Physical Exam Skills

[averagemedstudent]

Hi everyone, 

I am halfway through clerkship and I feel that my physical exam skills are abysmal. I can't diagnose CHF or PNA by physical exam. I am unable to listen to lung sounds because I usually can't hear anything when people breath in and out.   When I did my obs rotation, I was never able to get cervical dilation right.  What do people do to learn these basic skills. 

Thanks!

[frenchpress]

19 minutes ago, averagemedstudent said:

Hi everyone, 

I am halfway through clerkship and I feel that my physical exam skills are abysmal. I can't diagnose CHF or PNA by physical exam. I am unable to listen to lung sounds because I usually can't hear anything when people breath in and out.   When I did my obs rotation, I was never able to get cervical dilation right.  What do people do to learn these basic skills. 

Thanks!

Practice over and over and over again. In clerkship you think you’ve seen things a lot, but you haven’t really. A lot of presentations you’ve maybe only seen a few times.  Read the notes of your attending and look for the findings that are relevant for different presentations. And look for them yourself on patients. If you aren’t sure about a JVP, ask your attending to help you see it. Etc. I also found the Mechanisms of Clinical Signs book helpful. I was abysmal at things like cervical dilation until I did it dozens and dozens of times in residency. You’ll get better over time. Diagnosis is also not just physical exam. The history is often like 75% of it. 

[trimethoprim]

you know, this may reflect more on me being a shitty resident, but I would say there are very few physical exam findings I would actually hang a diagnosis on. For example for CHF - you might hear some crackles in the lungs, but I would also look for peripheral edema (way easier to reproduce) or pretend to look at JVP.

Ultimately there are further investigations that you would use in practice: CXR (for PNA and CHF), BNP, hyponatremia, bedside ultrasound etc.

And for obs, I don't think I've ever checked for cervical dilation lol.

[trimethoprim]

lung sounds are particularly difficult, because of poor respiratory effort on part of the patient, or if you cannot have the pt seated upright (obese, obtunded, frail) etc. CXR ftw.

[jb24]

To diagnose anything on physical exam alone is usually not practical (unless it's some sort of spot diagnosis).

A good history directs your physical examination, which overall guide your investigations and ultimately a differential diagnosis. At the medical student level, a good prioritized differential is key.

Then management comes later, with time.

In terms of lung auscultation, practice on yourself, or your colleagues. Get used to hearing what normal sounds like. Then you can listen to youtube videos of crackles or wheezes. Trust me you will hear these abnormal things when you get used to hearing normal.

Characterizing murmurs and stuff, I'm not good at myself (and I'd argue most non-cardiologists aren't). At least detecting abnormal, which can be worked up with refined modern testing (ie. an echo) is sufficient.

 

[1029384756md]

To get better at physical exam, practice practice practice. Eventually you'll develop a gestalt for what's normal and abnormal. For derm, neuro, and MSK, it can sometimes lead to a spot diagnosis.

 

[samy]

I highly suggest to get a copy of Evidence-based Physical diagnosis https://www.elsevier.com/books/evidence-based-physical-diagnosis/9780323392761 and to read the JAMA series on the Rational of Clinical exam on pertinent topics.

 

[Snowmen]

15 hours ago, 1029384756md said:

To get better at physical exam, practice practice practice. Eventually you'll develop a gestalt for what's normal and abnormal. For derm, neuro, and MSK, it can sometimes lead to a spot diagnosis.

 

I would add that for MSK, clinical evaluation >>> investigations 99% of the time.

[indefatigable]

16 hours ago, 1029384756md said:

For derm, neuro, and MSK, it can sometimes lead to a spot diagnosis.

Agree - also seems to be more used in peds where there appears to be less work-up.  

P/e can be seen as part of assessment and help determine need for further imaging or other investigations- e.g. for CNS, abdo, ortho and to a lesser extent with cardio-resp.  Plain film is generally quite accessible and often more informative than p/e for lungs imo and any serious cardiac structural concerns will need more advanced imaging (echo or nuclear) 

[medigeek]

On 3/12/2022 at 8:59 PM, averagemedstudent said:

Hi everyone, 

I am halfway through clerkship and I feel that my physical exam skills are abysmal. I can't diagnose CHF or PNA by physical exam. I am unable to listen to lung sounds because I usually can't hear anything when people breath in and out.   When I did my obs rotation, I was never able to get cervical dilation right.  What do people do to learn these basic skills. 

Thanks!

Physical exams are useless a lot of the time (depending on the system and patient) if that makes you feel better. If someone is incredibly volume overloaded and has obvious edema, you SHOULD be able to know that. But good luck doing a volume exam on someone who weighs 375lbs. Diagnosing a PNA? Same story, what value do lung sounds provide when they have COPD and CHF at baseline? You're getting a cxr no matter what. 

You're much better off learning POCUS to pick up that stuff in a more accurate way. 

Now for other things like MSK or Ob, yes you need the skills. Practice on models first, then do it on real people.

[medigeek]

On 3/12/2022 at 9:59 PM, jb24 said:

To diagnose anything on physical exam alone is usually not practical (unless it's some sort of spot diagnosis).

A good history directs your physical examination, which overall guide your investigations and ultimately a differential diagnosis. At the medical student level, a good prioritized differential is key.

Then management comes later, with time.

In terms of lung auscultation, practice on yourself, or your colleagues. Get used to hearing what normal sounds like. Then you can listen to youtube videos of crackles or wheezes. Trust me you will hear these abnormal things when you get used to hearing normal.

Characterizing murmurs and stuff, I'm not good at myself (and I'd argue most non-cardiologists aren't). At least detecting abnormal, which can be worked up with refined modern testing (ie. an echo) is sufficient.

 

Murmur --> echo lol.

After seeing how many times people thought they had the exact valvular disease down only for the echo to give something way different...

[shikimate]

What area are you interested? Some areas have different focus than others. For example I really enjoyed looking at things so I like the inspection aspect but I didn't really care much about moving manipulating things. My ortho feedback wasn't the greatest because I just didn't get how to twist arms and shoulders around lol.

[Arztin]

On 3/12/2022 at 9:59 PM, averagemedstudent said:

Hi everyone, 

I am halfway through clerkship and I feel that my physical exam skills are abysmal. I can't diagnose CHF or PNA by physical exam. I am unable to listen to lung sounds because I usually can't hear anything when people breath in and out.   When I did my obs rotation, I was never able to get cervical dilation right.  What do people do to learn these basic skills. 

Thanks!

Well first off, you can't diagnose these with physical exam. You aren't the only one with those problems. The sensitivity specificity of a physical exam vs a bedside POCUS is just not comparable for many things. I don't ever look for the JVP. I have my pocket US machine. I just look at the LVEF to have a rough idea instead. I can easily look at the IVC which is equivalent to the JVP. You can see consolidations on POCUS as well.

Here are just a few example of why POCUS is very important, way more than a stethoscope. There are all true patients I've seen recently, that changed the management entirely. I can go on and on.

- a lady in her 70s came with a presentation fairly classic for decompensated CHF, but not known for CHF. I POCUS her, and realized that she was actually in tamponnade. She had 600 cc of liquid drained. Her JVP would have been high either way and would not have helped. The fact that I couldn't hear her heart properly in a noisy ED wouldn't have helped. Not identifying the problem, and giving lasix and having her seen by cardio next day assuming she had a CHF could have been deadly.

- I saw a man recently who came to the ED hypotensive and had a couple of episodes of syncope. My bedside POCUS reveals RV dysfunction and fixed and dilated IVC. Especially with the clinical context, I knew the patient almost certainly had a massive or submassive PE, which was later confirmed by a scan. 

- A very obese elderly lady comes in for delirium and fever. I do all sorts of investigations, including a CT chest and abdomen. There is nothing. She seemed to have some pain when I moved her legs. I then POCUS her knees and she had a large effusion bilaterally. I asked for a joint tap which confirmed inflammatory arthritis. IM saw and admitted the patient with prompt treatment. There was no way you could palpate and ''milk'' the effusion on a physical exam.

- A lady came in with general weakness, only known for a DVT diagnosed recently on DOAC. Nothing specific on history and physical exam. I POCUS her and see a HUGE vegetation of mitral valve of like 3 cm. I also scanned her and she ended up having a cancer and bilateral PEs, but that large vegetation would not have been identified at all if I didn't POCUS.

Cervical dilation takes a bit of time. You need to do quite a few before starting to be good. Unless you do OB, you can forget about it. 

If you hear a murmur, you'll ask for formal echo anyways.

Now, the problem is that for physical exams, they teach completely useless things: especially the following: Traube space and castell sign? (can't even remember those). 99 and whatever else for effusions  (whispered pectoriloquy?) while a POCUS tells you right there if there is an effusion, and if there's a consolidation that touches the pleura. Then there are urban legends such as: thyroid bruits, abdominal bruits, 1/6 diastolic murmurs. When I was in med school, I've had a RC IM examiner giving us a lecture. I asked her how can you differentiate a thyroid bruit vs a carotid stenosis. She told me she didn't know and she never heard a thyroid bruit. But it is part of the physical exam that you need to mention for the RC. Yup...

Now there are truly very important things regarding physical exam, including those:

- doing a good MSK exam is of the uttermost importance. It is not taught properly usually

- same goes with the Neuro exam. People do it very poorly in general. Go shadow neurologists and see how they perform a complete neurological exam. 

- derm obviously. Many clinicians (including me) do not feel comfortable in derm at all.

- knowing how to recognize an acute abdomen

- if you do trauma, knowing how to do a good primary survey

- eyeballing, quick glance and recognizing a sick patient. This one just takes time and practice. Very difficult. Often not obvious. I still don't find this always easy.

Often, we fail to turn the patient and look at the patient's back and perianal area. I've seen countless times big surprises such as a big infection that you wouldn't have seen otherwise. Undressing the patient is often overlooked but it actually important. 

That being said, I still need a stethoscope. I can't entirely work without it. When patients come in for SOB, I still auscultate. You do need to hear what a normal lung auscultation sounds like. You need to identify wheezing and crackles.

And go read what Samy suggested. You'll realize that very often, many physical exam manoeuvers have a LR that don't ultimately doesn't matter, like less than 5, or sensitivity/specificity that is way too low to be of any use.

And a caveat, POCUS takes a lot of time and training to master. You always need to recognize your limits.

Finally you are precisely at that stage where learning physical exams is part of the curriculum. Don't be afraid of asking your senior or your staff to show you how to do it properly!

[lovemedicinesomuch]

2 hours ago, Arztin said:

Well first off, you can't diagnose these with physical exam. You aren't the only one with those problems. The sensitivity specificity of a physical exam vs a bedside POCUS is just not comparable for many things. I don't ever look for the JVP. I have my pocket US machine. I just look at the LVEF to have a rough idea instead. I can easily look at the IVC which is equivalent to the JVP. You can see consolidations on POCUS as well.

Here are just a few example of why POCUS is very important, way more than a stethoscope. There are all true patients I've seen recently, that changed the management entirely. I can go on and on.

- a lady in her 70s came with a presentation fairly classic for decompensated CHF, but not known for CHF. I POCUS her, and realized that she was actually in tamponnade. She had 600 cc of liquid drained. Her JVP would have been high either way and would not have helped. The fact that I couldn't hear her heart properly in a noisy ED wouldn't have helped. Not identifying the problem, and giving lasix and having her seen by cardio next day assuming she had a CHF could have been deadly.

- I saw a man recently who came to the ED hypotensive and had a couple of episodes of syncope. My bedside POCUS reveals RV dysfunction and fixed and dilated IVC. Especially with the clinical context, I knew the patient almost certainly had a massive or submassive PE, which was later confirmed by a scan. 

- A very obese elderly lady comes in for delirium and fever. I do all sorts of investigations, including a CT chest and abdomen. There is nothing. She seemed to have some pain when I moved her legs. I then POCUS her knees and she had a large effusion bilaterally. I asked for a joint tap which confirmed inflammatory arthritis. IM saw and admitted the patient with prompt treatment. There was no way you could palpate and ''milk'' the effusion on a physical exam.

- A lady came in with general weakness, only known for a DVT diagnosed recently on DOAC. Nothing specific on history and physical exam. I POCUS her and see a HUGE vegetation of mitral valve of like 3 cm. I also scanned her and she ended up having a cancer and bilateral PEs, but that large vegetation would not have been identified at all if I didn't POCUS.

Cervical dilation takes a bit of time. You need to do quite a few before starting to be good. Unless you do OB, you can forget about it. 

If you hear a murmur, you'll ask for formal echo anyways.

Now, the problem is that for physical exams, they teach completely useless things: especially the following: Traube space and castell sign? (can't even remember those). 99 and whatever else for effusions  (whispered pectoriloquy?) while a POCUS tells you right there if there is an effusion, and if there's a consolidation that touches the pleura. Then there are urban legends such as: thyroid bruits, abdominal bruits, 1/6 diastolic murmurs. When I was in med school, I've had a RC IM examiner giving us a lecture. I asked her how can you differentiate a thyroid bruit vs a carotid stenosis. She told me she didn't know and she never heard a thyroid bruit. But it is part of the physical exam that you need to mention for the RC. Yup...

Now there are truly very important things regarding physical exam, including those:

- doing a good MSK exam is of the uttermost importance. It is not taught properly usually

- same goes with the Neuro exam. People do it very poorly in general. Go shadow neurologists and see how they perform a complete neurological exam. 

- derm obviously. Many clinicians (including me) do not feel comfortable in derm at all.

- knowing how to recognize an acute abdomen

That being said, I still need a stethoscope. I can't entirely work without it. When patients come in for SOB, I still auscultate. You do need to hear what a normal lung auscultation sounds like. You need to identify wheezing and crackles.

And go read what Samy suggested. You'll realize that very often, many physical exam manoeuvers have a LR that don't ultimately doesn't matter, like less than 5, or sensitivity/specificity that is way too low to be of any use.

And a caveat, POCUS takes a lot of time and training to master. You always need to recognize your limits.

Finally you are precisely at that stage where learning physical exams is part of the curriculum. Don't be afraid of asking your senior or your staff to show you how to do it properly!

Thank you for your reply. That's very helpful. Where did you learn POCUS. My residency so far did not teach me POCUS. Did you do a specific course?

[Arztin]

11 hours ago, lovemedicinesomuch said:

Thank you for your reply. That's very helpful. Where did you learn POCUS. My residency so far did not teach me POCUS. Did you do a specific course?

This is the problem with the current medical education system. Many clinicians don't know how to do it, so they don't see the benifit of it, and therefore they don't teach it. Training should include some sort of basics.

To answer your question, I've done a POCUS+EM rotation as a trainee, and took multiple courses.

Regarding courses, look up the courses available on CPOCUS. They're mainly given by emergency physicians in Canada.

https://www.cpocus.ca/training-exams/courses-and-workshops/

Look if you can do a POCUS rotation as an elective. It's usually given by EM physicians where you do a mix of POCUS shifts with clinical shifts.

And something important to note: ultrasound is not there to replace physical exams. It's more of an extension of the physical exam.

EDIT: 

Nothing to dislose.

For books, I would suggest for beginners:

https://books.apple.com/ca/book/essentials-of-point-of-care-ultrasound/id841572764

Pretty cheap and basic. It has most of the POCUS applications you'll realistically use. Very good buy, especially for the price.

 

For free, you can also download if you have an Apple device the following: Introduction to Bediside: volume 1 and 2 by Matthew Dawson and Mike Mallin

 

Edited March 18, 2022 by Arztin

[medigeek]

12 hours ago, Arztin said:

Well first off, you can't diagnose these with physical exam. You aren't the only one with those problems. The sensitivity specificity of a physical exam vs a bedside POCUS is just not comparable for many things. I don't ever look for the JVP. I have my pocket US machine. I just look at the LVEF to have a rough idea instead. I can easily look at the IVC which is equivalent to the JVP. You can see consolidations on POCUS as well.

Here are just a few example of why POCUS is very important, way more than a stethoscope. There are all true patients I've seen recently, that changed the management entirely. I can go on and on.

- a lady in her 70s came with a presentation fairly classic for decompensated CHF, but not known for CHF. I POCUS her, and realized that she was actually in tamponnade. She had 600 cc of liquid drained. Her JVP would have been high either way and would not have helped. The fact that I couldn't hear her heart properly in a noisy ED wouldn't have helped. Not identifying the problem, and giving lasix and having her seen by cardio next day assuming she had a CHF could have been deadly.

- I saw a man recently who came to the ED hypotensive and had a couple of episodes of syncope. My bedside POCUS reveals RV dysfunction and fixed and dilated IVC. Especially with the clinical context, I knew the patient almost certainly had a massive or submassive PE, which was later confirmed by a scan. 

- A very obese elderly lady comes in for delirium and fever. I do all sorts of investigations, including a CT chest and abdomen. There is nothing. She seemed to have some pain when I moved her legs. I then POCUS her knees and she had a large effusion bilaterally. I asked for a joint tap which confirmed inflammatory arthritis. IM saw and admitted the patient with prompt treatment. There was no way you could palpate and ''milk'' the effusion on a physical exam.

- A lady came in with general weakness, only known for a DVT diagnosed recently on DOAC. Nothing specific on history and physical exam. I POCUS her and see a HUGE vegetation of mitral valve of like 3 cm. I also scanned her and she ended up having a cancer and bilateral PEs, but that large vegetation would not have been identified at all if I didn't POCUS.

Cervical dilation takes a bit of time. You need to do quite a few before starting to be good. Unless you do OB, you can forget about it. 

If you hear a murmur, you'll ask for formal echo anyways.

Now, the problem is that for physical exams, they teach completely useless things: especially the following: Traube space and castell sign? (can't even remember those). 99 and whatever else for effusions  (whispered pectoriloquy?) while a POCUS tells you right there if there is an effusion, and if there's a consolidation that touches the pleura. Then there are urban legends such as: thyroid bruits, abdominal bruits, 1/6 diastolic murmurs. When I was in med school, I've had a RC IM examiner giving us a lecture. I asked her how can you differentiate a thyroid bruit vs a carotid stenosis. She told me she didn't know and she never heard a thyroid bruit. But it is part of the physical exam that you need to mention for the RC. Yup...

Now there are truly very important things regarding physical exam, including those:

- doing a good MSK exam is of the uttermost importance. It is not taught properly usually

- same goes with the Neuro exam. People do it very poorly in general. Go shadow neurologists and see how they perform a complete neurological exam. 

- derm obviously. Many clinicians (including me) do not feel comfortable in derm at all.

- knowing how to recognize an acute abdomen

That being said, I still need a stethoscope. I can't entirely work without it. When patients come in for SOB, I still auscultate. You do need to hear what a normal lung auscultation sounds like. You need to identify wheezing and crackles.

And go read what Samy suggested. You'll realize that very often, many physical exam manoeuvers have a LR that don't ultimately doesn't matter, like less than 5, or sensitivity/specificity that is way too low to be of any use.

And a caveat, POCUS takes a lot of time and training to master. You always need to recognize your limits.

Finally you are precisely at that stage where learning physical exams is part of the curriculum. Don't be afraid of asking your senior or your staff to show you how to do it properly!

To add to that, using a stethoscope on an obese person is basically useless. That, and bowel sounds on anyone.