Honorable
Mention
2014 Richard Spear, MD,
Memorial Essay Contest
Warm and Dead?
Martin Huecker, MD
P
ERRL. CTAB. RRR. Soft NTND. We
write and dictate these acronyms so
often they seem to lose meaning. Sometimes I wonder, did I actively elicit these signs?
Did I actually listen to the lung sounds when I
auscultated? Does what I found matter in the
average patient? Is the physical exam dead?
With residents, I solemnly reflect upon the
diminishing emphasis on physical exam in education. Sure the
lungs sound clear, but we will likely obtain an X-ray to rule out
pneumonia. No conjunctival icterus or yellow under the tongue, but
still the bilirubin could be elevated. The Ottawa ankle rule obviated
the radiograph in Mr. Smith, but he’s not leaving without an X-ray.
EMS transmits the STEMI ECG and I activate the Cath Lab before
the patient even arrives. Does his physical exam matter?
Recently Dr. Sheri Welch wrote about the changing role of the
physical exam. She noted studies from the 1970s and 1990s showing physical exam contributing to a patient’s diagnosis 10 and 12
percent of the time. This was pre-everyone gets a CT- era. Welch
notes the lack of physical exam findings incorporated into modern
decision rules, the waning function of digital rectal exam in trauma,
and the apparent lack of utility of the pelvic exam in first trimester
bleeding. Another study suggests the pelvic exam may not change
management in most female patients with abdominal pain.
But Dr. Welch does not devalue the physical exam. She echoes
the appeal of Dr. Abraham Verghese that our patients want to be
touched – they are expecting more examination than we are giving.
This contrasts the discrediting looks I receive from patients when I
explain that their abdominal exam suggests a CT is not indicated to
rule out appendicitis. However, I agree that patients, often tacitly,
rely on some physical exam for a sense of connection (and in 2014
they also want their money’s worth).
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LOUISVILLE MEDICINE
With attention to these concerns, I decided to more closely observe
the implications of physical examination in a week at work. What
I found in the resuscitation of critically ill patients surprised me.
First patient: EMS brings her in short of breath. She is sweating,
hypertensive, tachypneic, speaks few-word sentences and cannot
give history. Physical exam is remarkable: JVD, crackles in bases,
peripheral edema, rapid pulse, frothy sputum. Start BiPAP, Nitro
drip, enalaprilat. We can order a BNP, troponin, chest X-ray, but
these will not alter her course.
Next patient: He is vomiting coffee grounds and blood and cannot
give history. On exam I feel a pulse of 140. Patient looks pregnant,
dilated veins on the abdomen, spider angiomata on chest. I palpate
a firm, enlarged liver. He has dry mucous membranes. I sit him up
and he turns pale, almost pa