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Examination Pearls

Medical Assessment Tips

In school and clinicals we all learn how to take a thorough history and perform a physical assessment. Collecting this information is the foundation for our diagnosis and plan of care for our patients. As we get into practice we continue to develop and fine tune our history taking and physical assessment skills.  I’m going to share a few pearls that I have learned along the way working as a nurse practitioner in the outpatient setting. 

Subjective

Never take the subjective portion of the exam lightly. The subjective portion of the exam yields 76% of the final diagnosis (Ohm, Vogel, Sehner, Wijnen-Meijer, & Harendza, 2013). Thorough history taking is a communication skill that some providers come by naturally and others have to work diligently at improving. Small details in the history can have a huge impact on the big picture. While some history taking questions/statements we use are broad, such as, “I see you are coming in with a complaint of headaches, tell me more about your headaches.” Other history taking questions we use need to be very specific. 

For instance, you are going over the social history and ask about alcohol use and frequency. The patient says, “I have a few drinks occasionally.” This is when we have to dig a little deeper because we need to know what “a few drinks occasionally” means for this patient. Is it beer, wine and/or liquor? Is it a couple of times a day, once a week or once a month? How many drinks in one sitting? All of these details are important in history taking. If a patient is having 3-4 liquor drinks every night before bed this very well could be a cause for their headaches. This information does not need to be missed. 

I had an admirable professor tell me one time, “always listen closely to what your patient is telling you, they are telling you what is wrong with them…they are telling you the diagnosis.” 

Objective

We all know that the physical assessment pillars are inspection, palpation, percussion and auscultation. The two pillars that I’m going to emphasize on in this blog post are, inspecting the area of complaint and palpating the area of complaint. 

Example, if a patient is complaining of back pain then we need to see their back. After we visualize the back then we need to lay our hands on the back to assess what the back feels like. Are the muscles in spasm?  Do the traps feel like a solid rock? Is one side of the lumbar paraspinals more inflamed compared to the other? Does one scapula sit higher than the other? Is their posture abnormal? I know this stuff seems simple but it’s important and shouldn’t be missed.  

Always continue building on your list of differential diagnoses. The larger this list the more you will know what specific questions to ask your patients and what to be looking for in your physical assessment to narrow in on a diagnosis.

Time Saving Tips

  • Delegate, delegate, delegate! I know this will be hard for some of you reading this blog, sometimes it’s still hard for me to delegate. We tend to want to do everything ourselves but that just isn’t possible. Know what you can and cannot delegate. Know the team of people you work with. It takes a village to do what we do. 
  • Have your medical assistant instruct your type 1 and type 2 DM patients take their socks and shoes off before you enter the room if the patient is there for their diabetes check that visit. 
  • Educate your medical assistant that for whatever area of complaint the patient has, you will need to see that area. Example, if the patient is complaining of knee pain and they have on tight jeans that do not rise above the knee that patient needs to be in a gown before you enter the room so you can fully examine the knee. 
  • If you walk in the room, introduce yourself and the patient immediately starts telling you what is going on with them without you asking, don’t interrupt the patient. You’ll very likely get the majority of information you’ll need. If there is any information they don’t give you then you can ask at the end. Not only does this build provider-patient rapport (because the patient feels they are being listened to and not interrupted) it usually takes less time collecting the needed information if the patient can tell you in their own way.

Do you have any exam pearls you’d like to share? Any tips on examination time management? 

References

Ohm, F., Vogel, D., Sehner, S., Wijnen-Meijer, M., & Harendza, S. (2013). Details acquired from medical history and patients’ experience of empathy – two sides of the same coin. BMC Medical Education, 13(67). doi:10.1186/1472-6920-13-67

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