Medical Expert Witness On Clinical Standards Part 6

In Clinical Standards in Medicine medical expert witness Barry E. Gustin, MD, MPH, FAAEM, writes:

For each of these rules, there are corresponding guidelines which may or may not be appropriate to act on. For example, under character of pain, it may or may not be useful to ask about the onset of the pain, the severity, the location, whether radiation occurs, its frequency, duration, similar previous episodes, precipitating or mitigating factors, its relationship to exertion, rest, movement or deep breathing and so on. It is clear to physicians that although this information is relevant for many patients presenting with chest pain, there are times when this information does not apply and has no real utility, such as the young otherwise healthy patient with fever who complains of chest pain only when coughing.

Similarly, there are no absolutes about what constitutes appropriate adherence to the guidelines for physical examination. A physician may decide, based on the overall clinical picture of the patient, to listen to the lungs, percuss the lungs, X-ray the lungs, assess the oxygenation of the lungs by doing pulse oximetry or arterial blood gases and so on. It would be left up to the physician to decide whether these things were or were not appropriate to do.

The decision to do or not to do is based on the “findings” for any given “variable”. The variable is defined as a component of any aspect of the history, physical examination, lab analysis, differential diagnosis, or disposition. Examples would be the patient sex or age, the chest X-ray, or the vital signs. The finding is defined as the value of the variable, such as male, 64 years old, enlarged heart, and a rapid irregular heart rate.