Breaking Wind

Cawdor Castle Gardens

Lucie of Lost Dogs had asked on my The Immortal Vagina post if there were other parts of the physical exam that had specific dialog/procedure associated with them.

Yes. Yes there are!

The chest exam is a case in point. 

Does your doctor listen to your heart or lungs first? When listening to your lungs do they listen for a fraction of a second or do they listen to the entire inspiration/expiration cycle? Do they listen to both sides or all four quadrants? Do they listen to the lungs at the front of your chest or at your back? 

In medical school I was taught to listen to all four quadrants of the chest at the back and to listen to the entire inspration/expiration. Otherwise you can miss something important. And yet as a student and resident I watched attending after attending as well as residents, and students listen for a fraction of a second on each side and declare the patient to have a negative lung exam. I call bull shit.

Lest you think I am better than everyone else, though:

No one ever taught me to listen to the heart first. Not officially. We did heart and lung modules separately. So I developed a nasty habit of listening to the lungs first…

“Uh, doc? That made me kinda dizzy!”

Hyperventilation. 

Many people are not used to breathing that deeply for that long. THEN, I immediately tell them to breath “normally” so that I can listen to the heart. 

Try that with me now. Four long, slow deep breaths then stop and imagine someone listening to your heart… trying to breath quietly, shallowly, while staying still.

Damn near impossible.

And yet, I cannot for the life of me switch it! I have that habit so rote, so ingrained, that I do it without even thinking. If I do happen to remember and switch it up, it disrupts my entire process for the rest of the exam and I look like some sort of stammering fool. A lot like other things in our lives that we cling to, huh? Things that are not exactly the best for us or anyone else but we cling to them because the change is too much to contemplate?

Gah! 

Now that I have confessed and written about it, displayed my dirty laundry for all to see, I will have to change in order to maintain credibility. I know you will be watching…

I would love to hear what your own physician does during your exams!

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128 thoughts on “Breaking Wind

  1. It makes me nervous to breathe like that. I pretty much reserve that deep breathing for avoiding pain and panic.
    My doctor listens to our breathing for a long time, although more in the front than the back. I remember when I had my first extremely thorough ob-gyn and she listened to my heart from different angles for what seemed like eternity. But I also felt appreciative of her thoroughness.
    If it makes you feel any better, I like to wipe out the sink and then turn around to find a spare dirty glass or a knife, or a forgotten pot on the stove…Even though it plagues me, I don’t change my behavior.

    Liked by 3 people

  2. I cant say that I remember what my physician does but I can totally relate to the work habit thing. As a hair colorist, I have always applied tint starting in the nape of the head and work my way to the front. I have a couple of clients who like me to start in front because they are more grey in the front and they want the tint to be there the longest. Makes sense. However, even when they remind me 3 seconds before i start the process I will start to begin in the back. Its an auto pilot that I cannot seem to break.

    Liked by 3 people

  3. Everything is about pattern in medicine! Even history taking… Don’t change my order of my history – even if I do it differently from you – damn it! Then I will forget something… Or is that your plan, to make me forget something so you can be the pompous start or senior resident who can point out my mistake? I’m on to you!!!

    Liked by 4 people

  4. I remember in high school going for sports physicals, one particular very old doctor, my pediatrician, barely listened. He used the fraction of a second timing AND his stethoscope earpiece wasn’t even on straight, LOL! Many docs don’t listen long enough. Next time I go for something, especially respiratory, I will be sure they listen. Thanks Victo, I learn so much from you!

    Liked by 3 people

  5. I don’t actually remember what order my doctor does the exam. I’m surprised he can hear anything through the many inches of rippling muscles. I have to be careful not to flex my pecs or I could easily cause damade to my poor doctors hand. 🙂

    Liked by 4 people

  6. When I have a sinus infection the doctor listens to all four quadrants for the entire length of the “breathe in/breathe out” cycle. I never paid attention to whether or not she listens specifically to my heart. The nurse takes my blood pressure and heart rate before I see the doctor.
    Yesterday I had to show her my armpits though because I’ve developed an allergy to something in my deodorant. That was pretty uncomfortable.

    Liked by 1 person

  7. Dr. always does heart, then 4 quadrants for lungs. So..I always assumed the deep breaths were calming, and would slow down the heart rate. But is it the other way around, does the heart speed up after ???
    A Confused Van

    Liked by 1 person

  8. I actually had my lungs and heart checked this week. the older doctor – actually an anesthesiologist , I have an small operation coming up tmw – and he listened carefully for a full cycle in each quadrant and then listened to my heart. His only comment was “You sure have a loud heart.” = which was apparently not bad because he then sat down and did some more paperwork. Ha! See, Victo, I have a lot to say even when my mouth is closed. Ha! When the nurses are putting me on dialysis, they always ask how the other nurses do it (do they use a tourniquet or not, what do they use for tape, etc) Honestly Victo, I tell them that each nurse is comfortable doing it their own way and from a patient’s perspective, they are all equally effective. It’s just what you get used to.

    When I was the Safety Director for a tanker company hauling gas and diesel – we trained our guys for 3-4 weeks on how to haul petroleum. The key factor was that they develop safe habits – then when the shit hots the fan you are exactly where you are supposed to be doing what you are supposed to be doing to minimize damage (spills, etc), Each driver had different but equally safe habits. So we had 2 weeks with a primary trainer, then 2 more weeks rotating between other good drivers who liked training (they got paid a premium for training) .They were shown and then told how to develop good habits. That may sound silly, but the trick is when you have a habit, you become super-sensitive to any changes or differences and will pick them up immediately. Without habits, you are listening or watching differently each time and not only risk missing a step but also risk missing a s\mall difference or fluctuation that you would catch if you were listening/ watching exactly the same way each time.

    So, as long as your routine covers all the bases Victo – the most important thing is that it remains the same. Oh, as an aside, you fix helicopters the same way. you assume an integrated and highly complex system and then look for aberrations or differences, then explore, diagnose and fix. Look for differences – that’s the trick

    Anyway, great post, i’m sure you are doing fine.

    Liked by 1 person

  9. I’m never sick thankfully but many years ago as a teenager, while training in the pool early one morning I got a pneumothorax. I can remember at the hospital nearly cracking up (and blacking out) as I was asked to breathe in and out for hours for examination by different doctors. Your post brought back those memories.

    Liked by 1 person

  10. The doctor I fled from would listen for half a second and say I was fine. Hello, thanks dork, I have asthma and would like you to listen for a *tad* bit longer! My new doctor does the exact same process you do and I love it. Sure I have to try and breathe really quietly and it’s a bit hard after the big breaths, but I love a challenge that I can win.

    Liked by 1 person

  11. So hard to change up routines and habits isn’t it? My Dr’s order seems to be heart, 4 quads/back/almost full cycle, which used to make me feel rushed, like I had to exhale faster to move on for him. Now I just take my own sweet time and inhale again when I’m ready. He never seems impatient.
    He loves his reflex hammer as well…I’ve always wondered just how many times med students have gotten kicked before they remember to move to the side 😉

    Liked by 1 person

  12. Heart first, then lungs. He is a very patient man and a great doctor. All of us patients are treated with dignity and respect. He has a wonderful bedside manor.

    You sound like a great doctor yourself. After all what doctor would be so honest with the world. Kudos Doc. I would have you as my physician in a heart beat. :o)

    Liked by 1 person

  13. When I was in my Cardiology rotation I listened to a patient’s lungs and the breath sounds on the left were absent. When I told my attending, he said he had just listened and he was fine. It turned out that he had a spontaneous pneumothorax. They don’t all take the time.

    Liked by 2 people

  14. This is fun ! Stethoscope ? What’s that ? I’ve seen my local Spanish GP and a variety of hospital specialists over the last 2 years and none listened to my chest ! Mind you, I’ve had 3 chest Xrays and the recent one this year denotes I have tuberculosis. I think it was caused by the tuning fork vibrating on my kneecap ! 😀

    Liked by 1 person

  15. When I have an appointment first it’s the ladies and their surveys at the desk, followed by someone who walks me to the room, then someone comes in takes my vitals and asks me why I need to see the doctor. After that, the doctor comes in. She doesn’t ever listen to my lungs unless it’s lung/breathing related but, when she does it’s the four long deep breaths like you talked about.

    Liked by 1 person

  16. And here I thought you were going to be writing about farts..lol
    You know I don’t think my present physician has ever listened to my heart. I’ve never had a full physical with him. Too scared for physicals.

    Liked by 1 person

  17. I have to reply again. I was born with Atrial Septal Defect and not ONE doctor caught it until I was 35 years old! Can you believe that? Talk about not really listening during an exam!!! I had to have open heart surgery when I was just 35!!

    Liked by 1 person

      • Yes, it is. I can’t tell you how many doctors listened to my heart and told me I had Mitro Valve Prolapse (which I do) but not one of those doctors could detect the difference between just that and also having Atrial Septal Defect and just send me for an EKG which when I finally did find a doctor who sent me for an EKG, the attending tech almost screamed and then ran out of the room when the results printed out. I heard the doctor yelling at her for doing that in the next room. That doctor was a bitch from hell and I couldn’t stand her but she may have saved my life…..

        Liked by 1 person

  18. I listen to patients in the exact same order all of the time. First heart, all four places. Then lungs anterior just the upper and posterior the four. The carotids and check for lower extremity edema. It is fine if it they are there for that, but sometimes, it’s just a sore throat and I do things in that order out of habit.

    I am glad you are thorough. We all know it’s all about the history, but the exam is becoming a lost art as many of us rely on imaging. I think I do a more complete exam because getting me to order x rays is nearly impossible.

    Liked by 2 people

  19. Gee did you post a winner here! Ooldes of comments. My GP of 27 yrs or so: Beginning at my back. Deep brearth. Uh huh. Breathe, again, uh huh, again. uh huh. Then onto my chest and has me breathe normally. I think he is about as good as any GP around. I would be afraid to change doctors.

    Liked by 1 person

  20. I have encountered three very good GPs … ever. Now deceased or retired.

    My husbands VA Cardiologist is very good. She can actually knows what she is listening to .. uses things like heat/color/doppler ultra-sound to confirm and for records, in case something comes up and she is not available. She does interview/history/questions then exam, after he is all relaxed and reassured, heart in front, several places, lungs, breaths in back, then often breaths in front too. Edema check on ankles … she and other physicians have missed mild edema with him, if they don’t check the tops of his feet, closer to the toes. But she is good, and usually can see it around the eues without bothering with the ankles … that is just part of the routine .. she never omits anything, and double checks every med and potential diet interactions. His GP … it is more polite if I don’t say. The ER docs … some are good enough, some others .. including triage nurses and PA have to hear certain cue words in order to slip into the trained routine .. like hypnosis .. if they don’t hear the right complaint terminology, they skip important diagnostics in the exam …

    Liked by 1 person

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  22. Almost didn’t read this post. Was expecting something else. Good one doc ^_^

    I love when doctors are thorough, it makes me feel my time in the waiting room was worth it! Especially since I’m going to be felt-up, probed and god knows what else by visit calls for. Even after three kids I’m still squeamish at physical exams!

    Recently had a doctor-in-training perform my exam for a routine physical. I was never asked to disrobe and put on the paper gown. So there I am laying on the exam table having my shirt lifted, my pants shifted, etc. It was rather an uncomfortable experience since there was no way he could have examined me properly with all my clothes on. He just seemed like an eager young lad who wanted to see what the body parts of an older woman looked like. Not for once did I feel like I had a professional exam.

    Surprisingly, the supervising doctor came in and did pretty much the same thing. So I now know where the student doc got his bad training! Awaiting blood work results…

    Liked by 1 person

    • Generally you CAN perform a good thorough exam with clothes on unless you are needing to do a boob or pelvic check. But if it didn’t feel like a good thorough check, then it probably wasn’t! 🙂

      Like

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  24. Becoming an orderly made me aware of heart rate, breaths, and being able to count to 15, then multiply by 4. Pretty cool, no? Now watching breathing to see how many respirations a minute? Where do I look? Well, at a heaving or non-heaving chest, male or female. I was young then–and felt like a voyeur looking at a woman’s chest (under the hospital gown) to see how “she” rose and fell. As I got older, married, and cast under the spell of female-ness, I had no trouble looking at heavings. Ah, sexist, objectifying me! Or am I simply a dirty old man?

    Liked by 2 people

  25. Well, I can tell you what my own physician does NOT do before an exam… He does NOT eat a TicTac, a Mentos, or a breath mint of any kind. Nor does he (apparently) brush his teeth! Then he puts his face wickedly close to mine to tell me to breathe while he listens. And (I guess in order to avoid staring where his stethoscope is – my boobs!) he looks me right in the eye, which makes me crack up each and every time! (While simultaneously trying not to gag from the foul stench of his breath!)

    But as for the order, he actually starts at the back, listens to the lungs first, then moves to the front, more lungs, then the heart, then eyes, ears and throat. Then he almost always draws me some sort of diagram of whatever’s wrong with me on the paper covering the table, which I actually like a lot. It makes me feel like he really cares enough to take that time, and make sure I know what I need to.

    Liked by 1 person

  26. While training a sleep doctor to use the EMR, I observed many “exams” that were hilarious. He placed his stethoscope on each patient’s throat (2 spots), chest, and abdomen (1 spot) for just a fraction of a second each. All this was done through their clothing! I’m sure he heard plenty in that abdomen, right? Don’t beat yourself up doc!

    Liked by 1 person

  27. Thank you for this thought provoking post.

    We were told to read Mcleod’s, go practise on patients, and to make up our own sequence of examination that feels most logical to us. As a result, there are some pretty funky stuff going on.

    One day, an old general practitioner, whom is well loved and respected, gave me some tips on listening for chest sounds. He told me, there are wheeze, crackles and rhonchi. I’ve heard of the other two, but rhonchus/rhonchi was alien to me. After some research, it became apparent that the term rhonchi had been essentially defunct since the 1990s, the GP, had qualified in the 80s, and the nobody had bothered to send him the memo.

    Liked by 1 person

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