I recently presented a vertiginous patient to my attending, after already having the discharge instructions printed and signed. Of course the attending comes back to me and states emphatically that the patient needs to be ruled out for a stroke! Through my exam, the patient had a peripheral cause of vertigo. Through the attending’s exam, the patient had a central cause of vertigo.
Upon hearing this, I slapped my hand against my forehead and quickly ran after the patient to make sure they didn’t leave.
How could I have gotten this diagnosis so wrong? Or at least, how did I and my attending come to two entirely polar conclusions regarding the patient with vertigo? Obviously, the answer comes down to history taking and physical examination.
I want to focus this write up on physical exam findings. Think really really hard, when is the last time you focused upon getting an accurate physical exam? In medical school, there are courses dedicated to fine tuning the art of physical exam. At my medical school, we spent the first two years of medical school understanding each body system and the numerous methods by which to thoroughly examine the patient. We scoured the body for Roth spots, we auscultated for elusive murmurs, and of course we always checked for dolls eye. Then came the clinical years in medical school where I watched stressed out residents just try to make it through each day. One of the rare times I remember focusing upon the physical exam was on my neurology block. I had an attending who just loved to bang on different parts of the body to elicit cool reflexes.
Then came residency! Sure, I can see 20+ plus patients on a busy day. But this is without writing a single T sheet, not taking a bathroom break, and barely talking to consults. What, I wonder, could possibly be the accuracy of my physical exam findings during those days?
We push so hard to be efficient, we take pride on being clinical monsters, but what is the impact on physical exams? Think of how often we probably inappropriately work up patients because we don’t take the time to do good exams. A great example, really deciphering right upper quadrant pain so that a patient gets an ultrasound to rule out cholecystitis versus quickly palpating the abdomen while taking a history and just going for an abdominal cat scan in order to find “something”.
Worse of all, we model this type of behavior for the medical students and junior residents who work with us. When is the last time you actually went back and reviewed the physical exam findings of a medical student who was presenting to you? When they told you that the patient was tachypneic, did you go back to the bedside, lift up the shirt and count the breaths together?
But to do so requires a firm understanding of physical exam findings for yourself. How do you do this?
Here are my thoughts:
- Examine all of your patients thoroughly, focusing upon the pertinent systems for their diagnosis. Get them undressed!
- Try to make time to watch consult services perform their physical exams, for example neurology specializes in the neuro exam, they have a lot to potentially teach us.
- Review exam findings with medical students and junior residents which will improve your own skills.
- Open up a physical exam book, I used Bates Guide to physical exam findings in medical school. There is no shame on opening it up now even in residency.
- Realize the extreme importance of physical exams! It is not as sexy as ultrasounding an optic nerve sheath, but it is absolutely vital to our role as physicians.
Going back to my stroke patient, I reexamined him (with a lot more humility). I realized that I had forgotten key parts of the neurology exam that were critical to vertigo work up such as assessing for nystagmus. And because I had the time, I watched neurology perform their own physical exam on the patient which allowed me to discuss findings with the consult resident and learn even more.
Bottom line – take time to understand the importance of the basics!
Nikita
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This is a very good example to highlight the physical exam. There are a lot of complaints where physical exam may not make a large difference in the patient outcome or diagnosis but neurologic complaints the exam is huge. If you do a complete neuro exam everytime it is pertinent it will become very easy to perform a complete and quick exam. Do it the same way everytime and it will become second nature and won’t miss anything. Don’t forget the cerebellar exam and the gait … caught a couple of mild strokes this way
Most chief complaints have one or two physical exams you do not want to miss. Be thorough and consistent.
Another interesting debate in the conversation of physical exams are the role of bedside sonos.. .. here is a post off of a sono blog by a doctor out at Stanford and her thoughts on the role of bedside sono and physical exams.
http://sonospot.wordpress.com/2012/11/08/sonopolitics-bedside-ultrasound-is-not-an-extension-of-the-physical-exam-its-much-more/