HonOrable Mention
2014 Richard Spear, MD, Memorial Essay Contest
occluded with secretions and patient not breathing, unconscious. I
intubate. Breathing shows no breath sounds on the left and paradoxical motion of a section of crunchy ribs. Chest tube placed. Cardiovascular exam shows no pulse in the left foot. I notice the hip is
internally rotated and the limb is shortened. After the perfunctory
X-ray, I will reduce the hip dislocation. Next, his pupils: one is dilated,
manual pulse check shows a heart rate of fifty. Bad news in the brain.
The neurosurgeon still needs a head CT, but I have his attention
(a facetious neurosurgical physical exam description: “Move your
right arm, move your left arm, what’s the CT show?”). We start
mannitol and elevate his head en route to CT. I have diagnosed
and temporized a severe head injury with increased intracranial
pressure, respiratory failure, pneumothorax and flail chest all with
physical exam alone.
In these patients I made decisions and witnessed the effects of
interventions based solely on physical exam findings. The most telling but rarely mentioned aspect of the physical exam, the general
appearance, represents the culmination of years of our “practice”
of medicine. Our art lies in this trained intuition inherent in the
ability to walk into a room, immediately read the situation and
begin caring for a patient.
Understanding the importance of a call to action, Dr. Welch proposes a five component physical exam to be done with all patients:
tactile temperature, manual pulse, stethoscope on the chest, push
on the belly, and a three-pronged neurological exam. Taking less
than a few minutes, these gestures will leave the patient with an
impression of completeness and satisfaction.
I propose a different call to action. Every workday we each recognize a physical exam finding that clinched a diagnosis or had
some true impact on patient care. In critically ill patients, I am
now convinced this will be easy. But in the monotonous day at the
office completing well checks and pap smears, I insist we have not
left Osler so far behind that we can simply autopilot every physical
exam as a means to the end of “real” diagnostics. The physical exam
just needs a little appreciation, resuscitation. Let’s not pronounce it
unless it is warm and dead.
References
Welch, Shari. Does a 10-Item Physical Exam Add Value to Patient
Care? ACEP Now: Vol 33 – No 02 – February 2014.
Hampton JR, Harrison MJ, Mitchell JR, et al. Relative contributions of history-taking, physical examination, and laboratory investigation to diagnosis and management of medical outpatients.
Br Med J. 1975;2:486-489.
Peterson MC, Holbrook JH, Von Hales D, et al. Contributions of
the history, physical examination, and laboratory investigation in
making medical diagnoses. West J Med. 1992;156:163-165.
Aldous SJ, Richards MA, Cullen L, et al. A new improved accelerated diagnostic protocol safely identifies low-risk patients with
chest pain in the emergency department. Acad Emerg Med.
2012;19:510-516.
Esposito TJ, Ingraham A, Luchette FA, et al. Reasons to omit digital
rectal exam in trauma patients: no fingers, no rectum, no useful
additional information. J Trauma. 2005;59:1314-1319.
Johnstone C. Vaginal examination does not improve diagnostic
accuracy in early pregnancy bleeding. Emerg Med Australasia.
2013;25:219-222.
Jeremy Brown, MD, Rita Fleming, MD, Jamie Aristzabel, MD, and
Rocksolana Gishta, BA. Does Pelvic Exam in the Emergency Department Add Useful Information? West J Emerg Med. May 2011;
12(2): 208–212.
Kravitz RL, Cope DW, Bhrany V, et al. Internal medicine patients’
expectations for care during office visits. J Gen Intern Med.
1994;9:75-81.
Bell RA, Kravitx RL, Thom D, et al. Unmet expectations for
care and the patient-physician relationship. J Gen Intern Med.
2002;17:817-824. LM
Note: Martin Huecker, MD, is a full time faculty member at the
University of Louisville who practices Emergency Medicine with the
University of Louisville Physicians group.
The Richard Spear, MD, Memorial Essay Contest is a yearly writing competition hosted by the Greater Louisville Medical Society. Dr. Richard Spear, a respected Louisville general surgeon, passed away in 2007 and left
GLMS a bequest to fund an annual essay contest. To view the Richard Spear, MD, Memorial Essay Contest
archives, visit www.glms.org/Default.aspx?PageID=530
July 2014
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