Friday, October 15, 2010

A Physical Exam Tale

I have a physician friend who told me the following tale.

A veteran nurse, well-versed in the art and science of diagnosis, came down with a sharp nagging supraclavicular pain.

Finally, when she could stand the pain no longer, she went to the emergency room, where she saw five specialists, who did a battery of imaging and blood tests to no avail.

Finally, she happened to visit my friend, a neighbor and a physician, and shared her frustrations.

He asked , ‘Where’s the pain?” She pointed to the source of the pain. He palpated the area of the pain, and he said, “There’s a mass here, and it’s about 2 cm by 5 cm. A biopsy needs to be done."

As it turned out, none of the 5 specialists had done a physical.

The moral of the tale is: do a physical before you rely on technology. About 70 % of the time, the history and the physical reveal the diagnosis.

If you want to learn more about the dying art of the physical, read “Physician Revives a Dying Art: The Physical,” NYT, October 11.

Doctor Abraham Vergese, a Stanford Professor of Medicine, tells how he teaches the physical to medical students.

He informs them the most important part of the stethoscope is between the ears.

Some doctors would gladly let the exam go, he says, claiming technology renders it obsolete and that there are better ways to spend their time with patients.

Some students admit they do the exam as a token gesture, because patients expect it.

Doctor Vergese is out to save the physical exam because it seems to be disappearing as an art in an era of CT, ultrasound, M.R.I., and countless lab tests.

As an example of what he teaches, Vergese asks students, “What if the patient says, ‘Whatever you do, Doc, don’t bump the bed?' ”

Vergese answers, “Consider peritonitis.”

In some cases,listening, observing, smelling, touching, and palpating, works better than high tech.

When all else fails, consider the physical and listen to what the patient is saying. You never know what you might hear, find, or feel.

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