Prakhar Agarwal Dr. Goodell CAP II Reflection Assignment November 18, 2010 Option 2.

In one paragraph, describe a patient encounter that left you feeling that there was something you needed to learn. In a second paragraph, explain what your perceived knowledge deficit is, how you will learn what you need to learn, and what you will do with the information once you have it.
I just had two recent patient encounters that reminded me about the questioning the utility of special tests of physical diagnosis. One was a hotel worker with numbness in her hands at night and she stated that her hands fell asleep at night. We suspected carpal tunnel and also performed a Phalens test(negative) and Tinels sign test (positive). The other patent was a young male in his 20s with chronic back pain that progressed to severe acute back pain to the point that he could not continue his work anymore. He went to the ER and was prescribed some strong pain medications and it still didnt help him. The ER doctors there stated that he had sciatica. To confirm this, my CAP partner performed a straight leg test (positive) and a cross legged test (negative). Does this patient really have sciatica from just from a positive straight leg test? I was questioning my partner in my mind about whether these two tests really had high sensitivity or specificity. A lot of special tests we learned in physical diagnosis did not have the sensitivity and specificity data attached to them. Now after learning from EBM and CAP about pre-test probability and the importance of test validity, Ive found that we should always question the results of our physical findings and be aware of the problems we may encounter as physical signs and reported symptoms during a specialized physical test may be different from person to person or may not necessarily be pathognomonic. I dont really have a clue about the sensitivity or specificity of common physical exam tests used in primary care. I will start using the JAMA clinical evidence series, which helps tell me about Likelihood ratio+/- and search up specificity and sensitivity for common physical exam tests using UptoDate and going through the latest primary literature sources. Once I get this information, I will feel more confident about the physical diagnosis tools I have and use evidence based medicine to dictate the best physical exam practices for help in diagnosing common medical problems that arise in the primary care office. I will be able to provide patients further scientific explanations as to why I came to the diagnosis with the information from these specialized tests and maybe alter my physical exam practices if I find that these tests are no longer useful for a specific hypothesis that I am presented with.