When I was in training, it was common knowledge that the observations we made when examining patients were important ones that enabled us to accurately diagnose the patient’s disease. Since then, a number of physical findings have been shown to be either inaccurate or less than helpful in diagnosing disease states. For example, I was taught a number of maneuvers to determine if abdominal ascites were present. However, in recent years, carefully controlled studies have demonstrated that the accuracy of physical examination findings predicting the presence of ascites are less accurate than I was taught.1, 2, 3 Similarly, the presence of crackles or rales noted during auscultation of the chest is not an accurate sign of heart failure because these findings can occur secondary to a long list of pulmonary diseases.2 Similar results have been obtained with other physical findings; for example, the presence of pleural effusion is defined with considerably greater accuracy with a computed tomography (CT) scan than with physical findings.4 Indeed, current imaging techniques, such as ultrasound, computed tomography, and magnetic resonance imaging (MRI), have repeatedly shown to be more accurate in diagnosing specific disease conditions when compared with the traditional physical examination. However, despite the potential inaccuracies of the physical examination, I and others contend that it is an important initial step that must be taken in the evaluation of patients.5, 6
In a previous issue of The American Journal of Medicine, Loloi et al measured the size of the liver by physical examination and by ultrasound.7 There was excellent correlation and even quite accurate absolute values when a modest correction factor was introduced. This is further evidence that a carefully done physical examination discloses clinically important information.
Let us examine two simple examples: Patient AB and patient CD both complain of effort intolerance, and both have prolonged aortic systolic murmurs consistent with severe aortic stenosis. On physical examination, AB is noted to have muscle wasting, a markedly protuberant abdomen with large visible veins, as well as palmar erythema, and multiple skin spider angiomas scattered over his body. Patient CD has none of these findings and appears well nourished with normal muscle tone and volume. Clearly, even before blood and imaging tests are obtained, the discussion with patient AB will be quite different from that held with patient CD. Patient AB is diagnosed with probable end-stage liver disease in addition to his aortic stenosis and thus making him a poor candidate for aortic valve replacement. Once confirmatory laboratory and imaging studies are obtained, the clinical focus for patient AB will be control of his end-stage liver disease. Patient CD will likely undergo surgical or catheter aortic valve replacement. The physical findings on these two hypothetical patients were clinically important and directed the rest of the diagnostic and therapeutic experience. Additionally, the physical examination was inexpensive compared to the subsequent laboratory and imaging studies, and the examination is not time intensive. As noted in my previous editorial on this subject,8 our patients expect to be examined and are disappointed if we fail to perform this straightforward clinical ritual.
The take-home message about the physical examination is that it does disclose important information. In addition, patients expect to be examined and are disappointed if this ancient clinical ritual is omitted.8 I have repeatedly noted that patients expect their physician to examine them despite the fact that this is an unusual situation (ie a relative stranger making physical contact with their body).
As always, I enjoy hearing from readers about this editorial or any other; please comment on our blog at amjmed.org or by sending me an e-mail at jalpert@shc.arizona.edu.
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-Joseph S. Alpert, MDa,b
This article originally appeared in the June 2019 issue of The American Journal of Medicine.
