# patient assessment...the house and monk way



## EMT91 (Jun 9, 2012)

I was reading a thread about amazing body facts on here and came across a mention that a lack of leg hair on a male may well indicate a cardiac history. So, does anyone else have things that people like monk or house would notice during an assessment like that?

My class was taught that if you touch the eyelash of an unresponsive pt and there eye moves under the lid they have a gag reflex intact.


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## Aprz (Jun 9, 2012)

That's neat if true, but when you think about the cranial nerves, it doesn't make sense. I looked it up and confirm that the sensory and motor of the eyelids are controlled by the trigeminal (V) cranial nerve, not vagal (X) and glossopharyngeal (IX). It is innervated by some other nerves, but I couldn't find if they were branched off from IX or X.

My class was taught that eyelid trick too, but we were taught many things that have either been proven wrong or cannot be backed up. I tend to take what I learned in EMT school with a grain of salt.

A better way to catch subtle findings would probably be to learn Anatomy & Physiology like I think most people recommend, appreciate anatomical variations, experience in doing a full head to toe to know what it looks and feels like, experience in patient interviewing to hear words patients may choose when they feel a certain way or describe their problems, hear it over and over, and there is a great book thay has pictures and description correlating different signs and symptoms you may find during a physical exam and while talking to the patient. It's called Bates' Guide to Physical Exam and History Taking.


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## NYMedic828 (Jun 9, 2012)

Can't say I've heard of the lack of leg hair being indicative of a cardiac history.

Plenty of people naturally aren't hair to begin with. Im sooner going to ask a patient or family about their history before I bother/remember to look at their leg hair.

What may be more valid to say is that people with odd patched in spots of hair on their arms or legs may indicate chronically poor blood flow to the extremity. That one I've heard many times but I have still never checked for it because quite honestly it's a useless diagnostic for anything prehospital.


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## Veneficus (Jun 9, 2012)

NYMedic828 said:


> What may be more valid to say is that people with odd patched in spots of hair on their arms or legs may indicate chronically poor blood flow to the extremity. That one I've heard many times but I have still never checked for it because quite honestly it's a useless diagnostic for anything prehospital.



Would it make a difference if you observed that and the patient told you they were not diabetic?


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## NYMedic828 (Jun 9, 2012)

If it wasn't normal for them I guess it is worth making a note of but I don't see how it would change anything I can do in an ambulance for the 30 minutes I am with them. 

Im sure you have a more in depth reason.


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## EMT91 (Jun 9, 2012)

Hmm. I will have to take the eyelid trick away then. Thank you! I doubt my instructor was wrong, I probably misunderstood the statement. Anyway, here is the thread I was referring to:

http://www.emtlife.com/showthread.php?t=7522


post number nine by  TKO:

"if your elderly male pt has no leg hair, ask him about his cardiac history.

if your pt has a yellow rim around the iris, ask him about his high cholesterol. "


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## AnthonyM83 (Jun 9, 2012)

While it might not be necessarily true, there might be a strong correlation just through your teacher's experience. Those cranial nerves aren't that far apart...


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## Aidey (Jun 9, 2012)

NYMedic828 said:


> If it wasn't normal for them I guess it is worth making a note of but I don't see how it would change anything I can do in an ambulance for the 30 minutes I am with them.
> 
> Im sure you have a more in depth reason.



It might not change what you do, but it is an indication of a risk factor. This is especially true if there is a line of demarcation where the hair stops at the same spot on both legs. It also can indicate poor nutrition/malnutrition.


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## medichopeful (Jun 9, 2012)

EMT91 said:


> I was reading a thread about amazing body facts on here and came across a mention that a lack of leg hair on a male may well indicate a cardiac history. So, does anyone else have things that people like monk or house would notice during an assessment like that?
> 
> My class was taught that if you touch the eyelash of an unresponsive pt and there eye moves under the lid they have a gag reflex intact.



I've never heard that, doesn't mean it's not true.  Is it possible you misheard and they said a thyroid issue?  Of course, if that was it the hair statement wouldn't be just the legs


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## beandip4all (Jun 9, 2012)

lack of leg hair on a male always indicates cyclist road weenie to me


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## EMT91 (Jun 10, 2012)

Lack of body hair on a male may indicate removal of his prostate or dodads right?


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## Veneficus (Jun 10, 2012)

EMT91 said:


> Lack of body hair on a male may indicate removal of his prostate or dodads right?



Professional fail


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## EMT91 (Jun 10, 2012)

Veneficus said:


> Professional fail



Testicles then.


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## VFlutter (Jun 10, 2012)

I thought sparse leg hair could indicate  peripheral vascular disease / insufficiency


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## Veneficus (Jun 10, 2012)

EMT91 said:


> Lack of body hair on a male may indicate removal of his prostate or dodads right?



While theorhetically possible, I would not use this as an indicator. 

Removal of the prostate should have no influence. 

Removal of the tesiticles themselves would also not likely produce this effect due to extratesticular androgen production. (mainly the suprarenal glands)

In the vascularly impaired (diabetic, vascular disease of various flavours, etc) loss of body hair is likely from inadequete local circulation.

If there is significant edema in the lower extremities, mass effect may also occlude folicular circulation, causing atrophy. 

But in an older male patient with no lower extremity hair, I would start looking for cardiovascular problems.

In a younger population, including those with no body hair at all, (seen it) central endocrine axis disorder is usually the cause.


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## Aidey (Jun 10, 2012)

The prostate does not produce hormones. The testes do. Removal of the testes can cause a decrease in body hair, along with anything else reliant on testosterone. It wound not only happen on the legs.


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## EpiEMS (Jun 10, 2012)

When I see minimal body hair, I think "swimmer," not "orchiectomy."
Those "House"-style assessment techniques probably have fairly low sensitivity and specificity. I'd wager that you'd get way more false positives from assuming minimal body hair --> cardiac hx, say.


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## Veneficus (Jun 10, 2012)

EpiEMS said:


> When I see minimal body hair, I think "swimmer," not "orchiectomy."
> Those "House"-style assessment techniques probably have fairly low sensitivity and specificity. I'd wager that you'd get way more false positives from assuming minimal body hair --> cardiac hx, say.



I think you have to take it in with the sum total of knowledge and findings. 

It is a failure of EMS education and knowledge to apply 1:1 models of assessment. 

If there is no/minimal body hair, there has to be a reason. That reason needs to be investigated, though not in the emergency setting usually. 

Because of the slowness of human evolution, people are predsposed to cardiovascular disease. (except some east asian populations, for reasons only speculated, but likely a combination)

Along with C/V disease comes a host of other related illness. Obesity, HTN diabetis, etc.

When you examine a patient, finding physical evidence of things like metabolic syndrome will usually not land you too far from the mark.

But it is the sum total of findings and understanding of inter-relations that permit accurate assessment like this. 

Another example is something like caput medusae, does it tell you if a blockage is pre, post, or intrahepatic? No. but when I see it I know there is some sort of portal system HTN. I know the sequele of that. 

Now start adding other history and physical findings and your accuracy can increase considerably. 

However it is all based on knowledge of phys and pathophys. Without it, your physical exam is going to be next to useless. (it has been my experience this knoledge and exam accuracy usually correlate) If you leave parts of your physical exam out, like liver/heart margins, percussion, etc. of course your findings are not going to be accurate. 

I have met physicians whose physical exam are as good as any battery of tests. I work hard to become as skilled as they are. But I can say for certain, it requires knowledge and practice. Merk Manuals and simple correlation is just not going to do it.


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## EMT91 (Jun 10, 2012)

Thus I made this thread; I am learning from the replies. The reason I mentoined prostate removal and lack of hair is due to a man I talked to who had his prostate removed and lost a lot of body hair.


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## VFlutter (Jun 10, 2012)

EMT91 said:


> Thus I made this thread; I am learning from the replies. The reason I mentoined prostate removal and lack of hair is due to a man I talked to who had his prostate removed and lost a lot of body hair.



Due to prostate cancer? Possibly from chemo/Radiation treatment


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## EpiEMS (Jun 10, 2012)

Veneficus said:


> I think you have to take it in with the sum total of knowledge and findings.
> 
> It is a failure of EMS education and knowledge to apply 1:1 models of assessment.
> 
> I have met physicians whose physical exam are as good as any battery of tests. I work hard to become as skilled as they are. But I can say for certain, it requires knowledge and practice. Merk Manuals and simple correlation is just not going to do it.



This is so true. I think you've spelled out a major problem with how EMS educators teach patient assessments.


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## AnthonyM83 (Jun 10, 2012)

EpiEMS said:


> This is so true. I think you've spelled out a major problem with how EMS educators teach patient assessments.



Increase the course length and hours dedicated to assessments and then maybe they can get somewhere...


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## EpiEMS (Jun 12, 2012)

AnthonyM83 said:


> Increase the course length and hours dedicated to assessments and then maybe they can get somewhere...



True that.


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## mycrofft (Jun 13, 2012)

Touch the eyelash of an unconscious pt and it if blinks he's likely conscious.
Touch the CORNEA and if nothing happens, he's probably dead. Or some cranial nerve thingee. Might want to check pulse as well?

Yeah, I lost leg hair in a pattern below the knees after atrial fib set in with evening edema. For poor circ, look for "chocolate spots" as well.

How about sweating only above the clavicles?


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## Ghostnineone (Jun 13, 2012)

I always thought the house way of assessing patients was to avoid them completely and just read about their symptoms???


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## mycrofft (Jun 13, 2012)

The House Method, pioneered in real life by the famous friend of Conan Doyle, Dr Bell, is to look at people and use your encyclopedic store of medical trivia to deduce what's wrong, often deducing the pt complaints before the pt voices them.

"Joseph Bell: Cheeky Diagnosis

One day Dr. Joseph Bell (Sir Arthur Conan Doyle's medical school mentor and the inspiration behind Sherlock Holmes) assembled a group of students around a patient's bed to demonstrate the deductive method of diagnosis.
"Aren't you a bandsman?" he asked the sick man. Yes, the man politely nodded. "You see, gentlemen, I am right," Bell continued. "It is quite simple. This man has a paralysis of the cheek muscles, the result of too much blowing at wind instruments. We need only inquire to confirm. What instrument do you play, my man?" The patient's reply? "The big drum, Doctor."

endquote
http://www.anecdotage.com/index.php?aid=136


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## Ghostnineone (Jun 13, 2012)

Bahahaha that's hilarious.


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## Martyn (Jun 13, 2012)

> That's neat if true, but when you think about the cranial nerves, it doesn't make sense. I looked it up and confirm that the sensory and motor of the eyelids are controlled by the trigeminal (V) cranial nerve, not vagal (X) and glossopharyngeal (IX). It is innervated by some other nerves, but I couldn't find if they were branched off from IX or X.


 
As far as I am aware it is not to check for and has nothing to do with nerve responses rather than checking the level of conciousness. If the eyelid flickers then there must be a level of conciousness to respond to that touch. Therefore there may well also be enough conciousness to realise someone is shoving a tube down your throat and start the gag reflex. It's a bit like saying what is the longest hair on the body? The ones around your butt hole 'cos if you pull one out it makes your eyes water therefore they must be connected from your butt hole to the back of the eyeball. KISS, don't overthink things.


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## Martyn (Jun 13, 2012)

> How about sweating only above the clavicles?


 
Spinal injury


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## Martyn (Jun 13, 2012)

> Can't say I've heard of the lack of leg hair being indicative of a cardiac history.
> 
> Plenty of people naturally aren't hair to begin with. Im sooner going to ask a patient or family about their history before I bother/remember to look at their leg hair.


 
So what about women? Most of them shave their legs!!!


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## NYMedic828 (Jun 13, 2012)

Martyn said:


> So what about women? Most of them shave their legs!!!



Right... Making assessment of leg hair even less useful to us than it already was.


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## mycrofft (Jun 14, 2012)

A House episode actually used two cases from some library book I read decades ago. One was an orange guy (in the book, I believe a German tourist?) who ate too many carrots. The second was a kid suffering organophsphate poisoning because Mom bought discount jeans from a store that stocked damaged shipments and that one had insecticide spilled on it.

Neat book. Had the case of a guy who got a souvenir South Pacific fish spear through the neck and they removed it without having to  reconstruct any major structures.


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