Death of the Physical Assessment

[blondy2061h]

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.

[nyteshade, BSN]

At least the OP had that much, last exam I had I got a pat on the back!

"Coniecturalem Artem Esse Medicinam" So very, very true...

[cardiacmadeline, 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

Interesting article. I listen to bowel sounds on all of my surgical patients, but I've always felt it really wasn't all that helpful. I just do it because that is considered part of our nursing assessment. It is when patients start experiencing N/V, distention, etc that I start worrying.

[leslie :-D]

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 did find that interesting, gila.

literature, such as your link, should be distributed to all hospitals so we know the latest ebp.

however, the op has a point, me thinks.

when i saw my pcp last yr for a long overdue physical, i had to ask her to listen to my lungs...

which was important to me, given that i am a heavy smoker and haven't had a cxr in decades.

you could tell it had totally slipped her mind (versus being negligent) and she hopped to it once i asked.

so sometimes, it really is just a matter of gently reminding your doc.

or, you can always ask, "is there a reason you didn't _____________?"

i can't say i do a total assessment q shift but definitely do assess the system that is failing.

leslie

[dcampbell]

To the OP:

I wonder how much you were charged for this "examination"?

[LeLeeFNP]

bowel sounds really dont tell a physician jack about the GI conditions they would want to rule out. Your symptoms and diagnostic tests are what they would be looking for, especially in an outpatient setting. I agree, acute care is different when a patient is in a hospital setting and their condition could change.

[ChristyRN2009]

I found that article really interesting, thanks for posting it PP. And to the OP, I know my docs don't do a thorough assessment, and I can't tell you how many doctors IN THE HOSPITAL don't go in the patient's room at all on rounds. I find it absurd but a lot of our specialists are bad about that.

[Mrs.Rollins, ASN, RN]

I have to echo ChristyRN's sentiments. Not too long ago a specialist charted on my ICU patient for a week and never once stepped foot in the room. It would explain why he continued to tell the family "If she's not responding it's just because she's getting sedation while she's on the vent" and that her pedals are "weak bilaterally with bilateral foot swelling +1". This patient had NO sedation running since the time of intubation and was a bilateral BKA. But who do you think the family spent all their time yelling at? Certainly NOT the dumb*** doctor, but the nurse (me) who had to chase down someone to give me a neuro consult because the woman was obviously in dire straights (pupils blown, but I'm sure you have guessed by now that doc in question charted PERRLA.) Ugh.

[caliotter3]

I have also witnessed doctors writing in patient charts without going near the rooms. Deplorable.

[Mrs.Rollins, ASN, RN]

It is absolutely deplorable, especially in an acute care setting. In my experiences with outpatient (I worked in cardiology for years before nursing school), our doctors did very, very thorough physical assessments. However, given the nature of cardiovascular disorder, the manifestations can be multiple and so it's very necessary to do a comprehensive assessment. However, I rarely receive such an in-depth assessment when I visit my PCP or specialist. As it has already been pointed out, many times it's really only necessary to focus on the system in question.

And bowel sounds? They really don't tell me jack. I can have patients getting continuous tube feeds at 50-75 an hour, no residuals, good bowel movements and great nutritional labs, and they'll all have hypoactive sounds. I do it and chart it because it's required, but I've yet to find it a useful assessment tool.

[Virgo_RN, BSN, 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?"

You said it yourself. Your issues have been well controlled for years, and have been stable for some time now. Exactly what will a physical exam tell your doctor if you have no new signs or symptoms to report?

[rngolfer53]

For a good book on the subject, try Every Patient Tells a Story by Lisa Sanders.

She's a doctor who tackles the problem of the decline in physical exam skills.

[Katie5]

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

Did you mean to write that?