HANDOUT_MTP015_Art_Physical_Diagnosis.pdf

The "Not Lost" Art of the Physical Diagnosis: An Evidence‐Based
Approach
American College of Physicians
Internal Medicine Meeting 2021: Virtual Experience
Faculty and Disclosure Information
Professor:
Paul J. Han, MD, FACP
Nothing to Disclose.
1. What is the value of the physical examination in both diagnosis and management?
2. What role does the physical examination play in patient–physician trust and relationships and
expediting appropriate patient care?
3. What is the evidence for common physical examination maneuvers, including
sensitivity/specificity, likelihood ratios, etc., to help interpret physical examination findings and guide
diagnostic work‐up?
4. Can physical diagnosis play a role in reducing the cost of health care?
5. How does the use of bedside ultrasound interact with physical examination?
Clinical questions to be addressed:
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Posted Date: April 27, 2021

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Back to the Future
Incorporating Point of Care Ultrasound to the Science and Art of Beside Physical
Examination
Paul Han, MD, FACP
Scripps Mercy Hospital, San Diego CA
Outline
• The evidence basis for the physical exam diagnosis and management
• Review of basic statistical concepts
• Review of the current evidence for diagnostic utility of the physical examination
• Reasons for the decline in physical examination
• The role of the physical exam BEYOND its use in diagnosis and management
• Point-of-Care Ultrasound (POCUS) as the next step in the evolution of the physical exam
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© 2021 American College of Physicians. All rights reserved.

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Disclosure of Financial Relationships
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Paul Han, MD, FACP
Nothing to disclose.
My Perspective
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The Symbolic Importance of the Physical Examination
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Title and content (table, chart, picture, movie, etc.)
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• “It comes as no surprise to me that many
students nowadays have already
discounted the importance of physical
examination, particularly when all their
upper classmates focus on reading
electrocardiograms, X-rays, and
computed tomography (CT) scans, and
interpreting laboratory data. I once
overheard a resident teaching a third-year
student physical diagnosis on the ward:
‘Mr. Jones’ CT scan shows massive
hepatomegaly, you should go feel his
liver.’”
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Review of Evidence Basis for Specific
Physical Examination Signs
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The Evidence Basis for the Physical Examination
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Accuracy and Precision
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Low Accuracy
High Precision
High Accuracy
High Precision
Low Accuracy
Low Precision
High Accuracy
Low Precision
Accuracy
Precision
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Is the Test Accurate?
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• Test Characteristics
• Sensitivity: 60/117 = 0.51
• Specificity: 400/401: 0.998
• Test Predictions
• Positive Predictive Value: 60/61 = 0.98
• Negative Predictive Value: 400/457 = 0.88
Prevalence: 117/518 = 0.23
PPV: 0.98. NPV: 0.88
Prevalence: 1000/2000 = 0.50
PPV: 0.96 NPV: 0.67
PPV and NPV are dependent on Prevalence
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Likelihood Ratio - Definition
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After
Likelihood Ratio - Calculation
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• Positive LR
• Sensitivity/(1-specificity) = 2.8
• Negative LR
• (1-Sensitivity)/(Specificity) = 0.10
Sensitivity: 14/15 = 0.93
Specificity: 32/48 = 0.67
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Likelihood Ratio - Interpretation
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LRs of Common Physical Exam Signs
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Findings Positive LR (95% CI) Negative LR (95% CI) Prevalence/Pre-test
Probability (Range)
Mini Cog Score 2 or less
for dementia
9.5 (4.5, 19.9) 0.1 (0, 1.6) 6-52
Spider Angioma for
Cirrhosis
4.5 (2.4, 8.3) 0.5 (0.4, 0.7) 7-67
Dilated Abdominal Wall
Veins for Cirrhosis
9.5 (1.8, 49.2) 0.8 (0.6, 1) 11-55
Ascites for Cirrhosis 6.6 (3.6, 12.1) 0.8 (0.7, 0.8) 16-55
Dry mucous membranes
of mouth and nose for
Hypovolemia
3.1 (1.6, 5.8) 0.4 (0.2, 0.9) 33-77
Moon facies for Cushing’s
Syndrome
1.6 (1.1, 2.5) 0.1 (0, 0.9) 58
Red or blue striae for
Cushing’s Syndrome
1.9 (1.3, 2.7) 0.7 (0.6, 0.9) 25-57
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LR of Common Physical Exam Signs
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Probability (Range)
Chaotic pulse for atrial
fibrillation
24.1 (15.2, 38) 0.5 (0.4, 0.6) 6
Kernig sign, detecting
CSF WBC count >100/μL
2.4 (1.2, 4.9) 0.9 (0.8, 1) 10-35
Brudzinski sign,
detecting CSF WBC count
>100/μL
2.1 (0.97, 4.5) 0.9 (0.9, 1) 10-35
Elevated venous
pressure, detecting CVP
>12 cm water
10.4 (5.5, 19.9) 0.1 (0, 0.6) 17-44
Elevated venous
pressure, detecting low
left ventricular ejection
fraction
6.3 (3.5, 11.3) 0.9 (0.8, 1) 8-69
S3, detecting ejection
fraction <0.3
4.1 (2.3, 7.3) 0.3 (0.2, 0.5) 19-47
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Probability (Range)
Crackles, detecting
pulmonary fibrosis in
asbestos workers
5.9 (2, 17.2) 0.2 (0.1, 0.5) 58
Crackles, detecting
elevated left atrial
pressure in patients with
cardiomyopathy
3.4 (1.6, 7.2) 0.7 (0.6, 1) 54-86
Crackles, detecting
myocardial infarction in
patients with chest pain
2.1 (1.6, 2.8) 0.8 (0.7, 1) 6-12
Crackles, detecting
pneumonia in patients
with cough and fever
1.8 (1.2, 2.7) 0.8 (0.7, 0.9) 3-38
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Probability (Range)
Supraspinatus test
causes pain
1.7 (1.3, 2.2) 0.4 (0.2, 0.7) 24-69
Supraspinatus test
reveals weakness
2.1 (1.4, 3.1) 0.5 (0.4, 0.7) 23-72
Infraspinatus weakness 2.3 (1.3, 4.1) 0.5 (0.4, 0.7) 39-67
Dropped arm test 2.9 (2.1, 4) 0.8 (0.7, 1) 39-50
Take Home Points
• Sensitivity and specificity are test characteristics
• They tell us something about the test’s accuracy
• The test’s predictive properties are dependent on both the prevalence of disease as well
as the test’s accuracy
• The likelihood ratio is the preferred statistical descriptor when evaluating physical exam
signs
• Low prevalence of any specific disease in a primary care setting makes application of
current evidence challenging
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Kappa Range
• -1.0 (where two clinicians would be in
perfect disagreement)
• 0 (where the agreement between two
clinicians can be attributed to chance
only)
• 1 (where two clinicians would in perfect
agreement)
Interpreting Kappa
• K 0.0-0.2 is considered “slight agreement”
• K 0.2-0.4 considered “fair”
• K 0.4-0.6 considered “moderate”
• K 0.6-0.8 considered “substantial”
• K 0.8-1.0 considered “almost perfect”
Is the Test Precise?
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Kappa for Common Physical Exam Signs
• Tachycardia: 0.85
• Bradycardia: 0.87
• Capillary refill > 3 second: 0.29
• Increased tactile fremitus: 0.01
• Crackles: 0.21-0.65
• Wheezes: 0.43-0.93
• Neck veins: 0.08-0.71
• Abdominal jugular test: 0.92
• Systolic murmur present or absent: 0.19
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• Systolic murmur, long systolic or early
systolic: 0.78
• Normal bowel sounds: 0.36
• Asterxis: 0.42
• Aymmetrical knee jerk: 0.42
• Finger-to-nose test: 0.60
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The Decline in the Physical
Examination
Absence of Evidence for the Benefits of Physical Examination (especially
in asymptomatic patients
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Absence of Evidence for the Benefits of Physical Examination (especially
in asymptomatic patients
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Current Health Care Environment
• Shortened times with patients
• Electronic Medical Records and Information Overload
• Increased emphasis on meeting “incentives” and “core measures”
• Easy accessibility of advanced diagnostic “gold-standard” studies
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Particular Challenge to the primary care physician
• The predictive power of physical exam
signs are prevalence dependent
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Prevalence of
Ascites (Pre-Test
Probability)
Post-Test
Probability
Hepatologist 60% 90%
Primary Care
Internist
20% 50%
Decline in Physical Examination Education
• Declining supply of physical exam masters
• Declining interest in learners
• Greater emphasis on cognitive evaluation by the internal medicine boards
• Decrease in amount of time available for rounds
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Concerns About the Validity of Evidence in Support of the Physical
Examination
• Sensitivities, specificities, and LRs derived from small studies performed in single
institutions
• Lack of outcome-based data
• Difficult to replicate the level of skills used to establish the initial evidence basis
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Benefits of the Physical Exam Beyond
Diagnostic Utility
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Ongoing Care and Prognosis
• Most suitable as daily assessment tool
• Daily assessment of JVP in CHF patients
• Daily assessment for wheezing in COPD
patients
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Patient Contact
• Survey study of 148 advanced cancer patients
• 123 out of 148 patients rated their experience
of the physical exam as positive to very
positive
• Only 1 patient found it a negative experience
• 142 patients agreed that the physical
examination allowed their physician to gain
useful information
• 125 patients agreed that the physical
examination suggested that their physician
cared about them
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Patient Contact
• A “Ritual” for transformation
• Symbolic Setting
• Symbolic Tools
• Defined identities in participants
• “In the last 10 years, I can count on one hand
the number of times that a doctor performed
a physical examination. But when done, it had
a profound impact on my perception of the
physician’s concern for me and their interest
and understanding of my symptoms. After
spending so much time doing their electronic
medical record on the computer, a doctor
stepping away to do a physical examination
can provide a much needed connection.”
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Accessibility
• No “special” tools or technology required
• Not limited by available resources
• Not limited by insurance authorization
• Immediate acquisition of information
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Pedagogic Value
• Evaluation of learner’s bedside skills
• Modeling of the teacher’s bedside skills
• Opportunity for discussion of
pathophysiology
• “A student who studies medicine without
books sails an uncharted sea, but he who
studies medicine without patients does
not go to sea at all.” - William Osler
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Cost
• The role of advanced diagnostic studies in
overall cost of health care
• “Choosing Wisely”
• Physician Burnout
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Patient Safety
Causes of Oversight
Failure to Perform Physical Exam 63%
Misinterpretation of correctly
identified sign
14%
Relevant sign missed or not sought 11%
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Consequences of Oversight
Delayed Diagnosis 76%
Incorrect Diagnosis 27%
Unnecessary Treatment 18%
No or delayed Treatment 42%
Unnecessary Diagnostic Cost 25%
Unnecessary exposure to radiation/contrast 17%
Treatment Complications 4%
Point-of-Care Ultrasound (POCUS)
Bringing Technology back to the Bedside
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Can Technology and the Physical Examination Mix?
• Collection of vital signs
• “Laennec created a stethoscope to
“…perceive the action of the heart in a
manner much more clear and distinct
than…by the immediate application of
[his] ear.”
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A Fifth Pillar to Bedside Physical Examination?
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POCUS and Diagnostic Accuracy
• Trained cardiologist using POCUS was
significantly better than cardiologist
performing only physical examination in
detecting abnormalities eventually found in
echocardiography.
• POCUS diagnosis is accurate when compared
to echocardiography
• Sensitivity: 97%
• Specificity: 93%
• PPV: 93%
• NPV: 87%
• POCUS can easily detect left ventricular
systolic dysfunction, left atrial enlargement,
lung congestion, and elevated central venous
pressures, signs often missed by physical
exam alone.
Heart 2017;103:987-994
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Ongoing Care and Prognosis
• A routine cardiovascular POCUS performed in a
primary care clinic revealed abnormalities in 37% of
patients examined with subsequent management
changes in 20% of the patients.
• Detection of left atrial enlargement is associated with
increased mortality over 5.5 years, and its absence in
outpatients less than 65 years without diabetes
constitute a low risk group for mortality (1.2% at 5.5
years).
• Detection of lung abnormalities (pulmonary edema
and pleural effusion) associated with increased
mortality during hospitalization as well as at 1 year.
• Abnormal cardiovascular limited ultrasound
examination in patients hospitalized to the wards was
related to longer length of stay.
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Patient Contact
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Accessibility
• Ongoing miniaturization
• Declining cost
• Portability and useful for home visits and
global medicine
• Point-of-care
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Pedagogic Value
• Increased appreciation for the value of
bedside care
• Increased appreciation for the underlying
pathophysiology
• Ample research opportunities
• Resident training feasible
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Cost and Patient Safety
• Presence of both left atrial enlargement
and dilated inferior vena cava associated
with increased mortality at 5.5 years
• Absence of left atrial enlargement and
dilated inferior vena cava can reduce
referral for echocardiography by up to
60% in patients at low risk for mortality.
• More outcome-based studies needed.
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Take Home Points
• Likelihood Ratio is an important statistical concept to learn for evaluating the evidence
for physical examination
• While useful in certain contexts, questions remain about the strength of the evidence for
the physical examination.
• Furthermore, the current climate makes practice of the physical exam difficult
• Nevertheless, there are many benefits to the physical exam that go beyond diagnostic
utility
• POCUS represents the future of physical examination that combines improved diagnostic
accuracy while maintaining other benefits.
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HANDOUT_MTP015_Art_Physical_Diagnosis.pdf

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