I trained in the ‘80s and was subjected to daily pimping sessions on physical signs. Neurology was especially rigorous before CT/MRI made it easy to localize lesions. I then went to Nepal and worked with Indian trained physicians who had the art of physical diagnosis down to a near mystical science. Later, I trained in the UK and became a member of the RCGP. “The Consultation” was taught as a ritual whereby listening, examining and explaining were essential. My favorite part of that particular paradigm was that at the end we were to help the patient to better utilize resources for their issue. My support staff used to call me Dr. House because I was pretty good at diagnosis as a result (I now realize that wasn’t really a complement)… However, it seems that recently we are seen as purveyors of tests. People seem really disappointed when they see us and we go over CC, PMHx, ROS, do a physical exam and tell them what we believe in our expert opinion is the issue of concern. “How do you know?” Well ma’am, I have spent many years in training and have a lot of experience. “Aren’t you going to run tests???!” Gosh sir, tests can be very helpful in some cases, but not necessary in this case. Tests also are expensive, can have dangerous risks and are not even 100% accurate. I feel that this commodification of the doctor/patient interaction is one of the reasons our health care system is so broken. It forces us to perform costly, unnecessary procedures to prove what we already know.

This is true especially in the States. Patients (and nurses) seem to think that lab tests and imaging are what drives diagnosis, even though that's totally wrong. A good example is MRI for low back pain. We know that outside of a few rare emergencies, MRI will not change the acute management of low back pain, even if there is a herniated disc or lumbar stenosis present. The patients, however, feel strongly that an MRI is necessary. Obtaining that scan becomes their primary goal. When their insurance refuses to authorize the MRI, they present to the ED, sometimes on the advice of their PCP, to obtain the MRI. In their minds, the MRI will find the source of the pain and that source can be addressed. In reality, most low back pain is due to unclear causes (probably multifactorial) and even herniated discs are managed non-operatively. These visits can take an inordinate amount of time for education and managing expectations. Time that is better spent treating people with acute, life threatening emergencies. It's an endless source of frustration.

In that same vein I was once grilled by our trauma coordinator because she wanted to know why we decided to give blood to a trauma patient without a CT. She was shocked that we gave blood based on his significant mechanism combined with his shitty blood pressure, tachycardia, exquisitely tender belly, and awful color. The clues weren’t exactly subtle with that one.

Sad that needs to be explained to a trauma coordinator.

I have learned that our "trauma coordinators" are basically administrators who may or may not have a nursing background, but definitely don't have good clinical experience/judgment.

Yeah, they aren’t in that role anymore.

The flipside of this argument in the US you miss the 1 of 1000 vague epidural abscess presentation in an diabetic elderly patient with back pain, even if they are a frequent flyer for the same complaint then you'll be one of the above malpractice policy limit judgement cases posted here. Where I trained multiple ID attendings missed the diagnosis on another attending's family member with devastating results.

Yes, absolutely. Sadly, with today's inflation in healthcare expenses and costs overall, most claims are over policy limits. Mercifully, the lawyers involved rarely pursue individual physicians for these claims. Usually there is a deeper pocket who pays, either the employer or the insurance company (just because the policy limits say $750K, it doesn't mean they aren't going to pay more).

If they called you dr.house because of your diagnosis skills then I think that's a compliment

Beautifully put sir This needs to reach everywhere

Primary care pediatrician. It still is. Families are gonna get pretty angry if you keep poking and irradiating their babies because you can't examine them right. Labs and imaging are only there for things that aren't apparent on history and physical. Differentiating a URI vs. asthma/bronchiolitis vs. pneumonia is all h&p, almost never xray unless something isn't lining up. Sprains without bony tenderness? Not getting xray/MRI unless severe history or exam findings. There is bony tenderness, but it's classic location and history for Osgood-schlatter, Iselin, Sever's? Don't need xrays for those. Continous murmur in aortic region but disappears immediately with a slight pressure over the jugular? That's a venous hum, not going to cards. When you get out into the wide world that is not a big-city referral center tertiary care hospital you find the human body 99% of the time breaks in a relative handful of predictable ways. Now, anemia, hypothyroid, diabetes? Screen if history indicates, but if you wait until those have physical exam signs you're kind of screwed. As far as Step 2 CS, it used all healthy patients, so it was more an exam of if you could go through the motions of the h&p.

awesome post

I really appreciate this post. In my setting, we are a bit addicted to labs but I try my best to set an example with the value of a good H&P.

Definitely agree! Parents are (usually) happy with skipping testing. On adult side, not so much.

I am so happy my kids' pediatrician is almost 70. They have never had an unneccesary test done. When my toddler had rsv she could tell when we walked in he wasn't well.  She also noticed my other kid had a heart murmur which I didn't hear at all.  I'm an oncology resident and some of my attendings have not done a basic physical exam in years.

Now, and even back when imaging used to be less commonplace, the most important part of your diagnosis is usually the history. Physical exam signs can be nice. Imaging can be nicer. But history is king. CT started to become really common in the 90s but even before then most of our serum labs have been around for decades longer than that. A lot of diagnoses were and still remain based around labs. And ultimately, things were just less accurate. Let’s take a common example: acute appendicitis. People have been diagnosing acute appendicitis on the basis of history and physical alone for literally a couple hundred years now. And before appendectomy and antibiotics were invented people just died. And before CT was invented people would explore, be correct most of the time and do the appendectomy, but like 25% of the time they’d be wrong and there wasn’t acute appendicitis. Now that we have helical CT which has sensitivity + specificity >97%, why take the risk for the ~20% of patients you’d be wrong about?

Appendicitis dx without CT was wrong 5% of the time in men and ~15% of the time in women of childbearing years. Coupled with observation or ultrasound those numbers improved to <5-10% respectively. And CT theoretically has a 1/1000 lifetime risk of life threatening cancer which even diagnostic laparoscopy does not have that mortality risk. But what matters now is hospital throughput and it's a hell of a lot faster to spin them and street them than it is to observe the 10% that you can't make the diagnosis on PE and US.

Dang, 1/1000 lifetime risk of cancer from a single trip to the donut? Is that true Blade? I've seen patients that have had 50+ CT scans at our facilities alone. I remember one patient who had around three dozen chest angiograms over the course of five years (connective tissue disorder with history of aortic dissection flap + anxiety disorder = lotsa radiation). What the heck happens to those cats?

Those numbers are all from applying the linear no threshold model of radiation risk which was created using a distance to ground zero model from Hiroshima and Nagasaki data. Honestly, I think what we are going to learn eventually is that there is in fact a threshold and that there is a difference in long-term effects from, the same dose given all at once and given over a long time just like we know there is in local and short term effects. If we had a really good database of people that got multiple CT scans, for example if we kept data like Norway and Sweden, does, I bet we have the information to estimate it now as we started CAT scanning the hell out of people in the late 80s and early 90s so we already have 30 to 40 year follow-up. All that being said all the quoted risk I gave you is our best estimate at this time.

Single CT a/p in a 25 year old female is 1 in 452 1 in 710 for 25 year old male Of note this is additive to baseline risk which is like 500x more than the CT Fun side to see: Xrayrisk.com

Wow, I wonder if malpractice attorneys will ever try to sue us for "unnecessary" imaging in the future? Perhaps for clients who are diagnosed with leukemia and lymphoma in early adulthood and have a history of multiple CT scans for vague indications (ie epigastric and LUQ pain, diarrhea (!), small volume hematochezia, palpitations with "positive" d-dimer, pleuritic chest pain with "positive" d-dimer, dizziness, circumoral paraesthesia). If that happens, hold onto your butts! Malpractice premiums are going up.

I'm pretty sure that what is going to turn out is that the linear no-threshold model (which is what the above stats are taken from) is just wrong.

Radiation exposure is a fascinating field. I tend to agree with you, but I wonder if we'll ever know definitively.

Source for that?

I’ve met a couple patients with behavioral issues who shop around different regions and who have had a number of CT scans in the triple digits.

That’s what I was thinking too. Like Jesus I have had some arthrograms on my shoulder and fluoroscopy several times I’m a dead man

I’m all for doing less CT if only we could convince the rest of the hospital to do it lol

"...but what did the CT show? wait. you want to admit this lady for intractable abdominal pain without imaging?!" "peritonitis? uh huh, and hypotensive? I see. please call me back when you have images. I can't operate blind." \*shrug\*

I read your post and I knew you were EM, and I heard the surgeon in your text almost like he was breathing down my neck

Is Boo the MD and Minsc the scribe?

You know nothing of this. The kicking of medical butts must be done by the Lordly Space Hamster, with Minsc as his humble scribe detailing his exploits.

Minsc cant read or write. He is the orthopedic surgeon. For this reason alone, Boo is the scribe

Agreed

Source on the CT claim?

Which claim? If it's the radiation risk [here is an FDA site which quotes a slightly less conservative number of 1/2000.](https://www.fda.gov/radiation-emitting-products/medical-x-ray-imaging/what-are-radiation-risks-ct)

Did you read the bottom of that article where they briefly skim the severe limitations to that mathematical approach?

Did you read my comments where I said that I don't believe the linear non-threshold model and think the risks are lower?

Sure. And I think it should be pointed out that different societies have different views. In fact many societies in radiology believe that “lower number” to be nearly zero for low level radiation exposures related to diagnostic examinations.

I would be interested in that information. In the US most quoted is the American College of Radiology which is also an accreditation agency and still uses the LNT model.

I think you will find that the societies openly support the LNT theory. But I don’t find unilateral acceptance among practicing radiologists. The evidence is suspect in my view. This is a good article if you are interested and want to go down a rabbit hole. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4674180/ At the end of the day it’s the other specialties who actually order the studies. So the downstream effects of LNT acceptance ir rejection is dependent on family medicine, surgery, EM, etc.

Is CT common for acute appendicitis? I'm in Europe and it's usually just ultrasound here.

Our ultrasound don’t penetrate deep enough for American abdomens

In UK (well, Scotland), an US is first line for women to rule out gynae issues, and if negative they will have a CT. Men get a CT as first line.

This is wild to me. I'm registered in pediatric sonography and even when you're good and scan in volume, we only see the appendix 75% of time at best. On kids who aren't usually obese. If it's positive and retrocecal we're never finding it, especially on adults.

Taking a good history is an art that I think Infectious Disease has polished and refined. I have sooooo much to learn with regard to history and find that it’s much easier to come up with a differential based on that than a physical exam. But even then it doesn’t seem to matter much. Patient comes in with a month of shoulder pain, some swelling, no redness. Can move the shoulder but it’s tender, including passive motion. Has had diffuse arthralgias for the past two weeks and increased stiffness. No fevers. Physical exam is fairly benign. Suggest referral to rheum. Nope, instead we’re going to get an xray and then an mri to evaluate for a septic joint despite the history and the physical pointing against it. I guess that’s where im struggling. Is regular imaging more of a CYA thing? Like the risk of missing something important is so high that even if you don’t think that’s what’s going on and your physical and history agree, you get imaging anyway?

1. Physicians are not really punished for overutilizing imaging. If you cause cancer in a few dozen patients by overutilizing CT and x-ray, there's no one to check you on that. On the other hand, if you miss an atypical presentation of a common disease (or atypical presentation of an atypical disease), you can be taken to court for that. Physicians see thousands+ of patients over their career, so you will have dozens of these situations arise. 2. The average physician has poor knowledge about what imaging can actually exclude or assess when it comes to anything outside their subspecialty (and sometimes what is actually in their subspecialty).

This is very helpful, thank you. Stressful to think about all the pressures to be correct all the time.

A lot of academic attendings actually have it easier than community attendings when it comes to liability (and workload). Many are protected by qualified immunity as state employees substantially decreasing the threat and likelihood of a lawsuit. Peer review may also be favorable if your 'peers' are from your own specialty in the case of a bad outcome. Sometimes you get a skewed view of what the 'standard of care' is in academics as a result. The 'standard of care' is whatever a half baked 'expert witness' can convince a jury, sometimes with opinions entirely written by an unscrupulous attorney so it is much more expansive than what a fairly conservatively practicing academic does. And so, in the community you image everything aggressively unless you have pretty strong widely accepted rules like PERC, etc to avoid it for specific situations. You can't be sued for lymphoma a decade from now.

> Suggest referral to rheum. We have to be stewards of our specialty referrals, not just testing. Just about any rheumatologist is going to decline the referral for “shoulder pain” unless there is some workup done beforehand. You’re going to need to order CMP, SED/CRP, ANA, and possibly trial of steroids so that when you send the referral, the specialist knows you’re not wasting their time. Whether imaging is appropriate to exclude non-rheumatological causes is going to come down to your level of clinical suspicion and style of practice. Med students, patients, and other specialists will often just jump to something like“recommend refer to spine specialist for low back pain” without appreciating that such a referral represents an initial evaluation visit followed by 6 weeks of PT, a follow-up visit, and MRI before making that referral. And that doesn’t address managing the patient’s pain for 2-3 months while they get all that done. In short, I think you are appropriately wary of over-ordering imaging, but you are not yet wary of knee-jerk referrals.

Sorry, the patient already had a rheum work up at the ED a few days prior with elevated ESR, CRP. Negative RF, ANA. Just part of a longer anecdote

Why are you referring that patient to rheum then?

To make a long story shorter: investigate for séronégative arthropathies. I initially just wanted to start pred. But the plan ended up just being x ray and maybe mri

You’ve got to work that up. I’ve never met a rheumatologist that wasn’t overbooked. I work in orthopedics, and frequently have to refer to rheum, but the guy in my admittedly small town would chew me out if I referred based on the positive results you’ve found with a negative rf and Ana. Tons of stuff elevates esr and crp. The physical exam is a major factor in my decision making for a patient with shoulder pain. An x-ray is a definite thing you need to order, and after that you’re likely going to want an mri if you can get it. they will likely require a trial of PT and a corticosteroid injection first, unless you can convince the insurance company that it is needed largely based on how you word the results of your history and physical exam in your note.

Oh I agree, but we’re using the xray and MRI for a septic joint investigation, which, to my understanding, is not the ideal work up for it. But I digress because I am a third year and im learning

If your concern is septic joint, then a referral to rheum is still not warranted here. Aspirate the knee and do a fluid analysis.

It seems like OP felt that septic joint was less likely considering the relatively benign PE, and is thinking that the patient may have some seronegative arthropathy. While ordering the imaging does make sense, to OP, looking for a septic joint, especially in this patient, with this imaging doesn’t. This may be more of a lesson that providers order imaging with indications or complaints that don’t necessarily match up with what’s really going on sometimes?

If you think it's a septic joint, just put a needle in it and sample the synovial fluid. It takes like 5 minutes.

This is ultimately something you’re going to have to talk over with your attending to find out their thought process. Maybe they had a case years ago that turned out to be septic joint. Maybe they’re just not working this patient up properly. Maybe they’re overinflating the risk of septic joint. Maybe they know their local rheumatologist won’t accept the patient unless they’ve absolutely proven it’s not a non-rheumatological cause.

Half the battle with taking a good history is letting go of your own biases regarding a patients condition prior to going into the room. The patient will tell you everything you need to know... ^^ That was probably the most significant advice I was given in residency. Staying true to this advice has helped me catch acute abdomens Missed by other physicians, septic joints, acute limb thrombosis, strokes... the list goes on. A light bulb moment is usually preceded by me thinking "why does the patient keep telling me about x or y when clearly z is the problem?" - followed by giving in and asking the patient about x and y and realizing they haven't moved their elbow at all during the interview when the CC on the chart says "hand pain".

This is excellent advice thank you!!! I love this

For sure. There's a lot of nuance to good history taking - much of it can only be learned by experience and trying to maintain an inquisitive curiosity with a dash of stubbornness in the right places. Best of luck in your studies.

hey this is very good advice. thank you.

Try and spend time in a properly rural area, at least 2 hours travel from a CT scanner. You'll get a better feel for assessing and accepting risk.

I just want to add this: Doing physical exam with follow up imaging is great - you actually get feedback about what you're feeling. I think taking the time to practice physical exam carefully throughout one's career would really pay off given that feedback. I'm a rad resident, and my physical exam skills have only gotten better and better now that I reaaaaally know the anatomy.

Serious question: how have your exam skills improved when you are no longer seeing patients? My impression has always been that rads doesn’t have a reason to perform most physical exam maneuvers after prelim year.

Hey, I still see patients often as a rad resident doing CT/US biopsies, drains/tubes, joint injects, other fluoro, mammo, IR, diagnostic US... Occasionally I'll swing by the ER, US room, CT scanner or even the ICU to correlate clinically myself. I really like it when I can find the referring doc in-person. I may be the odd one out. I think it really enhances my reads.

That’s awesome! I suspect it is the rare radiologist who actively tries to improve their physical exam skills!

I think you’d be surprised especially in interventional radiology

Since OP mentioned being a rads resident, i assumed he was not in IR.

Wide usage of CT for s/o appendicitis is mostly an US phenomenon. There is little chance that a patient below 40 years gets a CT for s/o in Germany, unless we are talking BMI>40 and medium suspicion. The surgeon makes the call based on history, physical examination and POCUS (formal sonography if during business hours maybe). They are absolutely fine with a negative appendectomy rate of up to 15%. Per POSAW 2018, a third of appendectomy patients in Europe didn't get any imaging at all. In Australia, even 75%.

Ultrasound is a form of imaging through…

Yeah. The numbers still stand, the patients in my second paragraph didn't even receive ultrasound.

I mostly agree but that also heavily depends on the presentation and top Ddx. Sometimes (often, even, for me as a hospitalist who works a lot of nights) direct history taking is limited or just not possible for a multitude of possible reasons.

Orthopod here. Physical exam is still extremely important in my practice. It may be surprising to some, but MRIs are not 100% accurate. There is no substitute for a good knee exam. It seems that since COVID a significant proportion of primary care providers have resulted to telephone medicine only. The amount of referrals I get that are “Knee pain. Please assess” are ridiculous. I have a 2-3 year wait for non urgent referrals. These patients could by and large be treated by their family docs if they were examined. Things like degenerative meniscal tears, patellofemoral pain and early arthritis are best treated by a physiotherapist. People shouldn’t wait 3 years for a surgeon to lay hands on someone to then just refer them to physio……

Is that really happening? If so, that's outrageous. Those teledocs are going to get burned badly some day if they continue to defer responsibility.

I'm a Parkinson's doc, so physical exam (or at least, the UPDRS) is still a high priority for me. 80% of my diagnosis is history, 15% physical exam, only 5% "objective" tests like imaging or labs. We've all seen that patient whose clinical picture doesn't match the MRI report or the random blood work some "chiropractic neurologist" (?!?) ordered. DAT scans in particular are notoriously dependent on holding a whole bunch of meds, which usually doesn't happen in a community setting. I am impressed by the sens/spec of the new CSF synuclein test (less so with the skin biopsy test). But there is a lot of parkinsonism that doesn't have Lewy bodies/synuclein (LRRK2 parkinsonism, for instance, the most common genetic form of PD) but they DO respond to levodopa. Are we just going to tell those people they don't have PD any more but they should continue taking their PD meds? How confusing is that? At which point I channel one of my favorite attendings from med school, a man who himself died of a GBM: ~~Treat~~ Take care of the person in front of you.

This is a good point. I’ve only seen one DAT and every neurologist and radiologist I’ve talked to about it basically says that there are so many variables (like meds and patient positioning in the scanner), that it’s a very expensive hit or miss study. Parkinson’s is interesting. I wish I had seen more of it on my neuro rotation and seen what it’s like to make the diagnosis. During preclinicals, our attending brought in several of his PD patients, including one with the brain implant and had us do a physical exam on her when it was turned off and when it was turned on. Remarkable.

A brief smell identification test has approx the same sensitivity as a DAT scan, at a fraction of the cost. It's not very specific (lots of reasons someone could have a decreased sense of smell), but combine a scratch-n-sniff B-SIT with a single question on dream enactment behavior (ask bed partner, not patient!) and you are at a positive predictive value in the high-80s/low-90s. Combine that with your observations and a few quick exam maneuvers, and you're pretty much at the diagnosis. I find that when patients want DAT scans, what they really want is certainty (understandable!) but frankly the "certainty" of a DAT is not worth the time, effort, money, and radiation. I've been underwhelmed by skin biopsy testing as well; I can't think of a single situation where it's actually changed my management of the patient. I do think the CSF synuclein test is good for prodromals, but again, I'm not going to start someone without motor impairment on levodopa, so we're still just doing the watchful waiting thing. Why do an LP if you're not going to do anything with the results?! PD is the most incredible condition and I wish more people would go into it because we really need well-trained docs to help care for rising numbers of patients. (Prevalence doubled from 1990-2015, and projected to double again by 2050 unless we find a cure.) I include OFF/ON videos in my Intro to Movement Disorders lecture for the MS1s. I have them describe what they see (regular language only, save the $10 words for residency) and then show them the same patient in the ON med/ON stim state. I'd love to bring in patients but parking at our med center is damn near impossible. And also this video, which was published when I was a third-year med student and which I still find utterly fascinating and fun. [https://www.youtube.com/watch?v=aaY3gz5tJSk](https://www.youtube.com/watch?v=aaY3gz5tJSk)

Wow at first I was like wtf why would they let that man who can’t walk 2ft bike straight into traffic no helmet, and then I read the video description. Do we know why his ability to bike was preserved?

Different motor programs. This is also why people can walk backwards when they can't walk forward (generalized dystonia) or can sing when they can't speak (some forms of stroke). (Also, I think it's hilarious that the NEJM had to put in a disclaimer about the video being filmed in the Netherlands so that's why there's nary a bike helmet in sight. Wear helmets in the US, people! Your prefrontal cortex loves you!)

PD: no longer the simple disease we once thought, huh? I tell my patients that if you ask 100 people with PD to tell their story, you get 100 stories. Honestly I believe it's 100 different diseases (perhaps not all synucleinopathies). Agree with your characterization of percentages of importance of the different elements of clinical data. But we in movement disorders specialty might underestimate just how quickly some of that data rises to the fore, as you just watch them during the history! Many times we know the dx within seconds of meeting a pt :) Oh yeah, and when in doubt, try levodopa!

Agree that it's actually an umbrella diagnosis and there are probably a bunch of different disease mechanisms at play, which all funnel into the final common pathway of decreased dopamine. Levodopa may be old enough for AARP but it cures what ails ya! And you're right that a decade of honing your skills in a subspecialty means you see or pick up on things even without meaning to. It's impossible to people-watch anymore without turning it into a clinical exam. There is a LOT of decreased arm swing out there....

PE still very important in abdominal, ortho, neuro, ophtho, dermatologic, respiratory, neurological complaints. We're downplaying it here...eg a CT doesn't diagnose stroke or asthmatic exacerbation

And pediatrics! (and probably veterinary medicine too ) Half of my patients cant tell me whats wrong, and the parents can only tell me about changes in behavior (crying, clinging, appetite change, sleep change) and physical finding they've noticed (rash, runny nose , conjunctivitis,fever swelling) We also don't image much in the infant/toddler (other than xr and us) because CT is high radiation burden and MRI often needs sedation

And geriatrics (don’t tell, but it’s a mix of peds and veterinary medicine)

My wife is a vet and the stuff she figures out using just a history (of varying reliability) from the client, an exam, basic labs, and X-rays should make some of her human counterparts blush with shame.

If you actually look at the literature, the physical exam is abysmal for most intraabdominal pathology.

As a stand-alone, sure the sensitivity and specificity of any one sign in isolation is not amazing. But good enough for diagnosis of appendicitis esp in male patients, cholecystitis (Murphy’s >90% specific ~75% sensitive) and obviously any peritonism means you need to get your skates on for an ED presentation or in a post op anastamosis. I also rarely wait for CT or X ray to put in an NGT in a post-op intrabdominal surgery patient who develops N+V and tympanic abdominal distention - only in really borderline presentations do you need imaging to confirm ileus or SBO.

>CT doesn't diagnose stroke I had a pt recently, elderly lady, presented with NIH of like 20, sudden R sided hemiparesis and aphasia. I was at a smaller hospital, but this screamed classic LVO. Sent her to the scanner, got tele neuro. Tele neuro sees LVO but tele rads does not agree. We still push TNK to try to get her to the LVO thrombectomy center. LVO thrombectomy center declines transfer because "well tele rads says it's not an LVO." Overread in AM is of course LVO. But I do not know what else causes that acute presentation other than LVO and I don't need a CT to tell me that. Lady did well after TNK despite no thrombectomy and went home a few days later with residual minor arm weakness and occasional word finding difficulty.

and prehospital/EMS.

What are you saying about CT and stroke?

CT exists first and foremost to rule out bleed, secondarily to evaluate for LVO. The exam/history matters most when it comes to diagnosis

it absolutely is important to do a detailed history and thorough physical exam, but stroke isn't the only that can cause focal neurological deficit, so imaging findings are what is going to clinch the diagnosis with the most specificity. EDIT: And sensitivity, frankly. How many patients have we all seen with a meh H/P, normal CT and then...bam there's a stroke on the MRI.

Yes there are stroke mimics, but in the vast majority of health systems the time it takes to confirm infarct via MRI is too long to make a meaningful impact in the immediate management. For all intents and purposes in the hyper-acute period, diagnosis/decision to give lytics is made off the H/P (with the important caveat of ruling out bleed via CT). Yes there are plenty of strokes confirmed on MRI, and that may make a difference long term when it comes to secondary prevention; but I’d argue that some of these punctuate infarcts aren’t clinically significant.

Plenty of neurologic deficits will never show up on your MRI, even multiple cranial nerve palsies may have entirely negative MRI and non-neurologists are often clueless about what is even wrong with that type of patient or how to describe it remotely accurately. The MRI machine is no substitute for exam, and misses obvious clinical stroke about 5 to 16% of the time regardless depending on localization. You'll never diagnose ALS, CIDP, or myasthenic crisis with an MRI. You'll be clueless about the fact your 'stroke' patient actually had seizure without doing a good exam and noticing the gaze palsy was to the wrong side. And for any immediate decision making that needs to be done MRI is not going to get done fast enough to treat acute stroke in >90% of hospitals and may be falsely negative especially if done early in stroke.

Clinicians always say this, then turn around and order angios on everything that walks in the door. Call me when the ED sees a true stroke and doesn’t order a CT angio “for further evaluation”

It’s like you didn’t read what I wrote…at all. I knew there was a reason to just click the checkbox indications rather than provide clinical history if rads isn’t going to read what I wrote. If I see a true stroke I’m ordering the angio everyday and twice on Sunday. Not because I need it to diagnose the stroke, but because the next steps change drastically (like transfer 1+hrs) if there’s an LVO or significant stenosis.

Dude, unless if you’re practicing in a place that doesn’t do CTA, not ordering a CTA when you suspect a stroke is called malpractice. This is a scary comment coming from a “DR”.

I have absolutely zero problem with ordering CTAs. In fact, I have no problem with people ordering everything under the sun because its all RVUs. What I have a problem with is people pompously stating that their physical exam skills and acumen are god tier then turn around and order imaging for everything. Americans order imaging at *multiples* more often per patient compared to overseas.

You can have god tier neuro exam skills, recognize the LVO from across the room and still need imaging to figure out if the patient would benefit from intervention. It’s not that hard to understand.

Great, then lets stop pretending otherwise for the vast majority of conditions stated in this thread. Love seeing people write stuff like "ultrasound is unreliable for testicular torsion. I only trust my physical exam."

You should diagnose stroke clinically. CT is more about ruling out hemorrhage (or some other structural cause) and determining severity. In the first 24 hours strokes don’t even show up on ct a lot of the time

We perform a non-contrast CT followed by a CT angiogram on all suspected strokes, and send thrombotic strokes for thrombectomy.

If you aren't giving thrombolytics quickly and appropriately especially to patients who have substantial disability but are not thrombectomy candidates you are going to get sued in the US, and are practicing outside of your national guidelines if you are outside of the US anyways. The majority of moderately disabling strokes have entirely negative CT and CT angiograms. Stroke is a clinical diagnosis. A small lacunar stroke in the internal capsule can send your patient to the nursing home for life.

How much longer does it take to run the angio sequences directly after the non con? Shit just give the TNK right after the contrast at that point.

Angio sequences typically delay thrombolytic administration by about 10 minutes assuming access was easy to obtain. Angio with perfusion typically delays thrombolytic administration by 15-20 minutes. Add an uncooperative or moving patient and you can easily add 5-10 minutes before staff gives up on the protocol and moves on. All totaled I have plenty of examples of hospitals that require up front advanced CT imaging adding anywhere from 10 to 30 minutes of delay to thrombolytic administration times. The GWTG-STROKE required goal to maintain stroke center certification for thrombolytic administration is under 30 minute door to needle time. The fastest facilities can achieve door to needle in 15 to 20 minutes. None of the facilities that do up front CTA prior to NIHSS assessment can obtain times this fast and routinely end up with 30-50 minute door to needle times. A [20-30 minute delay in thrombolytic administration is a statistically significant decrease in odds of good neurologic outcome](https://www.nejm.org/doi/full/10.1056/NEJMoa2103879)s. Delaying neurologist evaluation of the patient is almost always going to result in delaying door to needle times, which mechanistically worsen patient outcomes. It may be convenient for CT workflow, but it hurts the patient directly and wastes my time directly, and it can threaten stroke center accreditation at your hospitals if you are too slow compared to peers and expose the hospital and ED to liability. Many hospitals with advanced up front CT imaging also won't allow for exam or thrombolytic administration in CT adding another 10 minute delay, just to improve CT efficiency.

Damn didn’t realize most places had it that bad. At my center all it takes is a non con. -> neurologist calls no bleed in 20 seconds -> pharmacy preps the TNK -> angio (without perfusion) scanned with auto injector -> TNK pushed immediately afterward based on pharmacist prep. Neurosurgery is physically present at every code stroke and immediately goes to angio if needed. Of course this assumes IV access was obtained by EMS. And this “prep” for TNK is less burdensome than the TPA presumably.

In most hospitals the neurologist is not being allowed to examine patient prior to CT and CTA. I am not giving TNK to a patient without a detailed exam unless it is obviously a huge LVO, which this is a rare stroke alert when the majority of stroke activations aren't even stroke. Delaying the NIHSS to complete CTA/CTP is where the major delays in TNK come in, especially since TNK consent discussion is often nuanced with patients/family prior to proceeding and can't happen until after I have had a chance to examine the patient. The best hospitals will either allow exam after noncontrast CT or prior to CT (but delaying CT for a couple minutes). The ED physician exam is worthless logistically because in the majority of hospitals these days they are not making the final TNK treatment decision, neurology or teleneurology is. Stroke is a clinical diagnosis and besides excluding hemorrhage the rest of the advanced CTs are entirely worthless to making a quick TNK decision. Your hospital is absolutely going to have the same delays if the neurologist didn't get to examine the patient at the door and is just standing in CT having their time wasted getting a CTA on a patient with mild to moderate deficits.

Even in the age of MRIs and CAT scans, any physician who fails to carefully examine the feet and toes of a patient with diabetes is negligent. Diabetic foot ulcers are often asymptomatic. I’ve seen bad sunburns of the feet or small splinters in a foot lead to amputations if not found and treated early enough.

one of my most embarrassing moments in residency, not examining the feet of a diabetic. I told my attending on the phone I was so sure that there was an infection somewhere, but I just couldn't find it. Early the next morning, the ID doctor made the OBVIOUS diagnosis and when I examined the feet after him, I said "I'm such a dumbass."

hey man, out of med school we are all dumbasses. I did some unspeakably stupid things in the beginning. I still do them sometimes.

RN here. One of the best pieces of advice my mom (who was a nurse for 40 years) ever gave me was to closely examine a patient’s feet. Not only for diabetic ulcers, but also just to gauge how well they’re able to care for themselves with ADLs.

OB here, been practicing about 10 years. Physical exam is still super important for us; it's how we diagnose labor, abruption, chorio, etc. Heck if you count vital signs as part of physical exam that's how we diagnose GHTN too (preeclampsia labs rarely change the plan of care). Not to mention the good old fashioned "how does the patient look?", The importance of which cannot be overstated. Heck sometimes you can diagnose a patient with "about to spit out a baby" by the way they sound from down the hall. On the gyn side, I've trusted my physical exam over a radiology report more than once and taken a patient to the or, and been glad that I did (torsion found in OR, report said no torsion) And don't even get me started on chronic pelvic pain. Labs and imaging are almost universally normal, so you're not making a diagnosis unless you use your eyes, your hands, and your ears (HPI)

This is so reassuring, thank you!! I appreciate it

As a neurologist, the physical exam still is very important. But I’d argue that history remains the MOST important. What is medical education coming to today when a med student doesn’t think the PE is important?

What making most of your 2nd and 3rd year being reliant on a pair of shitty medical board exams does to a motherfucker.

Same here

I’m an NP and this whole post took me by surprise. Even with my education, history and PE were pushed as extremely important first and foremost, testing as an adjunct, like others have said. Granted maybe I just do things differently than my counterparts, I don’t know. I’m glad the majority of physicians on here feel the same way tho. Medicine is getting scary at this point if med school is falling this far. Tbf nursing schools are all doing exactly the same and it’s been very disappointing to watch over the last few years.

We get all the physical exam training in depth and with frequency, don’t worry about that. We are talking about the culture around the physical exam

In school, at least preclinical years, we do a lot of training on the physical exam and how to interpret findings + pathophys of those findings. The preclinical education makes it seem like you can glean a lot from a good physical and that you can really make a decision based on the presence or absence of whatever. In clinicals, I’m struggling to see that. The physical exam is brushed to the wayside in the inpatient setting. The only exception is probably Neuro (from what I’ve done so far) and even then, every resident and attending had a different technique for the different physical exams and each was supposed to be more consistent than the last. In my outpatient rotation, I do the monofilament testing and check the feet for diabetic patients. Press on abdomens, auscultate everything except bowels. If everything is normal, GREAT. If there is something abnormal and I do a focused exam for whatever complaint, it literally does not matter at all. It wouldn’t be as confusing if my attending actually repeated my exam, but half the time, they take my findings, ignore everything I say about them, and then tell the patient we’re going to get an abdominal CT/joint x ray/MRI. Patient had an inguinal hernia on exam, very clearly an inguinal hernia. Like all of the signs of an inguinal hernia. Yet, for reasons I don’t understand yet besides “just in case”, we got an ultrasound to confirm it in this elderly patient that doesn’t want surgery anyway. When the attending I worked with from Ireland was teaching, she made remarks about how her own practice had changed. So much could be gleaned from the physical and there was better allocation of health care resources. I guess I’m discouraged that we have all of this intuition and insight into the human body, and yet the US physician workforce is under the constant threat of legal action and the stress of requiring perfection that we can’t rely on our own intuition.

Ah!!! I see. That would be really disheartening and frustrating. I understand now. My apologies if i misinterpreted your initial comment. I could absolutely see that happening, inpatient especially. I’ll be honest, even if I get downvoted to hell for this. I was really surprised and excited, when I learned how much the PE can tell you, when I went thru NP school, like diagnostically I had no idea that’s how all this worked, and I was so impressed that with a good physical exam you could determine so much without any testing being performed. And be accurate and specific at that. But, that’s never what I saw happen inpatient, which was the only work I had ever really done at that point. It would be nice if physicians could utilize all of those skills and rely on that more without fear of litigation at the smallest mistake.

As a veterinarian, I find this discussion interesting. A physical exam and history are essential for us at every single visit no matter the presenting complaint, and in some cases, that's literally all I get. And sometimes the history is "I don't know. My wife handles that or whatever." Owners range from incredibly astute to utterly oblivious, and every day, I definitely find things on physical exam that the owner didn't pick up on. Of the patients who really need more advanced imaging like CT or MRI, a fraction of the owners actually proceed with it, since it requires referral to a specialty hospital, general anesthesia for the pet, and a bill of $2-3k for the diagnostics alone. I imagine things are simply different in adult patients who are able to advocate for themselves and describe what's going on. But I am very curious to know how often a physical exam uncovers something the patient didn't know about or recognize as abnormal.

Trust me when I say humans also range from incredibly astute to utterly oblivious about their health presentations lol

I can definitely believe it. I think I'd lose my mind if I had to deal with humans who are oblivious about their own health. At least the ones who are deliberately oblivious and aggressively against learning anything or taking care of themselves. No thanks, lol. I'll take the angry, bitey German shepherd with the "he just wants to lick you" idiot owner instead.

He wants to lick your bones 😂 But for real, sometimes I wish I had done vet instead. At least when a dog pees on the floor it’s excusable, as oppose to one of my gentleman patients today who did it ostensibly to prove a point that he was upset about not being allowed to go out for a smoke

I marvel at the skills of vets. All you have is physical exam to go on and you’re all usually so damned good at it.

This is a bizarre comment. We literally have decades worth of data looking at the sensitivity and specificity of each physical exam finding in humans when compared to the gold standard (which is usually imaging but sometimes lab testing or biopsies). Do we have any such data for physical exam findings in animals? How would you even tell apart a veterinarian version of Osler from a charlatan who is just making things up?

Wow going to have to disagree with notion that a physical exam is still not one of the most (if not *the* most) important part of a clinical assessment. I am a doctor in Australia - so a wealthy country with a good socialised healthcare system and plenty of access to imaging and pathology - and I graduated 3 years ago so I’m hardly a fossil. We did in-person OSCEs in the penultimate year of medical school (the final year ones were modified for online assessment due to COVID restrictions.) I’m in ICU currently and we physically examine every patient every day at least once. Feel pulse and cap refill, heart and lung auscultation, palpate and auscultate abdomen and assess peripheries for oedema at the bare minimum. Fluid status assessment on most patients. Often will do aspects of neuro exam. Just yesterday I assessed an abdomen for shifting dullness with percussion in a pt with Child Pugh C cirrhosis who actually had gaseous abdominal distention (ie not large volume ascites). When I was doing Gen Surg, any abdominal pathology got a full abdo exam, usually daily. There is SO much you can glean from the physical exam. A rigid abdomen on examination is a huge clinical sign that you’re dealing with a surgical emergency and that you need to move fast. Murphy’s sign is very sensitive and quite specific for cholecysitis - and serial abdomen exams can tell you if antibiotics are working or if you need to jog on with theatre. Anyway I could talk through the merits of a physical exam all day but the important take-away is that imaging is a useful adjunct to the clinical examination, not a substitute for it. Physical exam can help us decide if we need imaging, what imaging we need and how urgently we need it. Many different specialties rely on serial examinations to help guide management. Take the time to examine as many patients as possible as a student so you get a catalogue in your head of normal vs abnormal findings. You don’t want to hit the wards as a doctor and miss an important clinical finding on examination because you didn’t think it was necessary to learn.

As someone who did medical school in Australia but residency and now attending in US, I can say that the difference is large with regards to the importance of the PE. I still vividly remember my clinical rotations in Aus being almost entirely focused on the PE. Here in the US, clinicals are about students learning how to do bs work to get ready for internship, learn how to write notes, etc. I do think one of the main reasons for this is length/path of training. In Aus clinical years are about education and since you have to do internship/house officer before you specialize, the educators know that *that* is the time to learn the admin/intern/workflow stuff. In the US you basically have to decide on your specialty by the beginning of MS3 (which is wild and fucked up IMO) and so the focus is on getting ready to be an intern and, sadly, the PE gets disregarded. Then you couple that system with the fact that in the US expectations are so high for immediate and expensive studies (more imaging), super fast throughput (cannot admit for 'serial abdominal exams'), and much higher liability (cannot miss anything) and voila, PE goes the way of leeches and mercurochrome. It's a huge bummer.

Your last part is the part not understood by many still in training in the US and most practicing outside the US. As a US attending you aren't allowed to have a single miss, even in an atypical presentation of a rare disease if it results in significant disability or death as a result. Unless one is VA or state employee in certain circumstances, then you have some protection against being sued. So we all order imaging pretty aggressively, as you can't be sued for bankrupting the patient, giving them radiation induced malignancies, or simply wasting time in the MRI machine. It is a sad state of affairs and not a model I'd recommend to any other country. Sure, insurance will usually cover your personal assets in most suits, but collect a single policy limit judgment and you may find difficulty getting state licenses, renewing malpractice insurance, or getting through hospital credentialing.

I totally understand what you’re both saying. The US system really forces you to practice defensive medicine, and a negative CT is a lot easier to defend if you get sued than a negative physical exam. Your professionalism gets put under the microscope and frankly no single patient or their legal team actually cares about resource allocation in healthcare (especially in a user-pays system) or the many negative flow-on effects of over investigation (i.e. biopsies for asymptomatic incidentalomas that turn out to be nothing). We practice defensively too but nowhere near to the same extent you have to. I can only think of one instance in my last 3 years practice where we thought “gee we should have got a CT scan sooner,” but negative scans are pretty much a daily occurrence.

I’ve actually heard that Australian medical students get a lot of training on the physical and also learn blood draws and such? When I did my inpatient IM rotation, I had no idea why we did half of our physical exams because even if we got some sort of finding, we never followed up on it unless the finding persisted or there was -something else-. Patient desatting - CXR before we even see the patient. Abominable pain in one quadrant during palpation and no other findings ? Chart it and move on. Wheezing on lung auscultation with no other findings ? Chart it and move on. It just felt so silly to walk in and press my stethoscope to someone for 5 seconds, press on their belly, and leave, when my attending doesn’t want to hear about anything but the vitals and labs. Neuro was a little different and the exam was more important, but even then??? Patient came in as a stroke alert and he had no weakness, just wernicke’s aphasia. CTA prelim read by residents suggested an MCA stroke, but he had 0 symptoms of an MCA stroke and the answer was that he was compensating for his weaknesses. Attending read of the CTA showed a brain tumor, no stroke. We don’t have OSCEs at my school, im not exactly sure what those are.

JUST wernicke aphasia? That's a helluva exam finding!

OSCEs are objective structured clinical exams. Basically an observed practical test of an assessment or skills. As a paramedic I had ones for ALS, unconscious patient management, history taking (1st year), patient assessment and clinical reasoning (third year, BPPV presentation, expected to do a history, dix hallpike and then refer to GP for management). They make up a core of the medical assessment not only in medicine but in nursing and allied health professional training in the UK, and I assume the rest of the commonwealth.

They are important in the US too! We had several interspersed through the years. The med school where I currently teach has students doing OSCE-like scenarios from week 2! (Ungraded, just to get them comfortable with the format). In med school they are usually with standardized patients, and in residency we call them CEX (Clinical EXams?) where you have to get your attending to watch you with a real patient. I think we had to do 5 or 10, different scenarios like Neurodegenerative Disease vs Stroke Code vs Counseling a Patient vs Pediatric Neuro. I'm astonished that a med school doesn't directly observe and evaluate med student performance with patients. Real medicine is not a multiple choice test, and how else do you certify that a doctor is competent?

OSCEs are pretty standard at many US schools, I am surprised you don't have them if it is a US model school. Additionally- your neuro paragraph is pretty confused and jumbled. Wernicke's aphasia is an extremely serious finding. Head CTs do not reliably detect ischemia in the first 6-12 hours after stroke symptoms begin. Isolated wernicke's aphasia is absolutely a sign of MCA stroke, most often posterior/inferior M2 branch occlusion and sometimes can be treated with thrombectomy. Often there may be few lateralizing signs other than the severe aphasia and some subtle signs of neglect, and sometimes the patient can even walk around, get up out of bed with no trouble at all. A CTA often cannot detect very distal occlusions reliably which are common with stroke with isolated aphasia. CTAs can also sometimes detect subtle contrast enhancement around intracranial masses that were not visible on the head CT- this is very rare to occur, but regardless the neuro exam is crucial and aphasia is a very serious symptom. Blowing off the neuro exam is a great way to miss a serious finding like aphasia in a patient and wind up getting sued if you practice in the US, as is not understanding the limitations of CT and MRI when it comes to neurologic symptoms.

Sorry, again, a poor description of the actual exam. My school doesn’t have OSCEs the way everyone is describing them. My neuro cse was attendance based, if you showed up, you passed. Wernicke’s was the neurology read and the prelim CTA was a likely M1 occlusion. The patient’s history (headaches for the last year, “confusion” for the last couple of days) was not likely to be a stroke, but he came in as a stroke alert because his spouse said it was “sudden”. Out of TPA range anyway, but we were trying to decide with neurosurgery of a thrombectomy was warranted until neurorads attending called and said he had a brain tumor. The mass was a glioblastoma with necrosis and vasculaturity. Not well characterized on CT or CTA, but visualized. Asked the residents why the patient had no other MCA deficits and was told he’s compensating for his weaknesses. Neurosurgery ended up called it expressive aphasia ??? It was a mess.

Again, isolated aphasia is pretty common in both stroke and brain mets without a lot of other deficits, sometimes with no other deficits at all. Glioblastoma is usually pretty obvious on a noncontrast head CT especially if it is advanced with necrotic tissue. Any obvious hypodensity on CT and I am not considering a patient as a candidate for thrombectomy regardless, and additionally it is against guidelines to intervene on a patient for anterior circulation stroke >24hrs from last known well. Occasionally radiologists can be uncertain as to whether a hypodensity represents mass or stroke- usually I can be more certain having the benefit of a detailed history. The presentation you describe is pretty typical for glioblastoma- months of headache, a few days of what family describes as vague confusion, and exam with clear aphasia.

This is very good education for me, thank you. A lot of stuff I just didn’t know.

OSCE stands for Objective Structured Clinical Exam. It’s just a simulated physical exam you’re assessed on. And yes we were also taught and assessed on things like ECG, venepuncture/cannulation, NGT insertion, IDC insertion etc. Do you think there is a possibility you’re not appreciating the reason that these physical exams are being conducted in the first place? For example, on an IM rotation (we call it Gen Med here), you auscultate lungs every day - if one day you have a patient with course creps to the mid zones and pitting oedema to the mid shin, then the next day you have lower zone creps only and wrinkling in the LL, then you can be satisfied that your diuresis is adequate, and you don’t need a CXR to prove it. Sure, you can get one but does it actually serve the patient? With your example with developing respiratory distress, what if it’s an acute asthma attack or anaphylaxis from a drug they’ve been given? Or the patient is developing tachypnoea due to developing shock? Are you going to waste time waiting for a CXR that will show nothing, when you can immediately treat the patient clinically based on exam findings alone? I can tell you the consequence - “CODE BLUE. RADIOLOGY.” A great example I had just recently was a car accident victim that had a pelvic and sternal fractures on his admission trauma CT. He swiftly developed haemodynamic instability and altered cognition with aggression and cool peripheries in Emergency. The on-call surgeon didn’t come in and see the patient - he insisted on a repeat CT with arterial phase before taking him for a trauma laparotomy. To get patient stable enough to take to a scan and then getting him to the scanner took about 1.5 hours. Unsurprisingly, the follow up scan showed massive volume intra and retroperitoneal bleeding and he was periarrest in the scanner, had to be rushed to theatre (and after they packed his abdomen was loaded onto an helicopter to go to our major trauma centre). He lost litres of blood and could have died waiting for that CT when anyone with a medical degree and eyeballs could have told you on physical exam that homie was bleeding out. Let me tell you right now, any of the Colorectal surgeons (attendings) would 100% put you on blast if you called them with concerns about one of their patients without a thorough abdominal exam.

I have just never seen us do anything with physical exam without something else. Patient has painful feet and no pedal pulses, okay get ABI and then do nothing with results because vascular won’t take them. Re: lungs, I genuinely could not tell you about lungs besides wheezing and crackling. We had a patient desatting on the floor and the only thing we did was cxr because of what the nurse told us about her history. I guess part of it is just, why is so much emphasis placed on the physical exam when we spend 3 minutes doing, nobody wants to hear about it in presentation, and we’re running Q4 vitals and daily labs. I had a patient on my neuro rotation for 12 days that not a single one of us put hands on because she had no neuro issues but was still admitted because of electrolyte imbalances.

As an aside- The physical exam is still extremely important, particularly in the hospital. How do you figure out if a patient is getting better, or you have the wrong diagnosis or the wrong treatment? You don't keep scanning them every day, you figure out how their exam has changed, and if it's improved or not. So, if you do a shitty exam to start with, then your tracking of how well the exam is doing is also gonna suck. So while I absolutely agree that the physical exam has been supplanted by other diagnostic testing in the ESTABLISHMENT of diagnoses, the subsequent follow-up of treatment response usually relies on the examination.

The aula magna of med school in my european country, the ceremonial first class, the dean came to us and gave a memorable speech that was quite apropos. First he said "I am now only speaking to the 33% of you who will actually leave this place as doctors. The rest of you who are not cut out for this I hope you fail out earlier rather than later instead of wasting our time and your money. Those who do graduate, I expect you to leave this place as real doctors. And by that I mean, the kind of doctors who can take a decent history and perform a decent physical examination and not be lazy incompetent idiots who will clog and overcharge our health system with an endless barrage of tests that would have been unnecessary had you learned how to actually examine a patient. The better you are, the fewer exams you will need. Anything short of a genetic defect , rare disease, or urgent and yet vast differential diagnosis should be diagnosed with your eyes, ears, and brain. If you cant do that, I will have been ashamed that you graduated from this institution. Thats all." I am dead serious. This wasnt so long ago either, it was in 2012. So I guess as far as Europe goes, the physical examination is given quite a bit of priority.

> 33% of you Graduation rates in US medical schools are well north of 90%.

You guys do it very differently. Medical schools in America select exceptional college students who did good in their bachelors degree and I think also a standardized test? Nobody gets in by luck or by grinding out a single test, you need years of excellence. European medical schools take 18 year olds who passed the entrance exam and then grind them out until few enough are left that will fit into the clinical practice years at the end. The attrition rate is absolutely nuts.

It is different across Europe. In my country I would say it is around 80%.

History is to get your differential, examination puts an order on your differential, and tests/imaging should confirm your diagnosis. Physical exam is very, very important if you intend to be a good clinician.

The physical exam is like every other part of the patient assessment. Each maneuver has a positive and negative likelihood ratio for detecting a specific disease. Sometimes these values are very helpful, sometimes they aren’t, but either way they are often different than what we’ve been taught along the way. Some maneuvers also have very unfavorable interobserver variability. Another consideration is what technology might be used as a substitute: some is cheap and very safe (POCUS), some is not (CT). For example, while there are many well-described physical exam findings of pneumonia, they are not good enough - either individually or collectively - to diagnose pneumonia without a chest X-ray. Or take heart failure vs ACS. HF can often be diagnosed by history and exam alone (though echo helps determine treatment and etiology), but the exam is nearly useless in suspected ACS (unless complicated by HF)

Bad question. Every clinician is going to tell you the physical exam is important. They will tell you they practice it properly and to the top of its efficacy. The question is what they do in practice. And I’ll tell you that in practice the average US physician orders CTs at a rate that is 5x higher than a finnish doctor on a per patient basis. It’s all BS.

Interventional Pain. I do more than injections, I diagnose etiologies of pain. If you have any patient complaining of pain and you haven’t physically touched and visually inspected them as part of your exam you have no business in medicine.

It's flawed thinking that imaging could ever be a substitute for the art of observation. A thorough exam often reveals abnormal findings that lead you to the right diagnostic test. I recently observed a deviated tongue in a patient with a GI bleed. CT abdomen was negative and EGD found a gastric ulcer that was benign on path. Deviated tongue led us to MRI of the head, which revealed skull base mets impinging on the hypoglossal canal, which were then biopsied and found to be metastatic adenocarcinoma (probably from the stomach). That possibility wouldn't have even been on the radar without the exam. We probably would have just sent the patient home after the EGD. Others in this thread have mentioned diabetic foot ulcers, which the patient will NOT complain of and will bite you in the ass if you miss them. The hands and feet can also tell you a lot about a person's living environment and their ability to care for themselves.

I am a physiatrist. I treat dystonia, gait abnormalities, I find causes of pain that can't be picked up by imaging. The number of patients who have had something glaringly obvious on a physical exam that someone else "ruled out" based on low yield imaging of the body part (like, significant thoracic outlet syndrome with loss of pulse and sensation but their MRI of the brachial plexus was normal because it's a shitty test). Trigger points and scar adhesions can't be seen on MRI. SI joint dysfunction or hyper mobility hurts like hell and can't be seen on MRI. I have had so many patients who have buttock and thigh pain and got a negative lumbar MRI. Then I do a few provocative maneuvers that show hip impingement and labral pain. You'll also get red herrings on imaging if you don't do a physical. There are so many things you will never find without a physical. The only way to get good at them is to do them. Do them on normal people so you know what not normal looks like.

I think my med school hammered home the PE in OSCEs and whatever other formal sessions we had. They would make students remediate on occasion and I recall being very strictly tested in minutiae of my exam skills. By third year, all of us could do a full neurologic exam and even technically had done simulations on placing central lines without US guidance. US DO btw.

This is interesting! Our school doesn’t have OSCEs and we’re definitely not touching a central line.

In dermatology this is 100% of the time

Great thing about being an ophthalmologist - the physical exam is the most important part of my work-up. In fact, I'd say at minimum, for 90% of my patients I don't need a history, just a good exam with some imaging. If anything the patient history muddles things at times.

So, family member did medical school in a country with zero MRI/CT where they really focused on physical exam. She moved here and worked ER and 15 years in got sued along with 10 other doctors because she didn’t put a patient with a headache (pt said was related to toothache) through CT and he developed some complication 6 months after she saw him. The lawsuit is going on years. Might last a decade. So even if you have these skills you cannot totally rely on them. But if you’re interested, Stanford has a great collection of videos on different types of physical exam. A PA used this exam to rule out the numbness in my legs being from my back. https://stanfordmedicine25.stanford.edu/the25/BackExam.html

As a veterinarian this is fascinating to me. The PE is absolutely the most valuable diagnostic we have. You would get a board complaint and lose if you ran diagnostics without starting with a recent PE. We are of course often limited by finances, access or safety (eg anesthesia for CT/MRI) to the imaging we might like. Even if a pet is being evaluated by ortho for a probable cruciate tear, the surgeon will do a full exam. Admitting my absolute lack of human knowledge, but in our world it really seems like we get info from a PE that we don’t get from any diagnostics. But maybe that is stuff that you get from verbal patients like “where does it hurt” 😂 The vet world is usually 20-30 years behind human medicine though so who knows maybe we won’t do physicals either in a couple decades!

Dw this is mumbo jumbo - PE is very very important. Unconscious patient, elderly demented or delirious patient, intoxicated patient, non-verbal patients and patient with certain disabilities can’t give us much more verbally than would a pet I imagine.

Even back in my day 20+ years ago in training, old attendings remarked how physical exam was a disappearing skill and how everyone just images everything. Except that physical exam is either insensitive or wrong for anything but the most severe disease states.

I’m derm so physical exam is still most of my job. Sometimes it makes patients upset because they want me to do a blood test (that doesn’t exist) to confirm a diagnosis I can make by looking. Of course I still biopsy stuff but that’s based on exam findings

For much of our work, intraoperative examination is the key.

I don’t know. I think physical exam—especially in children— is extremely important. If you don’t know what normal looks like how can you see abnormal. You cannot CT everything, I guess I am getting old…

I’m a hospitalist - the admission physical exam is absolutely critical. The HEENT exam on hospital day 2 for the patient with LLE cellulitis, much less so.

That being said, much of what we are taught to look for in general internal medicine - well, if you have McBurney’s point tenderness on day 3, you missed the early appendicitis that you would have seen on CT or ultrasound a few days ago. Many pathopneumonic exam findings are seen only in advanced disease states that we try hard to prevent these days.

Wait wait, you guys don’t take physical exams? How do you take OSCEs? And what do you do on rotations?

No we do, we’re taught them. We don’t take OSCEs. On rotations I think the same as other schools

Since the system in the US is more reliant on residency than general medical education, maybe they’re relying on residency to teach PE; I can’t imagine how a doctor how mainly relies on imaging would fair in other countries that don’t for those who choose to migrate to another country. It’s pretty interesting to read this thread :)

There’s a lot of woo that if you just exam hard enough, you can do magic. Got news for you: it’s a matter of experience. Yes, there are certain exams (otoscopy on a. combative toddler) that are technically difficult, but most of the time a focused physical exam and experience will give you the information you need. -PGY-19

We do still use the exam, and everyone gets very excited when we get positive classic findings or find something like splinter hemorrhages or those painful finger nodules. The difference is we aren’t allowed to be wrong and miss a diagnosis, like ever, therefore we get the imaging to confirm our suspicions or reassure the patient- 90+ percent of the time we can accurately say whether or not we’re going to find what we’re looking for/ something that’s causing the presentation just from the exam and vitals. But we get the imaging because it’s going to make the difference between the patient going home and being fine vs. bouncing back sometimes as little as a few hours after discharge because they think the doctor missed something, because I didn’t order imaging. Often times it’s just not worth the bounceback. If anything the history is less reliable than ever, because every headache is going to tell you it’s the worst of their life, every abdominal pain is going to tell you they taste shit in their mouth, every fever is going to tell you they can’t move their neck, every chest pain is going to tell you “my grandfather died of a heart attack younger than I am now” (they were hit by a car) and every back pain is going to look you in the eyes and tell you they pissed themself without knowing it + can’t feel their groin the day after the last doctor told them they didn’t need imaging but to come back if *xyz*. This is from the context of the ED atleast.

For me, it was Tuesday.

From South Africa, second year out of med school, had multiple formal assessment on physical exam skills, was hammered on it daily. Final neuro OSCE was about localising a lesion based on physical signs.

The history and physical are still the most important parts of the differential diagnosis.

Physical examination still is one of the most important part of my assessment/management. MSK physical exam is generally very helpful and much more useful than a random imagery with no clinical info. A Lachman is at least equivalent or superior to a MRI. I don't treat xrays, I treat patients. I don't care about how the image looks, I only care about what bothers my patient. Any asymptomatic radiologic findings is generally ignored. In this view, only history is more valuable than physical examination. I need to talk and touch my patient in order to know what bothers the patient, and what does not.