A Very Tepid Defense of the Physical Exam

Complete with examples and stock images

Doctors of a certain age tend to fetishize the physical exam. I think this is because learning the physical exam is an important part of the socialization of the doctor. It is also a skill that doesn’t really wither with time. Though with every passing day I feel more and more like part of the old guard, I can only give the exam a tepid defense.

Twentieth century labs and 21^st century imaging technology have made the 19^th century physical exam less important. The decline is a self-fulfilling prophecy. As the perceived utility of the exam declines, so too do our examination skills, which in turn make the physical exam less useful.

When I read old physical examination textbooks, I am amazed at what doctors (thought they) could discern. However, I am usually left thinking:

Who needs to know that?

or

I am sure a CT (MR, Echo, PET, insert test here) could do a whole lot better.

I am hardly an obvious defender of the physical exam. I am far from Oslerian in my own skills. I interrupt patients too soon and too often. I listen to hearts and lungs through T-shirts.¹ Many of the exams I perform are meant not to diagnose an illness but to establish a therapeutic alliance. Some are even a form of continuing medical education — re-listening to textbook Velcro rales or feeling the goiter that has been present for 20 years.

But, there are still times that the exam can make a difference in the patient’s care.²

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A 50-year-old woman presents to an urgent care with about a day of right shoulder pain. There was no antecedent trauma, but she had been working out in the garden all weekend. The pain is mostly posterior, over the scapular spine. The pain is constant, worsened a bit by any movement. A medical trainee interviews and examines the patient. The differential diagnosis includes a rotator cuff strain (probably infraspinatus), osteoarthritis (maybe flared up with the gardening), the beginning of adhesive capsulitis (frozen shoulder), or even Lyme arthritis (again, given the gardening).

The attending physician listens to the presentation and is impressed with the differential diagnosis. Her first physical exam maneuver is to have the patient remove her shirt.³ The anterior shoulder looks normal. The posterior shoulder:

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An intern sees a 70-year-old man in the emergency room. The man came in feeling kind of crummy and was found to have a fever. There were no localizing concerns. The intern examines him and finds nothing. Lab work is normal other than leukocytosis (elevated white blood cell count). He discharges the patient with instructions to follow up if necessary.

The next night, it becomes necessary to follow up. The patient is admitted with a lower extremity cellulitis.

The resident who admits the patient asks the intern, “Do you think he had some sort of preclinical cellulitis when you saw him yesterday.” The intern, with admirable honesty, replies, “It was only preclinical in the sense that I did not see it through his socks.”

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A 50-year-old woman comes to an urgent care for a third visit with right upper quadrant abdominal pain. The pain started about 6 months ago. It is intermittent. She can’t seem to identify palliative or provocative features. On the first visit, she had a CBC and CMP, did a 6-week trial of omeprazole, and had a right upper quadrant ultrasound. The tests were negative, and the omeprazole had no effect. On her second urgent care visit, she was scheduled for an abdominal CT which revealed a small umbilical hernia and minimal biliary ductal dilatation. A follow up CMP was normal.

On the third visit, the trainee who sees her (the 5^th doctor to address this concern) recommends an MRCP given the persistent pain and CT abnormality. The attending examines the patient and elicits a quarter sized area of tenderness in the right upper quadrant. Palpation clearly reproduces her pain. The tenderness is only present with the patient standing. Carnett’s sign is positive. He diagnoses the patient with an abdominal nerve entrapment. A trigger point injection relieves the symptoms.

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In medical diagnosis, the physical exam was never the most important component. As our technologies improve and our physical diagnosis skills atrophy, it can only be decreasing in importance. Yet, a role for the physical exam remains. The ritual helps doctor and patient forge a relationship. The exam tests a diagnostic hypothesis. When an expected finding is present, it makes the hypothesized diagnosis more likely. When the finding is absent, the pretest probability is little affected. And, a well-done physical exam (actually, even just a physical exam that is done) enables us to employ our technology in safer, more cost effective ways.

1. Though, I swear, never through a puffy jacket.

2. One of these is a story from a colleague; in one I was the skilled examiner; in another, I was the failed examiner.

3. The classic order of the exam is observation, auscultation, palpation, percussion, manipulation.