11 January 2012


Although we've been taught how to perform a physical exam, I have a hard time knowing what is concerning and what is normal. If an obese patient can only weakly push up against my hand, does it signal underlying neurological damage or is it just a sign that they don't exercise? Is that yellowish coating on the patient's tongue a stain from tobacco or a precancerous lesion? What is a normal range of motion for the shoulder of a 70-year-old? Given my lack of experience performing physical examinations and interpreting them, I place little stock in my physical exam findings.

Something sounded funny when I listened to one patient's heart. Since she was morbidly obese, it was difficult to hear clearly through the layers of fat. I couldn't even figure out at which stage of the heartbeat I thought the irregularity was taking place, or what the irregularity might signify. I just knew that my "spidey sense" was going off. Another med student was also in the exam room, and I asked him to confirm. After listening for a long time, he gave up. "I can't hear anything strange."

When I stepped out of the exam room, I thumbed through her chart. The patient had been seen in clinic several times, and there was no mention of a heart murmur. This left three possibilities:

1. Her heart sounds were actually normal and I heard it wrong;
2. Her heart sounds were abnormal and every med student in the past had missed it;
3. Her heart sounds had changed recently from normal to abnormal.

I presumed that the answer was number 1, but I made sure that the attending physician had a listen anyway. The doctor listened for a long time and then announced that there was a faint (and harmless) systolic murmur. The patient confirmed that as a child she was told she had a slight heart murmur.

It felt good. I think I'm getting the hang of this.