10 Tips On How To Be An Effective Intern: The Physical Exam

A list of 10 clinical pearls about the physical exam that will help you be a more effective intern, and deliver better patient care.
I know that some of these (e.g. tailor your exam to why the patient is in the hospital, don't shortchange exams on patients with disabilities) seem obvious, but I see these concepts forgotten or ignored all of the time. If I had a dime for every progress note whose exam was verbatim: "Chest - CTAB; Heart - RRR, nl S1 S2, no m/r/g; Abd - Soft, NT, ND, normal BS; Extremities - No c/c/e; Neuro - AAOx3, non-focal" irrespective of whether the patient was admitted for a stroke, arrhythmia, or bowel perforation...
A few references:
The lack of hypotension in the majority of patients with pericardial tamponade: jamanetwork.com/journals/jama...
The uselessness of auscultation of bowel sounds:
www.ncbi.nlm.nih.gov/pmc/arti...
blogs.jwatch.org/frontlines-c...
Tips and exam strategies for patients with physical or cognitive disabilities:
wordpress.uchospitals.edu/tra...
www.mountsinai.org/about/dive...
A wonderful, general resource for learning more about the physical exam:
stanfordmedicine25.stanford.edu/
The video thumbnail incorporated a picture of a reflex hammer provided by user MacSeagull under CC BY SA 4.0 and downloaded from Wikimedia Commons July 2019.

[@howtomedicate]

Great tips! I totally agree with your standpoint on heart rate. It should indeed never be used as a primary indicator of volume status! Thank you for this video 👍

[@iamdanyboy1]

The last tip and the one about dyspnoea were super relevant. I just finished my internship this year February. Wish I had known these earlier.

[@BelalAlDroubi]

you won my heart when you said that listening for bowel sounds useless 😂 I completely agree, I've read papers where it was found that interobserver agreement was ZERO for this physical finding ! not to mention that it really never changes the medical management decisions, its just a waste of time

[@ozilala1610]

U donno how much I love and appreciate ur videos!

[@cornelbacauanu1544]

All points super relevant for physical examination .Thank you . The bowel sounds auscultation should be done in some one with Hx of bowel obstruction or simply, presenting with abdo pain, if abdominal u/s or a CT scan not available or in some one post abdominal surgery who does not pass gas or does not have a bowel movement .

[@BernardoDominguesMD]

I have some questions. 1) Do you check the respiratory rate for each and every patient and at every encounter? If so, how do you do it? Do you listen/look at chest expansions for one whole minute? 2) Despite being exhaustively taught in medical school, how often do you really perform fundoscopy?

[@studentforlife9687]

Thank you Dr Strong !

[@DrAdnan]

This is going to be so helpful in residency, thanks!

[@maazarif8903]

adnan, i see you again lolol

[@Cloudshaper]

Thank you for the video. However, I don't understand why every pt. needs a gait and balance assessment if you don't suspect a neurological condition?

[@mfrabbi2]

Thank you so much, Dr. Strong

[@mathesondaniel]

I will be incorporating these!

[@solidcaptain7576]

1. Start exam w/ hands, both for exam purposes & patient comfort/rapport-building 2. Tailor daily exam to CC (JVP for HF/MI, asterixis for liver failure) 3. HR =/= volume status!! Don't reflexively start IVF, many other causes of ^HR 4. Don't be reassured by NL O2sat in pt w/ dyspnea!! Many causes initially present this way (ACS, tamponade, PE, asthma exacerbation) 5. Always try to do gait & balance exam if possible, often more informative than CN exam 6. Reflex hammer on finger for better percussion 7. Don't assume pt w/ disability can't perform exam maneuver, ask them if they feel comfortable attempting 8. Try to perform sensitive exams (genital/rectal/breast) just one time if possible w/ all necessary parties present 9. Beck's triad is (mostly) useless, hypoTN only in minority of tamponade 10. Auscultating bowel sounds = USELESS! (but good proxy to subtly check rigidity/abdominal tenderness)

[@Iwannhs_]

Thank you Dr. Strong for all your hard work and really helpful videos all these years! I am really interested to know more about the last tip: Auscultation of bowel sounds. It is something still being teached and emphasised (at least in Europe). Could you please elaborate on that? Thank you very much in advance for you time!

[@StrongMed]

Auscultation of bowel sounds is still being taught in US schools too, and I'm required to teach it to my own students (which is frustrating). This NEJM Journal Watch blog entry sums up the issues as well as I could (though I'd personally use slightly stronger wording against the practice): blogs.jwatch.org/frontlines-clinical-medicine/2017/03/01/listening-bowel-sounds-outdated-practice/

[@Iwannhs_]

@@StrongMed Thank you very much!

[@soniyaabraham6465]

thank you so much

[@allabouthealth4787]

Very helpful

[@ArkopalGupta]

The intro and outro..... ❤▪️🎸 metal rules

[@jonathanpsg3845]

Hello doctor is 20/50 pass the vision? And let’s said I pass the vision test with glasses and I don’t pass it without the glasses what’s the answer

[@StrongMed]

I'm sorry but I can't offer specific, individualized medical advice on here. In addition, there is no one specific cutoff for "passing" a vision test - it depends on the indication. For example, how good your visual acuity needs to be in order to drive a car will be different in some jurisdictions compared to how good it needs to be in order to fly an airplane.

[@quakeroats111]

Would you mind explaining what makes the auscultation of bowel sounds worthless? I have heard this many times (about as many times as I had lectures on the abdominal exam that INCLUDED bowel sound auscultation). However, I am worried that it I am treating it just as received knowledge without a real basis for understanding, just as I did when I was learning the abdominal exam the first time.

[@sunving]

Thanks Doctor Strong but you trigger me into having PTSD now. :)

[@dineshmehta3283]

Tnx

[@germanmartinezcorral138]

Why is listening for bowel sounds useless? I’ve heard a very distinct bowel sound on a patient with bowel obstruction and i considered as an important finding, was it?

[@StrongMed]

There are 2 relevant references in the video description.

[@germanmartinezcorral138]

Strong Medicine I’ll read them, thank you for the answer and for what you do!

[@rekhapawar2023]

Mera dream aa k main doctor bna prr waheguru ji d mehar tou bina kush ni ho skda plz wish you

[@nurkoleptik_art]

That outro though.

[@Deepika-hk5ij]

Could you please elaborate on conditions where dyspnea can present without hypoxia ?

[@StrongMed]

A sensation of dyspnea can be caused by different mechanisms: - Hypoxemia - Hypercapnia - Acidemia - Increased mechanical loading of the respiratory system (e.g. bronchospasm, hyperinflation of the lungs leading to flattened diaphragms) - Chemical irritants in the airways - Pulmonary edema even before hypoxemia develops (probably) - Poor oxygen delivery to peripheral tissues in the absence of hypoxemia (e.g. cardiogenic shock, carbon monoxide poisoning, severe anemia) - Pain / anxiety There are many life-threatening pathologies which trigger one of these mechanisms other than hypoxemia. For example, an asthma attack leads to increased airway resistance and increased "work of breathing" before actual gas exchange abnormalities occur. An acute MI can lead to an abrupt decrease in cardiac output or pulm edema. DKA leads to acidemia triggering compensatory hyperventilation and dyspnea, while the O2 sat remains normal. There's at least one study (www.ncbi.nlm.nih.gov/pubmed/11112122) that found the presence or absence of hypoxemia was not even diagnostically helpful in diagnosing PEs. However, that doesn't mean that the presence or absence of hypoxemia in a dyspneic patient is irrelevant. All other clinical signs being equal, a patient with diagnosis X who is hypoxemic is likely more seriously ill than another patient with diagnosis X who is not hypoxemic. So the presence of hypoxemia is often a prognostic marker, and should thus be a consideration when making triage decisions (e.g. should a patient be admitted, should a patient be in the ICU, etc...).

[@Deepika-hk5ij]

@@StrongMed Thank you so much for your detailed reply , sir

[@strongmedicose7288]

Wow