How much physical diagnosis?

[sebsvenmdc]

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Hi All,

Just curious...how much physical diagnosis is involved in anesthesiology? I don't want to come off as a complete ignoramus! I am an upper level med student planning on an anesthesiology residency. Through some of my rotations, I have learned more about myself. For instance, I hate some aspects of physical diagnosis including:
1) otoscopic exams - I hate looking at tympanic membranes. It's just something that I find very difficult.
2) grading reflexes
3) percussion - not very good at it!
The main problems with many aspects of physical diagnosis for me is how subtle the differences can be...I just find subtle differences hard to tease apart from normal variations!

In anesthesiology, you rely a lot on data, right. I love the idea of vital signs! Pulse oximetry, drawing blood for numerical analysis of acid-base disorders, looking at waveforms. So, does practicing anesthesiology rely more on the integration of numerical data than other fields of medicine or how much physical diagnosis is required. I'm definitely working on trying to improve on PD. I just don't know that it's my strength. I've done well in subjects like physiology and pharmacology and I love theory. PD is a bigger challenge! If I need to try to address issues more like PD now, I'm willing to try to inject extra studying in this area, but I'm also trying to do well on my current rotations! Thanks for advice in advance!

 

[lazylikeapanda]

relax about the physical exam.

Cardiac exam: listen for murmurs, rubs, irregular rhythms in the appropriate positions. look at the neck for JVD, feel pulses in the extremities.

lung exam, listen to the posterior back for wheezes, crackles, inspiration/expiration
things to know
can you recognize a person who is in respiratory distress? tripod position, use of accessory muscles, nasal flaring, huffing/puffing, turning blue?

know cranial nerves, dermatomal distributions, proprioception exam.

reflexes- we're not neurologists. either they have one or they dont.

i think if you poke a patient and they swat your hand away and cuss you out, then you've basically covered the pertinent parts of the physical exam.

 

[sebsvenmdc]

relax about the physical exam.

Cardiac exam: listen for murmurs, rubs, irregular rhythms in the appropriate positions. look at the neck for JVD, feel pulses in the extremities.

lung exam, listen to the posterior back for wheezes, crackles, inspiration/expiration
things to know
can you recognize a person who is in respiratory distress? tripod position, use of accessory muscles, nasal flaring, huffing/puffing, turning blue?

know cranial nerves, dermatomal distributions, proprioception exam.

reflexes- we're not neurologists. either they have one or they dont.

i think if you poke a patient and they swat your hand away and cuss you out, then you've basically covered the pertinent parts of the physical exam.

Hey, thanks for the input! Today when I was trying to view the pharynx of a patient, her tongue was obstructing and I couldn't see the pharynx nicely...so I asked her to lie down and then I jaw thrusted her, and voila! So much better! (Btw I also took advantage of her supine position by doing an abdominal exam...didn't just get her to lie down for a view of the pharynx!)

 

[bne_12mne]

Hey, thanks for the input! Today when I was trying to view the pharynx of a patient, her tongue was obstructing and I couldn't see the pharynx nicely...so I asked her to lie down and then I jaw thrusted her, and voila! So much better! (Btw I also took advantage of her supine position by doing an abdominal exam...didn't just get her to lie down for a view of the pharynx!)

1) Please stop.
2) See #1.

BNE

 

[Fastrach]

Hey, thanks for the input! Today when I was trying to view the pharynx of a patient, her tongue was obstructing and I couldn't see the pharynx nicely...so I asked her to lie down and then I jaw thrusted her, and voila! So much better! (Btw I also took advantage of her supine position by doing an abdominal exam...didn't just get her to lie down for a view of the pharynx!)

Can I assume you also checked for shifting dullness, as well as did a full fundoscopic exam and rectal exam? 🙄

Here's a hint for examining the oropharynx: tongue blade.

 

[Magnus67]

1. 200 propofol, 100 Sux
2. Miller 3 blade
3. Look around all you want
4. There is no such thing as non-compliance or a poor view😀


Seriously though, I didnt think much about anesthesia and physical exam skills when I was a med student, but there are a few concise things you need to be able to do well.(listed in above post) Heart, Lungs, a solid neuro exam, and I would add a basic trauma evaluation are very helpful.

 

[paiute]

i'm semi-retired from anesthesia and now i do general practice.

physical exam is of utmost importance. i think it is even more important than hx.

however, all those subtle findings that some attendings rave about, like 3rd and 4th heart sounds, rubs, etc. aren't very reliable or even useful.

you are right in concentrating on hard data like BP, pulse, neck veins, retractions, SpO2, ...

i do a quit listen to the lungs, mostly listening for a wheeze. then i listen to the heart in 3 places: apex, aortic area, pulmonic area. then i listen to the belly for bruits (once i heard a loud bruit from an hepatic cancer). then i lightly push on the belly to see if there is peritonitis (trying to feel for organomegaly in fat americans is a waste of time!).

yes, i do funduscopy. most doc's omit this, but it's a good assessment of the microvasculature. i've amazed myself at the dx's made just from the optic fundal exam.

what i'm leading up to is this: ultrasonography!

i have a good US machine right here in the office and i do a quick US exam on my pts as part of the PE. i takes 1-2 minutes. i check liver/GB/spleen/kidneys/heart.
if there is a subQ mass, i check to see if it has liquid in it. if there is testicular pain, i check for hydrocele.

it's quick and the pts seem to really enjoy seeing their insides!

now, i can see the gallstones!

in anesthesia, i have used US for peripheral and central lines. i will soon learn how to use it for nerve blocks. in cardiac anesthesia, i understand transesophageal US is standard of care nowadays.

i suggest you try to learn as much as you can about US, because it will soon be an indispensible part of your practice, whether in anesthesia or general medicine.

 

[2win]

i'm semi-retired from anesthesia and now i do general practice.

physical exam is of utmost importance. i think it is even more important than hx.

however, all those subtle findings that some attendings rave about, like 3rd and 4th heart sounds, rubs, etc. aren't very reliable or even useful.

you are right in concentrating on hard data like BP, pulse, neck veins, retractions, SpO2, ...

i do a quit listen to the lungs, mostly listening for a wheeze. then i listen to the heart in 3 places: apex, aortic area, pulmonic area. then i listen to the belly for bruits (once i heard a loud bruit from an hepatic cancer). then i lightly push on the belly to see if there is peritonitis (trying to feel for organomegaly in fat americans is a waste of time!).

yes, i do funduscopy. most doc's omit this, but it's a good assessment of the microvasculature. i've amazed myself at the dx's made just from the optic fundal exam.

what i'm leading up to is this: ultrasonography!

i have a good US machine right here in the office and i do a quick US exam on my pts as part of the PE. i takes 1-2 minutes. i check liver/GB/spleen/kidneys/heart.
if there is a subQ mass, i check to see if it has liquid in it. if there is testicular pain, i check for hydrocele.

it's quick and the pts seem to really enjoy seeing their insides!

now, i can see the gallstones!

in anesthesia, i have used US for peripheral and central lines. i will soon learn how to use it for nerve blocks. in cardiac anesthesia, i understand transesophageal US is standard of care nowadays.

i suggest you try to learn as much as you can about US, because it will soon be an indispensible part of your practice, whether in anesthesia or general medicine.

Hey Paiute - how did you change from anesthesia to medicine?
Are you a PCP? Do you have an internal medicine residency?
2win

 

[sebsvenmdc]

i'm semi-retired from anesthesia and now i do general practice.

physical exam is of utmost importance. i think it is even more important than hx.

however, all those subtle findings that some attendings rave about, like 3rd and 4th heart sounds, rubs, etc. aren't very reliable or even useful.

you are right in concentrating on hard data like BP, pulse, neck veins, retractions, SpO2, ...

i do a quit listen to the lungs, mostly listening for a wheeze. then i listen to the heart in 3 places: apex, aortic area, pulmonic area. then i listen to the belly for bruits (once i heard a loud bruit from an hepatic cancer). then i lightly push on the belly to see if there is peritonitis (trying to feel for organomegaly in fat americans is a waste of time!).

yes, i do funduscopy. most doc's omit this, but it's a good assessment of the microvasculature. i've amazed myself at the dx's made just from the optic fundal exam.

what i'm leading up to is this: ultrasonography!

i have a good US machine right here in the office and i do a quick US exam on my pts as part of the PE. i takes 1-2 minutes. i check liver/GB/spleen/kidneys/heart.
if there is a subQ mass, i check to see if it has liquid in it. if there is testicular pain, i check for hydrocele.

it's quick and the pts seem to really enjoy seeing their insides!

now, i can see the gallstones!

in anesthesia, i have used US for peripheral and central lines. i will soon learn how to use it for nerve blocks. in cardiac anesthesia, i understand transesophageal US is standard of care nowadays.

i suggest you try to learn as much as you can about US, because it will soon be an indispensible part of your practice, whether in anesthesia or general medicine.

Thanks for the advice. It's interesting to hear this.

 

[paiute]

Hey Paiute - how did you change from anesthesia to medicine?
Are you a PCP? Do you have an internal medicine residency?
2win

i got tired of dealing with the politics of the OR and joined the Calif. prison system as a GP back in 1997. in those days, the prisons would hire almost anyone with a license and a pulse, regardless of specialty training.

anyway, i learned GP by myself, reviewing books and relearning things i did as an intern. it took about 2 years to get up to speed.

unfortunately, the prison now requires a residency in IM or FP. i was "grandfathered" in after completing a competency exam.

this is a great job for older doc's who are looking to retirement. it is salaried with excellent benefits. the work load is reasonable.

it is probably not a good job for the young doc. this is because the inmates sue you constantly.🙁 i have over 30 lawsuits filed on me. almost all get tossed out of court (summary judgment), but it goes on your record as having been sued. that makes it difficult to buy insurance, should you choose to rejoin society (i'll stay where i am, thank you).😍

 

[Gimlet]

it is probably not a good job for the young doc. this is because the inmates sue you constantly.🙁 i have over 30 lawsuits filed on me. almost all get tossed out of court (summary judgment), but it goes on your record as having been sued. that makes it difficult to buy insurance, should you choose to rejoin society (i'll stay where i am, thank you).😍

Yikes! How about the chances you'll get shanked on a day-to-day basis?

 

[urge]

Hey Paiute - how did you change from anesthesia to medicine?
Are you a PCP? Do you have an internal medicine residency?
2win

I saw an ad the other day in gaswork looking for an anesthesiologist to do anesthesia and GP. Must be a small town.

 

[MCYan]

i got tired of dealing with the politics of the OR and joined the Calif. prison system as a GP back in 1997. in those days, the prisons would hire almost anyone with a license and a pulse, regardless of specialty training.

anyway, i learned GP by myself, reviewing books and relearning things i did as an intern. it took about 2 years to get up to speed.

unfortunately, the prison now requires a residency in IM or FP. i was "grandfathered" in after completing a competency exam.

this is a great job for older doc's who are looking to retirement. it is salaried with excellent benefits. the work load is reasonable.

it is probably not a good job for the young doc. this is because the inmates sue you constantly.🙁 i have over 30 lawsuits filed on me. almost all get tossed out of court (summary judgment), but it goes on your record as having been sued. that makes it difficult to buy insurance, should you choose to rejoin society (i'll stay where i am, thank you).😍

Hey Paiute: do you get paid for using U/S as part of your physical exam?

 

[Sergio99]

Hello,

You don't need to be a super-physical-diagnostician like a modern day William Osler, but you cannot ignore some basic aspects of physical diagnosis that every doctor should know, regardless of whether you will use it later in anesthesia or not. During your internship year do as much as you can to get up to speed with it.

In anesthesia we do a focused history and physical, so that, in general, it does not involve otoscopy, pelvic exams, prostate, etc. You can relax.


Greetings

 

[IN2B8R]

Yikes! How about the chances you'll get shanked on a day-to-day basis?

 

[paiute]

Hey Paiute: do you get paid for using U/S as part of your physical exam?

no, i'm on salary.

i do it because it's fun and i think it makes me a better doctor.

 

[paiute]

Yikes! How about the chances you'll get shanked on a day-to-day basis?

to my knowledge, no doctor has ever been stabbed.

a doc, who has retired now, was kicked by an inmate who had a nail in the tip of his shoe. no serious damage was done.

i wear a stab-proof vest.

i have been threatened many times. that's part of the job.