Let’s Get Physical: Exam Maneuvers That Can Improve Your Clinical Judgement-Slides

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This presentation by Dr. Daniel D. Dressler at the SHM Converge 2024 in San Diego emphasizes the importance of a skillful physical examination in inpatient and critical care settings to improve clinical judgment and patient outcomes. The key objectives include identifying which elements of the physical exam to perform during daily hospital rounds, integrating high-yield maneuvers to enhance diagnostic accuracy, and utilizing specific exam findings valuable in critically ill patients.<br /><br />Dr. Dressler stresses that the physical exam should be tailored based on the patient’s diagnosis and clinical status rather than a blanket approach. Routine examination of heart, lungs, abdomen, extremities, and skin is important, but clinicians should thoughtfully prioritize systems relevant to the patient’s condition daily. Maintaining physical exam skills benefits diagnosis, management, patient safety, and the patient-doctor relationship.<br /><br />Case-based discussions illustrate how evidence-based examination techniques and likelihood ratios can guide diagnosis. For example, detecting anemia via conjunctival pallor or assessing hypovolemia using mucous membranes and skin turgor can refine risk assessment in gastrointestinal bleeding. Orthostatic vital sign measurements are crucial but should be performed carefully within 1 minute of standing to assess volume status.<br /><br />In heart failure evaluation, physical signs such as laterally displaced or enlarged apical impulse, elevated jugular venous pressure (JVP), abdominal jugular reflux (AJR), and an S3 gallop have high diagnostic value. While POCUS (point-of-care ultrasound) offers advantages, especially when physical findings are equivocal or difficult to obtain, it complements rather than replaces the physical exam.<br /><br />For ICU patients with septic shock, assessment tools like the Modified Early Warning Score (MEWS), capillary refill time, limb temperature, and skin mottling provide bedside indicators of perfusion and prognosis. Neurological signs including anisocoria and neck stiffness may signal critical intracranial pathology.<br /><br />Overall, this session underscores that applying evidence-based physical examination maneuvers enhances clinical acumen, supports patient-centered care, and remains indispensable even in an era of advanced technology. Skilled bedside evaluation paired with judicious use of tools like POCUS optimizes diagnostic efficiency and patient management in hospitalized and critically ill patients.

Keywords

Physical examination

Inpatient care

Critical care

Clinical judgment

Diagnostic accuracy

Heart failure signs

POCUS

Septic shock assessment

Evidence-based maneuvers

Patient-centered care