The physical exam

In telling this story, I’ve intentionally been as vague as possible.  I changed specific details and avoided identifying information.  Don’t hate me, HIPAA!

Our physical diagnosis course is wrapping up.  I don’t feel nearly as awkward as I did originally, when it felt strange and weird and somehow wrong to poke and prod a total stranger.  There are still moments when I feel lost and wish I could surreptitiously whip out Bates’ Guide to the Physical Exam; I usually forget to ask or examine at least one pertinent organ; but by and large, the routine physical exam has become, well, routine.

Today I was going through the motions of the physical exam, the way I always do.  It almost seems a waste, sometimes, when you know that real doctors just draw bloods and image the crap out of everyone anyway.

Today’s patient had a bad shoulder, which my preceptor pointed out was probably due to brachial plexus injury from a prior surgery. Straightforward. The rest of the physical exam seemed almost extraneous, but the more practice the better (and we have an evaluation coming up), so we did it all. “Can you take a deep breath in and then out, please?  And again.  And again.  Say ninety-nine.  Ninety-nine.  Ninety-nine.  Now, I’m going to press gently on your tummy; let me know if anything feels uncomfortable.”

When I got to the left upper quadrant, the patient winced.

“Does that hurt?”

“A little,” she admitted.

That was unexpected.

I tried again, a little deeper, and saw her grimace as my hand felt something hard, about the size and consistency of an unripe grapefruit.  From there, it was like I’d opened a new door.  I percuss everyone’s liver like a drummer, but I’d never percussed a spleen before.  I didn’t remember the normal value, but I dutifully pulled out a  ruler to measure the approximate distance between upper and lower borders.  When I told my partner the size of the spleen, our preceptor came around the bed and performed the same maneuver herself.  She excused herself, saying she had to check on our classmates down the hall.

We continued the physical exam.  Check leg strength.  Reflexes.  Two-point discrimination.  Oh wait, you mentioned difficulty hearing, so how does this tuning fork sound to you?  Everything, even her deficits, were just as we expected.

Just as we were finishing up, our preceptor came back and pulled me aside to say that she’d just spoken to the patient’s physician and no one had noted splenomegaly.  Because no one had done an abdominal exam on this lady with shoulder pain.  After all, why would you?  But I looked it up after getting home, and there is one diagnosis that explains every single one of her symptoms, even the ones that only came out on the Spanish Inquisition that is the review of systems.

I’m not saying that you have to do a full work-up on every sucker that walks into the ED with specific symptoms.  That takes way too long, and I know that as a medical student I’m privileged to have enough time to spend two hours with a single patient.  (Two hours! I kid you not.)  But I guess the point of this long-winded story is that the unexpected demands attention.  And that the physical exam, contrary to popular (and to some extent my own) opinion, is far from worthless.

2 thoughts on “The physical exam

  1. So, what was wrong with her? I have a bates….but it’s so far….in my apartment…and I’m at a friend’s place at the moment =(

    1. I don’t really want to say what I think her illness is, as it could be a privacy violation. (Yeah, I’m a little paranoid about that stuff, but I wouldn’t want MY medical information bandied around by someone I’d just met.)

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