Telemedicine talk teaches tips and tricks
By Mollie Frost
Although internists have gained more experience in telemedicine in the past year, there's always room for improvement.
During her Thursday talk on conducting virtual physical examinations at Internal Medicine Meeting 2021: Virtual Experience, ACP Resident/Fellow Member Romela Petrosyan, MD, a member of ACP's Clinical Skills Committee who takes office on Sunday, May 2, as Chair-elect of ACP's Council of Resident/Fellow Members, offered her advice, including the following tips and tricks, for maximizing the information gathered in the following areas of a virtual physical exam:
Visual acuity. A newspaper or magazine can be a handy tool for a virtual eye exam. An indication of 20/20 vision would be if the patient is able to read the smaller print while holding the paper about 3.2 feet away, said Dr. Petrosyan, who is a clinical research nephrology fellow at the combined Brigham and Women’s Hospital/Massachusetts General Hospital fellowship program at Harvard Medical School in Boston. "And if they're only able to read the headline, that can be equated to approximately a 20/80 vision."
Abdominal exam. The best way to perform this exam is having the patient lie supine with the assistance of a family member, friend, or trusted caretaker, she said. Then internists can coach their assistant through gently pressing down on the abdomen about one to four inches deep as they assess for distention and note any facial expressions the patient makes, said Dr. Petrosyan. The assistant can also tap on the patient's back to check for costovertebral angle tenderness, she said. "We can also ask the patient to jump to see if there are any potential peritoneal signs as well."
Even without an assistant, it's possible to teach patients about abdominal palpation and landmarks. First, ask the patient to locate the lower portion of the ribs, then walk her fingers to the center of the abdomen and up toward her chest until she finds a notch, which would be the xiphoid process, Dr. Petrosyan said. About an inch below is the epigastric region, which the patient can press and then report any tenderness before drawing an invisible line down to the umbilicus, then another horizontal invisible line at the umbilicus. "That way, they would separate their abdomen into four quadrants," she said. "This is a simple and easy way that patients are able to really speak in a common language along with us and identify where they might have abdominal pain or where the area of concern would be present."
Respiratory rate. To catch any respiratory distress, pay attention to whether the patient is able to speak comfortably in full sentences, Dr. Petrosyan said. "If you would like to count the respiratory rate, it would be also helpful to potentially tell the patient, 'I'm going to look something up" or 'I'm going to take a few notes,'" she said. "And while you're doing that, take some time to observe the patient and see how they're breathing and how often they're breathing at their normal pace."
Dermatologic exam. Despite all that is possible via telemedicine, a video stream is not the best way to identify skin conditions, said Dr. Petrosyan. "A high-quality, static image may provide a lot more information than video images, so whenever possible, really encourage your patients to upload high-quality photos to the [patient] portal prior to their visits," she said. "These images, combined with some of the dynamic aspects of the video, can really demonstrate the full distribution of the lesion or the rash to fully maximize your ability to diagnose virtually." ■