Editorial
Alvaro Nagib Atallah* * MD, PhD, MCE Chaiman, Department of Internal Medicine, Escola Paulista de Medicina, Editor, São Paulo Medical Journal.
Physical Diagnosis in the Contemporary Era
There is a consensus that clinical evaluation gives 80% of diagnoses. This is based on consistent historical experience. We already know that the positive value of signs, symptoms or diagnostic tests increases as the accuracy of clinical evaluation improves. Nowadays, as concepts of accuracy, sensitivity, specificity and predictive values are becoming popular in medical practice, the accuracy of the semiology needs to be reassessed in the light of such concepts. What are the characteristics of a physical heart examination when compared with echodoppler cardiography? What is the sensitivity and specificity of physical spleen examination when compared with ultrasonography, in which the CT scan is considered the gold standard? The Federal Council for Internal Medicine of the American College of Physicians moves a step forward in their guide to curriculum development, with the following:
"Physical Diagnosis
Even in this era of burgeoning diagnostic technology, the physical examination remains among the internist's most accurate set of tools. These skills play an essential role in estimating the pre-test probability of disease, which is the starting point for test interpretation. Moreover, there is an increasing body of knowledge about accuracy of physical signs. In many instances, bedside assessment is superior to noninvasive technology; in almost all cases, it is more accessible and cost-effective.
Expertise in physical diagnosis is a valued characteristic of the well-trained internist. Instruction in and evaluation of physical diagnosis skill should be part of every residency program's curriculum. We present first a list of general competency objectives for physical diagnosis, followed by an organ-specific list of the physical findings and maneuvers with which all residents should be familiar.
Competencies for Physical Diagnosis
Understand how to apply the concept of operating characteristics (specificity, sensitivity, and likelihood ratios) to the interpretation of physical examination findings
Understand the pathophysiologic explanation for common physical findings
Know when to abandon a physical finding because new evidence has impugned its validity and when to adopt new findings that have been shown to be clinically useful
Examine patients efficiently and systematically, maximizing accuracy and completeness, ensuring that the patient is comfortable, and protecting the patient's modesty
Use the physical examination in the context of the entire clinical database to evaluate the patient efficiently and effectively
Know the content of the screening physical examination that is appropriate for each patient's age, sex, and particular risk factors
Utilize repeated, focused physical examinations to follow the course of a patient's illness
Use physical findings to make decisions in settings that do not allow for extensive diagnostic testing."
REFERENCE
Federated Council for Internal Medicine, Task Force on the Internal Medicine Residency Curriculum. Graduate education in internal medicine: a resource guide to curriculum development. Philadelphia: American College of Physicians; 1997. ISBN 0-943126-60-6
Publication Dates
-
Publication in this collection
17 Dec 1999 -
Date of issue
Sept 1998