Tests, reflexes, signs...

[MagicTyler]

Does anyone know of any resourses for detailed exams? Im looking for a list of easy to do (can be done in the field) tests that are very specific (ie: Hepatojugular reflux sign, thompson test, cullen sign, ect) im looking to make a resource booklet for a more detailed physical.

 

[zmedic]

I think you might want to think about tests that are going to actually change your management or transport decisions. Also I would be careful about using tests that you haven't been actually trained to use if you are going to be giving medications or altering your plan based on them. Are you going to give someone aspirin because they have a Hommen's sign? Are you going to do something different based on hepatojuglar reflex?

I'd also point out that the sensitivity and specificity of many of these physical exam findings are pretty crappy, which is why we rarely base treatment on a given physical exam finding.

I'm all for more knowledge, and I think it's great that you are looking to learn. But for each test you are going to put in the booklet you should have an idea of how that test will fit into an EMS call, if it's reliable, and if it will change management.

I'd also point out that you should be pretty sure you know what you are talking about. Because if you walk into the ER and say the patient has Cullen sign and you are wrong, you look a lot worse than if you just say the patient has bruising on their abdomen.

It's worth thinking about how you would explain using one of these tests in court. It's one thing to say "I diverted to a stroke center because the patient had pronator drift, which we were taught in my paramedic class as part of the Cincinnati stroke score" vs "I decided that the patient did not have liver failure because of a test I red about online."

 

[Melmd]

Try reading a medical handbook "Physical diagnosis by De Gowin's"

 

[Akulahawk]

Does anyone know of any resourses for detailed exams? Im looking for a list of easy to do (can be done in the field) tests that are very specific (ie: Hepatojugular reflux sign, thompson test, cullen sign, ect) im looking to make a resource booklet for a more detailed physical.

There are lots of resources for various tests, various detailed exams, some of which can be very specific. I'm going to go with what zmedic had to say about this and you should learn specific testing that may change your care plan for a given patient. You can learn tests that are very specific, useful and good, but will not change your treatment plan because the treatment modalities you have on hand would not be affected by a specific finding.

In other words, if you're hearing hoof beats, think horses, not zebras. If your treatment for zebras is the same for horses... why make the distinction?

 

[Arovetli]

OP props for wanting to increase your knowledge. Any physical diagnosis text will be a good place to start. But I'm also in agreement with others, alot of these tests will do little to change your prehospital care. For example the Ottawa ankle rules are easy and great but I'm not going to put them into practice as a transport medic.

 

[Veneficus]

You may be looking at this backwards...

One of the most important points of physical exam I was ever taught was that knowledge of physiology and pathophysiology interprets your physical findings, your physical finding do not tell you the disease.

Explained in the easiest way I can, knowing that portal hypertension (among other things) can cause caput medusae; not that caput medusae means portal hypertension.

If you want to be good at physical exam, you must first understand phys and patho. Otherwise, you waste your time.

(also your physical findings will be grossly unreliable if you try to use physical exam without such knowledge)

 

[Brandon O]

I have not got my hands on a copy yet, but this has been recommended to me: http://www.amazon.com/Evidence-Based-Physical-Diagnosis-Steven-McGee/dp/0721686931

Gives evidence-based accuracy figures (likelihood ratios especially) for common PE exam signs.

As far as actually doing 'em, I recently came across this YouTube channel, which has a nice "video index" of such things: http://www.youtube.com/user/mdofola?feature=watch

 

[Akulahawk]

The way you were advised to approach things is just the other side of the coin. Knowing phys/patho is great when you're doing a physical exam... but when you're working up a patient for the first time, you're really going to be running both sides at the same time, where an exam both is confirmatory for what you're suspecting and, along with history and labs if available, points towards some possibilities as to what's going on which drives you to look at those differentials and further exam and testing.

I think that it's a great thing to learn and keep learning... as you learn more, you'll see and understand more and you'll pick things up about what you can do with the treatment "arsenal" you have at your disposal.

I'm all for learning new stuff!!!

 

[mycrofft]

The booklet ought to be sold as a supplement inside a phys exam and diagnosis book.
What is needed is a book that teaches which tests, presumably already technically known, can be PROFITABLY (not money, pt outcome) performed in a prehospital environment, including enroute.

 

[Veneficus]

The booklet ought to be sold as a supplement inside a phys exam and diagnosis book.
What is needed is a book that teaches which tests, presumably already technically known, can be PROFITABLY (not money, pt outcome) performed in a prehospital environment, including enroute.

A good physical exam and history.

It is the very bedrock of good medicine in any environment.

Unfortunately, it is an art. Some artists are better than others.

The value of the exam (and history henceforth refered to as just "exam") is not measurable by data sets of sensitivity and specificity. It is a fool's errand to think that is how it works.

A patient wants treatment, the doctor needs to have at least a good idea what is being treated or further diagnosed. It is not a shotgun effect where you run every test (or most of them) known to man on every patient.

I know there seems to be this delusion that anytime you go to the doctor, said doctor knows exactly what it is the first time all the time and dispenses you whatever treatment works perfectly; but I give you my loyal assurance that you can create a plethora of numbers that don't get you any closer to what you want.

That is unfortunately a mistake of many practicioners. The numbers and the like need to be interpreted and in the end, after you've run tests, asked the audiance, and phoned a friend, a decision has to be made a treatment plan started.

When you are staring at a CBCw/diff and all the numbers are within the normal ranges, but some numbers are near upper or lower limits of normal, "your numbers are normal so you must be ok" is not the answer a patient presenting with a complaint is really searching for. Because doing nothing doesn't usually resolve complaints or cure pathology.

It is in cases like this that the physical exam will be your very best tool.

Telling a patient you have a 90% of having X unless of course you don't have Y and Z which are possibilities isn't what a doctor is for. Because the next question the patient will ask is "so which one am I" and even if you figure that out rather on the simple and cheap, that lingering question of being the 1% with nontextbook findings will cause a lot of grief. Particularly since there really are very few 100% specific 100% sensitive tests.

Now I know a bunch of of scientific minded people will dismiss me as a fool and try to make themselves feel better with their statistics, but I know the scientific part very well too, and as I often post here, rather than convince myself the science is infallable and absolute, I simply use it as a tool in the bag.

(Afterall, much of the scientific assumptions are that we are right about them and that our knowledge of any given disease is absolute and will never change.)

 

[Brandon O]

The value of the exam (and history henceforth refered to as just "exam") is not measurable by data sets of sensitivity and specificity. It is a fool's errand to think that is how it works.
...
When you are staring at a CBCw/diff and all the numbers are within the normal ranges, but some numbers are near upper or lower limits of normal, "your numbers are normal so you must be ok" is not the answer a patient presenting with a complaint is really searching for. Because doing nothing doesn't usually resolve complaints or cure pathology.

It is in cases like this that the physical exam will be your very best tool.

Let's not get carried away here. I'm a big believer in the traditional history and physical, since it's largely all we have access to in the prehospital environment. Unquestionably it can do a great deal for you, if you know how to use it. But it's like anything else in that it has strengths and weaknesses, and knowing how it works is vital to implementing it appropriately. No diagnosis or decision should be based on a single sign or symptom; the overall gestalt is the name of the name; but the gestalt is still comprised of individual findings, and you can't weigh them if you don't know their weight. The fact that the history/physical is not traditionally taught in a quantifiable way doesn't change this, it just adds to the unnecessary Jedi-like handwaving mysticism surrounding it, and I think further turning off modern practitioners who are trying to dip a toe into the older methods. (This is fun.)

 

[Veneficus]

The fact that the history/physical is not traditionally taught in a quantifiable way doesn't change this, it just adds to the unnecessary Jedi-like handwaving mysticism surrounding it, and I think further turning off modern practitioners who are trying to dip a toe into the older methods. (This is fun.)

That was a great video. I will probably share it on FB later.

But I think you touched on the point exactly. "modern practicioners" which is to say "American practicioners" trying to dabble in it.

In the video, the doctor mentions his dad spent years perfecting his exam skills. That is what it takes. There is no shortcut for it.

It is like learning classical dance or a martial art, you spend a lot of time doing the same tedious things over and over again. (I listen to heart tones on the patient who has been admitted 7 days in a row, not because I think something has changed, but because it perfects the skill)

Is it easier to do an ultrasound? For certain. Take less time? Yep. Gets done no matter what the physical finding? Sometimes.

To steal the anology, it is like learing how to use the force. You have to surround yourself by people who believe and take pride in their physical exam skills. Who teach it, who use them to almost a level of perfection. You cannot CT scan everyone and expect that on the off chance you do a physical exam, you might do it well.

I make no secret of it, I chose my educational location first and foremost to learn this mastery of physical exam. While I am not as zen like as some of my mentors yet, I am rather skilled with it.

In the era of technology, that may seem like it is a waste of time. But I started my career working in the field, where technology is not readily available. I saw first hand the value of the history and physical.

It is operator dependant. But no matter where I find myself, academic hospital, community hospital, ambulance, home, disaster zone,refugee camp, or clinic in a war zone, the most constant piece of dependable equipment is the operator. I don't suddenly become impotent the minute the power goes out or the MRI isn't available.

There is a lot to be said when technology amplifies your ability instead of your ability being dependant on it. I think a lot of the antipathy towards physical exam comes from people who are just not good at it. But it is easier to say "physical exam" is not sensitive or specific" than to say "my physical exam is not sensitive or specific."

I have noticed even here in Europe, there is a shift of attitude in younger students towards technology first and foremost. But quicker and easier in my opinion is not always better.

Physical exam is not some strange jedi-like ability, it is a skill, like any other skill. It can be learned and perfected. Just like intubating a patient, if you don't practice, you will not be good at it.

But measuring the effectiveness of a bunch of providers who are not good at a skill is not the same as measuring the effectiveness of the skill.

(Being able to titrate a medication drip without an electronic pump also impresses the hell out of many nurses)

 

[Brandon O]

I am sympathetic that evidence-based quantifications of assessment tools may not always tell the whole story; I occasionally see ECG signs that I know to be reliable impugned in the literature because the testers didn't understand how to use them in the right context. But here's the point, I think: no aspect of our work should be totally immune from the lens of empiricism. There are things that aren't easily quantified, and the resulting numbers don't always say everything. But if we simply decide that we're not going to accept an evidence-based approach to the physical exam at all, then we're opening the door for a lot of error, bias, and nonsense.

You know and I know that there are wonderful practitioners out there who know how this stuff works. But even some of them, and certainly many of the less wonderful folks, probably believe things that aren't true. Their personal litany of anecdotal experience has told them, through statistical or cognitive flaws, that some findings are more or less reliable than is really the case. The whole point of Science is that it helps us crack these misconceptions. I know you're not suggesting that anybody, no matter how good they are, is totally perfect. Moreover, even some of the true beliefs that Yoda holds were only developed by those many years of experience; wouldn't it be nice if novice providers could get a few of these pearls immediately? (For instance, x sign is very reliable but y is not.) Isn't that sort of the whole point of education -- so you don't have to completely rediscover the wheel?

 

[Veneficus]

I think: no aspect of our work should be totally immune from the lens of empiricism. There are things that aren't easily quantified, and the resulting numbers don't always say everything. But if we simply decide that we're not going to accept an evidence-based approach to the physical exam at all, then we're opening the door for a lot of error, bias, and nonsense.

That door is already open. Empiricle numbers do not change that. As an example I use the ongoing debate of On pump vs. Off pump bypass.

There are basically 2 schools of thought. Both produce studies and evidence to support their claims. The long and short of it is studies are easily designed to prove an idea, not simply to observe what happens.

The problem with applying this to any physical skill is it is provider dependant. So it doesn't really measure objectively.

It is like the EMS intubation argument. SOme services do a good job, some don't.

You know and I know that there are wonderful practitioners out there who know how this stuff works. But even some of them, and certainly many of the less wonderful folks, probably believe things that aren't true. Their personal litany of anecdotal experience has told them, through statistical or cognitive flaws, that some findings are more or less reliable than is really the case.

Ok, but that is not changed by studies. Many older providers will never change their practice. If they read studies at all. In addition, provider experience counts.

I once witnessed a very heated argument between an EM physician and a new critical care surgeon. Long story short, the surgeon was quoting a study done in a specific area, the EM explained why that study did not apply to the local area.

As always, when there is a patient in front of you, it doesn't matter what works 70% of the time or shows up 90% of the time. You have to deal with what you have, not try to force your patients into a predetermined script. That is my major issue with midlevel providers, they have a predetermined script based on selected research or opinion, and somehow hold it as the one truth and best route.

It is not that I don't believe in studies, it is that I deal with them so much that I realize they are less perfect then they are given credit for. So when you start basing practice off of flawed studies or poor science, but have numbers to justify it, it becomes worse than having no study at all.

Moreover, even some of the true beliefs that Yoda holds were only developed by those many years of experience; wouldn't it be nice if novice providers could get a few of these pearls immediately? (For instance, x sign is very reliable but y is not.) Isn't that sort of the whole point of education -- so you don't have to completely rediscover the wheel?

There is a difference between rediscovering a wheel and shortcutting the foundation of a practice.

Wouldn't it be nice if you could give a dancer a few important tips and she could solo on a broadway stage? Wouldn't it be nice if you could give a few pointers to an amateur runner and make him gold medal competative at the olympics? A quick self defense class and be able to repel an attacker like a world class mixed martial artist?

Trying to scientifically assign sensitivity and specificity to physical exam and history is totally dependant on the performer. There is no way giving me some pointers on how to paint is going to alllow me the same results painting a chapel as Michelangelo in a few short days.

Even if you do a global study, wouldn't the areas that were really proficent look worse then they are? Wouldn't the areas that look bad look better?

The biggest flaw in science is the humans.

 

[tacitblue]

Let's not get carried away here. I'm a big believer in the traditional history and physical, since it's largely all we have access to in the prehospital environment. Unquestionably it can do a great deal for you, if you know how to use it. But it's like anything else in that it has strengths and weaknesses, and knowing how it works is vital to implementing it appropriately. No diagnosis or decision should be based on a single sign or symptom; the overall gestalt is the name of the name; but the gestalt is still comprised of individual findings, and you can't weigh them if you don't know their weight. The fact that the history/physical is not traditionally taught in a quantifiable way doesn't change this, it just adds to the unnecessary Jedi-like handwaving mysticism surrounding it, and I think further turning off modern practitioners who are trying to dip a toe into the older methods. (This is fun.)

A few things...

First, you wont meet a bigger advocate of science than myself. I have been fighting tooth and nail in my system to get more evidence based practice in our protocols and to get rid of the dogma. That said, I fear that we are headed to a mindset of complete reductionism in medicine. We assume that our statistics and microscopes will bring us ever closer to all of the answers. A good recent article on the weakness of these approaches here

http://www.wired.com/magazine/2011/12/ff_causation/all/1

We live in an interconnected world. Everything depends upon everything. It all hangs on you, and you hang on all of it as a zen buddhist might day. A patient does not care about microscopes, statistics, or ever clearer understandings of metabolic pathways. They want the doctor to listen to their problem and then examine them. They do not care that the sensitivity of the murphy's sign is x %.

Medicine is an art and a science. Certainly the science is a huge part of it. I grew up having to go to a cardiologist every year since birth, and I remember one thing very well. I was weighed, had EKGs done, had blood drawn, etc, but I do not remember these things; I remember my physician coming into the room and listening very intently to my heart and lungs with his stethoscope. I remember him feeling my liver and spleen, checking posterior tibial pulses, etc. I remember him confidently describing the size and location of the defect in my heart, only to have it confirmed every time on the echocardiogram. Thinking back on it, the guy actually seemed like a Jedi. There is something to be said for the accuracy of some expert practitioners who have a mastery of these techniques.

The history and physical exam, I fear, is becoming a lost art. I sometimes feel that I can preform a better physical than some physicians I run into. I have seen the utility of physical examination and believe strongly in it. It benefits the patient psychologically and establishes the healing relationship. Learning and mastering it cannot be stressed enough.

 

[EpiEMS]

The physical exam is key, though, isn't it? It's not as if physicians immediately refer to diagnostic imaging before looking with their own two eyes?

(This is fun.)

This was wonderful. (As is the blog, btw, I'm a major fan!)

 

[Brandon O]

Wouldn't it be nice if you could give a dancer a few important tips and she could solo on a broadway stage? Wouldn't it be nice if you could give a few pointers to an amateur runner and make him gold medal competative at the olympics? A quick self defense class and be able to repel an attacker like a world class mixed martial artist?

Obviously, the actual psychomotor skills of the exam have to be acquired through practice. I think the relevant issue isn't the palpation or the auscultation, but interpreting the results and placing them in clinical context. How WELL you do the skill may affect how USEFUL the results will be, but not infinitely; you can only do something useless so well.

Trying to scientifically assign sensitivity and specificity to physical exam and history is totally dependant on the performer. There is no way giving me some pointers on how to paint is going to alllow me the same results painting a chapel as Michelangelo in a few short days.

Even if you do a global study, wouldn't the areas that were really proficent look worse then they are? Wouldn't the areas that look bad look better

Yes all around, and I agree with the point on variability (although the science can be useful here as well, by telling us how consistent interpretations tend to be, and hence how difficult the skill is, which is something that's good to know for large-scale protocol or education changes). But just because the usefulness of a test varies from provider to provider doesn't mean that it varies infinitely. Some signs are more meaningful and some are less, some symptoms are more prevalent, some diagnostics are more useful. Maybe in 75% of cases you can make the right diagnosis given XYZ constellation of datapoints, and I'd only get it 50% of the time -- so there's a 25% range. But it's a finite range, and knowing those figures tells us approximately how reliable that diagnostic picture is, and helps us decide whether to run more tests and so forth. Now, with long experience, you MIGHT have a sense of that same reliability, based on the diagnoses and misdiagnoses you've seen. But you also might not, because people have biases and misconceptions, or simply because not everybody has seen every presentation of every disease enough to form a comprehensive view of its variability and spread. That's why dudes in white coats and Matlab tell us useful things, and why it's throwing out the baby with the bathwater if we chase them out the door yelling something about the unassailable and ineffable artistry of our craft.

 

[Brandon O]

I have seen the utility of physical examination and believe strongly in it. It benefits the patient psychologically and establishes the healing relationship. Learning and mastering it cannot be stressed enough.

I actually do agree. I remember hearing about an experienced neurologist who would always earnestly auscultate the patient's forehead, just because they seemed to appreciate the attention. There may be a fine line here between human connection and placebo trickery, but your point is taken.

 

[Dwindlin]

But I think you touched on the point exactly. "modern practicioners" which is to say "American practicioners" trying to dabble in it.

Are you talking EMS or in hospital?

 

[Veneficus]

Science as religion?

Brandon,

I appreciate your spirited defense of the idea of unbiased research and usable data, but I really think from my knowledge and experience working with scientific research that you are giving it far more credit than it deserves.

While that maybe great for developing algorithms and explaining to healthcare payers what they are getting, there are major flaws in medical research.

Nursing research sets out to validate what they practice. That is like saying "Here is my experiment showing what I am doing is right" obviously good for nursing, not really worthy of a scientific journal.

Medical research is sometimes a bit better. But not always. Certainly not reliably.

There are researchers with such a vested interest in a given topic, the whole method of create a hypothesis, test the hypothesis, by its very design is biased. In terms of reproducability, if you reproduce a biased study, you should get the same reproducable results.

S. Jay Ghould described it in his book as "subconscious bias" which was to say "inadvertant."

It is overly ideal to think all researchers are just measuring unbiased information and coming to conclusions. Not because researchers are malicious or corrupt, but there is a lot at stake, not least of which is money.

Do you think a researcher who believes he has discovered the perfect biomarker where non existed before isn't vested in a positive outcome?

What if it meant changing world wide medical practice?

You think pharm and med manufacturers don't want to see positive outcomes?

Do you know that one of the most common postive reviewer comments I see on submitted publications is "The results do not deviate from the mainstream."

Think about the implications of that!

That is not peer review, that is peer bias, those reviewers didn't reproduce the experiment, they offered their expert opinion on it.

I have the data from my current personal research, dozens of patients. I am not trying to prove anything, just demonstrate that what is currently being done matches what is currently professed in textbooks. (aka verifying)

Do you know who decides what parameters are included in the database I send to the stats dept.?
I do.

Do you know who selects which markers are important enough to be included in that database?
I do.

You know how I do it?
I take known and accepted biomarkers, look for gross trends (visible to my inspection) and decide they "may" come up as statistically significant in the calculations.

Do you not see what could go wrong with that?

Now what if I really was trying to prove a point I was emmotionally attached to?

Do you see how easy inadvertant bias can play a role?

What if I had an academic antagonist, whom I was trying to disprove?

You think that doesn't exist?

Not only does it at the individual level, as I pointed out earlier, there are whole schools of thought.

As if that wasn't enough, I can actually insert an equation that will put skewed results into a bell curve. That way I can demonstrate mathmatically exactly within accepted parameters there is a statistical significance.

The only study I am aware of that doing that actually made the results look less favorable is the original aspirin to prevent MI study.

Forget manufacturing, pharm, and nobel prizes, what if I was an insurance company and didn't want to pay for a particular treatment? How hard do you think it is to find a academically dissenting opinion and offer money to set up a study?

You fund it, he wants to prove your right even before you contact him.

What if you are a hospital that wants to scientifically verify, (to say use the scientific method to create academic credibility to your decision.) your new cost saving algorithm is not harmful to patients?

The scientific method is devised by man, to be used by man. S.Jay Ghould actually wrote a book, The mismeasure of man, detailing not only how science can be biased and used to further a particular goal, he listed examples where implmenting the scientific method, people actually had evidence that white males were scientifically smarter than every other population group! (along with a few others like intelligence testing as a means to justify conscription)

Want a modern example? Look how long and at what cost it took for a retraction of a scientific article of a link between autism and the MMR vaccine.

Let me have another go?

If I decide I want to publish a study, one of the things I can do to help get published is find a topic that doesn't have a lot published on it. (Like EMS treatments or maybe aneurysm resuscitation in relation to surgical technique.)

In the former, since there is so little interest in it, if I do publish something, it may be the undisputed authoritative study guiding treatment based on the fact there are no other studies.

In the later, despite my white coat and statistics program, I might be denied publication completely, because "I am not a board certified expert in those fields." Which means even if I point out the sky is blue using data obtained by every meterological and space agency in the world, until I am a meteorologist and an astronaut, (or at least an astronomer) no matter what I figure out is not suitable for publishing in any medical journal.

Your argument that guys in white coats and a math program give us important unbased data doesn't hold up to that practice.

Perhaps something closer to EMS? Take oxygen therapy. We have textbooks outlining the pathophysiological effects of over oxygenation described in biochemistry and molecular mechanisms.

Somebody who supports the practice will claim it clinically doesn't matter. Worse yet, they may claim there is no clinically evident short term harm so the practice should continue.

But there is no clinical evidence that fatty streaks in arteries have short term clinical consequence either.

Be careful about using science as your religion my friend.

I don't know who said it, but I am reminded of the quote, "In science there are no experts."

I could probably type another page on how to discount a given study. But I think by now you get the idea.