“I think he is a terrible doctor!”
My grandmother announced at the dinner table. Looking through the record for her visit, the accusation really didn’t add up. She went in to her primary care physician after noting her blood pressure was a bit high on her home machine.
“I told the nurse what was going on, gave them my notes with my pressures on it and he came in the room. He barely talked to me and didn’t even touch me! How would he know my blood pressure was high?”
As she told me the story, and with the bias in my head of knowing the outcome, I couldn’t comprehend the frustration. She went in with a problem, he quickly solved it and she left with the medication changes she needed. What didn’t click in my mind was the ever evolving “feeling” around healthcare and the disconnect between the provider and patient.
EMS clinicians have the special honor of having one on one patient contact, often for times extending well past the reach of other providers within the healthcare system. While primary care physicians and advanced practice providers are running room to room trying to sort through a long list of patients, we often have the ability to sit and have a conversation that lasts well past the allotted time in an annual checkup.
I know what you’re saying, how does this improve patient outcomes and what does this have to do with physical exam?
In the class I teach on physical exam I present the case of a 65 year old male with a headache.
I provide some vague symptoms and vital signs and ask for a differential. Rapidly, intracranial hemorrhage, meningitis and various other pathologies fly into the chat.
I then give this timeline, giving a brief overview of this gentleman’s course. He arrives, is triaged, has a brief 15 minute assessment with the provider and gets a CT scan.
Then I drop this little tidbit in…
The pain is actually caused from the patient hearing voices.
“That never happens Shane!”
I’m certain I’m not the only one who has had a patient describe chest discomfort well after I dropped them off at the hospital, or had a patient well into their care now note that they took a hard fall at home and think they may have passed out.
Alright, what does this have to do with the physical exam? Well, touch breeds trust and trust breeds honesty. We shake hands with strangers we are meeting, we hug family and friends when we greet them and we kiss our signifiant other. Each of these actions promote the feeling of safety and trust. Who do you trust more, the physician who pulls out their stethoscope and listens to your heart or the one who splits the visit between their iPhone and eRecord software?
Additionally, EMS is often limited on technology within ambulances and helicopters that allow for diagnosis with high specificity and sensitivity. While providers within hospitals and clinics have access to lab values, Xray images, MRI, CT scans and ultrasound, EMS is often limited to the physical exam. As a result, we should be absolute experts (or wizards) at physical exam.
This blog is going to be 3 parts. Each part will provide you with 2 or 3 physical exams you can integrate into your patient care tomorrow without expensive equipment. To start, let’s cover a complex and challenging area to assess - the brain!
Cerebellar strokes make up a low percentage of total CVAs (4% at most) however carry a mortality rate of 23% (1). These patients can be challenging to differential from many other presentations given that their symptoms are often quite vague. Dizziness, weakness, nausea and vomiting make up a great majority of their complaints, making it quite difficult to differentiate from other illnesses we may see. It makes sense that these are the symptoms often associated with cerebellar stroke and illness, given that it’s function revolves around balance, fine movement and equilibrium.
While various stroke exams, such as the Cincinnati Pre Hospital Stroke Scale offer a good sensitivity for catching strokes, we may need to do some more specific testing for the cerebellar region to help us find this disease process.
I want to introduce you to my two friends, Diadochokinesia (say that 3 times fast) and Dysmetria.
Diadochokinesia is the inability to perform rapid alternating muscle movements (2). This can be tested in several ways, but one of the easiest for us to perform will revolve around hand movement. Simply instruct your patient to place one hand on top of the other. Then, have them rotate/flip their hand as rapidly as possible.
A positive sign is uncoordinated flipping or performing the flip at a slower speed in order to compensate for a lack of coordination.
Next, our pal Dysmetria. Dysmetria is an inability to control distance, speed or range of motion. To test this, have the patient touch their nose with the tip of their finger. From there, have them extend their arm and attempt to touch the tip of your finger (2).
A failed examination will result in the patient extending past your finger or missing touching their nose or your finger.
Alright my wizard friends, there are two new examinations to utilize on your next dizziness call. Stay tuned to blog #2 to help us figure out what may be the cause of a strange generalized weakness.
1. Kimon Ioannides; Prasanna Tadi; Imama A. Naqvi. (n.d.). Cerebellar Infarct. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK470416/#:~:text=A%20cerebellar%20infarct%20(or%20cerebellar,in%20motor%20and%20balance%20control.
2. Stanford Medicine 25. (n.d.). Cerebellar exam. Stanford Medicine 25. Retrieved October 15, 2022, from https://stanfordmedicine25.stanford.edu/the25/cerebellar.html