Using the physical exam to direct chronic treatment of heart failure

March 3, 2010

Targeting a clinical score to a score of 2 or less based on the Framingham diagnosis of heart failure with the following findings may reduce mortality similarly to targeting a NT-proBNP level and better than usual care:

  • Major findings (1 point each)
  • Minor findings (0.5 point each)
    • Orthopnea
    • Reduction in exercise tolerance
    • Resting heart rate > 100 bpm
    • Hepatomegaly
    • Peripheral edema

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Lainchbury JG, Troughton RW, Strangman KM, Frampton CM, Pilbrow A, Yandle TG, Hamid AK, Nicholls MG, & Richards AM (2009). N-terminal pro-B-type natriuretic peptide-guided treatment for chronic heart failure: results from the BATTLESCARRED (NT-proBNP-Assisted Treatment To Lessen Serial Cardiac Readmissions and Death) trial. Journal of the American College of Cardiology, 55 (1), 53-60 PMID: 20117364


Predictive Value of Symptoms for Early Detection of Ovarian Cancer

January 29, 2010

The current study validates a prior symptom index developed by Goff (PMID: 17154394) and consensus critiera for prompting testing for ovarian cancer promoted by the Gynecologic Cancer Foundation (GCF), the Society of Gynecologic Oncologists (SGO), and the American Cancer Society (ACS). The current study reports test accuracy similar to the prior reports, but the current study adds the analyses that the societies failed to do: projecting the positive predictive values based on a the prevalence of ovarian cancer found in the Prostate, Lung, Colorectal and Ovarian (PLCO) cancer screening trial (PMID: 16260202). Not surprisingly, with such a low prevalence of cancer in the general population, the predictive values of these tests are all less than 1%. This study demonstrates a case of specialty societies prematurely promoting testing for their diseases.

Diagnostic accuracy for symptoms starting within the past year and an estimated prevalence of ovarian cancer of 60 per 100,000 women (0.06 %).
(starting in the last year)
(early stage – late stage dz)
Specificity (%) Positive predictive value
Pelvic or abdominal pain
49 to 52
< 1%
Bloating or feeling full
44 to 58
< 1%
Urinary frequency or urgency
30 to 30
< 1%
Symptom index (any of the above at least daily for at least 1 week in the last year) PMID: 17154394
62 to 71
< 1%
Consensus criteria (any of the above at least daily for at least 1 month in the last year) PMID: 17848663
59 to 69
< 1%


Rossing, M., Wicklund, K., Cushing-Haugen, K., & Weiss, N. (2010). Predictive Value of Symptoms for Early Detection of Ovarian Cancer JNCI Journal of the National Cancer Institute DOI: 10.1093/jnci/djp500

Accuracy of physical examination in subacromial impingement syndrome

January 28, 2010
In this study of 55 patients, the authors studied five findings and concluded, “The cut point of 3 or more positive of 5 tests can confirm the diagnosis…, while less than 3 positive of 5 rules out.” If you look at the accuracies and the predictive values below, I think you will agree these results are overstated and not very helpful clinically. The shoulder is still very hard to examine.
Diagnostic Accuracy for Impingement Shoulder Tests among 55 patients with a prevalence of impingement of 29%
Finding Sensitivity (%) Specificity (%) Kappa Positive predictive value Negative predictive value
Hawkins-Kennedy 63 62 39 40 61
Neer 81 54 40 42 13
Painful arc 75 67 45 48 13
Empty can (Jobe) 50 87 47 61 19
External rotation resistance 56 87 67 64 17
3 or more of 5 findings positive 75 74 54 12

How to do the tests

YouTube videos demonstrating the tests

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Michener LA, Walsworth MK, Doukas WC, & Murphy KP (2009). Reliability and diagnostic accuracy of 5 physical examination tests and combination of tests for subacromial impingement. Archives of physical medicine and rehabilitation, 90 (11), 1898-903 PMID: 19887215

Predicting cardiac arrhythmia among patients with palpitations.

November 22, 2009

Does This Patient With Palpitations Have a Cardiac Arrhythmia?

This systematic review by the  Rational Clinical Examination found that an arrhythmia was more likely (LR > 2) if that patient has:

  • A history of cardiac disease (likelihood ratio [LR], 2.03; 95% CI, 1.33-3.11)
  • Palpitations affected by sleeping (LR, 2.29; 95% CI, 1.33-3.94)
  • Palpitations while at work (LR, 2.17; 95% CI, 1.19-3.96)

A arrhythmia was less likely (LR < 0.5) if that patient has:

  • A known history of panic disorder (LR, 0.26; 95% CI, 0.07-1.01)
  • Palpitations lasting less than 5 minutes (LR, 0.38; 95% CI, 0.22-0.63)

Additional findings that need further discussion are:

  • Description by the patient of an irregular heart rate was an independent predictor of a cardiac arrhythmia(PMID: 8629647). The authors of the systematic review did not conclude this finding was helpful because the likelihood ratio, while significant, was within 0.5 to 2.0.
  • An increased number of symptoms suggested psychiatric causes in the univarate, but not multivariate  analysis of Weber  (PMID: 8629647). This finding is part of a theme in general that the more symptoms are present the more likely there is an underlying psychiatric diagnosis in the evaluation of syncope (PMID: 17397948) and symptoms in general in primary care (PMID: 7987511).

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Thavendiranathan, P., Bagai, A., Khoo, C., Dorian, P., & Choudhry, N. (2009). Does This Patient With Palpitations Have a Cardiac Arrhythmia? JAMA: The Journal of the American Medical Association, 302 (19), 2135-2143 DOI: 10.1001/jama.2009.1673 – PMID 19920238

Predicting low cardiac index and central oxygenation

November 22, 2009

Association of physical examination with pulmonary artery catheter parameters in acute lung injury
The authors found that physical findings had good specificity in predicting low cardiac index (CI) and low central oxygenation; however, at the low prevalence of low CI in this study, even when all three physical findings were present, the positive predictive value was 40%.
This cross sectional study looked at three physical findings (delayed capillary refill time, knee mottling, and cool skin temperature) in predicting cardiac index,  central venous oxygen saturation (ScvO2 – a quality measure of IHI), and mixed venous oxygen saturation (SvO2) among 392 patients with acute lung injury studied by ARDSNet.

For cardiac index < 2.5 (similar results for the measures of oxygenation):

Sensitivity Specificity Predictive values at prevalence of 8%
Positive Negative
Any one of three findings* present 52% 78% 17% 95%
All three findings* present 12% 98% 40% 93%
* Findings are: delayed capillary refill time, knee mottling, and cool skin temperature.
Did not look at proportional pulse pressure < 25% which has previously been found to be predictive (PMID: 2913385; PMID: 11420761)
The Rational Clinical Examination previously concluded that the capillary refill time did not help predict hyovolemia in adults (PMID: 10086438).
Nice to see that the National Institutes of Health/National Heart, Lung and Blood Institute Acute Respiratory Distress Syndrome Network (ARDSNet) is interested in the physical examination.

Grissom CK, Morris AH, Lanken PN, Ancukiewicz M, Orme JF Jr, Schoenfeld DA, Thompson BT, & National Institutes of Health/National Heart, Lung and Blood Institute Acute Respiratory Distress (2009). Association of physical examination with pulmonary artery catheter parameters in acute lung injury. Critical care medicine, 37 (10), 2720-6 PMID: 19885995

The history and physical examination and diagnostic error.

November 11, 2009

The medical history taking and physical examination each contributed to 10% of self-reported errors by internal medicine and emergency medicine physicians. This combined rate of 20% is a little higher than a prior report of 10%  (PMID: 16009864).

This has been added to Citizendium: Physical_examination –  Importance_of_the_physical_examination.


Schiff, G., Hasan, O., Kim, S., Abrams, R., Cosby, K., Lambert, B., Elstein, A., Hasler, S., Kabongo, M., Krosnjar, N., Odwazny, R., Wisniewski, M., & McNutt, R. (2009). Diagnostic Error in Medicine: Analysis of 583 Physician-Reported Errors Archives of Internal Medicine, 169 (20), 1881-1887 DOI: 10.1001/archinternmed.2009.333

Screening for dysphagia

October 20, 2009

Dysphagia among stroke patients is suggested by the following test:

  1. First check the patient for “swallowing complaints, abnormalities of voice quality, facial asymmetry, or either expressive or receptive aphasia.” If none is detected then go to step 2.
  2. Have the patient drink 10 mL of water from a cup without a straw while seated upright while oxygenation saturation is monitored during and for 2 minutes after the test. Check whether the patient
    • “Coughed or choked during the water drinking or had a change in voice quality after the swallow”.
    • Oxygenation drops by 2% or more.

In this small study of 84 patients, this two-step test detected 96% of patients with dysphagia as compared to testing by a speech pathologist.

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Turner-Lawrence DE, Peebles M, Price MF, Singh SJ, & Asimos AW (2009). A feasibility study of the sensitivity of emergency physician Dysphagia screening in acute stroke patients. Annals of emergency medicine, 54 (3) PMID: 19362752

Screening for diabetic neuropathy

October 20, 2009

ResearchBlogging.orgThe preferred locations for testing according to this systematic review are filled green in the image. As the independent addition of the monofilament to visually inspecting for deformities, pressure marks, cracked skin, infected nails, evidence of prior ulcers, and other findings is not clear in the major trial of screening (, it seems we should limit our time to testing three points rather than 10.footscreensites-rgb

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Feng Y, Schlösser FJ, & Sumpio BE (2009). The Semmes Weinstein monofilament examination as a screening tool for diabetic peripheral neuropathy. Journal of vascular surgery : official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter, 50 (3) PMID: 19595541

Postural hypotension in patients with syncope

September 18, 2009 Arch Intern Med 2009 PMID: 19636031

The authors report that in 2106 consecutive patients 65 years or older admitted for syncope, “Postural blood pressure (BP) recording, performed in only 38% of episodes, had the highest yield with respect to affecting diagnosis (18%-26%) or management (25%-30%) and determining etiology of the syncopal episode (15%-21%).”

  • The lower percentages are based on ‘strict criteria’ for abnormal changes:
    • drop in systolic BP of at least 20 mm Hg
    • or
    • drop in diastolic BP of at least 10 mm Hg
  • The higher percentages are based on ‘loose criteria’ for abnormal changes:
    • drop in systolic or diastolic BP of at least 10 mm Hg
    • or
    • systolic BP drop to 90 mm Hg or lower

A systematic review of postural blood pressure measurements has been published by the Rational Clinical Examination (McGee S, Abernethy WB, Simel DL The rational clinical examination. Is this patient hypovolemic? JAMA 1999;281 (11):1022-9. DOI:10.1001/jama.281.11.1022 PMID: 10086438 ) Their meta-analysis concluded that the following changes may occur in normal, euvolemic adults:

  • Pulse increase:11 (95CI: 9-13mm Hg)
  • Systolic blood pressure drop: 4 (95CI: 2 – 6mm Hg)
  • Diastolic blood pressure drop: 5 (95CI: 3 – 8 mm Hg)

Based on the Rational Clinical Examination review, which reveals how difficult it is to interpret orthostatic vital signs and that we cannot simply dichotomize the results into normal and abnormal, I think the strict criteria are better. Even with these criteria, orthostatic vital signs was the most important part of the evaluation for syncope.

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Mendu ML, McAvay G, Lampert R, Stoehr J, & Tinetti ME (2009). Yield of diagnostic tests in evaluating syncopal episodes in older patients. Archives of Internal Medicine, 169 (14), 1299-305 PMID: 19636031

Diagnosing irritable bowel

September 18, 2009 JAMA. 2009 PMID: 18854541
This comprehensive systematic review by the Rational Clinical Examination is very helpful after a few adjustments. First, the review allows source studies to place patients with symptoms of irritable bowel who are found to have diverticulosis or polyps into the category of underlying organic illness. Patients with diverticulosis who have symptoms of irritable bowel probably have irritable bowel syndrome.(PMID: 3717113) Likewise, polyps seem very unlikely to cause symptoms of irritable bowel and these patients also probably irritable bowel syndrome and coincidental polyps. Now that the USPSTF recommends screening for polyps starting at age 50, the presence of polyps among patients with irritable bowel syndrome is less important.(PMID: 18838716)
The review cites the study of Bellentani (PMID: 2289644) to conclude that 60% of patients in primary care with symptoms of irritable bowel have irritable bowel syndrome. However, if you group the patients with polyps or diverticulosis with the patients with irritable bowel, the prevalence becomes 87%.
Diagnosing irritable bowel syndrome
Likelihood ratio + Likelihood ratio –
History alone (Manning criteria) 2.9 0.29
History and physical examination (Rome criteria) 4.8 0.34
History, physical examination, and laboratory tests (Kruis score) 8.6 0.26
Thus, the Kruis score seems good enough to diagnose irritable bowel among patients in primary care (remember that patients over age 50 probably need endoscopy to screen for polyps). The composition of the Kruis score is:
Kruis score. Abnormal is < 44
Finding Score
Abdominal pain or flatulence or bowel irregularity 34
Duration of symptoms >2 y 16
Abdominal pain is “burning, cutting, very strong, terrible, feeling of pressure, dull, boring, not so bad” 23
Alternating constipation and diarrhea 14
History of blood in stool -98
Physical examination or history pathognomonic for an alternative diagnosis -47
ESR > 10 mm/hr -13
WBC > 10k -50
Hemoglobin < 12 g/dL for females or < 14 g/dL for males -98
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Ford, A., Talley, N., Veldhuyzen van Zanten, S., Vakil, N., Simel, D., & Moayyedi, P. (2008). Will the History and Physical Examination Help Establish That Irritable Bowel Syndrome Is Causing This Patient’s Lower Gastrointestinal Tract Symptoms? JAMA: The Journal of the American Medical Association, 300 (15), 1793-1805 DOI: 10.1001/jama.300.15.1793