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PubMed2005

Unnecessary laparotomy by using physical examination and different diagnostic modalities for penetrating abdominal stab wounds.

BACKGROUND: The modern management of penetrating abdominal trauma has decreased the incidence of unnecessary laparotomy by using selective non-operative management protocols. However, the real benefits of physical examination and different diagnostic methods are still unclear. METHODS: From January 2000 to April 2003, we prospectively collected data on 117 patients with penetrating stab wounds to the thoracoabdominal, anterior abdominal, and back regions who had non-operative management. Clinical examination was the primary tool to differentiate those patients requiring operation. Findings of physical examination, ultrasound, computed tomography, endoscopy, echocardiography, diagnostic peritoneal lavage, and diagnostic laparoscopy were reviewed. The number of therapeutic, non-therapeutic, and negative laparotomies were recorded. RESULTS: Non-operative management was successful in 79% of patients. There were 11 early (within 8 hours of admission) and 14 delayed (more than 8 hours after admission) laparotomies performed, depending on the results of various diagnostic procedures. Non-operative management failed in 21% of patients, and the rate of non-therapeutic laparotomy in early and delayed laparatomy groups was 9% and 14% respectively. There was no negative laparatomy. CONCLUSIONS: The use of physical examination alone and/or together with different diagnostic methods allows reduction of non-therapeutic laparotomies and elimination of negative laparatomies.

Abdominal Injuries↗

PubMed1988

Reliability of physical examination in penetrating chest injuries.

The decision to insert an intercostal drain in chest injury must occasionally be made without a chest radiograph. A prospective analysis of the reliability of physical examination in penetrating pleural injuries was undertaken. A total of 51 consecutive patients were examined before obtaining a chest radiograph. The presumptive diagnosis and decision to institute intercostal drainage were compared with the radiological diagnosis and the actual decision in each patient. A policy of selective drainage of large pleural collections was employed. The series consisted mainly of stab injuries in young men. Physical examination accurately diagnosed 13 of the 14 large pneumo- or haemothoraces. This reliability combined with the selective drainage policy showed that physical examination accurately predicted the need for tube thoracostomy with a sensitivity of 96 per cent and a specificity of 93 per cent. This study suggests that experienced clinicians should not hesitate to institute immediate life-saving intercostal drainage when needed, before a chest radiograph is obtained.

Adolescent↗

PubMed2004

What kind of physical examination does a young athlete need before participating in sports?

Recommendations exist for preparticipation physical examinations, but there is no national standard, and the recommendations are not widely followed. The most common reasons for denying clearance to play are musculoskeletal conditions, hypertension, and visual acuity problems. Although detecting potentially life-threatening conditions is an appropriate goal, preparticipation physical examinations have only a limited ability to detect cardiac abnormalities that dispose athletes to sudden death on the playing field; fortunately, these events are very rare.

Adolescent↗

PubMed1997

Blunt intestinal injury in children: the role of the physical examination.

PURPOSE: Although blunt intestinal injury in children is uncommon, prompt recognition and treatment is imperative. Because the best method for diagnosis remains undetermined, the authors reviewed their experience with this injury in children to determine the most reliable diagnostic method and to identify factors associated with treatment delays. METHODS: From January 1989 through December 1995, 2,284 children were admitted to the level I trauma center after sustaining blunt abdominal trauma. Of these, 32 (1.4%) had intestinal injury confirmed during laparotomy. Each case was reviewed with particular attention to the initial physical examination, abdominal computed tomography (CT) scan, laparotomy observations, complications, and the hospital at which the child was initially treated, if applicable. Fisher's Exact test and Wilcoxon's rank sum test were used for statistical analyses, with P < .05 considered significant. RESULTS: Twenty-five patients (78%) had major intestinal injuries that required repair or resection; seven had minor intestinal injuries only. Two-thirds of the 32 were restrained passengers in motor vehicle crashes. The initial physical examination was suggestive of intestinal injury in 94% of children. Twenty-one children (84%) with major bowel injuries had diffuse abdominal tenderness at the time of initial physical examination, and only one of the seven (14%) with minor intestinal injury had generalized tenderness (P = .0014). Sixteen of 21 restrained passengers had seat-belt ecchymoses, and 13 of the 16 sustained major intestinal injuries. Only 1 of 13 abdominal CT scans performed was diagnostic of intestinal injury. Ten of 12 patients (83%) who underwent delayed laparotomy (more than 12 hours after injury) were initially evaluated at hospitals without trauma center designation; whereas 6 of the 20 nondelayed patients were evaluated at these hospitals (P = .0091). All four major complications occurred in the delayed group. CONCLUSION: The authors conclude that signs suggestive of major intestinal injury are present in children at the time of initial physical examination or shortly thereafter. The decision to operate can be based on this examination alone in the pediatric population. Abdominal CT scan is not reliable for the diagnosis of blunt intestinal injury in children. To expedite diagnosis and treatment, children who sustain blunt abdominal trauma should be examined immediately by a physician experienced in pediatric trauma care or be transferred to a designated trauma center where this service is available.

Accidents, Traffic↗

PubMed1997

The effects of the presence of a companion animal on physiological arousal and behavioral distress in children during a physical examination.

The purpose of this study was to examine the effects of the presence of a companion animal on physiological arousal and behavioral distress exhibited by preschool children during a routine physical examination. A within-subject, time-series design was used to study 23 healthy children ages 3 years to 6 years during two physical examinations, with and without a dog. Statistically significant differences were found with greater reductions in subjects' systolic and mean arterial pressure, heart rate, and behavioral distress when the dog was present. Findings support the use of a companion animal in reducing stress experienced by children during a physical examination.

Analysis of Variance↗

PubMed1997

[Coping behaviors of the elderly with positive physical examination results in Kaohsiung City].

The objectives of this study were as follows: first, to investigate the coping behaviors of the elderly facing the stress of disease after free physical examination; Second, to identify personal and disease characteristics, and the social support that influences coping behaviors in the elderly. The study sample consisted of 661 elderly patients who were found to have abnormal findings during a free physical examination provided by 11 regional health stations in Kaohsiung City. Data were collected with questionnaires through home interview. Four hundred and eighty-four subjects completed the questionnaires. Data were analyzed using SAS computer program. The major findings were as follows: 1.Problem-oriented coping behaviors were the more frequently used. The most frequently used coping behaviors were "accepting the situation as it is", "reling on myself to solve problems", "hoping that things would get better", "seeking professional help", and "letting things follow their natural cause". 2. The relative variables for problem-oriented coping were marital status, religion, medical insurance, educational level, disease characteristics, and social support. Sex, marital status, religion, medical insurance, perceived disease severity, characteristics of health problem, and newly found abnormality at this free physical examination were the relative variables for affective-oriented coping. 3. The best predictive variables for using problem-oriented coping behaviors were medical insurance, self-esteem support from family and friends, tangible support from health professionals, emotional support from health professionals, and whether it was the first time the patients knew their health problems. Findings from this study had implications for development of nursing care plans for elderly clients, as well as for collaborative team exploration of coping behaviors in the elderly.

Adaptation, Psychological↗

PubMed1993

Sensitivity, specificity and predictive value of physical examination, culture and other laboratory studies in the diagnosis during early infancy of vertically acquired human immunodeficiency virus infection.

The medical records of 142 infants referred for evaluation solely because they were born to human immunodeficiency virus (HIV)-infected mothers (i.e. not because of signs or symptoms suggesting HIV infection), were reviewed. The infection status of 85 of these infants has been determined; 17 (20%) have confirmed HIV infection and 68 have seroreverted to HIV and lack evidence of infection. During the first 6 months of life HIV culture had better sensitivity, specificity, positive predictive value and negative predictive value for diagnosis of HIV infection than did physical examination, serum immunoglobulin determination or HIV p24 antigen determination. Of the 16 HIV-infected infants who were available for evaluation during the first 6 months of life, all had at least one culture from blood positive for HIV. Two of 4 and 10 of 11 infants were culture-positive at birth and during the first 3 months of life, respectively. A positive HIV culture results was the earliest finding of infection in 15 infants; 10 of these infants concomitantly were found to have hyperimmunoglobulinemia (8 cases) and/or an abnormal physical examination (4 cases). One HIV-infected infant developed hyperimmunoglobulinemia G and A at age 3 months without other evidence of HIV infection until age 5 months when a positive HIV culture was noted. All HIV-infected infants had abnormal findings by physical examination, a positive HIV culture, and/or hyperimmunoglobulinemia by 3 months of age. Infants with normal physical examination and laboratory test results at 3 and/or 6 months of age invariably were HIV-uninfected.

Female↗

PubMed2005

Comparison of effectiveness of hand-carried ultrasound to bedside cardiovascular physical examination.

This study compared the accuracy of cardiovascular diagnoses by medical students operating a small hand-carried ultrasound (HCU) device with that of board-certified cardiologists using standard physical examinations. Sixty-one patients (38% women; mean age 70 +/- 19 years) with clinically significant cardiac disease had HCU studies performed by 1 of 2 medical students with 18 hours of training in cardiac ultrasound and physical examinations by 1 of 5 cardiologists. Diagnostic accuracy was determined by standard echocardiography. Two-hundred thirty-nine abnormal findings were detected by standard echocardiography. The students correctly identified 75% (180 of 239) of the pathologies, whereas cardiologists found 49% (116 of 239) (p <0.001). The students' diagnostic specificity of 87% was also greater than cardiologists' specificity of 76% (p <0.001). For nonvalvular pathologies (115 findings), students' sensitivity was 61%, compared with 47% for cardiologists (p = 0.040). There were 124 clinically significant valvular lesions (111 regurgitations, 13 stenoses). Students' and cardiologists' sensitivities for recognizing lesions that cause a systolic murmur were 93% and 62% (p <0.001), respectively. Students' sensitivity for diagnosing lesions that produce a diastolic murmur was 75%; cardiologists recognized 16% of these lesions (p <0.001). The diagnostic accuracy of medical students using an HCU device after brief echocardiographic training to detect valvular disease, left ventricular dysfunction, enlargement, and hypertrophy was superior to that of experienced cardiologists performing cardiac physical examinations.

Aged↗

PubMed1999

Development and validation of a physical examination scale to assess vaginal atrophy and inflammation.

BACKGROUND: The assessment of vaginal atrophy is central to menopause-related research and clinical practice. However, methods of grading vaginal atrophy have not been subjected to reliability and validity assessments. OBJECTIVE: To assess the validity and reproducibility of selected vaginal examination findings proposed to represent vaginal atrophy and inflammation. DESIGN: Cross-sectional study. PARTICIPANTS: A convenience sample of 40 postmenopausal volunteers with past history of breast cancer. MEASUREMENTS: Participants completed questionnaires to assess vaginal symptoms. Pelvic examinations were carried out using specified criteria to assess the vaginal appearance. Vaginal cytological smears and pH measurements were performed using standardized techniques. RESULTS: A four-item physical examination atrophy scale had an alpha reliability of 0.48 and was statistically significantly correlated with pH (r = 0.55) and parabasal cells (r = 0.50). A three-item physical examination inflammation scale had an alpha reliability of 0.45. It was not significantly associated with vaginal smear-measured inflammation. Masked inter-rater agreement for the examination was 90%. Self-reported symptoms of itching/irritation or dryness were poorly related to findings on physical examination. CONCLUSIONS: These results offer objective validation that the physical characteristics proposed to represent atrophy are related to biomarkers of this condition. A relationship between examination characteristics believed to represent inflammation and inflammation biomarkers was not upheld.

Atrophy↗

PubMed1999

Diagnostic value of history and physical examination in patients suspected of sciatica due to disc herniation: a systematic review.

We conducted a systematic review of the literature from 1965-1994 to assess the value of history and physical examination in the diagnosis of sciatica due to disc herniation; we also included population characteristics and features of the study design affecting diagnostic value. Studies on the diagnostic value of history and physical examination in the diagnosis of sciatica due to disc herniation are subject to important biases, and information on numerous signs and symptoms is scarce or absent. Our search revealed 37 studies meeting the selection criteria; these were systematically and independently read by three readers to determine diagnostic test properties using a standard scoring list to determine the methodological quality of the diagnostic information. A meta-analysis was performed when study results allowed statistical pooling. Few studies investigated the value of the history. Pain distribution seemed to be the only useful history item. Of the physical examination signs the straight leg raising test was the only sign consistently reported to be sensitive for sciatica due to disc herniation. However, the sensitivity values varied greatly, the pooled sensitivity and specificity values being 0.85 and 0.52, respectively. The crossed straight leg raising test was the only sign shown to be specific; the pooled sensitivity and specificity values were 0.30 and 0.84, respectively. There was considerable disagreement on the specificity of the other neurological signs (paresis, sensory loss, reflex loss). Several types of bias and other methodological drawbacks were encountered in the studies limiting the validity of the study results. As a result of these drawbacks it is probable that test sensitivity was overestimated and test specificity underestimated.

Evaluation Studies as Topic↗

PubMed2003

Online commentary during the physical examination: a communication tool for avoiding inappropriate antibiotic prescribing?

A previously identified communication behavior, online commentary, is physician talk that describes what he/she is seeing, feeling, or hearing during the physical examination of the patient. The investigators who identified this communication behavior hypothesized that its use may be associated with successful physician resistance to perceived or actual patient expectations for inappropriate antibiotic medication. This paper examines the relationship between actual and perceived parental expectations for antibiotics and physician use of online commentary as well as the relationship between online commentary use and the physician's prescribing decision. We conducted a prospective observational study in two private pediatric practices. Study procedures included a pre-visit parent survey, audiotaping of study consultations, and post-visit surveys of the participating physicians. Ten pediatricians participated (participation rate=77%) and 306 eligible parents participated (participation rate=86%) who were attending sick visits for their children with upper respiratory tract infections between October 1996 and March 1997. The main outcomes measured were the proportion of consultations with online commentary and the proportion of consultations where antibiotics were prescribed. Two primary types of online commentaries were observed: (1) online commentary suggestive of a problematic finding on physical examination that might require antibiotic treatment ('problem' online commentary), e.g., "That cough sounds very chesty"; and (2) online commentary that indicated the physical examination findings were not problematic and antibiotics were probably not necessary ('no problem' online commentary), e.g., "Her throat is only slightly red". For presumed viral cases where the physician thought the parent expected to receive antibiotics, if the physician used at least some 'problem' online commentary, he/she prescribed antibiotics in 91% (10/11) of cases. Conversely, when the physician exclusively employed 'no problem' online commentary, antibiotics were prescribed 27% (4/15) of the time (p = 0.07). Use of 'no problem' online commentary did not add significantly to visit length. 'No problem' online commentary is a communication technique that may provide an effective and efficient method for resisting perceived expectations to prescribe antibiotics.

Anti-Bacterial Agents↗

PubMed1995

Assessment of response to therapy of primary breast cancer by mammography and physical examination.

BACKGROUND: Accurate assessment of response to treatment is necessary to treat appropriately primary breast cancers that are not surgically removed. This retrospective study was undertaken to compare the effectiveness of physical examination (PE) and mammography to assess response of primary breast cancer to medical therapy in women who were ineligible for initial surgical treatment. METHODS: Thirteen women with 14 breast carcinomas were evaluated for interval changes. Except for 1 patient who had two follow-up studies, the other 12 each had a single follow-up study including PE and mammography; changes therefore were assessed in 15 instances. Response to treatment also was judged by mastectomy results in two instances, changes in metastatic disease by other imaging procedures in five, and changes in primary tumor by computed tomography in two breasts. RESULTS: In 11 of 15 assessments of posttherapy changes, PE and mammography results were similar concerning treatment response. Of four discordant follow-ups, the tumors were found to be stable by PE, whereas they were found to be increasing by mammography in two. In both of these cases, progression of disease outside the breast was identified by other imaging studies, consistent with the mammographic findings. In another case, disease appeared to regress by PE but was unchanged by mammography; disease extent in mastectomy specimens was consistent with that found mammographically and more extensive than that suggested by physical examination. In the fourth case, superficial healing of a fungating tumor was obvious by clinical examination but could not be appreciated by mammography. The detectability of changes was not related to type of treatment. CONCLUSIONS: Physical examination and mammography are both useful in the serial evaluation of breast cancers. Although usually complimentary, disease progression, when it occurs, may be detected by only one of these methods.

Adult↗

PubMed1995

Comparing checklists and databases with physicians' ratings as measures of students' history and physical-examination skills.

PURPOSE: To compare two methods of rating students' performances on history and physical examination: (1) by using checklists completed by standardized patients (SPs) and databases completed by students, and (2) by using ratings of students by three physicians for each SP-student encounter. METHOD: Four cases were chosen for the study, and 30 students were examined per case. The students were all in their fourth year at the Southern Illinois University School of Medicine in the spring of 1991. Two of the cases had both checklists and databases, and the remaining two had databases only. Each SP-student encounter was videotaped and was viewed independently by three physicians unfamiliar with the contents of the checklists and databases. The physicians' pooled ratings were then compared with the checklist and database scores. Uncorrected and corrected correlations were obtained, with the generalizability coefficient used as the index of reliability. RESULTS: Interrater generalizability of physicians' ratings was very good, ranging from .65 to .93 for overall ratings. Generalizability of physicians' ratings pooled across the four cases was .85. Checklist scores tended to correlate higher with physicians' ratings than did database scores: across the cases, correlation coefficients between physicians' ratings and checklist scores and database scores were .65 and .39, respectively. CONCLUSION: The checklist scores correlated strongly with the physicians' ratings of history and physical-examination skills, providing some evidence of validity for their use. The checklist scores correlated much better with the physicians' ratings than did the database scores. Possible explanations for this finding are discussed.

Clinical Clerkship↗

PubMed1997

The palpable tendon friction rub: an important physical examination finding in patients with systemic sclerosis.

OBJECTIVE: To evaluate the clinical and prognostic significance of palpable tendon friction rubs in patients with systemic sclerosis (SSc). METHODS: SSc patients evaluated prospectively at the University of Pittsburgh were examined serially for the presence of tendon friction rubs on physical examination. Demographic, clinical, and laboratory features of disease were obtained by patient examination, annual patient questionnaire, and medical record review. Patients were classified as having limited or diffuse scleroderma according to standard definitions. The prognostic significance of the presence of tendon friction rubs was determined using this comprehensive database. RESULTS: The SSc patients (n = 1,305) were first evaluated during 1972 through 1991 and were followed up for a mean of 6.3 years. Tendon friction rubs were detected most frequently in patients who had or who developed diffuse cutaneous involvement. There were strong correlations between the presence of tendon friction rubs and symptoms and signs typical of diffuse scleroderma, including more severe skin thickening, more frequent heart and kidney involvement, and decreased survival. In multiple regression analyses, the presence of 1 or more tendon friction rubs was one of the best predictors of both evolution to diffuse scleroderma and reduced survival. CONCLUSION: The palpable tendon friction rub is an easily detected, inexpensively obtained physical examination finding which is highly associated with diffuse cutaneous scleroderma and decreased survival. This observation should lead to the early diagnosis of diffuse scleroderma and should identify patients at high risk for serious visceral involvement who are thus candidates for potential disease-modifying therapy.

Ankle Joint↗

PubMed1981

General physical examination of the canine patient.

It should be obvious from the above discussion that the physical examination of animals is not a simple task. The details that must be performed are numerous. Even more numerous are the abnormalities that can be discovered by the careful observer. My attempt was not to list all the abnormalities that can be detected during a physical exam, but rather to develop an organized approach to looking at your patients so that the most may be gained from the effort expended. If you know normal anatomy and physiology and study healthy animals thoroughly, significant abnormalities will become obvious. Your physical examination skills will continue to grow with each patient examined. Your data base of disease findings will be constantly expanding, and your diagnostic accuracy will improve every year of your practice life.

Animals↗

PubMed2002

Diagnostic value of history and physical examination in patients suspected of lumbosacral nerve root compression.

OBJECTIVE: To evaluate patient characteristics, symptoms, and examination findings in the clinical diagnosis of lumbosacral nerve root compression causing sciatica. METHODS: The study involved 274 patients with pain radiating into the leg. All had a standardised clinical assessment and magnetic resonance (MR) imaging. The associations between patient characteristics, clinical findings, and lumbosacral nerve root compression on MR imaging were analysed. RESULTS: Nerve root compression was associated with three patient characteristics, three symptoms, and four physical examination findings (paresis, absence of tendon reflexes, a positive straight leg raising test, and increased finger-floor distance). Multivariate analysis, analysing the independent diagnostic value of the tests, showed that nerve root compression was predicted by two patient characteristics, four symptoms, and two signs (increased finger-floor distance and paresis). The straight leg raise test was not predictive. The area under the curve of the receiver-operating characteristic was 0.80 for the history items. It increased to 0.83 when the physical examination items were added. CONCLUSIONS: Various clinical findings were found to be associated with nerve root compression on MR imaging. While this set of findings agrees well with those commonly used in daily practice, the tests tended to have lower sensitivity and specificity than previously reported. Stepwise multivariate analysis showed that most of the diagnostic information revealed by physical examination findings had already been revealed by the history items.

Adolescent↗

PubMed1990

A system to capture physical examination data suitable for paediatric practice.

A method is described to capture data on the physical examination of children. A personal computer with a keyboard, keypad and screen is used along with a menu driven software package. Little knowledge of computing is necessary and the system can be used to produce hard copy when a suitable printer is added. Accumulated data may be transferred to a statistical package for future analysis. The method used to capture data from children with respiratory disease, particularly acute asthma, is described here, but it is stressed that the method can be adapted easily to data collection from the results of the physical examination of any system.

Asthma↗

PubMed2004

Assessing the head-to-toe physical examination skills of medical students.

Second-year medical students performed a head-to-toe screening physical examination on trained patient instructors (PIs) as a high-stakes examination before beginning clinical clerkships. PIs completed a 138-item checklist and instructed the students in the proper performance of any incorrectly executed or omitted items. To assess the accuracy of the PI ratings, 'monitor' PIs watching the encounter by video completed checklists for 11 retests of failed students in 2001 and for 28 randomly selected encounters in 2002. Checklist-level discrepancies measured by mean absolute checklist difference were 8% in 2001 and 9% in 2002. Case-level mean difference between raters in 2002 was -2.9%. The inter-rater reliability for a single rater, estimated by the intra-class correlation coefficient for total encounter scores, was 0.95. The assessment and feedback were well received by the students. The Head-to-Toe examination provides a reliable assessment of a student's ability to carry out a complete screening physical examination. Patient instructors can be trained to acceptable accuracy and reliability despite the length and complexity of the exercise, and can provide effective feedback and teaching targeted to individual student deficiencies.

Clinical Competence↗