Unexamined Patients

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I am increasingly convinced that many (thousands) of patients pass in & out of our nation's "teaching hospitals" without ever really being examined: the interns/residents (our physicians-in-training) don't examine them, and their "teaching attendings" don't examine them either (they just "sign-off on" the trainees' notes). I've been an inpatient teaching attending (medicine) for >10 years, and I'm seeing this more & more.

Why do I type about it now? The other day, one of my interns (one of our program's better ones) checked the "PERRLA" box on her "Admission H & P" template note, for a new admission, a 50ish Hispanic man with new diabetes, admitted with poly/poly symptoms and glucoses >500. When I saw the guy, his dark eyes looked funny, and on closer inspection with some light, the right pupil was fixed & dilated at about 12mm, and the left was 4mm and constricted normally. It turned out he had some trauma to the right eye 10 years prior, which resulted in permanent blindness in that eye.

The finding was not immediately relevant to the patient's current medical issue, but it reminded me of how often I see this sort of thing (template exam boxes being checked, without the exams actually being done), and of how much more it is beginning to bother me. It's for this reason that I've started paying special attention to what physicians write down for their pupil exams; not for the clinical relevance, but as a gauge to assess how thorough their exam was, and to find out how often they aren't even looking- not even doing an exam. There are very few components of the physical exam that are clearly & objectively verifiable, and an abnormal pupil exam is one of them. One can always "fudge" a claim about the intensity of a heart murmur, or the presence of lung crackles, or say "that wasn't there when I examined him." But if you write down "PERRL" (or check the little PERRL box), and there's fixed anisocoria, you've documented evidence that you just didn't really...
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