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Value of the Lost Art of a Good History and Physical Exam

Johnson, David A1

Clinical and Translational Gastroenterology: January 2016 - Volume 7 - Issue 1 - p e136
doi: 10.1038/ctg.2015.59
Gut Instincts: My Perspective
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1Department of Medicine/Gastroenterology, Eastern VA Medical School, Norfolk, Virginia, USA

Correspondence: DA Johnson, MD, MACG, FASGE, Department of Medicine/Gastroenterology, Eastern VA Medical School, Norfolk, Virginia 23502, USA. E-mail: dajevs@aol.com

published online 7 January 2016

In my nearly 40 years of involvement, the medical field has seen incredible advances in advanced diagnostic and therapeutic technologies. This includes exquisitely sensitive imaging and laboratory testing, which open a wide array of access points for disease identification and appropriate management. As these advanced and expensive technologies have evolved and become more available, however, I have noted a significant trend away from bedside basics. In this ensuing discussion, I would like to point out how the bedside basics, with which we all initially were taught, i.e., taking a good history and performing a good physical exam, can lead one to the correct diagnosis.

A 34-year-old woman was referred for evaluation of the right upper quadrant abdominal pain. The pain was a dull ache with intermittent stabbing severe pains, but improved with recumbency, although with some intermittent nocturnal awakening, in particular if she rolled over on her right side. There was no change with eating or any associated relief with bowel movements, which were normal. She had noted this pain during a vacation trip to Europe, and since return home had experienced it on two separate occasions, which were severe enough that she went to the emergency room, where diagnostic testing included a normal computerized axial tomography (CAT) scan and labs. She was seen subsequently by a surgeon, who did an ultrasound and then a hepatobiliary (HIDA) scan with CCK, both of which were normal, and she was told that she had a nonsurgical problem. After her subsequent second trip to the emergency room she was referred to gastroenterology.

When I saw this patient in consultation, she noted that there was no prior history of similar symptoms of abdominal trauma. I asked about unusual activities for movement on that trip, and noted that she carried a backpack (swinging up to her back several times/day), as well as frequently carried her infant child, whom she positioned on her right hip.

On physical exam there was focal tenderness in the right upper quadrant. When the patient lifted her head and did a partial sit-up with my examining fingers in the point of maximal tenderness, she was exquisitely more tender (+Carnett's sign).

With our patient, it was apparent that she had an ongoing chronic abdominal pain for which she had been subjected to a variety of procedures and testing in an attempt to find a simple cause. These diagnostic tests then gave way to more complex and invasive testing in the pursuit of even more obscure diagnoses. The history, however, provided excellent guidance and the physical exam was confirmatory.

Carnett1 described a clinical test to aid in the diagnosis of abdominal wall pain. The initial description called for examination with the patient supine and the examiner finding the exact point on the abdominal wall, where the patient was maximally tender. The patient was then asked to fold their arms and sit halfway up while the examiner kept their fingers on the point of tenderness. Carnett's hypothesis was that if the pain was arising from the viscera in the peritoneal cavity, the tensed muscles would protect the abdominal cavity by lifting the examining fingers up and away, with the result of a lessening report of the discomfort. If however, this pain was coming from the abdominal wall, the pain should be intensified. In practicality, given the ever increasing habitus sizes we have for our patients, I have found it easier to simply flex their neck and lift their shoulder up from the exam table. This test has been found to be both sensitive and specific.2, 3 In one study, a savings average of $900 per case was evident by avoidance of unnecessary diagnostic testing.2

Reassurance to the patient is often enough to resolve their concern, but I always look closely as to the cause of why now the patient has developed this discomfort. In our patient, there was a history of repeatedly lifting up a backpack as well as carrying her infant child on her hip while traveling on her trip. If Carnett's sign is (+), I explain to the patient that if the internal organ was the source of tenderness, I would be pushing through the abdominal muscles to get to the internal organ, which would be the source of tenderness. If however, they tighten the abdominal muscles, I use the analogy of “creating a roof on the house” and my examining hand now is pushed up to only the abdominal wall and away from the abdominal cavity. As the abdominal wall is further tightened against the same examining pressure, it will be more tender in that muscle and not reflective of pain from abdominal cavity.

I also attempt to identify an etiology to explain why they have this muscular pain. I do a careful examination of the back and spine; admittedly may seem way off base for the gastroenterology consult!. What is often found is a mild scoliosis or pelvic tilt. Look closely at the spine, bend the patient forward and you may see a curvature or one shoulder higher than another, suggesting scoliosis. Then look the pelvic brim, with the patient facing away from you. Look for one side of the pelvis to be slightly higher—in particular suggesting with a mild leg length discrepancy. Then look at the patient's height over the last several years, loss of vertical height with age forces a compression of the abdominal wall muscles. In addition, look at their shoulders while facing the patient. Often as we age, and in particular, when patients spend a lot of time working on computers, the tendency is to hunch forward, developing mild kyphosis. All of these aforementioned results put unusual tension on the abdominal wall.

Analgesics with nonsteroidal anti-inflammatory agents coupled with local topical heat are my primary recommendation for initial treatment. Injection of a local anesthetic into the tender area – (can be done with lidocaine and triamcinolone) can be both diagnostic and therapeutic as well.4 If predisposing factors are identified on physical exam, e.g., scoliosis, postural changes with shoulders rolled forward, kyphosis or scoliosis, I refer the patient to work with a physical medicine and rehabilitation specialist. I suggest guidance for abdominal core strengthening, along with upper torso stretching extension of pectoral muscles and strengthening upper back (trapezius)—all of which are directed to help realign the more normative straight up posture and reduce ongoing abdominal wall muscular imbalanced tension. These recommendations are tempered with advice to have someone (physical trainer beyond the gastroenterologist…) evaluate and direct this to avoid possible muscular injury from an overzealous or misdirected approach. If a leg length discrepancy is identified, a shoe prosthesis or something as simple as a heel lift insert may be needed.

What is most important for this discussion is to not leave the patient with the diagnosis of—“not GI source of pain”…. These patients may have been through a number of other physicians already, so referral back to the primary physician without a more definitive diagnosis and explanation which is satisfactory to the patient, may not be definitively helpful. Furthermore, when showing the patient that this likely muscular, the next question is invariably—“why do I have this?” The ability to spend a few more minutes to help identify causality and better direct the patient to appropriate treatment can be invaluable. All of which can be done without a CAT scan and other expensive testing! Remember this valuable lesson for your next consultative opportunity. It is simple and back to basics!

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CONFLICT OF INTEREST

The author declares no conflict of interest.

1. Carnett JB. Intercostal neuralgia as a cause of abdominal pain and tenderness. Surg Gynecol Obstet 1926; 42: 625–632.
2. Greeenbaum DS, Joseph JG. Abdominal wall tenderness test. Lancet 1991; 337: 1606–1607.
3. Gray DWR, Seabrook G, Dixon JM et al. Is abdominal wall tenderness a useful sign in the diagnosis of non-specific abdominal pain? Ann R Coll Surg 1988;70:233–234.
4. Srinivasan R, Greenbaum DS. Chronic abdominal wall pain: a frequently overlooked problem-Practical approach to diagnosis and management. Am J Gastroenterol 2002; 97: 824–830.
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