Purpose of the Physical Exam

00:00 Hello and welcome to this course on the physical exam. During this presentation, I'm hoping to give a broad overview about why we're learning the physical exam at all. And I'm welcoming you to this course with a case. So starting off, we have a 49-year-old man with a medical history of obesity who presents with left-sided anterior knee pain that began immediately after twisting his knee during a basketball game. And he says he is concerned he might have torn his ACL and he would like you to get an MRI. Now this is a common scenario. And it brings us to the question "Well, why not just get that MRI? What's the purpose of learning how to do the physical exam and performing it on this patient?" I'm hoping we can answer that question over the course of this presentation. So just quickly shown here is a good example of something a physical exam would help to identify, but there's no lab test to show this. These are half-and-half nails, also called Lindsay's nails which suggest end-stage renal disease. So, a lot of people cite potential barriers to the physical exam. You know, maybe it's a thing of the past, it's too antiquated, no longer relevant in today's age of very advanced cutting edge radiologic imaging techniques. Maybe you just let them learn how to do it or maybe your colleagues or your professors have not learned how to do the physical exam effectively and they can't teach you. Is the exam even when you know how to do it really accurate and in particular is it more accurate than imaging? And do you have time to learn it and time to do it and staying with the patient rather than just quickly ordering that MRI and moving on to the next patient? In some ways, the decision about whether to learn the physical exam and apply it is a conflict between the physical exam and physical diagnosis versus radiologic diagnosis. Which is more accurate and are there any untoward consequences that can occur based on an overreliance on one versus the other? Well, let's talk about the potential differences between physical diagnosis and radiology. First off, let's say we were to get that MRI of that knee. Well, it turns out that there's been a lot of studies looking at particular patients who have no symptoms and then performing diagnostic imaging and seeing what you find in people with no symptoms at all. And this is a good example. Amongst a hundred asymptomatic persons over the age of 45 just like our patient who undergo a knee MRI, 36 of them, 36% actually have meniscal tears and had no manifestations of that meniscal tear. There are examples of this with every joint in the body. And it brings us to this question about accuracy versus precision. Think of this bull's eye figure here with right in the center is the actual source of the pain. Well, the hope here is that the physical exam helps us to hone in on the source of the pain at the center of the bull's eye. The problem with radiologic imaging is that oftentimes it has high precision but low accuracy. Meaning you'll find things but those things may actually have nothing to do with the source of the person's pain. And this comes up time and time again when we have an overreliance on radiologic imaging finding all kinds of things we weren't looking for and don't actually tie back to the physiology of the patient's pain. Likewise, those things that we find can actually be particularly problematic for patients. We find lots of thyroid incidentalomas when we rely upon ultrasound to look for nodules. We find adrenal incidentalomas in 4% of CT scans, pancreatic incidentalomas with 15% of MRI scans, and pituitary incidentalomas when we're looking at the head. And every time we find those incidentalomas, they can add anxiety to patients and potentially leave them to getting procedures that would not have been warranted. Likewise, radiation. One CT scan exposes patients to upwards of 10 millisieverts of radiation. That's the unit of measurement that we use to gauge how much radiation a person is exposed to. Cancer mortality we know historically that when people get upwards of 50-100 millisieverts of radiation in a year, they have an increased risk of malignancy of a variety of different types. It's been estimated that over 2% of all future cancers in the United States, which is approximately 29,000 cases per year, actually come from radiation exposure alone which is pretty concerning when you think about all the imaging that we rely upon in our country and in the world. And so many clinical signs to quote Abraham Verghese, one of my own heroes in the realm of physical diagnosis, saw many clinical signs such as rebound tenderness, lid lag, tremor, clubbing, or hemiparesis cannot be discerned by any imaging test. And here's another example of which is xanthelasma around the eyelids. You can see lipomatous lesions around the medial canthal folds in this lesion. So having talked about some of the disadvantages of an overreliance on radiologic imaging, let's talk about some of the advantages of using the physical exam. Well first off, it's unlikely you're going to identify lots of incidentalomas on your physical exam and unless you're drinking a pint of radioactive iodine before you examine patients, it's probably the case that you're not going to be exposed in the radiation and the process. Moreover, the physical exam is something that's exciting for us and enjoyable and rewarding. It may be one of the reasons that you went into medicine in the first place. You know we didn't come here to become data analyst or computer programmers. Being at the bedside with patients is a rewarding endeavor and it's worth continuing to flash out your own skill set. The physical exam is also free, you don't need to order an MRI and spend money and tax in the healthcare system.

05:56 Your skills are with you at all times, they're always available 24/7. And here's one of the most important points. A lot of the things that you're going to learn during your medical training will, I'm afraid, become obsolete within the next 5, 10, or 15 years particularly diagnostic testing approaches, laboratory testing, and a lot of pharmacotherapies. But the skills you learn now in this course on how to actually examine patients and identify subtle manifestations of systemic disease will stay with you for the rest of your career. So learning things today has a timelessness in terms of your proficiency. And lastly, and I harken back to the idea of ritual that Abraham Verghese has talked about, "Being at the bedside of patients allows us to connect with them." They don't want us connecting with their charts in a room elsewhere in the hospital. They want us at the bedside listening to them, looking in their eyes which brings me to this classic portrait from the late 1800's called The Doctor.

07:01 Now in this portrait what we can see is a doctor sitting at the bedside, gazing at his very sick patient lying in this bed with the mother and father hovering in the back around and you can see their grief-stricken postures. Imagine how different this portrait would be if instead of the doctor sitting there, gazing at his patient, sharing in the grief of the parents, he instead was looking at a laptop. It's a completely different experience if all we're doing is focusing on the medical record and not the medical patient. And as sir William Osler himself once said "The good physician treats the disease, but the great physician treats the patient who has the disease." So how do we do that, putting the patient first? First, you want to make sure you ask permission of your patients, they should not be viewed as objects. If you're going to examine them, they need to invite you in. Second, respecting modesty is so important. Only expose the part of the body, as little of the body, as is necessary to perform your exam. Also ensure patient comfort throughout then make sure they're not cold or uncomfortable while you're doing different parts of the exam. And also introduce everyone in the room. Your patient has the right to know who else is in the room when you're exposing parts of their body that normally are not exposed. And lastly, when you finish your exam, don't leave your findings shrouded in mystery. Let your patient know what you found and how you interpret it and what you're going to do about it.