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The Physical Examination: How Focusing Teaching Can Teach Focus


The Physical Examination: How Focusing Teaching Can Teach Focus Heather Harrell, MD, FACP Associate Professor of Medicine University of Florida * The rounds ... – PowerPoint PPT presentation

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Title: The Physical Examination: How Focusing Teaching Can Teach Focus

The Physical Examination How Focusing Teaching
Can Teach Focus
  • Heather Harrell, MD, FACP
  • Associate Professor of Medicine
  • University of Florida

845 AM on work rounds outside the room of a
patient admitted for r/o stroke
Does this sound familiar?
  • MS 3 Ms. J was resting comfortably w/o
    complaints. On exam NCAT, heart sounded good
    regular rate and rhythm, lung are clear, abdomen
    has good bowel sounds in all 4 quadrants, soft,
    nontender, no rebound or hepatosplenomegaly.

On entering Ms. Js room, you discover
  • Vital signs T38.5 P110 BP 92/50 R 24 O2 sat 88
  • She is obtunded
  • Posterior lung exam reveals dullness at the right
    base with crackles and egophony
  • Left patellar and Achilles reflexes are now
    hyperactive with a positive Babinski
  • just for starters

This is not time efficient.
And this is not optimal patient care.
  • Be able to describe 2-3 strategies to teach
    physical examination at the bedside without
    disrupting rounds.
  • Be able to describe a template for teaching
    students how to focus the physical examination
    correctly on an inpatient medical service.
  • Be able to identify written and web-based
    resources for improving physical examination

Rounds Approach to Physical Exam
  • Pre-rounds- prepare the student by giving a
    template (set expectations)
  • Work rounds- demonstrate only pertinent findings
  • Teaching rounds- save interesting (but less
    pertinent) or more time consuming physical
    findings for teaching rounds

Pre-roundsTemplate for focused physical
examination presentations
  • Vitals are vital, always start with them.
  • General appearance
  • Does the patient look sick?
  • Has there been a big change overnight? (Will the
    team be surprised by how the patient looks
  • What parts of the physical exam relate to the
    chief complaint? Those are the pertinent parts to
  • Are there any new findings overnight? If so, will
    it affect the plan? (If not, you probably dont
    need to bring it up on rounds.)

Omit if making true bedside rounds, as it will
be obvious to the team. (LaCombe MA On bedside
teaching. Ann Intern Med 1997126217-20.
For Those Who Like Mnemonics
  • Vitals
  • Appearance
  • Chief complaint
  • Abnormal findings
  • New findings
  • Treatment (would change)

Work Rounds Observation is Critical to
Assessing Technique
And it can be time efficient.
Show Not Tell
  • Show me what you found on exam.
  • Allows direct observation of student technique
  • Allows resident to perform/confirm key parts of
    the exam that they need to do anyway
  • Allows resident to direct student to the
    pertinent parts of the exam
  • Allows immediate feedback

Teaching Rounds Tips
  • Difficult to keep everyone engaged while awaiting
    a turn to examine the patient but all learners
    can practice observation skills by asking them
    what they notice
  • Students frequently overlook lines, catheters,
    infusions, old scars, skin and nail
    abnormalities, movement disorders
  • Ask what did you hear, see, feel? rather than
    did you hear, see, feel____?
  • Ask students to predict what an x-ray or ECHO
    will show based on the exam

Focusing Teaching, Helps Teach Focusing
  • By demonstrating the parts of the physical exam
    that you need to perform for patient care, you
    role model to students how to focus their
    physical examinations.
  • Conversely, reviewing every detail of the
    physical examination during rounds (as
    interesting as it may be) could encourage
    students to present every detail of the exam
    during work rounds.something you may regret on a
    busy service.
  • (Save something for the attending to cover on
    teaching rounds.)

Role-Modeling Caveat
  • Demonstration and role-modeling are critical when
    teaching physical examination.
  • Never assume students realize you are
    role-modeling make it explicit.
  • Watch how I position the patient.
  • Make a note of the parts of the exam I am going
    to repeat as this is what we mean by a focused
    exam for this patient.

Sample Case Using a Rounding Approach
  • RC is a 76 yo man with CHF and MR admitted last
    night for CHF exacerbation.
  • After diuresis overnight his lung exam, JVP, and
    peripheral edema have improved.

Rounds Approach
  • Pre-round- Student has template and should have
    gathered pertinent data
  • Work rounds- Student demonstrates JVP, pulmonary
    exam (residents listens with student), and
    peripheral edema
  • Teaching rounds- Attending (or resident) reviews
    cardiac exam with an emphasis on heart murmurs
    and may review technique of measuring JVP if the
    resident noted confusion on rounds.

  • I desire no other epitaphthan the statement
    that I taught medical students on the wards as I
    regard this by far as the most useful and
    important work that I have been called to do.
  • Sir William Osler

  • Using sample scenarios, residents can discuss how
    they would focus an exam on work rounds
  • Role play can reinforce that this is time
  • See handout

Consider the following questions when discussing
the practice cases
  • As the resident, what part of the exam do I need
    to perform/confirm on rounds?
  • Is this an appropriate patient for several people
    to exam?
  • What 1-2 key findings could be reviewed with the
    whole team that would not slow down rounds?
  • What 1-2 key findings should I make sure someone
    reviews with the medical students?
  • Would the physical findings of this case be good
    to save for attending rounds?
  • How can I involve the students?

Case 1
  • L.R.- 52 yo man w/ ETOH cirrhosis admitted 2 days
    ago w/ encephalopathy He has all the classic
    stigmata of chronic liver disease.

Case 2
  • J.C.- 70 yo woman w/ emphysema and community
    acquired pneumonia She has a classic emphysema
    exam along w/ consolidation in the LLL.

Case 3
  • M.K.- 85 yo woman w/ severe dementia social
    admit She is thin w/ multiple contractures and
    not interactive at all.

Case 4
  • S.T. - 23 yo woman w/ sickle cell crisis HD 5 w/
    pain 5/10 on morphine PCA Fit appearing young
    woman, who looks uncomfortable but o/w normal

Case 5
  • R.G. - 45 yo man w/ atypical chest pain
    admitted for R/O MI He is moderately obese w/
    II/VI systolic murmur at LUSB (c/w his old flow

Author Contact Information
  • Heather Harrell, MD, FACP