Physical exam--obsolete

[Shredder]

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cool--what's been the trend over time + future outlook. This boils down to tech progress. dvd players once cost $500 as well

 

[smq123]

Lab tests and imaging just haven't yet become cheap enough (maybe fast enough too) to supplant the PE. At some point they will right? What's keeping this from happening? It's feasible to think that the PE will be obsolete in some number of years. History alone should suffice, followed by the appropriate tests and scans. No more palpating etc. Hippocrates was doing that. The tech equivalent would be using vacuum tubes to run servers.

Just because a technique is "old" is no reason to abandon it.

History + tests/scans is NOT sufficient. As we've established, history is a good, but not foolproof, way to uncover problems. There's a reason why there is a "subjective" part of the SOAP note and a separate "objective" part.

Examples:
* Some STDs, particularly in females, do not cause any real symptoms. Even if they do, some of those symptoms are not readily distinguishable from other diseases. PE is needed to elicit important signs (like CMT, etc.)

* Diabetics often do not know how much damage they are doing to their eyes - it's wonderful (but scary) how your eyes will compensate for areas of poor vision. Only PE can let you determine how far the diabetic retinopathy has progressed in absence of any real "symptoms."

Finally - PE can help you confirm/corroborate part of the patient's history. When you do rotations, you will hear so many stories of times that the PE (even just inspection) totally disproved a certain part of the patient's reported history.

Oh yeah and defensive medicine for sure; better to order up a storm and avoid lawsuits. Even if PE diagnoses 90% of things the other 10% will get you.

1) Sadly, even "ordering up a storm" will not avoid lawsuits. If someone wants to sue you, regardless of what you did, they will. And if you don't handle it intelligently, you may still lose.

2) The concepts of a "false positive" or an "incidental, but clinically insignificant, finding" are good enough reasons not to order up a storm. You're probably going to uncover something and might decide to work it up - even though it's totally benign. That's going to increase costs, even if the cost of the initial test/scan was relatively low.

3) The problem is also with finding people to read these scans. Many doctors do read their own, but (in speaking of defensive medicine), you would need a radiologist/pathologist to sign off on an official report. Otherwise, you might open up another avenue to more lawsuits.

 

[PeepshowJohnny]

cool--what's been the trend over time + future outlook. This boils down to tech progress. dvd players once cost $500 as well

Of course, someday we will be practicing Star Trek style medicine, where the doctor performs a full body scan with 10X the resolution of an MRI by waving a wand over the patients body. Where a small sample of blood instantly scans for every known virus, fungi, and bacteria known. But that's the future.

Honestly, however, in our lifetime I wouldn't excpect things to change that significantly. The cost of fancy scans like MRI don't really go down because hospitals are constantly ordering newer, fancier ones with more power which are more expensive.

 

[TRAMD]

Of course, someday we will be practicing Star Trek style medicine, where the doctor performs a full body scan with 10X the resolution of an MRI by waving a wand over the patients body. Where a small sample of blood instantly scans for every known virus, fungi, and bacteria known. But that's the future.

Honestly, however, in our lifetime I wouldn't excpect things to change that significantly. The cost of fancy scans like MRI don't really go down because hospitals are constantly ordering newer, fancier ones with more power which are more expensive.

Will we wear silly outfits and consider anyone with prominent brows an "alien"? I hope not as I have prominent brows.

 

[AmoryBlaine]

So are we supposed to get CXR, CT, echo, EKG, etc on everyone who comes in? How would you know to get an echo if you didn't listen to the heart sounds? The PE is just another item in your toolkit. It helps you sometimes make a dx or narrow your differential to where you can get only pertinent imaging/labs rather than pan-imaging everyone.

My goodness did everyone miss the point of my earlier post (KentW, Law2Doc)! Do you really think I'm advocating scanning/echoing every patient that comes in the door?

What I'm saying is that if you hear a murmur, you need to get the damned echo, not sit there pontification about how it was "blowing" rather than "rumbing."

If you hear crackles on your lung exam, you need an x-ray. You don't diagnose pneumonia based on crackles.

 

[AmoryBlaine]

Diagnosis is 90% History, 9% Physical, 1% Labs/Imaging
Im not saying that its everything, but it certainly isnt useless. It is one part of the evidence you have for making a clinical decision. Unless you can come up with your own new way of arriving at a clinical decision, and get it published, I'll stick to my good old H&P

This is a silly statement. I will agree that for a number of conditions it holds true, most of these conditions are things that you see in an ambulatory setting. Vertigo, OA, lumbar strains, strep throat, sinusitis - yeah, I'll go with my H/P. Hell, I'll even give you AAA and maybe, maybe appendicitis.

But this 90-9-1 model fails pretty quickly. Is your dx of renal failure based "99%" on H/P?
How about hyperkalemia?
Should we send people for PTCA based on H/P or would you like to see an EKG and some trops?
Or maybe a new onset severe headache in a 60 year old, is that CT only worth 1%
Can you dx colon cancer based on a history?
How about PE? You want to heparinize people w/o a d-dimer and a VQ scan?

 

[TRAMD]

This is a silly statement. I will agree that for a number of conditions it holds true, most of these conditions are things that you see in an ambulatory setting. Vertigo, OA, lumbar strains, strep throat, sinusitis - yeah, I'll go with my H/P. Hell, I'll even give you AAA and maybe, maybe appendicitis.

But this 90-9-1 model fails pretty quickly. Is your dx of renal failure based "99%" on H/P?
How about hyperkalemia?
Should we send people for PTCA based on H/P or would you like to see an EKG and some trops?
Or maybe a new onset severe headache in a 60 year old, is that CT only worth 1%
Can you dx colon cancer based on a history?
How about PE? You want to heparinize people w/o a d-dimer and a VQ scan?

I want a CT. Lawyers scare me.

 

[Law2Doc]

1) Sadly, even "ordering up a storm" will not avoid lawsuits. If someone wants to sue you, regardless of what you did, they will. And if you don't handle it intelligently, you may still lose.

Not only this, but it has to the right storm. Just because you order a lot of things doesn't mean you are covered. In fact, in many many situations you are worse off, because once you order a scan or lab that shows something, it is now negligent to miss it or inadequately treat it, even if it wasn't the presenting problem you were worried about. So the more tests you order, often the more avenues to litigation you open up. Which is why practicing defensive medicine as some on this board are describing it is foolhardy.

Sure you may order a test just to confirm something you are pretty sure of from the PE, and to that extent you are being defensive. But to order a lot of other tests that don't tightly address your original ddx tends to open more doors for the lawyers than it closes.

 

[Law2Doc]

thx for the replies. i was frustrated after a long and boring PE class when i wrote the thread. I really feel like palpating, percussing and auscultating have been around for too long. It seems that the only justification for PE is cost. Basically I too am looking at this from a cost effectiveness standpoint, also time effectiveness (same thing, as time is money). Lab tests and imaging just haven't yet become cheap enough (maybe fast enough too) to supplant the PE. At some point they will right? What's keeping this from happening? It's feasible to think that the PE will be obsolete in some number of years. History alone should suffice, followed by the appropriate tests and scans. No more palpating etc. Hippocrates was doing that. The tech equivalent would be using vacuum tubes to run servers.

Anyone have data on the cost of lab tests and imaging? Oh yeah and defensive medicine for sure; better to order up a storm and avoid lawsuits. Even if PE diagnoses 90% of things the other 10% will get you.

I think cost is part of the benefit of PE, but not the whole picture. Even if tests were all half price, you still couldn't order them all. So you need a starting point. A history and PE is a great starting point, because it tells you where to look and for what. Use the PE to come up with a list of things it could be, and then use tests that narrow that list. Getting eg a CT or MRI or other expensive test at stage 1 is frequently useless if what ails the patient isn't something that shows up on such tests. I think the PE is unlikely to become obsolete. You might have more bedside tools to carry around with which to obtain the PE (Some of the tools med students carry around in their pockets may be improved with technology), but honestly until you find a better starting point for narrowing your needle in a haystack search, obscolescence of the PE cannot happen. Ordering lots of tests is taking a shotgun approach, and you often miss the target, never know what the target was, or hit other red herrings. There needs to be a stage where you sit down and say, from what I can see this patient might have X,Y, Z, A or B, so let's see how I can narrow that down.

 

[45408]

It's not about a paper trail -- you have that in the records already. It's mostly about not understanding how to correctly work up a ddx, taking the shotgun approach suggested by the OP, and then justifying it by blaming litigation risk. In fact, if you approached the ddx systematically, and ordered only the tests warranted, you are usually in decent shape when the lawyers come out of the woodwork. Thus I think the term defensive medicine is mostly a crutch to justify some folks haphazard approach to medicine.

I disagree. I think that some tests are often done because of the "one in a million" nature of some conditions that could come back to haunt you. Panda Bear had a post about this a while back, that even if a seasoned attending knows that it's extremely unlikely that a 25-year old with chest pain but no cardiac history is having a heart attack, he would be remiss if he didn't order a few "rule out" tests. If he didn't, and this was one of those freak occurrences, then he could be held liable.


edit: found it.

Consider, as one example, the typical cardiac work-up and the vast sums of money wasted every year on diagnostic testing and empiric treatment of patients with ridiculously low pre-test probabilities of being sick. (In other words, they are not sick.) A young male with no risk factors for heart disease should not need a complete cardiac work-up when he presents with chest discomfort as it is almost certainly going to end up being musculoskeletal pain, reflux, or anxiety. And yet the patient inevitably gets the whole enchilada including an expensive stress test and occasionally an admission if he is deemed to be unrealiable for follow up (because if he is told to return in the morning for his stress test, forgets, and dies three years later it is our fault). Now, it may come to pass that one day, out of ten thousand thirty-year-old otherwise healthy men you will isolate the one who does, in fact, have early coronary artery disease…but then you probably would have picked him out just from the history and review of systems. I don't deny that if I were that one guy I'd be pretty happy that our system is structured to spend billions protecting against lightning strikes but the fact remains that we are spending billions with a very little to show for it in actual treatment or prevention of morbidity.

http://pandabearmd.com/blog/2007/06/26/kabuki-medicine-and-other-wonderful-tales/

 

[Law2Doc]

I disagree. I think that some tests are often done because of the "one in a million" nature of some conditions that could come back to haunt you. Panda Bear had a post about this a while back, that even if a seasoned attending knows that it's extremely unlikely that a 25-year old with chest pain but no cardiac history is having a heart attack, he would be remiss if he didn't order a few "rule out" tests. If he didn't, and this was one of those freak occurrences, then he could be held liable.

Actually using a rule out test to eliminate something that is actually on your ddx (even if somewhat remote) is fine under my methodology. That is not a shotgun approach -- it is targeted to rule out something specific. But that isn't defensive medicine as folks are using the term.

 

[45408]

Actually using a rule out test to eliminate something that is actually on your ddx (even if somewhat remote) is fine under my methodology. That is not a shotgun approach -- it is targeted to rule out something specific. But that isn't defensive medicine as folks are using the term.

Even if it's "fine under your methodology," it will still add a (largely unnecessary) cost to the system. Either way, I would agree that a complete shotgun approach probably leaves you in worse shape as for liability, because it does start to look like you have no idea what/why you're ordering tests.

 

[howelljolly]

This is a silly statement. I will agree that for a number of conditions it holds true, most of these conditions are things that you see in an ambulatory setting. Vertigo, OA, lumbar strains, strep throat, sinusitis - yeah, I'll go with my H/P. Hell, I'll even give you AAA and maybe, maybe appendicitis.

But this 90-9-1 model fails pretty quickly. Is your dx of renal failure based "99%" on H/P?
How about hyperkalemia?
Should we send people for PTCA based on H/P or would you like to see an EKG and some trops?
Or maybe a new onset severe headache in a 60 year old, is that CT only worth 1%
Can you dx colon cancer based on a history?
How about PE? You want to heparinize people w/o a d-dimer and a VQ scan?

Hey, don't kill the messenger. I learned that aphorism in my physical diagnosis class in MS-2. But taking the last two points, and the one about the murmur.

I would think that one would believe with 99% certainty that a patient has CA colon, based on H&P, and then send a biopsy for confirmation. Would I heparinize a PE without d-dimers and a CT? Probably not, here in these United States. But in other countries that arent lawsuit-happy, it is done -- Ive seen an American doc who was volunteering on a "medical mission" do precisely that. As Ive indicated before, Im thinking of the future of diagnostic medicine on a global sense. Having gone to med school in the Carribbean, I got to work with a doctor who made clinical decisions based on cardiac auscultation, and not an echo...bringing me to my next point.
As for murmurs, some cardiologists advocate that all primary care docs be able to distinguish between an innocent/flow murmur and a pathologic one, because of the amount of unnecessary echos that are done these days, and especially because of the high false positive rate of echos. They only want the pathologic murmurs echo-ed. At least thats the impression I got from Chizner's text.

I guess, this topic is like a lot of others among med students... socialized medicine, best stethoscope, validity of the MCAT... Its up to personal preference or opinion.
Personally, Im very interested in diagnosis, and less so in management. Its just personal preference. Thats all I have to say about that.

 

[lilzelda2]

If the only interaction with ur patient is just listening to the CC and running a couple of test I don't think its going to build a good doctor-pt relationship...Isn't that why most people complain about doctors, that they don't even take 5 minutes to listen to them...In my opinion I think diagnosing is just one part of medicine and the other is patient interaction, b/c if u like someone ur less likely to sue them...

 

[mjl1717]

But it's free...all those tests and scans you're talking about cost money. Plus they can take time.

I guess I don't totally understand your frustration.

Except for some of the radiology the guy wants to practice NON patient contact
or dead patient medicine he doesnt really have to use much about physical exam.. The frustration?- Non Oslerian medicine

 

[mjl1717]

Just because a technique is "old" is no reason to abandon it.

History + tests/scans is NOT sufficient. As we've established, history is a good, but not foolproof, way to uncover problems. There's a reason why there is a "subjective" part of the SOAP note and a separate "objective" part.

Examples:
* Some STDs, particularly in females, do not cause any real symptoms. Even if they do, some of those symptoms are not readily distinguishable from other diseases. PE is needed to elicit important signs (like CMT, etc.)

* Diabetics often do not know how much damage they are doing to their eyes - it's wonderful (but scary) how your eyes will compensate for areas of poor vision. Only PE can let you determine how far the diabetic retinopathy has progressed in absence of any real "symptoms."

Finally - PE can help you confirm/corroborate part of the patient's history. When you do rotations, you will hear so many stories of times that the PE (even just inspection) totally disproved a certain part of the patient's reported history.



1) Sadly, even "ordering up a storm" will not avoid lawsuits. If someone wants to sue you, regardless of what you did, they will. And if you don't handle it intelligently, you may still lose.

2) The concepts of a "false positive" or an "incidental, but clinically insignificant, finding" are good enough reasons not to order up a storm. You're probably going to uncover something and might decide to work it up - even though it's totally benign. That's going to increase costs, even if the cost of the initial test/scan was relatively low.

3) The problem is also with finding people to read these scans. Many doctors do read their own, but (in speaking of defensive medicine), you would need a radiologist/pathologist to sign off on an official report. Otherwise, you might open up another avenue to more lawsuits.

this is on the money, big time !!!!

 

[howelljolly]

This is a silly statement. I will agree that for a number of conditions it holds true, most of these conditions are things that you see in an ambulatory setting. Vertigo, OA, lumbar strains, strep throat, sinusitis - yeah, I'll go with my H/P. Hell, I'll even give you AAA and maybe, maybe appendicitis.

But this 90-9-1 model fails pretty quickly. Is your dx of renal failure based "99%" on H/P?
How about hyperkalemia?
Should we send people for PTCA based on H/P or would you like to see an EKG and some trops?
Or maybe a new onset severe headache in a 60 year old, is that CT only worth 1%
Can you dx colon cancer based on a history?
How about PE? You want to heparinize people w/o a d-dimer and a VQ scan?

Another point, if I may... I think that the 90-9-1 model is more valid than you might think, it just depends on how you look at it. Take the PE, for example. You might have 90 different points on the history, sudden onset, tachypnea, CP, smoker, cancer, oral contraceptives, bedbound, remarkable review of systems, etc.etc. ... 9 points on the Px (central cyanosis, CP not reproduced on palp...). Would you not come to a Dx of PE already? Wouldnt your requisition slip say "R/O Pulmonary Embolism"? Wouldn't seeing that 1 gray spot on the CT be just 1% of the work you did to make that Dx?

Similarly, that new onset severe headache on the 60 year old of yours? Is the CT only worth 1%? I'd say so! You and I, and everyone reading this already have a good idea of what the Dx is. And we havent even seen the pt. let alone seen the head CT.

Another thing is that you can up with examples that require investigations, when you can just as easily come up with examples that dont. You agreed that the 90-9-1 model holds best in Ambulatory Care, and not in other major fields like Cardio, or Emergency. and Im suggesting that you extend it to all of medicine, and the entire process of clinical decision making, where I think it holds pretty good everywhere.

Can I make a definitive Dx of any type of cancer on H&P? Never. Pathology always makes the Dx. though H&P will be what leads me to take a biopsy. But can I Dx Shingles on H&P? Always.

You could sit in your Radiololgy rotation and think "Man! everything needs a film to make a Dx" Because, every diagnosis you are coming across really does need a film. Then you can sit in your Psychiatry rotation and think "Man! Labs are useless, all they ever do is assay for theraputic drug levels.

After youre experienced, you can Dx a bronchitis or most any pediatrics from across the room. When you're at that level, are you still going to think that investigations are that important? I bet that you'd say it isnt. What will be important is the inspection bit of your Px. Any attendings willing to back me up on this point?

Its a matter of perspective. Im trying to think over all fields.

 

[goodoldalky]

Not sure if anyone mentioned this yet because I didn't read through all of the posts, but 60% of all diagnoses can be made on the basis of a history and physical exam alone.
Reason enough, don't you think?

 

[jdh71]

K I haven't posted much in some months but I wanted a discussion on this. We're learning the physical exam and I can't help but feel how antiquated it is. Run some Googles on "physical exam obsolete" and there's some decent reading on it. This topic has surely been raised on various parts of SDN before but I wanted a fresh thread with fresh opinions on it. Do cite any good threads on it if you happen to know them--I'll search in a sec.

Rub here, press there, tap that, push this. Docs were doing this 100 years ago, where is the progress. I'd rather run some scans and lab tests and figure out with much greater accuracy and speed what the deal is. Incidentally I only plan on doing rads or path so I think this belief system is acceptable. Is cost the limiting factor? Can't that just be decreased, as technology usually does over time? I don't place any faith in the nostalgia factor, I think it's overrated. I would much prefer a doc not poking me and touching me; their hands are usually cold anyway.

Let me know what you think. Also if you see this as an opportunity to capitalize somehow let me know. I think this is the direction of medicine, as economics dominate nostalgia. I also feel this about cadaver dissection vs prosection but I've voiced that before and it's beside the point.

*sigh*

nOObs . . .

 

[osli]

K I haven't posted much in some months but I wanted a discussion on this. We're learning the physical exam and I can't help but feel how antiquated it is. Run some Googles on "physical exam obsolete" and there's some decent reading on it. This topic has surely been raised on various parts of SDN before but I wanted a fresh thread with fresh opinions on it. Do cite any good threads on it if you happen to know them--I'll search in a sec.

Rub here, press there, tap that, push this. Docs were doing this 100 years ago, where is the progress. I'd rather run some scans and lab tests and figure out with much greater accuracy and speed what the deal is. Incidentally I only plan on doing rads or path so I think this belief system is acceptable. Is cost the limiting factor? Can't that just be decreased, as technology usually does over time? I don't place any faith in the nostalgia factor, I think it's overrated. I would much prefer a doc not poking me and touching me; their hands are usually cold anyway.

Let me know what you think. Also if you see this as an opportunity to capitalize somehow let me know. I think this is the direction of medicine, as economics dominate nostalgia. I also feel this about cadaver dissection vs prosection but I've voiced that before and it's beside the point.

Oh wow, this is the type of thinking that has lead to the shotgun approach of primary care physicians (and others), and contributed to the sharp rise in health care costs.

Yikes. You scare me.

 

[logos]

I think most here are thinking of the issue in too much of a global manner. Its not that all physical exam is worthless or physical exam is all of vast importance. The reality is probably somewhere in the middle. Some physical exam techniques can be very usefull, others are next to worthless ("fluid wave" in an ascitic abd, for example).

 

[howelljolly]

I think most here are thinking of the issue in too much of a global manner. Its not that all physical exam is worthless or physical exam is all of vast importance. The reality is probably somewhere in the middle. Some physical exam techniques can be very usefull, others are next to worthless ("fluid wave" in an ascitic abd, for example).

I think that sounds fair. Maybe we can add ballottement to that list?

 

[PeepshowJohnny]

I think that sounds fair. Maybe we can add ballottement to that list?

Ballottement from OB/GYN or from joint effusions?


Although I feel the physical exam is valuable, a reason I believe (and this may just be a personal thing, but I've heard similar stories from friends) the physical exam is not being used as effectively these days is that a lot of the lesser utilized techniques are not standardized. This makes them harder to learn for students when they're dealing with multiple interns, residents, professors, and attendings all teaching them THEIR correct way to test for Rovsing's sign or whatever.

For example, couple weeks ago an attending showed me their technique for a portion of the physical exam in a patient. And I copied it and got a positive result, so I was very excited and pleased. Now, I'm with a new attending a few weeks later and he asks on a different but similar patient for me to demonstrate how to use that physical exam technique. I use the same method the previous attending taught me (that worked) and of course the new attending stops me saying "No, no, no, that's wrong. You'll never get it to work like that".

What incentive does that leave me as a student have to put the time in to learn and practice the physical exam when each attending is going to tell me THEIR way is the right way and have to learn it their way?

 

[Gut Shot]

Docs were doing this 100 years ago, where is the progress. I'd rather run some scans and lab tests and figure out with much greater accuracy and speed what the deal is. Incidentally I only plan on doing rads or path so I think this belief system is acceptable.

I'm so glad you posted. I've been seriously missing the periodic installments of Shredder's Medical Training Saga. For those who don't recall, it began as a premed when he refused to do volunteer work to buffer his application. Then he felt "fury" when rejected. To his credit, he did land an allopathic acceptance. Then there was the curious tirade against all things not inherently selfish. Those are just some of the highlights.

As other posters have mentioned, investigative modalities that are old are not necessarily inferior. They've simply stood the test of time. The x-ray, far and away the most common radiologic study, has undergone no fundamental revision since Wilhelm Röntgen zapped his wife's hand in 1896. That's 111 years. H&E stained slides, the cornerstone of anatomic pathology practice, haven't seen a significant alteration in over 150 years.

(First, we cut the tissue, then we stain the slides, then we get the women.)

Sorry, Shredder, you're just going to have to suck it up and admit that touching sick people can be a good thing. Hopefully, for your sake, you'll encounter some mentors who are highly skilled physical diagnosticians. It's really impressive... you might just change your mind.

 

[deleted29780]

K I haven't posted much in some months but I wanted a discussion on this. We're learning the physical exam and I can't help but feel how antiquated it is. Run some Googles on "physical exam obsolete" and there's some decent reading on it. This topic has surely been raised on various parts of SDN before but I wanted a fresh thread with fresh opinions on it. Do cite any good threads on it if you happen to know them--I'll search in a sec.

Rub here, press there, tap that, push this. Docs were doing this 100 years ago, where is the progress. I'd rather run some scans and lab tests and figure out with much greater accuracy and speed what the deal is. Incidentally I only plan on doing rads or path so I think this belief system is acceptable. Is cost the limiting factor? Can't that just be decreased, as technology usually does over time? I don't place any faith in the nostalgia factor, I think it's overrated. I would much prefer a doc not poking me and touching me; their hands are usually cold anyway.

Let me know what you think. Also if you see this as an opportunity to capitalize somehow let me know. I think this is the direction of medicine, as economics dominate nostalgia. I also feel this about cadaver dissection vs prosection but I've voiced that before and it's beside the point.

This is the most useless suggestion i have ever come across. I hope you take your clinical studies seriously, you seem to be the typical lazy student of our day. You want to scan the whole body in order to make a diagnosis. How dumb can you be...and you have the nerve to talk about progress.
You need a scan to diagnose a possible cardiac tamponade...by the time your scan is ready, your patient will be dead...know why? cos you did not recognise his distended internal jugular veins. I suggest you go to the ward and read the patients. The library is the ward.

 

[alwaysaangel]

cool--what's been the trend over time + future outlook. This boils down to tech progress. dvd players once cost $500 as well

Actually there isn't a lot of hope of those costs dropping anytime soon. The thing is - it doesn't really cost $2000 to take a read an MRI anymore. But for every 2 paying customers you have 3 acute uninsured patients that the hospital is required to check.

Paying customers cover the losses of the uninsured non-paying patients.

So until something changes in the way insurance works, there won't be a drop in imaging or labs so you're whole outlook won't happen.

I would pay attention in your physical class - I'd bet money that the physical isn't going out of style in your lifetime.

Oh and you're whole argument that being old = being usless is incredibly stupid anyway as others have pointed out.

 

[deleted29780]

- which is onen of the reasons I went into pathology.

do you know [email protected] ? he has an interesting website. He is in love with pathology. run a search of his email on google, i cannot remember his site.

 

[osli]

Overall, I think the OP is correct that PE is generally taught without any evidence -- which is onen of the reasons I went into pathology.

Try www.pathguy.com if you haven't already run across it for some fun. Great pathology resources, and this coming from a pathologist who really knows the merit of the PE (and Hx) and how to do them properly. You'd be surprised how easily your hands and eyes can pick up some things that are difficult and/or expensive to reveal with diagnostic tests. Of course, you have to start with a good Hx, and know what you are doing, which sadly is probably the problem with many of today's graduates.

 

[DrDrummer]

Eliminating the physical exam from toolbox would be one of the easiest and fastest ways to ensure the complete alienation and abandonment of patients and physicians working in rural and underserved parts of this country. You think every American hospital has MRI or a full complement of techs just standing around to ultrasound and x-ray everyone who comes through the door of an ER?

This is also to completely ignore the sacrosanct "laying on of hands" aspect of being a physician. It might sound ridiculous and anachronistic, but I believe it's really important to touch and feel someone. "Cold hands" might turn off a patient here or there who is particularly touch-averse, and in certain situations, time is money and that is a legitimate concern, but the perceived efficacy of a doctor poking and prodding and feeling and listening to your body and your concerns is a lot higher than one who takes a basic history and has you wheeled off to imaging.

 

[howelljolly]

Ballottement from OB/GYN or from joint effusions?

Ballottement to find a kidney

 

[deleted29780]

Ballottement to find a kidney

hey i hope you were not trying to correct the post...cos its correct...
you ballot the fetus if its less than 26 weeks- fetal parts cannot really be determined with Leopolds maneuovre's. and of course you ballot the patella if there is an effusion in the knee joint.
If you knew that, then thats fine...just to be sure.

 

[PeepshowJohnny]

hey i hope you were not trying to correct the post...cos its correct...
you ballot the fetus if its less than 26 weeks- fetal parts cannot really be determined with Leopolds maneuovre's. and of course you ballot the patella if there is an effusion in the knee joint.
If you knew that, then thats fine...just to be sure.

I must admit that I'd never heard of kidney ballotment prior to this. I guess it's not surprising, there are very few "good" abdominal mass teaching cases, since they're all either cut out quick or identified when they're small by an incidental finding on CT scan. Just goes to show you that there's always something new to learn (especially in the physical exam).

 

[howelljolly]

hey i hope you were not trying to correct the post...cos its correct...
you ballot the fetus if its less than 26 weeks- fetal parts cannot really be determined with Leopolds maneuovre's. and of course you ballot the patella if there is an effusion in the knee joint.
If you knew that, then thats fine...just to be sure.

Nah, I know its corect. I was suggesting that ballottement of the kidney was the most useless of the bunch. It was a feeble attempt at humor.

 

[bookmedic]

Shredder-
In EMS we have only our stethoscope, Monitor, basic vitals and hands (unfortunately, we lack brain power). Without the physical exam, we've got nothing. And we'd end up playing eeny meeny miny mo with our drugs- not that we're not doing that now.
I've seen Attendings lose it on residents and interns when the are assessing the patient and they don't touch them allover. I didn't see this personally, but I heard of one making a resident asses every patient in the ER with a Paramedic until the Paramedic said he was good enough. Granted, this was a new resident and very experienced medic.

 

[deleted29780]

Nah, I know its corect. I was suggesting that ballottement of the kidney was the most useless of the bunch. It was a feeble attempt at humor.

my bad, sorry mate....👍