Physical exams save lives. As a student, I found a suboccipital lymph node in a patient with an FUO; she had miliary TB. As a resident, I heard a diastolic murmur in a college student with a sore throat; he had aortic insufficiency. In the Yale MICU, I diagnosed pseudomonas bacteremia in a patient with ecthyma gangrenosum, and in clinic, I diagnosed small cell cancer in a patient with a hard supraclavicular lymph node.
My exam skills aren’t extraordinary, but I do my best to pay attention, and I think I’ve helped patients along the way. Here are a dozen suggestions to consider as you document your own exams:
- Provide a general description: Is the patient comfortable? In distress? Conversant? Calm? Agitated? This is how we distinguish sick from not sick, and your documentation will prove crucial when an RRT is called or the night shift cross-covers.
- Be thorough: H&Ps should include comprehensive exams. Wouldn’t it be tragic to miss a breast mass or melanoma, regardless of the patient’s reason for admission? With time, you’ll surely make surprising and life-changing diagnoses.
- Follow a template: Templates foster efficiency and completeness. If you’re not using a template yet, get one, then add and subtract as necessary.
- Highlight abnormalities: Use bold font to signify key findings. Readers will thank you.
- Elaborate as needed: Share details. If your patient has abdominal pain, tell us about distention, bowel sounds, tenderness (including severity and location), and whether she had guarding or rebound. Thorough exams can distinguish between appendicitis, bowel obstruction, mesenteric ischemia, kidney stones, and a host of other diagnoses.
- Report pertinent negatives: Anticipate what your audience will want to know, even if the exam is non-revealing. If your patient has nausea but his abdominal exam was benign, tell us. If your patient has a headache but no neck stiffness, say it. If your patient has a foot ulcer, but the pulses and sensory exam were normal, we need to know. If you don’t document normal findings, your audience will assume you didn’t check.
- Take pictures: Especially for rashes, there’s no substitute.
- Report the vitals: It’s a common error to report 24-hour ranges in the exam section—"the heart rate was 52 to 152”—but this is confusing. Just tell us what the vitals were when you saw the patient; 24-hour ranges belong in the history, not the exam. Also, provide context: if the patient was on pressors when the blood pressure was checked, or if the patient was on oxygen when the SpO2 was checked, we need to know.
- Include devices: Tell us if the patient has lines and tubes- and if the entry sites were clean and dry (or not).
- Establish a baseline: Follow up exams will be compared to your baseline. If your patient has CHF, how extensive were the crackles and how severe was the edema? If your patient has asthma, how many words could she say before pausing to inhale? When documenting follow up, refer to prior observations (e.g., “she was breathing more comfortably than the day before”).
- Note the timing: Your audience will assume your exam coincides with the rest of the note. If that’s not true, make it clear. It makes no sense to say the patient was intubated in the history and then say they were on high flow nasal cannula on your exam. Similarly, if the patient’s lungs were clear after getting albuterol, tell us.
- Never copy and paste: Exams that are copied forward always make me wonder if the patient was actually examined. Copied exams can also cause medical-legal trouble: “Doctor, on the day Mr. Smith perforated his appendix, you wrote that his exam was ‘benign,’ which is exactly what you said the day before and the day before that. Did you actually examine the patient?” Equally important, don’t ever, ever, ever copy someone else’s exam. The only exam you should document is your own- a subspecialty fellow once copied my joint exam on a patient with gout and I’m still shaking my head. Document a fresh exam every day.
Premier internists distinguish themselves by performing—and documenting—thoughtful, thorough exams. In doing so, you will pick up subtle findings, make elusive diagnoses, and show patients that you care. Nothing is more important.
Enjoy your Sunday, everyone; I’m heading out for a long bike ride!
Mark D. Siegel, MD, FCCP, FACP
Professor of Internal Medicine
Pulmonary, Critical Care & Sleep Medicine
Yale School of Medicine
Traditional Internal Medicine Residency