# Presentation: 007638

## Spotlight Case August 2006

**Physical Diagnosis: A Lost Art?**

## Source and Credits

- This presentation is based on the August 2006 AHRQ WebM&M Spotlight Case
- See the full article at _[http://](http://webmm.ahrq.gov/)__[webmm.ahrq.gov](http://webmm.ahrq.gov/)_
- CME credit is available through the Web site
- Commentary by: **George Thompson III, MD, and Abraham Verghese, MD,** University of Texas Health Sciences Center
- Editor, AHRQ WebM&M: Robert Wachter, MD
- Spotlight Editor: Tracy Minichiello, MD
- Managing Editor: Erin Hartman, MS

## Objectives

- Appreciate the decline in proficiency and reliance on physical exam skills among health care providers
- List barriers to performance of comprehensive physical examinations
- List interventions that may increase competence in physical exam skills

## Case: Physical Diagnosis: A Lost Art?

*A 57-year-old male with T8 paraplegia from a remote gunshot wound, hypertension, and diastolic dysfunction presented from home with 1 week of intermittent fevers, chills, increasing shortness of breath, and low back discomfort. Due to neurogenic bladder, the patient performed self-catheterization daily. Initial physical exam was recorded as follows:*

## Case: Physical Diagnosis: A Lost Art?

*General: Mild respiratory distress with audible wheezing*
*Vitals: Blood pressure 110/62, Pulse 106, respiratory rate 18, Temp 37.8 ̊, Room air saturation 100%*
*HEENT: Crusting periorbitally, no edema, extraocular movements intact, pupils equal round and reactive, dry tongue *
*Neck: No meningismus*

## Case: Physical Diagnosis: A Lost Art?

*Resp: Increased work of breathing with diffuse rhonchi, crackles bilaterally*
*Cardiovascular: Tachycardic without murmurs or gallops, normal apical impulse, 2+ pulses throughout, no lower extremity edema*
*Abdomen: Normal active bowel sounds with some tenderness to palpation over the suprapubic area*

## Case: Physical Diagnosis: A Lost Art?

*Skin: Stage I gluteal cleft decubiti*
*GU exam: Deferred*
*Neuro: Strength 5/5 upper extremities, 1/5 bilaterally lower extremities with flexion contractures; sensation absent below T8*

## The Art of Physical Examination

- The history and physical exam remain the backbone of medical evaluation and assessment
- "Observe, record, tabulate, communicate. Use your five senses....Learn to see, learn to hear, learn to feel, learn to smell, and know that by practice alone you can become expert."
*Sir William Osler*

*Sir William Osler at a patient's bedside. Reprinted with permission. *

*Photograph reprinted with permission of The Alan Mason Chesney Medical Archives of The Johns Hopkins Medical Institutions.** *

**Notes:**
Photograph reprinted with permission of The Alan Mason Chesney Medical Archives of The Johns Hopkins Medical Institutions. 

## The Art of Physical Examination

- Advances in laboratory and imaging technology, along with the pace of modern medicine, have resulted in the physical examination being abbreviated, undervalued, and viewed as redundant

## The Art of Physical Examination

- Skill and familiarity with certain bedside maneuvers and confidence in eliciting physical signs declining
- Increased dependence on aid of radiologist or first-tier laboratory data
- Skills in getting data back and arranging for tests to be done are valued as much or more than eliciting physical findings
- Emphasis on data illustrated by "rounds" at computer, PDA, not at bedside

## The Art of Physical Examination

- Physician reimbursement increasingly volume-driven
- Little or no financial reward for one's ability to pick up subtle physical examination findings
- Little time for detailed examination
- Reflexive ordering of tests to traverse assorted diagnostic algorithms

## The Physical Examination

- Higher sensitivity and specificity offered by laboratory and radiologic testing makes it more likely that a physician might be reluctant to make a clinical diagnosis that could be readily made at the bedside

## Case (cont.): Physical Diagnosis: A Lost Art?

*Initial labs were significant for a white blood cell count of 20.9 with 82% segs, bicarbonate of 19, blood urea nitrogen of 27, and creatinine 1.7. Urinalysis revealed 2+ protein, +nitrite, 3+leukocyte esterase, 3+ blood, 10-25 white blood cells, and 10-25 red blood cells. Electrocardiogram revealed sinus tachycardia only. Chest radiograph revealed a bilateral interstitial edema pattern. *

## The initial assessment by the female night float resident was sepsis from a urinary tract source and acutely decompensated diastolic heart failure. The patient was managed with afterload reduction, diuresis, oxygen, and intravenous antibiotics, and was evaluated for myocardial infarction with serial enzymes and electrocardiograms.

**Case (cont.): Physical Diagnosis: A Lost Art?**

## How Are Our Physical Exam Skills?

- Recent study cites inability of ICU personnel to accurately determine the jugular venous pressure, calling for central venous access for determination of this parameter
- Medical students performed best, residents and attending physicians were least accurate at JVP assessment
- Medical students had participated in weekly physical exam training
- Residents/attendings admitted to infrequent attempts to routinely assess JVP

*Cook DJ. **Am J Med Sci. 1990;299:175-178. *

## Why Do We Order So Many Tests?

- "Defensive" medicine in an increasingly litigious environment
- Loss of confidence in our abilities to extract meaningful information from the physical examination

## Consequences of Ordering So Many Tests

- The consequences of excessive reliance on diagnostic tests to convey information that should have been elicited on physical examination are twofold
- Time delay (often a day or two) in diagnosis as one awaits the test results
- The patient is exposed to the risk and side effects of tests that may not be necessary

## The Physical Exam: Patient Perspective

- Patients clearly value the physical exam
- 90% of patients expected their blood pressure to be measured, and their heart, lungs, abdomen, and reflexes be examined
- Even if not essential to actual patient care,  skilled exam is critical to the development of the physician-patient relationship
- Earns trust, patient confidence, may increase patient compliance

*Oboler SK, et al. Ann Intern Med. 2002;136:652-659.  *

## Case (cont.): Physical Diagnosis: A Lost Art?

*The next morning, the patient was handed off to the daytime medical team. Genitourinary examination was again "deferred," and the treatment plan continued. Later that day, the attending physician examined the patient and found ecchymotic, edematous scrotal skin, a purulent perirectal fistulous tract, and perirectal crepitus.*

## Case (cont.): Physical Diagnosis: A Lost Art?

*Urology and general surgery were contacted immediately. Shortly thereafter, the patient underwent surgical debridement for Fournier's gangrene, a life-threatening form of necrotizing fasciitis of the perineal area.*

## The Case of Necrotizing Fasciitis

- Predominantly a clinical diagnosis, which can be made at the bedside
- Direct visualization of the involved area is critical
- Delay in diagnosis can be deadly

*Example of Fournier's gangrene in a different patient. Reprinted with permission**. *

*Photograph reprinted from Jiang T, et al. Fournier gangrene associated with Crohn disease. Mayo Clinic Proceedings, 2000;75:647-649, with permission.*

**Notes:**
Photograph reprinted from Jiang T, Covington JA, Haile CA, Murphy JB, Rotolo FS, Lake AM. Fournier gangrene associated with Crohn disease. Mayo Clinic Proceedings. 2000;75:647-649, with permission.

## Deferring Part of the Exam

- Common practice of "deferring" aspects of the physical examination viewed as "non-essential" was responsible for this patient's initial incorrect diagnosis

## Barriers to Comprehensive Physical Exam

- The "hand off"
- Rely on previous caregiver's report of physical exam
- The targeted physical exam
- Failure to examine parts of the body that seem unlikely to contribute to the presenting complaint
- Patients unable to voice complaints
- Paraplegia

*Economides E, Stevenson LW. Am Heart J. 1998;136:6-9.**Powell HS, et al. Acad Med. 2006;81:286-289.   *

## Barriers to Comprehensive Physical Exam

- Lack of confidence in performing physical exam on opposite sex, lack of chaperone
- Lack of role models
- Lack of requirement to demonstrate competence in physical exam
- In the United States, internists can become board certified without having their skills at the bedside tested by certifying examiners

*Economides E, Stevenson LW. Am Heart J. 1998;136:6-9.**Powell HS, et al. Acad Med. 2006;81:286-289.   *

## Take-Home Points

- Physical exam skills appear to be declining as reliance on laboratory and radiologic testing has increased
- Revival of the art of physical diagnosis will require increased role modeling by faculty and senior residents of such skills, and demonstration of competence for board certification
- Proficiency in physical examination skills may lead to fewer missed diagnoses, improved physician-patient relations, and more economically sound medical care