Sunday, March 29, 2015

Lots of drugs with no physical exam

You see all kinds of things on Facebook.  For example, people are remarkably free with their medical information.  Still, some stories just call for more information.

Take this one.  What struck me was the phrase: "Lots of drugs with no physical exam." I'm no doctor, but I just wonder if that would be the norm?  What do you think?

A female in her 30s first writes from the emergency room of a local hospital:

Apparently my migraine isn't a migraine when my blood pressure is 151/112!

Five hours later, she files this report:

Discharged with a BP of 156/97 s/p phenagrin, compazine, 8mg ZOFRAN IVP, 4 mg Morphine IVP, 4mg Klonopin, 3mg Ativan. Migraine is now a headache and I am apparently stable for discharge. Lots of drugs with no physical exam. Just wondering what's going on as the pharmacodynamics are working away and since these drugs have been in for about 45min. What the pharmacokinetics have it out for me for the rest of the day. 

Who is placing bets on my vitals this am?


Roy M Poses MD said...

Let me say this diplomatically: if this is true, then this was not good practice, to say the least. She should at least have had a physical and neurological exam.

What is really odd, though, is that the list of drugs does not include any anti-hypertensive.

Of course, you can't always believe what people post on Facebook.

Anonymous said...

I'm less troubled by no med for hypertension (have seen 'high blood pressure' treated when it is from pain, only to lead to lightheadedness and passing out when the patient is 'compliant'). Lack of exam is not good... but not uncommon. Documentation of lack of exam is uncommon. Documentation of exam not done is common. My wife had no exam... her chart note indicated full exam. I've had reliable people, when I show them a specialists note, be shocked at the complete exam they received, along with 99214, for a sprained ankle. (Not to single out specialists, primary care notable notes include the normal extremity exams on amputees, the '2/5' strength a week after a stroke when the patient is walking, etc. Exam documentation is not sufficient to know what exam was done.

An ED MD said...

Paul, without commenting on the specifics of the case, when I see a patient with a migraine, I check their vital signs as taken by the nurse, and confirm by history that the pain is typical for them, that there is no fever, no recent trauma to the head, and there was not a sudden onset, and my exam is then very brief. I’ve already observed a fair bit of neurological functioning by my history taking (thought content, speech, facial symmetry), I check that their neck is supple, and frankly, mostly for “show” - so patients don’t feel I failed to examine them- I check their pupils, look at their fundi, confirm that their grips are equal and that’s about it!

A neurologist said...

I'm incredibly compulsive, but anyone sick enough to go to the ED or present emergently gets a full neurologic exam from me, especially funduscopic. And consideration for imaging.

Even people with stable migraines can have clots/hemorrhages/disections/etc. Discharging someone without any exam at all, just giving them meds, seems like folly...