In this era where point-of-care ultrasound (POCUS) may make the stethoscope obsolete, Dr. Daniel D. Dressler, professor of medicine at Emory University School of Medicine in Atlanta, started his presentation by asking if we should even do the daily exam anymore. Reviewing the Point:Counterpoint from Journal of Hospital Medicine 2021, he agreed with the summary that diagnostic finesse is necessary, practice is required to achieve this skill, inadequate or incomplete physical exams may lead to errors, and the ritual of the physical exam strengthens the patient-doctor relationship.1,2 If the physical exam is necessary, what maneuvers are most helpful on exam?
Likelihood ratios (LRs) were reviewed, to highlight that useful maneuvers are those that change your probability and management of a diagnosis. Meaningful maneuvers for anemia using a gastrointestinal bleed case study included conjunctival rim pallor of the eye (LR+ 16.7), dry mucosal membranes (LR+ 2.8), and poor subclavicular (not hand) turgor (LR+ 3.5). Postural blood pressure changes were also significantly helpful for decision making with LR+ of 30 for moderate blood loss (500 mL) and 98 for large blood loss (750-1,000 mL). He noted that there was no need to wait three minutes to assess orthostatic hypotension and quoted an article that one minute was more useful in predicting fractures and falls.3
A case study of the dyspneic patient noted that for diagnosis of heart failure, palpating the apical impulse was found to be an accurate evaluation. A laterally displaced apical impulse had an LR+ of 10.3 to predict a low ejection fraction, with an enlarged apical impulse more than 4 centimeters having an LR+ of 4.7. For those of us who do not routinely evaluate this, a normal apical impulse is dime-sized and under the nipple in the midclavicular line. Jugular venous distension had an LR+ of 5.1 for heart failure, with an S3 having an LR+ of 11 and an abdominal jugular reflex an LR+ of 6.4. To improve your exam for jugular venous distension, Dr. Dressler highlighted that the venous pulse (compared to the arterial pulse) is position-dependent (versus fixed), biphasic (versus monophasic), occludable (versus nonoccludable), not palpable (versus palpable), varies with respiration (versus constant throughout respiration), and augments with abdominal pressure (versus unchanged by abdominal pressure).
POCUS was compared to the physical exam in this talk, with POCUS lung findings for heart failure giving an LR+ of 8.8 and POCUS heart findings for heart failure associated with an LR+ of 6. If S3 and lateral displaced apical impulse are found, those LR+ are higher than POCUS for a diagnosis of reduced ejection fraction.
Sepsis in the ICU was the last clinical case considered. The modified early warning score, or MEWS, is often used in the ICU and is associated with an LR+ of 4.8 if it is over 5. Cool legs have an LR+ of 3.7 in shock, and mottled skin has an LR+ of 10.2. Capillary refill was reported as better than a lactate level for diagnosing shock. Anisocoria was also an important finding in patients on ventilators to diagnose possible intracranial bleeding in a sedated patient. Still, he noted, we also have to consider that eyes exposed to bronchodilators will do this as well.
Dr. Green
Dr. Green is an internal medicine hospitalist, internal medicine associate program director, and chief medical officer at Paris Regional Health in Paris, Texas.
References
- Rodman A, Warnock S. Rebuttal: Routine daily physical exam. J Hosp Med. 2021.doi: 10.12788/jhm.3672.
- McNamara LC, Kanjee Z. Counterpoint: routine daily physical exams add value for the hospitalist and patient. J Hosp Med. 2021. doi: 10.12788/jhm.3671.
- Juraschek SP, Daya N, et al. Association of history of dizziness and long-term adverse outcomes with early vs later orthostatic hypotension assessment times in middle-aged adults. JAMA Intern Med. 2017;177(9):1316-23.