Monday, April 27, 2009

The dying art of physical exam



I got called about an older lady to evaluate for a possible bowel obstruction. When I saw her, she looked fine. She denied nausea or abdominal pain. She was hungry. She'd been in the hospital for over a week, recovering from dehydration and a bad bout of pneumonia. On exam felt an obvious large, soft, mobile mass in the left lower quadrant. So I got a CT scan, seen above.

She'd been in the hospital for over a week. I was the fifth and latest consultant on the case. Reading through the chart, I kept seeing the same description of the abdominal exam in the progress notes of the various doctors involved: soft, non-tender, non-distended. This thing ended up being a complex ovarian neoplasm.

(Responses along the lines of "I've had surgeons who miss obvious cardiac murmurs/pulmonary edema/want to take a gallbladder out of a patient who just had a stroke" are appreciated and welcomed. We all miss things. Talking about it makes us better, right?)

6 comments:

platensimycin said...

a abd mass that size should have been readily palpatable!

this post ties well with the last ("machine"); H&P is indeed becoming a lost art in US.

Frank Drackman said...

Yeah, Yeah, like YOU would have found it you Rommel Worshipin Wierdo...
See that thick Black layer just superficial to the Watchamacallit??? My trained eye can see this patient has a BMI around 30, not at all unusual now a days, but certainly makes diagnosing an Adnexal Mass tricky...Even Buckeye needed Radiation to find it...

Frank

Buckeye Surgeon said...

Frank- The patient is obviously quite thin. The Ct was ordered to delineate size/location/structural relationship of a mass found on physical exam....

Anonymous said...

I got one for you. I was sent a patient with diagnosis of "bleeding umbilical hernia". My examination revealed about 50-60 grams of skin debris and hair impacted in a deep umbilicus causing dermatitis. Patient's BMI around 27.

Anonymous said...

So this is a case where "WNL = We Never Looked"!

Anonymous said...

"The [Dartmouth] research suggests that where there are more specialists, and more fancy equipment, patients get more tests and procedures," said AMA to POUS.

Should we regulate it? Should we limit the kinds of test that doctors can order like how we regulate the types of prescription health practitioners can prescribe?

There are general guidelines already in place, but should they be enforced? It's feared that such rigid DO's and DON'Ts will further compromise the quality of health care in US.

Any suggestions? WHAT DO DOCS WANT?