EvidenceBased Physical Diagnosis

1
Evidence-Based Physical Diagnosis

• Steven McGee, M.D.
• Professor, Medicine
• University of Washington

2
Changing Role of Physical Examination
Diagnosis 100 years ago
Technology
3
Changing Role of Physical Examination
Diagnosis 100 years ago
Diagnosis today
Technology
Technology
4
Changing Role of Physical Examination
Diagnosis 100 years ago
Diagnosis today
Technology
Technology
Evidence-Based Physical Diagnosis essential here
5
Traditional Measure Sensitivity and Specificity
Patients with suspected ascites
6
Better Measure Likelihood Ratio (LR)
Probability of finding in patients with disease
LR
Probability of finding in patients without
disease
7
How accurate is the fluid wave?

• In 100 patients referred with abdominal
  distension and suspected ascites
• - 50 with ascites have a positive fluid wave
• - 10 without ascites have a positive fluid
  wave
• Therefore

8
How accurate is the fluid wave?

• In 100 patients referred with abdominal
  distension and suspected ascites
• - 50 with ascites have a positive fluid wave
• - 10 without ascites have a positive fluid
  wave
• Therefore
• The LR for presence of fluid wave, in
  detecting ascites

Probability of finding in patients with disease
50



5.0
Probability of finding in patients without
disease
10
9
LRs Diagnostic Weights
8
0
0.1
0.2
0.5
1
2
5
10
10
LRs Diagnostic Weights
8
0
0.1
0.2
0.5
1
2
5
10
Increase probability
Decrease probability
No change in probability
11
LRs Diagnostic Weights
8
0
0.1
0.2
0.5
1
2
5
10
45
30
15
-15
-30
-45
No change in probability
12
LRs Diagnostic Weights
8
0
0.1
0.2
0.5
1
2
5
10
45
30
15
-15
-30
-45
No change in probability
13
Ascites
14
Ascites
Probability
decrease
increase
-45
-30
-15
15
30
45
LRs
LRs
0.1
0.2
0.5
1
2
5
10
15
Ascites
Probability
decrease
increase
-45
-30
-15
15
30
45
LRs
LRs
0.1
0.2
0.5
1
2
5
10
Fluid wave
Absence of edema
Flank tympany
Edema
Absence of bulging flanks
Shifting dullness
Absence of shifting dullness
Bulging flanks
Absence of fluid wave
Flank dullness
16
Ascites
Probability
decrease
increase
-45
-30
-15
15
30
45
LRs
LRs
0.1
0.2
0.5
1
2
5
10
Fluid wave
Absence of edema
Flank tympany
Edema
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3 Clinical Questions

• Does my patient with chest pain or dyspnea have
  elevated left atrial pressure?
• Does my patient with shoulder pain have a torn
  rotator cuff?
• Does my patient with acute respiratory complaints
  have pneumonia?

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Congestive Heart Failure Elevated Left Heart
Filling Pressures

• The patient cannot breathe in a horizontal
  positionthe pulse is frequent and weak...the
  veins are swollen in the neck...the strokes of
  the heart extend farther there is swelling of
  the feet and ankles

• J. N. Corvisart, 1812

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Congestive Heart Failure Elevated Left Heart
Filling Pressures
Heart rate gt100/min
Crackles
Elevated neck veins
Abdominojugular test
Displaced apical impulse
S3 gallop
S4 gallop
Edema
Probability
decrease
increase
-45
-30
-15
15
30
45
LRs
LRs
0.1
0.2
0.5
1
2
5
10
20
Congestive Heart Failure Elevated Left Heart
Filling Pressures
Heart rate gt100/min
Crackles
Elevated neck veins
Displaced apical impulse
S3 gallop
Abdominojugular test (positive or negative)
S4 gallop
Edema
Probability
decrease
increase
-45
-30
-15
15
30
45
LRs
LRs
0.1
0.2
0.5
1
2
5
10
21
Congestive Heart Failure Elevated Left Heart
Filling Pressures
NS (i.e., Not Significantly different from 1.0)
Crackles
S4 gallop
Edema
Probability
decrease
increase
-45
-30
-15
15
30
45
LRs
LRs
0.1
0.2
0.5
1
2
5
10
Positive abdominojugular test
Negative abdominojugular test
Displaced apical impulse
S3 gallop
Heart rate gt100/min
Elevated neck veins
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Congestive Heart Failure Elevated Left Heart
Filling Pressures
23
Congestive Heart Failure Elevated Left Heart
Filling Pressures
NS (i.e., Not Significantly different from 1.0)
Crackles
Probability
decrease
increase
-45
-30
-15
15
30
45
LRs
LRs
0.1
0.2
0.5
1
2
5
10
Positive abdominojugular test
Negative abdominojugular test
Displaced apical impulse
S3 gallop
Heart rate gt100/min
Elevated neck veins
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Characteristics of crackles
Late Inspiratory
Interstitial fibrosis
Congestive heart failure
Timing of crackles
Chronic obstructive lung disease
Pneumonia
Early Inspiratory
Fine
Coarse
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Rotator Cuff Tear
Age of patient
Hawkins/Neers impingement signs
Supraspinatus test
Supra-/infraspinatus atrophy
Painful arc
Dropped arm test
Probability
decrease
increase
-45
-30
-15
15
30
45
LRs
LRs
0.1
0.2
0.5
1
2
5
10
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Rotator Cuff Tear
Age 39 years
Age 60 years
Hawkins/Neers impingement signs (presence or
absence)
Supraspinatus test
Painful arc (presence or absence)
Supra-/infraspinatus atrophy
Dropped arm test
Probability
decrease
increase
-45
-30
-15
15
30
45
LRs
LRs
0.1
0.2
0.5
1
2
5
10
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Rotator Cuff Tear
Presence of Hawkins/Neers impingement signs
1.5-1.7
Supraspinatus test
Presence of painful arc NS
Supra-/infraspinatus atrophy
Probability
decrease
increase
-45
-30
-15
15
30
45
LRs
LRs
0.1
0.2
0.5
1
2
5
10
Age 39 years
Dropped arm test positive
Age 60 years
Absence of either impingement sign
Absence of painful arc
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Rotator cuff tear
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Pneumonia

• Using my new invention, the clinician can detect
  acute pneumonia in every possible case

• René Laennec, 1821

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Pneumonia

• Using my new invention, the clinician can detect
  acute pneumonia in every possible case

• René Laennec, 1821

• It is high time to strip the stethoscope of the
  extravagant pretensions thrust upon it

• Thomas Addison,1846

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Pneumonia
Cachexia
Heart rate gt 100/min
Percussion dullness
Diminished breath sounds
Bronchial breath sounds
Egophony
Crackles
Wheezes
Probability
decrease
increase
-45
-30
-15
15
30
45
LRs
LRs
0.1
0.2
0.5
1
2
5
10
32
Pneumonia
Cachexia
Bronchial breath sounds
Heart rate gt 100/min
Egophony
Diminished breath sounds
Crackles
Percussion dullness
Wheezes
Probability
decrease
increase
-45
-30
-15
15
30
45
LRs
LRs
0.1
0.2
0.5
1
2
5
10
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Pneumonia
Heart rate gt 100/min
Diminished breath sounds
LR 1.8
Crackles
Percussion dullness
Wheezes
Probability
decrease
increase
-45
-30
-15
15
30
45
LRs
LRs
0.1
0.2
0.5
1
2
5
10
Egophony
Cachexia
Bronchial breath sounds
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Pneumonia
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Pneumonia Combined Findings

• The clinician scores 1 point for each of the
  following findings
• Temperature gt 37.8
• Heart rate gt 100/min
• Crackles
• Diminished breath sounds
• Absence of asthma

Heckerling and others. Ann Intern Med
1990113664-670
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Pneumonia Combined Findings

• The clinician scores 1 point for each of the
  following findings
• Temperature gt 37.8
• Heart rate gt 100/min
• Crackles
• Diminished breath sounds
• Absence of asthma

Heckerling and others. Ann Intern Med
1990113664-670
37
Pneumonia
Probability
decrease
increase
-45
-30
-15
15
30
45
LRs
LRs
0.1
0.2
0.5
1
2
5
10
Heckerling score, 4-5
Heckerling score, 0-1
Egophony
Cachexia
Bronchial breath sounds
Percussion dullness
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Pneumonia Severity Index
N Engl J Med 1997 336 243-50
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CURB-65 British Thoracic Society

• CURB-65 is acronym for
• Confusion (disorientation to person, place, or
  time)
• Urea (BUN) level gt 20 mg/dL(gt 7 mmol/L)
• Respiratory rate 30 breaths/min
• Blood pressure low (systolic lt90 mmHg or
  diastolic lt60 mm Hg)
• Age 65 years

0-1 factors ? outpatients 2 or more factors ?
inpatients 3 or more factors ? ICU?
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Pneumonia Predicting Hospital Mortality
Probability
decrease
increase
-45
-30
-15
15
30
45
LRs
LRs
0.1
0.2
0.5
1
2
5
10
CURB score, 4 findings
CURB score, 0 findings
Systolic blood pressure lt 90 mm Hg
CURB score, 3 findings
Hypothermia
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Findings With Surprising Accuracy

• Conjunctival rim pallor, detecting Hb lt 11 gm/dL
• Pallor present 16.7, borderline 2.3, absent 0.6
• Characteristic diastolic murmur of AR
• Presence of murmur, LR 9.9 for mild AR or
  worse
• Absence of murmur, LR 0.1 for moderate AR or
  worse
• Palpable nontender gallbladder in patients with
  jaundice, detecting extrahepatic obstruction
• LR 26.0, LR- 0.7
• Pulsus paradoxus, detecting cardiac tamponade
• LR 5.9, LR- 0.03

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Summary Modern Role of Physical Diagnosis

• For entire areas of clinical medicine, bedside
  diagnosis remains the diagnostic standard

Technology
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Summary Modern Role of Physical Diagnosis

• For entire areas of clinical medicine, bedside
  diagnosis remains the diagnostic standard
• If technology is diagnostic standard, 3
  Approaches to Physical Diagnosis
• Accept it all, lock, stock, and barrel
• Toss the entire enterprise out

Technology
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Summary Modern Role of Physical Diagnosis

• For entire areas of clinical medicine, bedside
  diagnosis remains the diagnostic standard
• If technology is diagnostic standard, 3
  Approaches to Physical Diagnosis
• Accept it all, lock, stock, and barrel
• Toss the entire enterprise out
• Use an EVIDENCE-BASED approach

Technology
Evidence-Based Physical Diagnosis essential here
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Summary Modern Role of Physical Diagnosis

• For entire areas of clinical medicine, bedside
  diagnosis remains the diagnostic standard
• If technology is diagnostic standard, 3
  Approaches to Physical Diagnosis
• Accept it all, lock, stock, and barrel
• Toss the entire enterprise out
• Use an EVIDENCE-BASED approach

Technology
Evidence-Based Physical Diagnosis essential here

• A number of traditional physical findings in
  Internal Medicine remain accurate today
• Best measure of accuracy Likelihood ratio
• Ascites
• Congestive heart failure
• Rotator cuff tear
• Pneumonia diagnosis and prognosis

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Acute Abdominal Pain, Peritonitis
Guarding
Rigidity
Rebound tenderness
Percussion tenderness
Abnormal bowel sounds
Rectal tenderness
Positive abdominal wall tenderness
test
Cough test
Probability
decrease
increase
-45
-30
-15
15
30
45
LRs
LRs
0.1
0.2
0.5
1
2
5
10
48
Acute Abdominal Pain, Peritonitis
Guarding
Rigidity
Rebound tenderness
Rectal tenderness
Percussion tenderness
Positive abdominal wall tenderness
test
Abnormal bowel sounds
Cough test
Probability
decrease
increase
-45
-30
-15
15
30
45
LRs
LRs
0.1
0.2
0.5
1
2
5
10
49
Acute Abdominal Pain, Peritonitis
Guarding
NS
Rectal tenderness
Percussion tenderness
Abnormal bowel sounds
Cough test
Probability
decrease
increase
-45
-30
-15
15
30
45
LRs
LRs
0.1
0.2
0.5
1
2
5
10
Positive abdominal wall tenderness
test
Rigidity
Rebound tenderness
50
Acute Abdominal Pain, Peritonitis
51
Acute Abdominal Pain, Peritonitis
Probability
decrease
increase
-45
-30
-15
15
30
45
LRs
LRs
0.1
0.2
0.5
1
2
5
10
Positive abdominal wall tenderness
test
Rigidity
Guarding
Negative cough test
Percussion tenderness
Rebound tenderness
52
Acute Abdominal Pain, Peritonitis
Probability
decrease
increase
-45
-30
-15
15
30
45
LRs
LRs
0.1
0.2
0.5
1
2
5
10
Positive abdominal wall tenderness
test
Rigidity