Posts tagged physical exam

Mail: Impeccable History and Physical

Hi Tom! “Your histories and physicals are impeccable… ” Congratulations! Any advice on how to get there? As a medical student who has just started bedside clinics, I find them challenging. Thank you! :-)

i just started med school and it is so unbelievable that i am qualified to start learning how to do physical exams and volunteering as a 'student doctor' and taking bp and asking history... how long did it take you to feel like you were qualified to do true medical things? — Asked by twentyfourandnotpregnant

I do not think I will ever shake that feeling of being a student doctor. The learning never stops. For the basic clinical skills like doing physicals and taking vitals, I became more comfortable with practice and repetition. Now, I am at a point where I am comfortable enough to be thorough, put some of the pieces together, and figure out a basic differential based on the findings. For many other advanced skills that I have not had much exposure to, I still feel as lost as I did when I first learned the basic skills. To feel truly qualified is going to take more practice and experience. 

Like S***

  • A: How was your rounding today?
  • B: Well, I got to do my first DRE.
  • A: Oh? How was that like?
  • B: Like s***.

Not on my White Coat

  • While doing a physical on a volunteer patient, noticing he could not keep still.
  • Me: How are we doing here, sir?
  • Pt: Not so good. I think that stomach upset from this morning...I think it's back.
  • Me: Back?
  • Pt: I think I'm going to throw up.
  • Me: ?! Hold on, let me grab the bin for you.
  • After a vomiting bout, the patient starts to feel an urge to use the washroom. With some help from a nurse, we help him out but were unable to reach the washroom after he becomes dizzy. A doctor passes by and notices.
  • Dr: Whoa, what's going on here. Sir, are you okay?
  • Pt: I don't know, I really don't feel good.
  • Dr: We should get you checked out just to make sure you're okay.
  • While the patient is put into a bed and taken to the emergency department, my tutor returns.
  • Tutor: Tom...what did you do?
  • Me: Um...
  • Tutor: I said take a history and physical, not send him to the ER.
Do not forget the DRE.
The tutor’s comment to me while I neared the end of an abdominal exam.
Have you or will you experience a pelvic exam with a GTA (Gynecological Teaching Associate)? (I ask because I am one, and I don't know if your school uses this kind of program, but I'd be interested in hearing about it from the student's perspective.) — Asked by ammre

I did do a pelvic exam with a GTA and it was a very unique and very helpful experience. There were a couple of GTAs, and with them we went through various maneuvers and different exams, like the Pap smear and the bimanual. I really appreciated and respected their presence and willingness to go through those very private and intimate exams with us. The feedback from that experience was invaluable. Though we only went through the exams once, I definitely feel a little more comfortable with performing them now.

Ankle clonus.

Reading is one thing; seeing is another. In a group huddled around a patient, the instructor walked us through some of the signs we were able to reproduce in the patient. Based on some signs that pointed towards an upper motor neurone pathology, the instructor asked us what else we expected to see.

"Clonus?" came a reply.

"Right! Let’s see if we can reproduce it." The instructor tried to produce an ankle clonus for us first; it was faint and subtle. Given the time constraints of the session, the instructor decided we would give it one more try to produce a more noticeable one; I was picked to perform the maneuver.

A few loosening swings and a fast dorsiflexion later, I felt the clonus in my hand for the very first time - the sustained series of obvious contractions and relaxations of his foot pulsing against my palm.

If the medical school experience had a highlight reel, it would be for moments like this where knowledge meets application.

Do not move your head. Follow my finger.
As a fun exercise in understanding ocular anatomy, we were asked to reason out how we would isolate and test the extra ocular muscles and its innervations. The superior oblique muscle is innervated by the trochlear nerve, the lateral rectus by the abducens nerve, and all others by the oculomotor nerve. 
Drawing out our diagrams and isolating each muscle’s movements, we produced the following: starting from centre, looking laterally would test lateral rectus and moving up from that position isolated superior rectus. Returning down to horizon and moving medially would test the inferior rectus and medial rectus respectively. Looking further into the medial inferior corner would isolate superior oblique; the opposite, looking into the medial superior corner, tested inferior oblique.
Going through this pattern for both eyes produces the H-test. Neat!

Do not move your head. Follow my finger.

As a fun exercise in understanding ocular anatomy, we were asked to reason out how we would isolate and test the extra ocular muscles and its innervations. The superior oblique muscle is innervated by the trochlear nerve, the lateral rectus by the abducens nerve, and all others by the oculomotor nerve. 

Drawing out our diagrams and isolating each muscle’s movements, we produced the following: starting from centre, looking laterally would test lateral rectus and moving up from that position isolated superior rectus. Returning down to horizon and moving medially would test the inferior rectus and medial rectus respectively. Looking further into the medial inferior corner would isolate superior oblique; the opposite, looking into the medial superior corner, tested inferior oblique.

Going through this pattern for both eyes produces the H-test. Neat!

Hello, my name is…

As the eight of us crammed into the examining room, the doctor quickly greeted the volunteer patient, an old acquaintance. The elderly woman had been waiting in the room patiently as we discussed the clinical finding and examination techniques for skin lesions next door. She had a book in her lap, and quickly set it aside as we all shuffled into the room.

"Everyone, this is JS. She will be our subject today." She sat still in her chair, looking at us pleasantly.

"We will do this one at a time. Come up here, feel, and describe your findings," the doctor said in a soft voice. He looked to the student closest to him, and ushered him closer, pointing at a particular lesion on her arm. He quickly went to work trying to identify it.

"It feels flat…small diameter…so a macule…" and on he went. Still, the patient sat, motionless as this stranger felt and scratched at the mark on her arm.

For a moment, she looked at him, smiling. However, realizing that he was too invested in his findings to respond, she quickly looked elsewhere. I observed as she tried to get back to her book but unable to keep the pages open with only one hand, she abandoned the idea and decided to sit and wait as we all took our turn.

By the third student examining a lesion close to her forehead, she was visibly bored. Still, no one had addressed her. Not even a hello. 

It was my turn next, and even as the doctor tried to point out a lesion for me to identify, I quickly leaned in to shake her hand: “Hi, my name is Tom.” She sat up in her seat and beamed at me: “Nice to meet you, I’m J.”

It was a simple gesture, one that took less than five seconds to do. The interaction was humanizing, and put a patient that was otherwise not engaged in the situation at ease. A simple recognition is sometimes all that separates a good encounter from a great encounter. 

As I move forward into my clinical years, as I see more patients in my life, it is important for me to recognize the person behind every encounter, behind every chart, behind every diagnosis. It all begins with the words: “Hello, my name is…”

The Dichotomy of Diagnosis.
A classmate of mine sent this to me to my amusement. I have written in the past about my feelings on the importance of a good physical exam but sometimes it does make you wonder if it is worth doing. In medicine, they continuously tell you to “treat the patient, and not the numbers;” I think that expression extends to this realm too. There is something to be said about a physician’s clinical experience and the ability to assess patients through the five senses that a machine simply cannot translate to you. Instead, machines should act as a supplement to your own clinical abilities.

The Dichotomy of Diagnosis.

A classmate of mine sent this to me to my amusement. I have written in the past about my feelings on the importance of a good physical exam but sometimes it does make you wonder if it is worth doing. In medicine, they continuously tell you to “treat the patient, and not the numbers;” I think that expression extends to this realm too. There is something to be said about a physician’s clinical experience and the ability to assess patients through the five senses that a machine simply cannot translate to you. Instead, machines should act as a supplement to your own clinical abilities.