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Is the Physical Exam Obsolete?. Charles V. Sanders, M.D., M.A.C.P. Edgar Hull Professor and Chairman Department of Medicine LSU Health Sciences Center New Orleans, LA [email protected] March 25, 2011. Is the Physical Exam Obsolete?. And neither is taking a history!.

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Is the Physical Exam Obsolete?

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Is the Physical Exam Obsolete?

Charles V. Sanders, M.D., M.A.C.P.

Edgar Hull Professor and Chairman

Department of Medicine

LSU Health Sciences Center

New Orleans, LA

[email protected]

March 25, 2011


Is the Physical Exam Obsolete?

And neither is taking a history!

History

Physical Exam

Hand

Glove


New York Times October 11, 2010


Guide for Rounding with Dr. Sanders

FACTS

History

Physical Exam

Abnormal tests

(Labs, X-ray, etc)

HYPOTHESIS

Problem List

Differential Diagnosis

WIGOH?

WEIGOH?


1. Establishes a bond with the patient

2. It is fun-an opportunity to teach and learn

3. Compliments the history

4. Diagnosis-hypertension and obesity

5. Saves money

6. Saves lives

7. Creates interest in internal medicine**

8. Assists in deciding what tests to order

9. It is not obsolete

10. It will survive!

** Dr. Muslow-my mentor

C.V. Sanders, M.D.

My Thoughts-Physical Exam


“ To study the phenomena of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all…”Sir William Osler 1849-1919


“Medicine should begin with the

patient, continue with the patient,

and end with the patient”

Sir William Osler


“Learn to see, learn to hear, learn

to feel, learn to smell and know

that by practice alone can you

become experts.” “Medicine

is learned by the bedside and not

in the class room”

Sir William Osler


“In our era of diagnostic imaging

how careful are we when we

examine patients? How skilled

are we as practitioners of the

physical examination? If we don’t

listen we will never hear, if we don’t

look we will never see, if we don’t

touch we will never feel”

Roger Cass

Ann Intern Med June 1, 1989


“I sometimes joke that if you come to our hospital missing a finger, no one will believe you until we get a CAT scan, an MRI and an orthopedic consult. We just don’t trust our senses”

Abraham Verghese

NPR The Fading Art of the Physical

Exam September 20, 2010


NEJM December 25, 2008


March 11, 2011


My left eye is red and painful

• 50 y/o woman with a 3 day history of left eye pain and redness

• Two week history of intermittent burning, 5/10 left sided abdominal pain

• 20 # (unintentional) weight loss over 4 mo.

• Brother died of colon cancer at 49 y/o

PE: left subconjunctival hemorrhage and tenderness and guarding over left side of abdomen. Stool – for occult blood

• Hgb/Hct 11.2/34.4 (87.2) Ferritin + 4.0 (N 20-210)

• CT of abdomen-mass in the splenic flexure

• Colonoscopy- 5 x 3 cm. mass in splenic flexure


My throat is sore and my neck hurts

• 28 y/o woman with several-day history of fever, sore throat and malaise.

• PE She appears tired and has a fever of 102°. Diffuse pharyngeal erythema,

right posterior tender cervical adenopathy and splenomegaly.

• WBC is 30, 900 with 86% atypical lymphs.- Monospot +

• Acute abdominal series, ultrasound RUQ, and CT of abdomen and pelvis!


My bottom is so sore I can hardly walk

• 51 y/o man with above complaints. Two weeks ago smoked cocaine for 5 days-during this time his ears became swollen, painful and black. Ten days later noted that his right breast was painful, swollen and dark.

PE T = 101° P= 103; Ears and right breast; tenderness around anus-refused digital exam.

Labs: Albumin 2.9, ESR 85 and CRP 12.69

Urine + for cocaine and THC


The physical exam saves lives!!!!!

• 77 y/o man admitted to CHNO because of a stroke. We were asked to see the patient because he had a low-grade fever and crackes at his left posterior lung base. The resident thought that there was a left pleural effusion and planned to do a thoracentesis.

I found decreased vocal fremitus, dullness, decreased breath sounds and crackles at the left posterior lung base. I could not hear heart tones over the anterior precordium but found a bifid apex beat at the tip of the left scapula! WIGOH?


Christmas treat to chronic cough

• 63 y/o woman presents to ED with CC of dry hacking cough x 9 weeks. Multiple visits to ER and multiple course of antibiotics for “bronchitis”. Fever, malaise, night sweats, pleuritic right chest pain and 14# weight loss over 9 weeks

PE T= 101.2° R= 34; appeared chronically ill; paroxysms of cough during exam and an intermittent wheeze and crackles over right posterior chest

WBC =13.7K-L shift

Chest X-ray RLL infiltrate

Pulmonary consult: Dr. deBoisblanc


It looked like lung cancer

• 55 y/o alcoholic man with 6 month history of cough, occ. purulent sputum, fever, night sweats and 60# weight loss- 60 pack- year smoking history

• Patient was very cachectic

PE T= 100° P= 90 R= 20 BP= 110/70

Crackles and decreased breath sounds and decreased vocal fremitus at left posterior lung base and mass on left lower chest wall


Pneumonia that wasn’t

• 32 y/o diabetic man who presents with 4-5 day history of SOB, NP cough and subjective fever

• PE: R= 20 and crackles, dullness and decreased breath sounds at both posterior lung bases.

• Patient given IV penicillin G for “pneumonia” but SOB persisted.

• I saw patient in consultation and obtained a history of PND, orthopnea, nocturia and squeezing substernal chest pain. There was a prominent S3


JAMA, January 12, 2011


Morbid obesity and RUQ mass and tenderness

• 71 y/ woman with these problems:

Respiratory distress 11. R flank tender

Chest pain-CAD 12. Anasarca

Acute kidney injury

Anemia

DM-II

Tobacco abuse

Morbid obesity-BMI 41

Gout

Osteoarthritis

Cholelithiasis*


Both legs weak since 12-17-2010

• 51y/o man with pain and leg weakness (R > L) since12-17-10. Pain posterior aspect both thighs-non-radiating

PE Could not extend fingers right hand

Circumduction gait on right

Hyperactive knee jerk

Bilateral sustained ankle clonus

Right Babinski

Marked weakness of finger extension R

Hand

Video of patient and imaging studies


February 24, 2011


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