Faculty tips and pearls for H&P Skills 

Introduction:

Consider analyzing each historical question and physical exam component as a diagnostic test with sensitivity, specificity, predictive values and receiver-operator-characteristics.  Laboratory, imaging and diagnostic tests also have characteristic utilities such as likelihood ratios which can be found in the literature.

The LIKELIHOOD RATIO:

LR  =  Likelihood that a pt with + test has disease____________

 Likelihood that a pt with + test does not have disease

Some tips and quotes (also found merged in the Teaching Tips and Illuminating Quotes page)

1. Our senses as diagnostic aids have been almost completely replaced by laboratory instruments and the consequences may sometimes be disastrous.  (Louis K. Diamond, MD 1902-1999)

2. The physical exam can be viewed as a coordinated series of lab tests, each component of which has its own limitations in sensitivity, specificity and predictive values.

3. Worth re-emphasizing is the importance of examining patients with direct visualization and palpation, not through the gown, which can mask findings (e.g. skin lesions, decrease tactile sensitivity and lead to false-positive findings (e.g. spurious "rales")).

4. The physical exam is an active, iterative process.  Try to focus your exam on the clinical context of the patient being examined.  Look, feel and listen FOR, not TO. 

MD 1 Health and Illness

MD 2 Cardiopulmonary

• Auscultation of a pericardial friction rub is 100% specific for pericarditis

• Auscultation of an S3 gallop has a LR+ of 11 for heart failure

• + abdominojugular reflux (sustained neck vein elevation of >=4cm H2O during 10s) has a LR+ of 8 for elevated cardiac filling pressures

• Estimation of elevated central venous pressure (>8 cm) has a LR+ of 8.9.  Its absence has a LR- of 0.3.

• Auscultation of egophony on pulmonary exam has a LR+ of 8.6 for pneumonia

ADVANCED CARDIAC (not covered directly in PBL cases)

• Palpation of a slow carotid upstroke has a LR+ of 9.2 for aortic stenosis

• Auscultation of a systolic murmur radiating to the right carotid artery has a LR+ of 7.5 for aortic stenosis

• Systolic murmur that increases from squatting to standing has a LR+ of 5.9 for hypertrophic cardiomyopathy

• Systolic murmur that decreases in intensity with passive leg elevation has an LR+ of 9.4 for hypertrophic cardiomyopathy

• Syncope that occurs during exertion is associated with a LR+ 6.5-14 for a cardiac cause

• An abnormally decreased femoral pulse has a LR+ of 7 for peripheral arterial disease (PAD)

• An abnormally decreased posterior tibial pulse has a LR+ of 8 for peripheral artery disease (PAD)

Tips for assessment of heart murmurs:

• Right-sided murmurs increase in intensity with during inspiration

• Hypertrophic cardiomyopathy murmurs increase in intensity with Valsalva and from squatting to standing

• Fixed splitting of S2 occurs with: RBBB, pulmonary valve stenosis, VSD and ASD

• Paradoxical splitting of S2- splitting during expiration - occurs with: LBBB, HCM and severe AS

• Signs of serious cardiac disease: S4, murmurs >=3/6, any diastolic murmur, continuous murmurs, abnormal splitting of S2

ADVANCED PULMONARY

• In pts with dyspnea and or pleurisy but normal physical exam, obtain upright CXR (assess for pneumothorax)

• Approximated 35% of solitary pulmonary nodules are bronchogenic carcinomas

• Do not use long-acting beta-agonists (LABAs) as single agents for patients with asthma (increased mortality)

• A normal PaCO2 in an asthmatic pt with severe symptoms may indicate impending respiratory failure

• In COPD, do not use short-acting and long-acting anticholinergics together

MS 3 Renal and Hematology 

• Inspection and observation of conjunctival rim pallor has a LR+ of 16.7 for anemia

• Palpation of the spleen tip in a supine patient has a LR+ of 8.2 for splenomegaly

• Orthostatic hypotension defined as pulse increase >30 bpm from supine to standing,  has a LR+ of 48 for volume depletion or blood loss

• Increased pulse >30 bpm or SBP < 20 mmHg or DBP <10 mmHg from supine to upright has LR+ of 3-48 for volume depletion

MD 4 Endocrine and Gastrointestinal

• In patients who develop large bowel obstruction, 94% have had previous abdominal surgery (LR+ 11.5)

MD 6 Locomotor, neurological and behavioral

• Urinary retention has a LR+ of 18 for cauda equina syndrome, and LR- of 0.1 when absent

• A history of cancer has a LR+ of 14.7 for patients with back pain due to vertebral metastases

• A history of corticosteroid use has a LR+ of 12 for patients with osteoporotic compression fractures

• A wide-based gait has a LR+ of 13 for patients with spinal stenosis

• Presence of rheumatoid nodules have a LR+ 30 for the diagnosis of rheumatoid arthritis

MD 7 Life cycle

References:

1. Morrow D.A. (2022). Chest discomfort. J Loscalzo J, et. al.  Harrison's Principles of Internal Medicine, 21e. McGraw Hill.

2. Bickley L.S. (2021). Bates’ Guide to Physical Examination and History Taking, 13e. Wolters Kluwer.

3. Henderson M. C., & Tierney L.M., Jr., & Smetana G.W.(Eds.), (2012). The Patient History: An Evidence-Based Approach to Differential Diagnosis, 2e. McGraw Hill.

4. McGee S. (2022). Evidence Based Physical Exam Diagnosis, 5e. Saunders Elsevier.

5. Stern, SDC, Cifu, AS, Altkorn D. (2020) Symptoms to Diagnosis- An Evidence-Based Guide, 4th edition. McGraw Hill.

6. Alguire PC. et. al. (2022). Board Basics- An enhancement to Medical Knowledge Self Assessment Program (MKSAP) 6th edition: ACP