Bedside diagnosis

Xavier Prida dr.xavier.prida at GMAIL.COM
Tue Feb 19 20:08:23 UTC 2019


IMHO, it is all about the quality of teaching, and, are the learners
capable to 1.) learn 2.) refine. As I teach our fellows, we should be
better ausculters in this era with Echo/doppler feedback. As one who
trained as a medical student on the first HARVY simulator in Dr. Michael
Gordon's lab(U of Miami) and continued emphasis during training by Jeremiah
Barondess at Cornell - it is doable and can effectively guide diagnostic
hypothesis and downstream testing.

XEP
* praesent superare odio  **, if you can't, then - contra nando incrementum*
* (r**ise above)
(get increased swimming against the tide)*

Xavier E. Prida MD FACC FSCAI
Assistant Professor of Medicine
Program Director Cardiology Fellowship Training
USF Morsani College of Medicine
Department of Cardiovascular Sciences
2 Tampa General Circle
STC 5 th Floor
Tampa, Fl 33606
813 259 0992(O)
813 831 0721(H)
813 245 3143(C)


On Tue, Feb 19, 2019 at 2:51 PM Ed Hoffer <ehoffer at gmail.com> wrote:

> More years ago than I want to admit an MIT classmate who also went to
> medical school did as a thesis project a Baysean system to diagnose
> congenital heart disease based on ECG, CXR and auscultation findings. When
> Med students PE findings were used it did poorly. It was a bit better when
> residents’ findings were used and MUCH better when the auscultatory
> findings used were from the attending cardiologists.
> Edward Hoffer MD
>
> Sent from my iPhone
>
> On Feb 19, 2019, at 1:41 PM, Tom Benzoni <benzonit at gmail.com> wrote:
>
> This interests me.
> I use an electronic stethoscope with Bluetooth capability.
> This is great to share sounds with students and residents which their
> young ears don't discern.
>
> I find, however, what is between the stethoscope ear pieces is much more
> important.
> That's where the age issue comes to fore.
> The knowledge in a head that's "seen 3 of these" is not measured.
> So I'd approach decisions not based on evidence with the same reticence
> we'd show following any guidance not based on, well, evidence. Do you
> really know what you think you know?
> Do we ascribe  ordering too many CTs for PEs that aren't there to youth
> and inexperience, requiring corrective action?
>
> tom benzoni
>
> On Mon, Feb 18, 2019, 23:16 Peggy Zuckerman <peggyzuckerman at gmail.com>
> wrote:
>
>> How hard would it be to get someone to attach a stethoscope to an iPhone
>> with a good little microphone.  And what happens to the older doctor whose
>> hearing is slowly diminishing...does he not miss more and more things?  Any
>> studies on this?
>> Peggy Zuckerman
>> www.peggyRCC.com
>>
>>
>> On Mon, Feb 18, 2019 at 3:41 PM ROBERT M BELL <
>> 0000000296e45ec4-dmarc-request at list.improvediagnosis.org> wrote:
>>
>>> Thanks David,
>>>
>>> Excellent piece, thanks for sending - history and examination are so
>>> vitally important. The comment of "fighting through two gowns was
>>> interesting."
>>>
>>> I would think that SIDM alone, or maybe in collaboration with others,
>>> could do wonders for medicine by defining the accuracy of the stethoscope
>>> among HCPs with differing skills, experience and hearing loss.
>>>
>>> I would also predict that the results and recommendations would be
>>> pretty mind blowing!
>>>
>>> Rob Bell, M.D.
>>>
>>> On Feb 18, 2019, at 2:45 PM, David L Meyers <dm0015 at COMCAST.NET> wrote:
>>>
>>> A very interesting article on some realities of beside medicine, raised
>>> by Rob Bell and others on the listserv in the past.
>>>
>>> David
>>> David L Meyers, MD FACEP
>>> Society to Improve Diagnosis in Medicine
>>> Listserv Moderator/Board member
>>> www.improvediagnosis.org
>>> Save the Dates: Diagnostic Error in Medicine Conference (DEM2019),
>>> November 10-13, 2019 at Hyatt Regency Washington, DC (Capitol Hill)
>>> AusDEM2019, April 28-30, 2019; Melbourne, Aus
>>>
>>>
>>> https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2724394?guestAccessKey=a76c424d-dd3d-4d63-8ed8-70af67b2ca89&utm_source=silverchair&utm_medium=email&utm_campaign=article_alert-jamainternalmedicine&utm_content=olf&utm_term=021819
>>> <
>>> https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2724394?guestAccessKey=a76c424d-dd3d-4d63-8ed8-70af67b2ca89&utm_source=silverchair&utm_medium=email&utm_campaign=article_alert-jamainternalmedicine&utm_content=olf&utm_term=021819
>>> >
>>>
>>> The “Hemolyzed” Physical Examination—Situational Challenges to Accurate
>>> Bedside Diagnosis
>>>
>>> A page comes in from downstairs—another admission. A 41-year-old postal
>>> worker in bed 22, presented with severe back pain and needs pain control
>>> and a physical therapy evaluation. Three weeks ago, he was lifting a box
>>> when he felt a sharp pain in the middle of his lower back. The pain has not
>>> decreased, despite his taking naproxen around the clock. I look at the
>>> vital signs: temperature, 99°; pulse, 92 bpm; pressure, 140/90 mm Hg;
>>> respirations and oxygen saturation, normal. Nothing stands out as I click
>>> through the laboratory results.
>>>
>>> I look for this patient among the closely spaced cots in the emergency
>>> department. Before I can find him, I see another man in bed 18 whimpering
>>> in pain. I look at the cluster of computers where the nurses are charting;
>>> his nurse gives me a nod—“I know. I’m coming.” In bed 21, I recognize a
>>> woman behind a bilevel positive airway pressure (BiPAP) mask. She smiles
>>> weakly. In bed 22, the patient shivers under a blanket.
>>>
>>> Another page comes in for another admission. I will call back as soon as
>>> I finish here.
>>>
>>> The patient tells me that he has been shivering like this on and off for
>>> several weeks. However, what bothers him most is his back, and he worries
>>> he might lose his job if he does not get better. I gather some more history
>>> and move on to the examination. He looks tired, but his eyes, hands, nails,
>>> and teeth look healthy. His neck veins are normal. His lungs are quiet but
>>> clear—I think. I move on to listen to his heart, fighting through 2 gowns
>>> and an undershirt. I settle, trying to at least flatten any folds out of
>>> the way. I do not hear much, and I close my eyes to try to focus. I am
>>> struck by how much noise surrounds me. The cacophony of alarms, the BiPAP
>>> machine for the other patient, a patient with delirium yelling out to no
>>> one in particular. I open my eyes. He is shivering again—my cue to move on.
>>> His belly is soft, and his back is tender over the mid lumbar spine and
>>> surrounding muscles.
>>>
>>> Another page, another admission. I quickly put in orders for the patient
>>> and go to see the other patients—I am now 2 behind.
>>>
>>> Three hours later, I write my admission notes for this patient. Physical
>>> findings: “Lungs—diminished breath sounds, otherwise clear. Heart…” I
>>> pause, trying to remember what I had heard. Nothing echoes in my mind. I
>>> rub my eyes and look at the corner of the screen. It is almost 3:00 am. “JV
>>> [jugular veins] flat. RRR [regular rate and rhythm], no MRG [murmurs, rubs,
>>> or gallops].”
>>>
>>> I finish my notes in time for the next admission, a woman with black
>>> stools and lightheadedness. Her vital signs are stable after receiving some
>>> fluids. I click through her laboratory results. Hemoglobin is a bit lower
>>> than her baseline. Chemistry results are normal except that her potassium
>>> is 6.3 mmol/L, with a comment that the blood specimen is “grossly
>>> hemolyzed.” I order a repeat metabolic panel.
>>>
>>> On my way to see her, I notice a room on the floor labeled with the
>>> patient’s name. I stop in to check on his pain. The medicine has improved
>>> his pain, and he is hoping to finally rest, because “it’s so nice and quiet
>>> up here.” I look back at the closed door hiding the hallway. It is quiet. I
>>> ask the patient if I can listen to him again. He is able to move better and
>>> sits up on the edge of the bed. I untie his gowns and apologize for my cold
>>> stethoscope on his skin. I hear a systolic murmur over his apex and axilla.
>>> It is not subtle. I listen to his lungs again, hearing faint crackles at
>>> the left base and right mid lung. I look again in his mouth, at his palate,
>>> and see some petechiae.
>>>
>>> The patient’s echocardiogram the next day shows a large mitral valve
>>> vegetation. A magnetic resonance image of his lumbar spine shows
>>> osteomyelitis and diskitis as the cause of his pain. He began to improve
>>> with antibiotics and supportive care and eventually required a valve
>>> replacement.
>>>
>>> Several recent reviews and commentaries reflect a renewed interest in
>>> bedside medicine, including physical diagnosis.1-5 Some reviews remind us
>>> that certain aspects of the physical examination are irreplaceable in terms
>>> of the information they confer and the human connection they foster with
>>> the patient.4 Other reviews are more technical, providing data about test
>>> characteristics of specific maneuvers and outlining concepts such as
>>> likelihood ratios of examination findings.5
>>>
>>> An important aspect of physical diagnosis requires more
>>> attention—context specificity. When referencing sensitivities,
>>> specificities, and likelihood ratios of various examination findings, we
>>> should recognize that they are not universal or static. The percentages
>>> reported in the literature are averages across hundreds of patients,
>>> clinicians, and techniques. Even when the clinician and patient are the
>>> same, circumstance can change everything. When the blood sample of my other
>>> patient was hemolyzed, I was quick to regard the test as spoiled and repeat
>>> it. But the other set of tests—my physical examination of the patient—was
>>> also spoiled by noise, distraction, poor positioning, and haste. Only
>>> serendipity led me to repeat the physical examination that had been
>>> “hemolyzed.” Instead, we should be attentive to situational impediments to
>>> accurate bedside test results. Sometimes we can optimize the situation in
>>> the moment. Other times we may need to repeat the test under improved
>>> circumstances, or we may simply acknowledge that a particular test did not
>>> influence the diagnostic process. “JV flat. RRR. Exam for any abnormal
>>> sounds limited.”
>>>
>>> The notion that physical examination test characteristics are variable
>>> and dynamic adds to the uncertainty that already challenges clinicians
>>> every day. Yet this variability can also motivate us to improve our
>>> personal examination skills. The reported sensitivity of a new murmur in
>>> the diagnosis of endocarditis may be as high as 85%.6 But what is the
>>> sensitivity of murmur for endocarditis through your stethoscope, in this
>>> patient, in that moment, under those conditions? And can you improve it
>>> instead of settling for a hemolyzed examination?
>>>
>>>
>>>
>>> Article Information
>>>
>>> Corresponding Author: Zaven Sargsyan, MD, Department of Medicine, Baylor
>>> College of Medicine, 1504 Taub Loop, 2RM81-001A-F, MS: BCM285, Houston, TX
>>> 77030 (zavens at bcm.edu <mailto:zavens at bcm.edu <zavens at bcm.edu>>).
>>>
>>> Published Online: February 18, 2019. doi:10.1001/jamainternmed.2018.8753
>>> <http://jamanetwork.com/article.aspx?doi=10.1001/jamainternmed.2018.8753
>>> >
>>> Conflict of Interest Disclosures: None reported.
>>>
>>> Additional Contributions: I thank Chana Sacks, MD, Massachusetts General
>>> Hospital, Boston, Massachusetts, and Ricardo Nuila, MD, Baylor College of
>>> Medicine, Houston, Texas for reviewing earlier drafts of this article. They
>>> received no compensation for their contributions. I thank this patient for
>>> the lessons he taught me.
>>>
>>> Additional Contributions: We thank the patient for granting permission
>>> to publish this information.
>>>
>>> <>References
>>>
>>>
>>>
>>>
>>>
>>>
>>>
>>>
>>>
>>>
>>>
>>>
>>>
>>>
>>>
>>>
>>> Moderator: David Meyers, Board Member, Society to Improve Diagnosis in
>>> Medicine
>>>
>>> To unsubscribe from the IMPROVEDX list, click the following link:<br>
>>> <a href="
>>> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1"
>>> target="_blank">
>>> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1
>>> </a>
>>> </p>
>>>
>>> *From: *David L Meyers <dm0015 at comcast.net>
>>> *Subject: **The “Hemolyzed” Physical Examination—Situational Challenges
>>> to Accurate Bedside Diagnosis*
>>> *Date: *February 18, 2019 at 4:40:59 PM EST
>>> *To: *Society to Improve Diagnosis in Medicine <
>>> IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
>>>
>>>
>>> A very interesting article on some realities of beside medicine raised
>>> by Rob bell and others on the listserv in the past.
>>>
>>> David
>>> David L Meyers, MD FACEP
>>> Society to Improve Diagnosis in Medicine
>>> Listserv Moderator/Board member
>>> www.improvediagnosis.org
>>> Save the Dates: Diagnostic Error in Medicine Conference (DEM2019),
>>> November 10-13, 2019 at Hyatt Regency Washington, DC (Capitol Hill)
>>> AusDEM2019, April 28-30, 2019; Melbourne, Aus
>>>
>>>
>>>
>>> https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2724394?guestAccessKey=a76c424d-dd3d-4d63-8ed8-70af67b2ca89&utm_source=silverchair&utm_medium=email&utm_campaign=article_alert-jamainternalmedicine&utm_content=olf&utm_term=021819
>>>
>>> The “Hemolyzed” Physical Examination—Situational Challenges to Accurate
>>> Bedside Diagnosis
>>>
>>> A page comes in from downstairs—another admission. A 41-year-old postal
>>> worker in bed 22, presented with severe back pain and needs pain control
>>> and a physical therapy evaluation. Three weeks ago, he was lifting a box
>>> when he felt a sharp pain in the middle of his lower back. The pain has not
>>> decreased, despite his taking naproxen around the clock. I look at the
>>> vital signs: temperature, 99°; pulse, 92 bpm; pressure, 140/90 mm Hg;
>>> respirations and oxygen saturation, normal. Nothing stands out as I click
>>> through the laboratory results.
>>>
>>> I look for this patient among the closely spaced cots in the emergency
>>> department. Before I can find him, I see another man in bed 18 whimpering
>>> in pain. I look at the cluster of computers where the nurses are charting;
>>> his nurse gives me a nod—“I know. I’m coming.” In bed 21, I recognize a
>>> woman behind a bilevel positive airway pressure (BiPAP) mask. She smiles
>>> weakly. In bed 22, the patient shivers under a blanket.
>>>
>>> Another page comes in for another admission. I will call back as soon as
>>> I finish here.
>>>
>>> The patient tells me that he has been shivering like this on and off for
>>> several weeks. However, what bothers him most is his back, and he worries
>>> he might lose his job if he does not get better. I gather some more history
>>> and move on to the examination. He looks tired, but his eyes, hands, nails,
>>> and teeth look healthy. His neck veins are normal. His lungs are quiet but
>>> clear—I think. I move on to listen to his heart, fighting through 2 gowns
>>> and an undershirt. I settle, trying to at least flatten any folds out of
>>> the way. I do not hear much, and I close my eyes to try to focus. I am
>>> struck by how much noise surrounds me. The cacophony of alarms, the BiPAP
>>> machine for the other patient, a patient with delirium yelling out to no
>>> one in particular. I open my eyes. He is shivering again—my cue to move on.
>>> His belly is soft, and his back is tender over the mid lumbar spine and
>>> surrounding muscles.
>>>
>>> Another page, another admission. I quickly put in orders for the patient
>>> and go to see the other patients—I am now 2 behind.
>>>
>>> Three hours later, I write my admission notes for this patient. Physical
>>> findings: “Lungs—diminished breath sounds, otherwise clear. Heart…” I
>>> pause, trying to remember what I had heard. Nothing echoes in my mind. I
>>> rub my eyes and look at the corner of the screen. It is almost 3:00 am.
>>> “JV [jugular veins] flat. RRR [regular rate and rhythm], no MRG [murmurs,
>>> rubs, or gallops].”
>>>
>>> I finish my notes in time for the next admission, a woman with black
>>> stools and lightheadedness. Her vital signs are stable after receiving some
>>> fluids. I click through her laboratory results. Hemoglobin is a bit lower
>>> than her baseline. Chemistry results are normal except that her potassium
>>> is 6.3 mmol/L, with a comment that the blood specimen is “grossly
>>> hemolyzed.” I order a repeat metabolic panel.
>>>
>>> On my way to see her, I notice a room on the floor labeled with the
>>> patient’s name. I stop in to check on his pain. The medicine has improved
>>> his pain, and he is hoping to finally rest, because “it’s so nice and quiet
>>> up here.” I look back at the closed door hiding the hallway. It *is*
>>> quiet. I ask the patient if I can listen to him again. He is able to move
>>> better and sits up on the edge of the bed. I untie his gowns and apologize
>>> for my cold stethoscope on his skin. I hear a systolic murmur over his apex
>>> and axilla. It is not subtle. I listen to his lungs again, hearing faint
>>> crackles at the left base and right mid lung. I look again in his mouth, at
>>> his palate, and see some petechiae.
>>>
>>> The patient’s echocardiogram the next day shows a large mitral valve
>>> vegetation. A magnetic resonance image of his lumbar spine shows
>>> osteomyelitis and diskitis as the cause of his pain. He began to improve
>>> with antibiotics and supportive care and eventually required a valve
>>> replacement.
>>>
>>> Several recent reviews and commentaries reflect a renewed interest in
>>> bedside medicine, including physical diagnosis.1-5 Some reviews remind
>>> us that certain aspects of the physical examination are irreplaceable in
>>> terms of the information they confer and the human connection they foster
>>> with the patient.4 Other reviews are more technical, providing data
>>> about test characteristics of specific maneuvers and outlining concepts
>>> such as likelihood ratios of examination findings.5
>>>
>>> An important aspect of physical diagnosis requires more
>>> attention—context specificity. When referencing sensitivities,
>>> specificities, and likelihood ratios of various examination findings, we
>>> should recognize that they are not universal or static. The percentages
>>> reported in the literature are averages across hundreds of patients,
>>> clinicians, and techniques. Even when the clinician and patient are the
>>> same, circumstance can change everything. When the blood sample of my other
>>> patient was hemolyzed, I was quick to regard the test as spoiled and repeat
>>> it. But the other set of tests—my physical examination of the patient—was
>>> also spoiled by noise, distraction, poor positioning, and haste. Only
>>> serendipity led me to repeat the physical examination that had been
>>> “hemolyzed.” Instead, we should be attentive to situational impediments to
>>> accurate bedside test results. Sometimes we can optimize the situation in
>>> the moment. Other times we may need to repeat the test under improved
>>> circumstances, or we may simply acknowledge that a particular test did not
>>> influence the diagnostic process. “JV flat. RRR. Exam for any abnormal
>>> sounds limited.”
>>>
>>> The notion that physical examination test characteristics are variable
>>> and dynamic adds to the uncertainty that already challenges clinicians
>>> every day. Yet this variability can also motivate us to improve our
>>> personal examination skills. The reported sensitivity of a new murmur in
>>> the diagnosis of endocarditis may be as high as 85%.6 But what is the
>>> sensitivity of murmur for endocarditis through *your* stethoscope, in
>>> *this* patient, in *that* moment, under *those* conditions? And can you
>>> improve it instead of settling for a hemolyzed examination?
>>> Back to top
>>>
>>> Article Information
>>>
>>> *Corresponding Author:* Zaven Sargsyan, MD, Department of Medicine,
>>> Baylor College of Medicine, 1504 Taub Loop, 2RM81-001A-F, MS: BCM285,
>>> Houston, TX 77030 (zavens at bcm.edu).
>>>
>>> *Published Online:* February 18, 2019. doi:
>>> 10.1001/jamainternmed.2018.8753
>>> <http://jamanetwork.com/article.aspx?doi=10.1001/jamainternmed.2018.8753>
>>>
>>> *Conflict of Interest Disclosures:* None reported.
>>>
>>> *Additional Contributions:* I thank Chana Sacks, MD, Massachusetts
>>> General Hospital, Boston, Massachusetts, and Ricardo Nuila, MD, Baylor
>>> College of Medicine, Houston, Texas for reviewing earlier drafts of this
>>> article. They received no compensation for their contributions. I thank
>>> this patient for the lessons he taught me.
>>>
>>> *Additional Contributions: *We thank the patient for granting
>>> permission to publish this information.
>>>
>>> References
>>>
>>>
>>>
>>>
>>>
>>>
>>>
>>>
>>>
>>>
>>>
>>> ------------------------------
>>>
>>>
>>> To unsubscribe from IMPROVEDX: click the following link:
>>>
>>> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1
>>>
>>> or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG
>>>
>>>
>>>
>>> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
>>> Medicine
>>>
>>> To learn more about SIDM visit:
>>> http://www.improvediagnosis.org/
>>>
>>>
>>>
>>>
>>>
>>> ------------------------------
>>>
>>>
>>> To unsubscribe from IMPROVEDX: click the following link:
>>>
>>> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1
>>>
>>> or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG
>>>
>>>
>>>
>>> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
>>> Medicine
>>>
>>> To learn more about SIDM visit:
>>> http://www.improvediagnosis.org/
>>>
>>>
>>>
>>> ------------------------------
>>>
>>>
>>> To unsubscribe from IMPROVEDX: click the following link:
>>>
>>> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1
>>> or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG
>>>
>>> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
>>> Medicine
>>>
>>> To learn more about SIDM visit:
>>> http://www.improvediagnosis.org/
>>
>>
>> ------------------------------
>>
>>
>> To unsubscribe from IMPROVEDX: click the following link:
>>
>> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1
>> or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG
>>
>> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
>> Medicine
>>
>> To learn more about SIDM visit:
>> http://www.improvediagnosis.org/
>
>
> ------------------------------
>
>
> To unsubscribe from IMPROVEDX: click the following link:
>
> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1
>
> or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG
>
>
>
> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
> Medicine
>
> To learn more about SIDM visit:
> http://www.improvediagnosis.org/
>
>
> ------------------------------
>
>
> To unsubscribe from IMPROVEDX: click the following link:
>
> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1
> or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG
>
> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
> Medicine
>
> To learn more about SIDM visit:
> http://www.improvediagnosis.org/






Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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