Has anyone else noticed this??

more tissue between the heart and the stethoscope...

Yes. It does. Sometimes you can roll them to their left side, and a bit more over, have them rest the side of their head on their bent arm/hand and then try again. You gotta really shove that scope up in there.

Yep, the more flesh there is between the stethoscope and the heart, the harder to hear. Plus the extra fluid will muffle the sounds even further. Sometimes you just can't hear much. I did discover a number of years ago that a quality stethoscope makes a huge difference. I thought I had a good one, but did not hear wheezes on a kid when the doc did. I borrowed her Littmann and listened again and heard them clear as day. That was the day I ordered my Littmann!

i have a litman as well. Got rid of my stethoscope i got for free :) i couldn't even hear my own heart beat with that stethoscope.

we do have one on the unit that we can use that has a volume thing. I ended up using it on this patient.

i guess it makes sense. I have a very small frame, so less tissue to hear through. but even with the little old ladies who are itty bitty, its sometimes difficult to hear. Is this because their hearts are maybe just "weaker?"

sometimes heartbeats are as quiet as bird feathers against a pillow--I have troubles with some elderly patients' heartbeats too...

Place your steth on the PMI. I find that in fluffy pts, I can hear better if I firmly place my steth lateral of the left breast.

Also on fluffy people, you may have placed your 'scope over a rib, cutting down on sound transmission.

This has happened to me a couple times. In the chart: Heart Sounds: DISTANT

Varying auscultation points can help.

Ditto on the idea that getting a good scope is paramount. But wanted to add that the loudness of heart tones may also reflect contractile strength of the heart. People with weak hearts, or those that have low output, may not generate good outflows that make those loud enough tones on valvular closure (the Lub - Dub sounds that we try to hear). Thus, people with low or poor ejection fractions, may be one reason that heart tones become hard to detect. Another possibility is pericardial tamponade, where fluid collects within the pericardium, attentuating transmission of heart sounds. Still another is dextrocardia, where the usual standard locations for auscultation would prove counterproductive as the heart itself is in the right side of the chest instead.

Has anyone else found that it is sometimes more productive to listen to the heart using the pulmonic and aortic areas near the sternum rather than the PMI? The PMI is often blocked by breasts, fat and whatnot. I sometimes go, what the hey, I'm not doing nuanced assessments of murmurs and clicks. I just wanna know if their ticker is ticking, and this is where I hear it tick lol

If possible, I have them sit up. That seems to often help me hear the heart sounds. I will also palpate their radial pulse initially while listening, to help me get my bearings.