I welcome all of you, at every level, anyone who now or in the future will be caring for patients, from the beginning medical student through a practicing physician, nurses, nurse practitioners, physician assistants, paramedics also have to know a certain amount of bedside findings. We are going to boil all this down for you. My colleagues and I for many years have been involved in teaching cardiology that emphasizes bedside skills. It started for me with my exposure to W. Proctor Harvey, one of the greatest bedside clinicians and teachers that ever lived, and that was way back in the mid-1960s. And we want to bring that to you now, to boil this all down and make it simple. You know, you might think that these skills are mysterious. They are not. But also if you never drove a stick-shift car, you might think that is mysterious. It's not. It's just learning how to do it. So that’s what we’re going to take you through. We are going to tell you certain facts on which this is based, and those facts are very important for you to understand the rationale for how we evolved into these "Big 12" that we are going to learn together.

The goals of this program are very focused. The first, is for you to recognize the most important cardiac auscultatory findings. The emphasis is on auscultation, recognizing that other bedside skills, including assessment of the arterial and venous pulses and precordial movements are also important. The second goal is for you to understand and be able to outline the basic physiology and pathophysiology associated with the important auscultatory findings. The emphasis is on basic explanations, recognizing that complex and multiple mechanisms may account for a given finding.

When experienced cardiologists and generalists are asked to identify the most important bedside auscultatory findings, there are a dozen findings that are most often mentioned. We shall call them the “Big 12.” The findings include: four heart sounds: second sound splitting, third and fourth diastolic filling sounds and systolic clicks. The most important murmurs are the early systolic innocent murmur, and those of the four classic left-sided valve lesions: mitral regurgitation and aortic stenosis in systole and aortic regurgitation and mitral stenosis in diastole. To these may be added the murmur that is continuous through the second sound, from systole into diastole, the right-sided murmur of tricuspid regurgitation that may augment with inspiration, and the pericardial friction rub with components in both systole and diastole.

Not all of the “Big 12” findings are of equal importance, for example filling sounds, are amongst the most important heart sounds, as they may reflect left ventricular function. The four classic left-sided valve murmurs are also very important. You should also be able to identify findings beyond the “Big 12,” but our goal is to maintain our focus and once the “Big 12” are mastered, other sounds and murmurs will be easier to identify.