What is the Heldrich-10?
The Heldrich-10 is a web based curriculum that aims to improve the following pediatric residents and students clinical skills:
1. Clinical reasoning skills
2. Physical exam skills
3. Evidence based medicine
Initiatives with similar goals have been introduced in residency training, namely the internal medicine residency at Stanford university (http://stanfordmedicine25.stanford.edu). However, our curriculum provides a more comprehensive approach.
The Pediatrics Milestone Project, which is a joint initiative of ABP and ACGME emphasizes the importance of achieving high-quality physical examination skills as well as employing diagnostic hypotheses to drive the physical examination process in order to discriminate between competing similar diagnosis (1).
We believe that this important milestone can be taught by applying Adult Learning Theory principles (2). This curriculum is devised to enhance, complement and ultimately sustain high quality physical examination skills by providing an interactive, relevant, goal-oriented and independent learning experiences. This approach will lead to less unnecessary tests, less cost, and improve diagnostic accuracy.
1. Clinical reasoning skills
2. Physical exam skills
3. Evidence based medicine
Initiatives with similar goals have been introduced in residency training, namely the internal medicine residency at Stanford university (http://stanfordmedicine25.stanford.edu). However, our curriculum provides a more comprehensive approach.
The Pediatrics Milestone Project, which is a joint initiative of ABP and ACGME emphasizes the importance of achieving high-quality physical examination skills as well as employing diagnostic hypotheses to drive the physical examination process in order to discriminate between competing similar diagnosis (1).
We believe that this important milestone can be taught by applying Adult Learning Theory principles (2). This curriculum is devised to enhance, complement and ultimately sustain high quality physical examination skills by providing an interactive, relevant, goal-oriented and independent learning experiences. This approach will lead to less unnecessary tests, less cost, and improve diagnostic accuracy.
Using this curriculum, residents and medical students are expected to:
-Demonstrate competency in performing physical examination skills using high-yield techniques
-Approach patients with a hypothesis driven-physical examination mind-set based on differential diagnosis and clinical history
-Use evidence based medicine when generating differentials and plans
Roles and Responsibilities
Senior residents
- Please ensure that you observe and reflect on the physical examination techniques of your junior
residents and students. Choose two patients every week to observe a system-based physical examination (example: the abdominal exam) from the interns and students.
- When encountering patients in the ED or the floor, approach them with hypothesis-driven physical examination and discuss the rationale behind it.
Interns
- This curriculum aims at complementing your clinical examination skills by repetition, direct feedback and assessment.
- During morning rounds, when reporting abnormal physical signs, please take the time to go through your techniques and explain the meaning of abnormal findings to the team and parents.
- Whenever you encounter an interesting physical sign, please share it with the medical students.
- The well baby nursery is a "gold mine", Ask the attending on service to demonstrate a complete newborn examination on your first day and to give you a feedback on your examination.
Medical students
- This is your opportunity to learn, demonstrate and perfect your physical examination techniques.
- When a resident describes an abnormal physical sign that you could not elicit, please ask them to teach you the technique and give you a direct feedback.
- If imaging techniques show a local pathology that you couldn't elicit on exam (e.g: lung consolidation or hepato-splenomegaly), go back and re-examine the patient to identify potential flaws in technique.
- Discuss and practice the newborn exam in the well baby nursery
- Examine every floor patient daily even if they are not "your" patient.
- In the ER, focus on the PE. Observe how different attendings perform different aspects of the PE.
- A nice introductory video to the pediatric physical exam can be found at this webpage from COMSEP: https://www.comsep.org/educationalresources/currsupportservices.cfm
- Please ensure that you observe and reflect on the physical examination techniques of your junior
residents and students. Choose two patients every week to observe a system-based physical examination (example: the abdominal exam) from the interns and students.
- When encountering patients in the ED or the floor, approach them with hypothesis-driven physical examination and discuss the rationale behind it.
Interns
- This curriculum aims at complementing your clinical examination skills by repetition, direct feedback and assessment.
- During morning rounds, when reporting abnormal physical signs, please take the time to go through your techniques and explain the meaning of abnormal findings to the team and parents.
- Whenever you encounter an interesting physical sign, please share it with the medical students.
- The well baby nursery is a "gold mine", Ask the attending on service to demonstrate a complete newborn examination on your first day and to give you a feedback on your examination.
Medical students
- This is your opportunity to learn, demonstrate and perfect your physical examination techniques.
- When a resident describes an abnormal physical sign that you could not elicit, please ask them to teach you the technique and give you a direct feedback.
- If imaging techniques show a local pathology that you couldn't elicit on exam (e.g: lung consolidation or hepato-splenomegaly), go back and re-examine the patient to identify potential flaws in technique.
- Discuss and practice the newborn exam in the well baby nursery
- Examine every floor patient daily even if they are not "your" patient.
- In the ER, focus on the PE. Observe how different attendings perform different aspects of the PE.
- A nice introductory video to the pediatric physical exam can be found at this webpage from COMSEP: https://www.comsep.org/educationalresources/currsupportservices.cfm
Heldrich-10: The curriculum
Structured and objective-based encounters with patients during clinical rounds with focus on bed-side examination skills is the cornerstone of this curriculum with this interactive page that includes audiovisual material as well as relevant and high-yield evidence-based physical examination data adapted from McGee's evidence-based physical diagnosis textbook (5) .
The curriculum is devised to address the following clinical competencies:
1. High-quality physical examination skills
2. Hypothesis-driven physical examination (HDPE) approach to patients (4)
3. Evidence-based physical diagnosis (5).
1. High-quality physical examination skills
2. Hypothesis-driven physical examination (HDPE) approach to patients (4)
3. Evidence-based physical diagnosis (5).
The hypothesis driven physical exam occurs when the clinician makes diagnostic hypothesis prior to examining the patient, and then tests those hypothesis with specific physical exam tests. This is in contrast to the standard head to toe exam. Note the head to toe exam can still be important to pick up unpredicted findings.
Web Based Curriculum
Web Based Curriculum
With each case, you will be served questions that will probe your approach, observation skills, and critical thinking of how to anticipate and interpret physical signs and symptoms that ultimately lead to improved clinical diagnosis skills. Consider using evidence based medicine during your reasoning.
It's all about having FUN while learning. Practice the physical exam maneuvers on real patients throughout this rotation.
Discuss answers with your co-resident and/or student. Email your answers to Eric (ebaligh1@jhmi.edu) before moving on to the answers. Or discuss with your colleague the answers. Teach each other.
Table of Contents
1. Neurologic Exam
2. Abdominal Exam
3. Endocrine Exam
4. Respiratory Exam
5. Musculoskeletal Exam
6. Head and Neck Exam
7. Opthalmologic Exam
8. Dermatologic Exam
9. Cardiovascular Exam
10. General Appearance- coming soon
Please fill out this quick survey prior to starting the curriculum. The password for the survey is heldrich.
Students click here
Interns click here
ARs click here
Case 1 : My Child is not acting like her normal self.
A 4 year old who presents with
sleepiness.
Q1:
Describe in detail her general condition and mental status. Is she sick?
Toxic? What does toxic mean? How else can you describe her? Use the best and most descriptors you can.
Q2: What
is your differential diagnosis? Using this differential diagnosis, what physical exam signs and/or maneuvers would you do to test those diagnoses (perform a Hypothesis Driven Physical Exam)?
Q3: What would be your plan (what tests would you order, what would you ask for from the nurses)?
Q3: What would be your plan (what tests would you order, what would you ask for from the nurses)?
Q4: Using
the differential diagnosis that you have now astutely developed, what
physical signs differentiate between meningitis and an encephalopathy?
Q5: How do you correctly perform a Brudzinski and Kernig sign?
Q6: For
the Brudzinski and Kernig signs, are these signs more sensitive or more specific in
detecting meningitis?
Click here for answers
Case 2: Abdominal pain
A 7 year old boy presents with abdominal pain since yesterday. He was sent home from school today because of the pain. No vomiting and no fever at home. He did not eat lunch today.
Q1: What other questions would you ask?
Q2: What is your differential diagnosis? Using this differential diagnosis, what physical exam signs and/or maneuvers would you do to test those diagnoses (perform a Hypothesis Driven Physical Exam)?
Q3: Describe his exam. Does his exam change your differential?
Q4: What would be your plan thus far? (assume the rest of the history and exam do not help you much in re-weighing the differential). His temperature is 100.5. Are there scores that could help?
Q5: What are some tips and methods you have learned with the abdominal exam?
Answers
Case 3: I am Shaky
A 15 year old who presents with
weight loss and tremors.
Q1: Describe what you observe.
Q2: What
is your differential diagnosis? Using this differential diagnosis, what physical exam signs and/or maneuvers would you do to test those diagnoses (perform a HDPE)? What questions would you ask on history? Any additional testing?
Click her for answers
Case 4: My child is having trouble breathing
F is a 7 month old male who
presents with trouble breathing.
Q1:
Describe his respiratory exam in detail. You can describe a lot even without
listening with a stethoscope.
Q2: What
is the differential diagnosis?
Q3: Using this differential diagnosis, what physical exam signs and/or maneuvers would you do to test those diagnoses (perform a HDPE)? What questions would you ask on history?
Q4: How would you approach this patient?
Q4: How would you approach this patient?
Q5: How do
you differentiate an obstructive lung disease (RADE/asthma) vs. pneumonia vs.
bronchiolitis.
Q6: What
is the difference between coarse crackles, fine crackles, wheezes, and rhonchi?
Are crackles helpful in detecting pneumonia?
Q7: What
is the likelihood ratio of heart failure in his case if the liver is palpated
3-4 cm below the costal margin?
Click here for answers
Case 5: Knee Swelling
B is a 7 year old male who
presents with knee swelling and limp.
Q1:
Describe the abnormal findings.
Q2: What
is the differential diagnosis? Using this differential diagnosis, what physical exam signs and/or maneuvers would you do to test those diagnoses (perform a Hypothesis Driven Physical Exam)? How do you differentiate intra-articular
swelling from extra-articular swelling?
Q3: In
addition to knee examination, what other physical sings can help you
differentiate between local pathology and systemic disease?
Q4: In
case of monoarthropathy of the hip, how can you differentiate between
transient synovitis and septic arthritis?
Case 6: Lumps and Bumps
10 year old boy with neck swelling and pain.
Q1: Describe the abnormal findings.
Q2: What is your differential diagnosis? Using this differential diagnosis, what physical exam signs and/or maneuvers would you do to test those diagnoses (perform a Hypothesis Driven Physical Exam)?
Click here for answers
Case 7: An eye on you!
FUNdoscopic examination can be , at times, anything but FUN. Proper technique is invaluable and knowing your landmarks is essential. Click Fundoscopic exam for quick refreshment.
To successfully conclude this exercise, you have to grab the nearest ophthalmoscope next to you, start practicing on your patients or co-resident.
Balighian's tips for opthalmoscopy:
1. Dark room, really dark. Your eyes will adjust so it won't be that dark anymore.
2. Use the least amount of light intensity you need (turn the intensity down some) so the pupil stays big. Use the large circle light for large pupils and smaller circle if the pupil is smaller.
3. Have your patient focus on a very specific thing over your shoulder as opposed to a general area so they do not just looking around
4. Do not block their line of sight to that specific thing when you are opthalmoscoping. They won't tell you that you did and they their eyes will rove.
5. Be patient. It's hard to be that close to someone for a long time but be patient.
Case 8: Rashes
Your dermatology knowledge is as good as your description and terminology. Its inevitable that you will encounter "funny rashes" in most of your patient population.
We encourage you to look for them in your patients, describe them adequately and categorize them into a focused differential diagnosis list. So, until you meet your next patient with a rash, here is a good collection.
For each of the following rashes describe , in dermatological terms, the primary and secondary characteristics.
You may use the Dermatological exam checklist as a reference. Discuss with your co-resident your description and differential diagnosis (of note, viral exanthem does NOT count!).
Article about this rash
Describe this rash. There is no texture. This is the back of a young child. What is your differential?
Click Here for the discussion
Describe this rash. What is your differential?
Click for discussion
Describe this lesion. What is your differential?
Click for this discussion
Case 9: A "broken" heart!
You are not a musician, yet you are expected to appreciate and identify the abnormal tones of the heart.
For your morning rounds or when you admit a new patient, use a systematic approach for auscultating and reporting of your findings.
Go to a patient bedside and perform CVS examination. Always ask yourself: Do I hear a murmur? Is it a benign one? if not, can I characterize it ? Do I need to investigate it more?
Reflect on your techniques with your co-resident, discuss how could it be improved and how can it help with assessment and diagnosis of the patient.
Use the Cardiovascular Examination checklist ,The Murmur Lab and pted.org as references to verify your findings and understand the underlying patho-physiology.
Post Survey. Please complete the post-survey when you are done. Thanks! The password is heldrich.
Students click here
Interns click here
ARs click here
Resources:
- Complementary Complete Physical Examination Checklist.
- The murmur lab http://murmurlab.org
- Congenital Heart Disease website: http://www.pted.org
- Congenital Heart Disease website: http://www.pted.org
- Stanford University clinical skills initiative http://stanfordmedicine25.stanford.edu
- Evidence based physical diagnosis. Steven McGee. Saunders. Second edition, 2007
- Zitelli and Davis atlas of pediatric physical diagnosis text book.
- Evidence based physical diagnosis. Steven McGee. Saunders. Second edition, 2007
- Zitelli and Davis atlas of pediatric physical diagnosis text book.
References:
(1) The Pediatrics Milestone Project, 2012
(2) Malcolm
S Knowles, Elwood F Holton III, Richard A Swanson. The Adult Learner. the
seventh edition, Elsevier Inc, 2011.
(3) Neighbour R. The inner consultation. 2nd edn. Oxford:
Radcliffe Publishing, 2004.
(4) Rachel Yudkowsky, Junji Otaki, Tali Lowenstein, Janet Riddle, Hiroshi Nishigori & Georges Bordage. A hypothesis-driven physical examination learning and assessment procedure for medical students: initial validity evidence. Medical education, 2009: 43: 729-40.
(5) McGee S. Evidence based physical diagnosis, Second edition, 2005.
(6) Susanna Almond, David Mant and Matthew Thompson. Diagnostic safety-netting. British Journal of General Practice, November 2009
(7) Bilavsky E, Leibovitz E, Elkon-Tamir E, Fruchtman Y, Ifergan G, Greenberg D. The diagnostic accuracy of the 'classic meningeal signs' in children with suspected bacterial meningitis. Eur J Emerg Med. 2013 Oct;20(5):361-3.
(4) Rachel Yudkowsky, Junji Otaki, Tali Lowenstein, Janet Riddle, Hiroshi Nishigori & Georges Bordage. A hypothesis-driven physical examination learning and assessment procedure for medical students: initial validity evidence. Medical education, 2009: 43: 729-40.
(5) McGee S. Evidence based physical diagnosis, Second edition, 2005.
(6) Susanna Almond, David Mant and Matthew Thompson. Diagnostic safety-netting. British Journal of General Practice, November 2009
(7) Bilavsky E, Leibovitz E, Elkon-Tamir E, Fruchtman Y, Ifergan G, Greenberg D. The diagnostic accuracy of the 'classic meningeal signs' in children with suspected bacterial meningitis. Eur J Emerg Med. 2013 Oct;20(5):361-3.
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