Objectives — Physical Exam

History Physical Exam Data Synthesis Knowledge Management Skills Interpersonal Skills

Explanation: By the end of the clerkship you should have a good order to your physical examination which will help place the patient at ease. You should always maintain privacy by using sheets and curtains during the physical exam. Develop strategies for the four different age groups (infant, toddler, school age, adolescent). Infants are easy because they don't move around too much. Toddlers are the most difficult because they see you as a stranger. If you can be successful 50% of the time, you are doing very well. Trained pediatricians "fail" about 20% of the time and have to leave the room and come back. Its better to give up and come back with toddlers than to drive yourself crazy trying to do the exam. School age kids are like adults, but very concrete in their reasoning. They like for you to explain what you are doing, but they are usually very willing patients on whom you can practice a head to toe exam. You should always do the physical exam on adolescents with a chaperone in the room because everything you do will be taken in a sexual context.

Make sure that your physical exam is focused. Each patient does not need a head to toe exam. It is good to practice occasionally, but make sure that you are doing it when there are few patients and you have enough time to complete the exam. If you're not sure what level of detail the intern would like to see in the physical exam, clarify with them. Some interns will want you to do the entire exam and some will only want a very focused physical exam.

You should learn the screening exam in newborns for congenital defects. It is important to see a bunch of these so that you have an idea what looks normal and what is abnormal. Make sure that you feel comfortable holding an infant. The most important joint to learn to examine in pediatrics is the hip, so make sure someone shows you the hip exam and you feel comfortable with the it.

Ear exam: This is a difficult part of the physical exam, especially in toddlers. Your goal should be to always see the tympanic membrane. If you can see the ear drum by the end of five weeks, that is great, but not expected. The ear canal starts into the head in a medial-dorsal direction and then turns to be medial-ventral, therefore you must straighten it. You can do this by pulling on the ear in an up and out direction. Don't be too gentle, you have to pull to be successful. If you hold the otoscope upside down, then you need to pull down and out or down and in. Practice on older kids and not toddlers. To prevent yourself from hurting the patient, barely put the tip of the otoscope in the ear and torque the canal. Practice making the tympanic membrane move because mobility is important in the diagnosis of otitis media. This means that you need a bulb attachment for your otoscope.

Throat exam: In a school age kid or above, you should be able to do the throat exam without using a tongue blade. This exam should always be performed when the patient is sitting up.

Murmurs: You are not expected to be able to describe every pathological murmurs. You should be able to differentiate pathological systolic murmurs in the left cisternal border from functional murmurs in the left cisternal border. The pathological systolic murmurs are ventricular septal defects (VSD), peripheral pneumonic stenosis (PPS), micro regursion (MR) and aortic stenosis (AS).

Lung: Be able to differentiate wheezing from rhonchi during the lung exam.

Abdomen: Be able to rule out a surgical abdomen.

Know the level of illness of a patient.

Weeks 1-2: Get comfortable with the exam across all four age groups.

Weeks 3-4: Perform focused physical exams.

Example: If you have a patient with lupis and you know that renal problems are a complication, you should make sure that you palpate the kidneys and listen for bruits.

Methods:

 

Observe interns, residents, and mentors when they perform the physical exam and focus your observations on the order of the exam, the content of the exam, and aspects of the exams that are tailored to the patient's developmental stage. You should have the opportunity to observe during inpatient admissions, ER/Clinic visits, your mentor's office/clinic visits, and teaching resident rounds.

Use the computer cases to think about what elements you would include in a focused physical exam with special attention to developmental stage.

If you don't know how best to maintain privacy during the physical exam, ask!

When you are observing the intern/resident, watch how they perform the exam, how they maintain privacy, and how they put the patient at ease. Don't just watch, always look for something.

If you hear a murmur and you are not sure if it is functional or pathologic or you're not sure it is one or the other, ask an intern or resident to explain it to you.

Ask for feedback from the attendings, residents, and interns.

 

Feedback:

 

Resident Feedback Form