r/emergencymedicine • u/Dr-Discharge ED Attending • 2d ago
Discussion Do you still use a stethoscope?
/r/anesthesiology/comments/1ts6toe/do_you_still_use_a_stethoscope/Stolen from the anesthesia subreddit. I barely use it. Most helpful to find wheezing, that’s about it.
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u/ShadowSousChef 2d ago
Found a case of endocarditis recently...thought it was just a URI as it was one patient of a twofer...only thing that clued me in was a very loud new murmur heard on exam.
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u/ABabyAteMyDingo Physician 1d ago
Caught a massive PE a while ago as a gp. The history made me suspect it, the breath sounds were unmistakable.
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u/sad11001 16h ago
What breath sounds are you hearing for PE? Genuinely curious
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u/ExtremisEleven ED Resident 16h ago
If they look like they’re having an asthma attack and you’re surprised that you don’t hear wheezing and do hear good volumes, that’s a PE until prove otherwise.
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u/ABabyAteMyDingo Physician 15h ago edited 14h ago
No, at least not in my case.
It was the absence of breath sounds on one side, or greatly reduced at least.
Edit: also PE may well have chest pain, asthma usually doesn't have pain as such. Also asthma may not have wheeze at all.
Go read up!
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u/ExtremisEleven ED Resident 11h ago edited 11h ago
I see these all the time. Asthma that doesn’t have wheezing is not moving large volumes of air.
Not all PEs have chest pain.
Absence of breath sounds has several differentials including pneumothorax, large pleural effusion and obstruction in the bronchus. If you listen to a chest and fail to hear breath sounds unilaterally and your first thought is PE and not “Need to rule out pneumo”, you need to stick to GP.
A 3 second google search would tell you that it is very common for PEs to have surprisingly normal breath sounds. Med students know this.
You’re also really fucking rude. Get fucked.
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u/ABabyAteMyDingo Physician 10h ago
Excuse me, but what the fuck?
Where was I rude to you? Are you quite alright there??
Asthma that doesn’t have wheezing is not moving large volumes of air.
That was my point exactly. Severe asthma likely has no wheeze but will have poor air movement EVERYWHERE. She had normal on the left, markedly reduce on the right over the entire lung.
Not all PEs have chest pain.
Never said they did. I said 'may well have' which means that quite a few do have pain but not all. Nonetheless, chest pain + SOB fits PE much better than asthma, especially in an adult with no hx of asthma. In this case, she complained of shoulder pain initially. That's what brought her in. She said NOTHING relating to respiratory symptoms. It was after a few minutes that I picked up on resp signs.
A 3 second google search would tell you that it is very common for PEs to have surprisingly normal breath sounds. Med students know this.
Ok, but irrelevant to THIS CASE as she did NOT have normal breath sounds. You asked what I heard, I told you.
Absence of breath sounds has several differentials including pneumothorax, large pleural effusion and obstruction in the bronchus. If you listen to a chest and fail to hear breath sounds unilaterally and your first thought is PE and not “Need to rule out pneumo”, you need to stick to GP.
In the context of the consult, it was obvious what the top differential was.
She had markedly reduced breath sounds GLOBALLY on the right side with no added sounds, no cough and no temp and no immune suppression, she did not feel systemically unwell, normal appetite and energy. She had 2 recent long haul flights and was on the pill. She had no focal creps or crackles or rhonchi. Are you really telling me penumonia is your top differential here??
In this case it was obviously not pneumonia or PTX. Pleural effusion might be possible, yes, but I had taken a careful history which included 2 recent long haul flights and she was taking a contraceptive pill plus I was LOOKING at her so clearly PE was my top differential. There is very little reason to suspect a pleural effusion here in a young well patient. It's possible but much less likely than PE.
Pneumonia in a young healthy patient in summer with no medical history, no fever, and NO COUGH and no creps or rales or rhonchi or crackles is a massive stretch given her flight and COCP history. PE was my suspicion and I was correct in that.
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u/ExtremisEleven ED Resident 6h ago
I’m not reading your manifesto. I was not talking about your case. I was responding to the question. When you tell someone to read up, at least have an understanding of the context before you imply they don’t know what they’re talking about. Especially if you’re coming to another specialties sub. Bye.
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u/ABabyAteMyDingo Physician 14h ago edited 14h ago
It's the sound you don't hear. Hugely reduced air movement globally on the right. Obviously a ptx could also do that but it didn't fit the history and how she looked, not distressed but mildly sob and mildly raised resp rate.
CT showed many many PE all over right lung.
She had presented with a sore shoulder!
Not to be rude, but aren't you an ED doc? Wouldn't you know about diminished breath sounds??!
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u/jus-being-honest 2d ago
There are three breath sounds: normals, absent, and wheezes
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u/Comprehensive-Ebb565 ED Attending 1d ago
Wet crackles are the 4th.
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u/ExtremisEleven ED Resident 16h ago
Scribed for a for a guy who wanted “bibasilar rales” in every note. Stethoscope never left the desk.
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u/masimbasqueeze 20h ago
Wait wait wait. What about coarse crackles. That is distinct from the 3 you mentioned
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u/InitialMajor ED Attending 2d ago
Yes. Asthma? COPD?
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u/PillowTherapy1979 1d ago
Pleural effusion. Pneumothorax. Hell, even found a dissection this way. The stethoscope is far from obsolete
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u/Canesfan9510 ED Attending 1d ago
I would assume you “heard” pericardial effusion with the stethoscope and found the dissection as a result?
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u/ricktron ED Attending 1d ago edited 1d ago
Hi vascular, yeah I got a patient here w a vertebral dissection. No CTA, I heard the bruit. You gotta come down and hear for yourself. … did you at least do a bedside ultrasound. No, I have a littman IV cardiology
Edit: all in good fun, nice catch!
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u/PillowTherapy1979 1d ago
If you are actually interested in the case, I submitted it to Figure 1 years ago shoot me a message and I can give you the link
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u/Screennam3 ED Attending 2d ago
How else am I supposed to auscultate the scrotum for bowel sounds
/s
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u/Helassaid Paramedic 1d ago
You gotta put your ear directly on the taint, doc
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u/Caffeinated-Turtle 2d ago
Murmurs (more a yes or no in febrile patients but can also help with syncope etc.), exacerbations of reactive airways diseases to titrate therapy and diagnose, and less commonly as a tendon hammer.
You cant immediately get a TTE or imaging or find a tendon hammer.
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u/tokekcowboy ED Resident 1d ago
Out of curiosity how long have you been an attending? I ask because I suspect many residents feel differently. Unless I’m too busy I CAN get an immediate TTE. I just need to drag the ultrasound in there and do it myself.
Edited to add… But my stethoscope is still my go to if I ever need a reflex hammer
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u/Caffeinated-Turtle 14h ago
You work in ED and have an ultrasound next to you all day. Not every doctor is always in that same situation. Clinical exam screens use of resources and referral. I work in Australia where everything is free but we investigate less as no financial incentive to do things.
Maybe with increasing POCUS i mean to the point outpatient doctors or those volunteering in a lower resource setting have a shitty US slung over their shoulders as available as a stethoscope, perhaps even integrated with AI then we can completely disregard any form of clinical exam.
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u/tokekcowboy ED Resident 10h ago
I mean…I’d argue I use US as a part of my physical exam not infrequently. Just like I use my stethoscope. Sometimes a physical exam can involve tools, and I see pocus as just another tool. I’m not sure what all your comment means. But I’d argue that learning to use POCUS well as a physical exam tool is not the same as diminishing your medical role to US operator/AI monkey. It’s appropriately keeping up with the technology that has become standard practice in your field.
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u/Caffeinated-Turtle 8h ago
You have complefely misinterpreted me.
POCUS is great.
POCUS isnt always available.
If you work in ED POCUS is available.
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u/tokekcowboy ED Resident 8h ago
Okay, got it. Yes, I did completely misinterpret you. My apologies. I have no issue with what you just said. And I do use a stethoscope a lot and find it to be a valuable tool. I would just pick an ultrasound over a stethoscope given the option (and I have the option most of the time).
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u/Special-Box-1400 2d ago
Actually use it for SOB, cardiac complaints. Sometimes I pretend to use it, on unrelated complaints. Patients want to be touched and feel evaluated, patients are often sitting there for multiple hours, make them feel like you are doing everything.
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u/diniefofinie 1d ago
This. Patient perception matters a lot, if you’re not putting your hands on them, listening to their heart and lungs like they’re used to having done during every physical exam they’ve had in their life, they are going to perceive you did nothing for them.
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u/jenivalda ED Attending 1d ago
I diagnosed pneumonia in a cardiologist’s wife with abnormal breath sounds. He didn’t believe me because chest X-ray was normal. Talked to his ID friend who it wasn’t pneumonia. Came back to the ED and repeat chest X-ray 24 hours later showed the pneumonia.
Also had a once in a career diagnosis - vasculitis from a renal artery bruit.
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u/Daleeeeeeeeeee 1d ago
Why the hell were you listening the the renal artery’s
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u/the_silent_redditor 1d ago
I don’t mean to call out my colleagues but…
I’m not sure I believe the folk saying they diagnosed a dissection or vasculitis with a stethoscope haha.
Patient perception, sure; I think that’s a valid point and probably goes a long way in the theatre that is every consult.
COPD? If they have acceptable sats and can mobilise at their baseline, they can go home - I’m not keeping them in hospital to give puffers via a spacer and wait till their chest is clearer and then discharge home. If they are otherwise stable and have the capacity, it can be done at home with a rigorous inhaler plan; if not, admission.
PTx? Effusion? Everyone gets a CXR. Yes, useful if you don’t have access to XR, I guess.
Murmurs.. maybe once in a blue moon diagnostic dilemma where you might be actually considering IE. Otherwise, people with valve symptoms are going to get an echo. I used to listen to heart sounds all the time and would hear murmurs and it never changed management, other than doing an echo at some point, which the patient would be getting based on their history anyway.
Bowel sounds don’t change my management.
Definitely different in paeds, where all kids need auscultation.
Brittle asthma also yes, cause asthma is scary 👻
I didn’t use a stethoscope for a long time at my last place. I’m at a new joint now so use it most days for.. perception amongst colleagues. Hasn’t changed management over last six months on one occasion.
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u/adoradear 14h ago
Aortic stenosis in chest pain, CHF, or syncope will significantly change your management.
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u/eIpoIIoguapo 2d ago
Yes. Useful for wheezing. Even more useful for the ‘theater of medicine,’ making patients feel like they are getting full doctor attention.
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u/jimihana 1d ago
Med student. I always have one around my neck. Someone will always ask “who’s got a stethoscope?” And boom there I am. Solid part of the fit as well
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u/ExtremisEleven ED Resident 15h ago
Listen, if you want to be the best medical student, put lube in your chest pocket. Nothing is worse than rolling a trauma patient with unstable limbs and needing to do the trauma handshake but nobody can find lube.
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u/Extreme_Turn_4531 Physician Assistant 2d ago
Respiratory complaints, it's most useful.
- Makes a decent reflex hammer in a pinch.
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u/Neeeechy ED Attending 17h ago
Respiratory complaints, it's most useful.
Debatable. Really only need it for wheezes
Wheezing: * Yes -> nebs/steroids/bipap * No -> etomidate/roc/ETT
/s
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u/coffee_collection 1d ago
Patients think its amazing if you do a manual BP.
"Woah you are old school"
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u/Mowr 2d ago
I stopped for a long time because it just wasn’t that helpful. Then I started getting more nasty grams from patients that “that doctor didn’t do anything for me. He didn’t even listen my heart or lungs!” Granted you’ve had a cough for 8 hours Janet you will be fine. So now I do just to stop the emails. Still sometimes helpful in syncope in particular IMO.
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u/bubsybear1319 RN 1d ago
I use it for manual blood pressures. I also use it with cardiac or breathing complaints. For nurse-first protocols I can order chest x-rays or ekgs based on what I hear and their complaints. I also like to give providers a heads up on what they may be walking in to. Using it helps me learn to identify and associate sounds and complaints with the diagnosis later given. I'm always up for furthering my practice and being better.
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u/Ok_Childhood_2597 2d ago
Occasionally. I listen to every syncopal patient. Pick up a couple major valvular issues every year.
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u/diniefofinie 1d ago
So your documented exam for chest pain doesn’t include a heart and lung exam? I just know the malpractice attorneys are salivating at the thought.
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u/SkiTour88 ED Attending 1d ago
Regular rate/rhythm, extremities warm and well perused, no respiratory distress is acceptable in my book.
(I do listen for chest pain…but I don’t think you have to)
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u/diniefofinie 1d ago
I wonder how well this holds up on the stand or even case review for a bad pt outcome
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u/esophagusintubater 19h ago
Promise u documenting lung sounds isn’t gonna save u from malpractice. I bet u whoever the person you’re responding to has the same odds as u
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u/diniefofinie 8h ago
Thinking from a jury’s perspective, it’s going to sound pretty bad you didn’t bother to listen to heart and lungs for a chest pain complaint. It’s going to be seen as careless and negligent.
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u/Paramedickhead Paramedic 1d ago
Lung sounds and manual BP for every patient.
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u/26sickpeople Paramedic 1d ago edited 1d ago
Don’t know why you’re being downvoted.
We don’t have all the tools the ED has and our NIBP is a random numbers generator.
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u/MLB-LeakyLeak ED Attending 2d ago
GE 64 slice scanner
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u/Resussy-Bussy 1d ago
Yes everyday? lol. Patients also more likely to rate you higher if you courtesy listen to their heart/lungs.
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u/metforminforevery1 ED Attending 1d ago
It is for show like 80% of the time. Pts do not seem to understand to shut the fuck up when I'm using it for one, and in our ED extension portable classroom area, it's so damn loud I cannot hear shit. The other 20% of the time it's useful for lung complaints and re-evals and some cardiac complaints. But if someone is there for an ankle sprain or lac I do not use it. Abdominal pain cc gets a chest auscultation like 1/2 the time depending on story/age.
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u/Kaitempi 1d ago
Every time. Totally performative. Mr. DeMille, I’m ready for my close up. If you got that reference you’re old.
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u/trypan0s0miasis Flight Nurse 22h ago
Yes. It sometimes does indeed alter course of care. Am I doing it for patients with immediate known etiology like CVA? No. But otherwise it doesn’t take too much time.
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u/esophagusintubater 19h ago
One time I had an asthmatic come in short of breath and his breath sounds were normal. He had a PE. My only use in 10 years
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u/ExtremisEleven ED Resident 15h ago
Of course not, I haul the giant ultrasound into every level 1 trauma while they are still on the EMS stretcher and get in everyone’s way when I could just listen for breath sounds.
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u/InquisitiveCrane ED Resident 1d ago edited 1d ago
The more experience I get, the more useless I find it.
SOB with asthma/COPD? I’m giving a neb regardless.
Intubation? We have CXR and colormetric devices.
Trauma for pneumothorax concern? POCUS.
Murmur? Don’t care.
Concern for pneumonia? CXR, POCUS.
I believe people disagreeing are either not ER docs or not seniors ER residents. Anyone working significantly in the ED can understand these explanations.
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u/diniefofinie 1d ago
You don’t care if a patient has a murmur?
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u/InquisitiveCrane ED Resident 1d ago
No. Why would I as a ER doctor? That is what a PCP is for.
I guess you aren’t a doctor. A murmur is not life threatening nor is it going to change management in the ED.9
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u/esophagusintubater 19h ago
Not sure why you’re getting downvoted. Nobody here has made a decision on a murmur
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u/26sickpeople Paramedic 1d ago
and surely there will never come a day where one or more of those tools will be unavailable
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u/InquisitiveCrane ED Resident 1d ago
Well I can have one around just in case we go back to the stone ages.
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u/jjjjccccjjjj 1d ago
This is an embarrassing list. In many patients you cant wait to know if you mainstemmed it after intubation, you need to listen. If you diagnose a serious pneumothorax in a trauma using POCUS you are clown level incompetent. Giving a neb regardless of wheezing? Absolutely insane and how do you arrive at a diagnosis then? I am concerned.
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u/InquisitiveCrane ED Resident 1d ago
- CXR
. Are you seriously pulling on ETT before CXR if you “hear a mainstem”?
- Dx pneumos with US makes you incompetent? Lmao.
- Wheezing or not does not dictate need for a duoneb.
- I dx with my brain. It really isn’t that hard and a stereoscope isn’t going to improve that process.
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u/InquisitiveCrane ED Resident 1d ago
- CXR
. Are you seriously pulling on ETT before CXR if you “hear a mainstem”?
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u/Outside-Ad3455 2d ago
Patients feel like you did something when you use it. So yeah