H&p

[gschl1234]

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I'm finishing up my last month of IM rotation and just had a "supervised H&P" with a retired IM primary care doctor. He really made me second guess my whole approach to the H&P. I started out at the beginning of IM 2 months ago doing a really "complete" physical but after watching the interns, I started abridging my physicals so that I always do pupil test, look in mouth, palpate neck, CV, Resp, Abd, Ext exam on all patients with special focus on whatever the person is coming in for. Other than pupil test, I don't do any neuro exam. Anyhow, this doctor tears me a new one saying that he couldn't see how I'd "pass the exam" (I'm guessing he's talking about Step 2 with standardized patients since at my school, we just have a shelf for IM) since "you have no idea whether your patient's cranial nerves are intact" (person coming in w/ jaundice, no mental status changes, no indication of neurological deficit so I didn't do it) or "whether they're anemic" (since I didn't pull down their bottom eyelid. But every time I've gone down to the ER to admit, there's already been a partial work-up including CBC, chem7 at the least).

Here's my question to IM residents: when you're admitting someone are you supposed to always do a "head-to-toe physical"? If so, at some point do you have to draw the line? For example, for the MSK physical, last year they tought us to palpage all interphalangeal/metacarpo-phalangeal joints of the hands. For sensory, we did dull/sharp/vibrational on 3 sites on all extremeties as well as dull/sharp on the face. At some point, doesn't it become a mindless exercise? Is a full MSK/Neuro exam necessary in a patient with abdmonial pain? And on Step 2 do you even have enough time to do a "complete head-to-toe physical"?

 

[Sweet Tea]

Not an intern, but I am a MS4 who has recently taken Step 2 CS and can answer part of your question. No, you don't have time to do a complete head-to-toe physical on Step 2 CS. It's a focused physical, you have 10 or 15 minutes to do a history and physical and some counseling, and there's just no way to do a complete head-to-toe physical in that time. Just keep the exam centered around the CC; I examined the cranial nerves in the person complaining of a head ache, I did not examine them in the 18 year old w/costochondritis. Chances are, your retired preceptor has not taken Step 2 CS, so I wouldn't worry too much about that.

Hope that helps!

 

[Mumpu]

You are correct, realistically you do a basic exam with elaborations as warranted. You actually get most of CNs by a) shining a light in the pupils (CNII); b) observing the patient (speech CNV, VII, IX, X; facial expressions CNVII; EOMs CN III, IV, VI); c) having them say "ah" and stick out the tongue when you look in their mouth (CN IX, X, XII). You will pick up most deficits that way. Looking at oral mucosa is as good as conjunctival pallor IMHO for anemia.

FWIW, here's my typical exam:
- General impression (sick-not sick, pallor, jaundice, fingernails for clubbing, koilonychia, Mee's/Beau's lines/Terry's nails)
- Light in the eyes, fundoscopy when I have access to the opthalmoscope (for practicing this skill more often than for clinical indications), light in the nose and mouth, say "ah" (don't forget to look at the dental hygiene! consider a more thorough exam of the buccal mucosa and tongue in long-time smokers)
- Neck for nodes (A/P cervical, occipital, submandibular, supraclavicular), thyroid
- In one swoop motion, auscultate carotids, heart, stomach (scratch test for liver size while the stethoscope is on the belly), lungs; E-A egophony and percussion while I have the stethoscope on the back.
- Feel all four belly quadrants
- Check for pretibial edema
- Quickly test CNII-XII, a few DTRs (brachioradialis, biceps, triceps, patellar, Babinski), strength in major groups (finger squeeze, straight leg raise against resistance, plantar/dorsiflexion)
- All diabetics (since we see so many) get shoes/socks off and vibration/proprioception in the feet.
I tend to run through my ROS as I'm examining the relevant organ system.

 

[fang]

Another MS4 opinion here. I did a supervised H&P as well, and saw it as a testing situation... the point was to show the attending you knew how to do a full physical exam, and let them give you suggestions (so I did a complete head-to-toe exam). I don't think it's a wise use of time to do that every time, and I don't plan to. Also, when the residents are in a hurry, it's not that uncommon to find something new in the exam... it's rarely relevant to the pt's care but sometimes it's a good pick-up. Also, I was surprized at how many people have heart murmurs and how many elderly people have neurological findings if you really test. One thing that still kind of mystifies me is palpating or percussing a liver and/or spleen in overweight people.

Anyway, maybe you can do the test again for the attending and say you thought the point was to do a focused physical exam, but would be happy to demonstrate a full exam.

 

[gutonc]

When put in one of these testing situations, it's important to clarify, both with the examiner and the "supervising authority" (i.e. your clerkship director) what exactly you're expected to do. In my program, we had a formal supervised exam by an attending (not ours) at the end of our medicine clerkship which was expected to be a complete, full, head-to-toe H&P along w/ complete ROS. Different examiners expected different things (which I'd heard through the grapevine before I took mine) and so I asked mine before we entered the patient's room what she was looking for.

We then did a CS-style supervised clinical exam that allowed 30 min total (20 for HP, 10 for note) and they expected a slightly more extended exam and ROS than CS does.

Finally, there's CS. Here's the secret to success on that exam. Always hit the "Big 5" (HEENT, Heart, Lungs, Abd, Ext) and then tailor to the scenario. Keep your ROS relevant to the scenario. ALWAYS ask about smoking and EtOH and counsel about quitting (even on the woman who comes in or calls for advice on her kid who's been puking for 3 days).

Do those things and you'll likely pass.

Moral of the story is that you should always ask beforehand what's expected of you so you don't get surprised. Even at CS, they'll sit there and answer the same question from every single examinee before they get started.