The COVID-19 pandemic and the need to keep vulnerable patients (and clinicians) away from health care facilities to decrease risk of virus transmission, has resulted in a rapid increase in use of virtual, or telehealth (TH), visits.
Reliance on TH requires clinicians to develop skills to obtain objective information from the visits.
How can clinicians obtain such information in a TH visit?
Virtual visits require physicians to think about what information they wish to obtain from the examination that can be performed remotely. Video can provide visual clues, but it is possible to elicit additional, valuable clinical information through various patient-assisted maneuvers. The clinical examination can be focused by directly asking the patient, their caregiver, or both, a set of questions. This evaluation can be improved using digital devices potentially available to patients: wearables for heart rate and electrocardiogram, and home monitoring devices (scale, blood pressure cuff, pulse oximeter).
10 steps for a patient-assisted virtual physical examination
Step 1: Vital signs
Patients should use a validated, digital, upper-arm blood pressure (BP) cuff to measure their BP and heart rate and an electronic scale to measure daily body weight. Patients should be asked: 1) to weigh themselves in the morning of the morning of the TH visit, and 2) to take an accurate basal BP.
They should sit quietly for 5 minutes with the cuff fitted appropriately to their arm size without looking at any screens, talking, moving, or writing. They should take the BP and heart rate twice, then stand, wait 1 minute, then take a standing BP and heart rate. Heart rate is important in determining whether a significant postural decrease in BP is associated with a compensatory increase in heart rate or not (orthostatic hypotension?).
Temperature checks and pulse oximeter readings are especially important (COVID-19?).
Step 2: Skin
Instruct patients to perform a self-assessment. Ask patients to look at their face, neck, arms including elbows, chest, abdomen, and legs to identify any new bruises, rashes, lacerations, psoriasis plaques (especially on elbows or knees), or swelling. Ask if there are areas where they have scratched repeatedly (dermatitis?).
Video clue. Have the patient show you what they have found. If there is a trusted person with them, ask that person to show you the patient's back.
Step 3: Head, eyes, ears, nose, and throat
Ask about hearing to be sure the patient hears you! Are they wearing their hearing aids? Ask if vision or sense of smell is acceptable or has changed, including anosmia (COVID-19?).
Video clue. Have patients close their eyes and look for xanthelasma. After patients open their eyes, ask them to look up. Check for a prominent corneal arcus (familial hypercholesterolemia?). As patients look up, you can quickly see if their pupils are symmetrical and whether they are constricted or dilated. Assess the sclera and evaluate for icterus. Also note any ptosis.
Step 4: Neck
Instruct patients to look over their right shoulder and then look over their left shoulder. Do they notice any pain or limitation with motion? Ask the patient to swallow and see if there is any pain with swallowing (goiter?) Ask if they note a bounding pulsation in the neck?
Video clue.While sitting, ask patients to turn their head to the left and observe the neck veins while sitting; natural lighting may make observing patients’ neck veins easier. Have patients inhale to observe if the neck veins collapse (if they consistently swell with inspiration (Kussmaul's sign?). Look for a giant “a” wave (tricuspid stenosis?) or the presence of a regular rapid-pounding sensation (a specific type of tachycardia?).
Step 5: Lungs
Ask patients to deeply inhale and exhale through an open mouth. Listen for cough or wheezes. Ask patients to deeply inhale again and hold their breath while you count to 10 and listen again.
Video clue. Watch for tachypnea and accessory muscle use as signs of impaired respiration.
Step 6: Heart
Ask if the patient, or caregiver, to take the pulse at the wrist. Have them count out the beats they feel. Ask if there are any skips or pauses, or if the pulse is irregular in nature (atrial fibrillation, atrial flutter with variable block, or atrial or ventricular ectopy?). If the BP cuff has the visual pulse indicator, ask if they noticed irregularity to the rhythm.
Video clue. Ask if patients can show you the output from a watch or smartphone technology that shows heart rates and electrocardiograms.
Step 7: Abdomen
Ask patients if their abdomen is soft, nontender, and normal in size. If tender or distended, and especially if coughing causes tenderness, then an in-person clinic visit may be required. Ask if any abdominal scars are present, and if so, what they were from.
Step 8: Extremities
Ask if patients’ hands or feet are colder than usual, or just the fingertips and toes. If cold distally, ask questions about cold sensitivity and color changes (Raynaud's phenomenon?). Have patients feel their lower legs and ankles and use the thumb to note any pitting edema. Ask patients to put their hands around their calves and say whether one calf is more swollen than the other. For those with high cholesterol, have them feel the Achilles tendon and see if it feels lumpy or bigger than their thumb (tendon xanthoma in familial hypercholesterolemia?)
Video clue. Confirm impression of lower leg swelling, especially if one leg is more swollen. Have them show you the lower legs with natural lighting so you can see more clearly. You can direct where patients sink their thumb into the skin to determine pitting. If they have a measuring tape, then they can measure the calves a fixed distance up from the ankle.
Step 9: Neurological
Ask patients to hold their arms out with elbows straight, spread their fingers, and turn their hands up as if catching rain. Ask patients if they have noticed a tremor (or a tremor when using utensils to eat), or if one arm is weaker than the other. If so, then ask if shoulder problems cause them to keep one arm lower than the other when they extend their arms. Ask patients to rise up from a seated position with arms folded across the chest, to detect proximal weakness. Ask if the patient is light-headed when rising. Ask them to walk to the door and back. Ask whether their gait is steady and whether they use a cane or walker at times.
Video clue. Observe for pronator drift (subtle unilateral weakness?). Watch patients rise from a chair with arms folded (proximal muscle weakness, underlying muscular disorder, statin-associated muscle weakness?)
Step 10: Social determinants of health
Inquire about issues regarding changes in diet, physical activity, sleep, stress, and social support. Ask about if they have insecurities related to food, medicines, and supplies, if they have adequate housing and transportation, and if they feel safe at home.
Video clue. Observe patients’ surroundings and interactions with caregivers. Assess their mood and facial expressions during the visit.
Increasingly, patients and clinicians will use TH services during the COVID-19 pandemic, and likely for years in the future. Adapting to this new reality takes time for both parties. Physicians likely understand the tradeoffs involved in TH visit availability in the absence of an in-person examination. However, during the current pandemic, when it is critical to restrict hospital and clinic visits to reduce viral spread, TH are the best option to balance individual—and public health-related—safety and clinical effectiveness for ambulatory care.
See reference for more information.
Adapted from Benziger CP et al. The Telehealth Ten: A guide for a patient-assisted
virtual physical examination. The American Journal of Medicine. Internet. Available at https://www.amjmed.com/article/S0002-9343(20)30597-0/fulltext. Accessed on October 29, 2020.