Great tips! I totally agree with your standpoint on heart rate. It should indeed never be used as a primary indicator of volume status! Thank you for this video 👍
you won my heart when you said that listening for bowel sounds useless 😂 I completely agree, I've read papers where it was found that interobserver agreement was ZERO for this physical finding ! not to mention that it really never changes the medical management decisions, its just a waste of time
I have some questions. 1) Do you check the respiratory rate for each and every patient and at every encounter? If so, how do you do it? Do you listen/look at chest expansions for one whole minute? 2) Despite being exhaustively taught in medical school, how often do you really perform fundoscopy?
1. Start exam w/ hands, both for exam purposes & patient comfort/rapport-building 2. Tailor daily exam to CC (JVP for HF/MI, asterixis for liver failure) 3. HR =/= volume status!! Don't reflexively start IVF, many other causes of ^HR 4. Don't be reassured by NL O2sat in pt w/ dyspnea!! Many causes initially present this way (ACS, tamponade, PE, asthma exacerbation) 5. Always try to do gait & balance exam if possible, often more informative than CN exam 6. Reflex hammer on finger for better percussion 7. Don't assume pt w/ disability can't perform exam maneuver, ask them if they feel comfortable attempting 8. Try to perform sensitive exams (genital/rectal/breast) just one time if possible w/ all necessary parties present 9. Beck's triad is (mostly) useless, hypoTN only in minority of tamponade 10. Auscultating bowel sounds = USELESS! (but good proxy to subtly check rigidity/abdominal tenderness)
As a PA student who graduates soon and looking into EM, your videos have been some of the most important for my professional growth. Is there a medical author/book you recommend to learn more about effective, practical, evidence-based physical exam skills?
I'm glad that the videos have been helpful! There are 3 resources which formed the core of my exam knowledge: - Evidence-based Physical Diagnosis by Steve McGee: It's exactly what it sounds like - basically incorporates every primary paper on the exam ever written. The downside is that I think McGee can get a little too into the weeds with the numbers, and he doesn't always do an optimal job with differentiating between methodologically strong and weak studies. - The Rational Clinical Exam series in JAMA: A series of 50+ review papers, each of which is entitled something like "Does this patient have [clinical diagnosis]?". It discusses the evidence for both symptoms and signs, and to lesser extent common diagnostic tests, for a broad variety of common conditions (e.g. pneumonia, AAA, COPD, heart failure, ACS, etc...) to give you the most evidence-based way to make a diagnosis. - Sapira's Art and Science of Bedside Diagnosis: This is the classic old-timey text for physical exam gurus, but it ignores evidence and rather than cite the primary literature is more likely to state something like "Based on this one conversation I had with Dr. Andrew Smith of Gary Indiana in 1982, this is an underappreciated way to diagnose a left sided subdiaphragmatic abscess..." In some ways, it is the antithesis of McGee. I enjoy the book because it's entertaining and it reminds me of how the exam was approached prior to the advent of evidence-based medicine. But I don't come across too many things which literally change my practice. Other high quality resources include the Stanford 25 website (Disclaimer: I'm a colleague to many of the contributors). And if I can make a plug for my own material, I've been relatively happy with my own ongoing physical exam series, "Strong Exam". One final book to mention is Bedside Cardiology by Jules Constant. It is out of print and has been made obsolete by echocardiography, but the melding of cardiac pathophysiology and cardiovascular physical diagnosis is amazing. Things like using intracardiac pressure tracings to explain why severe AS has a more late-peaking crescendo-decrescendo murmur than mild AS. Constant has entire chapters dedicated to individual heart sounds. (I recommend only making the effort to track down a copy if you are particularly fascinated by the cardiac exam - but like I said, the majority of the book's teachings have been replaced by echo.)
Thank you Dr. Strong for all your hard work and really helpful videos all these years! I am really interested to know more about the last tip: Auscultation of bowel sounds. It is something still being teached and emphasised (at least in Europe). Could you please elaborate on that? Thank you very much in advance for you time!
Auscultation of bowel sounds is still being taught in US schools too, and I'm required to teach it to my own students (which is frustrating). This NEJM Journal Watch blog entry sums up the issues as well as I could (though I'd personally use slightly stronger wording against the practice): blogs.jwatch.org/frontlines-clinical-medicine/2017/03/01/listening-bowel-sounds-outdated-practice/
All points super relevant for physical examination .Thank you . The bowel sounds auscultation should be done in some one with Hx of bowel obstruction or simply, presenting with abdo pain, if abdominal u/s or a CT scan not available or in some one post abdominal surgery who does not pass gas or does not have a bowel movement .
Would you mind explaining what makes the auscultation of bowel sounds worthless? I have heard this many times (about as many times as I had lectures on the abdominal exam that INCLUDED bowel sound auscultation). However, I am worried that it I am treating it just as received knowledge without a real basis for understanding, just as I did when I was learning the abdominal exam the first time.
Why is listening for bowel sounds useless? I’ve heard a very distinct bowel sound on a patient with bowel obstruction and i considered as an important finding, was it?
I'm sorry but I can't offer specific, individualized medical advice on here. In addition, there is no one specific cutoff for "passing" a vision test - it depends on the indication. For example, how good your visual acuity needs to be in order to drive a car will be different in some jurisdictions compared to how good it needs to be in order to fly an airplane.
A sensation of dyspnea can be caused by different mechanisms: - Hypoxemia - Hypercapnia - Acidemia - Increased mechanical loading of the respiratory system (e.g. bronchospasm, hyperinflation of the lungs leading to flattened diaphragms) - Chemical irritants in the airways - Pulmonary edema even before hypoxemia develops (probably) - Poor oxygen delivery to peripheral tissues in the absence of hypoxemia (e.g. cardiogenic shock, carbon monoxide poisoning, severe anemia) - Pain / anxiety There are many life-threatening pathologies which trigger one of these mechanisms other than hypoxemia. For example, an asthma attack leads to increased airway resistance and increased "work of breathing" before actual gas exchange abnormalities occur. An acute MI can lead to an abrupt decrease in cardiac output or pulm edema. DKA leads to acidemia triggering compensatory hyperventilation and dyspnea, while the O2 sat remains normal. There's at least one study (www.ncbi.nlm.nih.gov/pubmed/11112122) that found the presence or absence of hypoxemia was not even diagnostically helpful in diagnosing PEs. However, that doesn't mean that the presence or absence of hypoxemia in a dyspneic patient is irrelevant. All other clinical signs being equal, a patient with diagnosis X who is hypoxemic is likely more seriously ill than another patient with diagnosis X who is not hypoxemic. So the presence of hypoxemia is often a prognostic marker, and should thus be a consideration when making triage decisions (e.g. should a patient be admitted, should a patient be in the ICU, etc...).
Great tips! I totally agree with your standpoint on heart rate. It should indeed never be used as a primary indicator of volume status! Thank you for this video 👍
you won my heart when you said that listening for bowel sounds useless 😂
I completely agree, I've read papers where it was found that interobserver agreement was ZERO for this physical finding !
not to mention that it really never changes the medical management decisions, its just a waste of time
U donno how much I love and appreciate ur videos!
This is going to be so helpful in residency, thanks!
adnan, i see you again lolol
I have some questions. 1) Do you check the respiratory rate for each and every patient and at every encounter? If so, how do you do it? Do you listen/look at chest expansions for one whole minute? 2) Despite being exhaustively taught in medical school, how often do you really perform fundoscopy?
1. Start exam w/ hands, both for exam purposes & patient comfort/rapport-building
2. Tailor daily exam to CC (JVP for HF/MI, asterixis for liver failure)
3. HR =/= volume status!! Don't reflexively start IVF, many other causes of ^HR
4. Don't be reassured by NL O2sat in pt w/ dyspnea!! Many causes initially present this way (ACS, tamponade, PE, asthma exacerbation)
5. Always try to do gait & balance exam if possible, often more informative than CN exam
6. Reflex hammer on finger for better percussion
7. Don't assume pt w/ disability can't perform exam maneuver, ask them if they feel comfortable attempting
8. Try to perform sensitive exams (genital/rectal/breast) just one time if possible w/ all necessary parties present
9. Beck's triad is (mostly) useless, hypoTN only in minority of tamponade
10. Auscultating bowel sounds = USELESS! (but good proxy to subtly check rigidity/abdominal tenderness)
The last tip and the one about dyspnoea were super relevant. I just finished my internship this year February. Wish I had known these earlier.
As a PA student who graduates soon and looking into EM, your videos have been some of the most important for my professional growth. Is there a medical author/book you recommend to learn more about effective, practical, evidence-based physical exam skills?
I'm glad that the videos have been helpful! There are 3 resources which formed the core of my exam knowledge:
- Evidence-based Physical Diagnosis by Steve McGee: It's exactly what it sounds like - basically incorporates every primary paper on the exam ever written. The downside is that I think McGee can get a little too into the weeds with the numbers, and he doesn't always do an optimal job with differentiating between methodologically strong and weak studies.
- The Rational Clinical Exam series in JAMA: A series of 50+ review papers, each of which is entitled something like "Does this patient have [clinical diagnosis]?". It discusses the evidence for both symptoms and signs, and to lesser extent common diagnostic tests, for a broad variety of common conditions (e.g. pneumonia, AAA, COPD, heart failure, ACS, etc...) to give you the most evidence-based way to make a diagnosis.
- Sapira's Art and Science of Bedside Diagnosis: This is the classic old-timey text for physical exam gurus, but it ignores evidence and rather than cite the primary literature is more likely to state something like "Based on this one conversation I had with Dr. Andrew Smith of Gary Indiana in 1982, this is an underappreciated way to diagnose a left sided subdiaphragmatic abscess..." In some ways, it is the antithesis of McGee. I enjoy the book because it's entertaining and it reminds me of how the exam was approached prior to the advent of evidence-based medicine. But I don't come across too many things which literally change my practice.
Other high quality resources include the Stanford 25 website (Disclaimer: I'm a colleague to many of the contributors). And if I can make a plug for my own material, I've been relatively happy with my own ongoing physical exam series, "Strong Exam".
One final book to mention is Bedside Cardiology by Jules Constant. It is out of print and has been made obsolete by echocardiography, but the melding of cardiac pathophysiology and cardiovascular physical diagnosis is amazing. Things like using intracardiac pressure tracings to explain why severe AS has a more late-peaking crescendo-decrescendo murmur than mild AS. Constant has entire chapters dedicated to individual heart sounds. (I recommend only making the effort to track down a copy if you are particularly fascinated by the cardiac exam - but like I said, the majority of the book's teachings have been replaced by echo.)
Thank you Dr. Strong for all your hard work and really helpful videos all these years!
I am really interested to know more about the last tip: Auscultation of bowel sounds. It is something still being teached and emphasised (at least in Europe). Could you please elaborate on that? Thank you very much in advance for you time!
Auscultation of bowel sounds is still being taught in US schools too, and I'm required to teach it to my own students (which is frustrating). This NEJM Journal Watch blog entry sums up the issues as well as I could (though I'd personally use slightly stronger wording against the practice): blogs.jwatch.org/frontlines-clinical-medicine/2017/03/01/listening-bowel-sounds-outdated-practice/
@@StrongMed Thank you very much!
All points super relevant for physical examination .Thank you . The bowel sounds auscultation should be done in some one with Hx of bowel obstruction or simply, presenting with abdo pain, if abdominal u/s or a CT scan not available or in some one post abdominal surgery who does not pass gas or does not have a bowel movement .
Thank you for the video. However, I don't understand why every pt. needs a gait and balance assessment if you don't suspect a neurological condition?
Thank you so much, Dr. Strong
Thank you Dr Strong !
Would you mind explaining what makes the auscultation of bowel sounds worthless? I have heard this many times (about as many times as I had lectures on the abdominal exam that INCLUDED bowel sound auscultation). However, I am worried that it I am treating it just as received knowledge without a real basis for understanding, just as I did when I was learning the abdominal exam the first time.
I will be incorporating these!
thank you so much
The intro and outro..... ❤▪️🎸 metal rules
Very helpful
Why is listening for bowel sounds useless? I’ve heard a very distinct bowel sound on a patient with bowel obstruction and i considered as an important finding, was it?
There are 2 relevant references in the video description.
Strong Medicine I’ll read them, thank you for the answer and for what you do!
Hello doctor is 20/50 pass the vision? And let’s said I pass the vision test with glasses and I don’t pass it without the glasses what’s the answer
I'm sorry but I can't offer specific, individualized medical advice on here. In addition, there is no one specific cutoff for "passing" a vision test - it depends on the indication. For example, how good your visual acuity needs to be in order to drive a car will be different in some jurisdictions compared to how good it needs to be in order to fly an airplane.
Could you please elaborate on conditions where dyspnea can present without hypoxia ?
A sensation of dyspnea can be caused by different mechanisms:
- Hypoxemia
- Hypercapnia
- Acidemia
- Increased mechanical loading of the respiratory system (e.g. bronchospasm, hyperinflation of the lungs leading to flattened diaphragms)
- Chemical irritants in the airways
- Pulmonary edema even before hypoxemia develops (probably)
- Poor oxygen delivery to peripheral tissues in the absence of hypoxemia (e.g. cardiogenic shock, carbon monoxide poisoning, severe anemia)
- Pain / anxiety
There are many life-threatening pathologies which trigger one of these mechanisms other than hypoxemia. For example, an asthma attack leads to increased airway resistance and increased "work of breathing" before actual gas exchange abnormalities occur. An acute MI can lead to an abrupt decrease in cardiac output or pulm edema. DKA leads to acidemia triggering compensatory hyperventilation and dyspnea, while the O2 sat remains normal.
There's at least one study (www.ncbi.nlm.nih.gov/pubmed/11112122) that found the presence or absence of hypoxemia was not even diagnostically helpful in diagnosing PEs.
However, that doesn't mean that the presence or absence of hypoxemia in a dyspneic patient is irrelevant. All other clinical signs being equal, a patient with diagnosis X who is hypoxemic is likely more seriously ill than another patient with diagnosis X who is not hypoxemic. So the presence of hypoxemia is often a prognostic marker, and should thus be a consideration when making triage decisions (e.g. should a patient be admitted, should a patient be in the ICU, etc...).
@@StrongMed Thank you so much for your detailed reply , sir
Thanks Doctor Strong but you trigger me into having PTSD now. :)
That outro though.
Mera dream aa k main doctor bna prr waheguru ji d mehar tou bina kush ni ho skda plz wish you
Tnx
Wow