Physical Exam Pearls: Evidence based exam

1. Physical Exam Pearls:Evidence based exam  Karen McDonough MD Assistant Professor, General Internal Medicine

2. Brief History of the Physical Exam 1550 BC Egyptian physicians describe inspection, palpation, percussion in hieroglyphs 400 BC Hippocrates describes the succusion splash in pleural effusion 1819 AD Laennec (inventor of the stethoscope) publishes �Treatise on the Disease of the Chest� 1885 AD Osler describes the protean exam findings of SBE 1950s AD The �Golden Age� of the cardiac exam

3. 2008 AD SKIP THE PHYSICAL EXAM, AND GET A PAN-MAN SCAN �AND A BUNCH OF LABS!!

4. Ideal Physical Exam Technique Straightforward to learn and perform Used in guiding evaluation and management common problems Sensitive enough to rule out disease if absent OR Specific enough to rule in disease if present

5. Likelihood ratios Positive LR refers to the presence of a physical sign � the bigger the number, the more helpful the sign Negative LR refers to the absence of a physical sign � the closer to zero, the more helpful the sign

6. For mid-range pre-test probability: +LR 1 doesn�t help -LR 1 no help +LR 2 increases 15% -LR 0.5 decreases 15% +LR 5 increases 30% -LR 0.2 decreases 30% +LR 10 increases 45% -LR 0.1 decreases 45%

7. Figure out ahead of time which exam findings will substantially help you in evaluating patients you commonly see, and remember those exam findings.

9. LE Edema in Ascites Patient with suspected ascites � 50/50 Physical finding: LE edema Positive LR: 3.8 Negative LR: 0.2

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12. Same patient� You check for a fluid wave Positive LR 5.0 Negative LR 0.5

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15. In abdominal distention� Argues FOR ascites + fluid wave (LR 5.0) + edema (LR 3.8) + shifting dullness (LR 2.3) Argues AGAINST ascites - edema (LR 0.2) - flank dullness (LR 0.3) - shifting dullness (LR 0.4)

16. Case #1 A 22 year old woman presents for an annual exam. She has a 2/6 systolic murmur along the left sternal border. Should we order an echo???

17. Telling systole from diastole At HR < 100, systole is much shorter than diastole At the left upper sternal border, S2 is louder than S1 Time the cardiac cycle to the carotid pulse � the carotid upstroke occurs after S1, during systole

18. Systolic Murmurs Broad differential: AS, MR, TR, HCM, ASD, VSD, PS, increased blood flow in anemia, fever, pregnancy, hyperthyroidism, or �innocent� Present in 5-52% of young adults >90% have normal echocardiograms Present in 29-60% of older persons >50% have no clinically significant valvular disease on echo

19. Innocent or Functional Murmur Short, early or midsystolic 2/6 or less Localized to left sternal border Normal neck veins, pulses, apical impulse and S1/S2 Hypertrophic cardiomyopathy should be ruled out by exam Should also ensure negative history and ROS for cardiac sx

20. Accuracy of exam in identifying �normal� and �abnormal�murmurs Murmurs meeting above exam criteria LR of valvular heart disease 0.3 (negative hx should decrease likelihood further) Murmurs not meeting above criteria LR of valvular heart disease 38

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23. Hypertrophic Cardiomyopathy Uncommon cause of systolic murmur Causes sudden death in young athletes SO�you don�t want to miss it

24. Hypertrophic Cardiomyopathy Unlike most other systolic murmurs, HCM should get LOUDER with decreased venous return because the walls of the left ventricle come closer together WAYS TO DECREASE VENOUS RETURN Valsalva x 20 sec (+) LR 14.0 (-) LR 0.3 Squat to stand (+) LR 6.0 (-) LR 0.1

25. HCM Unlike other systolic murmurs, HCM should get SOFTER with increased venous return because the LV walls are farther apart WAYS TO INCREASE VENOUS RETURN Stand to squat (+) LR 7.6 (-) LR 0.1 Passive leg (+) LR 9.0 (-) LR 0.1 elevation

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28. Case #2 A 62 year old man presents with 2 months of dyspnea on exertion. He used to be able to push his cart around Costco; now he is barely able to push it up the ramp.

29. Chronic Dyspnea 2/3 cardiac or pulmonary CHF COPD Asthma Atypical angina Restrictive lung disease Pleural effusion 1/3 other Anemia Deconditioning Kyphoscoliosis

30. CHF + LR - LR + abdominojugular 8 0.3 Apical impulse lateral to MCL 6 NS S3 6 NS Elevated JVP 4 NS Crackles NS NS Edema NS NS

31. Measuring JVP

32. Teaching MSIIIs: Jugular vs Carotid Most prominent in descent Not palpable Erased by pressure Usually two pulsations per cycle Inspiration = more visible Most prominent in ascent Palpable Not erased by pressure Only one pulsation per cycle Inspiration = no change

34. When will I REALLY use JVP in internship? Determining adequacy of fluid resuscitation Assessing low urine output Deciding on today�s diuretic dose in CHF or volume overload Assessing an acutely short of breath patient

35. Abdominojugular test Midabdominal pressure for 10 seconds Positive test = sustained rise in CVP > 4 cm Positive test indicates elevated left atrial pressure with + LR 8.0 - LR 0.3

36. Apical impulse Palpable apical impulse in one-third of adults when supine and 50% in L lateral decubitus In supine patient , apical impulse lateral to MCL supports CHF as the diagnosis with LR 6.

38. Diastolic sounds: S3&S4 S3 �rapid early diastolic filling Normal people under 40 Elevated left atrial pressure For CHF + LR 6 S4 � atrial contraction pushing blood into a stiff and non-compliant ventricle Not heard in atrial fibrillation Occurs in HTN, AS, CAD For CHF � LR NS

39. COPD Spirometry is more sensitive for early COPD; most exam signs identify more severe disease Not all smokers who are short of breath have COPD

40. COPD + LR - LR Subxiphoid PMI 7 NS Any unforced wheeze 6 NS Breath sound score < 9 10 -- 10-12 4 > 15 0.1

41. Breath sound score Listen at 6 sites � bilateral Anterior apices Midaxilllae Posterior bases Score breath sounds at each site Absent 0 Barely audible 1 Faint but audible 2 Normal 3 Loud 4

42. COPD Does patient have 2/3 of Tobacco use > 70 py Self described hx of emphysema or chronic bronchitis Decreased breath sounds + LR 25 - LR 0.3

43. Commonly missed uncommon cause of chronic dyspnea Pulmonary hypertension Especially in young women Findings Elevated JVP Loud P2 RV heave RV S3 In RV failure � wide split S2

44. Quick Quiz

45. Case #3 A 34 year old woman presents to the clinic with a 3 day history of productive cough. She is concerned about the possibility of pneumonia.

46. Findings supporting pneumonia + LR - LR Egophany 4 NS Bronchial breath sounds 3 NS Dullness to percussion 3 NS Decreased breath sounds 2.3 0.8 Crackles 2.0 0.8 Temperature > 37.8 2.2 0.7 HR > 100 1.6 0.7

47. Pneumonia Diagnostic Score Temperature > 37.8 Heart rate > 100 Crackles Decreased breath sounds Absence of asthma

48. 0 or 1 point LR 0.3 2 or 3 points NS 4 or 5 points LR 8.2

49. This patient has a temp of 38.2, decreased breath sounds and crackles at the right base, and no history of asthma. Her score is 4, LR of pneumonia is 8.2. A CXR shows a RLL infiltrate. You start her on azithromycin, and schedule follow up the next week.

50. 3 days later� She returns, still feeling sick. On exam, her temp is 37.9, HR is 88, RR is 20 and O2 sat is 94% on RA. She has markedly decreased breath sounds at the right base, but no audible crackles.

51. What are the possibilities?How will you tell them apart?

52. Consolidation Effusion Decreased BS yes yes Dull to percussion yes yes Tactile fremitus increased decreased Bronchial BS maybe no Egophany maybe maybe at top Crackles maybe maybe at top Pectoriloquy maybe no

53. Case #4 A 68 year old man with a history of tobacco use and knee arthritis presents with 3 months of pain in his right thigh when he walks.

54. Leg Symptoms in PAD Consecutive patients diagnosed with PAD in vascular lab Only 150/460 patients with PAD (ABI < 0.9) had typical claudication Other exertional leg symptoms in 131 pts Leg pain on exertion AND rest in 88 pts No leg pain but no exertion in 28 pts ABI similar in all groups ( ~ 0.6 � 0.7)

56. Pedal pulses In normal people 3-14% do not have palpable DP 0-10% do not have palpable PT BUT if one is absent in someone without PVD, the other makes up for it The absence of both pedal pulses has LR of 14.9 for PVD

57. What if you suspect PVD, but one or both pedal pulses is PRESENT? (-) LR of 0.3 for PVD Some patients with PVD will have palpable pedal pulses � with exercise, most will go away

58. OTHER EXAM FINDINGS Bruit LR 7.9 Foot wounds/ulcers LR 7.0 Absent femoral pulse LR 6.1 Asymmetric cool foot LR 6.1

59. NOT SO HELPFUL EXAM FINDINGS Prolonged capillary refill time (LR 1.9) Atrophic skin (LR 1.7) Hairless (LR 1.7)

60. Ankle Brachial Index Normal 1.0-1.2 Claudication 0.5-0.9 Rest pain <0.5 Gangrene <0.2