Trusting the Exam (Part Two)


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Part two begins where part one left off: history complete, we move to the tried and true physical exam. Which is neither tried, nor true. Discuss.

There are two types of complaints: those that warrant a physical exam and those that don’t. (Controversy! Gasp!) I think the physical exam will always remain a part of medicine, as it should: I believe patients like — and perhaps even benefit from — the laying on of hands. The fact that the physical exam takes time, concentration, and attention to one single person, when often in the emergency department we are constantly having to interrupt patients with phone calls, EKGs to interpret, or pages overhead. The physical exam requires a physician’s presence. It makes patients feel that the physician is being thorough, even when it may not change your plan one bit. You’ve made up your mind a long time ago it’s a cold, but looking in the mouth and the ears, listening to the lungs, feeling the neck and patting the shoulder with comfort may be the difference between “this doctor doesn’t care and rushed through everything and I think I need antibiotics” to “Okay, I trust and believe this guy.” I especially find reporting what I find to patients helpful. “Great, lungs are clear, ears look normal as well!”

But really, often, the physical exam doesn’t matter. You’re a 70 year-old febrile smoker with a new productive cough? I don’t care how clear your lungs sound to auscultation bilaterally, you’re getting an x-ray. Now, some will argue that the physical exam has gone by the wayside because our physical exam skills have deteriorated as we’ve had to see more patients in a shorter period of time; this is especially true in the emergency department with patients in pain, crowded, less-than-private exam rooms and a noisy environment prone to missing 1/6 systolic ejection murmurs. Sure. Fine. I don’t percuss my patient’s lungs routinely, nor do I listen for egophony. Whip out your copy of Evidence-Based Physical Diagnosis and you’ll find the physical exam, in many circumstances, just ain’t that great. Take pneumonia. Crackles has a likelihood ratio of 1.5-2.5; decreased breath sounds about 2; egophany about 2 to a respectable 8, depending on the study. Orthostatics suck for evaluating hypovolemia (LR+ less than 2), and everyone knows palpating a AAA is rare. Whip out your trusty Fagan nomogram, and these likelihood ratios aren’t moving you anywhere, fast. Take something like temporal arteritis — something we’re even less familiar or comfortable with than pneumonia –and having or lacking temporal artery tenderness barely changes anything. (Note, the “Does This Patient Have” Rational Clinical Examination series in JAMA, which is often summarized in the Annals of EM often provides a great list of these.)

And then there’s the cases where the physical exam is going to move your workup in one way or another. The neuro exam, the abdominal exam, the pelvic exam, por ejemplo. Vomiting, abdominal pain, tender is a very different story from vomiting, abdominal pain, not tender. Or cervical motion tenderness versus not. Os open versus os closed. Left-sided weakness with pronator drift.

Scrap the physical exam entirely? But then what’s the alternative? We image everything, work everything up? And cause how many cancers and incidentalomas and further complications?

It seems to always come back to that one thing in medicine: the art of it all. That intangible bit that makes guidelines impossible to write or adhere to, that makes the individual patient in front of you the conundrum and challenge, but also the curiosity. Finding that sweet spot on medicine’s moving target.

The physical exam is flawed, just as we are (our patients’ bodies don’t read the textbooks, either). It’s not the end-all be-all if your clinical suspicion is high, but should be taken together with all the other information you’ve got to make your diagnosis, plain and simple.

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  1. #1 by vc - July 15th, 2013 at 05:33

    cszaasasas

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