CP Physical Exam

[pathologyDO]

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We have a cumulative exam coming up which has me looking through our systems material. For some reason, I hate CP. I think half of it is because of the physical exam and the incredible amount of ways to describe murmurs and heart sounds. Do you actually use these signs in real practice? Furthermore, how much of the heart sounds is going to be on the USMLE? Seriously...

I mean, we have the echo, xrays, stress testing, angiograms, EKGs, etc to determine what is going on and those tests are going to be needed regardless of what type of murmur or heart sound we "think" we hear. Isn't it then but a formality, and ultimately, are auscultations done just because it is what we were taught to do, rather than what will make the best use of our time?

 

[boogaloo]

We have a cumulative exam coming up which has me looking through our systems material. For some reason, I hate CP. I think half of it is because of the physical exam and the incredible amount of ways to describe murmurs and heart sounds. Do you actually use these signs in real practice? Furthermore, how much of the heart sounds is going to be on the USMLE? Seriously...

I mean, we have the echo, xrays, stress testing, angiograms, EKGs, etc to determine what is going on and those tests are going to be needed regardless of what type of murmur or heart sound we "think" we hear. Isn't it then but a formality, and ultimately, are auscultations done just because it is what we were taught to do, rather than what will make the best use of our time?

Heart sounds are a quick and cheap way to guide your clinical diagnosis. They have shown up in real life for me more than once as a third year; I missed a new onset AF on a patient and was pretty mad at myself for second-guessing what I heard--would've impressed the attending too since it was undiagnosed at the time. You are guaranteed to have at least one heart murmur on Step I. Auscultation takes less than a minute to do and can identify pathology quickly with little cost. It's worth the time.

 

[AlmadeDr]

We have a cumulative exam coming up which has me looking through our systems material. For some reason, I hate CP. I think half of it is because of the physical exam and the incredible amount of ways to describe murmurs and heart sounds. Do you actually use these signs in real practice? Furthermore, how much of the heart sounds is going to be on the USMLE? Seriously...

I mean, we have the echo, xrays, stress testing, angiograms, EKGs, etc to determine what is going on and those tests are going to be needed regardless of what type of murmur or heart sound we "think" we hear. Isn't it then but a formality, and ultimately, are auscultations done just because it is what we were taught to do, rather than what will make the best use of our time?

Here's my experience with heart sounds on clinical rotations. Auscultation is an easy (to perform, more difficult to perfect) exam that always gives you at least some important information. In the classroom years a lot of emphasis is placed on the various murmurs. And I promise you, after some time out in the wards you won't just "think" you heard a murmur. But there's a ton of other information you can get out of this basic exam as well.

Regular vs. irregular you can always do. And as the poster above noted, you may pick up on AF because of it. If your patient is not on telemetry for some reason, your exam may be the only reason he/she gets worked up. If you hear a new S3 gallop in a patient, suspect CHF exacerbation and plan the rest of your exam/interview accordingly. If you hear an S4, pay attention to blood pressure control or even potential MI symptoms as even before ST segment changes occur on EKG the ventricular wall stiffens and can manifest as this sound. If you're rounding on a CCU patient and you hear a new holosystolic murmur you might just be the one who encourages your attending to get a new echo and catch the intraventricular septum rupture before the patient dies. Sure, some of these examples are dramatic, but if you catch on physical exam them you're far ahead of waiting for all your various tests and imaging to be performed by other people on whatever timeline they decide.

Can you get by without auscultation? On some services, you'd be okay. But if you have it, it's a useful tool. And will help with the USMLE. You'll definitely have the straightforward murmur question you'll need to be able to answer. But even on those long questions where they give lines and lines of lab values, they'll almost always have the cardiac auscultation exam findings listed somewhere. If you have a good handle on what these things mean, it can sometimes give you a shortcut right to the answer without you having to muddle through the other stuff. There's almost always another way to arrive at the answer, but it's a time saver if you're able to make use of them. I know everything sounds the same early on, but I'd encourage you to keep working at it and you'll start to be able to tell the differences before long. Good luck!

 

[DermViser]

Heart sounds are a quick and cheap way to guide your clinical diagnosis. They have shown up in real life for me more than once as a third year; I missed a new onset AF on a patient and was pretty mad at myself for second-guessing what I heard--would've impressed the attending too since it was undiagnosed at the time. You are guaranteed to have at least one heart murmur on Step I. Auscultation takes less than a minute to do and can identify pathology quickly with little cost. It's worth the time.

Had this moment too. So frustrating.