In message <[log in to unmask]> Toby Lipman wrote:
> In your message dated Friday 12, July 1996 Trefor wrote :
>
> > Are you saying that history and simple physical examination are all
> > one needs and that intimate examination is irrelevant to the
> > decision to refer?
>
> I've followed this thread with a lot of interest. It really boils down
> to how necessary is *any* physical examination? Can I refer you to one
> of my favourite papers of all time:
>
> Hampton et el: "Relative contributions of history-taking, physical
> examination, and laboratory investigation to diagnosis and management
> of medical outpatients". BMJ 1975, 2, 486-489
>
> This, very elegantly, looked at the suspected diagnosis at each stage
> of the hospital doctor's involvement with the case. He would record
> his suspected diagnosis after reading the GP's letter, after taking
> the history from the patient (then record predicted management), after
> examination and after investigations had been done. There were 80
> patients.
>
> The results are as follows:
>
> Referring practitioner's diagnosis unchanged: 37 patients
> Diagnosis changed after history taking: 34 patients
> Diagnosis changed after physical examination: 6 patients
> Diagnosis changed after laboratory investigation: 7 patients
Adrian Midgley added:
> Fascinating.
> "Listen to the patient - he will tell you the diagnosis"
Having trained on John Hampton's firm and then returned as an SHO I am
more than familiar with this adage. I still believe it holds true,
particularly in general practice, despite the fact that the paper was
written by a hospital physician.
It is fascinating to note that more than half the referring
practitioners' diagnoses (made presumably after history AND examination)
were subsequently altered.
But you should also note that this paper dates from the days when
general physicians were general physicians. The role of the general
physician has subsequently been subsumed by the "general practitioner".
What the patient tells us is the distress caused by their symptoms. Yet
it is important to quantify the symptoms in order to manage them.
Something that is bitterly distressing to one patient may be passed off
as normal by another.
Examples of objective assessment include:
Peak flow measurements in asthma
Urinary fow measurements in men with prostatic symptoms
Plain X-rays in patients with arthritis
Hb / MCH in women with menorrhagia
Helicobacter status in patients with dyspepsia
Echocardiography in patients with suspected heart failure
PSA in patients with established Ca prostate
Rectal examination
While we should continue to listen closely to what our patients tell us
we must also examine them and have open access to investigations in
order to determine best management for them.
A rectal examination (prompted by symptoms) revealing a hard knobbly
prostate remains a key indication for *urgent* referral.
Sorry Ahmad, but you'll have to get your digits dirty from time to time.
Trims.
________________________________________________________________________
Dr Ian Trimble email: [log in to unmask]
Sherwood Health Centre
Elmswood Gardens Tel: +44 115 962 4516
Nottingham NG5 4AD Fax: +44 115 985 7899
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