Wednesday, August 6, 2014
How and when is the physical exam useful?
Danielle Ofri, MD, FACP, has an important piece in the New York Times, titled “The Physical Exam as Refuge.” As an outpatient physician, she makes the case that the physical examination provides a special time for the physician to focus entirely on the patient. Is examination time the refuge for the harried physician, and the opportunity to engage the patient in extended conversation about their condition?
While I did outpatient medicine for almost 20 years, for the past 15 I have focused only on inpatient medicine. As some comments suggest, the physical examination yields more information when the patient has clinical symptoms that when the examination is routine.
I believe that the physical examination is useful in evaluating the hospitalized patient. Without spending much time I can quickly remember three recent patients who we helped considerably because of physical findings.
Patient #1 presented with nausea and vomiting. She had a history of intermittent vomiting for 6 months, approximately once every other day. She had some blood in her vomitus the night before, leading to her admission. Her abdominal film had some air fluid levels, but the radiologist read the film as “unremarkable.”
At the bedside, she complained of abdominal discomfort and continued vomiting, several times since admission. I started with the simple procedure of listening for bowel sounds. After not hearing any for 3 minutes, I asked the intern and resident to listen, and they too heard none. She had just vomited and we were able to see her vomitus was feculent. Obviously, we diagnosed her small bowel obstruction. Her CT confirmed our clinical diagnosis, and more importantly showed that she had an intussusception caused by a previous Roux-en-Y anastomosis. Surgery within 2 hours saved her bowel.
Patient #2 presented with chest pain. The chest pain was atypical, but because of his age, the resident had ordered a stress test. At the bedside, the patient said that his chest pain had resolved, but he complained of right upper quadrant pain. He told us that that pain started about 2 months ago, and was his major complaint.
On physical examination he had a positive Murphy’s sign. We suspected gallbladder disease as both the cause of his abdominal pain and perhaps his chest pain. The ultrasound showed a normal gallbladder and common duct, but also revealed a liver mass. The liver mass was eventually diagnosed as a Staph abscess, and the patient did well after drainage. The physical exam (combined with the history) changed our prioritization of his problems.
Patient #3 presented with recurrent pancreatitis. At first meeting, I shook her hand and immediately noted how cold the hand was. Noticing that she was sweating, I examined all her extremities. Both hands and both feet were “ice cold”. Obviously, this finding changed our consideration of her stability.
Other examples come to mind as I type this rant. I have written before about the value of watching the patient walk. We still diagnose pneumonia and pleural effusions with physical exams.
The physical exam is valuable, but is a routine physical exam valuable? While the data do not support the value, we should not extrapolate from the concept of “routine physical exam” to the practice of examinations targeted by a careful history.
There are several reasons for doing a careful physical examination. We must work at this skill and have it as a valuable diagnostic tool. The physical exam can help the patient and the physician. We should not ignore learning it and therefore teaching it.
db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.
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