Peripheral Pulse

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Lifting the right wrist of the patient and palpating the pulse with your 3rd and 4th fingers is the handshake of the physical examination. Lost and forgotten or never learned, buried in the M1 text books, the peripheral pulse should be or is the physician's first encounter with his or her patient. The act of palpating the pulse, tells the physician much about the patient and the patient much about the doctor, opening and sharing the patient's and the physician's personal space in a mutually gentle and informative way.



Unfortunately, a false sense of economy and efficiency relegates this seemingly simple recording of figures to others, to the lowest level of  competence. This first level of diagnostic data must not, however, be trusted to others. The same might be said of the blood pressure cuff. Hidden diagnostic nuances are lurking there behind the numbers. 



The weak pulse with a slow uptake and a prolonged peak, easily  suggests decreased stroke volume, volume depletion, heart failure, aortic stenosis, hypothyroid or congestive heart failure. Whilst the bounding pulse with short peak and steep sides, suggests increased volume, decreased peripheral resistance, fever, hyperthyroid, anemia, bradycardia, aortic regurgitation, patient ducts, A-V fistula or hardening of the arteries with age. The start of your differential diagnosis and knowledge of your patient lies right beneath your fingers.



Some of your differential diagnosis might be missed entirely but for the thoughtful palpation of the peripheral pulse. Bisferiens Pulse with a double peak, may be due to aortic regurgitation or regurgitation combined with stenosis or even hypertrophic cardiomyopathy. Pulsus Alterans for example, a normal beat alternating in regular interval with a weaker beat (and an S3), suggests left ventricular failure. While Bigeminal Pulse, a normal beat alternating in shorter interval with a premature contraction of weaker strength, suggests retrograde conduction etc. Intriguingly, Paradoxical Pulse, wherein pulse pressure increases more than 10 mm Hg on expiration, can lead to the early diagnosis of an unsuspected constrictive pericarditis, even  tamponade or COPD. The later can be life altering for the patient and greatly enhance the career satisfaction for the physician as it did for me.
 

La Maladie du Petit Papier

Share Jean-Martin Charcot (1825-1893) at Salpetriere in Paris - a neurologist famous for the beautiful hospital, the Charcot Joint and Charcot Marie Tooth syndrome - may have initiated the term "La maladie du petit papier" observing the triviality and the seeming benefit derived by the patient. The term has become a derogatory one, however, expressing the irritation to the physician from the patient's attempt to organize his or her problems. Does not the phrase, la maladie du petit papier, uttered in contempt, give a false sense of superiority and sophistication, suggesting that one can actually say something in French? 

As Koven's Perspective letter in NEJM implies, there may be more to this. "...even when I have no explanation for the headache, upset stomach, or itch - documented on the back of an envelope or punched into a smart phone, a patient feels better just having presented me with his or her recording of it. Perhaps naming our demons and saying their names aloud helps make them less frightening. Perhaps the shorthand of the list somehow abbreviates the anxiety associated with its entries."

Is not the patient, indeed, attempting to build his or her own problem list? Charcot was one of the great physicians of all time, but there was a first - greater yet - Hippocrates, who founded the very science of listening to the patient, observing the environment and documenting the patient's complaints. I rather imagine that Hippocrates would have welcomed la petit papier.

Indeed, is not the petit papier the patient's own problem list? Why not capitalize on the benefit to the patient of reducing their complaints to a problem list - be sure to include them all - and combine them with a check list of past medical illnesses, review of systems etc.? If the problem list has a placating effect on the patient, think what it does for the physician to actually see at a glance the patient's entire struggle with his or her environment and maladies. A problem is not a diagnosis, more likely a symptom, but without the complete problem list, there is no way to know that you've got it right with either the diagnosis or the underlying causes.

Suzanne Koven, M.D. NEJM 2014; 371:2251-2253; 11 Dec; DOI: 10.1056/NEJMp 1411685

(POMR) Problen Oriented Medical Record

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While POMR heads the Syllabus for the teaching of medical history taking, most first year medical students encounter a source oriented format or at best a hybrid system without ever learning the problem oriented system, a system first promoted by Larry Weed at Dartmouth in the early sixties. In truth, the hybrid system of charting a patient's medical history and progress, may be superior in that, including the source oriented, or more traditional, style better identifies the full character of the patient as seen through the physician's eyes. Tradition since Hippocrates tells us that "if you just listen," the patient will tell you everything you need to know. The traditional chief complaint, history of the present illness, past medical history, social and family history followed by a complete review of systems constitutes the source oriented medical history. The medical history is a story, with color, pathos, complication, progression, humanity and hopefully, with your guidance, a resolution. It is a story worth telling and worth telling well. Both the patient and physician will likely evolve in so doing.
The POMR, however, represents a far better way to organize information when there are multiple problems. For instance, for an older patient who might have a dozen or more concurrent, problems, some undiagnosed, some controlled and some resolved, the problem list brings together all of the concurrent problems. The POMR lists the patient's problems as a table of contents, numbering each problem, dating the identification of the problem and dating its resolution. The two dates are critical in referencing the place in the progress notes where and by whomever the problem was identified and the strategy outlined in the SOAP note for diagnosing and treating the problem. 
POMR, furthermore, helps with diagnosis, listing all the problems in one place, exposing their potential relationships and synergisms, opening a window to greater understanding of one patient's struggle with disease and his or her environment. Problems get lost in the time constraints of employed providers. A positive response on the (ROS) review of systems is by definition a problem worthy of placement on the problem list, yet problems get dropped, lost, forgotten, never to be seen by subsequent team members. One could therefore argue that the problem list is the most important but often least understood page on the patient's chart.
The SOAP note then describes the subjective information derived from the patient as well as the intuitions of the physician in a stylized format followed by objective data, an assessment of the condition and finally a plan to move forward. Larry Weed, he's now in his 90s living in Vermont, insisted on including a rationale and the goals you expect to achieve.
Thus:
# - Problem
S: subjective
O: objective
A: assessment
P: plan
The POMR oriented patient history consists of a series of SOAP notes: indexed to the problem list, replacing the traditional Chief Complaint and Present Illness, written in numeric order and positioned at the beginning of the patient history. The rest of the traditional source oriented history may follow or in the case of the POMR purist, included in the initial numbered SOAP format in the initial patient history.
Daily progress notes then follow in the same SOAP note format rationalizing every laboratory test and medication order - this in sharp contrast to the typically thick hospital chart in which the orders written have little or no relationship to the progress note or indeed the problem for which the order was written. With multiple specialists dealing with one patient, the organizational advantages of the POMR seem obvious.
An individual physician's own hybrid version combining the POMR with the narrative of the traditional source oriented history promises the best of both worlds. However, the advent of  the (EHR) electronic health record, makes a very loose structure out of either the POMR or source oriented system. There may be no way to write a program that will accommodate all patients and all doctors. The POMR does, however, lend itself rather well to the structured format of the EHR, but only if it accommodates a narrative and tells the story in supporting either the source oriented or POMR system or indeed the hybrid which should be taught. Voice recognition would seem essential in allowing the story to be told quickly and in depth.
 Now more than ever, the so called medical home, teaching hospital or multispecialty clinic depends upon a high quality medical record to paint a true picture of the patient, the patient's environment, their problems and relationships in order to build a differential diagnosis or to explore the subtle underlying causalities.

 

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