practicality of physical exam in modern medicine

[copes]

As med students on medicine rotation we are expected to do more comprehensive physical exams and to learn all the proper techniques and maneuvers. However, it seems like many physical exam findings have limited usefulness. Physical exam findings are almost always corroborated by further test results which provide far more sensitive and specific information. For example it is hard to be enthusiastic about percussing the lungs of someone with pneumonia if percussion has poor sensitivity and specificity and a chest xray was taken already. Secondly, residents and interns barely have time to do much of a physical exam. Third when it comes to progress notes the physical exam almost never changes but you have to write the same thing over and over again. Fourth I have seen attendings not do a physical exam and instead copy physical findings from someone elses note. The physical exam is a useful tool at times but I feel like attendings (especially the old school ones) are a bit hypocritical on their emphases of physical exam. Any thoughts?

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[FunnyCurrent]

As med students on medicine rotation we are expected to do more comprehensive physical exams and to learn all the proper techniques and maneuvers. However, it seems like many physical exam findings have limited usefulness. Physical exam findings are almost always corroborated by further test results which provide far more sensitive and specific information. For example it is hard to be enthusiastic about percussing the lungs of someone with pneumonia if percussion has poor sensitivity and specificity and a chest xray was taken already. Secondly, residents and interns barely have time to do much of a physical exam. Third when it comes to progress notes the physical exam almost never changes but you have to write the same thing over and over again. Fourth I have seen attendings not do a physical exam and instead copy physical findings from someone elses note. The physical exam is a useful tool at times but I feel like attendings (especially the old school ones) are a bit hypocritical on their emphases of physical exam. Any thoughts?

does the alias Copes refer to Cope's book the acute abdomen or is that a wonderful coincidence

 

[copes]

does the alias Copes refer to Cope's book the acute abdomen or is that a wonderful coincidence

Good pick up haha. Guess which book I bought and fully intended to read but never did...

 

[Skinceutical]

As med students on medicine rotation we are expected to do more comprehensive physical exams and to learn all the proper techniques and maneuvers. However, it seems like many physical exam findings have limited usefulness. Physical exam findings are almost always corroborated by further test results which provide far more sensitive and specific information. For example it is hard to be enthusiastic about percussing the lungs of someone with pneumonia if percussion has poor sensitivity and specificity and a chest xray was taken already. Secondly, residents and interns barely have time to do much of a physical exam. Third when it comes to progress notes the physical exam almost never changes but you have to write the same thing over and over again. Fourth I have seen attendings not do a physical exam and instead copy physical findings from someone elses note. The physical exam is a useful tool at times but I feel like attendings (especially the old school ones) are a bit hypocritical on their emphases of physical exam. Any thoughts?

I mostly agree.

I think that some basic elements of the PE are still vital to assessing a patient and formulating a differential. In fact, the specialty I'm in now almost exclusively relies upon visual exam findings to make most diagnoses.

However, many of the more esoteric PE tests (the ones that IM residents trained in India tend to harp on), while highly specific, are so insensitive, they're almost useless. Even some mainstays of the physical exam, like cardiac auscultation, have been shown to have poor intra-observer reliability, even in the hands of experienced cardiologists.

Personally, I think every med student and resident should take a look at this book at some point. It's truly eye-opening:

http://www.amazon.com/Evidence-Base...pert-Consult/dp/1437722075/ref=dp_ob_title_bk

 

[turkeyjerky]

Good pick up haha. Guess which book I bought and fully intended to read but never did...

You totally should read it though, definitely worth it.

 

[todds]

As med students on medicine rotation we are expected to do more comprehensive physical exams and to learn all the proper techniques and maneuvers. However, it seems like many physical exam findings have limited usefulness. Physical exam findings are almost always corroborated by further test results which provide far more sensitive and specific information. For example it is hard to be enthusiastic about percussing the lungs of someone with pneumonia if percussion has poor sensitivity and specificity and a chest xray was taken already. Secondly, residents and interns barely have time to do much of a physical exam. Third when it comes to progress notes the physical exam almost never changes but you have to write the same thing over and over again. Fourth I have seen attendings not do a physical exam and instead copy physical findings from someone elses note. The physical exam is a useful tool at times but I feel like attendings (especially the old school ones) are a bit hypocritical on their emphases of physical exam. Any thoughts?

A lot of why that happens here in the US is because of things that are much higher prevalence in the US: patients demanding/expecting tests, covering your ass with expensive test for the lawyers, the hospital promoting you to order expensive tests so they can milk the patient's insurance.

Make no mistake, "sophisticated" imaging and lab tests can have poor sensitivity and specificity but are still used for reasons stated above, almost specifically here in the US. There is ENORMOUS variability in the readings of films by radiologists. Read Jerome Groopman "What Doctor's Think" to learn more. Lab results can be tricky and finicky depending on the patients state, how the blood was drawn etc..

Canadian and European docs heavily use physical diagnosis because it tells you a lot about the patient in a short period of time and they have less of a need to worry about litigation and the hospital isn't always on their backs to order expensive tests because they usually are gov't funded and non-profit (although both of these things may be changing i hear).

Even if you use something not so sensitive/specific, multiple findings can mean a lot more than one expensive test.

The best approach would be to use Physical Diagnosis and inexpensive tests. No reason to percuss the lungs when you can get quick chest x-ray. However, for certain conditions, ausculation may be the only clue you find in someone with a normal EKG. THe opposite is also true. People can have normal CT findings but a surgical abdomen. People can have normal MRI's but subtle neurological findings that point you to many diagnoses. It all depends on the situation

 

[Votaku]

I have a feeling I'll get $hit on for this, but whenever I watch House MD, it almost always hinges on House finding some physical sign of the disease in question that ties all the symptoms together. I always think to myself, "man, if they had just done a proper PE when the patient first came in, they could've saved themselves a whole lot trouble, expensive tests and 30 minutes of prime time."

That aside, if nothing else, a PE may alert you to other problems they patient may have but was not aware of.

 

[Rendar5]

The Physiclal exam guides laboratory testing and imaging and without it you're going to be pretty lousy as a doctor, over-order tests, and plain miss things:

When are you even supposed to get an abdominal CT? on every single person who has abdominal pain? Not really, the nature of the physical exam should actually dictate it And how are you going to figure out who should have an ultrasound instead of a CT, or who should actually have an endoscopy because neither of those modalities would even pick up anything?

People will have "clinical pneumonias" that X-rays miss all the time, but based on their presentation and either some rales or , they will get antibiotics, and sometimes admissions. X-rays will miss a lot of pneumonias if you don't know better.

How are you supposed to pick up on a patient with endocarditis if you miss the new heart murmur on the febrile patient?

Do you really want to order varicella titers, when you can just diagnose chicken pox on physical appearance?

Do you want to let someone's foot become ischemic and require amputation because you're waiting for an X-ray on the fracture-dislocation of an ankle and miss the fact that it's pulseless?

And are you really going to wait 30 minutes while the patient with an acute CHF exacerbation tanks and requires intubation because you want the CXR back and the BNP before initiating BiPap and nitro drips? You don't trust your BP and the pitting edema and the rales up to his apices to tell you this?

Are you going to not order blood from the blood bank on your pale, syncopizing, orthostatic GI bleeder because you don't have the CBC yet.

 

[strongboy2005]

Patient presents with rapidly progressing hypotension, tracheal shift and absent breath sounds... are you really going to wait and get a chest xray when the patient could be having a tension pneumothorax?

 

[copes]

The Physiclal exam guides laboratory testing and imaging and without it you're going to be pretty lousy as a doctor, over-order tests, and plain miss things:

When are you even supposed to get an abdominal CT? on every single person who has abdominal pain? Not really, the nature of the physical exam should actually dictate it And how are you going to figure out who should have an ultrasound instead of a CT, or who should actually have an endoscopy because neither of those modalities would even pick up anything?

People will have "clinical pneumonias" that X-rays miss all the time, but based on their presentation and either some rales or , they will get antibiotics, and sometimes admissions. X-rays will miss a lot of pneumonias if you don't know better.

How are you supposed to pick up on a patient with endocarditis if you miss the new heart murmur on the febrile patient?

Do you really want to order varicella titers, when you can just diagnose chicken pox on physical appearance?

Do you want to let someone's foot become ischemic and require amputation because you're waiting for an X-ray on the fracture-dislocation of an ankle and miss the fact that it's pulseless?

And are you really going to wait 30 minutes while the patient with an acute CHF exacerbation tanks and requires intubation because you want the CXR back and the BNP before initiating BiPap and nitro drips? You don't trust your BP and the pitting edema and the rales up to his apices to tell you this?

Are you going to not order blood from the blood bank on your pale, syncopizing, orthostatic GI bleeder because you don't have the CBC yet.

Most of the things you listed can be covered by listening to the heart and lungs, bowel sounds + abdominal tenderness, and checking for peripheral edema. Those are the bare basics of the physical exam and basically all that I see my residents and interns do. I am aware that there are emergent situations like tension pneumonthorax and acute pericardial tamponade that require immediate treatment and can be diagnosed by history and physical. In many other cases however the physical exam really does not help with definitive diagnosis and management of the patient. For endocarditis, how many of Duke's criteria actually comes from the physical exam? For pneumonia, how often do you "empirically" treat someone based on "clinical judgment"? Furthermore as I was referring to earlier many classic physical exam findings have poor sensitivity and specificity (Murphy's sign?) so what is the point of doing them

 

[copes]

A lot of why that happens here in the US is because of things that are much higher prevalence in the US: patients demanding/expecting tests, covering your ass with expensive test for the lawyers, the hospital promoting you to order expensive tests so they can milk the patient's insurance.

Make no mistake, "sophisticated" imaging and lab tests can have poor sensitivity and specificity but are still used for reasons stated above, almost specifically here in the US. There is ENORMOUS variability in the readings of films by radiologists. Read Jerome Groopman "What Doctor's Think" to learn more. Lab results can be tricky and finicky depending on the patients state, how the blood was drawn etc..

Canadian and European docs heavily use physical diagnosis because it tells you a lot about the patient in a short period of time and they have less of a need to worry about litigation and the hospital isn't always on their backs to order expensive tests because they usually are gov't funded and non-profit (although both of these things may be changing i hear).

Even if you use something not so sensitive/specific, multiple findings can mean a lot more than one expensive test.

The best approach would be to use Physical Diagnosis and inexpensive tests. No reason to percuss the lungs when you can get quick chest x-ray. However, for certain conditions, ausculation may be the only clue you find in someone with a normal EKG. THe opposite is also true. People can have normal CT findings but a surgical abdomen. People can have normal MRI's but subtle neurological findings that point you to many diagnoses. It all depends on the situation

Points taken. It would be interesting to rotate through an European and Canadian medicine service to see how things are done differently. Although at the hospital I rotated through most house staff were not from the US. The best teaching residents and attendings had excellent physical exam skills, but I don't think those extra skills made much of a difference for their patients.

 

[officedepot]

.

 

[OPPforlife]

I used to hate on the physical exam as well. But honestly its such a critical component to all the information we as doctors have access too. Plus its like the best way to appreciate molecular basic science on a macroscopic level. Freakin' love that.

 

[Mattchiavelli]

One of the reasons students have to do so many exams is it's tough to appreciate pathology if you don't know the broad range of normal. If the basis of a worrisome abdominal exam is the patient's abdomen feels different than the examiner's or classmates you practiced on in MS1-2 and the patient says it hurts, one will order way too many abdominal CTs and dole out a few too many iatrogenic malignancies.

Med students will find relevant exam findings sometimes that residents and attendings miss because they just give the heart lungs press abdomen squeeze ankles once-ever. Taking socks off people is a very cheap and easy physical exam maneuver and you will be surprised what gets missed by not looking at feet. I feel like that's the prime time for a med student to shine- and if what you picked up was really just a very unique but normal finding it's important to learn those too.

You will eventually learn the emergency exam maneuvers that will change immediate management of serious situations, and stuff thats more inpatient admit exam, and outpatient exam things too and when to use them. Tapping stuff out is good for draining a thorax/abdomen to try to make sure you're at fluid and not a large hollow organ when you don't have ultrasound available. Just don't try to get patients up to walk if they're a fall risk in the interest of being thorough, so stupid and have seen it happen

My peeve in it is there are so many people who are obese/morbidly obese that it makes landmark finding tough and some parts of the exam meaningless.. like getting good breath sounds on someone 350+lbs

 

[FSU2013]

Watch a lecture (~15 mins) called "A Doctor's Touch" by Abraham Verghese - he's a IM prof at stanford.

I suspect it may change how you look at the physical exam.

Really, it's worth the time.

 

[operaman]

Aside from the great points already mentioned, there is a strong possibility that the PE will only become more important in the future. As the powers that be keep trying to finds ways to lower HC costs, they can only cut reimbursements so far (I hope). There have been many ideas floated for how to incentivize physicians to be more cost effective and/or penalize those who overtest and drive up costs. If this ever happens, having solid PE skills could prove financially beneficial as well.

 

[macgyver22]

As med students on medicine rotation we are expected to do more comprehensive physical exams and to learn all the proper techniques and maneuvers. However, it seems like many physical exam findings have limited usefulness. Physical exam findings are almost always corroborated by further test results which provide far more sensitive and specific information. For example it is hard to be enthusiastic about percussing the lungs of someone with pneumonia if percussion has poor sensitivity and specificity and a chest xray was taken already. Secondly, residents and interns barely have time to do much of a physical exam. Third when it comes to progress notes the physical exam almost never changes but you have to write the same thing over and over again. Fourth I have seen attendings not do a physical exam and instead copy physical findings from someone elses note. The physical exam is a useful tool at times but I feel like attendings (especially the old school ones) are a bit hypocritical on their emphases of physical exam. Any thoughts?

I could see where you would get that impression but its unfortunate that you have. The two single most important diagnostic tests a physician has at his/her disposal are the history and the physical exam. I would conservatively guess that 70% of my diagnosis are made with the history alone, another 20% by the physical with less than 10% being made primarily on test results. if you expect tests to make your diagnosis for you you're going to be in a lot of trouble.

As an example, you mentioned that chest xrays are more accurate at diagnosing pneumonia than a physicians physical exam. I disagree. If you are comparing the two techniques and a chest xray is used as the gold standard then of course the sensitivity is going to be 100% but its not an honest comparison. Pneumonina is a clinical diagnosis not a radiological one. A CXR can only diagnose pneumonia when there is enough fluid in the alveoli to make them radio opaque , but patients are often symptomatic before that point. In addition, the CXR often remains abnormal long after the patient has recovered.On the other hand, If you have a patient with an acute illness who is coughing, febrile, and complaining of dyspnea on exertion, with crackles on exam that person has pneumonia and it doesn't matter what the CXR says.

Tests should be your last resort in making your diagnosis, not your first impulse

 

[obgyny]

I think it might also be important to know the basics just in case you're practicing medicine in a place that doesn't have immediate (or any) access to fancy tests/technology, like in rural areas or countries outside the US. Even though parts of the PE aren't exact, sometimes it might be all that you have.

 

[jtdMU2010]

Well, they say a good history is 90% of a diagnosis, physical exam is 5% and labs/imaging is 5%. I think it's important to talk with your patients thoroughly, listen to them carefully and ask the appropriate questions. But I would imagine the physical exam is still very important despite the 5% at least on an initial visit/exam.

 

[copes]

Almost everyone feels differently than I do haha. I definitely do need more clinical experience. Dr Verghese is awesome. I read one of his books ( The Tennis Partner). He uses the physical exam for a different purpose than most of us which is pretty cool.
My question to macgyver - whether or not you heard crackles in the lungs would you not suspect pneumonia anyway? You could make the same diagnosis based on vitals and history. And since you listened to the lungs, why not percuss and check for egophony and tactile fremitus too? Where do you draw the line?

 

[macgyver22]

Almost everyone feels differently than I do haha. I definitely do need more clinical experience. Dr Verghese is awesome. I read one of his books ( The Tennis Partner). He uses the physical exam for a different purpose than most of us which is pretty cool.
My question to macgyver - whether or not you heard crackles in the lungs would you not suspect pneumonia anyway? You could make the same diagnosis based on vitals and history. And since you listened to the lungs, why not percuss and check for egophony and tactile fremitus too? Where do you draw the line?

Diagnosis isn't really a black and white issue. You build your case with the evidence you have. Sometimes the history is very strong and reliable and the physical exam is just confirmatory. Other times the patient is an unreliable historian or the symptoms are a bit more vague making the physical exam more important in adding confidence to the diagnosis. In the case described in my other post the exam is only confirmatory but if the history had been more vague or less impressive the physical becomes much more important.

There are many diagnosis where the physical exam is the single most important part of making the diagnosis, especially with orthopedic problems. For example, if a patient complains of pain over the radial styloid and is found to have pain on palpation and a positive Finklestein's maneuver they clearly have DeQuervain's tenosynovitis. Not only would an MRI or xray not be necessary but the would not pick up this diagnosis at all.

Orthopedic issues are not the only time the physical becomes critical though. Abdominal complaints frequently are diagnosed with the history and physical and the more experience you have the less often you need to depend on imaging studies. When i first went into practice every patient with left lower quadrant pain got a CT scan. Over the years I have become much more confident in my exam. If the patient complains of gradual onset of symptoms with no melena or BRBPR and the physical exam shows tenderness in the LLQ positive bowel sounds, no fever and no rebound I can be nearly certain they have diverticulitis. Most of these patients are then treated with antibiotics and followed up in a few days. If they get better as expected they don't need a CT or any other imaging studies.

CT's, MRI's and other imaging studies are useful tools but they can be awful crutches with unintended side effects when they are used indiscriminately. Aside form xray exposure, possible reactions to contrast material, and inconvenience there is the very likely possibility of false positive findings. One study showed that nearly 60% of people over the age of 50 will have an abnormal chest CT. The vast majority of these findings are benign ( old granuloma, vascular structures, scar tissue, benign congenital abnormalities) but may require multiple follow up studies or biopsies to determine the nature of the abnormality.

Take your time to learn as much as you can about performing a good history AND a good physical exam in med school. They are tools that will be extremely useful later in life and it really does separate the mediocre doctors from the very best ones. It takes no skill to order a test. It takes a lot of skill to know when to do so and when you dont need to. The physical can be a crucial step in making that decision

 

[Rendar5]

Your point about Duke's criteria including a lot of laboratory and echocardiographic issues is understandable, but the physical exam is what is going to dictate use of those tests. You should not be getting an echocardiogram or blood cultures on every patient with a fever. You should be when there is an atypical finding, often from the physical exam, that suggests an underlying endocarditis.

As for clinical pneumonia, you will see this plenty. Xrays are not an overwhelmingly sensitive approach to pneumonia, and there are plenty of pneumonias that do not have the typical combination of CP, SOB, fever, and cough. I'd say at least once a month one of my patients is diagnosed with a clinical pneumonia and given antibiotics, and that does not refer to COPD exacerbations which require antibiotics for their own reasons. I personally don't do egophony or fremitus, but I will auscultate carefully and I will percuss in the appropriate patient.

Murphy's? uncommon to find one in my ED, but I assure you that if I find one, the epigastric abdominal pain who has gallstones on ultrasound without signs of cholecystitis on sonography, is going to get his gallbladder out at some point. If there's no Murphy's and the same exam/imaging, I'm going to be in the dark if the gallstones are incidental or not. In that case, they get both surgery and GI follow-up because it could easily be PUD causing the pt's pain, and maybe a cholecystectomy is not the next step.

There are many physical exam maneuvers that you will discard, but you are not going to know which ones you need and which you don't need unless you've learned them all at some point. And what you keep and discard is going to change dramatically depending on what field you eventually go into.

 

[rigid]

A proper physical examination is crucial for diagnosis in my opinion, that is also why the FRACP puts an extremely heavy focus on clinical examination skills.

Things like argyll-robertson pupils on a standard cardiovascular examination though tends to be more bother than useful in most circumstances.

No matter how hard we try there won't ever be an investigation that tells you if a patient has an acute abdomen (nor will there ever need to be one). I was told once that 90% of diagnoses are made on history and physical exam and that investigations should be reserved for confirmation/medicolegal ass covering.

 

[BigRedBeta]

As med students on medicine rotation we are expected to do more comprehensive physical exams and to learn all the proper techniques and maneuvers. However, it seems like many physical exam findings have limited usefulness. Physical exam findings are almost always corroborated by further test results which provide far more sensitive and specific information. For example it is hard to be enthusiastic about percussing the lungs of someone with pneumonia if percussion has poor sensitivity and specificity and a chest xray was taken already. Secondly, residents and interns barely have time to do much of a physical exam. Third when it comes to progress notes the physical exam almost never changes but you have to write the same thing over and over again. Fourth I have seen attendings not do a physical exam and instead copy physical findings from someone elses note. The physical exam is a useful tool at times but I feel like attendings (especially the old school ones) are a bit hypocritical on their emphases of physical exam. Any thoughts?

The thing is, there's plenty of examples where the physical exam findings mean you don't have to do any further testing. In pediatrics, using your pneumonia example - a patient with tachpynea, fever and cough has about a 75% likelihood of having radiographic focal opacity on chest X-ray. Add in focal ausculative findings (localized crackles/diminished breath sounds) and it jumps to about 90%...there's no need to spend the time or money on an x-ray.

Further there are plenty of diagnoses that either a) don't require or don't have any sort of advanced test or b) physical exam signs give early clues well before a lab test would be of use (either because the lab finding is late in the disease course or because it takes too much time to complete the lab analysis you're relying on). As far as a) goes - there's no test for me to do in a 4 year old to tell if they have asthma (it's a rare 4 year old who can do PFT's). And in regards to b) I can diagnose bronchiolitis within 5 minutes of seeing a patient, and based on their exam findings predict with reasonable accuracy whether it's due to RSV or some other virus based on my clinical findings. Since it's not going to change any facet of my management why do I need to wait 4 hours and spend $200 for a respiratory antigen panel? There are plenty of other examples - septic shock? Tachycardia and poor cap refill are going to be present well before any hypotension or any portion of my lab work comes back and certainly before I get a chance to get set up for lines. Ear infection? Viral exanthum? Drug allergy/anaphylaxis? Staph skin abscess? Respiratory failure? Not one of those things requires anything other than your clinical exam.

Further proof exists in the research. A study (which I don't have in front of me) that came out in the journal PEDIATRICS in 2011 looked at febrile infants aged 29 to 60 days with confirmed UTI. The finding with the greatest significance for predicting poor outcome (bacteremia, etc) was medical providers assessment at presentation - if the kid looked "sick", there was an extreme change in the likelihood of severe complication. If the child looked well, the odds of complication were minuscule. Based on this study, recommendations were changed and these infants that typically would have gotten an LP and at least 48 hours of IV antibiotics are now being sent home.


As for your last points don't mistake laziness for ineffectiveness.

 

[surftheiop]

I always find it amusing that people often mention radiology as why we dont need the physical exam. It seems like every time we have a radiologist lecture they are lamenting the fact that crappy docs refuse to do (or trust) their physical exam enough to prevent irradiating every person with abdominal pain. I think the rads docs have been the biggest proponents I've seen of medstudents getting good at physicals.

 

[Dan1804]

Watch a lecture (~15 mins) called "A Doctor's Touch" by Abraham Verghese - he's a IM prof at stanford.

I suspect it may change how you look at the physical exam.

Really, it's worth the time.

Thanks for the link! Reading his books now. He's amazing.