In yesterday’s “physical
exam rounds” morning report, we learned about the JAMA rational clinical
examination for ascites. Our preceptor reviewed
the definitions for positive and negative likelihood ratios as well as
sensitivity and specificity to create a framework for the discussion.
In 1998, JAMA began creating
their “The Rational Clinical Examination” series to evaluate how certain
physical examination techniques can aid in our diagnoses. The series focuses on high-yield topics that
come up in common diagnostic dilemmas. The
chapters include an evidence-based approach to a particular examination based
on meta-analyses of the literature. (Garner,
2010).
The concept of evidence-based
medicine (EBM) is defined as the “integration of clinical expertise, patient’s
values and best available evidence in [the] process of decision making related
to patients’ health care.” (Masic et al., 2008) External clinical evidence does
not replace your clinical expertise however, it informs and guides your
decision-making. In fact, you use your
clinical expertise to decide if the external evidence applies to the patient in
front of you. (Sackett et al., 1996)
These evidence-based
rational clinical examinations provide a structure for a focused examination especially
when you are in a busy setting such as the emergency department and triaging
patients. From yesterday’s lecture, I
learned that one should start with the most sensitive
tests when performing your physical exam and then move to more specific tests because the sensitive
tests help you to rule out the
diagnosis if negative. For example, in
the examination for ascites, the most sensitive findings to rule out the diagnosis
are no history of ankle swelling or increased abdominal girth and the inability
to demonstrate bulging flanks, flank dullness, or shifting dullness. The most powerful findings for making the
diagnosis of ascites are a positive fluid wave result, shifting dullness, or
peripheral edema. (Simel & Rennie, 2009)
It was brought up in
rounds that in theory our pre-test probabilities would be based on epidemiological
data and the likelihood of a disease occurring in a particular patient
population. However, in practice we base
our pre-test probabilities on history-taking and physical examination. This is why learning the questions on history
or physical examination maneuvers that help you confidently rule in or rule out
diagnoses will aid you the most in medical decision-making. As the Garner article mentions, these physical
examinations force us to become resource stewards as well. Not only does certainty in our examination
increase confidence in medical decisions, it also decreases the number of
unnecessary tests that are ordered.
In the world of
medical education, evidence-based medicine is weaved in throughout. More than “physical exam rounds,” there are
also “EBM rounds” each week where we learn to interpret and critically
appraise primary research articles. I
am looking forward to next week’s sessions!
SH
Resources:
Garner, J. (2010). The
Rational Clinical Examination: Evidence-Based Clinical Diagnosis. Proc (Baylor University Medical Center
Proceedings), 23(1): 87.
Sackett, D. L. et al.
(1996). Evidence based medicine: what it is and what it isn’t. BMJ, 312: 71. doi: https://doi.org/10.1136/bmj.312.7023.71
Masic, I. et al.
(2008) Evidence Based Medicine – New Approaches and Challenges. Acta Inform Med, 16(4): 219 – 225.
Simel, D. L. & D.
Rennie. (2009). The Rational Clinical Examination: Evidence-Based
Clinical Diagnosis. JAMAevidence. Retrieved from
https://medicinainternaucv.files.wordpress.com/2013/02/jama-the-rational-clinical-examination.pdf Accessed on February 10, 2018
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