Saturday, April 27, 2013

The Physical Exam - a Lost Art?

Bobby was admitted to the hospital once again with overwhelming fatigue and shortness of breath. Yet this 37 year old farmer looked the picture of health. He grew up on a farm rising before dawn, milking cows and working long days in the fields with hay or corn. He was never seriously ill as a child and was a good football halfback in high school.

But this was his third admission for evaluation. He had been through heart and lung tests and even a psychiatric examination but everything was coming up normal. As is usual at a University Hospital Bobby's first "doctor" on that admission was Mike, a third year medical student who was being examined himself on his ability to evaluate a patient.

Mike spent about a hour going though Bobby's extensive chart: normal blood count, electrolytes, liver function, kidney function, calcium, and thyroid tests. The urinalysis was normal, as was the chest X-Ray and EKG. He had baffled the medical residents, research fellows, and faculty - so what in the world could he contribute?

Bobby told his story once again, "I feel OK when not doing much, but when I try to climb a ladder or haul some hay I just feel all in. There's no pain, but I just feel like keeling over." His treadmill test showed that he was limited, but no sign of coronary artery disease.

Mike noted this history at the beginning of his new evaluation, the "chief complaint."

"I'm going to ask you a bunch of questions you've probably been asked before, do you mind?", asked Mike.

"Not if you can fix me up, I don't want to die from this."

"OK, let's start way back. Tell me your story about growing up, I need to find all I can about you."

So Mike became a listener and Bobby began to tell stories from childhood, some of which we're pretty entertaining like tipping over outhouses at Halloween, once with a farmer inside!

"In fact, said Bobby, that guy was as mad as a hornet. We were running away, and I climbed over a fence, when he cut loose with his shotgun. Maybe he was just trying to scare us, but I took some buckshot in my rear."

For some reason, this intrigued Mike. He hadn't found anything in the prior records about trauma. "So what happened, did you need surgery?"

"No, but there were a bunch of skin holes and we only got out one or two pellets. It looked like I had chickenpox on my ass!"

Mike tucked this bit of information away and finished up with his hour long interview and taking of notes on family history, social history, occupational history, etc. He knew this was going to take hours to write up for his examiner. But as he was thinking, he couldn't get his mind away from the puzzle of the shortness of breath: it didn't seem to be heart disease, lung disease, or other organ failure, so what was it?

With an educated whim, Mike asked Bobby if anyone had ever listened to his bottom with a stethoscope. Bobby whooped, "Now wouldn't that be something. No nobody's touched my butt outside of my wife, that's for sure."

"Now Bobby this is going to seem more than a little crazy, but I'd like to check you there to see if the buckshot caused an unusual injury."

"Hey, Doc I'm desperate. If you think putting your stethoscope on my ass is the answer, then what the heck" said Bobby laughing.

With Bobby prone and rear exposed, Mike could see the multiple buckshot scars on the right buttock and thigh. He couldn't see any pulsations, but when he first placed his hand over the area he could feel a gushing sensation, which in medical terminology is called a "thrill' - perhaps a misnomer for trill. But it was a definite harmonic vibration with each heart beat. The stethoscope was next applied and revealed a very loud (grade 6/6) "murmur" - another strange medical term from the older lexicon.

Mike wasn't sure he had found the actual problem or, if so, anything could be done to fix it. The next day, on rounds with students, residents, and faculty zipping though the rounds with rapid file questions and orders they came to Bobby's bed. Bobby was beaming and couldn't contain himself, "Hey doctors, my bright young doctor here has found a murmur on my ass, how about that?"

Mike gulped, this wasn't how he had planned to present the problem. He did manage to give the gunshot history and detail the physical findings. At first there was skepticism by the junior staff that the findings were significant. But the senior cardiologist was savvy and recognized the brilliance of Mike's discovery. He said, "It's pretty clear to me, that this patient has high output heart failure. I would guess that he must be loosing 50% of his cardiac output to a shunt between a large pelvic artery and vein. He can function OK at rest but goes into high output heart failure with exercise because of the shunt."

Comment: That's how it turned out. Bobby's shunt was viewed with a dye contrast study and the vascular surgeons consulted. A large artery and vein had been joined together by the penetrating trauma of the buckshot. It was relatively straight forward surgery to close the shunt thus returning the blood flow to a normal pattern.

I wish I could say I was Mike in the story, but I was one of the many who missed the diagnosis. But I did learn that many medical problems can be uncovered by a good history followed by a detailed physical exam. As one professor said, "Listen to the patient with your eyes, ears, hands, and stethoscope."

In many ways physicians have mistakenly moved away from the comprehensive physical exam in favor of the high tech evaluations.  Abraham Verghese who is a Professor for the Theory and Practice of Medicine at Stanford University Medical School has reminded us in a TED video talk about the importance of touch, listening and the laying on of hands. 

Monday, April 8, 2013

Smart Cards for Your Health Care

Pierre arrives at the construction site, has his morning coffee and croissant, then ascends the scaffold to begin his work.  He felt a little woozy this morning but ignored it.  Becoming more dizzy, he loses his balance and falls two stories fracturing his femur and pelvis.  On arrival the paramedics find his health smart card in his wallet, scan it, and instantly have his medical records including medications, allergies and importantly prior EKG's.  He's found to have a new rapid irregular heart rate and given appropriate medical treatment on the way to the ER.  Pierre is lucky he lives in France where smart card technology is widely applied.

Billy has severe COPD and is on multiple medications.  Going out to pick up the morning paper, he trips, falls, becomes confused and can't respond logically to questions from a bystander.  911 is called and arrives.  No family members are present.  No medical information is available.  He's transported to the hospital where it takes 3 hours to track down a partial medical history and an advance directive.  There is a delay in recognizing internal bleeding until it's discovered that warfarin is one of his medications.  Billy is unfortunate he lives in a state not using smart card technology.

The smart card has been around for a few decades and is in wide use in Germany, France, Taiwan and several other countries.  Biometrics and other security measures have been developed to comply with patient privacy regulations.  The VA hospitals are using a smart card system successfully.  Other health smart card companies are competing for this potentially large market.

There are state wide and even nation wide efforts to have registries for advance directives and POLST forms in order to make them available on an emergent basis.  But we are a mobile society. Individual state registries can become redundant, expensive, and hard to maintain.  Oregon has the most advanced state registry for POLST forms but that is just one state.  Smart cards will allow each one of us to carry around our own health care information in our wallet or purse.  Privacy can be protected with use of a thumbprint.  Secure readers can be portable.

The lack of wide use of smart cards in the US health care delivery is one more symptom of a broken and dysfunctional non-system.

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