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Table of Contents    
COMMENTARY
Year : 2020  |  Volume : 68  |  Issue : 2  |  Page : 288-289

Has Physical Examination Superannuated? …Not Yet!


Department of Neurology, National Institute of Mental Health & Neurosciences, Bangalore, India

Date of Web Publication15-May-2020

Correspondence Address:
A B Taly
Department of Neurology, National Institute of Mental Health & Neurosciences, Bangalore 560029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.284365

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How to cite this article:
Nagappa M, Taly A B. Has Physical Examination Superannuated? …Not Yet!. Neurol India 2020;68:288-9

How to cite this URL:
Nagappa M, Taly A B. Has Physical Examination Superannuated? …Not Yet!. Neurol India [serial online] 2020 [cited 2020 Jun 1];68:288-9. Available from: http://www.neurologyindia.com/text.asp?2020/68/2/288/284365




Bedside evaluation is one of the most fascinating and gratifying exercises in the field of medicine. History of physical diagnosis dates back to Hippocrates and his colleagues but the foundations of modern physical examination as we practice today were laid in the eighteenth century. Its importance evolved over the decades and perhaps attained its peak in the early and mid-twentieth century. Seminal contributions by luminaries in the eighteenth and nineteenth century need to be acknowledged. Notable among these include the introduction of the technique of percussion by Auenbrugger and Corvisart, creation of the first stethoscope by Laennec, application of medical thermometry by Wunderlich, invention of the world's first ophthalmoscope by Helmholtz, description of plantar response by Babinski, use of a hammer to elicit muscle stretch reflexes by Erb and Westphal and the development of sphygmomanometer by Riva Rocci, to name but a few.[1],[2] William Osler is credited for bringing the patient from the classroom to the bedside and emphasising various components of physical examination as under:

'Observe, record, tabulate, communicate. Use your five senses. Learn to see, learn to hear, learn to feel, learn to smell, and know that by practice alone you can become expert.' – William Osler.[3]

Advances in laboratory technology and imaging mostly happened during the twentieth century and were quickly integrated into the evaluation process. Nevertheless physical examination continued to play a pivotal role in the evaluation process of patients and has been the essence of clinical training for generations.

During the past thirty years great concerns have been expressed regarding the fading relevance of clinical examination. It has been observed that many a time physical examination is not carried out at all or done only partially or improperly. Even when physical examination is performed, it is interpreted erroneously. A study that involved patients' feedback revealed that a substantial proportion of them were not examined physically during consultation! It is shocking to learn from another study that in an emergency room, an ophthalmoscope was not used even for patients presenting with headache as key symptom.[4] An inadequate clinical examination significantly contributes to errors and inaccuracies in diagnosis and treatment, qualifies for negligence, puts the patient at risk and invites law-suits.[5],[6] Objectively it has been attributed to a number of factors, the most important being the exponential increase in the number of patients seeking consultation. Thus the time available for clinical evaluation per patient has reduced. Patients want a 'fool-proof' diagnosis duly supported by objective evidences and clinicians rely heavily on investigations to avoid diagnostic delays and errors.[7],[8]

The past 50 years have seen a sea change in technology namely digitization, development of various imaging modalities, immunology, and molecular genetics. It has made a great impact on the understanding of various disease processes, documentation of anatomical substrates for clinical symptoms and has necessitated revision of the diagnostic algorithms. Easy availability of imaging tools such as magnetic resonance imaging (MRI) and “point-of-care” echocardiography and ultrasound has led to substitution/'outsourcing' of clinical examination. It is wrongly believed that there is an investigation for every disease that will provide objective, authentic and consistent results and will always score over clinical judgment. However, the “investigation first, examine later” approach has several pitfalls. It leads to the decline in competence in the physical examination and clinical reasoning. This in turn results in inaccuracies in diagnosis, and recommendation of sometimes risky and unnecessary interventions. Needless to say, it escalates the cost of management. Thus it is important to retain and sharpen the clinical skills while utilizing modern technology for complementing and optimizing patient care.[9]

In the faster paced health care scenario the manuscript titled 'The Physical Examination of the Patient with Ischemic Stroke' in this issue of Neurology India has come as a breather. The authors have carried out a systematic review of literature pertaining to the importance of physical examination in the evaluation of patients manifesting with ischemic stroke. They emphasize the contribution of physical examination in identifying the etiology of stroke as well as the factors that may predict its recurrence. Some of these observations include detection of undiagnosed hypertension, cardiac murmurs and arrhythmias, absence or the asymmetrical intensity of peripheral arterial pulses, cranial and cervical bruits, cutaneous markers for genetic, infective and autoimmune diseases, and changes in eyes and fundi reflecting the status of blood vessels among others. They also highlight that examination may also give a clue to the anatomical site of lesion, e.g., dysautonomia due to the involvement of insula. The serial examination also aids in recognizing the declining clinical state of the patient e.g., change in vital parameters due to cranio-caudal dysfunction secondary to increased intracranial tension. The authors make a a point that while the diagnosis of ischemic stroke can be made promptly by imaging of the brain within minutes the role of physical examination viz., inspection, palpation and auscultation needs to be re-emphasized in clinical practice.[10]

What holds true for ischemic stroke is true for several other diseases as well. Neurological examination is complex and time-consuming and therefore it is not surprising that it eats away the time to be spent on general physical examination and review of other systems. A quick, rational and thoughtful “head to toe” examination is often rewarding in many neurological disorders. These include identification of brittle tingled steely hair in Menke's disease, tightly curled hair in giant axonal neuropathy, heliotrope rash in dermatomyositis, adenoma over face and ash leaf spot in tuberous sclerosis in a child with seizures, waxy papules in amyloidosis, Kayser-Fleischer (KF) ring in Wilson Disease, orange tonsils in Tangier disease, blue lines over gums in chronic lead poisoning, multiple and large cafe-au-lait spots in neurofibromatosis, extensive Mongolian spots in a toddler with lysosomal storage disease, thickened nerves with hypopigmented-hypaesthesic patch in Hansen's disease, tendon xanthomas in cerebrotendinous xanthomatosis etc to name but a few. Many of these physical examination findings are considered signatures of the disease or important markers for underlying etiologies.

A thorough clinical examination is a very effective tool for medical professionals. It builds confidence in patients and clinicians alike. It guides the clinician to perform appropriate investigations, conserves healthcare and laboratory resources, reduces the cost of the evaluation, leads to precise diagnosis, helps in planning management as well as gives insight into the prognosis.[5],[11],[12]



 
  References Top

1.
Walker HK The Origins of the History and Physical Examination. In Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths; 1990.  Back to cited text no. 1
    
2.
Verghese A, Charlton B, Cotter B, Kugler J. A history of physical examination texts and the conception of bedside diagnosis. Trans Am ClinClimatol Assoc. 2011;122:290-311.  Back to cited text no. 2
    
3.
Bryan CS (Ed). Osler: Inspirations from a great physician. Oxford University Press, 1997, pp-114.  Back to cited text no. 3
    
4.
Hawkes CH. I've stopped examining patients!. Pract Neurol. 200;9(4):192-4. doi: 10.1136/jnnp.2009.181958.  Back to cited text no. 4
    
5.
Warlow C. Why I have not stopped examining patients. Pract Neurol. 2010;10(3):126-8. doi: 10.1136/jnnp.2010.212217.  Back to cited text no. 5
    
6.
Shelley BP, Chacko TV, Nair BR. Preventing “Neurophobia”: Remodeling Neurology Education for 21(st)-Century Medical Students through Effective Pedagogical Strategies for “Neurophilia”. Ann Indian Acad Neurol. 2018;21(1):9-18.  Back to cited text no. 6
    
7.
Verghese A, Charlton B, Kassirer JP, Ramsey M, Ioannidis JP. Inadequacies of physical examination as a cause of medical errors and adverse events: A collection of vignettes. Am J Med. 2015;128:1322-4.e3.  Back to cited text no. 7
    
8.
Prashanth LK, Taly AB, Sinha S, Arunodaya GR, Swamy HS. Wilson's disease: Diagnostic errors and clinical implications.J NeurolNeurosurg Psychiatry. 2004;75(6):907-9.  Back to cited text no. 8
    
9.
Garibaldi BT, Kugler J, Goyal A, Ozdalga E, Niessen T, Liu G, Manesh R, Desai S, Elder A. The physical examination, including point of care technology, is an important part of the diagnostic process and should be included in educational interventions to improve clinical reasoning. Diagnosis (Berl). 2019;6(3):299-300.  Back to cited text no. 9
    
10.
Garcia-Cazares R, Merlos-Benitez M, Marquez-Romero JM. Role of the Physical Examination in the Determination of Etiology of Ischemic Stroke. Neurol India 2020;68:282-7.  Back to cited text no. 10
  [Full text]  
11.
Nicholl DJ, Appleton JP. Clinical neurology: Why this still matters in the 21st century.J NeurolNeurosurg Psychiatry. 2015;86(2):229-33. doi: 10.1136/jnnp-2013-306881. Epub 2014 May 29.  Back to cited text no. 11
    
12.
Zaman JAB. The Enduring Value of the Physical Examination. Med Clin North Am. 2018;102(3):417-423. doi: 10.1016/j.mcna.2017.12.003. Epub 2018 Mar 5.  Back to cited text no. 12
    




 

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