As a primer for this article, please enjoy the first half of this short video by the physician-blogger ZDoggMD (warning: seriously great Yoda impression):
I’ll be the first to admit it – I don’t always complete (or repeat) an entire physical exam on my patients. But that’s okay — sometimes only a “focused” physical is warranted; if my patient has cellulitis and her pupils were equal, round, and reactive to light & accommodation (“PERRLA”) last night at admission, the chances that this will have changed by this morning are very slim. But should I carry forward in the patient’s chart something myself or a colleague assessed at a previous time, hoping it was right the first time & hasn’t changed?
My experiences during my neurology rotation made me think about this. When your role is to provide a consult on a particular body system, it’s not only easier to be more thorough & focused – it’s expected. As I’ve observed, it’s the luxury of being a specialist (though the burden of providing an answer is higher) – while my internal medicine residents may be side-tracked by a nurse asking about the patient’s blood pressure medication, this is easily swatted away on a consult by saying something like “I’m with neurology, ask the patient’s primary team” (now, I AM the primary team).
I was consulted on a particular patient who had a right-sided resting tremor, gait ataxia (difficulty walking) & memory loss – she had metastatic breast cancer and it was feared that the cancer had spread to her brain & was potentially causing neurological deficits. This was documented by her medical intern, resident, and an attending physician.
The utility of the neurological exam is not just to identify a lesion, but to localize it. This patient’s exam, however, is what we would call “non-focal” – I could not elicit any hard signs that there was a structural problem with any part of her brain or spinal cord. In fact, her tremor was bilateral, involving both of her hands – being right-handed, she must have complained to the intern only about her right side. Further, it was not present at rest, but was an “intention tremor” – it worsened when she tried to carry out certain tasks with her hands. Her tenuous gait was simply due to weakness & her “memory loss” was mental cloudiness. Having received such intensive treatment for her cancer, the law of diagnostic parsimony (Occam’s razor) would favor drug toxicity. In this case, my attending agreed & an MRI was normal.
So while it’s possible that whoever did the original history & physical got some things wrong (or, cutting him or her some slack, made a typo), there’s no way you can convince me that the 3 doctors who carried this note over got these exam findings, apparent to an inexperienced student (and the patient, if you would just ask), wrong.
What do you think — in an age of high technology, does the art of the physical exam fall by the wayside? Is it really important, or is it an antiquity of a kind of medicine no longer valued? Do we short-change our patients by simply taking the word of the person who was in the room before us? Further, by marginalizing hand-laying, do we run the risk of appearing cold & sterile, distancing ourselves from our patients?
I do know this much – the patients with whom I’ve spent the most time going through an exam where often incredibly thankful, even when I haven’t done anything for them or couldn’t tell them exactly what was wrong.
“Sometimes I wonder whether today we take sufficient care to make a thorough physical examination before our patient starts off on the round of the laboratories, which have become so necessary that oftentimes we do not fully appreciate the value of our five senses in estimating the condition of the patient.” –Dr. Will Mayo