Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Monday, May 19, 2008

Don't Forget the "P"

If you haven't heard fourteen million times that 99% of diagnosis comes from the medical history you are either:
  1. Not a doctor,
  2. Not in medical school, or
  3. Deaf.
I agree wholeheartedly that the history is the usually the key to making the diagnosis. Although many people think it's probably one word, "H&P" stands for History and Physical examination. Even when you find something unexpected on the exam, you can almost always go back to the history and find out something else that makes the physical finding less unexpected. Still, there are times when it is the physical examination that is more impressive than the history (and I'm NOT talking about those all-too-frequent occasions when there is no real history obtainable, as when dementia patients are transferred from nursing homes, or when the patient is too out of it -- or just too stupid -- to tell you what you need to know.)

I saw a woman last week who specifically refused to use the word "pain" to describe her "discomfort." It had begun in her upper abdomen the day before, and then moved to the upper right part of her abdomen (where she pointed, while sitting up) later in the day. It seemed worse when she moved around but was still present (and very annoying) when lying still. She didn't have any nausea and she hadn't vomited, though she did say she wasn't overly hungry and had to force herself to eat (and then kept it down.) She couldn't recall when her last bowel movement had been, but thought it might have been that morning. She did state that she was passing gas. Her last menstrual period was "now"; there were no UTI symptoms of dysuria, urgency or frequency; overall, she didn't feel terribly sick except for this "discomfort" on her right side.

On exam, she had no fever; her skin and eyes were anicteric; her lungs were clear and her heart exam was unremarkable. Her abdomen was non-distended and I could hear bowel sounds. When I went to palpate it, I began at the upper left quadrant, where she was fine. I moved down to the lower left quadrant and asked her if it hurt. It didn't, but as I began to move rightwards she began to wince by the time I got to the suprapubic region. She got squirmier as I moved to the right lower quadrant, screwing up her face as she informed me in no uncertain terms that it hurt quite a bit, even though I wasn't pushing very hard at all. The right upper quadrant also didn't hurt; there was no Murphy's sign. But whenever I moved back down to the lower right, I got the same reaction; her hands even started to come up as if to push mine away.

Finally, I tried to see if I could elicit rebound tenderness. Rather than the classic "push hard then let go" technique (since she wouldn't let me push any harder than I was, which was fairly lightly) I use something more subtle but just as effective: I jammed my hip against the exam table, jarring it -- and her potentially inflamed abdominal contents -- slightly. In my experience, this maneuver is just as sensitive (in the statistical sense of the term) at eliciting rebound, and much more kind to the patient. It still hurts, which gives you the information you need, but not nearly as much as pushing as hard as you can and releasing quickly.

The test was negative. She didn't have any rebound.

The concern, of course, was appendicitis. The problem was that the history was far from classic: no fever; no nausea or vomiting though her appetite was decreased; still passing gas and possibly moving her bowels normally. Granted there was epigastric pain that moved to the right lower quadrant, but it had been going on a little longer than usual for an acute appendicitis (more than twenty-four hours.)

Overall, though, I was impressed by how uncomfortable she was during the physical exam -- and I told her so. Under "Impression" in the chart, I wrote "?Appy; equivocal history but worrisome exam." What she needed was a CT scan, and since she would need surgery if it showed appendicitis, the best thing to do was send her to the ER; which I did.

Today I got a phone call from her: she had indeed had appendicitis. Her appendix was tucked behind the cecum and had not ruptured. She'd been operated on laparascopically that night and had gone home the next day, feeling much better.

The take-home lesson is that even though the history is indeed all-important, don't ever forget to pay attention to the physical exam.


At Mon May 19, 09:31:00 PM, Blogger Margaret Polaneczky, MD (aka TBTAM) said...

Nicely done, Dino.

At Mon May 19, 10:01:00 PM, Blogger rlbates said...

Ditto what TBTAM said.

At Tue May 20, 01:30:00 AM, Blogger LicensedToILL said...

Cheers to a doc who does a thorough hands on exam, manipulates the body, plays with it's condition- and not a physical exam from the stool.
Git dirty!

Keep making me believe, keep showing me you are invigorated by the puzzle of illness and not the battle of billing and the biz of referrals.

At Tue May 20, 08:52:00 AM, Blogger mark's tails said...

Nice post Dino and a classic example of another truth in medicine. The Unusual Presentation of a Common Disease Is Generally More Likely Than the Usual Presentation of an Uncommon Disease.

At Tue May 20, 11:41:00 PM, Blogger Doctor David said...

Great post! And great words of wisdom, too. There is no substitute for actually examining the patient.

At Wed May 21, 08:01:00 PM, Blogger John A said...

Good catch.

And "Even when you find something unexpected on the exam, you can almost always go back to the history and find out something else that makes the physical finding less unexpected." Heh. Shades of House sending people out to burgle patient's homes for histories and environmental data.

At Thu May 22, 06:54:00 AM, Blogger Ian Furst said...

Hey Dino -- if you were a more modern Dr. Dino and in tune with Customer Directed Care you could have had her log onto facebook, describe her vague symtoms and conducted a web-poll. I bet that 8/10 people that would have recommended a referral to a specialist. Probably GI because she described the discomfort in the epigastric region. If you where a paranoid Dr. Dino 2.0 you might even think cardiac and send her to Dr. Wes 2.0. When her web specialist appointment/facebook evaluation eventually came up you could then refer her to the morgue 2.0 when her appendix reptured. Good post about the importance of actually evaluating patients.

At Thu May 22, 06:56:00 AM, Blogger Ian Furst said...

great -- after your email about grammer I just spotted the typo.


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