Death of the Physical Assessment

[blondy2061h, MSN, RN]

I have a history of some GI issues, which have been well controlled for years. I see a GI doctor annually. Today I saw her. Of course in this day and age you expect almost no time to be spent with you. And my issues have been stable for some time now. However, I couldn't believe the cursory physical I got. It was practically to the point of "Why bother?"

First the MA took my vital signs. She told me my HR was "68." I was feeling anxious and could feel my heart pounding away. When she left the room I took my own HR and got 122.

For the physical exam, the doctor listened to my lungs in 2 places and listened to my heart for about 2 seconds. I was a little surprised to say the least when she told me that was it. I didn't even get on the exam table. There was no abdominal assessment at all.

That being said, I don't mean to single this particular person out, as this has become the norm. I understand that some of this is from time limitations, but I still feel you can do a more thorough exam.

Everyday when doing my initial assessment on my patients I do a more thorough exam than that. I typically listen to the heart for at least 30 seconds and usually in two different locations. I listen to lung sounds in all fields. I listen to bowel sounds. I look in their mouths. I check for pulses in all four extremities. I look for edema. I check for capillary refill. I look at any wounds. I look at their central line site and flush any unused lumens and check for blood return (so when I need that lumen later it's not a surprise that it's clotted). I ask them to demonstrate incentive spirometer use. That's it. It takes

I'm sure saying that I have no issues bought me a less thorough assessment. I'm also sure more complex diagnostic studies have led more to the death of the physical assessment.

But really, if I'm paying for your time and expertise, don't I deserve a bit more than that?

I wonder if it would have been different had she known I was an RN.

[caliotter3]

I would change doctors.

[ybq2008]

I thought the same thing the last time I went in for a sick visit. However, at my follow up appointment, I had the most thorough physical assessment and H&P of my adult life. And it was completed by an FNP. That made me feel better, especially considering my career goals. But anyway, I completely understand your frustration. I hope you have better experiences in the future :)

[blondy2061h, MSN, RN]

I would change doctors.

It's a group practice and the one I usually see is one of the smartest doctors I've ever seen.

[esrun00]

I don't know if it would have made a difference if she knew you were a RN or not. I was in the hospital last month for 24hrs for pneumonia and all three nurses I had contact with listened to my lungs and heart with one location for about 4 seconds and that location was right between my breasts! I thought I had been doing it wrong for the last 20+ years. And this was my hospital, not my floor though. And that was the only part of the assessment they did, only one asked me about pain.

I was glad I was there only 24hrs.

kt

[tewdles, RN]

There clearly is a difference in the physical assessment that you would receive as an inpatient in a hospital vs. a well patient on a routine office visit. You do make some excellent points that should be addressed with the doctor...like, why can the MA not obtain an accurate HR? That one vital sign result would have me wondering which of her vital signs are accurate and which ones are guesstimated.

If you have a GI problem which is well known to both you and your provider, I am not surprised that there is not a "thorough" exam for a routine visit. Presumably you are a good historian if you are having some sort of problem or exacerbation of your condition, in the absence of a specific complaint at the time of your visit I could well imagine that the "assessment" was cursory and was based more upon the subjective rather than objective data. Had your presentation been different I suspect the provider assessment might have been more focused.

On the other hand, when you have people in your nursing unit at the hospital, they are acutely ill and require 24 hour nursing care. These folks are at risk at any moment for complications and crashes. Anything short of a thorough nursing assessment is asking for trouble and you are correct to be diligent about completing such. Remember that you practice in acute care and the office nurses practice in ambulatory care. One is not better than the other nor is one smarter than the other...they are simply different ways to look at and provide care to the public.

I do worry about the MAs ability to accurately obtain VS ... I hope you follow up on that as it could have serious implications for someone visiting that office.

[bill4745, RN]

I was recently hospitalized with abdominal pain that turned out to be a blocked common bile duct. Three GI docs saw me over three days. Only one bothered to listen for bowel sounds. I was shocked.

[StNeotser, ASN, RN]

I was recently hospitalized with abdominal pain that turned out to be a blocked common bile duct. Three GI docs saw me over three days. Only one bothered to listen for bowel sounds. I was shocked.

Wow! Did the nurses though? They had to have done.

[P_RN, ADN, RN]

Every time I see my Internist I praise God he was sent my way..A 30 minute visit is at least 30 minutes whether it's for a cough, a blister, earache whatever. A complete physical is at least 75 minutes. If he finds something it may be more. He makes his referrals himself and seeks my approval of his choice of physicians to use. He diagnosed my daughter's rocky mountain spotted fever and sought his residency preceptor for advice though he was long done with his residency. You see in SC there was not supposed to BE RMSF. He picked up on my SSS when the ER docs were ready to send me home ergo the pacemaker I lug around in my chest.

I know he is precious to me and I so wish all of you could find such a physician, NP, PA. I praise my doc to everyone. The one tiny thing is he does not accept Medicare, but I do have a medi-gap that is well worth it.

Give your doc a chance though and call him on it. Hey doc 2 sites isn't sufficient to assess heart sounds, I bet you'll get how do you know.....then TELL. I AM A NURSE and I WAS TAUGHT THIS WAY BECAUSE IT IS THE ONLY WAY THAT IS CORRECT. If he fires you, then you can look for a better one. But I suspect he will gabble something oh I forgot. I got distracted.

[GilaRRT]

I think we need to look at things realistically guys. First, how many people actually do what we were taught? Remember, 5 minutes a quadrant from school? So, 20 minutes just listening to bowel sounds.

Next, many of the assessment modalities are subjective and not all that helpful for many conditions. Some bowel sound literature you may find interesting:

http://www.nysna.org/publications/newyorknurse/2007/jan/research.htm

[blondy2061h, MSN, RN]

I think we need to look at things realistically guys. First, how many people actually do what we were taught? Remember, 5 minutes a quadrant from school? So, 20 minutes just listening to bowel sounds.

Next, many of the assessment modalities are subjective and not all that helpful for many conditions. Some bowel sound literature you may find interesting:

http://www.nysna.org/publications/newyorknurse/2007/jan/research.htm

I was always under the impression that you had to listen for 5 minutes before determining that there are no bowel sounds, not that if you heard bowel sounds you had to keep listening for the whole five minutes.

I'm sure there is plenty of evidence that listening to lung sounds in all fields is useful. That being said, I'm okay with a GI doctor not listening to my lungs. That's not what I see them for. But don't "pretend" to listen to my lungs by listening in two places then charting that they're clear.

[GilaRRT]

I was always under the impression that you had to listen for 5 minutes before determining that there are no bowel sounds, not that if you heard bowel sounds you had to keep listening for the whole five minutes.

I'm sure there is plenty of evidence that listening to lung sounds in all fields is useful. That being said, I'm okay with a GI doctor not listening to my lungs. That's not what I see them for. But don't "pretend" to listen to my lungs by listening in two places then charting that they're clear.

Unless you fail to appreciate bowel sounds, then you continue to listen and listen? I never commented on lung sounds; however, how many people actually perform a proper IPPA pulmonary assessment? I do not disagree that some people are fakers.