Our chiropractic education teaches us that 70-90 percent of a patient's diagnosis is derived from the history. The purpose of the physical examination is, in part, to rule out certain conditions. I have no intention to tell doctors how to perform a physical exam or what tests to perform. Those decisions should be left to each physician's clinical judgment. However, I am going to make some recommendations.
As discussed in previous articles, soft tissue injuries do not lend themselves well to hard, objective documentation. The defense bar will capitalize on this fact and focus attention on the lack of this hard evidence. The typical series of questions will be something like this:
Q: "Doctor, how did you arrive at your opinions and conclusions?"
A: " I recorded the patient's medical history and conducted a thorough physical examination. Based on those findings, I ordered some diagnostic imaging."
Q: "Doctor, I noticed in your exam next to 'range of motion', you marked that 'Ms. X could not turn her neck beyond 10 degrees because of pain'. Isn't that true?"
A: "Yes"
Q: "Doctor, isn't it true that you were depending on your patient to tell you whether it hurt or not when she turned her neck?"
A: "Yes"
Q: "Doctor, isn't it true that when a patient tells you something, it is subjective?"
The questions will continue along these lines, with the defense attorney trying to make it seem like everything in your examination is based on the patient's subjective complaints. That is why it is so important to take a thorough history and perform a detailed examination.
The physical, orthopedic and neurological examination should generally be tailored to the individual patient's complaints. If a patient comes in following an automobile accident with a chief complaint of headaches and neck pain, and 50-70 percent of the examination is focused on the lumbar spine, the doctor is setting himself up. The defense attorney steers the deposition or cross-examination away from the patient's injuries and toward the normal findings recorded in the lumbar spine.
Why limit the exam? Some DCs might say that if a person has a problem with their neck, it will cause a compensatory problem in the lower back. I agree with these assertions, yet this type of practice will not "fly" in the medical legal arena. I recommend that the only areas treated are those of chief complaint. A cursory exam can be performed on other areas, but the area should only be treated if objective documentation is demonstrated and the doctor can demonstrate the causal relationship with the accident.
Physical Exam Recommendations
- Document at least the patient's vital signs, range of motion and chiropractic exam findings.
- Tailor the orthopedic and neurological portion of the exam to the patient's chief complaint.
- Utilize objective disability questionnaires such as the Neck Disability Index or Oswestry.
- Re-examine the patient every four-to-six weeks or 10 to 12 visits.
- Review the history and exam findings to make sure they correspond to the diagnosis provided.
- X-ray any area(s) of chief complaint if conditions warrant them.
- Document the x-rays taken and any clinical findings.
- Utilize special diagnostic testing if the patient's clinical condition warrants it.
- If findings in your physical exam or x-ray studies are questionable, refer the patient for a second opinion.
Procedures Not Recommended - Do not skip the exam.
- Do not re-check the same negative findings time and time again.
- Do not re-x-ray the patient without documenting the clinical necessity for the additional exam.
- Do not utilize scanning surface electromyography and computerized muscle testing without documenting the clinical necessity for the procedure.
These are just a few of the issues that will come up with this area of the personal injury patient's file. My recommendations, however, are no substitute for sound clinical judgment.
Guy DiMartino,DC,JD
Merrillville, Indiana
