Can't Find It in There, Doc?


This recent comment from a patient during an exam led Dr. Pullen to reflect on the many things that physicians do during an office visit that may seem odd to patients.

This article originally appeared online at, part of the HCPLive Network.

As I went through my routine heart exam for a patient this week, he commented, “Can’t find it in there, Doc?” I’m not sure if he was joking, or worried. This made me think about the routine things I do as a physician that may seem odd to patients.

When a physician listens to a patient’s heart certain aspects of the heart sounds are best heard by listening at different areas on the chest. The area just below the left nipple is where we listen for sounds from the mitral valve. This is also where we palpate (doctor talk for feel) to estimate the size of the heart and to see if there is a diffuse heave like movement of the chest wall that can suggest heart enlargement. The murmur heard from mitral valve disease is often best heard in this area, called the apex. At the left upper sternal border we listen more for the pulmonic valve sounds. At the right upper sternal border sounds from the aortic valve can be heard best. Careful auscultation of the heart involves listening carefully at all of these areas. To a patient I guess this may seem like we are searching to see if there is a heart in there somewhere.

If this seemed odd enough to a patient to make a comment, I have to wonder what patients may think when I examine their abdomen when they complain of swollen nodes and sore throat. I know I’m seeing if the liver or spleen is enlarged, as a clue to infectious mononucleosis, but they may think I’m just distracted or off target. Maybe questions I ask are just as obscure. Asking about bowel or bladder control problems in patients with back pain may seem weird to a patient, when I know I’m just screening for lower spinal cord injury symptoms. Sexual function problems can be a clue to cardiovascular disease, but I wonder what men may think when I ask them about erectile dysfunction when their complaint is chest pain, or visa versa.

I find that the best visits are usually when I talk the least and listen the most. Maybe I need to talk more, at least enough to explain why I’m doing what I’m doing, or why I’m asking obscure questions. Maybe not! Maybe the mystery of the doctors visit is a part of our ability to heal. I’ll be interested to see if readers have any experiences of this type to share as comments. Has your doctor sometimes done things or asked questions you wondered why they were doing or asking. I’ll try to respond with a reply comment to any comments you leave on this issue.

Ed Pullen, MD, is a board-certified family physician practicing in Puyallup, WA. He blogs at — A Medical Bog for the Informed Patient.

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