So the only person who likes change
is usually a baby with a wet diaper.
The only time not to expect change though
is when you’re dealing with
a vending machine.
Everything we do in healthcare
can be done differently
and will be done differently.
When I trained, we had paper charts.
Everything was written freehand.
We could draw drawings in
the medical record
to show what our patient looked like
or a piece of our patient,
or have our patient draw to
say what they felt like.
We guided the chart
and we guided how our notes were kept.
We focused on what we felt was important
or our patients felt were important.
The electronic medical record
is a self-populated, directive type of exam.
So this is much different than the
free handed exam in the past
in that templates will ask
groups of questions
and questions that lead the discussion
in a certain direction
and they lead the discussion
towards the most common
or most probable etiology of an illness,
and that’s how the bundling occurs.
The problem is, when people go off of
that or don’t have something
and we often say that
hoof beats come from zebras and horses,
so you don’t always look for the zebras.
You want to have the ability to find them.
So the examiner can create
their own template,
but medical students typically can’t.
You can put different systems in place
where you freehand within there
and that’s often where people cut and paste
which tends to fill the medical record
in ways that aren’t ideal.
Scribes also fill the medical record,
but they tend to listen to a provider
ask the questions,
and then try and backhand
it into where it fits.
So the electronic medical record
guides the exam
towards the most probable and common causes,
but again, hoof beats come from
both horses and zebras.
You want to start from where the patient is
and explore around the problem.
Any question or any issue the patient has
should have more questions asked.
Any positive needs to be pursued.
So when we do a review of systems,
it tends to be a list.
When we do our exam,
we tend to get bullet points where we say
any headaches, any nausea or vomiting, or
any dizziness. We go down the list—
any double vision, blurry vision,
or difficulty seeing.
You have your questions you ask
and they become rapid fire.
What you’re looking for is positives.
You get a positive, you stop,
because when you present—
presenting is how you’re thinking,
what you’re focusing on—
and when you present, that’s how
you’re going to be graded,
how you’re going to be assessed
by your superiors.
And they want to know if
you found abnormals.
They want to know if you’ve found
anything that didn’t fit,
anything that’s going to lead you to
need further investigation
and may need care.
So the subjective history and
review of systems
are done by the provider
when you explicitly ask if they’ve had
something or haven’t had something.
You also develop your own system.
How do you deal with 100 different
questions? You ask rapid fire.
Well, if I ask them, they admit or deny.
If they do it, they state it.
I’ve got my own system so I know
if I had to elicit something
or if it’s something that they cared about
and they wanted to talk about further.
So the history, again, subjective.
Patient complaint in their own words
and it’s prompted by the chief complaint—
the presenting symptom,
and why patient came to get care today.
So the history starts with
the patient’s agenda,
and then from the patient’s agenda,
we try and expand it.
The review of systems is a
review of systems.
You go through each system
and ask as many questions as you
can think of as fast as possible.
Do you have any headaches, blurry
vision, double vision,
difficulty seeing, any problems swallowing,
any change in taste—
it is a neuromusculoskeletal exam
looking and focusing on the nervous system
and the musculoskeletal system.
Does anything cause your arms
and legs to go numb?
Do you drop a coffee cup? Are you
having more clumsy movements?
Are you having more difficulty functioning?
Do you feel awkward cutting your food
now where you didn’t before?
Any tremors or shaking?
Any problems with coordination or balance?
And are you thinking as sharply
as you did before?
Do you rely on your memory like you
did before or are there any changes
in how you rely on your memory?
Do you need reminders?
These are all things I look at
for the neural system
to make sure that they’re thinking
okay and their nerves are intact.
When I get to the musculoskeletal
system, I ask about their back,
about their spine, about their joints,
and is there anything that they used to be
able to do that they can’t do now?
Do their muscles hurt them?
Do they feel like their bones
are creaking more
or functioning a little bit differently?
I care about joint noise.
I care about what things
sound like and look like.
People complain about this often
and I think it’s important to pursue it
to see if there’s any relationship.
We also focus on movement.
Does it hurt to move? Does it hurt to walk?
Can they walk as far as they walked before?
Any weakness or difficulty functioning?
And when we get to the 10-step exam,
I’ll give you some of my tricks,
but we know that at the peak of the life,
the most health,
the most ability to recuperate, is
when people are between
25 and 35 years of age.
At 35, you get old.
You can’t heal. You need more sleep. You need
more rest. You need more rejuvenation.
Blood pressure starts to go up
2 points systolic every year,
diastolic 1 point every year.
That happens at 35.
What’s that got to do with the
Your muscles are at their peak
between 25 and 35.
They’re their biggest, their plumpest,
and their strongest at that age.
At 35, we start to see weakness
in your non-dominant side.
The easiest way to test this,
is a 30-second stand.
Whoops. I’ll do the 1 I can do.
Dominant leg—you should be able to stand
on your dominant leg for 30 seconds
at 35 years of age.
Your non-dominant leg,
you may go down to 25 to 30.
So that’s a long test because
not everyone has a minute
to stand there but it’s fun to look
at and it’s fun to evaluate,
and it tells you how the person is aging
because we know 35 years of
age may be the decline,
but we also know that by working out,
by staying active, and by eating right,
you can delay that 15 to 20 years.
Your blood pressure doesn’t need to go up,
your muscle mass doesn’t need to decline,
and there are also hormonal effects
from the muscles that feedback
how much muscle loss you have
and where you have it.
A lot of people focus on the larger muscle,
and they look prettier
but they don’t help motion as much
as the smaller muscles.
So you need a mix of both.
So the movement matters.
Pain matters. Weakness matters.
Spasm and function—
and I always ask,
any noise, deformities, or asymmetries
in your joints?
Are there things you can do on your
right that you can’t do on your left?
Just part of a review of systems
that gives you a sense
of how somebody is functioning
and how they’re feeling and what’s going
on with their musculoskeletal system.
And each person has to
develop their own style.
They have to know what
they’re comfortable with.
Initially, you tend to ask all
the questions in sequence.
As you get more experienced, you can mix
the review of systems with the exam.
It saves time and it makes more
sense to the patient
when you’re pushing on their
ears and examining the ears,
that you ask any trouble with hearing?
Any trouble with balance? Any
trouble with infection?
Have you noticed any flaking?
We know that ears grow with age,
again, starting at 35 years of
age expanding at 55 to 60.
The ears start to grow. They
start to grow hair.
Part of the normal lifestyle.
It’s good to do that while
you’re doing the exam
and it makes sense to somebody
you’re off in left field.
If you’re asking about earwax—if it’s changed
color or consistency out of nowhere,
so it makes more sense if you do it during
exam but that takes time and practice.
And again, the electronic medical record
is pulling us away from the patient
and that’s something that needs to
be noted and guarded against.
You need to separate yourself from
the record to do the exam,
to touch the patient, and
to see what’s going on.
So quick change of pace
because as a practicing physician,
we always wonder what gets paid
for and what doesn’t,
and how does that change what we do
and does that dictate what we do?
And the truth is, payers do dictate
what we do sometimes.
How many body parts do you examine
and how often do you examine
them and how complicated
s what you’re going to do?
So CMS—Medicare and Medicaid services—
will determine what’s paid for.
Private insurance will modify that somewhat
and it will determine how many
body parts and how extensive
your review of systems is.
If you do a review of systems
on one part of the body,
it will get you to a certain level.
If you want to expand your visit
to a level 3, 4, or 5,
you need to get beyond the nervous system
and the musculoskeletal system
and examine heart, lungs, and abdomen
and go beyond it.
But to do that, you need to have a link
from the musculoskeletal system
to say why you’re doing that.
So that’s part of the holistic exam,
and if someone comes in complaining
of left shoulder pain,
but they’re walking funny
or they’re having other issues with sleeping
or chest pain,
those are things that are going to
lead you in other directions.
And the reward is that
if you follow those, you get reimbursed
at a higher rate.