If a doctor suspects mono should they do a physical exam?
December 28, 2016 9:26 PM Subscribe
If a family doctor suspects mononucleosis should they do a physical exam?
Asking this for a relative so I don't know the exact details. Doc's nurse took vitals, doctor suspected mononucleosis and ordered a test at a local lab. No physical exam by the doctor. Test result was negative.
If more details are needed I'll get them tomorrow. Searching around it seems that an exam would be likely. Would be especially interested in responses from current doctors and nurses.
Asking this for a relative so I don't know the exact details. Doc's nurse took vitals, doctor suspected mononucleosis and ordered a test at a local lab. No physical exam by the doctor. Test result was negative.
If more details are needed I'll get them tomorrow. Searching around it seems that an exam would be likely. Would be especially interested in responses from current doctors and nurses.
I was diagnosed based on blood work. I had symptoms that had largely resolved, then donated blood and received notice I had elevated liver enzymes. Follow up blood work at my college health clinic diagnosed mono.
posted by goggie at 9:47 PM on December 28, 2016 [1 favorite]
posted by goggie at 9:47 PM on December 28, 2016 [1 favorite]
I was also diagnosed based on lab tests. My first test was negative, then my symptoms got worse and my second test (a week later, IIRC) was positive.
posted by neushoorn at 2:56 AM on December 29, 2016
posted by neushoorn at 2:56 AM on December 29, 2016
My kids had this earlier this year. The only thing from a physical exam that tipped the doctors off were the highly swollen glands on the back of the neck. They could be seen with the totally untrained eye so his nurse could have easily related the info to the doctor. The labs confirmed it in our case.
posted by checkitnice at 3:27 AM on December 29, 2016 [1 favorite]
posted by checkitnice at 3:27 AM on December 29, 2016 [1 favorite]
I had mono a few years ago and didn't test positive on the quick test but did on the Epstein-Barr virus (EBV) test. It was a total pain. There should be a physical exam and the doctor should check for enlarged lymph nodes, enlarged liver, and an enlarged spleen. Another common adult symptom is night fevers. There are a bunch of possible complications if you don't get rest when you have mono as an adult so, no matter what, your relative should be taking it easy.
posted by JuliaKM at 6:10 AM on December 29, 2016
posted by JuliaKM at 6:10 AM on December 29, 2016
It would be typical to examine the lymph nodes. Doctors do fewer and shorter physical exams than they used to. How you feel about that depends on your world view and there's not a clear consensus on the "right" way to do this.
posted by latkes at 7:31 AM on December 29, 2016
posted by latkes at 7:31 AM on December 29, 2016
This was back in 1978 so maybe out-of-date but I had mono and went to my doctor (finally, after suffering through the weekend) and he did some test on the spot (I forget exactly what) and was so excited about the result that he called in his colleague to witness it, also -- "Have you ever seen such a positive result for mono?" he exclaimed. Then he gave me a shot of cortisone and 24 hours later I was almost entirely well.
posted by Rash at 11:43 AM on December 29, 2016 [2 favorites]
posted by Rash at 11:43 AM on December 29, 2016 [2 favorites]
Yes they should have, if for no other reason that for decent reimbursement their billing requirements include some kind of physical exam. if it makes you feel better, a friend of mine with b-symptoms and swollen lymph nodes was told by the student health md that she had lymphoma. she went home in a panic and got a monospot which was positive. with a convincing story and a common disease i could see a gp just ordering the test.
posted by a robot made out of meat at 6:56 AM on December 31, 2016
posted by a robot made out of meat at 6:56 AM on December 31, 2016
Best answer: I'm a doctor, but I find it difficult to answer your question without knowing a few more details. The question sounds simple, but I think it's actually quite complicated to answer.
1. Was the patient seen by a doctor? It's not clear. You say the patient had vital signs taken by a nurse, which implies that the patient was at a doctor's office and was seen by the doctor. If the doctor laid eyes on the patient, a physical exam WAS performed. That, of course, says nothing about how good or how detailed a physical exam it was. However, for the purposes of billing, a chart at nearly the highest level of medical complexity can be billed without laying a hand on the patient. If they weren't seen by a doctor, was the doctor trying to help them avoid being billed a professional fee or having to schedule an official visit by ordering the test without seeing them? There could be financial or convenience reasons to do this.
2. What does "should" mean? Whose perspective is the question from? As noted above, from the perspective of the insurance company or Medicare, a physical exam must be done in order to bill for a physician visit in the majority of cases. Most physicians cannot bill for time they spend on the phone, or answering your e-mails, or calling in your prescriptions, or interpreting your test results. They can only bill for the time they spent seeing you in their office, in a visit that includes some form of physical exam.
From the perspective of another physician, do I think a physical exam must always be done to diagnose mono? I suppose not necessarily. A lot of physicians do try to diagnose patients after only hearing about their symptoms on the phone or other analogous situations. As an emergency physician, I often order tests on patients before laying eyes on them in order to help expedite their stay (for example, their chief complaint is that it hurts to pee - I order a urinalysis). If the test comes back telling me what the diagnosis is, my gamble has paid off, because I can walk into the room and diagnose a UTI and make the patient's stay as short as possible, and if not, it's still useful to know the test was negative so I can refine my thought process while seeing the patient. A physical exam in cases with an accurate, positive test is not very useful, if the diagnosis is completely consistent with the described symptoms. Other similar infectious disease testing can be like this, for example - a positive strep test or flu test. There are physical findings that suggest mono, for example inflamed tonsils, or swollen neck glands, or maybe an enlarged spleen. But all those things can be found in other disease processes as well, and a person can have mono and have none of those findings, so mono is typically diagnosed by blood work. If the story sounds like mono, and the mono test is positive, then it's unlikely that anything on physical exam would change the treatment plan.
The physician thought the story sounded like mono and did a mono test (was this the only test ordered, or just one of several?). Had the mono test been positive, their gamble has paid off, because they can make a diagnosis of mono and now there's nothing remaining to do - there is no specific treatment for mono. Now the test has come back negative, and there are several possibilities:
1. The test is wrong, the patient does have mono, the physician was right, a physical exam wouldn't have changed anything. A Monospot test has a significant false negative rate, especially early on in the course of the disease, so this possibility could be likely.
2. The test is right, the patient doesn't have mono, the physician was wrong, and a more detailed physical exam might have helped them pick up clues for the diagnosis they missed.
2a) The actual diagnosis is not mono, but it's not anything serious either, and there is no other testing required. Fairly likely, since the symptoms of mono are common to a bunch of other benign illnesses like other viruses for which there is no specific treatment.
2b) The actual diagnosis is not mono, and it is something that could have or should have been treated differently than mono: this situation is the most important of the possibilities and could potentially be affected by lack of detailed exam.
I'm guessing that the truth of the situation is most likely that a physical exam was done, but maybe it was not in as much detail as the relative believed was necessary for a 'real' physical exam. If the physician did lay eyes on the patient, and they billed for the visit, that's probably technically valid. The professional standard, depending on the severity of the symptoms, was probably to have done a physical exam involving touching the patient (like listening to the heart, lungs, looking in the mouth, palpating the neck). Without knowing the specifics I can't say whether I think that the physician in question should have done anything differently, so I'll leave my answer as "possibly." If this convoluted answer isn't enough for you, feel free to MeMail me. :-)
posted by treehorn+bunny at 11:16 PM on December 31, 2016 [2 favorites]
1. Was the patient seen by a doctor? It's not clear. You say the patient had vital signs taken by a nurse, which implies that the patient was at a doctor's office and was seen by the doctor. If the doctor laid eyes on the patient, a physical exam WAS performed. That, of course, says nothing about how good or how detailed a physical exam it was. However, for the purposes of billing, a chart at nearly the highest level of medical complexity can be billed without laying a hand on the patient. If they weren't seen by a doctor, was the doctor trying to help them avoid being billed a professional fee or having to schedule an official visit by ordering the test without seeing them? There could be financial or convenience reasons to do this.
2. What does "should" mean? Whose perspective is the question from? As noted above, from the perspective of the insurance company or Medicare, a physical exam must be done in order to bill for a physician visit in the majority of cases. Most physicians cannot bill for time they spend on the phone, or answering your e-mails, or calling in your prescriptions, or interpreting your test results. They can only bill for the time they spent seeing you in their office, in a visit that includes some form of physical exam.
From the perspective of another physician, do I think a physical exam must always be done to diagnose mono? I suppose not necessarily. A lot of physicians do try to diagnose patients after only hearing about their symptoms on the phone or other analogous situations. As an emergency physician, I often order tests on patients before laying eyes on them in order to help expedite their stay (for example, their chief complaint is that it hurts to pee - I order a urinalysis). If the test comes back telling me what the diagnosis is, my gamble has paid off, because I can walk into the room and diagnose a UTI and make the patient's stay as short as possible, and if not, it's still useful to know the test was negative so I can refine my thought process while seeing the patient. A physical exam in cases with an accurate, positive test is not very useful, if the diagnosis is completely consistent with the described symptoms. Other similar infectious disease testing can be like this, for example - a positive strep test or flu test. There are physical findings that suggest mono, for example inflamed tonsils, or swollen neck glands, or maybe an enlarged spleen. But all those things can be found in other disease processes as well, and a person can have mono and have none of those findings, so mono is typically diagnosed by blood work. If the story sounds like mono, and the mono test is positive, then it's unlikely that anything on physical exam would change the treatment plan.
The physician thought the story sounded like mono and did a mono test (was this the only test ordered, or just one of several?). Had the mono test been positive, their gamble has paid off, because they can make a diagnosis of mono and now there's nothing remaining to do - there is no specific treatment for mono. Now the test has come back negative, and there are several possibilities:
1. The test is wrong, the patient does have mono, the physician was right, a physical exam wouldn't have changed anything. A Monospot test has a significant false negative rate, especially early on in the course of the disease, so this possibility could be likely.
2. The test is right, the patient doesn't have mono, the physician was wrong, and a more detailed physical exam might have helped them pick up clues for the diagnosis they missed.
2a) The actual diagnosis is not mono, but it's not anything serious either, and there is no other testing required. Fairly likely, since the symptoms of mono are common to a bunch of other benign illnesses like other viruses for which there is no specific treatment.
2b) The actual diagnosis is not mono, and it is something that could have or should have been treated differently than mono: this situation is the most important of the possibilities and could potentially be affected by lack of detailed exam.
I'm guessing that the truth of the situation is most likely that a physical exam was done, but maybe it was not in as much detail as the relative believed was necessary for a 'real' physical exam. If the physician did lay eyes on the patient, and they billed for the visit, that's probably technically valid. The professional standard, depending on the severity of the symptoms, was probably to have done a physical exam involving touching the patient (like listening to the heart, lungs, looking in the mouth, palpating the neck). Without knowing the specifics I can't say whether I think that the physician in question should have done anything differently, so I'll leave my answer as "possibly." If this convoluted answer isn't enough for you, feel free to MeMail me. :-)
posted by treehorn+bunny at 11:16 PM on December 31, 2016 [2 favorites]
Best answer: I should add that medicolegally, the answer to the question is a clear yes, because a documented detailed physical exam would help protect the physician by giving evidence towards the suspected diagnosis of mono and against other possibilities. A detailed chart is always in the physician's best interest medicolegally, but unfortunately due to the pressures of our system and a number of other factors (like the ones I mentioned above), charts for simple issues are typically pretty bare bones. Then again, if the complaint is very minor but the problem turns out to be something rare and serious, the physician could probably argue that they delivered the standard of care even without doing a detailed exam. Even though getting an incredibly detailed physical exam is always in the patient's interest, it's simply not possible given the other constraints placed on these encounters. That's why the devil is in the details of exactly how little physical exam was done and what the reasoning behind it was.
posted by treehorn+bunny at 11:24 PM on December 31, 2016 [1 favorite]
posted by treehorn+bunny at 11:24 PM on December 31, 2016 [1 favorite]
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