A FINAL YEAR MED STUDENT GUIDE TO PERFORMING A PHYSICAL EXAMINATION AND CASE TAKING

A good physical examination, as repeatedly told by my professors from the first ever clinical rotation I attended, is the biggest clue to diagnosing a patient. But when I got to the hospital after a close encounter with death at the entrance i.e., physically wringing out of the grip of a patient who wants to leave AMA , I was only shown a few clinical signs and watched as my professors sized up the patient and told me his diagnosis. So as a naive second year med student eager to absorb clinical knowledge like a sponge after being released from the clutches of cadavers, dissection hall and the biochemistry lab, I thought all I needed to know was how to read a CT/MRI/X-ray/ECG.

I wasn’t wrong, but I definitely wasn’t right. We were taught how to write case histories and recite them to our professors who paid irritating attention to details like negative history of every condition ever known to mankind and measuring the JVP which I’m sure is only a myth and no man has ever measured the JVP before, much like how no man has ever seen the loch ness monster or the bigfoot. The people who tell you they’ve measured the JVP, and worse told you about how clear the Kussmaul sign is in the patient in bed 3, are LIARS and conspiracy theorists.

So this, my fellow batchmates and underclassmen, is a guide on how to perform a good physical exam, and simultaneously impress your professor while also learning about the complete sham that is JVP examination (seriously, I stopped using a scale back when I was in 5th grade. What makes Hutchinson think I have TWO scales at my dispense and the time to cry my eyes out every time the JVP is normal/ definitely NOT raised/ invisible in every right heart failure patient)

시작합니다 – That’s Korean for let’s begin. Physical examination is hella confusing so what’s one more notch on the confusion scale amirite?

GENERAL DETAILS:
Ask the patient his
1. Name : don’t be a dick and call him ‘that mitral prolapse guy’ every time you need to address him.
2. Age : Definitely going to be lied to about this. Tell him you’re not here for a rishta and this is not a Swayamvar. You don’t care if he did his MS in the USA at only 23 years of age.
3. Address : So you can tell his mom when he sneaks out in the night.
You can then ask for additional details like – does he have a dog? What kind? What’s his name? Is he a good boy? Is he a very good boy? Who’s a very good doggie?
Sorry I get carried away but this is 100% the best way to impress your examiner from the very start. Show him pictures of cute dogs.

PRESENTING ILLNESS :
Start by asking him when he first started noticing the symptoms. He will definitely give you a ball park range, for example :
Me : So when did you first notice the cough?
Patient : When I was 3 years old.
Me : But.. you’re 37 years old now.
Patient : Baba Ramdev said I can cure this with deep breathing.
Me : …
Patient : *Starts deep breathing out of one nostril*

After writing everything in chronological order, and describing the fever in 782 different ways like low grade in the morning, high grade at 8.37 pm and now in a hectic picket fence pattern, move on to asking about negative history, which means asking questions to rule out other conditions. Ask about trauma, weight loss, blood in sputum, syncopal attacks etc. You can also ask who will kill Cersei Lannister in the next season and why you keep watching GoT when you have so much to study.

PAST ILLNESS : Same as above, but like in the past. Before that guy got that cough when he was 3 years old.

FAMILY HISTORY : Does the disease run in the family? Does the father also show extreme displeasure while being asked for medical history by undergrads? Why was the saasuma (mother in law) fuming at the bahu (daughter in law). Stay tuned to find out.

 

VITALS : Is the pulse even present? Okay good. The patient is alive. Makes it easier to diagnose this way. Did you count for a full minute or just for 15 seconds and multiplied it by 4? Is it pulsus paradoxus or pulsus bigeminus or pulsus tardus et parvus? You need a minute to read about those for the first time? Cool. You’ll need a crash course on Latin for that. Good luck.
The respiratory rate is always 17/min even though he is tachypneic, bradypneic or apneic.
Just like how the BP is always 120/80 mm Hg even in someone with severe hypotension. As long as you write mm Hg, you’re good.
Temperature – afebrile/febrile/ you’re hot then you’re cold, you’re yes then you’re no, you’re in and you’re out, you’re up and you’re down – as described by Dr. Katy Perry.

GENERAL EXAMINATION :
This is supposed to be a head-to-toe examination so you don’t miss anything in addition to the disease you’re trying really hard to diagnose without looking at the patient’s case file.
Did you check for PICKLE? I mean did you check if the patient is carrying any pickles on him? I’m starving and I could use some, thanks.
But don’t miss the clubbing on the chain smoker’s fingers. Don’t accept his invitation to go clubbing either. No thanks, second hand smoke.
Look at his gait. Is it wobbly/trendelenburg/ moon-walk? He might secretly be Michael Jackson. Oh wait..

INSPECTION : You’re supposed to look at the patient and ‘inspect’ him before touching. Does anyone do this anymore?
Imagine staring at him until you check off all the boxes under inspection.
Scars – check
Sinuses – check
Swellings – check
Engorged veins – check
Mild awkwardness progressing to extreme awkwardness – CHECK.

PALPATION : Did you touch the patient with your ice cold, nervous, quaking hands? Good job, you’re one of us now. This is your patients encounter with frost bite #1. Spend the next five minutes playing tag with the patient around the hospital because he doesn’t want to be touched by you ever again.
Did you feel for thrills/apex beat/tactile vocal fremitus? Feel for organomegaly – close to impossible, but your professor will always say “There’s massive splenomegaly! Look! Feel right here”, to which you will say “yes yes there is massive splenomegaly” while jabbing the poor patient with your cold hands and finding that there is actually NO splenomegaly. There might not be a spleen present too. This is all an act.
Run away whenever someone mentions Murphy’s sign.

PERCUSSION : Percussion is by far the hardest thing I have ever done and I have helped a woman give birth on the floor while she screamed and yelled at me. What is the note you hear when you percuss the lungs? Resonant/hyper- resonant/ dull/ stony dull/ emo/ very emo. Talk about how you heard a resonant note when you don’t even know what the ‘pleximeter’ is.
If everyone in your class cooperates, all of you could play a song out just with percussion.

 

AUSCULTATION:
Your patient’s encounter with frostbite #2 – the harsh, sub-zero temperature of your stethoscope diaphragm.
Did you listen for the first and second heart sounds? I have finished at least a million clinical rotations and I still say “lub-dub” out loud to differentiate the first heart sound from the second. The heart is weird man. It murmurs and stuff too. You have to then grade the murmur. Grade 1 – very faint to Grade 6 – very loud, very Arnab Goswami, very tantrum-throwing teenager-ish.
If you hear a gallop sound its best to bribe a resident with some food and actually confirm because everything sounds like a pathology to your underprepared, over enthusiastic ears.
To complicate things even further, there are some signs that combine the already complicated auscultation with other things – like the liver scratch test where the patient tells you his skin itches and you have to scratch him or he won’t let you examine, or the puddle’s sign which is impossible to perform and has joined the leagues of the JVP and the loch ness monster.

After finishing your case taking and examination, you must arrive at a diagnosis.
To summarise my case,
“37 y/o male patient who did his MS from the USA, a resident of Westeros, who sneaks out regularly in the night through the left window on the second floor, has a dog named snickers who is the cutest, won’t stop doing yoga (consult psychiatry), won’t tell me who will kill Cersei, never walks, only moonwalks (consult ortho), has invited me to go clubbing with him, has a grade 6 murmur yelling at me from across the room, most definitely a case needed to be taken up by Dr House”

*drops mic*