Physical Exam Manuevers and Detecting abnormal findings as a medical student

[Redpancreas]

So one of things we are expected to do on my service is the routine checks. For OB this includes being the sentinel for magnesium toxicity since DTRs are present before coma and respiratory depression...this includes reflexes, heart, and lungs.

On my first check I was able to hear the lungs but not the heart (not sure exactly why). Then, tendons literally took 10 minutes and I got lucky in the end and elicited a brachioradialis)

So when I entered my first note I said lung sounds negatives for Pulmonary effusion because I didn't know what anything else abnormal would sound like (I looked up the PE sound Beforehand), 2 + for brachioradialis, and heart still needs to be listened to (?).

I checked another student's note (to get an idea of whether I was doing it right) and it everything was listed perfectly.

Lungs clear, Heart sounds normal with no abnormal rhythms, rubs, or gallops, DTRs 2+ bilaterally on brachioradialis and patellar reflexes.

...if there was an abnormal rhythm in my patient I'm not sure I would have heard it...

So in my mind I'm like either this person's exceptional (no, because everyone else's notes looked similar), this person was just ball parking things kind of like how we said we "heard" everything in preclerkship training, or I'm terribly below average with physical exam maneuvers. If it's the latter I need help.

How did all of you improve your physical exam maneuvers specifically? Is it just experience? I literally picked up nothing from my school's preclerkship clinical skills course just going through most of the notions to pass only to find out that now we're expected to do these things correctly without guidance.

What I really need is for some super strict person to stand next to me, watch me do something, make sure I'm doing it correctly...until I do it correctly like 5 times in a row which would take at least a few days. In our course, we did have a guidance but we never had to repeat stuff until we perfected it...we just moved on. Right now I'm thinking of contacting my clinical skills center to see if they can squeeze me in for remedial training of some sort. Is this the way to go about it? I'm sure there are lots of kind attending out there who will accept this and maybe even go out of their way to teach me but at the same time I'm sure there's many that will see this as incompetence and get irritated quickly.


Sent from my iPhone using SDN mobile

---

Members don't see this ad.

 

[Amygdarya]

So one of things we are expected to do on my service is the routine checks. For OB this includes being the sentinel for magnesium toxicity since DTRs are present before coma and respiratory depression...this includes reflexes, heart, and lungs.

On my first check I was able to hear the lungs but not the heart (not sure exactly why). Then, tendons literally took 10 minutes and I got lucky in the end and elicited a brachioradialis)

So when I entered my first note I said lung sounds negatives for Pulmonary effusion because I didn't know what anything else abnormal would sound like (I looked up the PE sound Beforehand), 2 + for brachioradialis, and heart still needs to be listened to (?).

I checked another student's note (to get an idea of whether I was doing it right) and it everything was listed perfectly.

Lungs clear, Heart sounds normal with no abnormal rhythms, rubs, or gallops, DTRs 2+ bilaterally on brachioradialis and patellar reflexes.

...if there was an abnormal rhythm in my patient I'm not sure I would have heard it...

So in my mind I'm like either this person's exceptional (no, because everyone else's notes looked similar), this person was just ball parking things kind of like how we said we "heard" everything in preclerkship training, or I'm terribly below average with physical exam maneuvers. If it's the latter I need help.

How did all of you improve your physical exam maneuvers specifically? Is it just experience? I literally picked up nothing from my school's preclerkship clinical skills course just going through most of the notions to pass only to find out that now we're expected to do these things correctly without guidance.

What I really need is for some super strict person to stand next to me, watch me do something, make sure I'm doing it correctly...until I do it correctly like 5 times in a row which would take at least a few days. In our course, we did have a guidance but we never had to repeat stuff until we perfected it...we just moved on. Right now I'm thinking of contacting my clinical skills center to see if they can squeeze me in for remedial training of some sort. Is this the way to go about it? I'm sure there are lots of kind attending out there who will accept this and maybe even go out of their way to teach me but at the same time I'm sure there's many that will see this as incompetence and get irritated quickly.


Sent from my iPhone using SDN mobile

A couple of things. First - and I'm not saying that's the case with your fellow student, but unfortunately this does happen a lot - some people lie and include normal findings for things they didn't even look at - they're assuming these things are normal if the patient is in no obvious distress (eg. some surgeons who haven't touched a stethoscope in I don't even how long may write for heart "no murmurs rubs gallops" and for lungs "clear to auscultation bilaterally). This is dishonest and potentially harmful and should never be done. Be honest and only record the findings that you actually collected. Eg., some of the more honest non-stethoscope carrying surgeons would write something like "normal breathing effort, can speak in full sentences" (which signifies absence of respiratory distress) and "regular rhythm and rate, 2+ distal bilateral pulses" for grossly normally functioning cardiovascular system (this is done entirely by radial and dorsal pedal pulse palpating). This is not what a *nedical student* should write in his/her PE but it is at least an honest shortcut for residents.

Second, learn the lingo. You've already made a great first step for that - you read your fellow student's note. Also read your resident's and attending's notes - their notes may be more succinct than what's expected from a medical student note, but you can lean the organization and the language of nite writing from them. Plus, you should be reading all the notes posted for your patients anyway - residents, attendings, consults.
The language differs between rotations and even between different services on the same rotation (which gives you all the more reason to read other people's notes). Some services use abbreviations more than others etc.
Some of the common physical exam descriptions:
General: NAD (no apparent distress), well nourished/emaciated etc
HEENT (head, eyes, ears, nose, throat): for G-d's sake, unless you're on peds/trauma/neurosurgery skip "normocephaluc atraumatic"! Do include PERRLA (pupils equal round and reactive to light and accommodation - you will actually test these as part of your neuro exam, but for other purposes you can shorten it to pupils equal round), EOMI (extra ocular movements intact - also part of neuro exam, but can be "shortcutted" for non-neuro purpose by observing patient's eye movements as you talk to him/her), jaundice or none, clear vs injected sclera, scleral icterus vs anicteric, conjunctival pallor or none, moist or dry mucous membranes (MMM for moist), any oral lesions, may comment on the state of oral hygiene and any dental decay, any submandibular cervical or supraclavicular lymphadenopathy, presence of JVD (super important on medicine!), any notable features (honestly never really examined ears and nose)
Heart: RRR (regular rhythm and rate - can be done by heart auscultation or pulse palpating - the only rhythm irregularity you can really detect by physical is irregularly irregular), normal S1 and S2 (comment if you hear any additional sounds), no MRG (murmurs rubs gallops - this is where things get tricky and you actually need to hear these things; I personally can only hear some really bad AS or MR - and I mean cardio ICU level murmurs - but this is apparently something that us developed with practice... If you can't hear any murmurs just honestly write that none were appreciated)
Lungs: CTAB (clear to auscultation bilaterally - normal finding, means you can hear the air move nice and smooth throughout whole lungs on both sides - if unsure what normal lungs sound like, take a moment to listen to your friends' lungs), lung abnormalities are typically more easily heard than abnormal heart sounds - wheezes, rhales, crackles - if you're unsure what they sound like just YouTube them - also note how far up from the base of the lungs you can hear these and on which side (eg. "crackles 1/4 lungs from base bilaterally" - this is actually a useful metric to compare day-to-day progress of your patient, especially on medicine), record if you don't hear any air movement in any part of the lungs, if wheezes record whether inspirational and expirational, then you can report percussion (resonant to percussion = normal, hyporesonant/dull to percussion = likely effusion or consoludation, hyperresonant = pneumothorax), you can do egophony if suspected pneumonia, you can note symmetry or lack thereof of lung expansion etc
Abdomen: soft (normal; hard abdomen = call surgery consult like yesterday), NT/ND (nontender/nondistended = normal, can be mildly or severely distended, tender to palpation etc), note if there's any involuntary guarding or rebound with palpation
GU: not examined by students
Skin: warm, dry, not if any rashes/lesions, petichiae etc
Extremities: WWP (warm well perfused - also a proxy for cardiovascular function), 2+ distal bilateral pulses (2+ = strong, 1+ = weak), reflexes, note any abnormalities

This is a general idea - just like I said above, adjust your note to what's common on that rotation - not every single one of these things should be checked on all of your exams. Plus there may be additions:
Eg., for surgery you want to comment on incision and dressing (normally CDI = clean dry intact; note if any erythema, induration, tenderness exudate - note if clear or purulent and what color), as well as all the stomas (condition of the stoma itself - normally pink - and contents of the bag) and drains (typically describe the fluid, eg. serous, serosanguinous, bilious etc);
For pregnant women under "Abdomen" document estimated uterus size in cm
For neuro - obviously, complete neuro exam is paramount (and it's a whole different story)

If I remember correctly, you're on OBGYN now, which means that most of your patients have no significant 'medical" issues and therefore will give you plenty of examples of normal PE and normal PE writeup. Once you've done of few of these, you'll feel like a pro and will be ready to detect something that is actually abnormal.

 

[Amygdarya]

Oh, and importantly, in the physical exam part of your note (the Objective part of SOAP) note you only describe what you hear, you don't interpret it there! Assessment is where you interpret your findings! Eg., you can report "lungs clear to auscultation and resonant to percussion" in the physical exam part (Objective = what you Observe, see? Interpretation, by it's nature, is not objective) and opine that the patient doesn't have pulmonary edema in your Assessment.

 

[Redpancreas]

A couple of things. First - and I'm not saying that's the case with your fellow student, but unfortunately this does happen a lot - some people lie and include normal findings for things they didn't even look at - they're assuming these things are normal if the patient is in no obvious distress (eg. some surgeons who haven't touched a stethoscope in I don't even how long may write for heart "no murmurs rubs gallops" and for lungs "clear to auscultation bilaterally). This is dishonest and potentially harmful and should never be done. Be honest and only record the findings that you actually collected. Eg., some of the more honest non-stethoscope carrying surgeons would write something like "normal breathing effort, can speak in full sentences" (which signifies absence of respiratory distress) and "regular rhythm and rate, 2+ distal bilateral pulses" for grossly normally functioning cardiovascular system (this is done entirely by radial and dorsal pedal pulse palpating). This is not what a *nedical student* should write in his/her PE but it is at least an honest shortcut for residents.

Second, learn the lingo. You've already made a great first step for that - you read your fellow student's note. Also read your resident's and attending's notes - their notes may be more succinct than what's expected from a medical student note, but you can lean the organization and the language of nite writing from them. Plus, you should be reading all the notes posted for your patients anyway - residents, attendings, consults.
The language differs between rotations and even between different services on the same rotation (which gives you all the more reason to read other people's notes). Some services use abbreviations more than others etc.
Some of the common physical exam descriptions:
General: NAD (no apparent distress), well nourished/emaciated etc
HEENT (head, eyes, ears, nose, throat): for G-d's sake, unless you're on peds/trauma/neurosurgery skip "normocephaluc atraumatic"! Do include PERRLA (pupils equal round and reactive to light and accommodation - you will actually test these as part of your neuro exam, but for other purposes you can shorten it to pupils equal round), EOMI (extra ocular movements intact - also part of neuro exam, but can be "shortcutted" for non-neuro purpose by observing patient's eye movements as you talk to him/her), jaundice or none, clear vs injected sclera, scleral icterus vs anicteric, conjunctival pallor or none, moist or dry mucous membranes (MMM for moist), any oral lesions, may comment on the state of oral hygiene and any dental decay, any submandibular cervical or supraclavicular lymphadenopathy, presence of JVD (super important on medicine!), any notable features (honestly never really examined ears and nose)
Heart: RRR (regular rhythm and rate - can be done by heart auscultation or pulse palpating - the only rhythm irregularity you can really detect by physical is irregularly irregular), normal S1 and S2 (comment if you hear any additional sounds), no MRG (murmurs rubs gallops - this is where things get tricky and you actually need to hear these things; I personally can only hear some really bad AS or MR - and I mean cardio ICU level murmurs - but this is apparently something that us developed with practice... If you can't hear any murmurs just honestly write that none were appreciated)
Lungs: CTAB (clear to auscultation bilaterally - normal finding, means you can hear the air move nice and smooth throughout whole lungs on both sides - if unsure what normal lungs sound like, take a moment to listen to your friends' lungs), lung abnormalities are typically more easily heard than abnormal heart sounds - wheezes, rhales, crackles - if you're unsure what they sound like just YouTube them - also note how far up from the base of the lungs you can hear these and on which side (eg. "crackles 1/4 lungs from base bilaterally" - this is actually a useful metric to compare day-to-day progress of your patient, especially on medicine), record if you don't hear any air movement in any part of the lungs, if wheezes record whether inspirational and expirational, then you can report percussion (resonant to percussion = normal, hyporesonant/dull to percussion = likely effusion or consoludation, hyperresonant = pneumothorax), you can do egophony if suspected pneumonia, you can note symmetry or lack thereof of lung expansion etc
Abdomen: soft (normal; hard abdomen = call surgery consult like yesterday), NT/ND (nontender/nondistended = normal, can be mildly or severely distended, tender to palpation etc), note if there's any involuntary guarding or rebound with palpation
GU: not examined by students
Skin: warm, dry, not if any rashes/lesions, petichiae etc
Extremities: WWP (warm well perfused - also a proxy for cardiovascular function), 2+ distal bilateral pulses (2+ = strong, 1+ = weak), reflexes, note any abnormalities

This is a general idea - just like I said above, adjust your note to what's common on that rotation - not every single one of these things should be checked on all of your exams. Plus there may be additions:
Eg., for surgery you want to comment on incision and dressing (normally CDI = clean dry intact; note if any erythema, induration, tenderness exudate - note if clear or purulent and what color), as well as all the stomas (condition of the stoma itself - normally pink - and contents of the bag) and drains (typically describe the fluid, eg. serous, serosanguinous, bilious etc);
For pregnant women under "Abdomen" document estimated uterus size in cm
For neuro - obviously, complete neuro exam is paramount (and it's a whole different story)

If I remember correctly, you're on OBGYN now, which means that most of your patients have no significant 'medical" issues and therefore will give you plenty of examples of normal PE and normal PE writeup. Once you've done of few of these, you'll feel like a pro and will be ready to detect something that is actually abnormal.

I have copied this and set it aside because I know it well be a gem. Thank you for being so thoughtful to write such a guide as well as having the presence of mind to follow my pretty average situation.

 

[WheezyBaby]

How did all of you improve your physical exam maneuvers specifically? Is it just experience? I literally picked up nothing from my school's preclerkship clinical skills course just going through most of the notions to pass only to find out that now we're expected to do these things correctly without guidance.

Yes!! Well, not just experience, but doing a multitude of exams is absolutely essential to establish what's typical and normal, what's atypical but normal, and what's truly abnormal. You also need someone to let you know if you're right or not! You'll find everyone is very busy and it's difficult to find someone to go through a physical exam with you. That doesn't mean you can't verify your findings. A great way to do this is to read the PE's in your seniors' / staffs' notes. A big caveat to this is documented PE's are frequently either lazy or incorrect if they don't pertain directly to a patient complaint or to a given physician's area of expertise. I read genetics notes when I want to see what dysmorphic features I didn't pick up. I read neurologists notes when I want to see what neuro exam findings I didn't pick up. Always read your specialist's PE's within their system and their recommendations. Also, if you examine a patient and pick up on something prior to your resident or whoever doing their exam, just ask them "hey, I think I detected something weird on this patient's cardiac exam, could you pay special attention and let me know whether I'm just making things up in my mind?" Try not to lead them though.

 

[Redpancreas]

Yes!! Well, not just experience, but doing a multitude of exams is absolutely essential to establish what's typical and normal, what's atypical but normal, and what's truly abnormal. You also need someone to let you know if you're right or not! You'll find everyone is very busy and it's difficult to find someone to go through a physical exam with you. That doesn't mean you can't verify your findings. A great way to do this is to read the PE's in your seniors' / staffs' notes. A big caveat to this is documented PE's are frequently either lazy or incorrect if they don't pertain directly to a patient complaint or to a given physician's area of expertise. I read genetics notes when I want to see what dysmorphic features I didn't pick up. I read neurologists notes when I want to see what neuro exam findings I didn't pick up. Always read your specialist's PE's within their system and their recommendations. Also, if you examine a patient and pick up on something prior to your resident or whoever doing their exam, just ask them "hey, I think I detected something weird on this patient's cardiac exam, could you pay special attention and let me know whether I'm just making things up in my mind?" Try not to lead them though.

Thanks!


Sent from my iPhone using SDN mobile

 

[Amygdarya]

Oh, an important point for extremities I forgot: no CCE = no clubbing/cyanosis/edema - checking for peripheral edema is super important for OB patients, as it's a proxy for pre-eclampsia and more serious things.

 

[Amygdarya]

I have copied this and set it aside because I know it well be a gem. Thank you for being so thoughtful to write such a guide as well as having the presence of mind to follow my pretty average situation.

We've all been there. I'm still learning all of these things myself, but I have to tell you that 6 months and 3 rotations in (I'm on my fourth now), and I'm fairly comfortable doing full H&P and focused H&P, prerounding and writing admissions and progress notes on *adults* (an important distinction, as I've only been seeing adults so far, and kids are a whole different story and I feel just as clueless with them as when I first started my rotations). An important thing is, don't pass on opportunities to examine patients, do admissions (a *very* important skill) etc and write them up because that's how you learn. You'll get there! You're feeling now just as any other medical student has ever felt, and you'll learn all of these things just fine.

 

[Ismet]

If you're having trouble hearing heart sounds, have the person sit up/lean forward or lay on their left side. Brings the heart closer to the chest wall. Obviously may be difficult for a very pregnant patient, don't make them do acrobatics in bed unless absolutely necessary, but just a tip in general.

If you're going to document S1, S2 then make sure you say that they're "normal" and not that they're "present." If they weren't present the patient would be dead.

My typical normal heart exam is RRR, no murmurs, rubs, or gallops, 2+ peripheral pulses, brisk capillary refill (important for peds)

If you can get your hands on a copy of Bates Guide to Physical Examination, it's an excellent resource for physical exam maneuvers and reporting findings. I still reference it.

 

[Psai]

Listen to physical exam findings on rounds and when you have a chance just go through all the patients with interesting exams and experience it yourself

 

[CherryRedDracul]

As mentioned earlier, some people will BS their physical exam findings like documenting RRR when a person has a-fib or mentioning no murmurs when a dude has 3/6 midsystolic ejection murmur and a bioprosthetic aortic valve replacement.

 

[Crayola227]

-Bates
I second using Bates, and just see if you have a classmate that wants to practice together so you can get some feedback on learning to do exams.

-System
If you have memorized a system for each type of exam (heart, lungs, abd, etc) it's easier to remember, not miss anything, and you can skip steps that are less pertinent (eg I don't listen to lungs in 7 places front and back like Bates unless a screening listen or the presentation has me worried). Using a reference like Bate's or going online you can make/find notes that can act as a cheat sheet to help you remember what you are doing, and then using that over and over will help.

-Practice
You can practice on yourself, pets (dog/cat/heart/lungs), and even non-medical friends and family. I have my own opthalmoscope, and I don't know how I would have learned to use one if I didn't have someone I could torture with impunity (a proud parent). Practicing on myself got me really good at palpating the AMI, getting a really good sense of where it is by palpation/estimation was key to being able to find that spot on others for a good listen.

-Dr. Crayola's Neuro Exam Notes
If you SDN search my name and neuro exam I wrote up quite a few tips on the neuro exam.