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How not to do a physical exam

Yesterday I had APD and was with my classmate/partner and our instructor Dr. Phillips. He introduced us to a woman in the VA who had severe right lower abdominal pain who was admitted Thursday. She was on a morphine drip, and reported that the pain was so terrible she was passing out when she was admitted. Since APD is essentially a class on doing patient histories and physical exams, this was "practice" for us. We spent a good hour asking every question we could, exhausting our minds for medically relevant topics, and only then did a complete physical exam (almost a complete physical).

By the time we reached the physical exam, Dr. Phillips had left to go to the swamp (the residents' workstation room) and said he'd wait for us. As my classmate and I moved through the physical, we reached the abdomen. I gently examined the lady's abdomen, noting that she flinched and guarded when I began to press firmly. I moved back and Blair repeated, with questions in between. As Blair asked the woman a question, I was running in my mind the steps of the physical exam, and realized I needed to determine the woman's liver size. You determine this by lightly tapping the abdomen and listening for the difference in resonance. Something that didn't cross my mind was that this woman was in the hospital with severe abdominal pain, and as soon as i made my first tap (which she was not expecting) she grimaced and groaned in pain, doubling up on her bed.

The moral of the story is, don't do anything on a physical that you haven't informed/warned the patient you are about to do.

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