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Inadequacies of Physical Examination as a Cause

of Medical Errors and Adverse Events A Collectionof VignettesAbraham Verghese MDa Blake Charlton MDb Jerome P Kassirer MDc Meghan Ramsey MDa

John PA Ioannidis MD DScd

aThe Program in Bedside Medicine and d Stanford Prevention Research Center Stanford University School of Medicine Stanford Calif b Department

of Internal Medicine University of California San Francisco c Department of Internal Medicine Tufts University School of Medicine Boston Mass

ABSTRACT

BACKGROUND Oversights in the physical examination are a type of medical error not easily studied by chart review They maybe a major contributor to missed or delayed diagnosis unnecessary exposure to contrast and

radiation incorrect treatment and other adverse consequences Our purpose was to collect vignettes of

physical examination oversights and to capture the diversity of their characteristics and consequences

METHODS A cross-sectional study using an 11-question qualitative survey for physicians was distributed electron-

ically with data collectedfrom February to June of 2011 Theparticipants were allphysicians responding to e-mail or

socialmedia invitations to complete the survey There were no limitations on geography specialty or practice setting

RESULTS Of the 208 reported vignettes that met inclusion criteria the oversight was caused by a failure to

perform the physical examination in 63 14 reported that the correct physical examination sign was

elicited but misinterpreted whereas 11 reported that the relevant sign was missed or not sought

Consequence of the physical examination inadequacy included missed or delayed diagnosis in 76

of cases incorrect diagnosis in 27 unnecessary treatment in 18 no or delayed treatment in 42

unnecessary diagnostic cost in 25 unnecessary exposure to radiation or contrast in 17 and compli-

cations caused by treatments in 4 The mode of the number of physicians missing the 1047297

nding was 2 but many oversights were missed by many physicians Most oversights took up to 5 days to identify but 66

took longer Special attention and skill in examining the skin and its appendages as well as the abdomen

groin and genitourinary area could reduce the reported oversights by half

CONCLUSIONS Physical examination inadequacies are a preventable source of medical error and adverse

events are caused mostly by failure to perform the relevant examination

2015 Elsevier Inc All rights reserved The American Journal of Medicine (2015) 128 1322-1324

KEYWORDS Attending rounds Bedside Bedside teaching Diagnostic error Electronic medical record EMR Error

Medical error Medical mistakes Mistakes Oversights Patient examination Physical diagnosis

Physical examination Resident Teaching

SEE RELATED ARTICLE p 1263

According t o the Institute of Medicinersquos report entitled ldquoTo Err is Humanrdquo1 medical errors cause nearly 100000 deaths per

year The causes are systemic problems of inadequate organi-

zation a culture of nondisclosure and cognitive diagnostic

errors2-4 A potentially important type of error that has been

given meager attention is de1047297ciencies in physical examination

The high-tech transformation of medical care has resulted

in diminishing direct patient-physician interaction Hospi-

talists in America might spend only 18 of their on-duty

time in direct patient care5 and duty-hour restrictions have

Funding None

Con1047298ict of Interest None

Authorship All authors had access to the data and a role in writing the

manuscript

Requests for reprints should be addressed to Abraham Verghese MD

Stanford University Department of Medicine 300 Pasteur Drive S102

Stanford CA 94305-5110

E-mail address abrahamvstanfordedu

0002-9343$ -see front matter 2015 Elsevier Inc All rights reservedhttpdxdoiorg101016jamjmed201506004

CLINICAL RESEARCH STUDY



resulted in Internal Medicine interns spending on average

only 12 of their time wit h patients but 40 of their time

on computer-related tasks6

Diminished focus on the physical examination may result in

important errors We asked physicians to contribute clinical

vignettes of oversights and errors in physical examination and

adverse consequences that resulted

from them This database wascreated to identify the diverse types

and characteristics of errors that can

be made relating to the physical

examination

METHODSWe designed an 11-question qual-

itative survey for physicians who

were asked to send us vignettes of

known instances of oversights in

physical examination and to answer related multiple choice questions

The study was approved by the

Stanford University Institutional

Review Board the detailed instructions to the respondent and

the questionnaire can be found online at wwwsurveymonkey

coms8S6DL7V

A link to the questionnaire was sent to approximately 5000

physicians of diverse specialties using a commercial medical e-

mail marketing service (MMS Inc Woodale Ill) with an esti-

mated 2800 of these having teaching af 1047297liations In addition we

used social media sites to disseminate the link and we

encouraged physicians to share the link There were no limita-tions regarding type of specialty and clinical practice setting

Data were gathered from February to June of 2011 Each

entry was reviewed by 2 physicians We excluded entries that

did not form a vignette (eg ldquoresidents donrsquot do rectal exams

often enoughrdquo) entries missing critical information to form a

vignette (eg a failure to state what precisely was omitted

misinterpreted) entries with 2 or more vignettes combined

when it became impossible to parse out which one was being

addressed in the multiple choice questions We corrected a

response only when the answer to a multiple choice question

clearly contradicted the vignette suggesting the respondent

selected the wrong box (eg the narrative describes a missedhernia in a patient with pain because the abdominal exami-

nation was not done but the respondent ticks ldquo1047297nding elicited

but misinterpretedrdquo in lieu of ldquofailure to do relevant exam rdquo)

RESULTSOf the 263 responses received 55 were excluded of the 208

remaining responses 27 were corrected by the criteria

described in Methods

Sixty-three percent of vignettes reported that the over-

sight was caused by a failure to perform the physical

examination 14 reported that the correct physical exam-ination sign was elicited but misinterpreted Eleven percent

reported that the relevant sign was missed or not sought and

12 reported ldquoother rdquo as the cause of the de1047297ciency

Consequence of the physical examination inadequacy

included missed or delayed diagnosis in 76 of cases

incorrect diagnosis in 27 unnecessary treatment in 18 no

or delayed treatment in 42 unnecessary diagnostic cost in

25 unnecessary exposure to

radiation or contrast in 17 andcomplications caused by treat-

ments in 4

The person thought responsible

for the oversight was most often

an intern or resident (reported

in 95 of 208 cases or 46) a

primary care physician (84 40)

a specialist (79 40) or fellow

(18 9) Though there was no

multiple choice option available to

implicate onersquos self as the person

responsible 9 responders (4)indicated themselves as the

physician responsible

The number of physicians

thought to have missed an important aspect of the examina-

tion is shown in Figure 1 The oversight was typically

discovered within 5 days (Figure 2) When participants

were asked to estimate what percentage of practicing

physicians have made a similar error to the one described

they estimated it to be gt95 in 43 instances (20)

50-95 in 42 instances (20) and 5-50 in 78 oversights

(375) and less than 5 in 28 instances (28)

The list of 1047297ndings overlooked is long and diverse but those that were missed more than 5 times included abdominal

massorganomegaly (n frac14 21 including 3 pregnancies and

2 distended bladders) diagnostic skin 1047297nding (nfrac1415 such as

cafeacute au lait spots neur 1047297broma erythema migrans syphilitic

lesions and meningococcemia lesions but not including

herpes zoster) neurologic 1047297ndings (n frac14 18) murmursrubs

(n frac14 13 including 4 missed aortic stenosis 3 missed

pericardial rubs) lymphadenopathy (n frac14 10) groin hernia

(n frac14 10) or scrotaltesticular pathology (n frac14 6) signs of

peritonitis (n frac14 10) breast masses (n frac14 9) fracture or

orthopedic 1047297nding (n frac14 9) congestive heart failure (n frac14 8)

Figure 1 Distribution of number of overlookers for 208

oversights in physical exam

CLINICAL SIGNIFICANCE

Most errors in the physical examinationthat lead to consequences are related tonot performing an examination

Failure to undress the patient andexamine the skin is a frequent cause of error

In a patient with abdominal painfailure to examine the groin rectal area

and hernia ori1047297ces can have direconsequences

Verghese et al Oversights in the Physical Examination 1323



absent or abnormal pulses (n frac14 6) wound or ulcer (n frac14 6)

bruising (n frac14 6) and herpes zoster (n frac14 5)

Forty-seven oversights involved the skin and its append-

ages including the breast 37 were related to the abdominal

examination 37 involved the cardiovascular system and 36

involved the groingenitalrectal area Supplementary

Table 1 (available online) lists all items that were missed

DISCUSSIONRecent publications describe the decline of physical exam-

ination skills7-12 Our study highlights the consequences and

suggests that many adverse events are preventable Our

survey suggests that the major cause for error is simply that

the examination is not performed1213 In addition to diag-

nostic consequences approximately half of the vignettes

report treatment consequences Most oversights pertained to

a limited number of overlookers suggesting that some er-rors may be remedied if several people examine the patient

Although the majority of the errors were corrected within 5

days even a delay of 1 hour might affect patient outcomes

Examining a patient presenting with a complaint (as

opposed to the ldquoroutine physicalrdquo) is a low-cost procedure

that when done with skill can avoid the majority of over-

sights listed Many diseases involving the skin or the

nervous system cannot easily be diagnosed except by the

examination and for others the appropriate diagnostic test is

indicated by the examination The drop-down boxes of the

electronic medical record deceptively suggest every patient

has been thoroughly examined (and therefore can be billed)but it will be the responsibility of educators and professional

organizations to make sure the electronic medical record

truthfully re1047298ects what was done

A short checklist is suggested by our study physicians

should seek full exposure of the patient there must be a

mandate to examine hernial ori1047297ces and the genital

and rectal areas in acutely ill patients or with pain Pain

should prompt a search for the lesions of shingles Non-

neurologists need a sound neurologic skill set because im-

aging does not show the functional de1047297cits resulting from a

lesion seen For diseases like Wernickersquos encephalopathy or

Bellrsquos palsy imaging may not be diagnostic Finally there

should be a greater emphasis on actually performing the

examination In short physicians in training must be taught

and evaluated at the bedside to diminish this kind of error

Our survey was not designed to determine prevalence but

to generate an anthology of physical examination oversights

along with their characteristics The vignettes are subject to

recall and response biases We set no time limitation on re-

ports and did not ask responders to specify where they prac-

ticed medicine Finally even though we contacted thousandsof physicians only a small minority contributed vignettes

suggesting a cultural reluctance to admit and share errors

unlike for example in the aviation industry We as physicians

might work in an ldquoignorance traprdquo in which our physical ex-

amination oversights are rarely reported back to us

Diligence in actually teaching and performing the phys-

ical examination and continuing efforts to improve bedside

skills would diminish one kind of medical error and its

consequences for the patient

ACKNOWLEDGMENT The authors thank Ralph Horwitz MD for his encouragement of the First Stanford Symposium on Bedside Medicine in

2009 and for his helpful discussions in planning this study

References1 Kohn KT Corrigan JM Donaldson MS To Err Is Human Building a

Safer Health System Washington DC National Academy Press 1999

2 Kassirer JP Kopelman RI Cognitive errors in diagnosis instantiation

classi1047297cation and consequences Am J Med 198986(4)433-441

3 Graber ML Franklin N Gordon R Diagnostic error in internal

medicine Arch Intern Med 2005165(13)1493-1499

4 Singh H Graber ML Kissam SM et al System-related interventions

to reduce diagnostic errors a narrative review BMJ Qual Saf

201221(2)160-1705 OrsquoLeary KJ Liebovitz DM Baker DW How hospitalists spend their

time insights on ef 1047297ciency and safety J Hosp Med 20061(2)88-93

6 Block L Habicht R Wu AW et al In the wake of the 2003 and 2011

duty hour regulations how do internal medicine interns spend their

time J Gen Intern Med 201328(8)1042-1047

7 Feddock CA The lost art of clinical skills Am J Med 2007120(4)

374-378

8 Rahmani S Ring BN Lowe R et al A pilot study assessing knowledge

of clinical signs and physical examination skills in incoming medicine

residents J Grad Med Educ 20102(2)232-235

9 Willett LL Estrada CA Castiglioni A Does residency training

improve performance of physical examination skills Am J Med Sci

2007333(2)74-77

10 Sharma S A single-blinded direct observational study of PGY-1 in-terns and PGY-2 residents in evaluating their history-taking and

physical-examination skills Perm J 201115(4)23-29

11 Jauhar S The demise of the physical examination N Engl J Med

2006354(6)548-551

12 Ortiz-Neu C Walters CA Tenenbaum J Colliver JA Schmidt HJ

Error patterns of 3rd-year medical students on the cardiovascular

physical examination Teach Learn Med 200113(3)161-166

13 Bordage G Why did I miss the diagnosis Some cognitive explanations

and educational implications Acad Med 199974(10 suppl)S138-S143

SUPPLEMENTARY DATASupplementary table accompanying this article can be found

in the online version at httpdxdoiorg101016jamjmed201506004

Figure 2 Distribution of time to discovery for 208 oversights

in physical exam

1324 The American Journal of Medicine Vol 128 No 12 December 2015



Supplementary Table 1 Complete List of Items Missed as

Reported in Returned Questionnaires

Missed skin 1047297nding of subcutaneous emphysema

Missed pulse absence in ischemic foot

Missed pregnancy with twins before hysterectomy

Missed hip fracture labeled as right lower quadrant pain

Missed Bell rsquo s palsy

Missed liver mass abdominal mass in cholangiocarcinoma

Missed funduscopic 1047297nding of cupping

Missed strangulated groin hernia in small bowel obstruction

Missed incarcerated femoral hernia

Missed crackles in a patient with pulmonary edema

Missed 1047297nger pressure necrosis on microvascular free 1047298 ap

Missed peritoneal signs and free air on plain 1047297lm

Missed peritonitis in patient with gangrenous perforated gall

bladder

Missed adenopathy and therefore chronic lymphocytic leukemia

Missed thyromegaly in patient with tachycardia

Missed strangulated hernia

Missed fungating breast mass

Missed pelvic examination and therefore missed tubo-ovarian

abscess

Missed pregnancy by missed gynecologic examination in patient

with seizures

Missed pyoderma gangrenosum in skin

Missed Fournier rsquo s gangrene in groinmdashno genital examination

Missed clonus and hyperre1047298 exia

Missed abdominal examination 1047297nding of tenderness and Grey

Turner signs

Missed neuro1047297broma and cafeacute au lait spots

Missed large abdominal mass

Missed heart failure signs of cardiomyopathy after 1047298 u in a young

person

Missed pulse extremity examination missed Buerger rsquo sMissed testicular mass in teen

Missed massive splenomegaly

Missed second cervix

Missed abrasion on forehead clue to subdural

Missed bruising signs of abuse in child

Missed prostate mass with elevated prostate-speci1047297c antigen

Missed decreased pulses arterial occlusion in elderly man after hip

fracture

Missed strangulated femoral hernia in 88-year-old with emesis

Missed loud bruit in patient with renal failure and hypertension

Missed ruptured spleen after trauma

Missed ectopic pregnancy because no pelvic examination done

Missed obvious congestive heart failure (CHF) signs labeled asbronchitis

Missed rotatory and vertical nystagmus in patient with basilar

artery aneurysm

Missed abdominal examination old scar mislabeled as hernia scar

and patient operated on for ldquorecurrent rdquo hernia and nothing found

Missed pulses in patient with peripheral vascular disease

Missed tuberculosis signs in chest

Missed vital sign of tachypnea on 1047297rst visit in a patient later found

with bacteremic pneumonia

Missed adenopathy in lymphoma

Missed clavicle fracture labeled ldquorule out myocardial infarctionrdquoMissed the tan of hemochromatosis

Supplementary Table 1 Continued

Missed femoral fracture

Missed acute myocardial infarction by focusing on neck pain ear

pain

Missed hyperre1047298 exia and cord compression in Potts disease

Missed rectal and missed prostatic abscess

Missed supraclavicular mass in lung cancer

Missed splenomegaly and delayed diagnosis of chronic

myelogenous leukemia

Missed psoriasis and its signs

Missed groin cellulitis

Missed dislocated shoulder on examination

Missed adenopathy in germ cell tumor

Missed marked pallor in elderly anemic

Missed pulsatile abdominal aneurysm

Missed adenopathy in patient with Waldenstromrsquo s disease

Missed penetrating foreign body in vaginal 1047297stula

Missed gastric bypass scar in patient with malnutrition and

beriberi

Missed signs of CHF in a young patient

Missed femoral hernia in patient with vomiting

Missed signs of hypothyroidism and neck scar in unresponsive

patient

Missed retinal lesions in a child with poor vision

Missed signs of myocarditis and CHF especially the tachycardia in

a child

Misconstrued bruit from an aortofemoral bypass as a cardiac

murmur

Missed obvious CHF signs

Missed obvious pregnancy and labor

Missed huge spleen in cirrhosis

Missed previous appendectomy scar and made diagnosis of

appendicitis again

Missed ulnar nerve transection after traumaMissed male breast mass

Missed distended bladder

Missed incarcerated hernia

Missed breast mass and metastases

Missed zoster presenting as abdominal pain

Missed femoral hernia

Missed orchitis and diagnosed it as hernia

Missed aortic stenosis murmur preoperatively

Missed breast mass

Missed anus present in patient stated to have abdomino-perineal

resection when they had Hartman procedure

Missed prolapsing rectal cancer rectal examination not done

Missed incarcerated groin herniaMissed bruises of abuse

Missed large melanoma over scapula

Missed hoarseness puf 1047297ness and signs of hypothyroidism

Missed decubitus ulcer causing ldquoback painrdquoMissed leg ulcers and sores as a cause of fever in alcoholic

Missed skin 1047297ndings of secondary syphilis

Missed hip fracture in patient who could not walk

Missed gouty nodules

Missed breast mass

Missed mucor wound on hand in immunocompromised patient

Missed zoster in patient with chest pain

Missed foot ulcer in diabetic with fever

Verghese et al Oversights in the Physical Examination 1324e1




Missed signs of Parkinsonrsquo s in elderly being worked up for falls

Missed lymph node in a patient with breast cancer

Missed abdominal mass lymphoma in patient complaining of pain

Missed skin ash leaf macule in child with hypertension

Missed anterior cruciate ligament tear with classic signs

Missed giant ovarian cyst labeled as ascites

Missed giant ovarian cyst again thought to be ascites

Missed loud murmur of ruptured mitral valve chordae tendinae

Missed murmur and signs of subacute bacterial endocarditis

Missed cutaneous abscess in compromised patient with fever

Missed obvious CHF in 33-year-old with cardiomyopathy

Missed appendicitis signs


Missed Downrsquo s syndrome on examination in 6 month old

Missed acute central vein occlusion in patient with decreased

visionmdashno fundoscopy done

Missed anal cancer said to be hemorrhoids

Missed peritonitis signs in patient with Crohn rsquo s

Missed dentures in mouth during intubation

Missed signi1047297cant murmur of mitral stenosis called it aortic

stenosis

Missed abdominal mass turned out to be lymphoma

Missed aortic stenosis in preoperative examination

Missed scrotal mass until after surgery for abdominal mass Was

testicular tumor with metastases

Missed supraclavicular nodes in patient with lung cancer

Missed hyperre1047298 exia and clonus from epidural abscess

Missed adenopathy in non-Hodgkinrsquo s lymphoma with fever of

unknown originmdashcalled a hernia

Missed neck nodes

Missed pelvic in1047298 ammatory disease because no pelvic examination

done

Missed gunshot entrance wound in emergency roomMissed large abdominal masses in patient with bloating

Missed pregnancy in patient with large belly

Missed signs of CHF in patient presenting with ldquoscrotal swellingrdquoMissed liver laceration after trauma because focus on head

Missed enlarged tonsil that was cancer

Missed clavicle fracture in patient with syncope

Missed ecchymosis in patient from a fall and the left arm pain

assumed to be cardiac

Missed contact dermatitis

Missed constrictive pericarditis signs

Missed breast mass in patient with shoulder pain

Missed breast mass in patient with deep vein thrombosis

Missed rapid growth in head circumferenceMissed splinters and signs of subacute bacterial endocarditis

Missed systolic murmur cardiac labeled carotid bruits

Missed pericardial rub and pericarditis

Missed zoster rash

Missed hip disease as a cause of joint pain

Missed femoral pathologic fracture in patient with knee pain

Missed large liver in patient with diabetic ketoacidosis

Missed zoster as cause of chest pain

Missed watch battery in umbilicus in child

Missed purulence in tonsils

Missed normal ear examination labeled as perforation by not doing

pneumatic otoscopy


Missed breast mass in patient with chest pain and metastasis

Missed pregnancy called it constipation

Missed meningococcemia skin lesion in patient with fever

Missed CHF 1047297ndings in patient with postpartum cardiomyopathy

Missed hoarseness and laryngeal mass in patient labeled asthma

Missed rectal mass by gastrointestinal consultant after primary

care physician feels massmdashsigmoidoscopy negative but tumor

develops

Missed appendicitis by focus on chest

Missed rales and crackles

Missed obvious pleural effusion no examination

Missed signs of myasthenia in patient with weight loss

Missed signs of bowel obstruction

Missed signs of mitral regurgitation from torn lea1047298 et

Missed hepatomegaly and hepatocellular carcinoma in patient with

vague symptoms

Missed metastatic node from breast cancer in patient with weight

loss

Missed stone in urethra causing recurrent urinary tract infection

Missed pelvic examination in adolescent and missed pelvic

in1047298 ammatory disease

Missed radiculopathy causing abdominal pain

Missed signs of peritonitis


Missed abdominal mass in patient with back pain

Missed pelvic examination and missed procidentia

Missed skin signs of calcinosis in patient with mixed connective

tissue disease

Missed breast mass in patient being worked up for metastasis

Missed skin erythema migrans in patient with Bell rsquo s palsy

Missed abnormal pulses of combined aortic stenosisaortic

regurgitation and focused on treating high blood pressure and

pulse pressureMissed aortic stenosis murmur

Missed abdominal mass expanding aortic aneurysm in patient with

abdominal pain

Missed pericardial friction rub in chest pain

Missed nasal septal hematoma

Missed scrotal infection in diabetic

Missed Korsakoff rsquo s signs in many neurologic examinations

Missed zoster in patient with chest pain who had coronary

angiogram

Missed pelvic examination and missed ovarian cyst

Missed adenopathy and hepatomegaly in patient with anemia and

weight loss

Missed in1047298 ammatory knee effusion in intensive care unit patient with fever

Missed distended bladder labeled abdominal mass

Missed rectal examination and therefore missed prostatitis

Missed doing pulsus paradoxus in patient with tamponade

Missed abnormal decreased pulse and blood pressure in one arm

Missed purulence around IV catheter as cause of fever

Mistaken diagnosis of peritonitis bias from x-rays showing

pneumatosis intestinalis

Missed lytic lesions as cause of left-sided weakness in limbs

Missed CHF signs

Missed purulence at bone marrow biopsy site in patient with fever

Missed clubbing in patient with shoulder pain who has lung cancer

1324e2 The American Journal of Medicine Vol 128 No 12 December 2015




Missed hernia because of missed groin examination

Missed edema from hypoproteinemia labeled CHF

Missed peritonitis and perforation

Missed murmur of critical aortic stenosis

Missed butter 1047298 y bruises of factitious injury

Missed neurogenic bladder

Missed costochondritis in patient labeled as rule out myocardial

infarctions

Missed epididymitis in patient with abdominal pain

Missed scrotal examination

Missed erythema migrans in patient with fever and headache

Missed large abdominal mass on both pelvic and seated abdominal

examination

Missed embolic arterial occlusion

Missed uremic calciphylaxis in patient on dialysis




resulted in Internal Medicine interns spending on average

only 12 of their time wit h patients but 40 of their time

on computer-related tasks6

Diminished focus on the physical examination may result in

important errors We asked physicians to contribute clinical

vignettes of oversights and errors in physical examination and

adverse consequences that resulted

from them This database wascreated to identify the diverse types

and characteristics of errors that can

be made relating to the physical

examination

METHODSWe designed an 11-question qual-

itative survey for physicians who

were asked to send us vignettes of

known instances of oversights in

physical examination and to answer related multiple choice questions

The study was approved by the

Stanford University Institutional

Review Board the detailed instructions to the respondent and

the questionnaire can be found online at wwwsurveymonkey

coms8S6DL7V

A link to the questionnaire was sent to approximately 5000

physicians of diverse specialties using a commercial medical e-

mail marketing service (MMS Inc Woodale Ill) with an esti-

mated 2800 of these having teaching af 1047297liations In addition we

used social media sites to disseminate the link and we

encouraged physicians to share the link There were no limita-tions regarding type of specialty and clinical practice setting

Data were gathered from February to June of 2011 Each

entry was reviewed by 2 physicians We excluded entries that

did not form a vignette (eg ldquoresidents donrsquot do rectal exams

often enoughrdquo) entries missing critical information to form a

vignette (eg a failure to state what precisely was omitted

misinterpreted) entries with 2 or more vignettes combined

when it became impossible to parse out which one was being

addressed in the multiple choice questions We corrected a

response only when the answer to a multiple choice question

clearly contradicted the vignette suggesting the respondent

selected the wrong box (eg the narrative describes a missedhernia in a patient with pain because the abdominal exami-

nation was not done but the respondent ticks ldquo1047297nding elicited

but misinterpretedrdquo in lieu of ldquofailure to do relevant exam rdquo)

RESULTSOf the 263 responses received 55 were excluded of the 208

remaining responses 27 were corrected by the criteria

described in Methods

Sixty-three percent of vignettes reported that the over-

sight was caused by a failure to perform the physical

examination 14 reported that the correct physical exam-ination sign was elicited but misinterpreted Eleven percent

reported that the relevant sign was missed or not sought and

12 reported ldquoother rdquo as the cause of the de1047297ciency

Consequence of the physical examination inadequacy

included missed or delayed diagnosis in 76 of cases

incorrect diagnosis in 27 unnecessary treatment in 18 no

or delayed treatment in 42 unnecessary diagnostic cost in

25 unnecessary exposure to

radiation or contrast in 17 andcomplications caused by treat-

ments in 4

The person thought responsible

for the oversight was most often

an intern or resident (reported

in 95 of 208 cases or 46) a

primary care physician (84 40)

a specialist (79 40) or fellow

(18 9) Though there was no

multiple choice option available to

implicate onersquos self as the person

responsible 9 responders (4)indicated themselves as the

physician responsible

The number of physicians

thought to have missed an important aspect of the examina-

tion is shown in Figure 1 The oversight was typically

discovered within 5 days (Figure 2) When participants

were asked to estimate what percentage of practicing

physicians have made a similar error to the one described

they estimated it to be gt95 in 43 instances (20)

50-95 in 42 instances (20) and 5-50 in 78 oversights

(375) and less than 5 in 28 instances (28)

The list of 1047297ndings overlooked is long and diverse but those that were missed more than 5 times included abdominal

massorganomegaly (n frac14 21 including 3 pregnancies and

2 distended bladders) diagnostic skin 1047297nding (nfrac1415 such as

cafeacute au lait spots neur 1047297broma erythema migrans syphilitic

lesions and meningococcemia lesions but not including

herpes zoster) neurologic 1047297ndings (n frac14 18) murmursrubs

(n frac14 13 including 4 missed aortic stenosis 3 missed

pericardial rubs) lymphadenopathy (n frac14 10) groin hernia

(n frac14 10) or scrotaltesticular pathology (n frac14 6) signs of

peritonitis (n frac14 10) breast masses (n frac14 9) fracture or

orthopedic 1047297nding (n frac14 9) congestive heart failure (n frac14 8)

Figure 1 Distribution of number of overlookers for 208

oversights in physical exam

CLINICAL SIGNIFICANCE

Most errors in the physical examinationthat lead to consequences are related tonot performing an examination

Failure to undress the patient andexamine the skin is a frequent cause of error

In a patient with abdominal painfailure to examine the groin rectal area

and hernia ori1047297ces can have direconsequences

Verghese et al Oversights in the Physical Examination 1323









































































374-378






2007333(2)74-77




2006354(6)548-551









in physical exam



















bladder






abscess


with seizures





Turner signs




person








fracture







artery aneurysm












pain















beriberi




patient



a child


murmur





appendicitis again









Missed breast mass











Missed breast mass




























stenosis









Missed neck nodes


done















Missed zoster rash








pneumatic otoscopy









develops








vague symptoms


loss










tissue disease







abdominal pain






angiogram



weight loss










Missed CHF signs














infarctions





examination












































































374-378






2007333(2)74-77




2006354(6)548-551









in physical exam



















bladder






abscess


with seizures





Turner signs




person








fracture







artery aneurysm












pain















beriberi




patient



a child


murmur





appendicitis again









Missed breast mass











Missed breast mass




























stenosis









Missed neck nodes


done















Missed zoster rash








pneumatic otoscopy









develops








vague symptoms


loss










tissue disease







abdominal pain






angiogram



weight loss










Missed CHF signs














infarctions





examination





















bladder






abscess


with seizures





Turner signs




person








fracture







artery aneurysm












pain















beriberi




patient



a child


murmur





appendicitis again









Missed breast mass











Missed breast mass




























stenosis









Missed neck nodes


done















Missed zoster rash








pneumatic otoscopy









develops








vague symptoms


loss










tissue disease







abdominal pain






angiogram



weight loss










Missed CHF signs














infarctions





examination



























stenosis









Missed neck nodes


done















Missed zoster rash








pneumatic otoscopy









develops








vague symptoms


loss










tissue disease







abdominal pain






angiogram



weight loss










Missed CHF signs














infarctions





examination














infarctions





examination




inadekuat pemeriksaan fisik

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