Silly Question I know...

[rjhtamu]

---

Members don't see this ad.

But what is really the correct way to auscultate a female patient with a stethoscope? I've heard hold the bell with your palm out so that it doesn't seem like your copping a feel, but where are you supposed to put it, and how exactly do you hold it, and what if perhaps, your patient is slightly, ahem, topheavy?

 

[southerndoc]

I usually ask the patient to lift her breast up so I can auscultate. If it's a critical patient, then I just do it myself.

 

[doepug]

Great advice from geek medic.

I usually tell patients "I'm going to listen to your heart now," and when it's time to listen to the apex or axilla, I'll move the breast. I think as long as you're gentle, this is more comfortable for a patient who is lying in bed. In case you didn't pull the curtain at the beginning of your physical, be sure there's privacy when you pull back the patient's gown. Even though you're a student, most patients will view you as a doctor and won't think it unusual for you to examine them. Remember that they're patients and not customers; you're not making friends, you're being a good doctor.

On a side note, so far I've found an empty IV bag and a pen under some large (pendulous?) breasts. Anyone else find anything unusual?

Cheers,

doepug
MS III, Johns Hopkins

 

[ckent]

Do you guys listen to every woman's apex? A lot of times, I will put my stethescope there with minimal maneuvering and if I don't here anything because there is too much breast tissue in my way, I just move on. According to Bates, the proper way to do it is to use the back on one hand to push the breast out of the way while you are doing it, but it just seems to me that the chances of you actually picking up something new and doing anything about it in an asymptomatic patient or a patient there for other reasons is so remote that it doesn't seem worthwhile to subject the woman to the procedure. I shadowed a cardiologist during the summer of my first year who would just skip listening to women's apex while I was shadowing him. As a side note, doesn't it feel silly to some of you that we listen to the heart and lungs of everyone that comes in for things from acne to vaginitis? I don't think that there has ever been a study that showed actual benefit in terms of morbidity or mortality for asymptomatic patients to have their heart and lungs auscultated regularly, and according to one of my professor's, it's not even in any preventative medicine practice guideline.

 

[southerndoc]

Originally posted by ckent
As a side note, doesn't it feel silly to some of you that we listen to the heart and lungs of everyone that comes in for things from acne to vaginitis?

Yea, when we finally become attendings, we'll be able to skip those exams (like many of them currently do). I've seen attendings do follow-up exams on patients and not even touch them!

Of course we, as medical students, must do everything. So until then, if you come in with the sniffles, you gotta get the full body workup. (Unfortunately, this includes a DRE on some services!)

 

[ckent]

Originally posted by Geek Medic

Of course we, as medical students, must do everything. So until then, if you come in with the sniffles, you gotta get the full body workup. (Unfortunately, this includes a DRE on some services!)

That reminds me, I hate doing DRE's!!! I hate telling patients that I "have to do a DRE" when I know that I don't "have" to do one. Then when they ask me why when they are being admitted for COPD or cellulitis, I want to say "Because they told me to do one even though you don't need one. Feel free to refuse." If their crit is fine, and they don't have any GI complaints, is there any real reason for doing one? I know we do one on CP or CVA patients in case we have to give them TPA, but for most patients, even if they are heme positive, we usually just tell them to follow up as an outpatient for a work up.

This reminds me, if I ever get admitted into a hospital, besides refusing the DRE, I am going to refuse to let them check daily labs and CBC on me. If it's fine the first day that a patient was admitted, and they are being admitted for other problems, I don't see any reason that we have to keep sticking patients. Even patients with an elevated white count who have an active infection, does it really need to be checked every day? If you start abx on day one, I don't see what you hope to gain by checking their white count on day 2. Can't wait until I am an attending and I can do things my way.

 

[southerndoc]

Originally posted by ckent
That reminds me, I hate doing DRE's!!! I hate telling patients that I "have to do a DRE" when I know that I don't "have" to do one. Then when they ask me why when they are being admitted for COPD or cellulitis, I want to say "Because they told me to do one even though you don't need one. Feel free to refuse." If their crit is fine, and they don't have any GI complaints, is there any real reason for doing one? I know we do one on CP or CVA patients in case we have to give them TPA, but for most patients, even if they are heme positive, we usually just tell them to follow up as an outpatient for a work up.

I remember presenting a patient to an attending. The patient was here for URI symptoms. I thought he was joking when he asked "how was his rectal exam?" I had to go back in there and do a DRE on this guy, despite the fact that he was just seen a month earlier for his annual physical, had a documented benign DRE, and had a PSA level that was virtually non-existant. Ah, the joys of being a medical student! 🙄

The main indications for a DRE are annual exams, UTI-like symptoms, difficulty urinating (initiating mainly, but all difficulties with urination), abdominal pain, Foley insertion in blunt trauma patients, and of course, if you are being examined by a medical student.

This reminds me, if I ever get admitted into a hospital, besides refusing the DRE, I am going to refuse to let them check daily labs and CBC on me. If it's fine the first day that a patient was admitted, and they are being admitted for other problems, I don't see any reason that we have to keep sticking patients. Even patients with an elevated white count who have an active infection, does it really need to be checked every day? If you start abx on day one, I don't see what you hope to gain by checking their white count on day 2. Can't wait until I am an attending and I can do things my way.

Why must lab techs insist on using adult tubes? Virtually all labs can now be analyzed with pediatric tubes. Patients who come in and get daily labs usually are "phlebotomized" by day 5. Nothing like low Hct/Hgb and pending hypovolemia from overzealous labs with adult tube blood draws. 🙄 (I'm being sarcastic of course.)

 

[doepug]

You guys are right on the money.

Daily labs just end up exsanguinating patients for no reason... after all, is that CMP really going to change anything? I especially felt bad for the kids getting daily labs when I was on peds. In my opinion, this is a huge source of waste. Nothing like a little iatrogenic anemia to make your patients feel great, eh? When I'm an attending, "daily labs" will at most be qod, unless the pt is in an ICU.

I agree that DREs are annoying, but I can triumphantly say that I've only had to do two (count 'em, two) so far in my career as a med student. They're invasive and nonspecific, and fortunately, my interns/residents have only told me to do them when there's either a GI bleed or suspicion of prostate badness. Unfortunately, I've had to do more pelvic exams (and I haven't done OB/Gyn yet!)... it's pretty depressing to find gonorrhea in a pre-teen.

Cheers,
doepug