Why do most of us dread patients who complain of dizziness in the ED? Because it is so vague, and the differential is so broad from elusive posterior cerebellar strokes to ear wax clogging up our ear canals. And this is one of those diagnoses where the differential really depends upon performing a thorough physical examination.
Think really hard, when is the last time you focused upon getting a complete and accurate physical examination? In medical school, there are courses dedicated to the art. I always laugh when I think of my neurology attending who just loved to bang on different parts of the body with his reflex hammer to elicit cool reflexes.
Then comes the real world! Sure, we can see a waiting room full of patients on a busy day. But this is without writing a single note, not taking a bathroom break, and barely talking to consults. What, I wonder, could possibly be the accuracy of my physical exam findings during those days? Could we be missing important findings by skipping time consuming things such as pelvic exams?
We push so hard to be efficient, but what is the impact? Think of how often we probably inappropriately work up patients because we don’t take the time to do good exams. A great example: really deciphering right upper quadrant pain so that a patient gets an ultrasound to rule out cholecystitis versus quickly palpating the abdomen while taking a history and just going for an abdominal CT scan in order to find “something”.
Worst of all, we model this type of behavior for the medical students and junior residents who work with us. When is the last time you actually went back and reviewed the physical exam findings with your presenter? When they told you that the patient was tachypneic, did you go back to the bedside, lift up the shirt and count the breaths together?
But to do so requires a firm understanding of physical exam findings for yourself.
- Examine all of your patients thoroughly, focusing upon the pertinent systems for their diagnosis. Get them undressed!
- Try to make time to watch consult services perform their physical exams. For example neurology specializes in the neuro exam. They have a lot to potentially teach us.
- Review exam findings with medical students and junior residents which will improve your own skills.
- Open up a physical exam book. I used Bates Guide to Physical Examination and History Taking in medical school. There is no shame on opening it up now. For musculoskeletal examinations, The Orthopaedic Physical Exam by Bruce Reider is a must.
- Realize the extreme importance of physical exams! It is not as sexy as ultrasounding an optic nerve sheath diameter, but it is absolutely vital to our role as physicians.