American 

College of Physicians 
Internal Medicine Meeting 2021: Virtual Experience

Telemedicine Physical Exam Clinical Skills

Faculty and Disclosure Information
Professor:
Romela  Petrosyan, MD, Resident/Fellow Member
Nothing to Disclose.

Clinical questions to be addressed:
1. What are the Association of American Medical Colleges (AAMC) new standard of 
practice/competency measures for telemedicine?
2. What are some important limitations to the telemedicine physical examination in the practice of 
internal medicine?
3. What are three new strategies or techniques that can be used to maximize the information 
gathered from a telemedicine physical examination?

Posted Date:  April 27, 2021

©2021 American College of Physicians. All rights reserved. Reproduction of Internal Medicine Meeting 2021: Virtual Experience presentations, or 
print or electronic material associated with presentations, is prohibited without written permission from the ACP.

Any use of program content, the name of a speaker and/or program title, or the name of ACP without the written consent of ACP is prohibited. For 
purposes of the preceding sentence, “program content” includes, but is not limited to, oral presentations, audiovisual materials used by speakers, 
program handouts, and/or summaries of the same. This rule applies before, after, and during the meeting.
 Telemedicine Physical Exam
Tips and Tricks

April 29th, 2021

Romela Petrosyan, M.D.
Chair-Elect ACP Council of Resident and Fellow Members
Clinical Research Nephrology Fellow, Combined MGH & BWH Program,
Harvard Medical School
Member, ACP Clinical Skills Committee

Disclosure of Financial Relationships
Romela Petrosyan, M.D.

Nothing to disclose.

© 2021 American College of Physicians. All rights reserved. 1

 Objectives
1. List important limitations to the telemedicine physical examination
2. Identify 3 new strategies or techniques to maximize the information 
gathered from a telemedicine physical examination
3. Summarize the AAMC’s new standard of practice/competency 
measures for Telemedicine

Clinical Case:
Mass General Brigham 
Digital Case Repository

© 2021 American College of Physicians. All rights reserved. 2

 Digital Case Repository

Virtual Consult: Ventral Hernia
A 44‐year‐old male with a painless ventral hernia seeks virtual
pre‐operative evaluation and consultation

Digital Case Repository
History of Present Illness
• Overview/Setting: Patient at home; Physician in office
• Context: Initial consultation
• Chief Complaint:  Ventral hernia
• HPI: 44‐year‐old male s/p Hartmann’s procedure with descending colostomy, now 
s/p take down, who presents with chief complaint of a large, painless ventral 
wall hernia just to the left inferolateral aspect of the umbilicus where his prior 
surgical scar is located, measuring 10 x 8 cm and reducible on self‐palpation. 
• The patient first noticed the hernia several months after his Hartmann take‐
down surgery. 
• It enlarges when he coughs or bears down to defecate and makes it difficult to 
zip his jeans. No bloating. He is passing flatus and has a normal bowel 
movement every day. He does not take any medications.

© 2021 American College of Physicians. All rights reserved. 3

 Digital Case Repository
History Continued...
• ROS: No fevers, N/V/D/C, or blood in stools.  No abdominal bloating.  No dysuria or 
hematuria. No testicular pain. Eating/drinking normally.
• PMHx: HLD, diverticulitis, obesity
• PSHx: Hartmann’s colostomy (left descending), s/p takedown. Recovery was 
uncomplicated.
• FHx: No pertinent family history.
• Soc Hx: Denies drug, alcohol and tobacco use. Works as a software developer. No recent 
travel. 

Digital Case Repository

What aspects of the patient’s history indicate that the evaluation

can be completed remotely, and that he does not need to be
up-triaged to a clinic or Emergency Department for an in-person
evaluation at this time?
A. The hernia is painless.
B. His symptoms have been ongoing and unchanged for months.
C. No fevers.
D. No bloating, constipation, or vomiting
E. All of the above
F. None of the above

Clinical Pearl (Triage)

8

© 2021 American College of Physicians. All rights reserved. 4

 Digital Case Repository

What aspects of the patient’s history indicate that the evaluation

can be completed remotely, and that he does not need to be
up-triaged to a clinic or Emergency Department for an in-person
evaluation at this time?
A. The hernia is painless.
B. His symptoms have been ongoing and unchanged for months.
C. No fevers.
D. No bloating, constipation, or vomiting
E. All of the above
F. None of the above

Clinical Pearl (Triage)

9

Digital Case Repository
Physical Examination
• Vitals: RR 14 breaths/min, non‐labored; T 98.6F; HR 80, regular. No orthostatic 
symptoms with position change from sitting to standing (no BP cuff at home)
• EKG: (On smart watch) – N/A
• Exam: NAD. Obese. Pt is 6’3” and 280 lbs. 
• Abdominal self‐palpation: Soft. Non‐tender to palpation. Reducible 10x6 cm ventral 
wall hernia to left and inferior aspect of umbilicus, no overlying skin discoloration.
• Labs: N/A
• Imaging: CT A/P (ordered 2 days prior to virtual encounter) demonstrates 10x6 cm 
left inferolateral to umbilicus ventral hernia containing small bowel, without 
evidence of strangulation, incarceration or perforation.

10

© 2021 American College of Physicians. All rights reserved. 5

 Available Data:

11

Digital Case Repository

Based on his virtual abdominal exam, can you safely

continue to evaluate the patient remotely?
A. Yes – the exam is benign, and the patient can be safely evaluated
remotely
B. No – the exam is concerning for a strangulated hernia, and
should go directly to the Emergency Department
C. No – the exam is equivocal, and the patient should be evaluated
in clinic for an in-person abdominal examination
D. No – the patient does not have a blood pressure cuff, so he
should go to the clinic for evaluation.

Clinical Pearl (Abd Exam)

12

© 2021 American College of Physicians. All rights reserved. 6

 Digital Case Repository

Based on his virtual abdominal exam, can you safely

continue to evaluate the patient remotely?
A. Yes – the exam is benign, and the patient can be safely evaluated
remotely
B. No – the exam is concerning for a strangulated hernia, and should go
directly to the Emergency Department
C. No – the exam is equivocal, and the patient should be evaluated in clinic
for an in-person abdominal examination
D. No – the patient does not have a blood pressure cuff, so he should go to
the clinic for evaluation.

Clinical Pearl (Abd Exam)

13

Limitations and Advantages of 
Telemedicine

14

© 2021 American College of Physicians. All rights reserved. 7

 Limitations and Advantages of Telemedicine
Limitations Advantages
• Ability of patient to connect/utilize  • Connect with patients through a 
telemedicine platform different perspective
• Exam limited by quality of image/video • Increased frequency of visits
• Unable to auscultate without advanced  • Reduction of time needed to travel, 
technology
traffic, missing work, parking fees, etc.
• Lack of access to technology 
• Convenience and flexibility
(smartphones, computers, etc.)

• Limited availability of medical 
interpreters

15

15

Physical Exam (12 Organ Systems)

1. Constitutional (vital signs, general appearance)
2. Eyes
3. ENT (ear, nose, mouth, throat)
4. Cardiovascular
5. Respiratory
6. Abdominal
7. Genitourinary
8. Musculoskeletal
9. Skin
10. Neurological
11. Psychiatric
12. Heme/Lymphatic/Immunologic

16

© 2021 American College of Physicians. All rights reserved. 8

 Constitutional
Vital Signs
• Pulse (coach patient to check radial pulse,
have the patient count out loud to observe
regularity and measure rate)
• Respiratory Rate
• Temperature/Weight/Pulse Ox/BP
(devices at home)
• Visual Acuity: read newsprint > finger
counting > movement > light perception
• Note if wearing glasses/contacts, note if
vision corrected/uncorrected
• Ability to read newsprint at 100cm (3.2 ft) is
approximately 20/20 vision
• Ability to read newspaper headline is
approximately 20/80 vision
17

17

Constitutional
• Set up training/teaching
• Remind patients to maintain a 
journal of BP readings
• ValidateBP.org for resources

General/HEENT
• Alert, obvious pain, respiratory 
distress, home environment
• Palpate lymph nodes and pressing 
on sinuses
• Move neck through full range
• Pain with movement of the pinna

18

18

© 2021 American College of Physicians. All rights reserved. 9

 Cardiovascular
Neck: JVD
CV: Patient/assistant can 
demonstrate capillary refill to 
assess perfusion
Extremities: Swelling (sock 
indentation)

19

19

Respiratory
• Increased work of breathing
• Respiratory rate
• Nasal flaring
• Accessory muscle use
• Presence and quality of 
cough, sputum
• Prolongation of expiratory 
phase

20

20

© 2021 American College of Physicians. All rights reserved. 10

 Abdominal
• If possible, a supine abdominal exam with 
family/friend/caretaker
• Patient lays flat
• Assess for distention
• Family/caretaker gently presses down on abdomen (1‐4”)
• Note facial expressions
• CVA tenderness: assistant taps on back
• Have patient jump to assess for tenderness (peritoneal sign)

21

21

Abdominal
• Teach how to do palpation and landmarks
•Lower portion of ribs to middle of chest (find 
notch=xyphoid process) down to umbilicus
•Visualize skin of abdomen

22

22

© 2021 American College of Physicians. All rights reserved. 11

 Skin
• Teledermatology highly dependent on quality of 
image
• Signs of trauma, bruising/petechiae, rashes 
• Instruct patient to test whether rash blanches or test 
for Nikolsky sign
• Will need an assistant to operate the camera to see 
the scalp/back/posterior legs

23

23

Skin: Full View and Distribution of Concerning Lesions
Context and perspective may alter final diagnosis.

24

24

© 2021 American College of Physicians. All rights reserved. 12

 All of the following are tips to improve the quality of
information you can gather from the physical exam via
video EXCEPT:
A. Encourage the patient to identify someone they trust to assist with the exam
B. Provide clear directions to the patient and/or their assistant how to position
the camera
C. Take time initially to observe the patient to assess acuity, home environment
and cognition
D. Discourage patients with a dermatologic complaint from uploading static
photos through the portal, video viewing of the rash/lesion should be
sufficient

25

All of the following are tips to improve the quality of

information you can gather from the physical exam via
video EXCEPT:
A. Encourage the patient to identify someone they trust to assist with the exam
B. Provide clear directions to the patient and/or their assistant how to position
the camera
C. Take time initially to observe the patient to assess acuity, home environment
and cognition
D. Discourage patients with a dermatologic complaint from uploading
static photos through the portal, video viewing of the rash/lesion
should be sufficient

26

© 2021 American College of Physicians. All rights reserved. 13

 All of the following are reasons to convert a video visit to
an in-person visit EXCEPT?

A. The exam via video is equivocal or concerning

B. The patient and/or assistant is not able to position the camera effectively
and a physical exam is necessary
C. The patient does not have remote monitoring capabilities and these data are
essential to your assessment (home BP cuff, pulse oximeter, etc…)
D. You have openings in your in-office schedule you need to fill

27

All of the following are reasons to convert a video visit to

an in-person visit EXCEPT?

A. The exam via video is equivocal or concerning

B. The patient and/or assistant is not able to position the camera effectively
and a physical exam is necessary
C. The patient does not have remote monitoring capabilities and these data are
essential to your assessment (home BP cuff, pulse oximeter, etc…)
D. You have openings in your in-office schedule you need to fill

28

© 2021 American College of Physicians. All rights reserved. 14

 Summary

29

Summary
• Educate/prepare patients prior to telehealth visit
• Involve trusted care partner/family member
• Be mindful of camera position—static or dynamic
• Observe: home, acuity, cognition
• Instruct by demonstrating exam
• Assessment of patient dependent on context

30

30

© 2021 American College of Physicians. All rights reserved. 15

 www.virtualcarecompetency.com

31

AAMC Telehealth Competencies – September 2020

AAMC Domain Telehealth Competency Goals

Patient Safety and Appropriate
Use of Telehealth
Data Collection and Assessment
Communication Via Telehealth
Clinicians will understand when and why to use telehealth, as well as assess patient
readiness, patient safety, practice readiness, and end user readiness.
Clinicians will obtain and manage clinical information via telehealth to ensure appropriate
high-quality care.
Specific to telehealth, clinicians will effectively communicate with patients, families,
caregivers, and health care team members using telehealth modalities. They will also integrate
both the transmission and receipt of information with the goal of effective knowledge
transfer, professionalism, and understanding within a therapeutic relationship.

Ethical Practices and Legal
Requirements for Telehealth
Technology for Telehealth
Access and Equity in Telehealth
https://www.aamc.org/system/files/2020-09/hca-telehealthcollection-telehealth-competencies.pdf
Clinicians will understand the federal, state, and local facility practice requirements to meet
the minimal standards to deliver healthcare via telehealth. Clinicians will maintain patient
privacy while minimizing risk to the clinician and patient during telehealth encounters, while
putting the patient interest first and preserving or enhancing the doctor-patient relationship.
Clinicians will have basic knowledge of technology needed for the delivery of high-quality
telehealth services.
Clinicians will have an understanding of telehealth delivery that addresses and mitigates
cultural biases as well as physician bias for or against telehealth, accounts for physical and
mental disabilities, and non-health related individual and community needs and limitations to
promote equitable access to care

32

© 2021 American College of Physicians. All rights reserved. 16

 Telemedicine Discussion:  3:00‐3:45pm EST Thursday
Share your perspectives on ramping up your telemedicine practice at an informal, 
drop‐in discussion hosted by ACP staff. 
• What resources were most helpful to you? 

• What challenges are you still facing? 

• What would you like ACP to offer to help you achieve sustainable and optimal integration 
of telemedicine into your practice?

Go to:  “ACP Featured Networking Experiences” in the Exhibit Hall for this event.

33

Thank You!

34

© 2021 American College of Physicians. All rights reserved. 17

 References
• Ansary AM, Martinez JN, Scott JD. The virtual physical exam in the 21st century. J Telemed Telecare. 2019 Nov 6:1357633X19878330. doi:
10.1177/1357633X19878330. Epub ahead of print. PMID: 31690169.
• Batsis JA, Pletcher SN, Stahl JE. Telemedicine and primary care obesity management in rural areas - innovative approach for older adults? BMC Geriatr.
2017 Jan 5;17(1):6. doi: 10.1186/s12877-016-0396-x. PMID: 28056832; PMCID: PMC5216556.
• Donaghy E, Atherton H, Hammersley V, McNeilly H, Bikker A, Robbins L, Campbell J, McKinstry B. Acceptability, benefits, and challenges of video
consulting: a qualitative study in primary care. Br J Gen Pract. 2019 Aug 29;69(686):e586-e594. doi: 10.3399/bjgp19X704141. PMID: 31160368; PMCID:
PMC6617540.
• Greenhalgh T, Koh GCH, Car J. Covid-19: a remote assessment in primary care. BMJ. 2020 Mar 25;368:m1182. doi: 10.1136/bmj.m1182. PMID: 32213507.
• Hammersley V, Donaghy E, Parker R, McNeilly H, Atherton H, Bikker A, Campbell J, McKinstry B. Comparing the content and quality of video, telephone,
and face-to-face consultations: a non-randomised, quasi-experimental, exploratory study in UK primary care. Br J Gen Pract. 2019 Aug 29;69(686):e595-
e604. doi: 10.3399/bjgp19X704573. PMID: 31262846; PMCID: PMC6607843.
• Lee JJ, English JC 3rd. Teledermatology: A Review and Update. Am J Clin Dermatol. 2018;19(2):253-260.
• Liu S, Tanaka R, Barr S, Nolan RP. Effects of self-guided e-counseling on health behaviors and blood pressure: Results of a randomized trial. Patient Educ
Couns. 2020 Mar;103(3):635-641. doi: 10.1016/j.pec.2019.10.007. Epub 2019 Oct 19. PMID: 31669047.
• McConnell KJ, Charlesworth CJ, Zhu JM, Meath THA, George RM, Davis MM, Saha S, Kim H. Access to Primary, Mental Health, and Specialty Care: a
Comparison of Medicaid and Commercially Insured Populations in Oregon. J Gen Intern Med. 2020 Jan;35(1):247-254. doi: 10.1007/s11606-019-05439-z.
Epub 2019 Oct 28. PMID: 31659659; PMCID: PMC6957609.
• Mihalj M, Carrel T, Gregoric ID, Andereggen L, Zinn PO, Doll D, Stueber F, Gabriel RA, Urman RD, Luedi MM. Telemedicine for preoperative assessment
during a COVID-19 pandemic: Recommendations for clinical care. Best Pract Res Clin Anaesthesiol. 2020 Jun;34(2):345-351. doi:
10.1016/j.bpa.2020.05.001. Epub 2020 May 14. PMID: 32711839; PMCID: PMC7255146.
• Powell RE, Henstenburg JM, Cooper G, Hollander JE, Rising KL. Patient Perceptions of Telehealth Primary Care Video Visits. Ann Fam Med. 2017
May;15(3):225-229. doi: 10.1370/afm.2095. PMID: 28483887; PMCID: PMC5422083.
• Rasmussen OW, Lauszus FF, Loekke M. Telemedicine compared with standard care in type 2 diabetes mellitus: A randomized trial in an outpatient clinic. J
Telemed Telecare. 2016 Sep;22(6):363-8. doi: 10.1177/1357633X15608984. Epub 2015 Oct 14. PMID: 26468213.
• Seuren LM, Wherton J, Greenhalgh T, Cameron D, A'Court C, Shaw SE. Physical Examinations via Video for Patients With Heart Failure: Qualitative Study
Using Conversation Analysis. J Med Internet Res. 2020 Feb 20;22(2):e16694. doi: 10.2196/16694. PMID: 32130133; PMCID: PMC7059096.
• Weinstein RS, Krupinski EA, Doarn CR. Clinical Examination Component of Telemedicine, Telehealth, mHealth, and Connected Health Medical Practices.
Med Clin North Am. 2018 May;102(3):533-544. doi: 10.1016/j.mcna.2018.01.002. PMID: 29650074.
• Image Credit: https://www.shoreeye.com/news/blog/160-how-does-shingles-effect-my-eye, Measuring capillary refill time on the finger. © Nazir Hamid,
http://acuclinic.com.au/pocit/JVP.htm, © alphabetMN/iStock

35

© 2021 American College of Physicians. All rights reserved. 18