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The physical examination remains a vital part of the clinical encounter.
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Many physical examination maneuvers are just as reliable as diagnostic gold standard tests.
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A hypothesis-driven approach to the physical examination emphasizes the performance of specific physical examination maneuvers that are able to alter the likelihood of disease in a given patient.
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The physical examination should be taught to trainees in a context-specific manner as opposed to the traditional head-to-toe approach.
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The Hypothesis-Driven Physical Examination
Section snippets
Key points
Basics of the hypothesis-driven physical examination
The performance of the HDPE can be separated into 3 tasks that can be then integrated into the whole task of a patient encounter (or simulated encounter for learning). First, accurate pretest probabilities for the likelihood of possible conditions in each patient must be considered. Second, physical examination maneuvers that have adequate operating characteristics to revise the probability of disease should be selected and performed. Lastly, the results of these findings must be combined with
Not All Examination Maneuvers Have Associated Likelihood Ratios
It is important to note that not all examination maneuvers have reported LRs. For example, if the presence of a physical examination finding defines the disease (ie, it is the gold standard test), there will not be an associated LR. Think of a patient with a herpes zoster rash. One does not need to calculate pretest or posttest probabilities of disease if the rash is characteristic; the patient has zoster. There are also examination maneuvers for which robust LR data are not available. This
The Concept of Coselection
In addition to routinely performing more than one examination maneuver during a patient encounter, clinicians usually consider more than one diagnosis at a time. The process by which multiple potential diagnoses are considered and evaluated is called coselection. Instead of creating diagnostic hypotheses after the history and physical examination (as is done in many morning reports), the HDPE encourages clinicians to consider diagnostic hypotheses before and during the application of history
Summary
The physical examination remains a vital part of the clinical encounter. For some diagnoses, the physical examination remains the gold standard diagnostic test. For other diagnoses, the physical examination provides prognostic information above and beyond technologically based tests. Although some physicians think that technology is more reliable than bedside observation, this is simply not true for several important physical examination maneuvers. When faced with a clinical question, it is
References (30)
- et al.
Moving toward cost-effectiveness in physical examination
Am J Med
(2015) - et al.
Airway obstruction in never smokers: results from the Third National Health and Nutrition Examination Survey
Am J Med
(2005) - et al.
Can moderate chronic obstructive pulmonary disease be diagnosed by historical and physical findings alone?
Am J Med
(1993) - et al.
Value of assessment of pretest probability of deep-vein thrombosis in clinical management
Lancet
(1997) - et al.
Celebrating two centuries since the invention of the stethoscope: RenéThéophile hyacinthe laënnec (1781-1826)
Ann Am Thorac Soc
(2016) - et al.
The value of physical examination: a new conceptual framework
South Med J
(2016) Evidence-based physical diagnosis
(2018)- et al.
Clinical determinants of mortality in chronic congestive heart failure secondary to idiopathic dilated or to ischemic cardiomyopathy
Am J Cardiol
(1987) - et al.
Confidential testing of cardiac examination competency in cardiology and noncardiology faculty and trainees: a multicenter study
Clin Cardiol
(2010) - et al.
A novel bedside cardiopulmonary physical diagnosis curriculum for internal medicine postgraduate training
BMC Med Educ
(2017)
Bedside medicine: back to the future?
South Med J
In the wake of the 2003 and 2011 duty hours regulations, how do internal medicine interns spend their time?
J Gen Intern Med
The other sylvian fissure: exploring the divide between traditional and modern bedside rounds
South Med J
Assessing the validity and reliability of diagnostic and screening tests
Hypothesis-driven physical examination curriculum
Clin Teach
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Disclosure Statement: The authors have no conflicts of interest to disclose.