Lecturio Live: Physical Examination with Dr. Stephen Holt (2022)

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    00:02 Hello, everyone.

    00:03 Welcome to our live event today.

    00:05 It's been a while.

    00:06 I'm really excited for everyone to be back, for me to be back.

    00:10 And especially for Dr. Stephen Holt from Yale to be back because we are so so excited about our presentation today.

    00:17 While we are waiting for everyone to pop in, please go ahead and let us know in the chat where you are tuning in from.

    00:23 We already have Luis from Puerto Rico.

    00:26 I am actually broadcasting live from Germany right now.

    00:31 Dr. Holt, where are you? I'm broadcasting from Connecticut.

    00:37 Alright.

    00:38 All right, so we've got a lot of well, many, many countries represented Egypt, Philippines, Ghana, Lebanon, Italy, Australia, Netherlands, Russia, New Zealand, Nepal, Sweden, Georgia, USA, Tanzania, Nigeria, Belarus.

    00:56 All right, UK, Syria, Columbia.

    01:01 All right, Peru, Belgium.

    01:04 I don't think I can list them fast enough.

    01:07 But yeah, awesome.

    01:08 It is so wonderful to have you all here today.

    01:11 I'm gonna go through a couple of short housekeeping things, since many of you are probably new to this.

    01:17 But I would like to start with an introduction.

    01:20 Who are you? So there's a poll question that is going to be popping up in just a second.

    01:25 Go ahead and answer that.

    01:26 We just want to know where you are in your studies.

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    02:12 The family nurse practitioner, awesome, an RN.

    02:17 Happy to see some pre-medical students there like contemplating this career path and getting jump on things early so that's great.

    02:27 Physician assistant or flight nurse, that sounds like a fun job.

    02:30 Stressful but fun job.

    02:36 All right, excellent.

    02:39 And one other question, how familiar are you guys with Lecturio? So another poll is going to pop up.

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    04:10 All right, so last question and then I will stop talking.

    04:14 Because I know I'm not the person you came here to see.

    04:17 Have you been to one of our events before? You all are using the chat already very well.

    04:23 So go ahead and just let us know there.

    04:25 Give us a yes or no.

    04:27 If you've been to one of our events before, if maybe you were at our physical examination about last year.

    04:34 Just go ahead and let us know.

    04:35 Looks like we have a pretty good mix here.

    04:39 And a lot of people who haven't been yet.

    04:40 So we're very, very excited to both welcome you back and to have all of our new friends here.

    04:48 But yeah.

    04:50 All right.

    04:51 So those of you who can't hear at the moment will not hear what I'm saying.

    04:57 But in case anyone later has a question or an issue with audio or something, go ahead and refresh and we're also going to post some tips for any connection issues in the chat as well.

    05:11 And Tailor yes we do record these and a link will be sent around to you in our follow up by the end of the week.

    05:18 So without further ado, I'm not the one you want to talk to.

    05:21 Today, we're talking about physical examination, physical exam likelihood ratios, our physical examination course and of course, we have a Q&A session.

    05:29 So you can pop your questions in the chat throughout the entire presentation.

    05:32 We'll get to them at the end.

    05:34 But without further ado, I would love to introduce you to Dr. Stephen Holt.

    05:38 He's a professor at the Yale School of Medicine and I will let you introduce yourself even more.

    05:43 So thank you so much for being here everyone.

    05:47 Thanks so much, Kate.

    05:48 So I'm delighted to be here as well.

    05:50 It's so great to see such a range of folks who are joining us today this morning.

    05:56 I am Stephen Holt.

    05:58 I'm an Associate Professor of Medicine at Yale School of Medicine.

    06:01 I'm an internist.

    06:02 And I'm also a board certified in addiction medicine so I do a lot of addiction work as well.

    06:07 And kudos to it was Simon's who said in addiction medicine.

    06:12 Physician joining the chat as well, this talk in particular, of course, is focused on the physical exam, which is one of my passions, and it's been one of my passions for 20 years now.

    06:24 And we'll talk about why I'm so excited about the physical exam and have sort of promoted it's used for quite a while now.

    06:34 I do internal, I do inpatient medicine on the general medicine ward boards, and I do a lot of outpatient medicine.

    06:40 And I teach musculoskeletal exam and a variety of other sort of content areas at the medical school as well as within the primary care internal medicine residency program, where the physical exam is really such an important skill.

    06:53 So with that, let's jump in.

    06:56 I'm going to start with a case as is often a good thing to do.

    07:00 So let's say you're seeing a 49-year-old man with a medical history of obesity who presents with left-sided anterior knee pain that you know, he's out there playing with some of his friends.

    07:11 And this injury began immediately after twisting his knee during a recreational basketball game.

    07:19 He's concerned that he might have torn his ACL is anterior cruciate ligament.

    07:25 So he's coming to see you right after this injuries occurred and he's asking to get an MRI.

    07:30 Now, you may ask yourself, "Well, it's let's just get the MRI." It's easy enough to just click that button on the order screen or write the MRI order on paper and make it happen, especially if you're coming from our healthcare system that has that resource.

    07:44 Why not just order the MRI? Well, I hope that by the end of this presentation, I've explained why getting an MRI and over relying on diagnostic imaging more generally, has its own perils.

    07:58 So what is the purpose of performing a physical exam? What do you guys think on this particular patient? What is the purpose of getting performing a physical exam? Why not just get that MRI? Great, so I'm hearing different components of the physical exam.

    08:22 A rationale there, cost effectiveness, cheaper and more reliable in some cases, wanting to avoid additional costs.

    08:30 And...

    08:34 to make a preliminary diagnosis before even thinking about doing before getting diagnostic imaging, in a lot of areas, of course, the MRI is not available.

    08:43 And that is absolutely the case.

    08:46 You know, I'm working in the United States healthcare system where there is without question and over reliance on diagnostic imaging and including the MRI.

    08:54 That's not the case in many other places.

    08:56 And the MRI does cost a lot even if you do have access to it, is it right? That sort of spend somebody for $5,000 test when there may be other ways to do it.

    09:06 So value basic care.

    09:07 I'm seeing some other comments about that as well.

    09:08 Outstanding, great, great comments in the chat.

    09:10 So let's go through some of the things in a bit more detail.

    09:14 So in many ways discussion about the physical exam is pitting the physical exam on one side against diagnostic imaging on the other side.

    09:24 And each one of course, has its own advantages and disadvantages.

    09:28 And we have to sort of think about what what are the advantages and disadvantages of each of those two camps, if you will.

    09:36 As we do that a few times in the talk where we're going to just put in some little physical exam findings that you can see that may be hard to detect with diagnostic imaging, or impossible to detect in diagnostic imaging.

    09:48 So for example, what is this finding and what might it signify in a patient with a fever? Great seeing a couple different things are opening all kinds of stuff in the chat there.

    10:08 And actually, oh, perfect yes.

    10:09 So somebody said, oh, there's nodes, which is right.

    10:12 And then of course, the follow up there is bacterial endocarditis.

    10:16 This is one of the many stigmata of spontaneous bacterial endocarditis.

    10:22 And Osler's nodes would certainly be something you're going to miss if you're not looking for it in a patient who has a fever, and then hopefully, later on, you might detect that murmur on exam, or some of the other classic stigmata of endocarditis.

    10:37 So excellent.

    10:43 All right, so there's the answer there.

    10:47 So let's think about what are the barriers to the physical exam? Why do I even have to give a talk promoting the physical exam? Well, many people may view the physical exam as antiquated, you know.

    10:59 It's an old approach to diagnosis that has been around for centuries, but maybe it's just out of date now, you know, there's so many advanced diagnostic imaging tests and so many other modalities for making that diagnosis.

    11:12 Do we really need the physical exam anymore? And many people may think about the physical exam as a place that it's people just aren't trained to do anymore.

    11:20 You know, maybe you haven't been trained in your own clinical training, or perhaps your professors aren't really emphasizing it.

    11:29 And maybe they even themselves may not have learned a lot about the physical exam.

    11:32 And so it's being undervalued in that way.

    11:35 Is the physical exam really an accurate modality? Like can we use it to really diagnose things compared with diagnostic imaging? And lastly, do we have time? Do we have time to train ourselves and learn these skills? And moreover, do we have time to do these exam tests when we're with the patient? You know, honestly, writing MRI of the left knee is a pretty fast thing to do, and probably faster than performing that physical exam.

    12:01 So, you know, is it something where we really have time to do it? Those are all potential barriers that we need to think about.

    12:09 So let's focus first on accuracy of radiology compared with the physical exam.

    12:16 So this test, this study has been done in every joint in the body in some form or other.

    12:22 And this particular study looked at 100 individuals who had absolutely no symptoms.

    12:27 They were all over the age of 45.

    12:29 So someone like me, I'm 47.

    12:31 And I'm out there playing tennis, no issues, and I participate in this study.

    12:36 I have no symptoms whatsoever.

    12:38 And it turns out that if you do an MRI of these 100 individuals, 36 of them had asymptomatic meniscal tears.

    12:48 So what does that tell us? It tells us that if a patient comes in and they have knee pain, before we even try and figure out where their knee pain is coming from.

    12:56 If they're over the age of 45, a third of them have a meniscal tear that's not even causing them any problems.

    13:03 So if we do an MRI, and we find a meniscal tear.

    13:06 Does it really mean that that's the cause of their pain? It gets really difficult to tease that apart.

    13:11 And this is the case for MRIs of asymptomatic people in terms of looking at their backs, looking at their ankles, looking at the shoulders, you'll find stuff that's pathology, but actually may not be bothering the patient.

    13:24 It may have nothing to do with the source of their pain.

    13:26 This gets to this concept of accuracy versus precision.

    13:30 If you look at the physical exam, I like to think of it as, if the center of this bullseye like on a dark board is the source of somebody's pain and the center is is sort of where the pain really is, the physical exam, sort of will get you to the source of the pain.

    13:47 All these different physical exam findings, each one is represented by a red dot are honing in on the source of the pain.

    13:53 So there's accuracy.

    13:55 We're moving in on the target the actual place where the pain is generated from.

    14:00 In contrast, an MRI on the right hand side has very high precision.

    14:05 You know, if I get five MRIs in a row and have five different radiologists read it, it will probably all identify this meniscal tear, but they're not really showing you what the cause of the pain is.

    14:18 So high precision below accuracy.

    14:21 And that's why all these red dots are clustered in one area on the dartboard but they're not clustered in the middle where the source of the pain actually is.

    14:29 So just wanted to highlight that distinction between accuracy and precision.

    14:34 And of course, when we over rely on diagnostic imaging, there's also this potential for so called incidentalomas.

    14:41 An incidentaloma as written here is a lesion found incidentally through radiologic imaging, you weren't looking for it.

    14:47 They are of unknown clinical significance and often further investigation of these lesions requires repeated risky radiation exposure.

    14:57 If you look at the variety of different diagnostic imaging tests that we've perform, you may have had a decent reason to use them up front.

    15:04 But unfortunately, now you're getting all this extra data.

    15:08 When you get a CT scan of the abdomen, because you're concerned about gallbladder disease or something, maybe you're screening for some condition or looking at the aorta, etc.

    15:19 Unfortunately, you're looking at the whole abdomen, you're getting everything in the abdomen, including adrenal incidentalomas, pancreatic incidentalomas, etc.

    15:27 And now you have to deal with that.

    15:29 So by going and looking for things with unfortunately, this sort of big shotgun approach, diagnostic test, you oftentimes will find things you weren't looking for.

    15:39 In this case, you tend to 67% of neck ultrasounds will reveal thyroid nodules.

    15:45 4% of CT scans and that's a lot will have adrenal masses.

    15:50 And then 15% will have pancreatic masses that now you have to show your what you're going to do with and that can add a lot of stress to the patient, a lot of unnecessary procedures down the road and more diagnostic imaging, you know, they need to get a follow up CT scan every 6 months or 12 months.

    16:05 So this is certainly can be very challenging as well.

    16:10 And of course, radiation itself is dangerous.

    16:13 If you perform radiologic tests over and over and over again, you can really dramatically increase the exposure of particular patients radiation, which we know is itself dangerous.

    16:25 So for example, in this first bullet here, a single CT scan, single CAT scan expose the patient to approximately 10 millisieverts of radiation.

    16:34 Millisieverts is the unit of measurement we use to describe how much radiation somebody's being exposed to.

    16:41 And we know that every excess 50 to 100 millisieverts of exposure for a patient, statistically significantly increases that person's risk of cancer.

    16:54 So if a person gets five CT scans in a year, they've got an already an additional 50 millisieverts beyond kind of background radiation.

    17:03 And that can increase statistically significantly their risk of cancers down the road.

    17:08 It's estimated that as many as 2% or more of all future cancers, at least based on United States data will come from just getting CT scans alone, which you hate for the diagnostic test to also be the cause of problems down the road.

    17:26 That's absolutely the case when we overdo it with CT scans.

    17:32 And to quote Abraham Verghese, one of my own role models, and just an exceptional clinician out at Stanford, he said, "And so many clinical signs such as rebound tenderness, lid lag, tremor, clubbing, and hemiparesis cannot be discerned by any imaging test." It's just highlighting here that there's so many things which you can't even find with diagnostic imaging.

    17:54 You need to be able to find these things with your physical exam skills in order to make some of these diagnoses.

    18:02 Again, just another little physical exam primer here.

    18:08 So, can any of you identify these findings and what they might signify? Yes, so that is correct.

    18:22 I'm seeing both things.

    18:23 So pectus excavatum, that's the one on the left and then pectus carinatum is on the right.

    18:29 This is sort of a caved in chest.

    18:32 And this is so called pigeon chested or carinatum.

    18:38 And what are these signifying? Well yes, correct Marfan Syndrome.

    18:41 So these are classic findings that you might see in Marfan syndrome.

    18:45 And that's certainly important because you don't want to ignore a diagnosis of Marfan Syndrome as there are these attended consequences involving the aortic root and other cardiovascular structures.

    18:56 So that's the diagnosis you don't want to miss, but you can easily miss it if you're not savvy to some of these classic physical exam findings.

    19:03 Excellent.

    19:07 Some concern and ribs may be a sign of connective tissue diseases such as Marfan.

    19:16 All right, so we've just talked about some of the disadvantages of Radiology.

    19:21 Now let's talk about some of the advantages in particular of the physical exam.

    19:29 So first off, and I'm gonna go through this quickly.

    19:33 Physical exam, it's pretty rare that you're going to find incidentalomas, right? I'm definitely not going to find on my physical exam and adrenal mass safe to say nor am I going to find a pituitary mass either.

    19:45 So you're less likely to find things you're not looking for.

    19:47 I'm not going to say that, you know, people don't occasionally auscultate the carotid and think that they hear a brewery and now this person has to get a you know a carotid ultrasound etc.

    19:57 So occasionally there are incidental findings, but they're much more rare compared with diagnostic imaging.

    20:03 Likewise, unless you're drinking, you know, a half a pint of radioactive iodine before you perform your physical exam.

    20:09 It's pretty unlikely that you are exposing any of your patients to radiation while performing the exam.

    20:15 So we don't have to worry about, you know, adding millisieverts of radiation to people with some year.

    20:23 Secondly, you know, I don't know about you, but most of us went into this business because we like the challenge of being with patients, of having face to face contact with patients.

    20:36 The excitement of trying to make...

    20:47 Doctor, you've just muted yourself accidentally.

    20:57 You might need to unclick it on your screen.

    21:00 There's like a mute button.

    21:02 I can't hear you.

    21:16 Give us just a minute, everyone.

    21:17 We'll fix the audio issue.

    21:36 I can't hear you.

    21:44 Oh, yep, there you are.

    21:47 I think we lost you at rewarding.

    21:50 Go ahead.

    21:51 I know, you could hear me there for a second.

    21:53 Can hear me now as well? Yes.

    21:55 Yes okay, all right great.

    21:57 Let me continu then, something happened with my...

    21:59 It's a little quiet.

    22:00 So you might want to speak.

    22:02 A second...

    22:07 I want to highlight was rewarding.

    22:09 We view the physical exam as an opportunity to spend time with patients exciting to sort of look at the theology of disease, like how does disease manifests in the body.

    22:21 Seeing those manifestations on the skin, on the organs, you know honestly, physical exam, I think most of us went into medicine, not because we were excited about being data programmers or data analysis and computer programmers looking at computer screens all day.

    22:36 Being with patients, it's so much more exciting and fun and rewarding.

    22:40 And so I'm hoping that argument is pretty straightforward.

    22:51 The third bullet there is, and this goes back to what somebody said before about how we don't always have an MRI.

    22:56 We always have your hand diagnostic ability that we have with our own hands with our own senses.

    23:02 It's free, and it's always available.

    23:04 Wherever I am, I know I can use my physical exam to try and make a diagnosis.

    23:08 And that's not the case at two o'clock in the morning, I'm not gonna get an MRI, it's not the case if I'm not in my own hospital or from somewhere else, or a different healthcare system, I'm not going to have access to those things.

    23:19 But my physical exam, I always have access to at all times.

    23:24 Of course, bullet point there is the timelessness of proficiency.

    23:28 I've got bad news for you guys.

    23:30 There is a lot of things that you're going to learn during your professional training, whether it's nursing school, medical school, PA school, etc.

    23:37 That will expire within the next 5,10-15 years.

    23:41 There's a lot of diagnostic tests, a lot of medications, a lot of laboratory testing, a lot of those things become obsolete over time with further innovation and further understanding of physiology, etc.

    23:59 The only thing that I promised you will never expire and will never become obsolete is your physical exam skills.

    24:05 You can effectively test the deep tendon reflexes and look for a Hoffman for upper motor neuron disease.

    24:14 Today, you can do it effectively 50 years from now.

    24:17 It will never expire.

    24:18 And there's certainly something awesome about the timelessness of that.

    24:24 And lastly, connection to patients, as I said, being at the bedside with patients, connecting with them, holding their hand if need be providing some assurance.

    24:35 It's such an important part of our role as clinicians.

    24:40 And you're not going to get that by sitting in front of a computer constantly ordering and looking at diagnostic imaging tests.

    24:46 Physical exam of the time to be with your patients.

    24:50 And that laying on a pan that ritual of being with them is such an invaluable thing that we have.

    24:58 And it's really an honor and a privilege that patients put us in a position to be there with them.

    25:09 Alright, so how do we do this? How do we make sure that we're doing this properly? "Good physician treat the disease, but the great physician treats the patient who has the disease." by Sir William Osler But first off, make sure you're asking permission, when you're examining patients especially if there's a room of you, you're rounding on the wards and there's a team of four or five people.

    25:33 You can't just jump in, put your hands on their back, listen to their lungs.

    25:38 Ask permission.

    25:39 Is it okay now if we take a listen to your lungs? Is it okay if we test your reflexes and perform a pyramidal compression test on your cervical spine? Just have the patient invite you in, patients are not object.

    25:54 Secondly, respect modesty.

    25:56 I've been in exam rooms, especially when I've traveled internationally in various places where the patients are almost completely disproved for physical exam.

    26:05 There's no reason for that.

    26:06 You only need to expose the parts of the body that you're going to examine.

    26:09 So I'm going to listen to somebody's lungs.

    26:11 I don't need to have them disrobe in the front as well.

    26:15 I'm assessing just their knees today that I only need to have them, if they can still wear their shirt and whatever above their waist.

    26:22 I just need to be able to examine their legs.

    26:25 So just really respect modest.

    26:27 Likewise, ensuring patient comfort.

    26:29 Make sure your patient isn't freezing or make sure your patient is not in an uncomfortable position for a long time.

    26:35 Because you're talking about what we found you know, typically you have a patient hold their breath while you're doing a particular maneuver, examining the heart and you forget to tell the patient it's okay to breathe now.

    26:48 I've seen some pretty obedient patients hold their breath for a long time.

    26:52 So make sure you're always attending patient comfort.

    26:56 Introducing everyone in the room, especially again, if it's a team of four or five people, everyone should introduce themselves so that there aren't strangers, especially when you're exposing sensitive areas.

    27:07 And lastly, depending upon what you were talking about with your peers, your colleagues in the room, you're talking about whether this finding of a swollen lymph node in the axilla could indicate something like sarcoidosis or some viral condition, but it could also represent lymphoma or cancer.

    27:27 You're starting to talk about those kinds of things, make sure you explain what you're going to do to patient what the diagnostic plans are going forward.

    27:37 Don't just leave, you know, the your conversations shrouded in mystery.

    27:41 And your patients can really get very anxious and worried about what you're talking about.

    27:45 Summarize your finding facts to the patient.

    27:50 Alright, let's transition now to talking a little bit about likelihood ratio and how to use them.

    27:59 So going back to our initial patient who had this left knee popping sensation while playing basketball is now concerned they have an ACL tear.

    28:09 Is anyone able to name some exam findings that are specific to an ACL tear? Tell us some stuff.

    28:21 If your door test is correct there is another one that's important.

    28:24 This was Lachman.

    28:25 Nice job Sandeep, that is correct.

    28:28 So I'm your Tuesday maneuvers.

    28:30 And they are the Lachman in the middle column here in this little table.

    28:36 And then on the far right is the Anterior Drawer Test.

    28:39 So you know, every physical exam maneuver, and this one that's been studied has the likelihood ratio, positive likelihood ratio and a negative likelihood ratio.

    28:51 And we use those numbers to help them modify our pre-test probability.

    28:55 How likely is it that this person does or do not have a particular disease? In this particular case, I'm going to be the paragraph on the left.

    29:05 We already talked about our patients on exam.

    29:08 The Lachman and anterior door tests are both negative.

    29:12 Look at our table here.

    29:14 And look at the row that says negative LR, negative likelihood ratio.

    29:18 A Lachman negative likelihood ratio was 0.2.

    29:23 And the anterior door is negative likelihood ratio was 0.5.

    29:27 So what does that mean? What are we actually going to do with that information? Step one is to come up with a pre-test probability.

    29:40 That is before you even perform the physical exam, how likely is it that a 49-year-old man who present with anterior knee pain after twisting his knee, how likely is it that this person has an ACL tear? Now, you can base that on your own experience.

    29:57 You can base it on what you're attending things or you base on something like the rational, Gemma's rational clinical exam series where they actually look at historical finding age groups, etc, to help predict how likely it is that somebody with this story has a particular condition like if a person report substernal chest pain that radiates through both arms.

    30:20 There's the rational clinical exam series that tells you what the likelihood that represents acute coronary syndrome.

    30:27 So in this case, on the data we have so far, we know that the pre-test probability that this patient has an ACL tear 20%.

    30:36 A 20% chance they have an ACL tear, I mean, it's an 80% chance, they don't have an ACL tear.

    30:42 And so the odds of having an ACL tear is 20:80.

    30:46 So 20:80 which is 1:4.

    30:48 So it's a 4:1 chance that this person has an ACL tear just before we even done the physical exam.

    30:54 So pre-test odds is 1:4.

    30:58 You can take those pre-tests odds now and multiply that likelihood ratio we looked at in the prior slide.

    31:05 Remember, the negative likelihood ratio for a Lachman maneuver is 0.2, which probably is really good, really good test.

    31:12 So 1/4 with our pre-test odds, multiply that by 0.2, which is one over five, and you end up with this new number 0.05 convert that back to a percentage.

    31:29 And you end up with a new post-test probability of 4.8% would actually do that calculation, if you take your post test on your 0.05.

    31:40 We do 0.05 over 0.05 plus 1, we got an equation on the far left that yield 0.05 over 0.05 plus 1 times 100 fields a percentage of 4.8%.

    31:54 So with one single exam maneuver, I've been able to reduce the likelihood that this person has an ACL tear from 20% down to less than 5%.

    32:06 So there's a 95% chance that this person's knee is going to be fine.

    32:12 What does that tell me as a as a provider, if I'm in the urgent care setting and a patient tells me, Hey, here's what we're gonna do.

    32:19 I'm gonna put you on crutches.

    32:20 I'm gonna give you some NSAIDs, you know, some ibuprofen or Motrin, and I may put a brace on your knee temporarily.

    32:27 But we're not going to do an MRI, we're going to see how you feel in like two or three days.

    32:31 And it may be that if you just injured your knee or maybe strained or sprained one of the ligaments in your knee, it's going to start feeling better within the next couple of days.

    32:40 Whereas if you really had an ACL tear, I'm going to be able to detect that again, 3 or 4 days from now with another physical exam.

    32:48 And if I'm concerned at that time that you've had an ACL tears, and yes, I can get an MRI.

    32:52 There's no reason to jump into getting an MRI today because I've just reduced your likelihood of having it but less than 5%.

    33:01 You learn how to do Lachman maneuver and an anterior drawer by watching the video where we go through in detail all the differences contaminate the pelvic muscles.

    33:14 But previous probably derived history and prevalence LRs negative likelihood ratio all that stuff.

    33:20 Now that was a couple a series of steps there.

    33:22 Here's how to deal with calculations.

    33:24 There are some easy ways to do this a little bit quickly.

    33:29 First is looking at the picture on the right, this is called a nomogram.

    33:32 That lets you get ratio in nomogram.

    33:34 And you're certainly welcome to carry around one in your pocket or have it on your phone or whatever they're easy to download.

    33:42 Find a PDF of one on Google or what have you.

    33:46 And where to use it is you look at the far left line that says pretest probability.

    33:52 In this case, our pretest probability was 0.2 or 20%.

    33:56 We start your line there.

    33:58 And then negative likelihood ratio for the test we were doing was 0.2.

    34:02 You draw a line from 0.2 on the left to the 0.2 that in that next line, then minus likelihood ratio.

    34:11 That line basically depicts a range of likelihood ratios from 1000 down to 0.001.

    34:19 Our tests with 0.2 draw a line through those things.

    34:22 And the other end of that line on the vertical line on the far right tells you your post-test probability.

    34:29 In this case, as I said it was around 0.05 or 5%.

    34:33 So that's how that nomogram can be useful.

    34:36 You don't even need a calculator if you have that handy.

    34:41 Likewise, you can see that for Lachman test if it was positive, the likelihood ratio, the blue line now for the positive test LR is 10.

    34:51 So you take that zero points from starting value.

    34:54 Then you're using an LR a pen, drawing your line through that, and low and behold you end up with a post-test probability of around 0.75 which is 75%.

    35:05 So I'd be 75% confident that somebody tore their ACL if they had a positive blocking maneuver.

    35:12 So pretty dramatically useful physical exam maneuver you have in your back pocket.

    35:20 Many of you may not wish to carry around a likelihood ratio with nomogram chart.

    35:24 And I can understand that.

    35:25 So there are a couple other quick easy tricks, and one of them is shown here on the left.

    35:32 In general, you can remember this simple mnemonic here.

    35:35 So for positive likelihood ratios 2, 5 or 10, you can add 15, 30, or 45% to the pre-test probability.

    35:44 So somebody's pretest probability of disease was 50%.

    35:48 And you perform a physical exam maneuver that has a likelihood ratio, a positive likelihood ratio of 5.

    35:54 And I would take that initial pre-test probability at 50%.

    35:58 And I would just add 30% to it.

    36:00 So my post-test probability would be 80%.

    36:02 I didn't need a nomogram or anything for calculation.

    36:06 Likewise, for negative likelihood ratio, or negative likelihood ratios of 0.5, 0.2 and 0.1, you can subtract 15.30 or 45% from the post-test from the pre-test probability of your post-test probably.

    36:22 That was just different kinds of tricks and different ways to use this stuff efficiently.

    36:29 Of course, in general...

    36:40 We can't hear you again.

    36:45 One second, everyone.

    37:13 Can you hear me now? Yes. Oh, much better, too.

    37:16 Yeah.

    37:19 Okay.

    37:23 All right, you good. We're good.

    37:24 You can hear me I can hear you, okay.

    37:27 You know what the trouble is, I think the slide advancer is right next to my mute button.

    37:32 And so it keeps, it's very tricky hit, I think that's what's going on anyway.

    37:36 So one would never want to rely upon a single physical exam maneuver to make any decision.

    37:44 I always like to think of the physical exam as a, it's a whole bunch of tools in your tool belt, and you want to use as many of them as you as you can.

    37:52 So this sort of goes back to this metaphor, this sort of story of the elephant and the blind man.

    37:57 If you have three blind men who come upon an elephant.

    38:02 The first blind man maybe finds just the trunk of the elephant and then describes, "Oh, well, an elephant is like a snake.

    38:09 It's long and it's flexible." And then another blind men may come across the side of the elephant and push on the side of it and feel like, "Oh, an elephant is like a wall.

    38:16 It's immutable, you can't move it. It's so so strong." And then a third blind man may find the tail and say, "Oh, an elephant is like a rope.

    38:25 You guys are all wrong, it's thin. And it's sinewy. It's like a rope." And so all of them are, of course wrong.

    38:32 But if you put all of their stories together, maybe you'll actually find the truth what an elephant is actually like.

    38:38 Similarly, you know, when playing the piano.

    38:41 If you just play a single note, a single note doesn't really tell much of a story, it's just a single note.

    38:46 But if you can play a whole D sharp minor seven, with your fingers, you're you're telling a story, there's a whole lot of sounds and richness that comes from that.

    38:55 The physical exam is a lot like that.

    38:57 I like to think of the joy of the physical exam is putting all these different pieces of the puzzle together and perhaps incorporating some laboratory findings or some diagnostic imaging to come up with a cohesive whole.

    39:10 So never rely upon any single test to make or to clinch a diagnosis.

    39:17 Alright, so moving on to another case here briefly, can anyone name some findings that would support the presence of ascites? And just put them in the chat.

    39:35 Shifting dullness, excellent.

    39:38 Fluid wave, ultrasound.

    39:40 Thank you, that's true.

    39:42 Pitting edema, excellent comments.

    39:46 Caput Medusa.

    39:47 Nice, all kinds of great findings here.

    39:49 Distended abdomen or sort of bulging flanks what you're getting out there.

    39:53 Of course, we'd see it with cirrhosis palatable, nice.

    39:58 Excellent, great job.

    40:00 Great stuff there.

    40:02 Now let's take a look at a specific case.

    40:04 So let's pretend we had another patient.

    40:06 This is just another way to sort of show how we can use likelihood ratios and combined physical exam maneuvers.

    40:13 So this is a 62-year-old man with three weeks of progressively increasing abdominal girth, and a 12-pound weight gain.

    40:20 This patient has no known history of liver, kidney or heart disease.

    40:24 He says he consumed about six cans of beer daily for the past 35 years.

    40:29 He has no history of illicit drug use, tattoos or blood transfusions.

    40:33 On exam, flank dullness and leg edema are both absent.

    40:39 Now, as we've discussed, every exam maneuver has a positive and a negative likelihood ratio.

    40:45 In this case, looking at flank dullness and negative likelihood ratio, we see that the negative LR is 0.3.

    40:51 And then for leg edema, the negative LR is 0.2.

    40:56 So let's see how we can incorporate that information and see if we can use both exam maneuvers.

    41:00 Last time we just used the Lachman to help with the ACL test.

    41:03 But how can we use these things here.

    41:07 So just based on the information we have so far, we probably say that there's a pre-test probability that this person has ascites of around 30% based on the weight gain, based on the fact that they clearly drink too much alcohol and could certainly have developed alcohol-related liver disease.

    41:24 And, you know, some things you guys had mentioned was like bulging flanks, or shifting dullness, and those sorts of are depicted here in these two figures, so pre-test probability of 30%.

    41:36 The patient told us or our exam, I should say, showed us, there's no actual flank illness, and there's no evidence of leg edema.

    41:44 So looking at our pre-test odds, it was 30% or I should say our pre-test probability was 30%.

    41:50 That means there's a 70% chance they don't have the disease, the pretest odds is 30 over 70.

    41:56 So that's shown in the third bullet, the post test odds is 3:7, 3 over 7 times both of those likelihood ratios.

    42:05 So basically, you just multiply the likelihood ratios from the different exam maneuvers you're using, so it's actually pretty easy.

    42:12 So if you take 3 over 7 times 0.2, which was for your bulging flanks, and 0.3, I'm sorry, 0.2 is for the flank dullness, and then 0.3 for the absence of leg edema, you end up with a post-test odds of 0.026, which converting that to a post-test probability is simply 0.026/1 plus 0.026, which yields a post-test probability of 2.5%.

    42:42 So before we did our physical exam, there's a 30% chance that this person had ascites and I'm sure we would get an ultrasound and further evaluate.

    42:51 But now, based on these physical exam maneuvers, the likelihood that they have ascites is less than 3%, only 2.5%.

    43:01 So what we can conclude from our now post-test probability, that's a little bit of a typo there, post-test probability of 2.5%, that this person has just gained adipose weight.

    43:14 There's no ascites there.

    43:15 All that beer is just adding lots of calories to their system.

    43:19 And so they're just gaining adipose weight, but they haven't actually developed ascites.

    43:25 So that's a good sign.

    43:29 Alright, with that, done sort of talking about the formal part of my presentation today, we're going to have room for some questions.

    43:35 I just wanted to give a shout out for our full course.

    43:38 I've sort of talked about the rationale for the physical exam.

    43:41 But of course, the course itself goes through all the nuances of how to perform and evidence based physical exam.

    43:48 We try to incorporate likelihood ratios as often as possible throughout the course.

    43:54 And I should also just make a point here that I in no way dismissing diagnostic radiology.

    44:01 It's an important part of a patient assessment and it is gone progressed leaps and bounds over these past few decades with increasingly advanced technological diagnostic imaging.

    44:13 My point is simply that we have to not over rely on diagnostic imaging.

    44:19 It needs to be used as a tool just like the physical exam is also an important diagnostic test.

    44:25 And the two of them together can do wonders as long as you don't over rely on either.

    44:31 And with that, I'll turn things over to Kate.

    44:34 All right, thank you so much, Dr. Holt.

    44:36 This was very, very interesting an in depth, I'm not sure if it's just me hearing myself twice.

    44:44 I think I can hear from your background a little bit.

    44:46 But that's okay.

    44:47 So yeah, everyone, as we said, you know, definitely check out the course.

    44:52 Please go ahead and pop your questions in the chat because we now have some time for Q&A.

    44:58 I can answer the question about certificate right away, we do not provide certificates for our free events.

    45:04 These are just here as extra things for you.

    45:07 But, you know, we don't like accredit them or anything.

    45:11 Obviously, we have a wonderful speaker who is extremely knowledgeable who is here to talk to you.

    45:17 But we do not provide certificates for our free student events.

    45:23 Go ahead, keep popping some questions in the chat, we'll give it a couple of seconds.

    45:27 These are just some of the topics covered in the physical exam course on our platform.

    45:32 We've linked it a couple times earlier, but we will link it again.

    45:34 And of course, in the email that we send you with the recording of this presentation.

    45:42 While we are waiting for a couple more questions to pop up, I just want to remind you all this is what Lecturio Medical is.

    45:50 So we have our video lectures, our spaced repetition algorithm, which are like quiz questions that pop up for you.

    45:57 We have clinical case questions, we have concept pages which are text-based resource, and many, many other things and many topics covered on our platform.

    46:10 So we are going to give you guys a special deal.

    46:11 But I do see we have a few questions in here that we can already start answering.

    46:17 So Dr. Holt, I'm going to turn it back to you.

    46:20 And I'll just pop up some questions as we go, alright? Great.

    46:26 So our first is from Andrea who is a new student and about to learn about physical exams.

    46:32 Is there something you've noticed is missing in general physical examinations that's important or something maybe commonly missed in teaching or not gone into as much depth? Yeah, that's such a great question for someone who's just starting to get into the physical exam.

    46:50 I'll approach that two ways.

    46:51 One is that, you know, oftentimes, there's this focus on this concept of an annual physical exam and patients come in and they want their annual physical exam done.

    47:02 It's really been shown that an annual physical exam is largely useless.

    47:10 And of course, I just gave you a whole talk on the importance of the physical exam.

    47:15 The problem is that an annual physical exam is done on a person who has no symptoms.

    47:19 So it's basically like, it's as useless as doing a total body MRI on a person with no symptoms.

    47:27 You may find things but you're not looking for anything.

    47:30 The physical exam should be used in the same way that we use any other diagnostic tests.

    47:36 It should be used as a hypothesis testing tool.

    47:40 So a person comes to me and they have knee pain, I'm going to do all the exam findings relevant for the knee.

    47:47 I'm not going to listen to their lungs.

    47:49 I'm not gonna do their heart exam, because nothing involving their knee is going to steer me towards thinking about a cardiopulmonary problem.

    47:57 So my first instinct in answering your question is that there is no physical exam maneuver that should be done in every patient.

    48:05 Because the problem is that we just shouldn't do physical exam maneuvers on every patient.

    48:10 We should only test hypotheses using the physical exam.

    48:12 There's a hypothesis that this person has an ACL tear, or they have pes anserine bursitis, or they have an effusion in their knee.

    48:20 I'm going to do all the maneuvers related to that and nothing else.

    48:23 That's my first comment.

    48:25 But then, in thinking about what are some of the things that are very commonly missed, or parts of the physical exam that are neglected and that can be really useful that I just see a lot of residents and students sort of failed to do.

    48:39 I would say, assessing the jugular vein is such an important skill.

    48:45 You know, unless you have point of care ultrasound at your disposal, and you're really good at it.

    48:52 And you can very easily sort of assess the IVC, so I know you're getting into your medical time or medical training here, but you know, trying to assess volume status basically, is somebody overloaded with fluid or are they dehydrated is such an important distinction in patients so often, especially on inpatients and being able to use physical exam skills to distinguish them between a person who's overloaded versus dry is an important skill.

    49:20 And I would say assessing the jugular vein is such an excellent tool for hypothesis testing, you think some of the things are supporting if this person is dehydrated, some things are going against it.

    49:32 Let's take a look at his jugular vein and the pulsations of the jugular vein.

    49:37 How high is the jugular vein to give an indication of central venous pressure is probably one of the most important physical exam skills that it can take a while to learn how to do it effectively, but it's really important.

    49:51 All right, thank you.

    49:53 One question that we have from Sandeep and many others in the chat is how do we get that pretest probability? Oh yeah.

    50:01 Great question. Yeah, I meant to say this.

    50:03 So there's three textbooks that I routinely use.

    50:07 And I actually can't remember if in our in our slide set.

    50:10 I'm going to skip ahead for just one second to see something.

    50:13 No, they're not there.

    50:14 So there's three textbooks that I commonly use.

    50:18 And I'll actually throw them in the chat.

    50:20 Oops, sorry.

    50:24 Joseph Sapira's evidence base.

    50:26 I'm sorry, Joseph Sapira's Art and Science of Physical Diagnosis.

    50:34 Forgive my spelling, I'm being quick.

    50:36 And then Steven McGee's Evidence-Base Physical Exam or something like that.

    50:47 The first one, there is one of my favorite textbooks.

    50:50 The author is actually in the fifth or sixth edition now and he's not the author, but it's someone who's taken it over for him.

    50:57 Just gives such a great history of the physical exam, all of its uses over time, while also just really fleshing out some of the nuances of the physical exam.

    51:07 It's a longer book does take a while to go through, but it's really a fascinating, deep dive into the physical exam.

    51:14 The second book that I've given there, Steven McGee's is a bit more practical.

    51:17 Steven McGee really is one of the authors for the Gemma's rational clinical exam series or has authored many of those articles and he really goes into the likelihood ratios.

    51:28 What is the sensitivity and specificity of different findings? What are the positive and negative likelihood ratios? You know, he really debunks a lot of tests, you know, people focus on using the phalen's sign for carpal tunnel syndrome, but he shows that the actual characteristics of this test make it not particularly useful or Koenigs and Brzezinski's for bacterial meningitis are not very useful.

    51:52 And sort of he really summarizes that data and can provide you with the likelihood ratios.

    51:58 The most recent edition of the book also comes with a downloadable app for your cell phones.

    52:03 You can actually have those likelihood ratios at your disposal and it's very searchable.

    52:08 So you can quickly find how useful a particular test is.

    52:12 All right, awesome.

    52:13 And one other question related to the pre-test probabilities.

    52:17 Are these done the same for children and adults? It's a great question.

    52:24 I can't answer that question only and so far as I'm not a pediatrician.

    52:27 I don't work that much with children.

    52:29 I don't pay a lot of attention to physical exam findings in kids.

    52:34 And obviously, many of the diseases we're talking about would be very unusual to find in children.

    52:40 Perhaps in adolescence, yes, but not in not in children.

    52:44 So I would, I'm pretty sure in Steven McGee's book, he covers a lot of pediatric content.

    52:50 And so there will be likelihood ratios for various pediatric diseases in there.

    52:55 They're just not within my skill set.

    52:57 And so I'm not very savvy to them.

    53:02 All right, thank you.

    53:04 So obviously, we've been online for a while.

    53:09 With COVID, we're obviously doing this event online and telemedicine is obviously become even more of a big deal than it was before.

    53:18 So what are some of the difficulties brought by physical examinations done online or some of the challenges related to this? And how can we overcome them as physicians? Oh boy, that's a tough question.

    53:31 Yeah, I've certainly had more than my share of awkward moments with patients trying to, you know, via telemedicine, they're trying to show me some funny rash and some funny place or they're trying to show me how their shoulder doesn't do what it's supposed to do.

    53:48 But it's so hard to tell over a video what's really going on.

    53:51 And I'm trying to tell a patient, "Okay, what I want you to do is I want to apply downward pressure on your knee while you're lifting up at your thigh." And it gets pretty difficult to do musculoskeletal testing in that way.

    54:04 I don't have a secret solution for that.

    54:07 Oftentimes, we do the initial visit over the phone to sort of figure out what we think is going on and what's on our differential.

    54:16 And then we'll have the patient come in for the physical exam.

    54:19 Because oftentimes, you'll find you don't need a physical exam like, you know, if a person's calling because they think they want antibiotics for an upper respiratory infection.

    54:29 Oftentimes, I can just talk to them on the phone and I can tell they don't need to be seen.

    54:34 I'm not going to give them antibiotics.

    54:35 They have a common cold.

    54:37 So I do think we've, by using telemedicine, we've been able to reduce the number of times that we need to see people in the office to perform their physical exam.

    54:47 But for many conditions, you need a physical exam.

    54:51 Bringing them into that physical exam is no more risky than sending them to radiology to get an unnecessary imaging test.

    54:58 They're also going into into healthcare setting and being exposed to equipment and other people and everything else.

    55:03 So I still think the physical exam should be the priority.

    55:07 But you can sort of prescreen patients to decide which folks really need to be examined or not, I guess.

    55:15 All right, thank you.

    55:16 And related to radiology, we talked a bit today about incidentalomas.

    55:22 Can finding these also be beneficial to the patient? Yeah.

    55:26 That's a great question.

    55:28 So, you know, it's funny there's some places at least the United States where you can without insurance, you can pay five grand or $5,000 or some outrageous sum, to have your whole body imaged, like to get a head to toe CT scan, or head to body MRI.

    55:46 Without a doctor's order even.

    55:48 These places are terrible.

    55:49 They're just preying on people.

    55:51 And of course, when you do that, I can guarantee you if you do a head to body, head to toe MRI on me, you're going to find some stuff in there that I didn't want to know about and I wasn't looking for.

    56:03 The problem is that so many of these incidental findings, studies have shown that they were never going to cause harm.

    56:12 Yes, of course, there's the potential that there's a real malignant cancer in there.

    56:17 That is in its infancy, and it'd be great to take it out before it became a problem.

    56:24 But the research has not shown that pan scanning is sort of a phrase you would use to sort of scan somebody from head to toe has any value to individual people, because, you know, if 9 times out of 10, you're going to find such more looking for and now you have to engage in potential procedures, you have to remove things, you have to do future follow up studies down the road exposing me to more and more radiation over time.

    56:55 You've added a lot of anxiety and stress to my life.

    56:58 And so when you look at actually quality of life and quality of life, finding these things is more of a complication than than a benefit.

    57:08 So sure, many of us would like to know what's going on in their bodies at all times.

    57:12 But it turns out that it actually does more harm than good.

    57:15 With of course, rare exceptions.

    57:19 But based on the current evidence, there's incidentalomas that are more of a problem than a benefit, but good question.

    57:29 We'll just take two more, just so that we kind of keep to our timing.

    57:34 Would you say that physical examination in history taking should be a first observation and how would you advice interns to kind of process this without maybe jumping to a diagnosis? Yes, so I guess, if I understand the question, your physical exam starts with observation.

    57:59 And I often like to do with my residents or when I visit another hospital, I do what I call Sherlock Holmes rounds, hearkening back to Arthur Conan Doyle's stories of Sherlock Holmes, or Sherlock Holmes could just look at a person standing in front of them.

    58:14 And he would know like, where they had breakfast that morning, what kind of job they do, where part of the country they're from, and where they visited within the past week.

    58:22 I mean, it was just unbelievable the stuff that he would do which is really fun.

    58:25 That's all from observation, that's before he's laid hands on a patient or took out his stethoscope or anything like that, right.

    58:32 So I find that when I go into the room of a patient or if I see a patient in in front of me in clinic, I like to really focus my powers of observation.

    58:43 And I like to think of it as deliberate practice or reflective observation.

    58:48 I'm trying to live in the moment, trying to be present and looking at the patient, looking at their rate of speech, looking at their eyes, looking at their sclera, looking at what they're wearing, looking at their shoes, looking at if there's other people in the room with them.

    59:03 If somebody's in a hospital bed looking at, are there any flowers or things that have been brought for the patient, which would give me an indication that there's other people looking out for this patient.

    59:13 They say that they have diabetes, but I'm looking at the selection of foods and beverages on the tray next to them, and it's a lot of soda and like somebody brought in the box of doughnuts, or I'm thinking about I'm told that this person is getting IV fluids overnight, but I look at the IV pole next to them, there's actually no fluids hanging on the IV pole.

    59:34 So trying to be very actively engaged and attending to the room around the patient before I even think about doing physical exam.

    59:46 Getting into that posture of reflective observation, I think it's very important.

    59:51 In addition, again, I think of the physical exam and the history taking as a hypothesis testing tool.

    59:58 So as I'm talking to a patient, I'm adding things to my differential diagnosis from the history, I'm building my list of potential things this person can have.

    1:00:10 And then when I go to my physical exam, my physical exam is driven by what was on my list.

    1:00:16 If this person says that they're having dyspnea, having shortness of breath, and they've gotten all the important information about their shortness of breath.

    1:00:23 Now my physical exam is about looking for signs of DVT, to look for a PE, it's looking at volume status to see if there's evidence of heart failure.

    1:00:32 It's listening to the lungs to listen for crackles or some evidence of interstitial pulmonary fibrosis or pulmonary edema.

    1:00:38 It's looking for other potential signs of a chronic pulmonary process, like maybe we'll look for clubbing or signs of, again, an interstitial pulmonary fibrosis disease.

    1:00:50 Or, you know, you can imagine, you can go through a whole litany of different things to look for causes of dyspnea.

    1:00:56 But my physical exam is guided by my initial reflection during the history taking and that big picture view of the room.

    1:01:06 So don't just launch a new physical exam, because you're coping with physical exam, use it as a test, as a diagnostic test and it will serve you well.

    1:01:15 All right, thank you so much.

    1:01:18 Before I take our last question because it's actually something about Lecturio, I just want to say thank you so much Dr. Holt for joining us today.

    1:01:25 Those of you still in the room, we do have a special deal that's going to pop up in just a second.

    1:01:30 But is there anything else you wanted to add? I know we're at the top of the hour in case you had to rush off to classes of thing.

    1:01:37 No, nothing, nothing new to add.

    1:01:39 See, there's lots of great questions in the chat.

    1:01:41 I'm sorry, we couldn't get to all of them, of course, but it's always a pleasure to speak with all of you and good luck in your training.

    1:01:49 And again, the physical exam is timeless.

    1:01:51 Once you learn how to do it today, you will never have to relearn it.

    1:01:54 It is always with you, unlike so many other things that we've learned.

    1:01:59 All right, thank you so much.

    1:02:01 And then last question, do you have a platform for preparing for USMLE? I'm actually going to steal the stage and answer this because yes, we do, Lecturio.

    1:02:09 We are the platform hosting this event.

    1:02:13 And I've, you know, mentioned our videos, our quiz questions or clinical case questions.

    1:02:19 And while it is a platform you can use from day one, through all of med school, in your residency, etc.

    1:02:25 We do actually have a lot of USMLE specific content.

    1:02:29 So we have cases that are specific to this.

    1:02:33 We have study plans specifically for the USMLE, lots and lots of content that will help you there.

    1:02:39 We also do events about the USMLE as well.

    About the Lecture

    The lecture Lecturio Live: Physical Examination with Dr. Stephen Holt (2022) by Lecturio Online Courses is from the course Lecturio’s Free Student Events On-Demand.

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    Physical Examination Session
    By Ricardo N. on 30. October 2021 for Lecturio Live: Physical Examination with Dr. Stephen Holt (2022)

    Dr. Stephen Holt was amazing and really motivated me to further develop my physical examination skills.