Method and system for identifying cardiopulmonary findings by
Contents
1. supine upright respiratory patterns normal tachypnea Cheyne Stokes or patient maneuvers e g egophony The user then compares the selected combination with the patient s lung sounds and modifies the selected combination as necessary to improve the match to the patient s lung sounds The lung sounds builder is configured to suggest differential diagnoses based on the combination selected In various embodiments the lung sounds builder suggests additional listening locations maneuvers and items in the patient s history or clinical set ting to narrow further the differential diagnosis In various embodiments the lung sounds builder can be used in reverse starting with a condition and playing back the spectrum of lung sounds that are associated with the selected patient con dition In the foregoing specification the invention is described with reference to specific embodiments thereof but those skilled in the art will recognize that the invention is not limited thereto Various features and aspects of the above described invention may be used individually or jointly Fur ther the invention can be utilized in any number of environ ments and applications beyond those described herein without departing from the broader spirit and scope of the specification The specification and drawings are accord ingly to be regarded as illustrative rather than restrictive As used herein logic refers to hardware firmware or a combi nat2. Adding more than one example of each murmur or sound will increase the combinations but more importantly increase the verisimilitude of the combi nations For example the first heart sound of mitral stenosis is louder than normal thus a loud first heart sound of mitral stenosis would be substituted for a normal first heart sound As another example the midsystolic murmur of aortic steno sis can sound harsh when listening at the cardiac base but musical at the cardiac apex US 8 734 358 BI TABLE 1 1 is a valid combination 0 is an invalid combination Allowed SIS Sle Sin S2b S28 Sla Slb SIS Sle Sin S2b S28 ES ES MSC 3 S4 OS HSM ESM MSM LSM EDM MDM PSM CM 3 sa OS HSM ESM MSM LSM EDM MDM PSM CM TFA TFM The user can look at and listen to as well as palpate the created combination The Sound Builder application seam lessly loops the audio of the created combination and the user may choose to listen via headphones a wireless headset an electronic stethoscope or a wired or wireless speaker attached to an acoustic stethoscope for example While a loudspeaker can be used it is noted that loudspeakers can distort audio The user can also observe the ECG waveform and the phonocardiogram and also the selected buttons on the pro vided interface The ECG waveform can indicate for example the onset of systole The ECG waveform may morph consistent with the s
3. from Memory and sent to the Audio Mixer before being sent to Audio Output The Display Output is updated to reflect the new sound combination chosen by the user The following is a step by step description of how various embodiments of the invention may be used The computing device of the invention can be configured to perform some or all of these steps The various alternatives provided are not meant to be limiting Other alternatives are considered to be within the scope of the invention A user listens to a patient s heart sounds for example through an acoustic stethoscope through an electronic stethoscope from a received live transmission via computer network from a recorded transmission via computer net work from a locally stored recording or from a remotely stored recording Transmission methods to reach the user s ear include for example 1 via headset wired or wireless attached or paired to an electronic stethoscope 2 via head phones wired or wireless attached or paired to an electronic stethoscope 3 via a wired or wireless speaker placed under or attached to an acoustic or electronic stethoscope and 4 via external audio input and or electronic interface with the transmitting stethoscope or system The user launches the Sound Builder application on the computing device The Sound Builder application can be implemented in hardware firmware and or software store on a computer readable medium and executed by a proc
4. 442 8 012 098 8 034 000 8 084 001 8 096 954 8 108 034 8 133 187 8 162 844 8 167 811 8 211 034 8 277 389 2004 0092846 2005 0048455 2005 0119585 2008 0232605 2009 0117527 References Cited U S PATENT DOCUMENTS 4 2011 5 2011 5 2011 6 2011 7 2011 8 2011 8 2011 9 2011 10 2011 12 2011 1 2012 1 2012 3 2012 4 2012 5 2012 7 2012 10 2012 5 2004 3 2005 6 2005 9 2008 5 2009 Zhang et al Carlson et al Siejko et al Daum et al Siejko et al Wariar et al Carlson et al Maile et al Zhang et al Burns et al Stahmann et al Patangay et al Holmstrom et al Carlson et al Scheiner et al Patangay et al Carlson et al Watrous Hayamizu et al Watrous Bagha Lecat OTHER PUBLICATIONS Adolph R J et al Teaching selective attention to the cardiac cycle The Cardio gator Am Hit J Aug 1971 Criley J M Beyond Heart Sounds vol 1 Companion Study Guide 2000 Cardionics CardioSim VII Sales Literature Aug 2008 Cardionics CardioSim VII Sales Literature 1995 Cardionics Learning Cardiac Auscultation CD ROM application Sales Literature 2003 iMurmur iPhone app Product information 2010 iMurmur iPhone app Product information 2009 Levinson D A New Audiovisual Aid to Heart Sound Instruction JAMA Sep 1968 Easy Auscultation website http www easyauscultation com MedEdu LLC 2010 Pinnacle Heart Sounds Tutor website http www pinnacletec com medical trainin
5. be provided to the user as a list of potential differential diagnoses based on the final combination entered The Dx button turns green in some embodiments to indicate that the list of poten tial diagnoses has become very narrow In the illustrated example S1 ES MSM S2 has a short list of potential diag noses either bicuspid aortic stenosis or aortic stenosis The Sound Builder application can help narrow the choices fur ther with queries to the user For example the user can be asked to report the contour of the carotid pulse for aortic stenosis the pulse is parvus et tardus to compare 2nd right vs 2nd left intercostal listening areas or the user can be prompted to learn more about the clinical setting by suggest ing interview questions for the patient The Sound Builder application may create the Dx list by consulting a Sounds Murmurs Dx Matrix that contains likely diagnoses mapped to the selected sounds and murmurs This list of differential diagnoses can be dynamically updated based upon further input from the user including listening location patient history and vital signs e g pulse contour heart rate body temperature blood pressure Patient history can comprise the patient s chief complaint social history e g smoking IV drug abuse any childhood illness and country of origin e g where rheumatic fever is still preva lent The Dx list can be sorted by plausibility or severity and each Dx entry can be linked
6. studies of cardiac examination skills document a rise in test scores until the third year of medical school but no further improvement thereafter despite years in residency training or even further years in practice See e g Arch Intern Med 166 610 617 2006 and Clin Cardiol 33 12 738 745 2010 Indeed full time internal medicine professors perform no better in tests of cardiac examination skills than the third year medical students they teach Compounding the problem is a lack of critical reinforcement when auscultating patients Critical reinforcement implies a commitment to confirming or refut ing one s bedside diagnostic impressions by critical review and correlation with available imaging and or hemodynamic studies performed on that patient Unfortunately patient exposure without critical reinforcement seems to be the norm for the average medical resident explaining their lack of advancement in examination skills despite clinical encoun ters with hundreds of patients SUMMARY This invention relates to audiovisual display on a digital computer system in particular visual as well as audio display 20 25 30 35 40 45 50 55 60 65 2 of cardiac and lung auscultation allowing the selection of individual sound components to create custom combinations that match the sounds heard from a patient during physical examination with a stethoscope allowing the selection of different pulsewave contours t
7. the ability to modify a combination to create a closer match to the patient s sounds for example through an interactive pro cess possibly over several iterations of selecting a combina tion comparing the combination to the patient and modify ing the combination to hone in on a best match to the patient findings The Sound Builder application can also offer plausible alternatives to aid in the step of modifying the combination For instance sound combinations near S1 and S2 are often confused heart sounds are often not heard when a murmur is present systolic murmurs are often confused diastolic mur murs are often confused continuous murmurs are often con fused with to fro murmurs certain sound murmur combina tions are commonly confused and confusion of systole and diastole leads to a large number of errors Regarding sound combinations near S1 the combinations of S4 and S1 split and S1 S1 and ES S1 and early MSC are commonly confused Regarding sound combinations near S2 the combinations of late MSC and S2 split and S2 S2 and OS and S2 and S3 are commonly confused Heart sounds that are often not heard when a murmur is present include S1 and S2 with HSM S3 with HSM or another murmur and MDM S3 rumble with EDM Austin Flint Systolic murmurs that are often confused include MSM vs HSM Here right sided murmurs may in fact be midsystolic but run into or past the aortic valve closure sound usually the loudest compon
8. to explanatory text illustrations and audio or audiovisual examples of patient recordings The Sound Builder application in some embodiments suggests additional actions to narrow the differential diagno sis including altering the listening location switching from stethoscope bell to diaphragm postural maneuvers and the postextrasystolic beat Altering the listening location can help for example to differentiate between whether an extra heart sound near S1 is an S4 a split S1 or an ejection sound If the extra sound is heard at locations in addition to the cardiac apex it is likely to be an ejection sound with a softer S1 preceding it Likewise listening at the apex with the stethoscope bell will most likely detect the low frequency S4 but switching to the stethoscope diaphragm which filters low frequency sounds should make the extra sound go away Postural maneuvers can help detect the midsystolic click of mitral valve prolapse which can occur earlier or later as a function of standing and squatting and as a function of the Valsalva maneuver The postextrasystolic beat the beat that follows a preventricular contraction or PVC can narrow the origin of a systolic murmur Systolic murmurs that augment following a PVC are generally confined to the ventricular US 8 734 358 Bl 11 outflow tract such as aortic stenosis and hypertrophic cardi omyopathy while systolic murmurs that do not augment include the holosystolic murmur
9. 07 Maile et al 7 424 321 B2 9 2008 Wariar et al 7 438 689 B2 10 2008 Munk 7 517 319 B2 4 2009 Kushnir et al 7 559 901 B2 7 2009 Maile et al 7 611 471 B2 11 2009 Thiagarajan et al 7 615 012 B2 112009 Von Arx et al 7 645 141 B2 1 2010 Lecat 7 662 104 B2 2 2010 Siejko et al 7 670 298 B2 3 2010 Carlson et al 7 736 319 B2 6 2010 Patangay et al 7 780 606 B2 8 2010 Carlson et al 7 806 833 B2 10 2010 Thiagarajan et al 7 853 327 B2 12 2010 Patangay et al 7 883 470 B2 2 2011 Scheiner et al Continued OTHER PUBLICATIONS Littman Cardiac Exam Virtual Trainer CD ROM application manual 2007 Continued Primary Examiner Joseph Stoklosa 74 Attorney Agent or Firm Peters Verny LLP 57 ABSTRACT A system is provided for creating a sound profile that matches sounds produced by a patient during a physical examination such as a cardiac or pulmonary examination A user selects multiple sounds from a library and combines them to form the profile which may then be modified by the addition of further sounds adjustments to their relative timing duration loud ness and so forth The refinement continues iteratively and after each change the profile is provided by the system to the user for example as a phonocardiogram for comparison against the sounds observed during the examination 8 Claims 6 Drawing Sheets US 8 734 358 B1 Page2 56 7 922 669 7 938 781 7 951 087 7 962 210 7 972 275 8 000 780 8 007
10. ad to erroneous selections for instance the user may confuse a systolic murmur with a diastolic murmur In various embodiments the Sound Builder application provides an info section that the user can access by pressing the info button for instance in order to learn more about each sound murmur choice The first page displayed in the info section can be linked to the last button the user selected on the control panel Additional pages that describe other control panel choices can be made available from a table of contents or by pressing previous or next buttons Similarly various embodiments the Sound Builder appli cation provide a help section that can be accessed for example by pressing the help button to display the help section on the screen The help section can provide a descrip tion each button s appearance and function program flow a description of each section the role of the differential diag nosis section including limitations and when alternative diagnoses should be considered recommended customized settings based on the user s preferences and cardiac exami nation tips and tricks to improve detection and identification of findings Various embodiments the Sound Builder application can also provide the user the ability to customize certain settings Examples of customizable settings include the display warn ings and preferences for sending and receiving data The Sound Builder application can also provide the user
11. atent US 8 734 358 B1 Sheet 3 of 6 May 27 2014 U S Patent ZC Sid SUIPIOA jo3u02 eBed ayes LBSH sisoubmp jenuolojHp THOS D aud dea QR LEAL seed mosson Oi USMS Shed pepe EE e wee aud shumes Anowuejdxe 01 EONS o uos REGBI umuDogpues poop US Patent May 27 2014 Sheet 4 of 6 US 8 734 358 B1 FIG 3 US Patent May 27 2014 Sheet 5 of 6 US 8 734 358 B1 Ol ATAT 23 4 26 PM O YOU wantto fur these alerts FIG 4 US Patent May 27 2014 Sheet 6 of 6 US 8 734 358 B1 20 PM Bicuspid Aortic Stenosis Pulmonic Stenosis FIG 5 US 8 734 358 BI 1 METHOD AND SYSTEM FOR IDENTIFYING CARDIOPULMONARY FINDINGS BY USING A HEART AND LUNG SOUNDS BUILDER CROSS REFERENCE TO RELATED APPLICATIONS This application is a Divisional of U S patent application Ser No 13 252 023 filed on Oct 3 2011 and entitled Method and System for Identifying Cardiopulmonary Find ings by Using a Heart and Lung Sounds Builder which claims the benefit of U S Provisional Patent Application No 61 389 164 filed on Oct 1 2010 and also entitled Method and System for Identifying Cardiopulmonary Findings by Using a Heart and Lung Sounds Builder and also claims the benefit of U S Provisional Patent Application No 61 542 293 filed on Oct 3 2011 and entitled Arterial and Venous Pulsations Precordial Impulses and Respiratory Pattern Finder all of which are incorporated herein by ref
12. az United States Patent Criley et al US008734358B1 US 8 734 358 B1 May 27 2014 10 Patent No 45 Date of Patent 54 71 72 73 21 22 62 60 51 52 58 METHOD AND SYSTEM FOR IDENTIFYING CARDIOPULMONARY FINDINGS BY USING A HEART AND LUNG SOUNDS BUILDER Applicant Blaufuss Medical Multimedia Laboratories LLC Rolling Hills Estates CA US Inventors Stuart Ross Criley Palos Verdes Estates CA US John Michael Criley Sr Palos Verdes Estates CA US Blaufuss Medical Multimedia Laboratories LLC Rolling Hills Estates CA US Assignee Notice Subject to any disclaimer the term of this patent is extended or adjusted under 35 U S C 154 b by 0 days Appl No 13 926 254 Filed Jun 25 2013 Related U S Application Data Division of application No 13 252 023 filed on Oct 3 2011 now Pat No 8 491 488 Provisional application No 61 389 164 filed on Oct 1 2010 provisional application No 61 542 293 filed on Oct 3 2011 Int Cl AGIB 5 02 U S CI USPG eA dete tee dis 600 528 Field of Classification Search USPC set det e t Ke E 6001528 See application file for complete search history 2006 01 56 References Cited U S PATENT DOCUMENTS 5 687 738 A 11 1997 Shapiro et al 5 957 866 A 9 1999 Shapiro et al 6 220 866 Bl 4 2001 Amend et al 6 527 559 B2 3 2003 Yoshii et al 7 107 095 B2 9 2006 Manolas 7 248 923 B2 7 20
13. e occurs close in time with ventricular systole or distal to the heart systolic rise is delayed and the pulse contour is distorted The user can compare the combination to the patient s heart sounds For instance by switching back and forth to the patient s heart sounds the user can check whether the selected combination is a reasonable match to the patient s heart sounds Two methods for making the comparison involve either switching ear pieces or not switching ear pieces Where switching ear pieces is employed the Sound Builder application plays the selected audio combination and a stethoscope or playback device plays the patient s heart sounds on a separate system Alternatively the Sound Builder application can be switched between playing the selected audio combination through a set of ear pieces and either a live transmission or a recording of the patient s heart sounds In US 8 734 358 BI 9 another alternative the Sound Builder system includes an external speaker and the user moves the stethoscope between the patient s chest and the external speaker to make the com parison A good match with the patient will not require further modification of the combination A poor match will prompt the user to modify his selected combination Errors in under standing the definitions can lead to erroneous selections for example the user may confuse a continuous murmur with a to fro murmur Failure to identify systole can also le
14. eadable medium including a library of visual pulsations and visual precordial impulses 4 The system of claim 1 further comprising a non transi tory computer readable medium including a library of pal pable pulsations and palpable precordial impulses 5 The system of claim 1 wherein the graphical represen tation and corresponding audio of the combination comprise a phonocardiogram 6 The system of claim 5 wherein the logic is further con figured to display an ECG proximate to the phonocardiogram on the display of the computing device 7 The system of claim 1 wherein the two bodily sound components comprise two breathing sounds 8 The system of claim 1 wherein the logic is further con figured to compare the received first and second user selec tions against a matrix of allowed combinations
15. ent of S2 tricking the user into thinking the murmur is holosystolic An ejection sound ES may precede the MSM tricking the user into thinking the murmur begins with S1 and concluding the murmur is ESM or HSM Cre scendo decrescendo holosystolic murmurs are possible and 20 25 30 35 40 45 50 55 60 65 10 may confuse the user who expects this shape of murmur to be exclusively midsystolic Other systolic murmurs that are often confused include MSM vs ESM both end before S2 LSM vs MSM vs HSM regurgitation following the click of mitral valve prolapse and musical murmurs Gallavardin which are often considered different in origin from harsh murmurs when in fact they have the same etiology Diastolic murmurs that are often confused include EDM vs MDM EDM long vs CM and EDM with MDM Austin Flint vs EDM Sound murmur combinations that are often confused include SI MSC LSM S2 S1 ES MSM S2 and S4 S1 HSM S2 The best match result of this refinement process may be definitive or may contain ambiguous features In the latter instance for example the user may not be able to determine whether an extra sound near S1 is S4 S1 S1 ES ora split S1 Over specificity may not be appropriate when the findings cannot be firmly established and alternative findings can be stored with equal weight or with preferential weights assigned to the alternatives FIG 5 illustrates a differential diagnosis list that can
16. ere a finding can not be firmly established Documented findings can be uploaded securely with encryption to a database that stores the patient s electronic health record In some instances the Sound Builder application can be used in reverse by using a lesion based menu on the control panel Here the user starts with a diagnosis and the Sound Builder application then reproduces the spectrum of findings associated with that lesion for comparison against the patient For instance selecting congenital aortic stenosis will cause the application to produce the pattern of S1 ES MSM S2 while selecting calcific aortic stenosis will cause the applica tion to produce the pattern of S1 MSM S2 Similarly select ing well tolerated chronic aortic regurgitation will cause the application to produce long EDM selecting acute severe aortic regurgitation will produce short EDM MSM S1 soft or absent and selecting Austin Flint aortic regurgitation will produce in addition to the sounds of acute severe aortic regurgitation MDM at the apex Mitral stenosis and regurgitation provide additional examples Mitral stenosis may be tolerated by the patient at a slow heart rate become more severe with moderate heart rate or very severe with fast heart rate Tolerated mitral stenosis is indicated by an opening snap and a barely detectable mid diastolic murmur The more severe mitral stenosis is indicated by loud S1 MDM perhaps no PSM and longer S2 OS in
17. erence BACKGROUND OF THE INVENTION Echocardiography was initially developed in the mid 20 Century and its adoption in the subsequent decades has strongly influenced how clinicians are trained and how they subsequently perform cardiac examinations of patients A readily available non invasive method of imaging the beating heart that could provide critical reinforcement of what was heard through the stethoscope should have enhanced physical examination skills but in fact the opposite has happened Cardiac examination skills have declined since the advent of echocardiography a function of overreliance on technology and the present healthcare environment that emphasizes rapid delivery of care Several decades ago patients hospital stays were long providing trainees and their instructors frequent opportunities for bedside teaching rounds Today hospital admissions are short and intensely focused with fewer oppor tunities for trainees to learn and practice bedside examination skills Attending physicians having been trained in this envi ronment further amplify the problem if their own cardiac examination skills are not well developed In the absence of bedside training with patients audio recordings of heart sounds has served as a poor substitute and as a result clini cians now commonly close their eyes while conducting car diopulmonary examination shutting out important visual and palpable cues exhibited by the patient Multicenter
18. ering the frequency spectrum Using discrete sound components allows the heart rate to be varied up or down without adversely affecting the frequency of the play back FIG 3 illustrates a chest diagram with circles indicating four common listening locations for a stethoscope during cardiac examination other listening positions are possible The numbers indicate intercostal spaces Locations are gen erally noted as left or right and by intercostal space In the Sound Builder application the location of the current heart sounds recording can be noted by this chest diagram as well as alternate listening areas For breath and lung sounds a similar diagram is used The user can change to a new listen ing position by selecting a different circle In addition if the user selects combinations that are specifically heard at one or two locations the sound builder updates the displayed loca tion to show where these sounds and murmurs would be heard Manually switching to a new location will cause the sound murmur combination to change what would be expected to be heard in a patient in many cases removing the extra sound or murmur altogether 20 25 30 35 40 45 50 55 60 65 6 As noted the location of the stethoscope chest piece and the choice of stethoscope bell or diaphragm affects the loud ness and quality of heart sounds and murmurs and some sounds and murmurs are only detectable in specific locations on t
19. essor of the computing device The Sound Builder application option ally comprises a smartphone application a website based program an application installed on a personal computer an application installed on a personal digital assistant an embed ded application of an electronic stethoscope The user selects a sound murmur combination for example by pressing inputs e g on screen buttons The sound builder takes the one or more selected audio compo nents and mixes the audio tracks dynamically to create a repeating heart and or breath sounds This audio playback optionally continues uninterrupted until a further sound mur mur or breath sound is added or removed or until the user halts the playback FIG 1 5 shows an exemplary control panel provided by the Sound Builder application executing on an electronic com puting device In some embodiments the user starts with a blank slate or more specifically a simple S1 S2 combination By adding sounds or murmurs a combination of sounds is built up to match what is heard in the patient Each time a 20 25 30 35 40 45 50 55 60 65 4 button is selected on the control panel the sound component is added to the playback the visual display of the phonocar diogram shows the new component in its proper temporal location and the selected button lights up to show the user which components are already active The Sound Builder application is configured to genera
20. g products Heart Sounds TUTOR html 1990 Cardioscan User Manual Zargis Medical 2009 Vukanovic Criley J M et al Competency in Cardiac Examination Skills in Medical Students Trainees Physicians and Faculty Arch Intern Med vol 166 2006 Vukanovic Criley J M et al Confidential Testing of Cardiac Examination Competency in Cardiology and Noncardiology Faculty and Trainees A Multicenter Study Clin Cardiol vol 33 No 12 pp 738 745 2010 US Patent May 27 2014 Sheet 1 of 6 US 8 734 358 B1 Audio Input User Input Device Network Interface v I Memory Processor Graphics Library Explanatory Text Audio output Audio Mixer hl E PxEna TOME Explanatory Graphics So Display Output FolowonDx GU Questions Engine i Allowed Sound ee Combinations Matrix Sound Display Training amp Testing Engine Control Panel Sounds Dx mode Patient Findings Saved combinations Tutorial Module Text S Tm Patient Findings Train Test Scores Uplink Module i Settings E N ee Differential Dx Save Combinations FOREN DENN HRS Module Power Patient Findings Source Test scores i FIG 1 S T DIH US 8 734 358 B1 No um e z NO parajes GRI SET un soen TT d aed an 01 sur N N S S Mn siu punog U S P
21. h the location on the patient is specified For early diastolic murmurs quality harsh or high pitched shape de crescendo or crescendo decrescendo and duration long and tapering or short and abruptly terminated can be selected For mid diastolic murmurs quality and loudness can be selected and for presystolic murmurs shape crescendo loudness and accompanying sounds and murmur can be selected Accompanying sounds and murmur can comprise a mid diastolic murmur an OS and a loud S1 Selectable systolic murmurs include holosystolic early systolic mid systolic and late systolic murmurs and as US 8 734 358 BI 5 above for each the location on the patient is specified For each too the quality is selectable harsh blowing or musi cal The holosystolic shape can be equal intensity cre scendo decrescendo or decrescendo The early systolic and late systolic shapes can be decrescendo while the mid sys tolic shape can be equal intensity or crescendo decrescendo The duration of the late systolic murmur is also variable For continuous murmurs location on the patient is speci fied Timing is also controllable as the peak of murmur inten sity varies depending upon the etiology To fro murmurs comprise semilunar and atrio ventricular murmurs both have systolic and diastolic components and for both the location on the patient is specified Semilunar to fro murmurs can be aortic or pulmonic and either can be characterized as t
22. hat match the arterial venous or precordial impulses seen on a patient during physical examination and allowing selection of different respiratory patterns that match the respiration seen and heard from a patient during physical examination Various embodiments of the invention are used in human and veterinary medicine as a tool to aid in identification of a patient s cardiopulmonary findings These embodiments include a computing device configured for selecting a com bination of sounds murmurs and or lung sounds visual examples of arterial venous and precordial impulses and respiratory patterns and combining the selected sounds and visual examples into an audio and audiovisual sequence The audio sequence is checked for accuracy by direct comparison to sounds heard in a patient The video sequence animation or example patient video is checked for accuracy by direct comparison with the patient The selection is quickly refined by an iterative process until a satisfactory match between selected findings and patient findings has been achieved These findings can be documented locally on the computing device as well as securely uploaded to a database and linked to the patient s electronic health record In some embodi ments the computing device is configured to list differential diagnoses based on a user s selection of heart or lung sounds In some embodiments the computing device is configured to work in reverse listing diagnoses and t
23. he patient s chest and only with either the stethoscope bell or diaphragm Also the quality of the same murmur can beharsh or musical depending upon the location ofthe stetho scope The location ofthe stethoscope can be indicated on the screen by text and or by an indicator on a chest diagram Switching to a different location will cause the selected sound combination to update For example moving from the cardiac apex 5th left intercostal at the midclavicular line to the 2nd right intercostal space will cause S3 or S4 to disappear and moving from the cardiac apex Sth left intercostal at the midclavicular line to the 2nd left intercostal space will cause MDM and PSM to disappear The Sound Builder application can provide the user with an option of focusing on similar heart sounds and murmurs combinations while changing the location For instance extra sounds near S2 include S1 S2 OS cardiac base S1 Split S2 cardiac base and S1 S2 S3 cardiac apex Extra sounds near S1 include S1 ES S2 cardiac apex or sometimes base Split S1 S2 cardiac apex and S4 S1 S2 cardiac apex The Sound Builder application is optionally configured to account for one or more of the following maneuvers and perturbations The sound sequence can be varied depending on user selectable factors such as respiration posture extra systolic beat hand grip and Valsalva maneuver Options for respiration include apnea inspiration and expiration the lat te
24. hen playing the appro priate audiovisual findings including clinical variations that are encountered across the spectrum of acute versus chronic mild versus severe congenital versus acquired Finally in some embodiments the computing device is configured to function in a training or testing mode playing a patient recording and prompting the user to identify correctly the heart sounds and murmurs breath and lung sounds pulsa tions in the neck and precordium and respiratory patterns grading the user entries and storing the results locally or remotely BRIEF DESCRIPTION OF DRAWINGS FIG 1 is a schematic representation of a sound builder system according to various embodiments of the present invention FIG 1 5 is a graphical representation of a control panel provided through a user interface according to various embodiments of the present invention FIG 2 is a graphical representation of a phonocardiogram created through the Sound Builder application and displayed with a corresponding ECG through a user interface according to various embodiments of the present invention FIG 3 is a schematic representation of common listening locations for stethoscopic cardiac examination FIG 4 is a graphical representation of an alert provided by the Sound Builder application and displayed through a user interface according to various embodiments of the present invention FIG 5 is a graphical representation of a differential diag nosis sc
25. ion of hardware and software such as a processor and computer readable instructions stored on a computer readable medium but logic as used herein specifically excludes soft ware alone It will be recognized that the terms comprising including and having as used herein are specifically intended to be read as open ended terms of art US 8 734 358 BI 13 What is claimed is 1 A system comprising acomputing device including a display an input device an audio output and logic configured to provide a user interface on the display receive a first user selection of a first bodily sound com ponent from a menu of sound components receive a second user selection of a second bodily sound component from the menu of sound components repeatedly play a combination of the two bodily sound components where the second bodily sound compo nent follows the first bodily sound component in the combination and playing the combination includes providing a graphical representation of the combina tion on the display while providing corresponding audio of the combination to the audio output and receive a user selection of a modification to the combina tion of the two bodily sound components 2 The system of claim 1 further comprising a non transi tory computer readable medium including a library of the sounds provided by the menu of sound components 14 3 The system of claim 1 further comprising a non transi tory computer r
26. o FRO louder diastolic component or TO fro louder systolic com ponent Aortic to fro murmurs can also be Austin Flint mur murs while pulmonic to fro murmurs can be right sided Aus tin Flint murmurs Atrio ventricular to fro murmurs can be mitral or tricuspid FIG 2 illustrates a sound sequence assembled from sound components according to various embodiments of the inven tion The sound sequence displayed shows the ECG phono cardiogram and the phases of the cardiac cycle systole and diastole Control buttons switch the display to settings help explanatory text and the relevant differential diagnoses for this sound combination Slider controls allow the user to vary the heart rate and the playback volume In some embodiments the Sound Builder application is configured to allow user control of heart rate rhythm and regularity Heart rate can be varied to reflect different patient conditions such as slower heart rates for relatively longer diastoles and faster heart rates for relatively shorter diastoles Heart sounds and murmurs can be affected by changes in rhythm for example cannon wave post extrasystolic beat augments does not augment murmurs and atrial fibrillation long or short diastoles The frequency of the sound or mur mur is not generally affected by the heart rate for this reason the rate may increase but the sounds and murmurs them selves must be changed in temporal location and often dura tion without alt
27. of mitral regurgitation The Sound Builder application in some embodiments suggests items in the patient s history or the clinical setting to investigate to narrow further the differential diagnosis As examples a patient presenting with worsening dyspnea dur ing pregnancy suggests mitral stenosis while being from certain areas of the world e g the Pacific Rim and Latin America can implicate rheumatic fever As another example aortic regurgitation secondary to endocarditis can be due to IV drug abuse with infected needles As yet another example a third heart sound can be physiologic or pathologic in origin where a physiologic third heart sound is common in athletes the healthy young and pregnancy while a pathologic third heart sound can be due to ventricular dysfunction secondary to myocardial infarction hypertension or dilated cardiomy opathy The Sound Builder application can assist the user to docu ment the patient s cardiac examination findings by appending the patient name ID number location of the patient time and date to the findings and by adding the patient s history vital signs and other patient data Listening location can be added by selecting a listening area off ofa chest diagram The examination findings can indicate that the final selection sat isfied the user that these are the findings established upon examination of the patient or may indicate that the final selection contains appropriate ambiguity wh
28. ound murmur combination selected The phonocardiogram provides a visual depiction of heart sounds and murmurs and can be selected to show the selected combination the actual heart sounds and murmurs of the patient as well as cartoon depictions of idealized forms no confusing artifacts and to enhance recognition at small resolutions The combination selected can be indicated in some embodiments by labeled buttons in an ON state e g a white colored button The last button selected is optionally highlighted a different color e g a yellow colored button As noted the user can palpate the created combination In some embodiments a signal to drive a palpable pulse will accompany the audio Some embodiments provide a stereo output where one channel contains the audio and the other 40 45 50 65 channel contains the pulse signal including modulation and DC voltage Locations include carotid left or right apical apex beat parasternal brachial left or right radial left or right femoral left or right popliteal left or right and post tibial left or right Contour can include normal quick flick ing upstroke bounding collapsing slow rising or distorted when palpating pulse at peripheral vessels These pulse con tours can be displayed as waveforms or as audiovisual ani mations of the neck and precordium Intensity and timing are additional options where timing can be proximal to the heart systolic ris
29. r example positioning the audio location of S1 and S2 behind the user s head and positioning the murmurs in front can help the user identify the sounds and differentiate them from the murmurs Likewise the pres enceofan extra heart sound can be highlighted by placing the extra sound in yet another position e g left or right Merg ing the sounds and murmurs back into monoaural space will reflect what is heard through the stethoscope while expand ing the sounds to highlight components aids in their identifi cation Another aid in identification is matching visual infor mation either video of patient or computer animation of an avatar to the sounds to aid in recognition Human hearing becomes more sensitive and specific if a sound is accompa nied by a visual cue Animation or video of pulsations in the neck or precordium or movement of the chest during respi ration when displayed in time with the heart and lung sounds will aid the user in identifying individual sound components The Sound Builder application can also comprise a lung sounds builder module that functions analogously and with the same technology as the heart sounds builder module illus trated above but employing breath sounds components Here the user listens to the patient s chest for lung sounds and consults the lung sounds builder to select lung sound compo nents in order to create a matching combination The user can also select different patient postures e g
30. r two of which can augment murmurs augment sounds and split sounds Posture options include supine left lateral decu bitus sitting upright sitting while leaning forward standing squatting and passive leg elevation The extrasystolic beat can augment or not augment the murmur Hand grip options include control grip and release while options for the Val salva maneuver include control strain release and recovery FIG 4 illustrates an alert provided to the user through the Sound Builder interface when an implausible combination is selected as not all combinations of heart sounds and murmurs are physiologically possible An exemplary implausible com bination is an opening snap OS and a third heart sound S3 These sounds are not likely to occur simultaneously in a patient since the opening snap requires a narrowed stenotic mitral valve while a third heart sound usually requires a wide open mitral valve In various embodiments a caution triangle appears in the sound display and the user is alerted with a notice It is noted that with 20 heart sound and murmur compo nents there are an excessive number of possible combina tions but by limiting the combinations to only allowable combinations a sounds and murmurs matrix includes 75 344 valid combinations The Sound Builder application can auto matically screen implausible selections by consulting a Sound Murmur Plausibility Matrix an example of which is shown below in Table 1
31. reen provided by the Sound Builder application and displayed through a user interface according to various embodiments of the present invention DETAILED DESCRIPTION FIG 1 illustrates the general architecture of the sound builder system as embodied in an electronic computing US 8 734 358 BI 3 device configured to execute a Sound Builder application In some embodiments the electronic computing device includes a cellular telephone digital pad personal digital assistant personal computer and or the like Audio input is received from an external source from a wired audio connection to a microphone and or stethoscope from a wireless connection via the Network Interface e g WiFi Bluetooth USB and or from a live transmission or recorded transmission of a patient recording User input is received via a user input device The user input device uses the user input to select sound components switch to text help settings or diagnosis sections Dx of the Sound Builder application to submit answers to training test questions to record patient findings or to control the volume temporal location tempo of the sound combinations and or the like In some embodiments selected sound combinations are checked against an Allowed Combinations Matrix before playing Combinations may be saved for later recall Patient findings may be saved and or uploaded via the Network Inter face In some embodiments sound components are recalled
32. right ventricular can be recorded Other selectable sounds can include an opening snap OS an ejection sound ES which can be aortic or pulmonic and a mild systolic click MSC The OS loudness can vary from soft to loud and the OS timing can be shifted relative to the timing of other sounds For example the S2 OS interval can vary either continuously or in discrete steps shorter inter vals higher left atrial left ventricular pressure gradient implying more severe mitral stenosis and longer intervals lower left atrial left ventricular gradient implying less severe mitral stenosis The MSC can be selected for the mitral valve or the tricuspid valve The MSC timing can likewise be shifted relative to the timing of other sounds such that for instance the S1 MSC interval can vary with shorter intervals implying an earlier systolic prolapse and longer intervals implying a later systolic prolapse The MSC can be given an accompanying murmur For example mitral or tricuspid regurgitation may occur with prolapse causing a murmur that immediately follows the click The timing of this murmur depends upon the timing of the click such that the murmur can be holosystolic midsystolic or late systolic Other selectable sounds comprise murmurs such as dias tolic murmurs systolic murmurs and continuous and to fro murmurs Selectable diastolic murmurs include early dias tolic mid diastolic and presystolic murmurs and as above for eac
33. te the control panel which provides the user with menus such as a component based menu and a lesion based menu The com ponent based menu allows the user to select sounds mur murs and murmur combinations e g to fro murmurs used to create a combination The lesion based menu allows the user to select a lesion and optionally to further modify the lesion Selected lesions can be acute or chronic and vary from mild to severe The control panel can also be configured to allow the user to vary or specify the heart rate and the listening location In various embodiments some or all of the features below can be selected and or controlled A first heart sound S1 is selected for instance by recording the location on the patient at which the sound is heard as the location will influence the sound Sound components their loudness and their relative timings can also be selected for S1 Sound components can be ofdifferent types such as single and split e g physiological paradoxical or persistent loudness can vary from absent to soft to loud and their timings can be adjusted from early through the expecting timing to late Second S2 third S3 and fourth S4 sounds are simi larly selected In some embodiments the quality of S3 can be selected such as dull rumbling and knocking and the loud ness can be varied from soft to medium to loud The loudness of S4 can also be varied from soft to medium to loud and the location left or
34. ter val The very severe mitral stenosis is indicated by a louder and later S1 PSM MDM and short S2 OS interval The Sound Builder application optionally may be config ured to facilitate methods to improve identification of indi vidual sound components As one example by adding and removing a single component to highlight its presence or absence against the background of other sounds and mur murs With S1 S2 S3 often the user does not perceive the low frequency low intensity S3 thus by adding and remov ing S3 while S1 and S2 remain can improve detection by giving the user a visual cue when S3 is present on the phono cardiogram as well as by playing the extra sound As another example positional audio processing can be employed to place components in three dimensional space so that the user 20 25 30 35 40 45 50 55 60 65 12 can perceive some sounds as occurring in front to the side or behind the ears Human hearing is very sensitive to positional cues that occur as sounds are modified as they reflect off external surfaces as well as the portions ofthe external ear In addition subtle differences in frequency and arrival time to both ears give the brain cues as to the location of a particular sound These audio cues can be added to existing audio with head related transfer functions or similar methods to create the perception that a particular sound is emitting from a certain position in space Fo
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