Is the Physical Exam Obsolete?

1. Is the Physical Exam Obsolete? Charles V. Sanders, M.D., M.A.C.P. Edgar Hull Professor and Chairman Department of Medicine LSU Health Sciences Center New Orleans, LA csande@lsuhsc.edu March 25, 2011

3. Is the Physical Exam Obsolete? And neither is taking a history! History Physical Exam Hand Glove

4. New York Times October 11, 2010

6. Guide for Rounding with Dr. Sanders FACTS History Physical Exam Abnormal tests (Labs, X-ray, etc) HYPOTHESIS Problem List Differential Diagnosis WIGOH? WEIGOH?

7. 1. Establishes a bond with the patient 2. It is fun-an opportunity to teach and learn 3. Compliments the history 4. Diagnosis-hypertension and obesity 5. Saves money 6. Saves lives 7. Creates interest in internal medicine** 8. Assists in deciding what tests to order 9. It is not obsolete 10. It will survive! ** Dr. Muslow-my mentor C.V. Sanders, M.D. My Thoughts-Physical Exam

12. “ To study the phenomena of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all…”Sir William Osler 1849-1919

13. “Medicine should begin with the patient, continue with the patient, and end with the patient” Sir William Osler

14. “Learn to see, learn to hear, learn to feel, learn to smell and know that by practice alone can you become experts.” “Medicine is learned by the bedside and not in the class room” Sir William Osler

15. “In our era of diagnostic imaging how careful are we when we examine patients? How skilled are we as practitioners of the physical examination? If we don’t listen we will never hear, if we don’t look we will never see, if we don’t touch we will never feel” Roger Cass Ann Intern Med June 1, 1989

16. “I sometimes joke that if you come to our hospital missing a finger, no one will believe you until we get a CAT scan, an MRI and an orthopedic consult. We just don’t trust our senses” Abraham Verghese NPR The Fading Art of the Physical Exam September 20, 2010

17. NEJM December 25, 2008

18. March 11, 2011

19. My left eye is red and painful • 50 y/o woman with a 3 day history of left eye pain and redness • Two week history of intermittent burning, 5/10 left sided abdominal pain • 20 # (unintentional) weight loss over 4 mo. • Brother died of colon cancer at 49 y/o PE: left subconjunctival hemorrhage and tenderness and guarding over left side of abdomen. Stool – for occult blood • Hgb/Hct 11.2/34.4 (87.2) Ferritin + 4.0 (N 20-210) • CT of abdomen-mass in the splenic flexure • Colonoscopy- 5 x 3 cm. mass in splenic flexure

20. My throat is sore and my neck hurts • 28 y/o woman with several-day history of fever, sore throat and malaise. • PE She appears tired and has a fever of 102°. Diffuse pharyngeal erythema, right posterior tender cervical adenopathy and splenomegaly. • WBC is 30, 900 with 86% atypical lymphs.- Monospot + • Acute abdominal series, ultrasound RUQ, and CT of abdomen and pelvis!

21. My bottom is so sore I can hardly walk • 51 y/o man with above complaints. Two weeks ago smoked cocaine for 5 days-during this time his ears became swollen, painful and black. Ten days later noted that his right breast was painful, swollen and dark. PE T = 101° P= 103; Ears and right breast; tenderness around anus-refused digital exam. Labs: Albumin 2.9, ESR 85 and CRP 12.69 Urine + for cocaine and THC

22. The physical exam saves lives!!!!! • 77 y/o man admitted to CHNO because of a stroke. We were asked to see the patient because he had a low-grade fever and crackes at his left posterior lung base. The resident thought that there was a left pleural effusion and planned to do a thoracentesis. I found decreased vocal fremitus, dullness, decreased breath sounds and crackles at the left posterior lung base. I could not hear heart tones over the anterior precordium but found a bifid apex beat at the tip of the left scapula! WIGOH?

23. Christmas treat to chronic cough • 63 y/o woman presents to ED with CC of dry hacking cough x 9 weeks. Multiple visits to ER and multiple course of antibiotics for “bronchitis”. Fever, malaise, night sweats, pleuritic right chest pain and 14# weight loss over 9 weeks PE T= 101.2° R= 34; appeared chronically ill; paroxysms of cough during exam and an intermittent wheeze and crackles over right posterior chest WBC =13.7K-L shift Chest X-ray RLL infiltrate Pulmonary consult: Dr. deBoisblanc

24. It looked like lung cancer • 55 y/o alcoholic man with 6 month history of cough, occ. purulent sputum, fever, night sweats and 60# weight loss- 60 pack- year smoking history • Patient was very cachectic PE T= 100° P= 90 R= 20 BP= 110/70 Crackles and decreased breath sounds and decreased vocal fremitus at left posterior lung base and mass on left lower chest wall

25. Pneumonia that wasn’t • 32 y/o diabetic man who presents with 4-5 day history of SOB, NP cough and subjective fever • PE: R= 20 and crackles, dullness and decreased breath sounds at both posterior lung bases. • Patient given IV penicillin G for “pneumonia” but SOB persisted. • I saw patient in consultation and obtained a history of PND, orthopnea, nocturia and squeezing substernal chest pain. There was a prominent S3

26. JAMA, January 12, 2011

27. Morbid obesity and RUQ mass and tenderness • 71 y/ woman with these problems: Respiratory distress 11. R flank tender Chest pain-CAD 12. Anasarca Acute kidney injury Anemia DM-II Tobacco abuse Morbid obesity-BMI 41 Gout Osteoarthritis Cholelithiasis*

28. Both legs weak since 12-17-2010 • 51y/o man with pain and leg weakness (R > L) since12-17-10. Pain posterior aspect both thighs-non-radiating PE Could not extend fingers right hand Circumduction gait on right Hyperactive knee jerk Bilateral sustained ankle clonus Right Babinski Marked weakness of finger extension R Hand Video of patient and imaging studies

29. February 24, 2011