In pediatric urology, there are many technological advances that have created the illusion that the physical exam is not as important as it once was. For example, with testicular torsion, we now have extremely sensitive scrotal ultrasonography. This has allowed us to observe testis flow with high precision, and has led to the development of new signs such as the whirlpool sign (Esposito et al, 2014), which now makes the sensitivity and specificity of scrotal ultrasound higher than it has ever been (Agrawal et al, 2014). In the late 1990s, surgical decisions relied heavily on the physical exam, but today, they rely heavily on diagnostic imaging. This is a good thing in that it leads to overall better outcomes, but it does jeopardize the existence of the well-performed history and physical exam, and the nuances that can be learned from the exam. This chapter summarizes the art of the history and physical exam in a way that it can be used to compliment new technologies, rather than be usurped by them.
INTERACTING WITH PATIENTS AND THEIR FAMILIES
In order to be able to perform a detailed history and physical exam, patients and their families need to feel comfortable, whether in the clinic, emergency department, or as inpatients on the floor (Chiocca, 2010a). The healthcare provider needs to approach the patient and family in a calm yet confident manner. Having as much information as possible about the patient prior to the visit will help. This includes not only reviewing the medical records and imaging but also being attentive to the nurses and other providers’ interactions with the family. Walking into the room blindly will make the entire visit more difficult than it need be. Once informed, the next step is meeting the family and patient, gathering the history, and performing the physical exam. For the best results, these steps need to be carried out differently depending on the patient’s age, diagnosis, and other medical conditions, which will be discussed below.
All patient interactions and information are governed by the HIPAA Privacy Rule (Herold and Beaver, 2010). In addition to privacy of medical records, these rules also include verbal information that is given out to patients and their families. Before any patient information is discussed with the family, it is important to establish who the legal guardian is, and others in the room. This can be done very politely in a nonawkward way with statements such as “Hello, I’m Doctor Smith, and you are? And you?” This is also a way of breaking the ice, similar to the way one meets people in a social situation.
Finally, it should be remembered to never examine the patient prior to introductions. The patient and family should be told how the exam will proceed prior to the exam, as will be discussed below.