lung auscultation during weekly checkups?

[FreakFlag]

i'm already having having flashbacks to residency after having a few drinks tonight...

does anyone actually auscultate lungs routinely during weekly on-treatment checkups for their lung patients? i saw attendings do that often on the thoracic service, even at 2 Gy cumulative with no complaints or chest pain.

sure, you might "hear" a new malignant pleural effusion, but the cone-beam CT would probably spot it sooner.

has lung auscultation ever significantly altered your radiation management?

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[medgator]

Nope. Sometimes pts ask though and I'm happy to oblige

 

[RadOncDoc21]

Nope. Sometimes pts ask though and I'm happy to oblige

Sometimes I do it to look the part... “concerned doctor”

 

[RickyScott]

About looking the part. During residency had an attending who would do rectal exams on prostate pts during treatment and assure them radiation was working. As field moves to hypofrac/5 fractions, we will shift to becoming technicians vs clinicians. Maybe playing doctor will become more important than ever?

 

[Lamount]

I don’t routinely do this in asymptotic patients in the COVID era... especially since we do daily CBCT. It’s most relevant in symptomatic patients. I’ve caught a few new a-fibs w/RVR missed by the vitals machine in patients who “just didn’t feel right”

 

[radOresident]

If your vitals machine is somehow missing HR > 150 that seems like an indication to get a new machine.

 

[RadOncG]

I’ve caught a few new a-fibs w/RVR missed by the vitals machine in patients who “just didn’t feel right”

Everyone remembers these.

I'm sure you've caught a few nothings that led to extra workup, overtreatment, and potential for harm too.

 

[radoncopotamus]

One of the attendings I trained with insisted on scoping their head and neck patients on treatment every few weeks. Seemed crazy to everyone else. Is this common practice elsewhere?

 

[Lamount]

Everyone remembers these.

I'm sure you've caught a few nothings that led to extra workup, overtreatment, and potential for harm too.

I’m pretty reluctant to send in an asymptomatic patient unless it’s for something like having an HR > 120

 

[RadOncG]

I’m pretty reluctant to send in an asymptomatic patient unless it’s for something like having an HR > 120

That's probably smart. There is a lot of statistical noise workup/treatment when doctors treat numbers instead of patients.

Regardless, I would say the sensitivity and specificity of a radiation oncologist using a stethoscope likely leaves a lot to be desired.

 

[metallica81788]

One of the attendings I trained with insisted on scoping their head and neck patients on treatment every few weeks. Seemed crazy to everyone else. Is this common practice elsewhere?

Mine as well - every other week. I've learned that it was mostly for scope charge.
If you're reviewing CBCT every day you will see if tumor/nodes are responding or not. Also on your weekly OTV if nodes are palpable or visible tumor in tonsil/oral cavity. If it's endophytic and tougher to see on CBCT, you probably can't see it on scope very well anyway.
The only utility I can see is for things like plaques on TVCs, larynx, pharyngeal wall creeping lesions - things you can't see as well on CBCT from the beginning.

 

[gmsquid]

Mine as well - every other week. I've learned that it was mostly for scope charge.
If you're reviewing CBCT every day you will see if tumor/nodes are responding or not. Also on your weekly OTV if nodes are palpable or visible tumor in tonsil/oral cavity. If it's endophytic and tougher to see on CBCT, you probably can't see it on scope very well anyway.
The only utility I can see is for things like plaques on TVCs, larynx, pharyngeal wall creeping lesions - things you can't see as well on CBCT from the beginning.

Yeah the only reason I do it is concerns regarding airway or symptomatic evidence of disease progression.

 

[evilbooyaa]

One of the attendings I trained with insisted on scoping their head and neck patients on treatment every few weeks. Seemed crazy to everyone else. Is this common practice elsewhere?

What the what?

I don't even scope people at 2 weeks or 1 month (or frequently even 2 months out) from the end of H&N RT without extenuating circumstances because of how uncomfortable a scope exam is for patients when there is any residual mucositis from radiation. And if I see residual tumor at 2 weeks or 1 month? So ****ing what? Great I saw it. We'll monitor it patient. Sorry that you're in rip roaring pain from passage of a rigid scope rubbing against your swollen inflamed oropharynx.

I could not in a million years thinking it's OK to scope a oropharynx patient actively on treatment while they're in the middle of G2 oropharyngeal mucositis in week 4 or 5 (or later) of RT. This **** is either being done for the money or people so stuck in dogma and "how they were trained" in a field where stuff is usually outdated within 5-10 years.

If there is a big exophytic primary, CBCT tells me that **** is shrinking as the airway opens up more... if there's a big palpable LN it shrinks visibly and becomes non-palpable during RT. Tada, look the RT is working, patient!

To the OP's question - I do not unless asked by patient. If they have inflammation from RT I usually see it on the CBCT. Lung patients are at extremely high risk of completely inappropriate Abx and mostly inappropriate use of a medrol dose pak during fractionated lung RT.

 

[Radonc 2013]

So if I perform routine rectal exams (despite MRI), auscultate the lungs (although asymptomatic and with CBCT), and come in on the weekends a lot to treat, does that make me a great radiation oncologist?

 

[RadOncDoc21]

So if I perform routine rectal exams (despite MRI), auscultate the lungs (although asymptomatic and with CBCT), and come in on the weekends a lot to treat, does that make me a great radiation oncologist?

 

[kimplera]

One of my attendings taught there are 3 types of radiation - curative, palliative, and lucrative... maybe less of the latter now...

One of the attendings I trained with insisted on scoping their head and neck patients on treatment every few weeks. Seemed crazy to everyone else. Is this common practice elsewhere?

 

[Neuronix]

Physical exam during treatment is useful to look at skin toxicity or if the patient is complaining of something.

I always felt that way, and now with COVID I strongly feel that way.

I had an attending who used to scope his H&N patients weekly on treat. Plenty of practice for me I guess. No way I'd do that now.

 

[RadOncMegatron]

Common sense is STRONK in this forum. Next thing ya'll gonna say is that you don't really go through 10-15 Review of Systems with each and every patient.

 

[evilbooyaa]

Common sense is STRONK in this forum. Next thing ya'll gonna say is that you don't really go through 10-15 Review of Systems with each and every patient.

That's the nurses job as part of their rooming process, which they put into the templated note that automatically pulls in:

 

[Neuronix]

Review of systems is no longer required in the new billing rules for outpatient visits.

They never had a place in OTV notes as far as I'm aware.

I try to minimize documenting something I didn't do. And ain't nobody (including our nurses) got time for a full ROS every OTV.

 

[RadOncMegatron]

That's the nurses job as part of their rooming process, which they put into the templated note that automatically pulls in:

View attachment 326556

LOL.

I should've been more clear I meant the complete 15 ROS for new consults not OTVs that meme though lolol

 

[medgator]

Common sense is STRONK in this forum. Next thing ya'll gonna say is that you don't really go through 10-15 Review of Systems with each and every patient.

That's what nurses are for?

 

[evilbooyaa]

Review of systems is no longer required in the new billing rules for outpatient visits.

They never had a place in OTV notes as far as I'm aware.

I try to minimize documenting something I didn't do. And ain't nobody (including our nurses) got time for a full ROS every OTV.

Right, figured he meant for consults. Very glad that it is no longer necessary as maybe now I can see my 10 o'clock patient at 10:45 instead of at 11:00