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PubMed2003

Assessing physical examination skills of senior medical students: knowing how versus knowing when.

PURPOSE: Literature has documented a lack of physical examination proficiency among medical students. To investigate UCLA medical students' physical examination proficiency, this study compared their performance on a multiple-station Clinical Performance Examination (CPX) focused on clinical cases with that on a thorough physical examination objective structured clinical examination (OSCE) of the same organ systems. METHOD: One hundred sixty-three beginning fourth-year students participated in the study. Four organ systems were included in both the CPX and OSCE. Pearson's correlation coefficients and paired-sample t-tests were conducted to determine the correlations between and differences in the two tests. RESULTS: The physical examination scores on the CPX were significantly (p <.001) lower both by organ subscale and in total than those on the OSCE. Correlation coefficients between the two tests were negligible. CONCLUSIONS: The study suggests that fourth-year medical students may demonstrate competency in directed examination of organ systems while being unable to correctly apply those examination skills to the work-up of clinical cases.

California↗

PubMed1987

An evaluation of the performing and recording of physical examinations by psychiatric trainees.

The physical examination on admission, as recorded in the psychiatric case notes, was assessed for 100 consecutive admissions under the age of 65. Assessment was made on the presence or absence of reference to 43 items of examination and the recording of the examinations was found to be uniformly poor. One of the authors re-examined 50 patients within 48 h of admission and the findings were then compared with the initial recorded examination. Significant unrecorded positive findings were most frequent in the neurological and locomotor systems.

Education, Medical, Graduate↗

PubMed1976

Physical examination in ischaemic heart disease.

Physical examination can yield valuable diagnostic clues in a patient suspected of ischaemic heart disease. Examination during chest pain is especially informative. The haemodynamic abnormalities which accompany angina pectoris may precipitate elevation of blood pressure, pulsus alternans, pulsus bigeminus, abnormal precordial pulsations, a fourth heart sound or a systolic bruit; all of these may subsequently disappear with cessation of the anginal attack. Careful technique of examination, especially in detecting a fourth heart sound, is essential.

Angina Pectoris↗

PubMed2003

Medical students' perceptions of their housestaffs' ability to teach physical examination skills.

PURPOSE: To evaluate the amount of time housestaff spent at the bedside on physical examination skills with third-year medical students and whether housestaff enhanced physical examination skills. METHOD: All Albert Einstein College of Medicine students who completed the third-year medicine inpatient clerkship at one of five participating sites evaluated housestaff (interns and residents) with whom they spent at least ten days. The students quantified the amount of time housestaff spent with them at the bedside and used a modified five-point Likert scale to evaluate housestaff's enhancement of students' physical examination skills. Data were analyzed separately for interns, but pooled for residents (years two and three). Differences between groups were tested using Wilcoxon rank-sum and by Mantel-Haenszel chi-square tests. RESULTS: Totals of 191 responses for interns and 166 responses for residents were collected from October 1999 to October 2000. Fifteen (8%) of the intern group and 59 (36%) of the resident group spent no time at the bedside (p <.0001). Students were most satisfied with enhancement of pulmonary, cardiovascular, and gastrointestinal skills and least satisfied with enhancement of ENT, eye, and genitourinary skills (p <.0001). CONCLUSIONS: Interns spent more time with students than did residents. Almost one third of the residents spent no time on physical examination skills with students. Training programs should re-emphasize the importance of housestaff's teaching at the bedside and address areas of deficiency.

Attitude of Health Personnel↗

PubMed2006

Accuracy of physical examination, ultrasonography, and mammography in predicting residual pathologic tumor size in patients treated with neoadjuvant chemotherapy.

OBJECTIVE: To assess the accuracy of physical examination, ultrasonography, and mammography in predicting residual size of breast tumors following neoadjuvant chemotherapy. BACKGROUND: Neoadjuvant chemotherapy is an accepted part of the management of stage II and III breast cancer. Accurate prediction of residual pathologic tumor size after neoadjuvant chemotherapy is critical in guiding surgical therapy. Although physical examination, ultrasonography, and mammography have all been used to predict residual tumor size, there have been conflicting reports about the accuracy of these methods in the neoadjuvant setting. METHODS: We reviewed the records of 189 patients who participated in 1 of 2 protocols using doxorubicin-containing neoadjuvant chemotherapy, and who had assessment by physical examination, ultrasonography, and/or mammography no more than 60 days before their surgical resection. Size correlations were performed using Spearman rho analysis. Clinical and pathologic measurements were also compared categorically using the weighted kappa statistic. RESULTS: Size estimates by physical examination, ultrasonography, and mammography were only moderately correlated with residual pathologic tumor size after neoadjuvant chemotherapy (correlation coefficients: 0.42, 0.42, and 0.41, respectively), with an accuracy of +/-1 cm in 66% of patients by physical examination, 75% by ultrasonography, and 70% by mammography. Kappa values (0.24-0.35) indicated poor agreement between clinical and pathologic measurements. CONCLUSION: Physical examination, ultrasonography, and mammography were only moderately useful for predicting residual pathologic tumor size after neoadjuvant chemotherapy.

Adult↗

PubMed1979

Sensitivity of mammography and physical examination of the breast for detecting breast cancer.

Mammography and physical examination of the breast are evaluated as screening instruments for detecting breast cancer based on local biopsy data obtained from women enrolled in a national breast cancer screening program. One hundren thirteen cancers (15.5%) of women who underwent biopsy) were detected. The individual sensitivities of mammography and physical examination for detecting breast cancer are 62% and 24%, respectively. The sensitivity of the two methods combined is 75% (85 of 113). Thirty-seven cancers were in situ or minimally invasive (less than or equal to 1 cm in greatest dimension). Eighty-one percent (30 of 37) of these small cancers were detected by screening, and they comprised 35% (30 of 85) of all cancers detected by mammography, physical examination, or both. Improved survival is anticipated due to this high rate of discovery of small cancers.

Adult↗

PubMed2001

The preparticipation physical examination.

For decades the preparticipation physical examination (PPE) has been used to screen athletes prior to sports participation to prevent injury or illness. Evolution of the PPE, it is theorized, originated from the need to identify individuals with conditions that may predispose them to injuries or life-threatening situations. However, the effectiveness, practicality, and worthiness of the examination are a matter of debate. As members of a medical team, physicians are responsible for the health and safety of the athlete. The PPE is the first step in satisfying this responsibility. This article discusses the components of the PPE and presents the evidence-based model of knowledge behind the PPE.

Death, Sudden↗

PubMed2000

A study on relative contributions of the history, physical examination and investigations in making medical diagnosis.

Here we report an attempt to quantitate the relative contributions of the history, physical examination and investigations in making medical diagnosis. In this prospective study of 100 patients, with new or previously undiagnosed conditions, we listed their differential diagnosis with confidence score; after the history, after physical examination and after the investigations. In two patients no definite final diagnoses could be arrived even after extensive investigation--these two cases were excluded from the study. In seventy seven patients (78.58%) patients, the history led to diagnosis. The physical examination led to diagnosis in eight patients (8.17%); and investigations led to diagnosis in 13 patients (13.27%). The confidence in correct diagnosis increased from 6.36 on a scale of one to ten after the history to 7.57 after physical examination and 9.84 after investigations--implying that history, physical examination and investigation have their own limitation at each stage and an integrative approach is needed in making a medical diagnosis with more emphasis on history.

Diagnosis↗

PubMed2000

Can history and physical examination be used as markers of quality? An analysis of the initial visit note in musculoskeletal care.

BACKGROUND: The medical record serves as an important source of information regarding the care process, but few studies have examined whether thoroughness of documentation is associated with outcomes. OBJECTIVE: The objectives of this study were to analyze the initial visit note for 513 patients presenting with acute musculoskeletal pain, compare thoroughness of documentation by physician specialty, and determine whether thoroughness of documentation was associated with clinical improvement or patient satisfaction. METHODS: A structured medical record abstraction was performed to examine whether treating physicians documented key historical and physical exam findings. Satisfaction with care, symptom relief, and functional improvement were assessed after 3 months with validated survey instruments. RESULTS: In the initial visit note, 43+/-16% of selected historical findings and 28+/-17% of physical examination findings were documented. Orthopedic surgeons documented 2 to 4 more historical and physical examination items (P <0.01) and assigned more specific diagnoses (P <0.01) than rheumatologists and general internists. Multivariate models showed a very weak association between all aspects of documentation and patient satisfaction with the provider-patient interaction (all partial R2 <0.016) and no association between documentation and 3-month pain relief or functional status. Patients' perception of physician communication was more highly associated with patient satisfaction (P = 0.0001) than was documentation. CONCLUSIONS: No provider types consistently documented many important historical items and physical examination findings. While thoroughness of documentation was not associated with clinical outcomes, there was a very weak relationship between documentation and patient satisfaction with provider-patient interactions.

Acute Disease↗

PubMed1998

[The teaching of physical examination in undergraduate nursing schools in the city of Sao Paulo].

The present study is an exploratory survey attempting to get the point of view of the faculty of subjects considered responsible by teaching physical examination in the nursing undergraduate schools of São Paulo city that were selected for this study. The goals were: to detect the situation of teaching of propaedeutics basis; to identify factors that make them difficult; and to identify the recommendations of the faculty for the improvement of teaching and its implementation. The population studied was formed by 39 faculty of the subjects considered responsible by teaching physical examination. Results show us there is not a specific subject to teach physical examination, although it is taught mainly in Fundamental Nursing; faculty are not entirely prepared to teach physical examination. To improve teaching of physical examination, the faculty suggest enhancing their knowledge and skills as well as to create a specific subject to teach physical examination with sufficient hours according to the content.

Brazil↗

PubMed1992

Contributions of the history, physical examination, and laboratory investigation in making medical diagnoses.

We report an attempt to quantitate the relative contributions of the history, physical examination, and laboratory investigation in making medical diagnoses. In this prospective study of 80 medical outpatients with new or previously undiagnosed conditions, internists were asked to list their differential diagnoses and to estimate their confidence in each diagnostic possibility after the history, after the physical examination, and after the laboratory investigation. In 61 patients (76%), the history led to the final diagnosis. The physical examination led to the diagnosis in 10 patients (12%), and the laboratory investigation led to the diagnosis in 9 patients (11%). The internists' confidence in the correct diagnosis increased from 7.1 on a scale of 1 to 10 after the history to 8.2 after the physical examination and 9.3 after the laboratory investigation. These data support the concept that most diagnoses are made from the medical history. The results of physical examination and the laboratory investigation led to fewer diagnoses, but they were instrumental in excluding certain diagnostic possibilities and in increasing the physicians' confidence in their diagnoses.

Clinical Laboratory Techniques↗

PubMed1999

Preparticipation physical examinations: a collegiate experience.

OBJECTIVE: To determine the relative frequency of limiting conditions in collegiate preparticipation physical examinations. DESIGN: Prospective recording of physical examinations over a 2-year period. SETTING: West Virginia University Department of Intercollegiate Athletics. PARTICIPANTS: A total of 596 student athletes, including 405 men and 191 women, involved in 22 sports at the intercollegiate level. MAIN OUTCOME MEASURES: The number of all athletes that passed, passed with follow-up or restriction, and failed the preparticipation examinations were recorded along with the specific abnormalities that resulted in follow-up/restriction or failure. RESULTS: Of the athletes, 512 (85.9%) passed without significant medical or orthopedic abnormalities; 83 (13.9%) passed with a condition requiring follow-up or restriction; and one (0.2%) failed the examination. Medical and orthopedic abnormalities were responsible for 55.4% and 44.6% of the restricted athletes, respectively. Elevated blood pressure was the most common medical condition (47.8%), and knee problems were the most common orthopedic abnormality (43.2%). CONCLUSION: Outcome results of collegiate preparticipation physical examinations compare favorably with results in high school students and support the need for detailed examinations before competition. The results also underscore the importance of proper rehabilitation of previous injuries.

Adolescent↗

PubMed1997

The value of physical examination in the diagnosis of patients with blunt abdominal trauma: a retrospective study.

Between 1 January 1993 and 1 January 1994, 204 consecutive patients with possible blunt abdominal injury were analysed retrospectively. All patients underwent a standardized diagnostic approach on admission to the emergency room. Abdominal ultrasound (AUS) was performed in all cases. If there was evidence of intra-abdominal injury on physical examination or AUS, without signs of persistent hypovolaemia after initial assessment, contrast-enhanced computed tomographic scanning (CECT) of the abdomen was carried out without exception. Physical examination was equivocal in 13 and 3 per cent, respectively, of patients with 'isolated' abdominal trauma (N = 23) or with fractures of lower ribs 7-12 as a sole diagnosis (N = 30). In multiple injury patients (N = 95) or those with suspected 'isolated' head injury (N = 56), these figures reached 45 and 84 per cent, respectively. AUS (N = 204) revealed intra-abdominal injury in 20 per cent of patients, and CECT (N = 43) resulted in additional information in 49 per cent. Patients with 'isolated' head injury showed 9 per cent abnormalities on abdominal evaluation versus 32 per cent in multiple injury patients. In lower rib fractures (7-12) in multiple injury patients abdominal injury was diagnosed in 67 per cent of the cases. We conclude that: (1) negative findings following reliable physical examination of patients with 'isolated' head injury show very high values (NPV 100 per cent), but reliable physical examination is very infrequent (16 per cent); (2) NPV in lower rib fractures due to low energy impact is very high (100 per cent), with a reliable physical examination in most patients (97 per cent); (3) in patients with isolated abdominal trauma 87 per cent have a reliable physical examination with a moderately high NPV (71 per cent); (4) almost half the multiple injury patients have an unequivocal physical examination (45 per cent), with a high NPV following reliable physical examination for abdominal injury (85 per cent); (5) abdominal ultrasonography should be the first step in the radiological assessment of all patients with possible blunt abdominal injury; (6) in multiply injured patients with fractures of their lower ribs (7-12) due to high energy impact the incidence of abdominal injury is very high and CECT might be indicated even in the case of normal AUS findings.

Abdominal Injuries↗

PubMed1997

Relative value of physical examination, mammography, and breast sonography in evaluating the size of the primary tumor and regional lymph node metastases in women receiving neoadjuvant chemotherapy for locally advanced breast carcinoma.

The purpose of this study was to correlate physical examination and sonographic and mammographic measurements of breast tumors and regional lymph nodes with pathological findings and to evaluate the effect of neoadjuvant chemotherapy on clinical Tumor-Node-Metastasis stage by noninvasive methods. This was a retrospective analysis of 100 patients with locally advanced breast cancer registered and treated in prospective trials of neoadjuvant chemotherapy. All patients received four cycles of a doxorubicin-containing regimen and had noninvasive evaluation of the primary tumor and regional lymph nodes before and after neoadjuvant chemotherapy by physical examination, sonography, and mammography and underwent breast surgery and axillary dissection within 5 weeks after completion of neoadjuvant chemotherapy. The correlations between clinical and pathological measurements were determined by Spearman rank correlation analysis. A proportional odds model was used to examine predictive values. Eighty-three patients had both a clinically detectable primary tumor and lymph node metastases. Sixty-four patients had a decrease in Tumor-Node-Metastasis stage after chemotherapy. For 54% of patients, there was concordance in clinical response between the primary tumor and lymph node compartment; for the rest, results were discordant. Physical examination correlated best with pathological findings in the measurement of the primary tumor (P = 0.0003), whereas sonography was the most accurate predictor of size for axillary lymph nodes (P = 0.0005). The combination of physical examination and mammography worked best for assessment of the primary tumor (P = 0.003), whereas combining physical examination with sonography gave optimal evaluation of regional lymph nodes (P = 0.0001). In conclusion, physical examination is the best noninvasive predictor of the real size of locally advanced primary breast cancer, whereas sonography correlates better with the real dimensions of axillary lymph nodes. The combination of physical examination with either mammography or sonography significantly improves the accuracy of noninvasive assessment of tumor dimensions.

Adult↗

PubMedDate not supplied

Preoperative physical examination for primary vascular access--reliability in determining vessel quality.

BACKGROUND AND AIMS: The purpose of this prospective clinical study was to evaluate the reliability and adequacy of preoperative physical examination in determining the quality of vessels prior to primary vascular access procedure by performing peroperative completion fistulography. MATERIAL AND METHODS: 26 consecutive patients who were scheduled for primary vascular access surgery, between July 2001 and June 2002, were included. Findings between the preoperative physical examination and peroperative completion fistulography were compared. RESULTS: Of the 26 patients that were initially enrolled in the study, 4 patients were excluded because physical examination showed poor superficial arm veins and 2 patients had not undergone access procedure by the end of the study. The remaining twenty patients constituted the actual study group. The arteriovenous fistula could be performed at the chosen level and way in all 20 patients. The findings between preoperative physical examination and peroperative fistulography were compatible and the specificity of physical examination to detect patent inflow and outflow vessels was 100%. Due to the fact that 4 patients in whom a poor vein was suspected were excluded, the sensitivity could not be assessed. CONCLUSIONS: Preoperative physical examination seems to be reliable and adequate method in determining vessel quality prior primary vascular access surgery. According to our study, its specificity is high in determining patent inflow and out-flow vessels. However, because of exclusion of patients with suspected problem, sensitivity cannot be determined.

Adolescent↗

PubMed1998

The preparticipation physical examination: Mayo Clinic experience with 2,739 examinations.

OBJECTIVE: To report the results of preparticipation physical examination (PPE) performed on 2,739 high school athletes and present a model for providing PPEs in similar practice settings. DESIGN: We analyzed 2,739 PPEs performed on high school athletes by means of a station examination approach in our Sports Medicine Center during a 3-year period. MATERIAL AND METHODS: Personnel from the Departments of Physical Medicine and Rehabilitation, Orthopedics, Family Medicine, and Internal Medicine participated in performance of a comprehensive station-based physical examination of high school athletes. The final reviewing physician assigned one of three dispositions to each athlete: cleared for participation in sports, not cleared, or cleared with follow-up recommended. RESULTS: On the basis of PPE findings, 53 athletes (1.9%) were disqualified from participation in sports. Abnormalities that did not preclude participation but necessitated follow-up were identified in another 327 athletes (11.9%). Musculoskeletal problems were the leading cause of restriction from sports activities (43.4%) and the second leading cause for recommended follow-up (27.8%). Clinically significant cardiac abnormalities were noted in only 10 athletes (0.37% of the overall group of students). Our methods and results are discussed in relationship to previous PPE studies. CONCLUSION: On the basis of this study, we conclude that (1) a Sports Medicine Clinic can efficiently administer PPEs to a large number of athletes by using an adaptable station approach, (2) the musculoskeletal component of a PPE is an important part of the process that often reveals abnormalities and should be performed by qualified personnel, and (3) each practice must refine its delivery of PPEs on the basis of its particular environment.

Adolescent↗

PubMed1987

Evaluation of physical examination skills. Reliability of faculty observers and patient instructors.

Effective teaching of physical examination skills requires an evaluation system that can identify trainees who need further instruction. To study the evaluation of physical examination skills by faculty observers and patient instructors, the reliability of their observation of medical students performing a general physical examination was measured. Faculty observers did not reliably evaluate 32% of examination skills. Faculty agreement was lowest when observing components of the head, neck, and abdominal examinations. Patient instructors, with limited faculty training, reliably evaluated 83% of those skills that were reliably assessed by the faculty. These findings demonstrate limitations in the current methods of evaluating performance and point out the need to examine systems of trainee assessment.

Clinical Competence↗

PubMed2004

Vascular injuries in knee dislocations: the role of physical examination in determining the need for arteriography.

BACKGROUND: Popliteal artery injury is frequently associated with knee dislocation following blunt trauma, an injury that is being seen with increasing frequency. The primary purpose of the present study was to evaluate the use of physical examination to determine the need for arteriography in a large series of patients with knee dislocation. The secondary purpose was to evaluate the correlation between physical examination findings and clinically important vascular injury in the subgroup of patients who underwent arteriography. METHODS: One hundred and thirty consecutive patients (138 knees) who had sustained an acute multiligamentous knee injury were evaluated at our level-1 trauma center between August 1996 and May 2002 and were included in a prospective outcome study. Four patients (four knees) were lost to follow-up, leaving 126 patients (134 knees) available for inclusion in the study. The results of the physical examination of the vascular status of the extremities were used to determine the need for arteriography. The mean duration of follow-up was nineteen months (range, eight to forty-eight months). Physical examination findings, magnetic resonance imaging findings, and surgical findings were combined to determine the extent of ligamentous damage. RESULTS: Nine patients had flow-limiting popliteal artery damage, for an overall prevalence of 7%. Ten patients had abnormal findings on physical examination, with one patient having a false-positive result and nine having a true-positive result. The knee dislocations in the nine patients with popliteal artery damage were classified, according to the Wascher modification of the Schenck system, as KD-III (one knee), KD-IV (seven knees), and KD-V (one knee). CONCLUSIONS: Selective arteriography based on serial physical examinations is a safe and prudent policy following knee dislocation. There is a strong correlation between the results of physical examination and the need for arteriography. Increased vigilance may be justified in the case of a patient with a KD-IV dislocation, for whom serial examinations should continue for at least forty-eight hours.

Adolescent↗