The Demise of the Physical Exam

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The Demise of the Physical Exam

• Cam Hebson, MS IV
• 04/11/06

Jauhar, S. NEJM. 3546, 548-551.
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Karel Wenckebach 1899

• "On the analysis of irregular pulses," describing
  progressive lengthening and blockage of AV
  conduction
• Wenckebach block (Mobitz type I) or Wenckebach
  phenomenon.
• Ascertained from timing arterial and venous
  pulsations in his patients

Jauhar, S. NEJM. 3546, 548-551. http//www.ecglib
rary.com/ecghist.html
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Mr. Abbott

• 55 years old, HTN, high cholesterol, smoker, 9/10
  chest pain
• PE unremarkable?
• EKG T-wave inversions, elevated serum troponin
  level
• ACS
• Hours later writhing, hypotensive
• Check his blood pressure, both arms
• Left 160/90, Right Nothing?

Jauhar, S. NEJM. 3546, 548-551.
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Mr. Abbott (cont)

• No blood pressure in right arm, must be the
  noise/confusion?
• Next day Aortic Dissection, diagnosed by
  overnight resident
• Unoperable, died 8 hours later
• Was it the medical students fault? Or the
  resident for delegation and lack of follow-up?

Jauhar, S. NEJM. 3546, 548-551.
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Has the decline already begun?

• 1992 Duke study roughly half of internal
  medicine residents could not identify MR or AR
  66 missed MS.¹
• 2nd study recorded heart sounds from real
  patients, residents scored on average 20²

¹Ann Intern Med. 1992 Nov 1117(9)751-6. ²JAMA.
1997 Sep 3278(9)717-22.
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Reasons for the Apparent Demise

• Busier doctors
• Housestaff training hours restrictions
• Belief in exams inaccuracy and subjectivity
• Need for absolute certainty
• Fear of litigation

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Goals

• List advantages inherent to the physical exam
• Provide individual examples, based on EBM, of how
  the physical exam is still of utmost importance
• Point out that a test can do harm
• Convince you to consider Master Physical Diagnosis

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1. Advantages

• Less expensive
• Performed anywhere
• Serial observations
• Doctor-patient relationship

Jauhar, S. NEJM. 3546, 548-551.
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Ottawa Ankle Rule

• Although most patients with ankle
• sprains who present to the ER
• undergo radiography, less than
• 15 will have a fracture
• Ottawa Ankle Rule x ray films are
• required only if
• 1. Any pain at any of the bony
• areas to the right OR
• 2. The patient is unable to bear
• weight (walk four steps)
• Using the physical exam,
• unnecessary radiographs
• can be reduced by 40 while
• maintaining almost 100 sensitivity

Inferior or Posterior Pole of Malleolus
Navicular bone
Base of 5th metatarsal
Bachmann, LM. BMJ. 326417, 1-7.
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Acute Meningitis

• Classic Triad Fever, AMS, neck stiffness
• Meningeal signs Kernig, Brudzinski
• Results
• - Between 99-100 of patients with acute
  meningitis will have at least 1 triad symptom
• - Meningeal signs are very specific (97-100)
• Conclusion Among adults with presentation that
  is low risk, the clinical exam can effectively
  exclude the diagnosis.

Attia J. JAMA. 282 175-81.
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3. Test at your own risk

• PSA levels carcinoma vs. hypertrophy vs. other
• Incidental adrenal mass on CT of abdomen
• Overlapping sutures vs. skull fracture in a
  newborn

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4. Master Physical Diagnosis

• Improve your exam techniques faculty
  demonstration and feedback knee exam techniques,
  heart sounds, etc.
• Evidence-based medicine how to read studies and
  which exam techniques are supported and can be
  relied upon
• No call, no weekends

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Conclusions

• Using EBM, the PE has been validated to be the
  best means of diagnosis in many instances
• The benefits of the physical exam go beyond
  diagnosis
• Extra tests often add nothing or can even do harm
• Remember Mr. Abbott, sometimes your exam will
  yield the vital clue

• Take advantage of Dr. Estradas class!

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Interested in improving yourphysical exam
skills? 4th Year ElectiveMASTER PHYSICAL
DIAGNOSIS28-518 Every FebruaryJan 29-Feb 25
2007

• Goals
• Master / improve physical exam skills
• Be proficient in interpreting phys diagn
  literature
• Learn fundamentals of medical-decision making
  using the physical exam as a diagnostic test
• If interested, contact Carlos Estrada, MD, MS
  cestrada_at_uab.edu

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Case 1. Warfarin Dose?

• Both need to start warfarin
• What warfarin dose will you start?

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Amiodarone-Induced Skin Discoloration

• Amiodarone, long term use
• Blue-gray discoloration
• Sun exposed areas
• After d/c, may clear after months/ years

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Case 2. What Symptoms / SignsCould He Have?
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Centor Criteria

• Group A Strept
• Fever by history
• No cough
• Tonsillar exudates
• Tender ant. LAN

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Case 3. What is Her History?
BP cuff 10 mmHg above SBP
BP cuff deflated
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Trousseau's Sign

• HTN on HCTZ
• Paresthesias in arms and legs
• Cramps in hands and face
• Intermittent diarrhea
• Mild hyperreflexia, Chvostek's sign
• Mg 0.5, Ca 5.4 mg

BP cuff 10 mmHg above SBP
BP cuff deflated
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Evaluation of Corticosteroid Injections in
Osteoarthritis

Elizabeth Brooke Orr, MS IV
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Procedure

• Lateral approach
• Note contraindications
• Be clean!
• Patient supine, knee extended
• Inject between patella and medial femoral condyle
• Insert needle at 45 degrees

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Safety of Long-Term Intraarticular Steroid
Injections in OA of the Knee

• Radiologic progression of joint space narrowing
  of the knee over two years

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Efficacy Metanalysis of corticosteroid injections

• Improvement of Symptoms at two weeks
  RR 1.66 (95 CI
  1.37-2.0) NNT 1.3 -
  3.5
• Improvement of Symptoms at 16-24 weeks RR
  2.09 (95 CI 1.2-3.7)
  NNT 4.4

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Conclusions

• Repeat injections seem safe over two years
• More studies are needed concerning long-term
  safety
• Injections are for acute knee pain
• Dont forget weight loss, physical therapy,
  NSAIDS, and topical analgesics