Documenting physical exam findings you aren't able to get?

[Depakote]

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Still getting the hang of all the formal h&p ins and outs... Is there a specific way to document a physical exam fining you attempted to elicit but were unable to get?

Example: I was doing a post op an a dude, he was alert and oriented with palpable pulses, but I just couldn't auscultate his heart. No matter where I tried, I even checked the right chest to r/o dextrocardia.

In my note, under heart, I just put "unable to auscultate", but is there some better way to approach this... Is it even acceptable to not hear the heart?

 

[FractureFixer]

It is acceptable to not hear the heart......IN OBESE patients. Otherwise you should hear it. Did you have the person do any manuevers to increase the sound of this heart?😕

 

[njshibby]

Still getting the hang of all the formal h&p ins and outs... Is there a specific way to document a physical exam fining you attempted to elicit but were unable to get?

Example: I was doing a post op an a dude, he was alert and oriented with palpable pulses, but I just couldn't auscultate his heart. No matter where I tried, I even checked the right chest to r/o dextrocardia.

In my note, under heart, I just put "unable to auscultate", but is there some better way to approach this... Is it even acceptable to not hear the heart?

uh sure you had the steth on right?
if anyones reading it i definitely would not put that

 

[michaelrack]

"Heart sounds distant" (don't put down that they are so distant that you can't hear them at all)

 

[bkpa2med]

Seems a bit weird not to be able to auscultate his heart, but nevertheless you could of just left out the auscultatory component of the exam if you weren't able to do it.

 

[Depakote]

It is acceptable to not hear the heart......IN OBESE patients. Otherwise you should hear it. Did you have the person do any manuevers to increase the sound of this heart?😕

He was larger, could fit the criteria for obesity, but I don't know that that was the problem... I was wearing the steth correctly, heard his lungs and didn't have trouble with any other heart sounds that day/week.

As for trying to accentuate his heartsounds, I didn't. I guess I could have had him take a deep breath in and out for me, but he had just had abdominal surgery a few hours prior so I wasn't going to do anything to stress his wound.

 

[Deferoxamine]

The killer for me is the fundoscopic exam in hypertensive or headache patients. God damn. Usually I don't even document having done it because it's nearly impossible for me to see anything going on.

 

[TopSecret]

The killer for me is the fundoscopic exam in hypertensive or headache patients. God damn. Usually I don't even document having done it because it's nearly impossible for me to see anything going on.

It's the most important part of the exam for headache patients....

You should try using a PanOptic.

 

[FractureFixer]

It's the most important part of the exam for headache patients....

You should try using a PanOptic.

sure because I have $500 just lying around to buy one!

 

[Substance]

Did you make sure your patient was still alive? lulz

but really...

Did your patient have COPD? Sometimes the hyperinflated lungs get in front of the heart and make it almost impossible to hear.

Even so, your question is: do you document that you could not hear his heart. Sure. Say "heart sounds distant" because that's what all the other type-A docs have done time and time again when they were in your situation. Don't worry about it making you look stupid or incompetent, because it doesn't. Nobody is going to say "Look at ol Dr. Depakote's note from 3 years ago - he said "the heart sounds were distant". What a fool."

Personally, I don't see what cardiac auscultation adds in an exam of a patient who is otherwise well post-op or in an emergency situation. Any chronic cardiac abnormalities would be documented pre-op, and if he had any type of emergency like a post-operative MI he'd probably complain of angina, or exhibit pulmonary edema etc. If anything, your stethoscope's major yet dubious role is to transfer spore-forming bacteria between your patients.

As for panoptics, they are 100% better than those stupid stirrup ones. I don't know why they even still make the regular old kind because they're basically useless outside of an ophtho clinic setting(what with the beta-agonist drops they use). I don't have time to try to shine a magnifying light through a hole the size of a pin trying to see vessels and optic discs.

 

[45408]

If you can feel a pulse, you can document a "regular rate and rhythm," if that's the case. I think the biggest cardiac concerns after a non-thoracic surgery would be tachycardia, new onset a-fib, or a really weak, thready pulse - all of which you could pick up without hearing any heart sounds.

 

[lord_jeebus]

If you can feel a pulse, you can document a "regular rate and rhythm," if that's the case. I think the biggest cardiac concerns after a non-thoracic surgery would be tachycardia, new onset a-fib, or a really weak, thready pulse - all of which you could pick up without hearing any heart sounds.

👍

"CV: RRR, distant heart sounds"

 

[Zetterberg07]

I couldn't hear the heart the other day on a larger man. I realized after I told my resident this that I'd been listening with the diaphragm but had the steth set to bell. I really hope I start looking less stupid as 3rd year progresses.

 

[Scaredshizzles]

If you can feel a pulse, you can document a "regular rate and rhythm," if that's the case. I think the biggest cardiac concerns after a non-thoracic surgery would be tachycardia, new onset a-fib, or a really weak, thready pulse - all of which you could pick up without hearing any heart sounds.

I think you would wanna be sure they don't have fluid in their pericardial sac if a person who you've been hearing the heart sounds on all week you no longer hear them....Of course there would be other signs and symptoms, but still...

On an aside, even with a good stethoscope, if you have those soft tips on, sometimes those things get squashed in your ear canal to the extent that the opening of the soft tip gets obstructed, and you can barely hear anything. That seemed to happen a lot in my ear canals and I would have to keep readjusting my stethoscope until I switched to the other kind of tip.

 

[Droopy Snoopy]

Couple of other things to try before giving it up would be to borrow a different steth, or have the pt exhale completely to reduce the distance between heart and chest wall.

I think we've all been there though, fat COPDers mainly. Certainly don't fabricate that you heard heart sounds when you didn't, but as others have stated you can use peripheral/carotid pulses as a stand-in and, in the absence of JVD or other s/sx can be rest easy you're doing your best.

 

[45408]

I think you would wanna be sure they don't have fluid in their pericardial sac if a person who you've been hearing the heart sounds on all week you no longer hear them....Of course there would be other signs and symptoms, but still...

That would be a different story and would be concerning. For my post-op checks, I had never examined the patient before, because I usually met them in pre-op and just said hi.

 

[nogolfinsnow]

I had a pt like that yesterday. He was a large man just and I just couldn't hear his heart. I looked back through everyone else's notes and they said "heart sounds distant"; "heart sounds difficult to auscultate"; "heart sounds faint." So I guess it happens.

 

[OncoCaP]

I used to have this same issue at first when I was doing physical exams, particularly on obese women with low blood pressures. Having the pt breathe out and temporarily stop breathing, pushing down hard to compress their chest somewhat with the bell/diaphragm and your hand (so as not to leave a mark) will sometimes help w/hearing the heart. Another trick is to have the pt roll over to his/her left side or bend forward (beyond the tipping point) at the waist w/extreme expiration + breath holding so that the heart is pushed up, falling forward and down with no breath sounds can increase the heart sounds easier to hear. An electronic steth or just a better quality steth also helps, of course ;-). Sometimes you can hear the heart better from the back or axiallary position. Turning off TV's and closing doors to pt's rooms can help.

Unless the person has too much tissue between your steth and the heart, or is in cardiac arrest you should be able to hear the heartbeat with repositioning and/or squeezing. If you can't, I would suggest getting some help with this part of the physical exam. My own preference might be to say "unable to appreciate heart sounds in left/right/anterior/posterior/ upper/ lower/ axillary thorax."

Although "Distant heart sounds" is descriptive in this situation, it suggests that you actually heard the heart sounds, which you did not. It might be the only viable if you have an attending/resident who "punishes" students who put findings "Unable to auscultate heart sounds." Most attendings/residents I have run across are fine with "unable to auscultate heart sounds" and will work with you to improve your physical exam so that you can hear the sounds but you can better judge the situation you are in.

 

[Deferoxamine]

It's the most important part of the exam for headache patients....

You should try using a PanOptic.

at that patient.

Sad thing is, I think they suckered me into buying one of those things during MS1, and it's just sitting here in my bedroom.

 

[TMP-SMX]

Yeah I was auscultating a "large" woman a few weeks ago and couldn't hear a thing except her wheezing from asthma.