Abstract
Background:
Direct-to-consumer (DTC) telemedicine platforms have been increasingly implemented by large hospital systems. This care delivery mechanism shares similarities with bedside medical care, but also differs in key attributes such as the inability to perform a “hands-on” physical examination.
Methods:
We present a case of DTC telehealth evaluation that resulted in the diagnosis of acute appendicitis. The case of one female patient presenting to our urgent care mobile application and subsequently to the emergency department (ED) is discussed.
Results:
Physician-guided patient self-examination of the abdomen demonstrated concordance with findings on bedside physical examination in the ED, leading to the correct diagnosis of acute appendicitis.
Conclusions:
For the patient presented here, physician-guided patient self-examination resulted in appropriate referral to the ED and diagnosis of appendicitis. Additional research on the reproducibility of virtual physical examination findings and potential cost savings of telemedicine visits is warranted.
Introduction
Telemedicine has been widely adopted by hospital systems predominantly for provider-to-provider communication. 1 In emergency departments (EDs), telemedicine applications have focused on expediting stroke, trauma, and mental health screening consultations and increasing the availability of these services in rural or remote areas. 2 More recently, direct-to-consumer (DTC) telemedicine is being explored by large, established hospital systems to provide patients with access to urgent care physicians via mobile applications, a market that was previously dominated by startups and commercial companies. 3,4
The growing adoption of DTC telemedicine services by traditional healthcare institutions raises the question of whether medical evaluation by these methods, including both history taking and physical examination, provides sufficient information for high-quality medical decision-making. It is a medical aphorism that “a careful history can lead to the correct diagnosis 80% of the time,” a phase that dates back at least four decades. 5 In our experience, eliciting a patient history using an audiovisual virtual platform functions well. Although we have not yet encountered any literature on history taking during telemedicine encounters, perhaps, as intuition would suggest, the verbal and visual component of history taking functions similarly to what occurs in person. In fact, we have observed that the uninterrupted and private nature of the telemedicine encounter, compared to communication in a busy ED, may in some ways be superior to what we experience in a typical face-to-face encounter. In contrast, virtual physical examinations are fundamentally different from physical examinations performed in person—there is no “hands-on” examination.
There is little scientific evidence on the techniques, accuracy, and reproducibility of virtual physical examinations. In the absence of published guidance or established training, we find our evaluation process often relies heavily on physician creativity and resourcefulness to gather information analogous to that of a bedside physical examination. This is accomplished through visual inspection and the request for patient or caretaker assistance in components of the physical examination. 6
We describe a case of remote evaluation of a patient with appendicitis by physician-guided patient self-examination. We do not believe that this type of case has been previously described and feel that it highlights the value of physician-guided patient self-examination for medical assessment in DTC telemedicine care.
Case Report
Virtual Visit
A 22-year-old woman with no significant medical history called our university-based DTC telemedicine service complaining of a “stomach ache.” She also reported nausea, vomiting, diarrhea, and a fever. The physician, seeing the patient in the virtual waiting room, began a face-to-face video encounter, in which he conducted a history and physical examination. The patient noted abdominal pain that started the previous evening and was located primarily in the left upper abdomen. The next morning, the patient reported that the pain had disappeared but that she had experienced nausea, two episodes of nonbloody, nonbilious vomiting, nonbloody diarrhea, and a fever to 102.3°F. The patient denied any urinary or vaginal symptoms. She had an intrauterine device in place and therefore rarely menstruated. She denied any recent travel or sick contacts. The physician described the patient as mildly ill but nontoxic appearing and proceeded to guide the patient in performing a self-examination of the abdomen.
The physician first explained to the patient the difference between feeling pressure versus focal tenderness or pain with palpation. He then asked her to relax her abdominal muscles and guided her through a self-examination of all abdominal quadrants, instructing her to push with two fingers (second and third digits) in each location. On self-examination, the patient noted very mild focal tenderness to her right lower quadrant, corresponding to McBurney's point. She denied any rebound tenderness or palpated masses. She did not demonstrate pain in her right lower quadrant when she palpated her left lower quadrant (negative Rovsing's sign). She indicated the pain severity in the right lower quadrant upon palpation at only 1/10 on a 10-point-scale.
There was a wide differential for her presentation, including self-limited conditions such as viral or bacterial gastroenteritis and food poisoning. However, given the focal nature of the tenderness and the progression of pain from the left upper abdomen to the right lower quadrant, the telemedicine physician encouraged her to come to the ED to be reevaluated by an on-site physician due to the possibility of acute appendicitis.
ED Visit
The evaluating telemedicine physician and the DTC platform she was evaluated on were part of the same hospital system. The telemedicine physician called the ED to alert the on-site physicians about this patient's case and imminent arrival to the hospital. The patient arrived in the ED 1 h following her telemedicine consultation. Her history of present illness was confirmed, and the physical examination performed at the bedside demonstrated right lower quadrant tenderness to palpation at McBurney's point without rebound or guarding, in concordance with the findings noted on the physician-guided self-examination described above.
Outcome
A CT scan performed in the ED showed an acute, nonruptured appendicitis. The patient was taken to the operating room for a laparoscopic appendectomy. She had no intra- or postoperative complications and was discharged from the hospital the next day. The pathology report subsequently confirmed acute appendicitis.
Discussion
In 1999, an on-site primary care physician in Antarctica used telemedicine for a virtual surgical consultation in a case of suspected acute appendicitis. 7 After conducting the history and physical examination in person, the physician used telemedicine for provider-to-provider communication with a surgeon regarding the need for operative intervention. Our case, presented above, is unique in its description of a physician-guided patient self-examination of the abdomen in the diagnosis of acute appendicitis. We highlight this case as an example of the technique used for this type of virtual examination, as well as the concordance between the telemedicine and bedside physical examinations. This case also illustrates the potential benefit of telemedicine as a care delivery platform to improve the ease of and expedite access to care. In this case of acute appendicitis, the telemedicine encounter accurately directed the need for an immediate and comprehensive ED-based workup based on the initial physician-guided patient self-examination.
In an era in which physicians are becoming increasingly reliant on laboratory results and diagnostic imaging, the technology that supports the virtual medicine platform may counterintuitively enable physicians to return to two core foundations of medical practice, namely the reliance on the history of present illness and the physical examination. There is as yet little research into the characteristics of the virtual physical examination and its comparison with the traditional in-person physical examination. One study demonstrated poor concordance between telemedicine and in-person physical examinations in ED patients with sore throat. 8 However, these findings may not be generalizable to the entirety of virtual physical examination, as demonstrated by the concordance between the virtual and ED examination of our patient presenting with acute appendicitis. Moreover, one recently published article discussed the telemedicine clinical examination, citing the inability to palpate patients as a major limitation to virtual examination. 9 In this case report, we introduce the possibility that there might be creative solutions to this limitation, namely a physician-guided patient self-examination. As the field of telemedicine expands and the merits of the virtual physical examination are better understood, medical education may benefit from shifting its focus both back to training students in bedside clinical skills and forward to their virtual equivalents. 10
This case also demonstrates the potential for DTC virtual urgent care platforms to decrease delays in presentation to a hospital. Data have shown that delayed presentations of acute appendicitis can result in increased morbidity and mortality. 11 Implementation of telephone triage systems staffed by registered nurses demonstrated reduced time to evaluation for patients with appendicitis, implying the potential for decreased morbidity and mortality from complications such as abscess or rupture. 12 However, the rate of false positive ED referrals that resulted from this phone triage service was not reported. A telemedicine evaluation, which includes both audio and video communication with a patient, may allow for increased diagnostic accuracy, when compared to telephone evaluations, due to the ability for a physician to guide and observe a patient self-examination of the abdomen. Use of this virtual physician-guided self-examination may have resulted in decreased time to definitive diagnosis and surgical management of acute appendicitis. These virtual urgent care platforms may also ultimately allow for decreased ED volume and cost savings by obviating the need for unnecessary ED visits.
Conclusions
In the case reported above, the initial virtual physician-guided patient self-examination and the following traditional physician bedside abdominal physical examination in the ED demonstrated high concordance and resulted in the correct diagnosis of acute appendicitis. Additional research to establish the accuracy and reliability of virtual physician-guided patient self-examination of the abdomen, as well as any potential outcome benefits from these clinical encounters, is warranted. Finally, refocusing medical student and resident training on proper physical examination technique and the translation of this skill to the virtual clinical setting may be beneficial, as these technologies are increasingly used in the provision of medical care.
Footnotes
Disclosure Statement
No competing financial interests exist.