My personality has changed quite a bit as rotations started, out of adaptation. On your rotations you have to be assertive, work hard, look things up, and take charge.
Take charge with your patients: I noticed that at least in the older population, patients like it more when you're direct, and instruct them rather than ask them to do things. There's some room for "Can you sit up for me?" but I've had better patient visits when I'm like "Okay, let's sit up and I'm going to listen to your lungs." You're more active and it shows you're confident, which is what patients want. Try to read your patient's personality: people with military service and the older population respond better to assertive individuals, and less so with a kind of "soft" approach. Just my experience.
Also, invite people on your team to come check out a new finding in a patient with you, teach your fellow students and they'll reciprocate. Interns and residents are always pretty busy, but us students have more time.
Take Your Time:
Take your time on the physical exam: this is how you learn! The thing is, your team will be going around saving lives without you, so it's okay. Just don't be too late to anything. I take my time on the physical exam because I'm still learning and if I'm like "umm was that a crackle?" I'll listen and listen and listen. Take a good history and physical! You're the eyes and ears of your team, and will get asked about findings! Also: Don't make anything up! You really don't want the attending or anyone on your team be like "no crackles? Just look at the chest x-ray!!" or "No murmur? This patient has mitral stenosis.." That's why you take your time, and you'll be amazed by how much skill you build.
Bowel Sounds: Listen to at least 30 seconds in each quadrant (really it's supposed to be 1-2 minutes but hey) to not only hear that there are sounds there, but the character of the sounds. Physical findings always should be reported with a characteristic or a "personality." "Hyperactive bowel sounds" is way better and tells you a lot more about a patient's condition than "Bowel sounds x4." Act like every patient could have a right lower quadrant with Debussy heard coming from it. You'll be surprised and what you can find and learn if you pay enough time and attention to it.
More GI stuff: knees have to be bent in a supine patient so the abdominal wall isn't too stuff. Also, once you put your hands down in deep palpation, shift your pushing hand around a little like you're moving dough around: the GI isn't a point inspection exam! You have to push in and "knead" a little (but not too hard!) to where you feel like you're displacing the adipose around your fingers. I make my pushing hand as firm and with the fingers together with enough tension/muscle power so it has the firmness of a military salute, have it do the pushing, and let my top hand add a little bit of force and a little bit of push/guidance.
Extremities: I can't emphasize this enough.
1. "No pedal edema" isn't enough..find those pulses!
2. Is the patient cool or warm to the touch?
3. Test capillary refill!
4. Check for clubbing and osteoarthritis/joint findings
Extremities' health can tell you how well a patient is perfusing and if they have peripheral vascular disease.
Chest Exam:
1. Look for surgical/injury scars
2. Look for equal chest expansion
3. I'm terrible at percussing, and I'm still working on it. It takes time!
4.STYLE POINTS! This is actually a good time to check for respiratory rate (or during the CV exam: pretend you're just listening extra hard/are interested in heart sounds and take the RR: it'll be easier because you can both hear lung sounds and see the chest rise/expand).
CV:
I'll do more on the CV exam: but always find the PMI and look for heaves. I like to put my palm over the general area of the heart, then localise the PMI with 2 or 3 finger tips, then listen in to know what is diastole and systole when I'm diagnosing heart murmurs. Holding the pulse is okay too, but when I do the fingers on PMI thing, I don't have to do more effort to hold up a patient's wrist, and they also get to relax. You probably also look really cool and look like you know what you're doing.
That's it for now mates, go master the physical exam!
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