Heart sounds can be difficult to hear in someone whose lungs are hyperinflated (e.g., a patient with longstanding chronic obstructive pulmonary disease). Placing the stethoscope over the epigastrium makes the heart sounds much easier to detect. — Annette O’Gorman, FNP-C, Yarmouth, Me. (186-7)

These are letters from practitioners around the country who want to share their clinical problems and successes, observations and pearls with their colleagues. We invite you to participate. If you have a clinical pearl, submit it here.