Introduction to Physical Examination

1. Introduction to Physical Examination Stanford Massie M.D. ICM Course Director January 19, 2007

2. What purpose does the PE serve? • Gathering objective data • Testing hypotheses (a diagnostic test) • Surveying for undiscovered problems • Communicating (the power of touch)

3. What is the ultimate goal of physical examination? • To obtain valid information about the health of the patient • To do so, examiner must be able to: • Competently perform the maneuvers and • Identify, Analyze and Synthesize accumulated information

4. Goals of this talk with regard to physical examination • Review: • Its current status in clinical medicine • The benefits of performing it skillfully • Share general tips and suggestions about how to approach the physical exam • Introduce skills required for the general survey and vital signs • Emphasize the importance of observation in patient encounters

5. Road Map: Intro to PE • Background/historical perspective • Benefits of the PE • Tips for Conducting a PE • Specific Techniques: • General Survey • Vital Signs • Resources for learning the PE

6. Background and Historical perspective • The clinical examination has been in practice for over 2500 years. • The physical exam: • Serves a number of important purposes • Has evolved over the years as science and technology have grown • The stethoscope is the oldest diagnostic instrument in continuous routine clinical use 1Perloff J. NEJM 2001;345:612-614. 2http://inventors.about.com/library/inventors/blstethoscope.htm

7. The clinical exam • “In addition to its roles in developing rapport with and understanding of our patients, and in expressing our respect for them and their predicaments, the clinical examination permits us to execute three other powerful clinical acts.” • Clinch a diagnosis • Rule out a diagnosis • Identify serious disorders at an early, asymptomatic stage (ex. HTN) Sackett DL, Rennie D.JAMA 1992;267:2650-2652.

8. Physical exam in today's teaching hospital • The pace of modern medicine • Ascendancy of technology • Decline of bedside teaching • Decline of clinical skills of physicians

9. PE in today's teaching hospitalDecline of bedside teaching • Students get “lost in the shuffle” • “While every medical school provides formal instruction in physical diagnosis, the outcome of this instruction, particularly when tested at the residency level, is disturbing” • Are we “Losing the Touch”? Ende J, Fosnocht K. Transactions of the American Clinical and Climatological Association. 2002; 113: 137-150.

10. PE in today's teaching hospitalDecline of clinical skills of physicians • 453 residents, 88 medical students (3rd/4th year students only) • 12 cardiac events recorded from patients • Participants asked to identify them • On average, residents recognized 20% of all cardiac events tested (1/5) • No significant difference in overall performance (students vs. residents) Cardiac auscultatory skills of Internal Medicine and Family Practice trainees. JAMA 1997;278(9): 717-722.

11. PE in today's teaching hospitalDecline of clinical skills of physicians • Implications: • Physicians in training had great difficulty in identifying 12 commonly encountered and important sounds from the cardiac exam • Performance showed minimal improvement with year of training • Learning these skills in medical school appears crucial JAMA 1997;278(9): 717-722.

12. Losing the Touch • “The problem is that it is easy for a doctor to spend very little time with a patient and just order a CT scan… • Had the doctor spent more time speaking with the patient, he may have recognized that the patient did not need the test… • It is just easier to do a brief history and some part of the physical and send the patient quickly off to a test” Mark Swartz, author of Swartz’ Textbook of Physical Diagnosis Obel J. “Losing the Touch” 6.16.03. The Washington Post

13. Losing the Touch • PE skills peak in medical school and decline thereafter • Shift away from the patient: “The heart failure exacerbation in 902” • “Computer centric” • Patient expectations: the annual physical Obel J. “Losing the Touch” 6.16.03. The Washington Post

14. Road Map: Intro to PE • Background/historical perspective • Benefits of the PE • Tips for Conducting a PE • Specific Techniques: • General Survey • Vital Signs • Resources for learning the PE

15. What are the benefits of PE? • Hypothesis generation (and testing) • Doctor patient communication • Information to guide therapy or further testing • Prognostic information

16. What are the benefits of PE?Hypothesis generation • Scientists use two different types of observational data: • One to generate hypotheses • One to test hypotheses • A clinical encounter is essential for generating hypotheses and limiting the possibilities Sapira J. Why perform a routine history and physical examination? South Med J 1989;82: 364-5.

17. On the cardiovascular physical examination • “Intelligent selection of investigative procedures from the ever-increasing array of tests now available requires… sophisticated decision-making…” • “The clinical exam provides the critical information necessary for most of these decisions.” Eugene Braunwald Perloff JK. Physical examination of the heart and circulation. 3rd ed. Philadelphia: W.B. Saunders 2000:v-vi.

18. What are the benefits of PE? Doctor-patient communication • Physical diagnosis and history taking contribute to: • Patient satisfaction • Comfort and trust • Potential therapeutic value Mangione S, Niemann LZ. JAMA 1997;278: 717-722.

19. What are the benefits of PE? Doctor-patient communication • What do patients think about the PE? • Patients perceive PE as a diagnostic tool and a means to convey empathy and caring • Patients may interpret omissions as: • A lack of caring • A lack of thoroughness • A lack of knowledge • Be mindful of patients’ expectations (and ask about them) Patients’ perceptions of omitted examinations and tests. JGIM 2000;15: 38-45.

20. The science of the art of the clinical examination “No wonder, then, that obtaining an accurate clinical history and performing a proper physical examination are venerated elements of the art of medicine; they are the best series of diagnostic “tests” we ever have.” Sackett DL, Rennie D. JAMA 1992;267:2650-2652.

21. Conclusions about the status of physical examination • Remains a key part of the clinical encounter • Leads to a number of specific benefits • Skills of physicians in performing it are on the decline • Scientific studies ongoing to assess which parts of the exam are most useful • Learning these skills in medical school a key factor in determining future competence

22. Road Map: Intro to PE • Background/historical perspective • Benefits of the PE • Tips for Conducting a PE • Specific Techniques: • General Survey • Vital Signs • Resources for learning the PE

23. “The physical exam is the study of a patient using [all] five senses” Adapted from “Losing the Touch” 6.16.03. The Washington Post

24. General pearls about the physical examination “Don’t be discouraged by what at first seems an overwhelming task. Attention to detail at the beginning is time consuming, but necessary and richly rewarding in the long run.” Sapira Textbook The art and science of bedside examination.

25. Preparing for the PE • Reflect on your approach to patient • Adjust the lighting and environment • Determine the scope of the exam • Choose the sequence of the exam • Observe the correct examining position and handedness • Make the patient comfortable Bates’ Guide to Physical Examination and History Taking. 9th Edition.

26. Get the setting right • First impressions/introductions • Privacy • Lighting • Minimize distractions • TV • Roommates • (Family) • Pagers

27. Preparation • Handwashing/Sterilization • Patient comfort • Modesty • Barriers • Causing discomfort • Remember: many patients have some anxiety about being examined

28. Sequence and standardization • Head to toe • Sequence of examination: • Inspection • Palpation • Percussion • Auscultation • Stand on the right side of the patient • Minimize positioning changes

29. General tips about the physical examination • Compare side to side, look for asymmetry • When in doubt, ask the patient for help • Talk to the patient during the exam • Explain what you are are doing • Ask if you are causing discomfort • Don’t examine through clothes!!!

30. General tips about the physical examination • How long does it take? • How detailed should I be? • Comprehensive vs. Problem Focused • Variables: • Setting • Purpose of visit • Skill level • Experience

31. General tips about the physical examination • Which things should I learn? • Toolbox analogy

32. The importance of practice “According to Tinsley Harrison, Ben Friedman of Alabama was the best diagnostician he knew, and Ben Friedman was still learning (and teaching) pearls when he was more than 70 years old.” Sapira J. The art and science of bedside examination. p1.

33. Road Map: Intro to PE • Background/historical perspective • Benefits of the PE • Tips for Conducting a PE • Specific Techniques: • General Survey • Vital Signs • Resources for learning the PE

34. Count the “f’s” Finished files are the re- sult of years of scientif- ic study combined with the experience of years. Swartz MH. Textbook of Physical Diagnosis. 4th ed.

35. Quotes • “What one knows, one sees” (translated from German)--Goethe • “You can observe a lot by watching” Yogi Berra • “Don’t touch the patient—state first what you see; cultivate your powers of observation” Sir William Osler

36. The power of observation • Master clinicians seem to possess incredible powers • “Sherlock Holmes”: Dr. Bell, Arthur Conan Doyle’s medical school teacher • Employ all senses (sight, hearing, touch, smell, taste?) • Observation is an “active” process • Careful, methodical investigation Sapira J. The art and science of bedside examination. p. 79.

37. http://www.surgical-tutor.org.uk/default-home.htm?system/hnep/thyrotoxicosis.htm~righthttp://www.surgical-tutor.org.uk/default-home.htm?system/hnep/thyrotoxicosis.htm~right

38. http://www.angelfire.com/al/andrethegiant/images/andrelabeled1.jpghttp://www.angelfire.com/al/andrethegiant/images/andrelabeled1.jpg

39. http://silviawagner.com/IMAGES/Bilder/St_Sebastian/21_CASTAGNO.JPGhttp://silviawagner.com/IMAGES/Bilder/St_Sebastian/21_CASTAGNO.JPG

40. http://www.collegian.psu.edu/archive/1997/09/09-22-97tdc/09-22-97d03-020.htmhttp://www.collegian.psu.edu/archive/1997/09/09-22-97tdc/09-22-97d03-020.htm

41. Images in Clinical Medicine Neelon FA, Harvey EN. NEJM.1999; 340:196.

42. The General Appearance and Vital Signs • Initial components of a comprehensive examination • Always relevant even with more focused examinations

43. The General Appearance Key features • Level of consciousness • Signs of distress • Apparent state of health • Height, weight, and build • Posture and motor behavior • Dress, grooming and hygiene • Facial expression • Affect • Odors

45. Vital signs: Key points • What are the Vital Signs? • Blood Pressure • Pulse • Respiratory rate • Temperature • (Pain score, Oxygen saturation)

46. Blood Pressure technique • Position cuff properly, above inner crease of elbow, arm at heart level, patient seated and back supported • Estimate BP by inflating cuff while feeling brachial/radial pulse • Inflate cuff quickly but carefully; deflate cuff slowly • Determine systolic and diastolic pressure

48. Road Map: Intro to PE • Background/historical perspective • Benefits of the PE • Tips for Conducting a PE • Specific Techniques: • General Survey • Vital Signs • Resources for learning the PE

49. Overview of the PE Series • Sessions: • Introduction to PE, VS, General appearance • HEENT • Cardiac and peripheral vasculature • Pulmonary • Abdomen • Musculoskeletal • Other areas covered next year (GU, Breast and Pelvic, Neurologic examinations)

50. Overview of PE series • Format: • Lecture by expert clinician the week before • SGM for practice/refining techniques • Focus on techniques and normal findings • Encourage preceptors to close session with trip to wards or clinics for practice on real patients