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PubMed1990

The carpal tunnel syndrome: diagnostic utility of the history and physical examination findings.

STUDY OBJECTIVE: To assess the value of a history and physical examination findings in diagnosing the carpal tunnel syndrome, and to determine whether constellations of clinical findings identify patients at high or low risk for the carpal tunnel syndrome. DESIGN: Comparison of diagnostic tests with neurophysiologic testing. SETTING: Patients with upper extremity complaints of diverse causes referred to a neurophysiology laboratory for diagnostic studies. METHODS: Before nerve conduction testing, a history, demographic and physical examination data, and a hand pain diagram were obtained from each patient. Diagrams were categorized as indicating the classic carpal tunnel syndrome, or as probable, possible, or unlikely to indicate the carpal tunnel syndrome. Associations between clinical data and nerve conduction results were examined in univariate and multivariate analyses. RESULTS: Of 110 patients in the study, 44 (40%) had the carpal tunnel syndrome. Individually, the best predictors were hand pain diagram rating (positive predictive value, 0.59; 95% CI, 0.48 to 0.68) and Tinel sign (positive predictive value, 0.55, CI, 0.45 to 0.65). The combination of a positive Tinel sign and a probable or classic diagram rating had a positive predictive value of 0.71; CI, 0.53 to 0.85. Other findings from physical examination and the history were less useful. Just 9% of patients under 40 years of age with possible or unlikely diagram ratings had the carpal tunnel syndrome. CONCLUSIONS: With the exceptions of age, Tinel sign, and hand pain diagram rating, findings from the physical examination and the history had limited diagnostic utility. Patients under 40 years of age with possible or unlikely diagram ratings were at low risk for the carpal tunnel syndrome. This finding, which should be confirmed in an independent population, suggests that subsets of patients may be managed without nerve conduction studies.

Adult↗

PubMed1993

Physical examination of the thrower's elbow.

The physical examination of the thrower's elbow presents the clinician with the clinical challenge of differentially diagnosing specific pathologies. The examination should include a thorough history and a well-organized physical examination, which relies on an extensive knowledge of the functional anatomy of the elbow. The components of an elbow examination include inspection/observation, palpation of bony and soft tissues, range of motion assessment, resisted muscle testing (both manual and mechanical), neurologic testing, and special tests. The special tests commonly performed on the thrower's elbow are the Tinel test, tennis elbow sign, ulnar collateral ligament stability testing, valgus extension overload test, and radiocapitella chondromalacia test. Other tests include radiographic examination, such as computerized tomograph arthrogram and magnetic resonance imaging testing. Information presented in this paper will provide the clinician with a systematic and thorough evaluation process for the thrower's elbow.

Athletic Injuries↗

PubMed1989

The periodic physical examination in asymptomatic adults.

The components of the periodic physical examination have been evaluated according to contemporary epidemiologic standards. For the asymptomatic, nonpregnant adult of any age, no evidence supports the need for a complete physical examination as traditionally defined. The efficacy for three screening procedures has been established: Blood pressure should be measured at least every 2 years; women more than 40 years of age should have a breast examination done by a physician annually; and sexually active women should have a pelvic examination and a Papanicolaou test at least every 3 years after two initial negative tests have been obtained 1 year apart. Because of the prevalence and morbidity of specific diseases, and the sensitivity and specificity of screening tests, several other maneuvers are recommended for screening asymptomatic adults, although the optimal frequency has not been determined experimentally. Weight should be measured every 4 years. Visual acuity should be tested annually in adults older than 60 years of age. To identify patients at high risk for melanoma, a complete skin examination should be done once. Hearing should be tested by audioscope annually in adults older than 60 years of age. Physicians should encourage patients to have annual dental visits. To identify valvular abnormalities requiring antibiotic prophylaxis, cardiac auscultation should be done at least twice in an adult. Men older than 60 years of age should have a yearly examination of the abdomen for the presence of aortic aneurysm. Although the other components of the complete physical examination may be important in establishing and maintaining the physician-patient relationship, they have not been shown to be effective screening maneuvers for asymptomatic disease.

Adult↗

PubMed2006

Modeling an integrative physical examination program for the Departments of Defense and Veterans Affairs.

Current policies governing the Departments of Defense and Veterans Affairs physical examination programs are out of step with current evidence-based medical practice. Replacing periodic and other routine physical examination types with annual preventive health assessments would afford our service members additional health benefit at reduced cost. Additionally, the Departments of Defense and Veterans Affairs repeat the physical examination process at separation and have been unable to reconcile their respective disability evaluation systems to reduce duplication and waste. A clear, coherent, and coordinated strategy to improve the relevance and utility of our physical examination programs is long overdue. This article discusses existing physical examination programs and proposes a model for a new integrative physical examination program based on need, science, and common sense.

Delivery of Health Care, Integrated↗

PubMed1999

Reproducing a cancer patient's pain on physical examination: bedside provocative maneuvers.

While various aspects of the physical examination in pain patients have been validated, the value of screening maneuvers that reproduce a cancer patient's pain on physical examination has been less well defined. The purpose of this prospective case series is to better characterize the role of bedside provocative maneuvers as part of the comprehensive evaluation of cancer pain patients. Fifty consecutive patients referred to an ambulatory cancer pain clinic were evaluated; they described a total of 89 discrete pains. All or much of the pain that brought each patient to medical attention was reproduced by a provocative maneuver in 47 (94%) patients; 79 of 89 (89%) pains were elicited at the bedside. Pains that were not reproducible with any provocative maneuver included paroxysmal spells of pain, neuropathic pain, and steady headache. On the basis of the history, physical examination, and both positive and negative provocative maneuvers, all pains were characterizable as somatic, visceral, neuropathic, or mixed, and a pathophysiological basis for the pain was inferred in 85 of 89 (95%) pains. On the basis of this preliminary report, we conclude that provocative bedside maneuvers are usually able to reproduce a cancer patient's pain. They help to better characterize the pain and identify the pain sensitive structure, and should be a routine part of the comprehensive assessment of cancer pain patients. Further research is needed to validate the diagnostic role of standardized pain-provoking maneuvers in a variety of clinical situations.

Humans↗

PubMed2002

Confirmation of the safety and accuracy of physical examination in the evaluation of knee dislocation for injury of the popliteal artery: a prospective study.

BACKGROUND: Knee dislocation, which poses a significant risk for injury of the popliteal artery, prompts many surgeons to evaluate these patients with arteriography routinely. Our hypothesis was that physical examination alone (without arteriography) accurately confirms or excludes surgically significant vascular injuries associated with knee dislocation. METHODS: All patients diagnosed with a knee dislocation by an attending orthopedic surgeon between January 1990 and January 2000 were prospectively managed by protocol at our Level I trauma center according to their physical examination. Those with hard signs (active hemorrhage, expanding hematoma, absent pulse, distal ischemia, bruit/thrill) underwent arteriography followed immediately by surgical repair if indicated. Patients with no hard signs (negative physical examination) were admitted for 23 hours, underwent serial physical examination, and then followed as outpatients. RESULTS: There were 35 knee dislocations in 35 patients during this 10-year period. The average age was 31 years; 18 dislocations were on the right knee and 17 were on the left. Two patients died from closed head injuries and multisystem trauma. Eight patients were found to have hard signs (positive physical examination) either at presentation (six patients) or during their hospitalization after reduction of their dislocation (two patients). All eight patients demonstrated a loss of pulses only. Six of these patients showed occlusion of the popliteal artery on arteriography and underwent surgical repair without complication (five vein grafts, one primary repair), one demonstrated spasm of the popliteal artery, and one showed a normal artery that required no treatment. None of the 27 patients with negative physical examination during their hospitalization ever developed limb ischemia, needed an operation for vascular injury, or experienced limb loss. Sixteen patients were available for follow-up (46%). Twelve patients with negative physical examination (44%) were contacted (mean, 13 months; range, 2-35 months), and four of the eight patients with positive physical examination (50%) and surgical repair were contacted (mean, 19 months; range, 6-49 months). None of the patients in either group developed any vascular-related symptoms or suffered from a vascular repair complication over the follow-up interval. CONCLUSION: This limited series suggests that the presence or absence of an injury of the popliteal artery after knee dislocation can be safely and reliably predicted, with a 94.3% positive predictive value and 100% negative predictive value. Arteriography appears to be unnecessary when physical examination is negative but may avert negative vascular exploration when physical examination is positive. This approach substantially reduces cost and resource use without adverse impact on the patient.

Angiography↗

PubMed2002

Physical examination signs, clinical symptoms, and their relationship to electrodiagnostic findings and the presence of radiculopathy.

The validity of the history and physical examination varies with study method and the gold standard used. In general, symptoms are more sensitive than specific, and most patients with radiculopathy do present with some characteristic complaints. With the exception of the ipsilateral SLR, most physical examination findings are more specific than sensitive. In patients with suspected radiculopathy, having at least one abnormal physical examination finding makes the probability of having an abnormal electrodiagnostic study more likely than if the results of the physical examination are normal. Having a normal physical examination, however, does not rule out the possibility of having a radiculopathy that is revealed either electrodiagnostically or surgically. Although the history and physical examination may not be perfect tools for the diagnosis of radiculopathy or predicting electrodiagnostic outcome, they are an essential part of the clinical evaluation to assist in formulating a differential diagnosis and guiding the electrodiagnostic study.

Animals↗

PubMed1997

Color Doppler ultrasound criteria to diagnose varicoceles: correlation of a new scoring system with physical examination.

OBJECTIVES: Color Doppler ultrasound (CDU) diagnostic criteria for varicoceles are poorly defined, and the role of CDU in diagnosing varicoceles is controversial. The purpose of this study is to assess the diagnostic accuracy of CDU for varicoceles compared to physical examination. METHODS: We prospectively studied 64 patients with CDU and collected the following data: maximum diameter of scrotal veins, the presence of a venous plexus, sum of the diameter of up to six veins of the plexus, and the duration and amplitude of flow change on Valsalva maneuver. To avoid interphysician variation, all patients were examined by one designated senior urologist with the sonographer remaining unaware of the findings. RESULTS: CDU parameters of 127 testis units in 64 patients were analyzed and compared to the physical findings. Fifty-nine testis units were positive and 57 units were negative for varicocele on physical examination. In 11 testis units, results of physical examination were inconclusive regarding the presence of varicocele. The commonly accepted CDU criterion for varicocele (maximal vein diameter of 3 mm or greater) had a sensitivity of 53% and specificity of 91% compared to physical examination. We developed a new scoring system incorporating the maximal venous diameter (score 0 to 3), the presence of a venous plexus and the sum of the diameters of veins in the plexus (score 0 to 3), and the change of flow on Valsalva maneuver (score 0 to 3). Using a total score of 4 or more to define the presence of CDU-positive varicocele, we observed a sensitivity of 93% and a specificity of 85% when compared to physical examination. All moderate to large varicoceles found on physical examination were positive by CDU diagnosis using the scoring system, but the same group had only a 68% positive rate by traditional CDU diagnostic criteria. CONCLUSIONS: Using the proposed new scoring system, CDU has been shown to be a reliable and accurate method of diagnosis for varicoceles compared to the current reference standard physical examination. CDU has the advantages of being able to objectively examine venous plexus and measure blood flow parameters and to be less observer-dependent than physical examination.

Adult↗

PubMed2003

A comparison of physical examination and imaging in determining the extent of primary penile carcinoma.

OBJECTIVE: To determine the accuracy of physical examination and imaging in assessing the extent of the primary tumour in squamous cell carcinoma of the penis. PATIENTS AND METHODS: A physical examination, ultrasonography and magnetic resonance imaging (MRI) were used before surgery in 33 patients with penile carcinoma. The tumour size, infiltration of the penile structures and infiltration depth were assessed. The results were compared with the histopathological examination of the resected specimen. RESULTS: Tumour size was determined with the highest precision by the physical examination (residual sd of 8.1 mm); ultrasonography and MRI were less precise (residual sd 8.9 mm and 9.3 mm). In assessing infiltration depth, ultrasonography and MRI had comparable precision (residual sd 3.7 mm and 3.8 mm). The positive predictive value of corpus cavernosum infiltration was 6/6 for physical examination, 4/6 for ultrasonography and 6/8 for MRI; the sensitivity was 6/7, 4/7 and 6/6, respectively. CONCLUSION: Physical examination is a reliable method for estimating penile tumour size and predicts corpus cavernosum infiltration with a high positive predictive value. Tumours for which the infiltration of the corpora cannot be determined properly by physical palpation only should be examined by imaging.

Carcinoma, Squamous Cell↗

PubMed1997

The physical examination of the glenohumeral joint: emphasis on the stabilizing structures.

Thorough descriptions of specific physical examination tests used to determine glenohumeral instability are lacking in the scientific literature. The purpose of this paper was to discuss the importance of the subjective history and illustrate the physical examination of the glenohumeral joint. Additionally, the authors will illustrate specific stability assessment for the glenohumeral joint based on current basic science and clinical research. The physical examination of a patient whose history suggests subtle glenohumeral joint instability may be extremely difficult for the clinician due to the normal amount of capsular laxity commonly present in most individuals. An essential component of the physical examination is a through and meticulous subjective history which includes the mechanisms of injury and/or dysfunction, chief complaint, level of disability, and aggravating movements. The physical examination must include an assessment of motion, static stability testing, muscle testing, and a neurologic assessment. A comprehensive understanding of various stability testing maneuvers is important for the clinician to appreciate. The evaluation techniques discussed in this paper should assist the clinician in determining the passive stability of the glenohumeral joint.

Humans↗

PubMed1990

[Relative contribution of history-taking, physical examination, and stat laboratory test to diagnosis in chest pain patients].

To evaluate the relative importance of the medical history, physical examination, and stat laboratory tests in diagnosis, twelve general internists recorded their hypotheses (diseases) with subjective probabilities assigned to them after taking the history, and after performing the physical examination, and again after obtaining stat laboratory test results. The resultant hypotheses generated for chest pain patients were compared with the final diagnoses which were determined an average of 7.6 months later. A hypothesis subjectively determined to have the highest probability was shown to agree with the final diagnosis in 71.1% of the patients after taking the history: the physical examination was useful in raising this proportion only by 5.0%. Stat laboratory tests, however, raised the proportion from 63.6% to 81.4% for patients where stat laboratory tests were done. When subjective probabilities were used as a measuring index, earlier hypotheses were correct with an average predictive value of 0.57 after the history-taking, 0.62 after the physical examination, and 0.73 after stat laboratory tests. The average subjective probability after physical examination for a group of patients who subsequently underwent stat laboratory tests was 0.59, while that for a group of patients who did not undergo stat laboratory tests was 0.78. Based on these results test-treatment threshold was estimated to be approximately 0.69. The number of hypotheses were, on the average, 2.48 after the history-taking, 2.35 after the physical examination, and 1.90 after stat laboratory tests. From the stand point of social responsibility and individual patient perspectives quantitative measurement of physicians' predictions should be provided as the basis for assessment of the benefit of high medical technologies.

Chest Pain↗

PubMed2006

Follow-up of ovarian and primary peritoneal carcinoma: the value of physical examination in patients with pretreatment elevated CA125 levels.

OBJECTIVE: To assess the value of routine periodic physical examination in the follow-up of ovarian (OvC) and primary peritoneal carcinoma (PPC) patients with pretreatment elevated CA125 levels. METHODS: Included were patients who had a pretreatment serum CA125 level above normal limits, had completed initial treatment, were in complete clinical remission on completion of the initial treatment and routinely attended the gynecologic oncology outpatient clinic. Recurrence was diagnosed when at least one of the following criteria was abnormal: symptoms, physical examination or elevated serum CA125 levels. RESULTS: Of 69 patients, a recurrence was diagnosed in 43. Abnormal physical examination for diagnosis of recurrence yielded a sensitivity rate of only 34.9%. The diagnosis of recurrence was based on an abnormal physical examination alone in 2 (4.6%) patients. CONCLUSION: In OvC and PPC patients with elevated pretreatment CA125 levels, physical examination has a limited impact on the diagnosis of recurrence.

Adult↗

PubMed1985

Predictive value of abnormal physical examination findings in ill-appearing and well-appearing febrile children.

In order to study the occurrence and positive predictive value of history and physical examination findings suggestive of serious illness in ill-appearing and well-appearing febrile children, 103 consecutive children aged less than or equal to 24 months with fever greater than or equal to 38.3 degrees C were evaluated from July 1, 1982 to Nov 24, 1982. Patients were initially classified by an attending physician (A) as to whether they appeared ill (Yale Observation Scale score greater than 10) or well (scale score less than or equal to 10). The history was then taken by two attending physicians (A and B) and a resident; the physical examination was performed by attending physician B and the same resident. As history and physical examination findings were elicited, they were scored as to whether they did or did not suggest a serious illness. Serious illness was defined as the presence of a positive laboratory test. Ill-appearing patients had a significantly greater (P less than .001, Fisher's exact test) occurrence of physical examination findings suggesting serious illness (14 of 22, 64%) than well-appearing children (12 of 81, 15%). The positive predictive values of abnormal physical examination findings for serious illness in ill-appearing (11 of 14, 79%) and well-appearing children (3 of 12, 25%) were significantly different (P = .02 by Fisher's exact test). The trends for abnormal history findings in ill-appearing and well-appearing children were similar to those for abnormal physical examination findings but did not achieve statistical significance. The results, indicating an important interaction between a febrile child's appearance and physical examination findings, are discussed in terms of probability reasoning in clinical decision making.

Bayes Theorem↗

PubMedDate not supplied

How useful are physical examination procedures? Understanding and applying likelihood ratios.

OBJECTIVE: To describe the calculation and interpretation of likelihood ratios for examination procedures performed by certified athletic trainers. BACKGROUND: Physical examination procedures or "special tests" are commonly taught to athletic training students and performed by certified athletic trainers. Likelihood ratios offer an approach to assessing test performance that incorporates estimates of sensitivity and specificity into a clinically useful value. We describe the calculation of likelihood ratios and the application of likelihood ratios to clinical decision making. RECOMMENDATIONS: The performance characteristics of physical examination procedures taught and practiced in athletic training should be considered in the planning of course materials as well as test interpretation after a physical examination. Research is needed to better understand how well physical examination procedures, when performed by certified athletic trainers, identify those athletes with and without specific musculoskeletal injuries.

Journal Article↗

PubMed1984

Detection of breast carcinoma: comparison of automated water-path whole-breast sonography, mammography, and physical examination.

A comparative study of independently conducted physical examination, x-ray mammography, and sonography of the breast was carried out on 786 women having 77 excisional biopsies with 31 proven breast carcinomas. On breast sonography, 68% of the carcinomas were demonstrated with three false-positive diagnoses, compared with 65% cancer detection rate on physical examination with 37 false positives, and 77% detection rate on mammography with 15 false positives. Sonography was considered complementary to the other methods and of distinct usefulness after mammography (1) to examine the dense breast; (2) to study dense, poorly demonstrated areas; (3) to differentiate cystic from solid masses; and (4) to study breasts with augmentation mammoplasties. There were no added benefits in mammographically normal fatty breasts. The procedure was readily accepted by both women and their referring physicians.

Adult↗

PubMed2000

Levator claviculae muscle discovered during physical examination for cervical lymphadenopathy.

During a routine physical examination of an adult female with a history of breast cancer and cervical lymphadenopathy, a mass was noted in the right supraclavicular region. The mass was unilateral and easily palpable along the superior border near the median aspect of the clavicle. Plain film radiography, performed to determine whether the mass represented an enlarged jugulo-omohyoid lymph node, revealed an elongated opaque mass in this region. Computed tomographic (CT) and magnetic resonance (MR) images were subsequently obtained. Sequential axial CT scans revealed a cylindrical mass that appeared to be independent of contiguous muscles, including the sternocleidomastoid, anterior, and middle scalene muscles. This mass attached inferiorly to the clavicle and superiorly to the transverse process of the sixth cervical vertebra. Sagittal, coronal, and axial MR scans confirmed the presence of a well-defined superficial mass. It is concluded that the mass represents a levator claviculae (cleidocervical) muscle. This observation underscores the importance of understanding soft tissue variants that may be encountered during a routine physical examination.

Adult↗

PubMed1988

Clinical skills of medical residents: a review of physical examination.

Students are introduced to techniques of physical examination at medical school. However, their skills are deficient at the time of graduation, and with the increasing shift of clinical teaching away from the bedside and into the conference room it is expected that these skills will weaken in succeeding generations of physicians. A practical and satisfactory method of addressing this problem during internship and residency training has not been forthcoming because of the lack of a regular forum for the teaching of clinical skills in busy tertiary referral hospitals and the shortage of teachers with the necessary skills and commitment to teaching a large number of house staff. We describe a program whose unique hierarchical approach has permitted a detailed ongoing review of physical examination. One clinician was able to teach 24 residents by instructing a small group of senior residents, who in turn, after practising with clinical clerks, taught groups of junior residents.

Clinical Clerkship↗

PubMed1994

Using chart reviews to assess residents' performances of components of physical examinations: a pilot study.

PURPOSE: To evaluate chart review as a method of assessing residents' performances of physical examinations in an ambulatory care setting. METHOD: In 1992, nurse authors at the Affiliated Hospitals at Canton of the Northeastern Ohio Universities College of Medicine assessed whether 22 internal medicine residents performed ten components of the physical examination by interviewing patient volunteers immediately after the patients' examinations. A total of 89 patient interviewees were included in the analysis; these patients were all new outpatients who had been scheduled for initial visits to obtain complete histories and physical examinations. Charts for the same patients were then retrospectively reviewed. The residents and faculty were blinded to both the chart reviews and the interviews. Statistical methods used were Pearson correlational analysis and variance-component analysis. RESULTS: The interviews and chart reviews showed 81% agreement in component performance. Completeness of the physical examination (whether measured by chart review or interview) did not correlate with other standard methods of resident evaluation, and completeness did not show a significant association with characteristics of the residents and patients. Two of the 22 residents assessed were identified as having completeness scores so low as to be unsatisfactory. CONCLUSION: That residents were identified as failing to perform examination components suggests that chart reviews, especially when independently verified by patient interviews, may be a useful evaluation tool for identifying inadequate performance of components of the physical examination and may identify the need for remediation.

Adult↗