Primary care needs better physical exam skills

by Joseph Biundo, MD

Not long ago, primary care physician Rob Lamberts did a blog post about the economics of seeing Medicare and Medicaid patients, stating that doing so was bad business. While I agree with most of his points, I have a quarrel with his statement that primary care physicians keep down the cost of care by keeping people healthy, away from specialists, and out of the hospital.

That may be true in theory, but I see patients in my rheumatology office every day who have been “worked up” by primary care physicians and come in with piles of lab tests, and x-ray and MRI reports but are diagnosed in my office by a simple history and physical exam.

Those expensive tests certainly did nothing to hold down the cost of care. But, a primary care physician with good diagnostic skills can, indeed, keep patients out of a specialist’s office.

And, perhaps more importantly, they can spare the patient some unnecessary and expensive tests.

Speaking from the rheumatologist’s perspective, it takes just a few minutes to do a brief but meaningful joint examination. Yet, too often, I find the primary care physician’s physical examination of the joints and extremities consists only of recording the mantra, “no clubbing, cyanosis, or edema.”

That notation allows a physician to justify the coding requirements for extremities, but use of this shortcut makes it too easy not to look any further for more common and more important problems.

Everyone would agree that edema is common and noting it is important. But, clubbing, even though it might be important if present, is very rare in the typical primary care office. Cyanosis is also important, but it, too, is not a common finding.

What then, besides edema, should a primary care doctor record in the physical examination of the extremities?

It would be more valuable to describe that there is no swelling, tenderness, or loss of motion of the joints, if that is the case. Otherwise, a short list of the abnormal findings would be of value.

Extremity strength of both arms and legs is also much more significant to record than clubbing or cyanosis.

That is not to say one should ignore clubbing or cyanosis, if present. The issue here is the mindless notation of highly unlikely physical findings while overlooking disease that is much more common and relevant.

A quick assessment of joints can begin by inspection and palpation of the hands, which can confirm the presence of osteoarthritis in identifying Heberden’s nodes in the distal interphalangeal (DIP) joints and Bouchard’s nodes in the proximal interphalangeal (PIP) joints and bony swelling of the first carpometacarpal (CMC) joint.

These nodes are due to bony swelling and not synovial swelling that is seen in rheumatoid arthritis primarily in the metacarpophalangeal (MCP) and PIP joints of the hand.

Often, the appearance of the hands is so clear cut that OA can be diagnosed without need of an x-ray or ordering a rheumatoid factor.

A very common but often overlooked problem in the hands is volar flexor tenosynovitis, in which pain, tenderness on palpation, and tendon sheath swelling occurs. Progression to triggering or locking of the digit on flexion at the PIP can occur.

Again, an x-ray is unnecessary to make this diagnosis, and a local corticosteroid injection into the tendon sheath is often helpful.

In the wrist one may note the presence of a ganglion over the dorsal area, which is an outpouching of the synovium of the wrist joint or extensor tendons.

A complaint of pain over the medial aspect of the wrist could be due to de Quervain’s tenosynovitis, which is manifested as swelling and tenderness over the extensor pollicis brevis (EPB) and abductor pollicis longus (APL) tendons.

When the complaint is tingling or numbness of the fingers, then carpal tunnel syndrome might be the cause of the symptoms. A positive Tinel sign helps with the diagnosis.

In the elbow region swelling of the olecranon area can be seen and palpated due to bursitis, rheumatoid nodules, or gouty tophi.

A quick assessment of shoulder motion and presence of pain on motion might detect rotator cuff tendinitis, rotator cuff tears, or adhesive capsulitis.

Pain on hip flexion or loss of motion on flexion, internal or external, could signify OA of the hip. A Trendelenburg gait is also associated with the condition. Remember, we must see the patient walking to detect this. Often, in a busy office the physician may not see the patient walk into or out of the office.

With the knees, effusions and increased temperature can be palpated, and genu valgus or genu varus can be observed.

In the ankles and feet, pes planus, hallux valgus, and hammer toes are noteworthy in patients complaining of foot pain.

Additionally, in the patient who complains of generalized pain, palpation of the various muscle groups, including chest wall, trapezius and cervical spine muscles should be done to help identity the presence of tenderness which can be related to fibromyalgia.

In summary, instead of writing “no clubbing, cyanosis or edema,” it is much more valuable to do a practical musculoskeletal examination and describe the abnormalities.

If the exam is unremarkable, then one could record the following summary statement for the extremity exam: “The joint examination reveals no swelling, tenderness, or loss of motion. Muscle strength is adequate, and no peripheral edema is present.”

Primary care physicians who do that kind of exam can communicate more clearly if they do need to refer to a rheumatologist, and the patient may be able to forgo expensive tests entirely.

In this day of rising healthcare costs, it’s my firm belief that one of a physician’s most important assets is the ability to do an excellent physical exam.

Joseph J. Biundo is a rheumatologist and physiatrist.

Originally published in MedPage Today. Visit MedPageToday.com for more rheumatology news.

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  • ninguem

    And……although it’s likely primary care needs the exam skills, so do the specialists. Cardiology consults coming back to me rarely discuss physical findings. They go straight to echo and cath, etc. Straight to the CT, MRI, etc., for the various other specialists.

  • ninguem

    Anybody here ever read Sapira’s “Art and Science of Bedside Diagnosis”?

    With physical exam skills and nature of finding or sign or diagnostic maneuver tracked down to the original writing of the physician originally describing it.

    It’s fun to read.

  • http://pagingdoctorgeek.blogspot.com Dr. Geek

    Sounds more like an issue of communication and recording than necessarily PE, which is also a problem, but of a different sort.
    There’s also something to be said for over-generalization, a problem that we all fall prey to in practice…

  • pheski

    I agree. But there is more to this story.

    When the primary care physician sends you her patient with fatigue and joint pain and intermittent rash with an ESR of 39, how long is the appointment your office makes? How much information is gathered by your nurse or using a form? How many problems are you dealing with during your (?30 minute or longer) initial patient evaluation.

    Are you aware of the likely context of the referral? The patient was there for an annual health maintenance visit (30 minutes) and mentioned that his headaches had come back but were not the same as before, that the Cialis no longer worked well for his ED which was causing problems at home, wanted to review his recent lipid studies, had an article he had cut out of the paper to ask you about, and was having joint pain and more fatigue and had had a rash that came and went. The PCP suggested a second (longer) visit to address some of these things, but the patient objected, noting that he had already saved these up for this visit, taken time away from work, and paid a co-pay for today’s visit. Besides, a colleague at work had the same symptoms and turned out to have Lyme disease with the which his doctor missed but the specialist found, and he may be going out on disability.

    OK. I’m exaggerating – but only a little.

    You are absolutely correct that a careful and detailed history and then appropriated focused exam will make or suggest the diagnosis 75-85% of the time, and further testing or referral may be primarily for confirmation or management suggestions.

    You are, apparently, not aware of why that history and exam did not occur.

    Your very valid point would have been easier for me to read without a rise in my PCP blood pressure, if it had not been accompanied by the implication that the PCP is lazy, unskilled, or incompetent.

  • PAUL MD

    Gee, the physical exam. What a quaint concept. Is there an APP for that?

    Dr. Biundo, I totally agree with your position, but there is, as usual, more.

    My concern for the patient’s well being though is that the primary care provider should also recognize (with the same humility that we all do) when they don’t know what they don’t know, and REFER.

    We in ophthalmology have seen patients stumble into our offices having been treated for undiagnosed uveitis with topical gentamycin or undiagnosed angle closure glaucoma (either from Topamax or from anatomical predisposition) with similar topical meds that don’t conform to care standards and delay diagnosis. Permanent damage is sometimes the result.

    What I have experienced in the capitated care environment is that the patients are sent to us emergently for broken glasses or presbyopia which is ridiculous and robs time from folks with real and pressing problems. Straight fee for service is at patients or referring providers discretion most of the time with very little hint of any self serving agenda.

    I am, by my experience having worked amidst the HMOs, reduced fee for service contracts, PHOs and IPOs of the late 90s, not optimistic of the process or results when soon to be working in the newly rebadged ACOs.

    When PMDs are incentivised to not refer for remunerative purposes (also secondary to the current environment of spite aimed at specialists) whether it be branded as “medical home” , “ACO”, Gatekeeper or just caring and deep regard for their patients’ welfare….Irrational RATIONING is the result.

    I mean this with all sincerity. If you care that much, and with the patients permission, I welcome you to accompany your patients to my office and sit in on the appointment with us and participate. Bring your laptop and polish up your office notes if you must. I do understand those particular pressures that you are under. For the patients benefit, educational purposes and absolute transparency, please come.

    This may be one of the services provided by primary care physicians that attempt concierge boutique practices. There is a local private boarding High School that has its in-house physician accompany students to doctors appointments in the community and it is fabulous albeit not realistic for most of us. Case workers for the mentally impaired and/or incompetent also seem to add a layer of “patient’s best interests” and I/we encourage and welcome them.

    All is not wrong with the current system. Tort reform, decent pay, freedom from mandated care tyranny and dealing with reasonable physicians and patients with reasonable expectations would have gone a long way in curbing costs and continuing high quality care but it seems we will never know.

    We have nothing to apologize for. WAKE UP PEOPLE.

  • http://nostrums.blogspot.com Doc D

    A historical note: One of the best and still useful books I’ve ever read is Cope’s Early Diagnosis of the Acute Abdomen. Originally written in 1921, the edition I used in the 70′s was chock full of subtle H&P stuff.. I have run across more than one surgeon these days who has asked “what did you mean by a positive internal obturator sign?” when considering ruptured appendix.

  • http://warmsocks.wordpress.com/ WarmSocks

    @pheski – You asked about the amount of time allotted for an initial appointment. I’ve had two different rheumatologists. They allowed a LOT of time.

    The first said to allow 2-4 hours for the initial appointment. x-rays were done on-site and viewed during the visit. Blood was drawn for labwork to be run by a local lab. The most thorough physical that I’ve ever had was done, and it took 3.75 hours. Follow-up appointments were 30 minutes (except one that took 45 minutes – his fault, not mine; I was ready to leave in 10minutes but he kept talking).

    My current rheumy took 90 minutes for the initial appointment, again performing a very thorough exam. Part of the reason it took less time is that I had to go elsewhere for x-rays and the blood draw. Follow-ups are usually 30 minutes.

    My very limited experience is that rheumatologists don’t skimp on time with patients.

  • alex

    This seems to be much ado about nothing. You presumably know that “no c/c/e” just means “looks unremarkable”, not specifically “no c/c/e”. It would be unnecessary to even mention were it not for Medicare’s stupid requirement to do so. The PCP looked at the person’s hands and decided whether they thought it looked like simple OA or something more complex to refer. What they scribbled down for the beancounter’s approval is largely unrelated.

  • ninguem

    Doc D – One of the best and still useful books I’ve ever read is Cope’s Early Diagnosis of the Acute Abdomen.

    I’ve mentioned that book to medical students and they did not know what I was talking about. It was mandatory reading in my medical school. Short and pleasant read with a lot of good information. Are they not teaching with that book anymore?

  • http://pagingdoctorgeek.blogspot.com Dr. Geek

    @warmsocks,

    point of clarification. The statements weren’t intended to convey that rheumatologists didn’t spend enough time, but rather that they have an over abundane of time to spend with each patient, whereas a lot of PCPs (and other physicians, as this problem is system-wide, it’s just easy to dump on primary care)operating in the magical world of RVUs and “oh by the ways” don’t have that much time.

  • pheski

    @WarmSocks ~>

    Thanks. I hear similar reports from my referred patients.

    If I saw patients in 30 and 90 minutes blocks, my daily load would drop from the 20-24 range (though, to be fair, this includes basically healthy patients with truly minor single problems or quick rechecks) to 12-16 patients. As a family doc, I don’t do much in the way of procedures. The revenue from lab and radioogy studies is not mine. I would need a smaller staff and would charge more per visit, so it might be financially viable.

    But who would see the 8-12 patients I didn’t see?

  • Meryl Steinberg ( @meryl333)

    Last year I had angina symptoms from extreme exhaustion. Primary doc & ER focus on worry about instability & possible heart attack led to rush to judgement that a 70% artery closure was the cause. My efforts to relate a medical history that would have revealed the underlying issues were dismissed. Chest pains persisted after 5 stents were put in and I was told it was not related to stents or heart, yet not one doc could figure out the problem. An expert at Oriental pulse diagnostics did. Difference between health care and medical care. If Western docs don’t have the time, would love to see alternative practitioners trained and licensed for diagnostics and referral. The medical model’s stranglehold on health care is stifling. Lack of time for care & proper diagnosis is very costly to the institutions and the patients.

  • http://medicalspamd.com Medical Spa MD

    Eh, I’m in agreement with all sides here. We all know about the ‘code dance’ that goes on in every practice I’ve seen.

  • http://www.mesm.co.uk medical fridge hire

    when people are getting treated they expect to have the best service possible but of course not in every case this is true. More physical exam tests would beat great getting them ready before going into the real medical world. However there is only so much they can be shown. perhaps the teachings need to reviewed so they closely match what is really practiced

  • LynnB

    I know that when I refer to specialists they take pains to quarrel with PE findings so I REMOVE then from the notes .

    Ex: Classc MR murumur. I work in a “semiclosed system” with 6 cardiologists. 3/6 cardiologists accept without comment 1/6 calls me and says I am over my IM training, 2/6 never read the note and just repeat the echo at their institution and the patients complain “he never listened to my heart”

    Ex: Patient appears to have pulmonary htn. This requires an out of system referral. Pulmonologist in the system says “there is no loss of nail angle you don’;t know, you are are a general internist” ” the tricuspid regurg is overestimated on the echo’”, “Those blood gase s are wrong, the patient was SOB” (DUH!!!). This patient can be managed here without expensive meds.

    I actually wrote once (courtesy of Dragon and a late night) “The patient has a striated penis overhanging her right thumb that may relate to her nudeness , but also has atopy of the vastus labialis , suggesting motor involvement as well as more distal disease. ” Not one of the 4 docs who saw her even noticed . I was mean to my least favorite cardiologist and did not correct the referral note that the patient had a history of melanoma that was 25.5 cm in diameter to see if he would notice. OF COURSE NOT, my notes are from a dumb PCP and not worth his valuable time .

    It’;s more complex than the hand on the doorknob naure of the arthralgias and rash. .I may have done a more complete joint exam 2 visits ago , which was not normal and made me willing to do that referral –the EMR (cream of the crap) can only pull up the joint exam from last visit which was when he came in with prostatitis and the relevant fact may have been “no indication of sepsis” eg no c/c/e

    We all have too little time and too many demands. Can we assume each others good will? I promise not t make fun of Dr. Pompous Swindbag the specialist if you promise not to assume the FP or internist is a fool. I agree with my ophthalmology colleague I see too many serious problems neglected .

  • pheski

    @LynnB ~>

    “We all have too little time and too many demands. Can we assume each others good will?”

    Beautifully said. Thank you.

  • http://curbside.posterous.com Nuclear Fire

    @WarmSocks:
    Thanks you warmed my heart. That is why I went into rheumatology.

    @prettymucheveryoneelse:
    Actually, having good PCP documentation of their exam is very helpful so that the specialist (or PCP at the next visit or the follow up from the specialist visit) can tell if things are progressing, moving to new joints, improving slightly, or is the reported “swelling” edema, fibrosis or neuropathy. This is just as important in neurology, cardiology, etc.

    All Dr. Biundo really said was that doctors should do a good physical exam and document it adequately. (He also thoughtfully laid out what to look for.) That is really something you want to argue about? Don’t your patients deserve that kind of care?

    Does this really seem unreasonable:
    “Primary care physicians who do that kind of exam can communicate more clearly if they do need to refer to a rheumatologist, and the patient may be able to forgo expensive tests entirely.”

    @LynnB:
    Shame are you. Removing important documentation from your note is pathetic. Grow a pair and stand up to the jerk specialists not cower from them at the expense of your patient.

    @Paul MD:
    I agree; better not to miss soemthing. I also thank my Ophtho colleagues who graciously agree to see my patients quickly when I am concerned about some occular complaints or findings.

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