how do i deal with Murmurs ?

[rs_med_student]

i'm about to finish my 4th year in med school (our course is 6 years)
one thing that really irritates me is the way physical exam is so glorified and they keep telling us hypothetical stuff about murmurs and stuff (murmur timing, change with position and maneuvers and such) when in reality, hearing a murmur & catching it is the only feasible thing i've seen.

it is extremely difficult to pinpoint the "timing" (mid-pan-early- systolic/diastolic) and it carries basically ZERO diagnostic weight..cuz in the end..you will ALWAYS do an echo when there's a murmur/ suspected cardiac abnormality/ symptoms.
such physical tests are really extremely unreliable and are never used to confirm/rule-out a diagnosis

don't even get me started on chest percussion for "dullness" in pneumonia..or abdominal shifting dullness for ascites (which is +ve in half the people i've tried on)

i mean is there really any point in these test? or are they just a waste of time..after all, i've never seen a Dr. apply half the physical tests we learn.

anyone care to disagree, or share how it is in your medical schools?

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[deleted645092]

After a month long cardiology rotation I can promise that there is diagnostic utility to correctly identifying murmurs. The most important takeaway is to recognize pathological murmurs. A perfect example is distinguishing whether that bruit you heard in the neck is really a stenosis bruit or aortic Stenosis. One ha
D better be worked up, the other may not need to be.

 

[Merely]

After a month long cardiology rotation I can promise that there is diagnostic utility to correctly identifying murmurs. The most important takeaway is to recognize pathological murmurs. A perfect example is distinguishing whether that bruit you heard in the neck is really a stenosis bruit or aortic Stenosis. One ha
D better be worked up, the other may not need to be.

If you’re not a cardiologist, you will NEVER be diagnosing murmurs. If you do, have fun getting sued after you misdiagnose because you don’t know wtf you’re talking about since you’re not the specialist.

 

[BorntobeDO?]

i'm about to finish my 4th year in med school (our course is 6 years)
one thing that really irritates me is the way physical exam is so glorified and they keep telling us hypothetical stuff about murmurs and stuff (murmur timing, change with position and maneuvers and such) when in reality, hearing a murmur & catching it is the only feasible thing i've seen.

it is extremely difficult to pinpoint the "timing" (mid-pan-early- systolic/diastolic) and it carries basically ZERO diagnostic weight..cuz in the end..you will ALWAYS do an echo when there's a murmur/ suspected cardiac abnormality/ symptoms.
such physical tests are really extremely unreliable and are never used to confirm/rule-out a diagnosis

don't even get me started on chest percussion for "dullness" in pneumonia..or abdominal shifting dullness for ascites (which is +ve in half the people i've tried on)

i mean is there really any point in these test? or are they just a waste of time..after all, i've never seen a Dr. apply half the physical tests we learn.

anyone care to disagree, or share how it is in your medical schools?

PE is overrated. Lawyers/insurance don't really care what we call it. They do care if you don't do appropriate imaging. PE is overrated by the faculty who teach it because they don't want to admit that the specificity and sensitivity of thinks like chest percussion and dullness are so low as to make it useless. Admitting that its mostly a waste of time would be the same as saying their instruction on the matter is useless. Their egos could never tolerate it.

This post made me think of when I did an respiratory exam during an OB rotation per my preceptors request. I said it was negative, he didn't recheck, and still gave the patient antibiotics for walking PNA.

 

[Crayola227]

This is crap. This is just the attitude... I can think of at least 4 patient lives I saved just as a med student and resident (as in, they would have died within hours in the hospital) because I did a thorough physical exam. What I caught anyone should have been able to catch, but no one did, because they were lazy and falsely believed the PE didn't matter.

(4 lives directly saved by PE over the course of med school residency might not seem like a lot, but actually, our sense of scale of the good done with one life saved tends to become skewed over the course of training, and there are plenty of things I probably spent just as much time learning that has saved/will save less lives than that.... I have yet to see Wilson's disease, but if I am to be competent and be capable of saving the most number of lives possible, it is expected that I know that, and a whole number of other rare diagnoses. Med school is about giving you all the tools a doctor can have without a residency).

I'm not defending every single maneuver you're taught as having utility or equal utility or saying that every cough needs a 14 point steth exam.

In my opinion, there's a lot of reasons physicians have come to have an incompetent attitude towards the physical exam, not the least of which is purely the time crunch. It's a psychological defense when we're unable to do our jobs properly, instead of despairing, to tell ourselves it doesn't matter. Also, certainly, a false belief that imaging or other tests can take its place.

People, like myself, and instructors, believe in the physical exam, because when you do it properly and widely, it will prove its utility to you, as it did to me. If you go through life half-arsing your exams, it's no wonder to me that one comes to believe it's useless. Self-fulfilling prophecy.

There is actually data that backs up some of these maneuvers, and even shows that they can avoid any number of bad outcomes such as unnecessary testing/imaging, and all the cost and other harms that can be associated with that.

Lastly, and understandably, another context where physical exam, and even more arcane maneuvers can make a big difference, is outside the hospital or clinic, or emergent settings.

I have family members in EM who went to Haiti after the quake, for example. No electricity. They were indeed using percussion to diagnose pneumothorax and PNA and the like.

Same thing when I went to Costa Rica, Panama, and Ecuador.

I will be ready when the zombies hit or global warming levels society there is no more electricity.

Certainly this doesn't apply to all, but nor does a peds rotation have that much utility (I would still put it above none) to someone who ends up in IM. Medical school teaches broadly and with good reason. I think enough providers will be in a position that justifies an understanding of these skills, even if they are not often needed, to justify being taught.

My own school put quite a bit of emphasis on PE, and I don't think we really questioned it. We were pleasantly surprised upon graduation and release into the wilds of residency to find that it made us stand out in a positive way and served us in good stead compared to our peers. It's embarrassing how poor some colleagues' skills are, but what's more, I've seen it be dangerous.

I don't know how people feel comfortable calling themselves doctor upon graduation without a basic competency in all of the physical exam. It's not particularly difficult or time-consuming compared to so many things in med school, to learn how to perform, despite the fact it takes a lot more than that to glean all its usefulness. I have Mosby's and I love it, I've even pulled it off the shelf from time to time to brush up or do a more in-depth exam. PE is a tool to have at your fingertips at least upon graduation. What you need from there will be honed by residency.

Of all the less high yield things to complain about being taught in med school....

 

[Crayola227]

As far as the murmurs, in the limited practice settings I describe, is probably where it really would have the most utility. If you don't have access to echo or it is quite limited, then correctly identifying murmurs and their underlying pathology would be truly important in applying the best management. Not exactly saying that everyone is going to do global health or that is the sole reason to teach these skills to everyone.

Not every murmur gets an echo, by the way, for example physiologic murmurs. At minimum, you want to be able to identify those and save everyone the echo. The concept of being stewards of limited healthcare resources, including the finances of your patient, is real. Being able to reassure a patient has value. As does being able to convince them to get an echo. All of which is easier to do when you do a real exam and have some idea what you suspect.

 

[OrthoTraumaMD]

I completely agree @Crayola227
Laying your hands on the patient is the number one most useful thing in medicine. In my field, most of the things I see can be diagnosed by physical exam, before you even get an x-ray, let alone an MRI or a CT scan. I’ve picked up a few compartment syndromes that were missed by multiple providers over the course of the night, despite very clear physical manifestations… But they were subtle, and if you don’t do it, easily missed. For example, early compartment syndrome usually presents in the anterior compartment, and other than pain, which anyone with a broken leg can have, you will start having numbness in the first web space between the great toe and the second toe. If you don’t check that particular area and just swipe at the foot and ask if the patient feels it, you’ll miss it.

Now, that said, i’m not sure anyone can reliably tell between the different subtypes of murmurs, unless they are really experienced. But complacency breeds incompetence. Even if you are not sure what you’re listening to, you should always try to listen.

 

[deleted645092]

PE is overrated. Lawyers/insurance don't really care what we call it. They do care if you don't do appropriate imaging. PE is overrated by the faculty who teach it because they don't want to admit that the specificity and sensitivity of thinks like chest percussion and dullness are so low as to make it useless. Admitting that its mostly a waste of time would be the same as saying their instruction on the matter is useless. Their egos could never tolerate it.

This post made me think of when I did an respiratory exam during an OB rotation per my preceptors request. I said it was negative, he didn't recheck, and still gave the patient antibiotics for walking PNA.

TBH that's because you had a **** preceptor, not because the physical exam is useless. Prescribing or ordering based solely on the complaint without any actual physical evidence is almost the definition of poor resource stewardship and exactly what we are taught not to do.

If I extrapolate the situation you described to a kid coming to the ED with belly pain but completely benign exam and stone cold normal labs and you call the surgeon for an appy, you'll get laughed at and chewed out.

 

[Crayola227]

TBH that's because you had a **** preceptor, not because the physical exam is useless. Prescribing or ordering based solely on the complaint without any actual physical evidence is almost the definition of poor resource stewardship and exactly what we are taught not to do.

If I extrapolate the situation you described to a kid coming to the ED with belly pain but completely benign exam and stone cold normal labs and you call the surgeon for an appy, you'll get laughed at and chewed out.

then comes the moment where someone decides instead to lie, and half the time you can see it in their face

again, shameless plug for one thing I'm proud my school did well (which believe me was not everything), I saw a lot of providers do amazing things with the PE and that also sold me on its importance

and maybe there's a bit of medical nerd wanking off with some of the murmur stuff, but I'd rather be showing off skills to identify a murmur with nothing but my hands ears and a steth, than whining about having to learn it

perception of competency also has some utility in carrying out your job as leader of the team, so making the right dx yourself and being proved correct by imagining just does more to inspire confidence in your judgment

as does not being caught out lying or skipping the simple steps that are in the PE

 

[studentdocftw]

Just note the basics...what grade..where it is the loudest...if it radiates anywhere..and if it’s diastolic or systolic. Everyone should be able to do that at a minimum. Also, know Stills murmur vs. a true ejection murmur, and PDA vs a venous hum if you want to do pediatrics

 

[Rendar5]

EM here. I have diagnosed pna based on percussion that doesn't show up on XR, and also based on egophony. It is rare that I check such maneuvers but in the right setting it is useful (maybe once a year) and does precede XR findings. And while I don't diagnose fully on murmurs, I have to be cognizant of them and recognize a few of them because I don't get to order echo's (except in very rare settings), and I need to have a sense if someone has syncope 2/2 to Aortic stenosis or has a regurg murmur in the setting of possible endocarditis. You just need to know when to do less common maneuvers, and if you don't practice it in med school and residency, you will not be able to perform it when it is actually needed.

Just like doing 1000 FAST u/s exams on every trauma patient you see in EM residency, it's not useful type test in 99% of traumas you see and I skip it almost everytime as an attending, but you better be able to do one when it's needed.

 

[nlax30]

While I agree that not every subtle physical exam maneuver we learn in med school is ultimately clinical that useful, I DO believe that a good detailed history and physical exam are probably two of the most important skills you can have. At least in my field (a Cardiac subspecialty) a detailed history and exam usually seals the diagnosis for me and any additional imaging study, lab or monitor is to confirm it or r/o something else.

Besides the actual clinical utility of it it's just good patient care and helps that physician-patient relationship. When more and more of our attention is focused on a computer and you see a pissed off patient who talks about how the last doctor just stood in the doorway and said "hi" you can earn soo much more respect by, not evening taking more time, but actually doing an exam/listening/touching than you would otherwise get.

As far as murmurs go obviously start with the basics... is it systolic or diastolic? Character of the sound? Worse with inspiration or expiration? What's better though is with each murmur you listen to then go and look at the echo and see what the valve pathology actually is. Do that for each pt you see and just start to form those relationships in your head. It'll make you a better doctor, maybe not from a diagnostic standpoint as in practice you're going to get an echo anyway, but if you're a PCP/Hospitalist consulting me on a pt and call up with a quick "Hey I got this guy who passed out, has a significant systolic ejection murmur I'm concerned could be severe AS, could you take a look?" you can bet your stethoscope that I am going to have that much more respect for you as a physician. Maybe that's not how I should be looking at it but I see too many lazy physicians who just go through the motions that I'm not even sure what they know or don't know.

 

[WinslowPringle]

How to deal with murmurs:
1. Place your stethoscope confidently against the skin on the chest. Somewhere. Probably at least two places in front.
2. One hand on the stethoscope bell, one hand on the patient back.
3. Close your eyes. Furrow your brow.
4. Murmur "shhh" to the patient, the preceptor, and anyone else in the room. You are really concentrating now.
5. Your next move is a slight head nod as you move the stethoscope to the next position.
6. Gently go "Hmm" under your breath. Furrow the brow again for effect.
7. Open your eyes, take off your stethoscope with a slight shake of the head. Hand the stethoscope confidently to the preceptor; maintain eye contact. "Sounds like a II/VI to me. Subtle. No clicks, no rubs. Needs an echo. I'll call the tech. See what you think." Turn to the patient. Gentle back pat. "We'll take good care of you. You're in good hands."
8. March out of the room like the boss you are.


*******
Mainly sarcasm....but I'm pretty sure it's how 85% of my med school cohort made it through our cards rotation...

 

[Radetzky]

I think what's missing in this discussion is an appreciation of pretest probability. If you listen for a murmur (or any exam finding) in a person where the pretest probability of pathology is low, you will most likely get false positive findings.

If you apply your physical exam to the right patient where the pretest probability is moderate then it becomes useful eg the pt with syncope

If your pretest probability is very high then you will be falsely reassured by negative exam findings eg the person with septic emboli and a fever needs an echo regardless what your PE shows.

EM here. I have diagnosed pna based on percussion that doesn't show up on XR, and also based on egophony

Just to be annoying, how do you know they had pneumonia? What was your gold standard reference? There is the potential for significant confirmation bias in this. I'm skeptical of the idea that inflammation can be so gross to be heard with the stethoscope but not appear on a CXR.

 

[Rendar5]

Just to be annoying, how do you know they had pneumonia? What was your gold standard reference? There is the potential for significant confirmation bias in this. I'm skeptical of the idea that inflammation can be so gross to be heard with the stethoscope but not appear on a CXR.

Skepticism is good. About a week after I wrote what I initially said about percussion I had a patient who presented with URI vs. pna. I got to thinking exactly what you thought, that maybe it was all confirmation bias (i.e., it's pna because I said so and they only got better because I wrote for antibx). So I ordered a non-con CT of the chest. Sure enough there was a mild pneumonia seen on CT that didn't show up on CXR in the exact location that I found dullness to percussion. So yes, I confirmed that percussion was able to identify an area of pneumonia.

The first time I saw this done, I was an MS3 on IM rotation with a very skilled physician, and my attending dx'd pna on someone w/ dullness on percussion but a negative CXR. Repeat CXR the next day showed a blooming infiltrate confirming the suspected dx.

Chest X-rays are good, but not great. Seen plenty of missed rib fractures, missed pneumonias, missed effusions that were suggested by either by history or physical exam, and only appeared when more detailed imaging was ordered (or in the case of pneumonia, when the patient was better hydrated). Physical exam itself isn't perfect either, as I've caught things on CXR that weren't suggested by physical exam. The two complement each other.

 

[SLC]

Similar to Crayola, I had a few really big catches in Med school and residency based on Physical exam findings. Including a case of situs-inversus in a 14yo F that to that point had never been noticed. I’m guessing nobody ever listened to the mitral valve because when I did, there were no sounds on the left side; but there were on the right.

Echocardiogram confirmed situs when we could see liver on the left and stomach on the right.

The physical exam I s not the panacea some of your professors will try to claim; but it’s not something to blow off either. It’s an incredibly useful tool for those who have some skill with it.