In echocardiography there are a number of standard positions in which images of the heart can be made. These so-called acoustic windows are only recordable between/below and / or above the ribs. Every sonographer must reckon the fact that not every patient’s heart is actually in the same position to be imaged. Sometimes it is necessary to scan an intercostal space higher or lower, or more medial or lateral. Also, not every patient equally absorb the ultrasound waves for example fat (obesity)) or air (COPD) will require a lot of creativity and improvisational skills of the sonographer. It is advisable to operate according to the same protocol so all the information is delivered to the assessor in order and there is less chance of forgetting recordings and / or measurements.