Physical Diagnosis: Clinical Skills for Third Year, Fourth Year, and Beyond

What is Physical Diagnosis?

The official name for this course is Clinical Skills and Physical Diagnosis. And true to its name, in this course, you will learn how to develop your clinical skills of physically examining patients to figure out exactly what is wrong with them.

If you have ever visited the doctor for a check-up, he or she probably has placed a stethoscope over your chest (to listen to your heart) and over your back (to listen to your lungs). And based upon what he (assuming a male doctor) auscultates or hears, he can tell if you have any heart problems of respiratory problems. What the doctor did is a small scope of what you will learn in physical diagnosis. Not only will you learn how to examine the heart and lungs, you will learn how to examine pretty much the whole body, from head to toe.

physical diagnosis - doctor auscultating lungs

A doctor is listening to the patient’s lungs for any crackles, rales, or rhonchi.

Although the physical diagnosis course will comprise mostly of learning how to conduct a physical exam, you will also learn how to get a history from the patient (finding out exactly what is wrong and anything else related to the illness) and how to write a SOAP (subjective, objective, assessment, and plan) note.

Pay attention during class because you will actually use what you learn in this class throughout your rotations in the third and fourth year of medical school. Although pathology and pharmacology are the second year’s two most important courses in term of preparing for the board exam, physical diagnosis is the second year’s most important course for teaching you how to be a doctor. Of course, there are some specialties with minimal patient contact, but most specialties will require you to get a patient’s history and to conduct a physical exam. At the very least, the skills are required if you want to get through your intern year, which is the first year of residency. So you cannot forget what you have learned once medical school ends!

At the time of writing this, I am in my third year of medical school. I remember during first day of rotations, one of the patients had abdominal pains. So some of the questions I had to ask were:

  • Which quadrant was the pain in?
  • Was there abdominal rigidity and guarding?
  • Was there rebound tenderness?
  • Is the pain present if I press deeply on the upper right abdominal quadrant and have the patient breath in deeply (Murphy’s sign)?
  • Is the pain present in the lower right abdominal quadrant if I press down on the lower left quadrant (Rovsing’s sign)?

By doing exploring the location of the pains and performing the different physical tests, it enables me to come up with a proper diagnosis. You will learn about Murphy’s sign, Rovsing’s sign, and various other signs in this course.

Required and Recommended Equipment for Physical Diagnosis

Stethoscope (required). If you do not currently have one, buy it now. Even if you do have one, make sure it is a quality stethoscope. Do not be cheap because you will be using it for the rest of your career. A higher quality stethoscope allows you to better auscultate the heart and lung sounds. Personally, I use the Littmann Cardiology III because almost every doctor uses it. If cardiologists use this model, you know it is good.

Ophthalmoscope and otoscope (recommended).
You will need these (or at least need access to these) if you want to get through the course. The practical exam (doing a physical exam on a simulated patient) will require the use of the ophthalmoscope and otoscope. The brand most medical students and hospitals use is Welch Allyn. It offers equipment that is very good quality, very durable, but also very pricey. Expect to pay around $500 for the set. Personally, I use the Welch Allyn 3.5v Diagnostic Model 97250.

If you just want to get through the course, you could just buy a cheap set for about $100, just like this one:

Better yet, just borrow the set from an upperclassman or your peer in class. From what I have experienced in my two months of my third year, I did not use the ophthalmoscope and otoscope much. If I needed them, they were available in the room.

If you really want a Welch Allyn for a good price, I would not buy it new. Instead, I would send an e-mail to the previous year’s class and ask if anyone wants to sell their ophthalmoscope and otoscope. Most likely than not, the set is collecting dust somewhere and the student is probably willing to unload his or her set for a fair price.

Tuning fork (required). You will need it for the practical exam. Technically, you can borrow it. But since it is only a few dollars, just buy it.

Reflex hammer (required).
Again, you will need it for the practical exam. It is only a few dollars, so just buy it.

Blood pressure cuff (recommended).
You will not need this for the physical exam. But as a future doctor, you should know how to take blood pressures. Hypertension (high blood pressure) is one of the most common diseases. Know how to diagnose it! During my summer vacation in Guatemala, I measured blood pressures until I was blue in the face. Ok, not literally, but you get the point. But if you are not fortunate as me and did not get much practice using the cuff, get it and practice using it. By the time you are in the third year of medical school, the doctors will expect you to know how to use get a blood pressure reading.

Even if you already know how to measure blood pressures, I would still recommend that you get a blood pressure cuff. A good cuff is only around $20 and it is staple equipment for pretty much all doctors.

Physical Diagnosis in My School

At my school, not much time was spent on the course. Only two hours per week were allocated to the learning of clinical skills and physical examinations. The course comprised of two parts:

  • lecture (which took one hour per week)
  • lab (which took one hour per week)

Lecture is self-explanatory. You listen to the lecturer and take notes. Before each lecture, you will have to complete a timed quiz. You will have 10 minutes for 10 questions. So make sure you study the lecture and lab notes before tackling the quiz. Since I studied the notes beforehand (thanks to the quiz), I did not have to pay attention during lecture.

Lab is time for you to practice what you have learned. Just partner up with another student, follow the directions in the lab notes, and go through each physical exam. If you have any questions, there are doctors you can ask to assist you. You should be able to finish lab in less than one hour.

Overall, the grade is determined by the pre-lecture quizzes and the four exams. Two exams pertain to the materials you should have covered in lecture. For the other two exams, you must do a full physical exam on simulated patients (actors and actresses) in 20 minutes or less.

How to Succeed in Physical Diagnosis?

I did extremely well in the physical diagnosis course. I honored it. Let me share with you some tips so you too can do well.

To do well on the quizzes, just read the lecture notes and lab notes before you attempt them. If you do so, you should get at least 8 out of 10 right on each quiz. After you are done with a quiz, print it out or save it to your computer so you can study from it.

The week before taking either of the two written exams, the professor will go through the topics you should know for the exams. He will give you the page number in the textbook for you to study. If you want to honor the exam, read the textbook or get someone to send you notes. A very cool classmate read the textbook, took notes on it, and sent the notes to the whole class. Without the notes, I may not have done as well as I did. If you only want to high-pass, there is no need to read the textbook.

Here are two more tips for the written exams:

  • If you can, try to find old exams or practice questions. They will help a lot.
  • Definitely review the quizzes too. You did save them like I told you to, right?

As for the two practical exams, you will get a list of what you must do. You cannot bring the list with you during the exam. Basically, half of doing well on the practical is to memorize the list. The other half of doing well is to perform within the time constraints. The key to honoring the practical exams is to keep on practicing. I started practicing three days before the practical. I would first run through the whole list, from beginning to end, looking up whatever I did not remember. Once I ran through the list once, I would go through the list again all from memory. From there, I would time myself to make sure I was within the 20 minutes. I spent about 2 hours each night practicing. On the day of the practical exam, I was confident and fluent in my abilities.

Study Tips

  • do pre-lecture quizzes
  • diligently practice during lab time
  • do practice problems to prepare for written exams
  • time yourself when you practice for practical exams

Additional Physical Diagnosis Resources

Although the teacher recommended Bates’ Guide to Physical Examination and History Taking, I did not use it. That textbook is almost 1000 pages long! I would not recommend it because reading that monster of a book would not be an efficient use of your time. It is the second year and you have many other things to worry about.

Online Resource(s)

Personally, I did not need anything but the lecture notes, lab notes, and review notes that my classmate sent out.

However, your school may not have supplied you with good notes. In that case, I would recommend you check out University of California’s physical exam study guides. My lab notes were largely based upon this excellent source. The guides would teach you everything you will need to know regarding physical exams for the third and fourth year of medical school.

Hey, you! Do you want to know how an accountant, without a science background, made it through medical school without any difficulty? Do you want to know how I memorized a sea of information without cracking my skull in half and dumping the books into my brain? No, I did not slave away all night studying in the library either. If you want to know my complete study system, check out The Secret of Studying.

This article is part of the How to Survive Medical School series. Click on the link if you want more tips and hints about surviving academic hell.

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