Evidence-based Physical Exam

CONTEXT: Blunt abdominal trauma often presents a substantial diagnostic challenge. Well-informed clinical examination can identify patients who require further diagnostic evaluation for intra-abdominal injuries after blunt abdominal trauma. OBJECTIVE: To systematically assess the precision and accuracy of symptoms, signs, laboratory tests, and bedside imaging studies to identify intra-abdominal injuries in patients with blunt abdominal trauma. DATA SOURCES: We conducted a structured search of MEDLINE (1950-January 2012) and EMBASE (1980-January 2012) to identify English-language studies examining the identification of intra-abdominal injuries...

Our objective was to review the available evidence of the precision and accuracy of the clinical examination for abnormal systolic murmurs. We conducted a MEDLINE search, manually reviewed all reference lists, and contacted authors of published studies. Each study was independently reviewed by 2 observers and graded for methodologic quality. We found that most studies were conducted using cardiologist examiners. In the clinical setting, the reliability of detecting systolic murmurs was fair (kappa, 0.30-0.48)...

Appendicitis is a common cause of abdominal pain for which prompt diagnosis is rewarded by a marked decrease in morbidity and mortality. The history and physical examination are at least as accurate as any laboratory modality in diagnosing or excluding appendicitis. Those signs and symptoms most helpful in diagnosing or excluding appendicitis are reviewed. The presence of a positive psoas sign, fever, or migratory pain to the right lower quadrant suggests an increased likelihood of appendicitis. Conversely, the presence of vomiting before pain makes appendicitis unlikely...

Community-acquired pneumonia is an important cause of acute respiratory symptoms (eg, cough) in the ambulatory care setting. Distinguishing pneumonia from other causes of respiratory illnesses, such as acute bronchitis and upper respiratory tract infections, has important therapeutic and prognostic implications. The reference standard for diagnosing pneumonia is chest radiography, but it is likely that many physicians rely on the patient's history and their physical examination to diagnose or exclude this disease...

CONTEXT: Diagnosis of Parkinson disease (PD) remains challenging. An accurate diagnosis is important because effective symptomatic treatment for PD is available. OBJECTIVE: To systematically review the literature for information on the precision and accuracy of the clinical examination for diagnosing PD. DATA SOURCES: MEDLINE database was searched for all English-language articles related to the diagnosis of PD published from January 1966 through April 2001...

CONTEXT: A family history of certain cancers is associated with an increased risk of developing cancer. Both cancer screening and genetic services referral decisions are often based on self-reported pedigree information. OBJECTIVE: To determine the accuracy of self-reported family cancer history information. DATA SOURCES: English-language articles were retrieved by searching MEDLINE (1966-June 2004) using Medical Subject Headings family, genetic predisposition to disease, medical history taking, neoplasm, and reproducibility of results...

CONTEXT: Experienced clinicians' gestalt is useful in estimating the pretest probability for pulmonary embolism and is complementary to diagnostic testing, such as lung scanning. However, it is unclear whether recently developed clinical prediction rules, using explicit features of clinical examination, are comparable with clinicians' gestalt. If so, clinical prediction rules would be powerful tools because they could be used by less-experienced health care professionals to simplify the diagnosis of pulmonary embolism...

CONTEXT: The diagnosis of acute thoracic aortic dissection is difficult to make and often missed. OBJECTIVE: To review the accuracy of clinical history taking, physical examination, and plain chest radiograph in the diagnosis of acute thoracic aortic dissection. DATA SOURCES: A comprehensive review of the English-language literature was conducted using MEDLINE for the years 1966 through 2000. Additional sources were identified from the references of retrieved articles...

CONTEXT: Although few patients with acute abdominal pain will prove to have cholecystitis, ruling in or ruling out acute cholecystitis consumes substantial diagnostic resources. OBJECTIVE: To determine if aspects of the history and physical examination or basic laboratory testing clearly identify patients who require diagnostic imaging tests to rule in or rule out the diagnosis of acute cholecystitis. DATA SOURCES: Electronic search of the Science Citation Index, Cochrane Library, and English-language articles from January 1966 through November 2000 indexed in MEDLINE...

CONTEXT: Hearing impairment is prevalent among the elderly population but commonly underdiagnosed. OBJECTIVE: To review the accuracy and precision of bedside clinical maneuvers for diagnosing hearing impairment. DATA SOURCES: MEDLINE and EMBASE databases (1966 to April 2005) were searched for English-language articles related to screening for hearing impairment. STUDY SELECTION: Original studies on the accuracy or precision of screening questions and tests were included...

Detection of pericardial effusions using point-of-care focused echocardiography is becoming a common application for clinicians who care for critical patients. Identification of tamponade physiology is of great utility, as these patients require urgent evaluation and management. We describe techniques that the point-of-care clinician sonographer can use to determine the presence or absence of echocardiographic evidence of cardiac tamponade.

CONTEXT: Pleural effusion is a common finding among patients presenting with respiratory symptoms. The value of the bedside examination to detect pleural effusion is unclear. OBJECTIVE: To systematically review the evidence regarding the accuracy of the physical examination in assessing the probability of a pleural effusion. DATA SOURCES: We searched MEDLINE (1950-October 2008) and EMBASE (1980-October 2008) using Ovid to identify English-language studies conducted in a clinical setting...

CONTEXT: Abdominal paracenteses are performed in patients with ascites, most commonly to assess for infection or portal hypertension and to manage refractory ascites. OBJECTIVES: To systematically review evidence for paracentesis methods that may decrease risk of adverse events or improve diagnostic yield and to determine the accuracy of ascitic fluid analysis for spontaneous bacterial peritonitis or portal hypertension. DATA SOURCES: Relevant English-language studies from Medline (1966-April 2007) and EMBASE (1980-April 2007)...

CONTEXT: Ventilator-associated pneumonia (VAP) is a common and serious nosocomial infection. Accurate, timely diagnosis enables affected patients to receive appropriate therapy and avoids mistreatment of patients having other conditions. OBJECTIVE: To review the published medical literature describing the precision and accuracy of clinical, radiographic, and laboratory data to diagnose bacterial VAP relative to a histological gold standard. DATA SOURCES: English-language articles identified by a structured search strategy using MEDLINE (January 1966-October 31, 2006) and Google Scholar...

CONTEXT: Outpatients with suspected deep vein thrombosis (DVT) have nonspecific signs and symptoms. Missed DVT diagnosis may result in fatal pulmonary embolism. Since many patients may have DVT, a selective and efficient diagnostic process is needed. OBJECTIVE: To systematically review trials that determined the prevalence of DVT using clinical prediction rules either with or without D-dimer, for the diagnosis of DVT. DATA SOURCES: English- and French-language studies were identified from MEDLINE from 1990 to July 2004 and supplemented by a review of all relevant bibliographies...

CONTEXT: Cardiac tamponade is a state of hemodynamic compromise resulting from cardiac compression by fluid trapped in the pericardial space. The clinical examination may assist in the decision to perform pericardiocentesis in patients with cardiac tamponade diagnosed by echocardiography. OBJECTIVE: To systematically review the accuracy of the history, physical examination, and basic diagnostic tests for the diagnosis of cardiac tamponade. DATA SOURCES: MEDLINE search of English-language articles published between 1966 and 2006, reference lists of these articles, and reference lists of relevant textbooks...

CONTEXT: Osteomyelitis of the lower extremity is a commonly encountered problem in patients with diabetes and is an important cause of amputation and admission to the hospital. The diagnosis of lower limb osteomyelitis in patients with diabetes remains a challenge. OBJECTIVE: To determine the accuracy of historical features, physical examination, and laboratory and basic radiographic testing. We searched for systematic reviews of magnetic resonance imaging (MRI) in the diagnosis of lower extremity osteomyelitis in patients with diabetes to compare its performance with the reference standard...

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CONTEXT: Many patients have palpitations and seek advice from general practitioners. Differentiating benign causes from those resulting from clinically significant cardiac arrhythmia can be challenging and the clinical examination may aid in this process. OBJECTIVE: To systematically review the accuracy of historical features, physical examination, and cardiac testing for the diagnosis of cardiac arrhythmia in patients with palpitations. Data Source, Study Selection, and DATA EXTRACTION: MEDLINE (1950 to August 25, 2009) and EMBASE (1947 to August 2009) searches of English-language articles that compared clinical features and diagnostic tests in patients with palpitations with a reference standard for cardiac arrhythmia...

CONTEXT: Erythema migrans, while not pathognomonic, is the most common manifestation of early Lyme disease. Accurate diagnosis of this rash is essential to initiating appropriate antibiotic therapy. OBJECTIVE: To determine the sensitivity of history and physical examination characteristics for the diagnosis of erythema migrans. DATA SOURCES: Structured MEDLINE searches of articles written only in English, 1966 through March 2007. STUDY SELECTION: Studies were included if they enrolled at least 15 consecutive patients with the diagnosis of erythema migrans and reported original data regarding the history and physical examination characteristics of the patients...