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John W. Thomas, M.D.: Surgical patients require complete physical exams

CHARLESTON, W.Va. -- In medical school students are taught basic science, anatomy, physiology, biochemistry, pathology, microbiology among other things medical. The most important instruction is in taking a patient history and performing a physical examination. We often practice on each other and, if lucky, team up with a student of the opposite sex, or same sex if one prefers.

The physical exam is extremely important because tremendous information is right there for the observing and touching. Diagnoses can be made entirely on examination. I have done so many times. In performing an exam we often use the short cut phrase, "within normal limits," or WNL, meaning we thoroughly examined that part or system and found it to have no evidence of pathology.

Sometimes when rushed, tired, or just plain lazy I have used the abbreviation "WNL," but I really did not thoroughly examine the part. I just assumed it was normal with a quick look or no look at all. This is called "We Never Looked," WNL.

When I was young in practice I learned the seriousness of this mistake and nearly lost a patient. Mrs. S came to me, an internist, complaining of depression. Her husband died a year before and then her daughter was brutally raped a few months later. I performed a hurried physical exam and omitted a good neurological exam. She looked normal. Her entire exam was within normal limits. But I never really did a neuro exam, so we never looked.

I placed Mrs. S on an anti-depressant and had her come back. She was worse. I saw her once more and she looked terrible, very depressed. I sent her to a very good psychiatrist who did what I did not -- a meticulous neurological exam. It was not within normal limits. A CAT scan showed a very large operable brain tumor. She is alive today, no thanks to me.

I recently had outpatient surgery. I will not name the institution because I think my experience to be widespread. I had a pre-surgical "physical exam" by a physician's assistant of some sort. She gave me the "We Never Looked" type exam. She did not see a large scar on my neck from old trauma. My neck is always stiff. Her report stated: Neck supple. She did not hear a low-grade heart murmur because she listened through my shirt and T-shirt. My heart was reported WNL. She wrote my abdominal exam as WNL even though I never was placed down to be examined. I have a large ventral hernia I fondly call Ernie. She never felt Ernie.

I was upset by the lack of thoroughness but knew that I was healthy. What if a person not medically aware who rarely saw a physician presented for the same examination? Imagine him with high-grade aortic stenosis, a very serious heart problem. Imagine the characteristic murmur not being heard through two or three layers of clothing, a sort of we never looked exam. Now imagine this patient undergoing anesthesia and developing a serious cardiac complication, even death. All because of "We Never Looked."

The same patient could have had a large abdominal aortic aneurysm that was never examined, like my Ernie was not looked at.

Medical payment has changed since I was first in practice, but the practice of medicine should be the same. Every patient undergoing surgery requires a complete examination. Limited exams may be tolerated only in small exceptions. We Never Looked can cost lives.

Thomas lives in Charleston.


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