How Much Is Enough?

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Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of Wounds or HMP Global, their employees, and affiliates.

Dear Readers:
Many of us work in mixed environments. What do I mean by that? We see wound care patients, but we also see patients who have physical therapy needs and ambulatory challenges; we see wound care patients and we see patients who have undergone bowel surgery and now need stoma care; we see wound care patients and we also see patients who are recovering from a distal bypass… I think you get my point.

Most of us are not general practitioners, and therefore we are primarily trained in the focused physical exam and even the focused history. In addition, in the wound care practice we often see patients on a weekly basis, or even twice a week, and it would seem obvious that listening for heart murmur or carotid bruit every week you see a patient for their toe ulcer is probably too much. However, looking at both of the patient’s feet at every visit probably makes sense. Repeating a comprehensive venous exam at every office visit would not be necessary, but feeling for pulses at every visit probably is reasonable. 

Does the patient who comes to see you for a dehisced surgical breast wound also need a comprehensive pulse exam? And then there is the question of how comprehensive the patient wants the exam to be. They have come to you with a focused question, and they do not understand why you may be looking at the pulses in the right groin for the ulcer on the left toe. 

Does every office visit start with blood pressure, heart rate, respiratory rate, temperature, and even pulse ox? If the patient is seeing you weekly and the above parameters have been normal, is there a scientific reason to continue to assess them at a weekly interval? My friend and colleague recently shared a very well-written article about the lack of use of vital signs in the hospital setting.¹ I would propose that while "meaningful use" dictates that we obtain blood pressure heart rate and respiratory rate at every visit, if those numbers are within normal limits or very stable, obtaining such information at every visit provides no medical benefit. Of course, if the patient is complaining of increased pain, a recent fever, or any other form of generalized malaise, we should immediately obtain vital signs—and in a majority of our patients, probably a blood sugar test as well.

The balance between efficiency, scientific and medical utility, and simple time management dictates our ability to provide good care to the most patients that need our services. As a proponent of the focused physical exam and even the biased and focused history, I welcome your comments and feedback as to how you provide care to your patients. Do you thoughtfully review the vitals that are obtained at the beginning of every office visit? Do you actually address abnormalities in the vitals in your medical record? How comprehensive is your exam at every visit? We all know we should look at both feet and both legs, but do you know where your stethoscope is?

John C. Lantis II, MD, FACS
Editor-in-Chief, Wounds 
woundseditor@hmpglobal.com

Reference

1. Kellett J, Sebat F. Make vital signs great again – a call for action. Eur J Internal Med. 2017;45:13-19. doi:10.1016/j.ejim.2017.09.018