of a layperson completing the survey, the survey was distributed among the academic medical community and in hospitals. It was also passed on to interested people by both lecturers at medical universities and by practicing doctors. In the first part, a survey was used. The second part focused on the classification of auscultation sounds presented to each participant.
This part consisted of 24 sounds see Table 1 for details that the test participant listened to, evaluated and assigned to specific classes details below. Nine sounds were selected from the demonstration recordings included on the CD companion to Fundamentals of Lung and Heart Sounds [ 8 ]. The remaining sounds were recorded with a Littmann electronic stethoscope and consisted of the respiratory sounds of children aged 5 months to 14 years average 7. The choice of sounds for the test was conducted in two steps. First, sounds from a database of over sounds were selected by acousticians. The chosen sounds contained the least number of distortions and artifacts caused by the transducer of the stethoscope.
The second equally important step was the choice of sound classes so as to have a pool of as diverse and unambiguous sounds as possible. In this way 50 different sound examples were selected. At the meeting of these physicians, a Fostex PH headset coupled with high quality professional headphones Sennheiser HD enabled all the physicians to listen simultaneously to sound samples.
Upon listening to each signal, they classified the sound. A common position was then reached after a discussion. The final set of sounds chosen for the test consisted of sounds that did not lead to any cause of doubt among the physicians. The sounds represented certain classes Table 1 and were presented to the participants as a collection of signals from 24 different patients. An exemplary answer sheet illustrating the scope of data presented to the participants is presented in Fig 1. During the experiment more than one class could be marked and each sound could be played as many times as needed. The terms used in the classes were chosen to include the entire spectrum of nomenclature that is used in contemporary medical literature [ 1 , 4 , 6 , 8 — 11 ].
Some of the descriptions e. During the experiment more than one class could be assigned to each sound by a listener. Each sound signal was supplemented with the following additional graphical and textual information: position where the stethoscope chestpiece was placed on the chest during the recording, and the age, height and weight of the patient Fig 1. Each participant was informed of the need to use high quality headphones during the experiment. The participants were allowed to rerun each sound as many times as they needed and return to and modify previous descriptions.
No feedback was used, i. Moreover, the order of the presentation of the data was random though identical for all participants. This was done to inhibit the possibility of systematic learning of patterns and hence correct answers by the participants during the listening task. The survey was anonymous and voluntary. The participants were informed in the survey that their results would be analyzed and published. All the participants were over the age of 18 years. Also, the legal guardians of children taking part were required to sign written permission for the recordings to be made.
Both parts of the experiment survey and descriptions were completed by participants. Firstly, the results from the questionnaires were analyzed for their quality. The average time taken to complete the questionnaires was 25 min. The total duration of the signals, excluding the survey part, was about 4 minutes. Therefore, the responses of the participants who completed the entire experiment in less than 5 minutes were rejected as unreliable, and the remaining questionnaires were approved for further analysis. Among these, there were: 16 pulmonologists, 22 pediatricians, 29 doctors of other specializations, 50 doctors during their internship and 68 medical students. Only 4. Fig 2 shows how the physicians rated their skills in the auscultation of children and adults.
For each sound presented to the participants, the responses were categorized as in Table 2 and the percentage distribution of each such category is shown in Fig 3. Analyzing all the data presented up to now, one may infer that doctors classify sounds with varying accuracy Fig 3. In general, after averaging the responses for all the sounds we find that there are Pair analysis of the differences in answers between groups of physicians of different specializations using post hoc tests with a Holm correction show that pulmonologists have statistically higher scores With regard to incorrect answers N , students obtained the most Next, the differences for individual sound classes Fig 4 are analyzed on the basis of a Kruskal-Wallis test and post hoc tests with a Holm correction for statistically significant differences.
For further analysis, the sounds were grouped according to their class and the percentage of correct responses P , and considered for each medical specialization separately Fig 4. The cases of the vesicular breath and bronchical sounds, are each treated as standalone sounds. In this way, five main classes of sounds were created Table 3. Plan your initial assessment so that you can use the position change and turning time with an assistant or auscultate the posterior. You must address all of the questions. Lungs: The lungs are clear to auscultation and percussion.
Heart: Regular rate and rhythm. Abdomen:Bowel sounds are normal. There is rebound tenderness with maximal discomfort on palpation in the right lower quadrant. Extremities: No clubbing, cyanosis, or edema. Laboratory Data: Hemoglobin Sodium , potassium 3. Urinalysis was negative. Diagnostic Studies: Flat plate and upright films of. Processes of a case study methodology for postgraduate research in marketing Chad Perry Processes of a case study methodology 7 85 U n ive rsi ty of Sou the r n Q ueensl a nd, Toowoomba , A ust r a l i a Introduction C a s e s t u d i e s a re f a m i l i a r t o m a rke t i n g e d u c a t o r s a n d t h e i r s t u d e n t s a s a teaching device.
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