Medical Errors and Adverse Events from a Missed or Inadequate Physical Exam

January 13, 2016

In the last 20 years the knowledge base for a physician has grown exponentially. Meanwhile technological advances, combined with a growing healthcare system and greater demands on the physician have left the need to find more ways to overcome these challenges. The physical exam, once regarded in the medical profession and the litmus test to the quality of a doctor and vital to the care of patients has been slowly forgotten. Now doctors, who once spent the majority of their time at their patient’s bedside and nearby collaborating with others are sitting at a computer feeding the hungry monster we call the electronic health record: often times ordering test such as CT scans, MRI’s and other advanced and often expensive diagnostics tests with hope that diagnoses will be not be missed, nor will the need for the physical exam. But this comes at a price. A recent published article in The American Journal of Medicine from author’s at Stanford School of Medicine, including the lead author, ourDr. Abraham Verghese interviewed physicians and documented where the physical exam was missed or not conducted. They reported 208 clinical vignettes and found that 63% of these events occurred because the exam was not conducted, 14% reported that correct exam finding was elicited but misinterpreted and 11% were from a relevant exam sign missed or not sought out. They also found that the physical examination inadequacy included missed or delayed diagnosis in 76% of cases, incorrect diagnosis in 27%, unnecessary treatment in 18%, no or delayed treatment in 42%, unnecessary diagnostic cost in 25%, unnecessary exposure to radiation or contrast in 17%, and complications caused by treatments in 4%.



Most errors in the physical examination that lead to consequences are related to not performing an examination.


These vignettes were recorded from both residents and practicing physicians and highlight issues surround the medicine where it was noted in the paper that at much as 100,000 deaths occur in the United States that are attributable to medial error. While it’s not been studied how much improving physical exam skills and providing a culture doctors have more time to be with their patients, we believe this is crucial. The Stanford 25 is leading the charge in this area and support from large entities such as the Institute of Medicine whose recent mention of the importance of the bedside physical exam in their report is leading to a change in our culture that will make our doctors better.

Read the full article to learn more. Below is additional information from this publication including a full list of the physical exam findings that were missed.

Sister Mary Joseph

Figure showing time to identifying discovery of missed exam.

Supplementary Table – Complete List of Items Missed as Reported in Returned Questionnaires
Missed skin finding of subcutaneous emphysema
Missed pulse absence in ischemic foot
Missed pregnancy with twins before hysterectomy
Missed hip fracture labeled as right lower quadrant pain
Missed Bell’s palsy
Missed liver mass, abdominal mass in cholangiocarcinoma
Missed funduscopic finding of cupping
Missed strangulated groin hernia in small bowel obstruction
Missed incarcerated femoral hernia
Missed crackles in a patient with pulmonary edema
Missed finger pressure necrosis on microvascular free flap
Missed peritoneal signs and free air on plain film
Missed peritonitis in patient with gangrenous perforated gall bladder
Missed adenopathy and therefore chronic lymphocytic leukemia
Missed thyromegaly in patient with tachycardia
Missed strangulated hernia
Missed fungating breast mass
Missed pelvic examination and therefore missed tubo-ovarian abscess
Missed pregnancy by missed gynecologic examination in patient with seizures
Missed pyoderma gangrenosum in skin
Missed Fournier’s gangrene in groin—no genital examination
Missed clonus and hyperreflexia
Missed abdominal examination finding of tenderness and Grey Turner signs
Missed neurofibroma and café au lait spots
Missed large abdominal mass
Missed heart failure signs of cardiomyopathy after flu in a young person
Missed pulse extremity examination, missed Buerger’s
Missed testicular mass in teen
Missed massive splenomegaly
Missed second cervix
Missed abrasion on forehead, clue to subdural
Missed bruising signs of abuse in child
Missed prostate mass with elevated prostate-specific antigen
Missed decreased pulses, arterial occlusion in elderly man after hip fracture
Missed strangulated femoral hernia in 88-year-old with emesis
Missed loud bruit in patient with renal failure and hypertension
Missed ruptured spleen after trauma
Missed ectopic pregnancy because no pelvic examination done
Missed obvious congestive heart failure (CHF) signs labeled as bronchitis
Missed rotatory and vertical nystagmus in patient with basilar artery aneurysm
Missed abdominal examination, old scar mislabeled as hernia, scar and patient operated on for “recurrent” hernia and nothing found
Missed pulses in patient with peripheral vascular disease
Missed tuberculosis signs in chest
Missed vital sign of tachypnea on first visit in a patient later found with bacteremic pneumonia
Missed adenopathy in lymphoma
Missed clavicle fracture, labeled “rule out myocardial infarction”
Missed the tan of hemochromatosis
Missed femoral fracture
Missed acute myocardial infarction by focusing on neck pain, ear pain
Missed hyperreflexia and cord compression in Potts disease
Missed rectal and missed prostatic abscess
Missed supraclavicular mass in lung cancer
Missed splenomegaly and delayed diagnosis of chronic myelogenous leukemia
Missed psoriasis and its signs
Missed groin cellulitis
Missed dislocated shoulder on examination
Missed adenopathy in germ cell tumor
Missed marked pallor in elderly anemic
Missed pulsatile abdominal aneurysm
Missed adenopathy in patient with Waldenstrom’s disease
Missed penetrating foreign body in vaginal fistula
Missed gastric bypass scar in patient with malnutrition and beriberi
Missed signs of CHF in a young patient
Missed femoral hernia in patient with vomiting
Missed signs of hypothyroidism and neck scar in unresponsive patient
Missed retinal lesions in a child with poor vision
Missed signs of myocarditis and CHF, especially the tachycardia in a child
Misconstrued bruit from an aortofemoral bypass as a cardiac murmur
Missed obvious CHF signs
Missed obvious pregnancy and labor
Missed huge spleen in cirrhosis
Missed previous appendectomy scar and made diagnosis of appendicitis again
Missed ulnar nerve transection after trauma
Missed male breast mass
Missed distended bladder
Missed incarcerated hernia
Missed breast mass and metastases
Missed zoster presenting as abdominal pain
Missed femoral hernia
Missed orchitis and diagnosed it as hernia
Missed aortic stenosis murmur preoperatively
Missed breast mass
Missed anus present in patient stated to have abdomino-perineal resection, when they had Hartman procedure
Missed prolapsing rectal cancer, rectal examination not done
Missed incarcerated groin hernia
Missed bruises of abuse
Missed large melanoma over scapula
Missed hoarseness, puffiness, and signs of hypothyroidism
Missed decubitus ulcer causing “back pain”
Missed leg ulcers and sores as a cause of fever in alcoholic
Missed skin findings of secondary syphilis
Missed hip fracture in patient who could not walk
Missed gouty nodules
Missed breast mass
Missed mucor wound on hand in immunocompromised patient
Missed zoster in patient with chest pain
Missed foot ulcer in diabetic with fever
Missed signs of Parkinson’s in elderly being worked up for falls
Missed lymph node in a patient with breast cancer
Missed abdominal mass lymphoma in patient complaining of pain
Missed skin ash leaf macule in child with hypertension
Missed anterior cruciate ligament tear with classic signs
Missed giant ovarian cyst, labeled as ascites
Missed giant ovarian cyst again thought to be ascites
Missed loud murmur of ruptured mitral valve chordae tendinae
Missed murmur and signs of subacute bacterial endocarditis
Missed cutaneous abscess in compromised patient with fever
Missed obvious CHF in 33-year-old with cardiomyopathy
Missed appendicitis signs
Missed strangulated hernia
Missed Down’s syndrome on examination in 6 month old
Missed acute central vein occlusion in patient with decreased vision—no fundoscopy done
Missed anal cancer said to be hemorrhoids
Missed peritonitis signs in patient with Crohn’s
Missed dentures in mouth during intubation
Missed significant murmur of mitral stenosis, called it aortic stenosis
Missed abdominal mass turned out to be lymphoma
Missed aortic stenosis in preoperative examination
Missed scrotal mass until after surgery for abdominal mass. Was testicular tumor with metastases
Missed supraclavicular nodes in patient with lung cancer
Missed hyperreflexia and clonus from epidural abscess
Missed adenopathy in non-Hodgkin’s lymphoma with fever of unknown origin—called a hernia
Missed neck nodes
Missed pelvic inflammatory disease because no pelvic examination done
Missed gunshot entrance wound in emergency room
Missed large abdominal masses in patient with bloating
Missed pregnancy in patient with large belly
Missed signs of CHF in patient presenting with “scrotal swelling”
Missed liver laceration after trauma because focus on head
Missed enlarged tonsil that was cancer
Missed clavicle fracture in patient with syncope
Missed ecchymosis in patient from a fall, and the left arm pain assumed to be cardiac
Missed contact dermatitis
Missed constrictive pericarditis signs
Missed breast mass in patient with shoulder pain
Missed breast mass in patient with deep vein thrombosis
Missed rapid growth in head circumference
Missed splinters and signs of subacute bacterial endocarditis
Missed systolic murmur cardiac, labeled carotid bruits
Missed pericardial rub and pericarditis
Missed zoster rash
Missed hip disease as a cause of joint pain
Missed femoral pathologic fracture in patient with knee pain
Missed large liver in patient with diabetic ketoacidosis
Missed zoster as cause of chest pain
Missed watch battery in umbilicus in child
Missed purulence in tonsils
Missed normal ear examination labeled as perforation by not doing pneumatic otoscopy
Missed breast mass in patient with chest pain and metastasis
Missed pregnancy, called it constipation
Missed meningococcemia skin lesion in patient with fever
Missed CHF findings in patient with postpartum cardiomyopathy
Missed hoarseness and laryngeal mass in patient labeled asthma
Missed rectal mass by gastrointestinal consultant after primary care physician feels mass—sigmoidoscopy negative, but tumor develops
Missed appendicitis by focus on chest
Missed rales and crackles
Missed obvious pleural effusion, no examination
Missed signs of myasthenia in patient with weight loss
Missed signs of bowel obstruction
Missed signs of mitral regurgitation from torn leaflet
Missed hepatomegaly and hepatocellular carcinoma in patient with vague symptoms
Missed metastatic node from breast cancer in patient with weight loss
Missed stone in urethra causing recurrent urinary tract infection
Missed pelvic examination in adolescent and missed pelvic inflammatory disease
Missed radiculopathy causing abdominal pain
Missed signs of peritonitis
Missed fungating breast mass
Missed abdominal mass in patient with back pain
Missed pelvic examination and missed procidentia
Missed skin signs of calcinosis in patient with mixed connective tissue disease
Missed breast mass in patient being worked up for metastasis
Missed skin erythema migrans in patient with Bell’s palsy
Missed abnormal pulses of combined aortic stenosis/aortic regurgitation and focused on treating high blood pressure and pulse pressure
Missed aortic stenosis murmur
Missed abdominal mass, expanding aortic aneurysm in patient with abdominal pain
Missed pericardial friction rub in chest pain
Missed nasal septal hematoma
Missed scrotal infection in diabetic
Missed Korsakoff’s signs in many neurologic examinations
Missed zoster in patient with chest pain who had coronary angiogram
Missed pelvic examination and missed ovarian cyst
Missed adenopathy and hepatomegaly in patient with anemia and weight loss
Missed inflammatory knee effusion in intensive care unit patient with fever
Missed distended bladder labeled abdominal mass
Missed rectal examination and therefore missed prostatitis
Missed doing pulsus paradoxus in patient with tamponade
Missed abnormal decreased pulse and blood pressure in one arm
Missed purulence around IV catheter as cause of fever
Mistaken diagnosis of peritonitis, bias from x-rays showing pneumatosis intestinalis
Missed lytic lesions as cause of left-sided weakness in limbs
Missed CHF signs
Missed purulence at bone marrow biopsy site in patient with fever
Missed clubbing in patient with shoulder pain who has lung cancer
Missed hernia because of missed groin examination
Missed edema from hypoproteinemia labeled CHF
Missed peritonitis and perforation
Missed murmur of critical aortic stenosis
Missed butterfly bruises of factitious injury
Missed neurogenic bladder
Missed costochondritis in patient labeled as rule out myocardial infarctions
Missed epididymitis in patient with abdominal pain
Missed scrotal examination
Missed erythema migrans in patient with fever and headache
Missed large abdominal mass on both pelvic and seated abdominal examination
Missed embolic arterial occlusion
Missed uremic calciphylaxis in patient on dialysis

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