Physical Exam Pearls: Evidence based exam

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Physical Exam PearlsEvidence based exam

• Karen McDonough MD
• Assistant Professor, General Internal Medicine

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Brief History of the Physical Exam

• 1550 BC Egyptian physicians describe inspection,
• palpation, percussion in hieroglyphs
• 400 BC Hippocrates describes the succusion
• splash in pleural effusion
• 1819 AD Laennec (inventor of the stethoscope)
  publishes Treatise on the Disease of the
  Chest
• 1885 AD Osler describes the protean exam
  findings of SBE
• 1950s AD The Golden Age of the cardiac exam

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2008 AD

• SKIP THE PHYSICAL EXAM, AND GET A PAN-MAN SCAN
  AND A BUNCH OF LABS!!

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Ideal Physical Exam Technique

• Straightforward to learn and perform
• Used in guiding evaluation and management common
  problems
• Sensitive enough to rule out disease if absent OR
• Specific enough to rule in disease if present

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Likelihood ratios

• Positive LR refers to the presence of a physical
  sign the bigger the number, the more helpful
  the sign
• Negative LR refers to the absence of a physical
  sign the closer to zero, the more helpful the
  sign

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• For mid-range pre-test probability
• LR 1 doesnt help -LR 1 no help
• LR 2 increases 15 -LR 0.5 decreases 15
• LR 5 increases 30 -LR 0.2 decreases 30
• LR 10 increases 45 -LR 0.1 decreases 45

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• Figure out ahead of time which exam findings will
  substantially help you in evaluating patients you
  commonly see, and remember those exam findings.

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Figure from p. 165 Tally NJ OConnor S.
CLINICAL EXAMINATION. 4th Edition. Blackwell
Science, 2001.
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LE Edema in Ascites

• Patient with suspected ascites 50/50
• Physical finding LE edema
• Positive LR 3.8
• Negative LR 0.2

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• Graph

Postest probability
Pretest probability
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• Graph

Post test probability
Pretest probability
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Same patient

• You check for a fluid wave
• Positive LR 5.0
• Negative LR 0.5

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• Graph

Postest probability
Pretest probability
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• Graph

Postest probability
Pretest probability
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In abdominal distention

• Argues FOR ascites
• fluid wave (LR 5.0)
• edema (LR 3.8)
• shifting dullness (LR 2.3)
• Argues AGAINST ascites
• - edema (LR 0.2)
• - flank dullness (LR 0.3)
• - shifting dullness (LR 0.4)

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Case 1

• A 22 year old woman presents for an annual
  exam. She has a 2/6 systolic murmur along the
  left sternal border.
• Should we order an echo???

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Telling systole from diastole

• At HR lt 100, systole is much shorter than
  diastole
• At the left upper sternal border, S2 is louder
  than S1
• Time the cardiac cycle to the carotid pulse the
  carotid upstroke occurs after S1, during systole

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Systolic Murmurs

• Broad differential AS, MR, TR, HCM, ASD, VSD,
  PS, increased blood flow in anemia, fever,
  pregnancy, hyperthyroidism, or innocent
• Present in 5-52 of young adults
• gt90 have normal echocardiograms
• Present in 29-60 of older persons
• gt50 have no clinically significant valvular
  disease on echo

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Innocent or Functional Murmur

• Short, early or midsystolic
• 2/6 or less
• Localized to left sternal border
• Normal neck veins, pulses, apical impulse and
  S1/S2
• Hypertrophic cardiomyopathy should be ruled out
  by exam
• Should also ensure negative history and ROS for
  cardiac sx

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Accuracy of exam in identifying normal and
abnormalmurmurs

• Murmurs meeting above exam criteria
• LR of valvular heart disease 0.3
• (negative hx should decrease likelihood
  further)
• Murmurs not meeting above criteria
• LR of valvular heart disease 38
  

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• Graph

Postest probability
Pretest probability
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• Graph

Postest probability
Pretest probability
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Hypertrophic Cardiomyopathy

• Uncommon cause of systolic murmur
• Causes sudden death in young athletes
• SOyou dont want to miss it

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Hypertrophic Cardiomyopathy

• Unlike most other systolic murmurs,
• HCM should get LOUDER with decreased venous
  return because the walls of the left ventricle
  come closer together
• WAYS TO DECREASE VENOUS RETURN
• Valsalva x 20 sec () LR 14.0 (-) LR 0.3
• Squat to stand () LR 6.0 (-)
  LR 0.1

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HCM

• Unlike other systolic murmurs,
• HCM should get SOFTER with increased venous
  return because the LV walls are farther apart
• WAYS TO INCREASE VENOUS RETURN
• Stand to squat () LR 7.6 (-) LR 0.1
• Passive leg () LR 9.0 (-) LR 0.1
• elevation

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• Graph

Postest probability
Pretest probability
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• Graph

Postest probability
Pretest probability
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Case 2

• A 62 year old man presents with 2 months of
  dyspnea on exertion. He used to be able to push
  his cart around Costco now he is barely able to
  push it up the ramp.

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Chronic Dyspnea

• 2/3 cardiac or pulmonary
• CHF
• COPD
• Asthma
• Atypical angina
• Restrictive lung disease
• Pleural effusion
• 1/3 other
• Anemia
• Deconditioning
• Kyphoscoliosis

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CHF

• LR - LR
• abdominojugular 8 0.3
• Apical impulse lateral to MCL 6 NS
• S3 6 NS
• Elevated JVP 4 NS
• Crackles NS NS
• Edema NS NS

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Measuring JVP
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Teaching MSIIIs Jugular vs Carotid

• Most prominent in descent
• Not palpable
• Erased by pressure
• Usually two pulsations per cycle
• Inspiration more visible

• Most prominent in ascent
• Palpable
• Not erased by pressure
• Only one pulsation per cycle
• Inspiration no change

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When will I REALLY use JVP in internship?

• Determining adequacy of fluid resuscitation
• Assessing low urine output
• Deciding on todays diuretic dose in CHF or
  volume overload
• Assessing an acutely short of breath patient

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Abdominojugular test

• Midabdominal pressure for 10 seconds
• Positive test sustained rise in CVP gt 4 cm
• Positive test indicates elevated left atrial
  pressure with
• LR 8.0
• - LR 0.3

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Apical impulse

• Palpable apical impulse in one-third of adults
  when supine and 50 in L lateral decubitus
• In supine patient , apical impulse lateral to MCL
  supports CHF as the diagnosis with LR 6.

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Diastolic sounds S3S4

• S3 rapid early diastolic filling
• Normal people under 40
• Elevated left atrial pressure
• For CHF LR 6
• S4 atrial contraction pushing blood into a
  stiff and non-compliant ventricle
• Not heard in atrial fibrillation
• Occurs in HTN, AS, CAD
• For CHF LR NS

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COPD

• Spirometry is more sensitive for early COPD most
  exam signs identify more severe disease
• Not all smokers who are short of breath have COPD

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COPD

• LR - LR
• Subxiphoid PMI 7 NS
• Any unforced wheeze 6 NS
• Breath sound score
• lt 9 10 --
• 10-12 4
• gt 15 0.1

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Breath sound score

• Listen at 6 sites bilateral
• Anterior apices
• Midaxilllae
• Posterior bases
• Score breath sounds at each site
• Absent 0
• Barely audible 1
• Faint but audible 2
• Normal 3
• Loud 4

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COPD

• Does patient have 2/3 of
• Tobacco use gt 70 py
• Self described hx of emphysema or chronic
  bronchitis
• Decreased breath sounds
• LR 25
• - LR 0.3

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Commonly missed uncommon cause of chronic dyspnea

• Pulmonary hypertension
• Especially in young women
• Findings
• Elevated JVP
• Loud P2
• RV heave
• RV S3
• In RV failure wide split S2

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Quick Quiz
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Case 3

• A 34 year old woman presents to the clinic
  with a 3 day history of productive cough. She is
  concerned about the possibility of pneumonia.

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Findings supporting pneumonia

• LR - LR
• Egophany 4 NS
• Bronchial breath sounds 3 NS
• Dullness to percussion 3 NS
• Decreased breath sounds 2.3 0.8
• Crackles 2.0 0.8
• Temperature gt 37.8 2.2 0.7
• HR gt 100 1.6 0.7

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Pneumonia Diagnostic Score

• Temperature gt 37.8
• Heart rate gt 100
• Crackles
• Decreased breath sounds
• Absence of asthma

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• 0 or 1 point LR 0.3
• 2 or 3 points NS
• 4 or 5 points LR 8.2

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• This patient has a temp of 38.2, decreased breath
  sounds and crackles at the right base, and no
  history of asthma.
• Her score is 4, LR of pneumonia is 8.2.
• A CXR shows a RLL infiltrate. You start her on
  azithromycin, and schedule follow up the next
  week.

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3 days later

• She returns, still feeling sick.
• On exam, her temp is 37.9, HR is 88, RR is 20 and
  O2 sat is 94 on RA.
• She has markedly decreased breath sounds at the
  right base, but no audible crackles.

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What are the possibilities?How will you tell
them apart?
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• Consolidation Effusion
• Decreased BS yes yes
• Dull to percussion yes yes
• Tactile fremitus increased decreased
• Bronchial BS maybe no
• Egophany maybe maybe at top
• Crackles maybe maybe at top
• Pectoriloquy maybe no

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Case 4

• A 68 year old man with a history of tobacco
  use and knee arthritis presents with 3 months of
  pain in his right thigh when he walks.

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Leg Symptoms in PAD

• Consecutive patients diagnosed with PAD in
  vascular lab
• Only 150/460 patients with PAD (ABI lt 0.9) had
  typical claudication
• Other exertional leg symptoms in 131 pts
• Leg pain on exertion AND rest in 88 pts
• No leg pain but no exertion in 28 pts
• ABI similar in all groups ( 0.6 0.7)

McDermott JAMA 20012861599
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COMMON SITES OF CLAUDICATION
Buttock, hip,
Aorta or
Buttock, hip,
Aorta or
iliac arteries
thigh
thigh
Thigh,
Femoral artery
Thigh,
Femoral artery
or branches
or branches
calf
Calf,
Calf,
Popliteal
Popliteal
artery
artery
foot
foot
Tibial
Foot
arteries
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Pedal pulses

• In normal people
• 3-14 do not have palpable DP
• 0-10 do not have palpable PT
• BUT if one is absent in someone without PVD, the
  other makes up for it
• The absence of both pedal pulses has LR of 14.9
  for PVD

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What if you suspect PVD, but one or both pedal
pulses is PRESENT?

• (-) LR of 0.3 for PVD
• Some patients with PVD will have palpable pedal
  pulses with exercise, most will go away

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OTHER EXAM FINDINGS

• Bruit LR 7.9
• Foot wounds/ulcers LR 7.0
• Absent femoral pulse LR 6.1
• Asymmetric cool foot LR 6.1

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NOT SO HELPFUL EXAM FINDINGS

• Prolonged capillary refill time (LR 1.9)
• Atrophic skin (LR 1.7)
• Hairless (LR 1.7)

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Ankle Brachial Index

• Normal 1.0-1.2
• Claudication 0.5-0.9
• Rest pain lt0.5
• Gangrene lt0.2