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PubMed2001

Error patterns of 3rd-year medical students on the cardiovascular physical examination.

BACKGROUND: Recent research documents widespread deficits in the physical examination skills of practicing physicians. PURPOSE: This study explored physical examination skills of 3rd-year medical students after completion of a course in physical diagnosis. METHODS: Standardized patient physical examination checklist data were analyzed for a cohort of 2,038 medical students for a patient presenting with classic signs and symptoms of an acute myocardial infarction. A follow-up paper case and survey explored reasons underlying omissions. RESULTS: Students systematically omitted 3 of 10 component maneuvers critical to the evaluation of a patient with shortness of breath and chest pain. The same pattern of omissions was observed across 8 medical schools and over 2 successive years. The paper case follow-up study ruled out time constraints and performance anxiety as the cause. Survey data revealed that students may omit a maneuver due to inability to recall pertinence (blood pressure in both arms) or difficulty discriminating findings (heart sounds at different locations), or because of inadequate technical mastery (percussion of the lungs). CONCLUSIONS: These data suggest fundamental inadequacies in the current paradigm for teaching physical examination skills. Standardized patient checklist data can provide an informative window into the efficacy of teaching practices.

Clinical Competence↗

PubMed1992

The focused physical examination. Should checkups be tailor-made?

The "complete physical examination" taught in medical schools is not always the best approach to clinical assessment of asymptomatic adults. The authors of this article review the controversy surrounding the utility of routine physical examination, advocating evolution in medical practice from use of the complete physical examination toward the focused physical examination.

Aged↗

PubMed1999

Physical examination of passerines.

A physical examination of a passerine incorporates the same basic techniques used for other avian species. Although frequently a concern for practitioners, the small size of many of these patients can be overcome with a few technical and equipment modifications. When evaluating clinical findings and collecting diagnostic samples, veterinarians must remain cognizant of important anatomical differences between passerines and psittacines so that they can interpret the results of these tests properly. Because of the many species contained within this order, practitioners should gather as much useful information as possible when examining a novel species. In this way, we will continue to expand the medical knowledge base for this large and diverse group of birds.

Animals↗

PubMedDate not supplied

The physical examination in acute cardiac ischemic syndromes.

The physical examination in acute cardiac ischemia remains a valuable tool when done with skill. Ischemia without infarction alters cardiac function, and the physical examination yields findings that reflect these changes. Ischemia with infarction alters structure and function, resulting in physical findings that are usually more dramatic and of longer duration, sometimes permanent. Carefully done, the physical examination provides information that helps in management of the immediate course, predicts prognosis, and allows for better interpretation of cardiovascular tests, both invasive and noninvasive.

Aortic Valve Stenosis↗

PubMed1996

Physical examination is sufficient for the diagnosis of sprained ankles.

We studied the merits of physical examination after inversion injury of the ankle in 160 consecutive patients. They had an explanatory operation if they had a positive arthrogram and/or positive signs on a delayed physical examination. To determine the interobserver variation in delayed physical examination, five different examiners were asked to give independent assessment of the injury. Those with limited clinical experience produced more accurate results when physical examination was performed at five days after the injury, rather than within 48 hours. The specificity and sensitivity of delayed physical examination for the presence or absence of a lesion of an ankle ligament were found to be 84% and 96%, respectively. The interobserver agreement for the delayed physical examination of the ankle was good (kappa values 0.5, 0.6, 0.6 and 1.0). Delayed physical examination gives information of diagnostic quality which is equal to that of arthrography, and causes little discomfort to the patient.

Adult↗

PubMed1983

Comparative values of school physical examinations and mass screening tests.

In this study mass screenings identified more problems than did physical examinations, but more problems per 100 contacts were identified by physical examinations (51.6) than by screenings (4.7). When time necessary to accomplish the evaluation is considered, screenings are a more efficient way of identifying problems in the general diagnostic categories for which screenings can be provided, but most (85.8%) of the problems identified by physical examination were in categories for which screenings are not provided. Overall, 99.1% of the problems were identified without overlap between physical examinations and screenings. Eighty-three percent of the problems identified by physical examinations were previously unknown. By the end of the school year, 86.3% of the problems identified by physical examinations and 94.5% of those identified by screenings had been or were in the process of being resolved. The integration of physical examinations and screenings in a school setting, staffed by nurse practitioners supported by physicians, can maximize the identification and resolution of health problems.

Child↗

PubMed1991

Indications for radiography in patients with acute ankle injuries: role of the physical examination.

A prospective study was performed to test the hypothesis that a thorough physical examination can eliminate the need for a large number of radiographs obtained in patients with acute ankle trauma. Two hundred one patients were seen in the emergency department for acute ankle trauma and referred to the department of radiology for ankle radiographs. Radiology residents performed a brief but thorough physical examination of the ankle in all 201 patients. Solely on the basis of a strict set of physical examination criteria (examination for gross deformity, instability, crepitation, focal bony tenderness, severe soft-tissue tenderness, moderate or severe soft-tissue swelling, and ecchymosis), the radiologists determined whether or not the radiographs were indicated. All patients, irrespective of the physical examination, underwent ankle radiography, and the results were correlated with those of the physical examination. On the basis of the results of the physical examinations, 101 (50%) of the radiologic studies were not indicated. In only one of these patients was a fracture seen on radiographs. The radiograph in this case showed a small avulsion fracture of the dorsal aspect of the talus that was clinically insignificant (no cast or surgery was required). Our results suggest that a brief but thorough physical examination can eliminate the need for a large percentage of radiographs ordered in patients with acute ankle trauma.

Adolescent↗

PubMed1991

Basic history taking and the avian physical examination.

As one may readily see, the basic avian physical examination should be an extensive, thorough procedure. A wide array of diseases and conditions can be detected during the examination. A flow sheet or checklist should be instituted to maintain consistency and cover all aspects of the history and physical examination. I highly recommend as an adjunct to the basic physical examination Gram stains of the choanae, crop, and cloacae or feces. Owing to the fact that a great number of compromised avian patients either are ill because of gram-negative bacteria or have become more compromised by opportunistic organisms such as yeast or gram-negative bacteria, identification of these conditions greatly facilitates treatment and recovery of the avian patient. Other ancillary tests, such as fecal flotation, complete blood count, culture and sensitivity, Chlamydia test, chemistry profile, radiology, and laparotomy/laparoscopy, are available to the practitioner to aid in the diagnosis of various diseases involving the avian patient. [Editor's note: The editors suggest that the complete blood count be done before an extensive physical examination is undertaken to avoid a stress hemogram.]

Animals↗

PubMed2006

Interrater reliability of the history and physical examination in patients with mechanical neck pain.

OBJECTIVE: To examine the interrater reliability of the history and physical examination in patients with mechanical neck pain. DESIGN: Single-group repeated measures for interrater reliability. SETTING: Outpatient physical therapy clinic. PARTICIPANTS: Twenty-two patients with mechanical neck pain underwent a standardized history and physical examination by a physical therapist. INTERVENTION: Following a 5-minute break, a second therapist who was blind to the findings of examiner 1 performed the second standardized history and physical examination. MAIN OUTCOME MEASURES: The Cohen kappa and weighted kappa were used to calculate the interrater reliability of ordinal level data from the history and physical examination. Intraclass correlation coefficients model 2,1 (ICC(2,1)) and the 95% confidence intervals were calculated to determine the interrater reliability for continuous variables. RESULTS: The kappa coefficients ranged from -.06 to .90 for the variables obtained from the history. Reliability values for categorical data collected during the physical examination ranged from no to substantial agreement depending on the particular test and measure. ICC(2,1) for cervical range of motion (ROM) measurements ranged between .66 and .78. CONCLUSIONS: We have reported the interrater reliability of the history and physical examination in a group of patients with a primary report of neck pain. The reliability variables varied considerably for manual assessment techniques and were significantly higher for the examination of muscle length and cervical ROM. Ultimately, it will be up to each clinician to determine if a particular test or measure poses adequate reliability to assist in the clinical decision making process.

Adult↗

PubMed1993

The quality of mass screening for breast cancer by physical examination.

Mass screening for breast cancer using physical examination alone has been carried out since 1983 in Zentsuji, Kagawa Prefecture, Japan. Over a 7-year period, breast cancer was detected in 11 of a total 8,271 examinees, the detection rate being high at 0.13%. The detected cases included a few early-staged breast cancers, suggesting that mass screenings are of slight efficacy. Seven cases of interval cancer were found by breast self-examination after the mass screenings, supporting the value of breast self-examination. A relatively large number of interval breast cancers was detected in 1985 and 1986, when the rates of required further examination remained under 1%. The sensitivity and specificity of this screening were 61.1% and 94.5%, respectively, indicating a low sensitivity. These results suggest that the qualitative diagnoses made from the first screening by physical examination alone were often revealed to be false negatives. Therefore, the existing diagnosis should be employed in the first screenings. It is recommended that mammography be introduced to detect breast tumors which are nonpalpable or undetectable by physical examination alone.

Adult↗

PubMed2003

Physical examination of the knee: a review of the original test description and scientific validity of common orthopedic tests.

OBJECTIVES: To present the original descriptions of common orthopedic physical examination maneuvers of the knee and then to review the literature to support the scientific validity of these tests. DATA SOURCES: MEDLINE (1970-2000) searches were performed, as were reviews of various musculoskeletal examination textbooks that describe physical examination maneuvers of the knee. These references were then reviewed for additional references and crossed back to the original description (when possible) of these named tests. STUDY SELECTION: All articles that discussed the sensitivity and specificity of the physical examination maneuvers were extracted. This information was reviewed for accuracy and then summarized. DATA EXTRACTION: Multiple MEDLINE and text searches were performed by using the terms of the test maneuver, the joint tested, and the term physical examination. Any article with this information was reviewed until the article describing the original description was found. Articles dating from that original article to the present were reviewed for information on the sensitivity and specificity of the test. DATA SYNTHESIS: Literature reviewing the sensitivity and specificity of the tests reviewed is summarized in text and table form. The Lachman test seems to be very sensitive and specific for the detection of anterior cruciate ligament tears. For posterior cruciate ligament tears, the posterior drawer test is also very sensitive and specific and is enhanced with other tests, such as the posterior sag sign. For meniscal tears, the McMurray test is very specific but has a very low sensitivity, whereas joint line tenderness has fairly good sensitivity but lacks good specificity. Although collateral ligament testing seems to be sensitive and specific, there is a lack of well-designed studies that scientifically validate the sensitivity and specificity of these tests. Common tests for patellofemoral pain and patellar instability lack sensitivity when correlated with pathologic operative findings. CONCLUSIONS: Most physical examination tests could be referenced back to an original description, with variable information on the sensitivity and specificity along with other information about the validity of these tests in clinical practice. To standardize how physical examinations are performed and compared, they should follow the original description or agreed-on standards. In addition, the significance of a physical examination finding must be understood to ensure that patients with knee complaints are accurately diagnosed and properly treated.

Biomechanical Phenomena↗

PubMed1995

Degenerative lumbar spinal stenosis. Diagnostic value of the history and physical examination.

OBJECTIVE: To assess the value of the history and physical examination findings in the diagnosis of symptomatic degenerative lumbar spinal stenosis (LSS). METHODS: The study was performed in 3 specialty clinics, and included patients with low back pain who were at least age 40. Findings from a standardized history and physical examination were compared with the diagnostic impression of expert attending clinicians. Imaging studies were available in 88% of those with LSS, and the findings further supported the diagnosis of LSS in each case. The sensitivity, specificity, and likelihood ratio associated with each history and physical examination finding were calculated in bivariate analyses, and independent correlates of LSS were identified with multivariate analyses. RESULTS: Ninety-three patients were evaluated. History findings most strongly associated with the diagnosis of LSS (likelihood ratio > or = 2) were greater age, severe lower-extremity pain, and absence of pain when seated. Physical examination findings most strongly associated with the diagnosis were wide-based gait, abnormal Romberg test result, thigh pain following 30 seconds of lumbar extension, and neuromuscular deficits. Independent correlates of LSS included advanced age (P = 0.0001), absence of pain when seated (P = 0.006), wide-based gait (P = 0.013), and thigh pain following 30 seconds of lumbar extension (P = 0.002). CONCLUSION: Specific history and physical examination findings are useful in the diagnosis of LSS and should be ascertained routinely in older patients with low back pain.

Adult↗

PubMedDate not supplied

Birth, death, and resurrection of the physical examination: clinical and academic perspectives on bedside diagnosis.

The physical examination has a historically prominent role in medical practice, being an important tool in diagnosis and in developing rapport with patients. Yet, physicians have lost bedside skills in recent years, with increasing use of technology at the expense of time spent with the patient. This is concerning, especially in the present era of cost-containment in health care. Approaches to improve bedside diagnosis skills include increased emphasis on instruction in physical examination during medical school and postgraduate training, and careful scrutiny of physical examination techniques, with formal evaluation of their accuracy and reproducibility. Only through education and research will the physical examination recover its central role in the clinical encounter.

Education, Medical, Continuing↗

PubMed2006

Chronic low back pain in older adults: prevalence, reliability, and validity of physical examination findings.

OBJECTIVES: To develop a structured physical examination protocol that identifies common biomechanical and soft-tissue abnormalities for older adults with chronic low back pain (CLBP) that can be used as a triage tool for healthcare providers and to test the interobserver reliability and discriminant validity of this protocol. DESIGN: Cross-sectional survey and examination. SETTING: Older adult pain clinic. PARTICIPANTS: One hundred eleven community-dwelling adults aged 60 and older with CLBP and 20 who were pain-free. MEASUREMENTS: Clinical history for demographics, pain duration, previous lumbar surgery or advanced imaging, neurogenic claudication, and imaging clinically serious symptoms. Physical examination for scoliosis, functional leg length discrepancy, pain with lumbar movement, myofascial pain (paralumbar, piriformis, tensor fasciae latae (TFL)), regional bone pain (sacroiliac joint (SIJ), hip, vertebral body), and fibromyalgia. RESULTS: Scoliosis was prevalent in those with (77.5%) and without pain (60.0%), but prevalence of SIJ pain (84% vs 5%), fibromyalgia tender points (19% vs 0%), myofascial pain (96% vs 10%), and hip pain (48% vs 0%) was significantly different between groups (P < .001). Interrater reliability was excellent for SIJ pain (0.81), number of fibromyalgia tender points (0.84), and TFL pain (0.81); good for scoliosis (0.43), kyphosis (0.66), lumbar movement pain (0.75), piriformis pain (0.71), and hip disease by internal rotation (0.56); and marginal for leg length (0.00) and paravertebral pain (0.39). CONCLUSION: Biomechanical and soft tissue pathologies are common in older adults with CLBP, and many can be assessed reliably using a brief physical examination. Their recognition may save unnecessary healthcare expenditure and patient suffering.

Aged↗

PubMed1997

Physical examination during space flight.

OBJECTIVE: To develop techniques for conducting a physical examination in microgravity and to describe and document the physiologic changes noted with use of a modified basic physical examination. DESIGN: On the basis of data gathered from physical examinations on KC-135 flights, three physical variables were assessed serially in astronauts during two shuttle missions (of 8- and 10-day duration, respectively). Preflight, in-flight, and postflight examinations were conducted by trained physician-astronauts or flight surgeons, who used this modified examination. MATERIAL AND METHODS: Five male and two female crewmembers participated in the "hands-on" physical examination of all physiologic systems except the genitourinary system. Level of edema, intensity of bowel sounds, and peripheral reflexes were assessed and graded. RESULTS: This investigation identified unique elements of a physical examination performed during space flight that will assist in the development of standard methods for conducting examinations of astronauts in weightlessness. In addition, demonstrable changes induced by microgravity were noted in most physiologic systems examined. CONCLUSION: The data support the hypothesis that the microgravity examination differs from that conducted on earth or in a 1g environment. In addition, alterations in the physiologic response can be detected with use of hands-on technique. These data are invaluable in the development of optimal medical care for humans in space.

Auscultation↗

PubMed2002

Public expectations and attitudes for annual physical examinations and testing.

BACKGROUND: Recent guidelines for adult prevention do not recommend a comprehensive annual physical examination, but current public expectations in light of this change are unknown. OBJECTIVE: To determine public belief in the need for and content of an annual physical examination and to examine the effect of financial charges on these beliefs. DESIGN: Telephone survey. SETTING: Three U.S. cities. PARTICIPANTS: Adult English-speaking respondents. MEASUREMENTS: Percentage of respondents answering that an annual physical examination is necessary and percentage desiring individual components of the history, physical examination, and laboratory testing, with and without knowledge of charges. RESULTS: Of 1203 respondents, 66% (67% in Denver, Colorado; 71% in Boston, Massachusetts; and 58% in San Diego, California) believed that in addition to regular care, an annual physical examination is necessary. Among the 600 respondents presented with charge information, interest decreased from 63% to 33% if payment were required. For history, greater than 90% believed that diet, exercise, and tobacco and alcohol use should be discussed, while 60% believed that seatbelt use and sexual history should be discussed. For the physical examination, greater than 90% felt that blood pressure should be measured and that the heart and lungs, abdomen, reflexes, and prostate should be examined. However, fewer than 80% thought that hearing and vision should be tested. Many tests, including the Papanicolaou smear (75%), mammography (71%), cholesterol measurement (65%), prostate-specific antigen test (65%), urinalysis (40%), blood glucose measurement (41%), fecal occult blood testing (39%), and chest radiography (36%), were desired. Interest in these tests decreased substantially when the charges were known. CONCLUSION: Public desire for a comprehensive annual physical examination is high across the United States and is sensitive to charges.

Adult↗

PubMed2002

Two educational interventions to improve pediatricians' knowledge and skills in performing ankle and knee physical examinations.

BACKGROUND: Methods are needed to improve pediatricians' skills for physical examination of the ankle and knee. OBJECTIVE: To compare the effect of 2 methods of teaching the physical examination of the ankle and knee on the knowledge and skills of pediatricians. DESIGN: Prospective intervention trial with preintervention and postintervention tests. SETTING: Pediatricians' offices. PARTICIPANTS: Twenty-three practice groups of community pediatricians, including 75 pediatricians (74% of the eligible sample). INTERVENTIONS: Practice groups were assigned by clustered randomization to 1 of 2 teaching interventions: (1) a videotape showing correct performance of the ankle and knee physical examinations (videotape only; 15 groups) and (2) the same videotape plus a skills building session (18 groups). The randomization was stratified by practice size. MAIN OUTCOME MEASURES: Knowledge of ankle and knee examinations and ankle and knee physical examination skills, assessed by means of a Clinical Skills Assessment Examination (CSAE), at 18 weeks. RESULTS: The pediatricians' baseline mean ankle CSAE score was 26% correct in both groups. These scores improved to 44% and 59% correct in the videotape and videotape plus skills instruction groups, respectively, at 18 weeks (P<.001 for both). The baseline mean knee CSAE score was 25% in both groups and improved to 30% (P =.02, videotape group) and 41% (P<.001, videotape plus skills instruction group) at 18 weeks. The change in CSAE scores was greater in the videotape plus skills instruction group. Written test scores improved significantly in both groups. CONCLUSIONS: Pediatricians' skills were lacking at baseline. Both teaching interventions were associated with improved skills and knowledge.

Adult↗

PubMed1985

History and physical examination by oral and maxillofacial surgeons: the development of a physical assessment course.

Qualified oral surgeons may be granted hospital privileges to perform history and physical examinations on their patients as a result of a JCAH policy change, which became effective in January 1982. Oral surgeons must apply for and be granted this privilege from their affiliate hospitals and must demonstrate their qualifications. Various criteria can be used to assess qualification, including a review of the applicant's training in physical diagnosis in residency training, and participation in physical assessment continuing education programs. Review courses that feature hands-on practice are useful to oral surgeons interested in updating and refining their skills. Since the University of Illinois began offering a review course in 1981, 91 oral surgeons have completed the 2-day intensive review program. A follow-up survey of the participants indicates that the oral surgeons are applying for medical staff privileges. In a survey of 30 oral surgeons who participated in the course during 1982, 13 (43%) indicated that they had obtained the privilege to perform histories and physical examinations from their local hospitals.

Clinical Competence↗