Bedside diagnosis

Robert Bell rmsbell200 at YAHOO.COM
Wed Feb 20 15:06:38 UTC 2019


 Thanks Tom,
Why do we not know the accuracy in different groups of the most frequently used diagnostic test in medicine. 
The stethoscope has been around for 200+ years!
What are the obstacles?
Rob 
    On Tuesday, February 19, 2019, 11:43:23 AM MST, 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. 
DavidDavid L Meyers, MD FACEPSociety to Improve Diagnosis in MedicineListserv Moderator/Board memberwww.improvediagnosis.orgSave 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>).

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

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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. 
DavidDavid L Meyers, MD FACEP
Society to Improve Diagnosis in MedicineListserv Moderator/Board memberwww.improvediagnosis.orgSave 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

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                             
 












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