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1 Evidence-Based Physical Diagnosis Steve McGee, MD Professor, University of Washington Alaska ACP and AKOMA 2016 March 31, 2016 Diagnosis today: Bedside diagnosis Technology Evolution of Diagnostic Standard Diagnosis historically: Diagnosis today: Bedside diagnosis Technology Evolution of Diagnostic Standard Dermatologic diagnosis Cellulitis Zoster Psoriasis Neurologic diagnosis Parkinson’s disease Bell’s palsy Amyotrophic lateral sclerosis Musculoskeletal diagnosis Cardiologic diagnosis Pericarditis Mitral valve prolapse Ophthalmologic diagnosis Diabetic retinopathy Psychiatric diagnosis Diagnosis historically:

Evidence-Based Physical Diagnosis - ACP€¦ · 2 Diagnosis today: Bedside diagnosis Technology Evolution of Diagnostic Standard Evidence-Based Physical Diagnosis essential here Dermatologic

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Page 1: Evidence-Based Physical Diagnosis - ACP€¦ · 2 Diagnosis today: Bedside diagnosis Technology Evolution of Diagnostic Standard Evidence-Based Physical Diagnosis essential here Dermatologic

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Evidence-Based Physical Diagnosis

Steve McGee, MD

Professor, University of Washington

Alaska ACP and AKOMA 2016

March 31, 2016

Diagnosis today:

Bedside diagnosisTechnology

Evolution of Diagnostic Standard

Diagnosis historically:

Diagnosis today:

Bedside diagnosisTechnology

Evolution of Diagnostic Standard

Dermatologic diagnosisCellulitisZosterPsoriasis

Neurologic diagnosisParkinson’s diseaseBell’s palsyAmyotrophic lateral sclerosis

Musculoskeletal diagnosisCardiologic diagnosis

PericarditisMitral valve prolapse

Ophthalmologic diagnosisDiabetic retinopathy

Psychiatric diagnosis

Diagnosis historically:

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Diagnosis today:

Bedside diagnosisTechnology

Evolution of Diagnostic Standard

Evidence-BasedPhysical Diagnosis

essential here

Dermatologic diagnosisCellulitisZosterPsoriasis

Neurologic diagnosisParkinson’s diseaseBell’s palsyAmyotrophic lateral sclerosis

Musculoskeletal diagnosisCardiologic diagnosis

PericarditisMitral valve prolapse

Ophthalmologic diagnosisDiabetic retinopathy

Psychiatric diagnosis

Diagnosis historically:

Traditional Measure: Sensitivity and Specificity

Patients with suspected ascites:

Finding Sensitivity(%)

Specificity(%)

INSPECTION

Bulging flanks 73-93 44-70

Edema 87 77

PALPATION AND PERCUSSION

Flank dullness 80-94 29-69

Shifting dullness 60-87 56-90

Fluid wave 50-80 82-92

Better Measure: Likelihood Ratio (LR)

Probability of finding in patients with disease

Probability of finding in patients without disease

LR =

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How Accurate is the Fluid Wave?

In 100 patients referred with abdominal distension and suspected ascites:

- 50% with ascites have a positive fluid wave

- 10% without ascites have a positive fluid wave

Therefore:

How Accurate is the Fluid Wave?

Probability of finding in patients with disease

Probability of finding in patients without disease

= = =50%

10%5.0

In 100 patients referred with abdominal distension and suspected ascites:

- 50% with ascites have a positive fluid wave

- 10% without ascites have a positive fluid wave

Therefore:

0.1 0.2 0.5 1 2 5 10

LRs = Diagnostic Weights

0 ∞

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0.1 0.2 0.5 1 2 5 10

LRs = Diagnostic Weights

0 ∞

Increase probability

Decreaseprobability

No change in probability

0.1 0.2 0.5 1 2 5 10

LRs = Diagnostic Weights

0 ∞

+45%+30%+15%-15%-30%-45%

No changein probability

0.1 0.2 0.5 1 2 5 10

LRs = Diagnostic Weights

0 ∞

+45%+30%+15%-15%-30%-45%

No changein probability

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Ascites

Finding Likelihood ratio if finding:

Present Absent

INSPECTION

Bulging flanks 1.9 0.4

Edema 3.8 0.2

PALPATION AND PERCUSSION

Flank dullness NS 0.3

Shifting dullness 2.3 0.4

Fluid wave 5.0 0.5

0.1 0.2 0.5 1 2 5 10 LRsLRs

-45% -30% -15% +15% +30% +45%

Probabilitydecrease increase

Ascites

0.1 0.2 0.5 1 2 5 10 LRsLRs

-45% -30% -15% +15% +30% +45%

Probabilitydecrease increase

Fluid wave

Absence of bulging flanksAbsence of shifting dullness

Flank tympanyAbsence of edema

Shifting dullnessEdema

Ascites

Absence of fluid waveBulging flanks

Flank dullness

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0.1 0.2 0.5 1 2 5 10 LRsLRs

-45% -30% -15% +15% +30% +45%

Probabilitydecrease increase

Fluid waveFlank tympany

Absence of edemaEdema

Ascites

4 Clinical Questions:

Does my patient with chest pain or dyspnea have a increased left atrial filling pressure?

Does my patient with lymphadenopathy have serious disease?

Does my patient with a systolic murmur have significant valvular heart disease?

Does my patient with acute respiratory complaints have pneumonia?

Congestive Heart Failure: Increased Left Heart Filling Pressure

“The patient cannot breathe in a horizontal position…the pulse is frequent and weak...the veins are swollen in the neck...the strokes of the heart extend farther… there is swelling of the feet and ankles…”

J. N. Corvisart, 1812

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0.1 0.2 0.5 1 2 5 10 LRsLRs

-45% -30% -15% +15% +30% +45%

Probabilitydecrease increase

Heart rate >100/minCracklesElevated neck veins

S3 gallopDisplaced apical impulse

EdemaS4 gallop

Abdominojugular test

Congestive Heart Failure: Increased Left Heart Filling Pressure

0.1 0.2 0.5 1 2 5 10 LRsLRs

-45% -30% -15% +15% +30% +45%

Probabilitydecrease increase

Heart rate >100/minCracklesElevated neck veins

S3 gallopDisplaced apical impulse

EdemaS4 gallop

Abdominojugular test (positive or negative)

Congestive Heart Failure: Increased Left Heart Filling Pressure

0.1 0.2 0.5 1 2 5 10 LRsLRs

-45% -30% -15% +15% +30% +45%

Probabilitydecrease increase

Heart rate >100/min

Elevated neck veinsS3 gallop

Displaced apical impulse

(i.e., Not Significantly different from 1.0)

EdemaS4 gallop

Crackles

Negative abdominojugular test Positive abdominojugular test

Congestive Heart Failure: Increased Left Heart Filling Pressure

NS

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Finding Likelihood ratio if finding:

Present Absent

Heart rate > 100/min 5.5 NS

Crackles NS NS

Elevated jugular venous pressure 3.9 NS

Positive abdominojugular test 8.0 0.3

Supine apical impulse lateral to MCL 5.8 NS

S3 gallop 3.9 NS

S4 gallop NS NS

Edema NS NS

Congestive Heart Failure: Increased Left Heart Filling Pressure

0.1 0.2 0.5 1 2 5 10 LRsLRs

-45% -30% -15% +15% +30% +45%

Probabilitydecrease increase

Heart rate >100/min

Elevated neck veinsS3 gallop

Displaced apical impulse

Crackles

Negative abdominojugular test Positive abdominojugular test

Congestive Heart Failure: Increased Left Heart Filling Pressure

NS

Characteristics of Crackles

Fine Coarse

EarlyInspiratory

LateInspiratory

Chronic obstructive lung disease

Congestive heart failure

Interstitial fibrosis

Pneumonia

Timing ofcrackles

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Peripheral Lymphadenopathy

*Serious disease: malignancy, granuloma

Setting No. patients(no. studies)

Seriousdisease, %

Family practice 249 (1) 1

Lymph Node clinics 1049 (3) 25

Surgical series 2174 (8) 56

Bubonic plague (Boccaccio’s Decameron, 1348)‘there appeared at the beginning of the malady, certain swellings, either on the groin or under the armpits…named plague-boils…a very certain token of coming death”

Peripheral Lymphadenopathy

*Serious disease: malignancy, granuloma

Setting No. patients(no. studies)

Seriousdisease, %

Family practice 249 (1) 1

Lymph Node clinics 1049 (3) 25

Surgical series 2174 (8) 56

Bubonic plague (Boccaccio’s Decameron, 1348)‘there appeared at the beginning of the malady, certain swellings, either on the groin or under the armpits…named plague-boils…a very certain token of coming death”

0.1 0.2 0.5 1 2 5 10 LRsLRs

-45% -30% -15% +15% +30% +45%

Probabilitydecrease increase

Lymphadenopathy

Age of patient

Weight lossPalpable spleen

Lymph node size

Supraclavicular nodesFixed lymph nodes

Hard nodes

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0.1 0.2 0.5 1 2 5 10 LRsLRs

-45% -30% -15% +15% +30% +45%

Probabilitydecrease increase

Lymphadenopathy

Age of patient

Palpable spleen

Lymph node size

Supraclavicular nodesFixed lymph nodes

Hard nodes

Weight loss

0.1 0.2 0.5 1 2 5 10 LRsLRs

-45% -30% -15% +15% +30% +45%

Probabilitydecrease increase

Lymphadenopathy

Age < 40 years

Weight loss

Palpable spleen

Lymph node size ≥ 9 cm2

Supraclavicular nodes

Fixed lymph nodes

NS

Hard nodes

Lymphadenopathy

Finding Likelihood ratio if finding:

Present Absent

Age ≥ 40 years 2.4 0.4

Weight loss 3.4 0.8

Supraclavicular location 3.2 0.8

Generalized lymphadenopathy NS NS

Lymph node size< 4 cm2

4-8.99 cm2

≥ 9 cm2

0.4NS8.4

Hard texture 3.2 0.6

Lymph node tenderness 0.4 1.3

Fixed lymph nodes 10.9 NS

Palpable spleen NS NS

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Systolic Murmurs:

A Treatise on the Diseases of the Heart and Great Vessels

James Hope, 1832

Increased AV velocity Aortic stenosis Increased AV flow without obstruction

Mitral regurgitation

Tricuspid regurgitation

Location of sound: Important landmark

Aortic valve

Boundary of all systolic murmurs

Mitral valve

3rd left parasternal space

Systolic Murmurs: 4 (of 6) Basic Patterns

Above and below landmark:“Broad apical-base”

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Systolic Murmurs: 4 (of 6) Basic Patterns

Above and below landmark:“Broad apical-base”

ECHO:

• Increased aortic velocity (98%)

• 2/3 aortic stenosis

• 1/3 increased flow (no stenosis)

Systolic Murmurs: 4 (of 6) Basic Patterns

Above and below landmark:

Entirely above landmark:

“Broad apical-base”

“Isolated base”

Systolic Murmurs: 4 (of 6) Basic Patterns

Above and below landmark:

Entirely above landmark:

“Broad apical-base”

“Isolated base”

ECHO:

• Normal!

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Systolic Murmurs: 4 (of 6) Basic Patterns

Above and below landmark:

Entirely above landmark:

Entirely below landmark:“Broad apical-base” “Left lower sternal”

“Isolated base”

Systolic Murmurs: 4 (of 6) Basic Patterns

Above and below landmark:

Entirely above landmark:

Entirely below landmark:“Broad apical-base” “Left lower sternal”

“Isolated base”

ECHO:

• Moderate/severe TR (65%)

• Increased AV flow (40%)

Systolic Murmurs: 4 (of 6) Basic Patterns

Above and below landmark:

Entirely above landmark:

Entirely below landmark:“Broad apical-base” “Left lower sternal”

“Broad apical”“Isolated base”

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Systolic Murmurs: 4 (of 6) Basic Patterns

Above and below landmark:

Entirely above landmark:

Entirely below landmark:“Broad apical-base” “Left lower sternal”

“Broad apical”“Isolated base”

ECHO:

• Moderate/severe MR (63%)

• Plus mod/severe TR (34%)

Systolic Murmurs: 4 (of 6) Basic Patterns

Above and below landmark:

Entirely above landmark:

Entirely below landmark:“Broad apical-base” “Left lower sternal”

“Broad apical”“Isolated base”

Systolic Murmurs and Valvular Disease

Murmur pattern Aortic stenosis*

Mitral regurg†

Tricuspid regurg†

Broad apical-base 9.7 NS NS

Isolated base NS NS NS

Left lower sternal NS NS 8.4

Broad apical 0.2 6.8 2.5

No murmur 0.05 0.4 0.6* Peak aortic velocity ≥ 2.5 M/sec†Moderate or worse

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Pneumonia

“Using my new invention, the clinician can detect acute pneumonia in every possible case”

René Laennec, 1821

“It is high time to strip the stethoscope of the extravagant pretensions thrust upon it”

Thomas Addison,1846

Pneumonia

“Using my new invention, the clinician can detect acute pneumonia in every possible case”

René Laennec, 1821

0.1 0.2 0.5 1 2 5 10 LRsLRs

-45% -30% -15% +15% +30% +45%

Probabilitydecrease increase

Percussion dullness

Pneumonia

Egophony

Cachexia

Crackles

Vital sign abnormalities

Diminished breath soundsBronchial breath sounds

Wheezes

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0.1 0.2 0.5 1 2 5 10 LRsLRs

-45% -30% -15% +15% +30% +45%

Probabilitydecrease increase

Percussion dullness

Pneumonia

Egophony

Cachexia

Crackles

Vital sign abnormalities

Diminished breath soundsBronchial breath sounds

Wheezes

0.1 0.2 0.5 1 2 5 10 LRsLRs

-45% -30% -15% +15% +30% +45%

Probabilitydecrease increase

Percussion dullness

Pneumonia

Egophony

Cachexia

Crackles

Vital sign abnormalities

Diminished breath soundsBronchial breath sounds

Wheezes

0.1 0.2 0.5 1 2 5 10 LRsLRs

-45% -30% -15% +15% +30% +45%

Probabilitydecrease increase

Percussion dullness

Pneumonia

CracklesDiminished breath sounds

Wheezes

EgophonyCachexia

O2 saturation <95%Bronchial breath sounds

1.8

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Pneumonia

Finding Likelihood ratio if finding:

Present Absent

Cachexia 4.0 NS

O2 saturation <95% 3.1 0.7

Percussion dullness 3.0 NS

Diminished breath sounds 2.2 0.8

Bronchial breath sounds 3.3 NS

Egophony 4.1 NS

Crackles 2.3 0.8

Wheezing 0.8 NS

Do combinations of findings increase accuracy?

SUSPECTED PNEUMONIA:The clinician scores 1 point for each of the following findings:

Temperature > 37.8 Heart rate > 100/min Crackles Diminished breath sounds Absence of asthma

Heckerling and others. Ann Intern Med 1990;113:664-670

Finding Likelihood ratio if finding:

Present Absent

0 or 1 findings 0.3 …

2 or 3 findings NS …

4 or 5 findings 8.2 …

Pneumonia

0.1 0.2 0.5 1 2 5 10 LRsLRs

-45% -30% -15% +15% +30% +45%

Probabilitydecrease increase

EgophonyCachexia

O2 saturation <95%Bronchial breath sounds

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Pneumonia

Heckerling score, 4-5Heckerling score, 0-1

0.1 0.2 0.5 1 2 5 10 LRsLRs

-45% -30% -15% +15% +30% +45%

Probabilitydecrease increase

EgophonyCachexia

O2 saturation <95%Bronchial breath sounds

Do combinations of findings increase accuracy?

Finding Points

Age > 40 years +5

Lymph Node Tenderness -5

Lymph Node Size< 1 cm2

1 – 3.99 cm2

4 – 8.99 cm2

9 cm2 or more

0+4+8+12

Generalized pruritus +4

Supraclavicular nodes present +3

Lymph node hard +2

Correction factor -6

Vassilakopoulos and others. Medicine 2000: 79: 338-347

For example, a 55-year-old asymptomatic patient with nontender but hard supraclavicular adenopathy 6 cm2:

5 + 8 + 3 + 2 – 6 = 12

LYMPHADENOPATHY:

Finding LR

- 3 or less 0.04

-2 or -1 0.1

0 to 4 NS

5 or 6 5.1

7 or more 21.9

0.1 0.2 0.5 1 2 5 10 LRsLRs

-45% -30% -15% +15% +30% +45%

Probabilitydecrease increase

Lymphadenopathy

Weight lossLymph node size ≥ 9 cm2

Supraclavicular nodes, or hard nodes

Fixed lymph nodes

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0.1 0.2 0.5 1 2 5 10 LRsLRs

-45% -30% -15% +15% +30% +45%

Probabilitydecrease increase

Lymphadenopathy

Weight lossLymph node size ≥ 9 cm2

Supraclavicular nodes, or hard nodes

Fixed lymph nodesLymph node score ≥ 7Lymph node score -3 or less

Lymph node score -2 or -1

Findings With Surprising Accuracy

Conjunctival rim pallor, detecting Hb < 11 gm/dL

LR = 16.7

Absence of percussion dullness, detecting pleural effusion

LR = 0.1

Characteristic diastolic murmur of ARMurmur present, LR = 9.9 (mild AR or worse)Murmur absent, LR = 0.1 (moderate AR or worse)

Pulsus paradoxus, detecting cardiac tamponadeParadox present, LR = 5.9Paradox absent, LR = 0.03

Summary: Modern Role of Physical Diagnosis

For entire areas of clinical medicine, bedside diagnosis remains the diagnostic standard

Bedside diagnosisTechnology

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Summary: Modern Role of Physical Diagnosis

For entire areas of clinical medicine, bedside diagnosis remains the diagnostic standard

If technology is diagnostic standard, 3 Approaches to Physical Diagnosis Accept it all, “lock, stock, and barrel” Toss the entire enterprise out

Bedside diagnosisTechnology

Summary: Modern Role of Physical Diagnosis

For entire areas of clinical medicine, bedside diagnosis remains the diagnostic standard

If technology is diagnostic standard, 3 Approaches to Physical Diagnosis Accept it all, “lock, stock, and barrel” Toss the entire enterprise out Use an EVIDENCE-BASED approach

Evidence-Based Physical Diagnosis essential here

Bedside diagnosisTechnology

Summary: Modern Role of Physical Diagnosis

For entire areas of clinical medicine, bedside diagnosis remains the diagnostic standard

If technology is diagnostic standard, 3 Approaches to Physical Diagnosis Accept it all, “lock, stock, and barrel” Toss the entire enterprise out Use an EVIDENCE-BASED approach

Best measure of accuracy = Likelihood ratio Ascites Increased left heart filling pressure Lymphadenopathy Systolic murmurs Pneumonia

Evidence-Based Physical Diagnosis essential here

Bedside diagnosisTechnology

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Thanks!