Beauty is in the eye of the examiner: Reaching agreement about physical signs and their value

Internal Medicine Journal

Volumn 35, Issue 3, 2005, Pages 178-187

  Joshua, Anthony M ^a,d   Celermajer, D S ^a,b   Stockler, M R ^a,c  

^a UNIVERSITY OF SYDNEY   (Australia)

^b ROYAL PRINCE ALFRED HOSPITAL   (Australia)

^c UNIVERSITY OF SYDNEY   (Australia)

^d PRINCESS MARGARET HOSPITAL   (Canada)

Author keywords

Accuracy; Kappa; Physical examination; Reliability; Sensitivity; Specificity

Indexed keywords

ACCURACY; CLINICAL EXAMINATION; DIAGNOSTIC VALUE; GASTROENTEROLOGY; NEUROLOGIC EXAMINATION; OBSERVER VARIATION; OUTCOMES RESEARCH; PHYSICAL EXAMINATION; PRIMARY MEDICAL CARE; PRIORITY JOURNAL; RELIABILITY; REVIEW; RISK ASSESSMENT; TECHNIQUE;

CLINICAL COMPETENCE; EVIDENCE-BASED MEDICINE; HUMANS; OBSERVER VARIATION; PHYSICAL EXAMINATION; PREDICTIVE VALUE OF TESTS; REPRODUCIBILITY OF RESULTS; SENSITIVITY AND SPECIFICITY; SICK ROLE; STUDENTS, MEDICAL;

EID: 15244351000     PISSN: 14440903     EISSN: None     Source Type: Journal    
DOI: 10.1111/j.1445-5994.2004.00795.x     Document Type: Review

References (121)

1. Crombie DL. Diagnostic process. J Coll Gen Pract 1962; 6: 579-89.
2. Sandler G. The importance of the history in the medical clinic and the cost of unnecessary tests. Am Heart J 1980; 100: 928-31.
3. Simel D, Drummond R. The clinical examination: an agenda to make it more rational. JAMA 1997; 277: 572-4.
4. Talley N, O'Connor S. Examination Medicine - A Guide to Physician Training, 4th edn. Sydney: MacLennan, Petty; 2001.
5. Yusuf S, Cairns JA, Camm AJ, Fallen EL, Gersh BJ, eds. Evidence-Based Cardiology, 2nd edn. Philadelphia: BMJ Books; 2003.
6. Sapira JD. The Art and Science of Bedside Diagnosis, 1st edn. Baltimore, MD: Williams & Wilkins; 1990.
7. Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics 1977; 33: 159-74.
8. Hansen M, Sindrup SH, Christensen PB, Olsen NK, Kristensen O, Friis ML. Interobserver variation in the evaluation of neurological signs: oberserver dependent factors. Acta Neurol Scand 1994; 90: 145-9.
9. Altman DG. Practical Statistics for Medical Research. London: Chapman & Hall; 1996.
10. Myers KA, Farquhar DR. The rational clinical examination. Does this patient have clubbing? JAMA 2001; 286: 341-7.
11. Pyke DA. Finger clubbing. Lancet 1954; 2: 352-4.
12. Spiteri MA, Cook DG, Clarke SW. Reliability of eliciting physical signs in examination of the chest. Lancet 1988; 1: 873-5.
13. Smyllie HC, Blendis LM, Armitage P. Observer disagreement in physical signs of the respiratory system. Lancet 1965; 2: 412-13.
14. Rawles JM, Rowland E. Is the pulse in atrial fibrillation irregularly irregular? Br Heart J 1986; 56: 4-11.
15. Armitage P, Rose GA. The variability of measurements of casual blood pressure, I. a laboratory study. Clin Sci 1966; 30: 325-35.
16. Hypertension Detection and Follow-up Program. Variability of blood pressure and the results of screening in the Hypertension Detection and Follow-up Program. J Chron Dis 1978; 31: 651-67.
17. Scherwitz LW, Evans LA, Hennrikus DJ, Vallbona C. Procedures and discrepancies of blood pressure measurements in two community health centers. Med Care 1982; 20: 727-38.
18. Neufeld PD, Johnson DL. Observer error in blood pressure measurement. Can Med Assoc J 1986; 135: 633-7.
19. Smith D, Neutel J, Lacourcière Y, Kempthorne-Rawson J. Prospective, randomized, open-label, blinded-endpoint (PROBE) designed trials yield the same results as double-blind, placebo-controlled trials with respect to ABPM Measurements. J Hypertens 2003; 21: 1291-8.
20. Davison R, Cannon R. Estimation of central venous pressure by examination of jugular veins. Am Heart J 1974; 87: 279-82.
21. Eisenberg PR, Jaffe AS, Schuster DP. Clinical evaluation compared to pulmonary artery catheterization in the hemodynamic assessment of critically ill patients. Crit Care Med 1984; 12: 549-53.
22. Cook DJ. The clinical assessment of central venous pressure. Am J Med Sci 1995; 299: 175-8.
23. Connors AF, McCaffree DR, Gray BA. Evaluation of right heart catheterization in the critically ill patient without acute myocardial infarction. N Engl J Med 1983; 308: 263-7.
24. Chambers BR, Norris JW. Clinical significance of asymptomatic neck bruits. Neurology 1985; 35: 742-5.
25. Sauve JS, Thorpe KE, Sackett DL, Taylor W, Barnett HJM, Haynes RB et al. Can bruits distinguish high-grade from moderate symptomatic carotid stenosis? Ann Intern Med 1994; 120: 633-7.
26. Hankey GJ, Warlow CP. Symptomatic carotid ischaemic events: safest and most cost effective way of selecting patients for angiography, before carotid endarterectomy. BMJ 1990; 300: 1485-91.
27. Dobrow RJ, Calatayud JB, Abraham S, Caceres CA. A study of physician variation in heart sound interpretation. Med Ann Dist Columbia 1964; 33: 305-8.
28. Forssell G, Jonasson R, Orinius E. Identifying severe aortic valvular stenosis by bedside examination. Acta Med Scand 1985; 218: 397-400.
29. Taranta A, Spagnuolo M, Snyder R, Gerbarg DS, Hofler JJ, Enslein K. Data Acquisition and Processing in Biology and Medicine, Vol. 3. New York: Macmillan Publishing Co Inc; 1964: 23-52.
30. Lembo NJ, Dell'Italia LJ, Crawford MH, O'Rourke RA. Bedside diagnosis of systolic murmurs. N Engl J Med 1988; 318: 1572-8.
31. Hoagland PM, Cook EF, Wynee J, Goldman L. Value of noninvasive testing in adults with suspected aortic stenosis. Am J Med 1986; 80: 1041-50.
32. Aronow WS, Kronzon I. Correlation of prevalence and severity of aortic regurgitation detected by pulsed doppler echocardiography with the murmur of aortic regurgitation in elderly patients in a long-term health care facility. Am J Cardiol 1989; 63: 128-9.
33. Etchells E, Bell C. Does this patient have an abnormal systolic murmur. JAMA 1997; 277: 564-71.
34. Rahko PS. Prevalence of regurgitant murmurs in patients with valvular regurgitation detected by Doppler echocardiography. Ann Intern Med 1989; 111: 466-72.
35. Meyers DG, McCall D, Sears TD, Olson TS, Felix GL. Duplex pulsed Doppler echocardiography in mitral regurgitation. J Clin Ultrasound 1986; 14: 117-21.
36. Grayburn PA, Smith MD, Handshoe R, Friedman BJ, De Marie AN. Detection of aortic insufficiency by standard echocardiography, pulsed Doppler echocardiography, and auscultation. Ann Intern Med 1986; 104: 599-605.
37. Bloomfield DA, Sinclair-Smith BC. Aortic insufficency: a physiological and clinical appraisal. South Med J 1973; 66: 55-65.
38. Cohn LH, Mason DT, Ross J, Morrow AG, Braunwald E. Preoperative assessment of aortic regurgitation in patients with mitral valve disease. Am J Cardiol 1967; 19: 177-82.
39. Frank MJ, Casanegra P, Migliori AJ, Levinson GE. The clinical evaluation of aortic regurgitation. Arch Intern Med 1965; 116: 357-65.
40. Spagnuolo M, Kloth H, Taranta A, Doyle E, Pasternack B. Natural history of aortic regurgitation: criteria predictive of death, congestive heart failure, and angina in young patients. Circulation 1971; 44: 368-80.
41. Smith HJ, Neutze JM, Roche HG, Agnew TM, Barratt-Boyes BG. The natural history of rheumatic aortic regurgitation and the indications for surgery. Br Heart J 1976; 38: 147-54.
42. Mangoine S, Nieman LZ. Cardiac auscultatory skills of internal medicine and family practice trainees. JAMA 1997; 278: 717-22.
43. St Clair EW, Oddone EZ, Waugh RA, Corey GR, Feussner JR. Assessing housestaff diagnostic skills using a cardiology patient simulator. Ann Intern Med 1992; 117: 751-6.
44. Surawicz B, Mercer C, Chlebus H, Reeves J, Spencer F. Role of the phonocardiogram in evaluation of the severity of mitral stenosis and detection of associated valvular lesions. Circulation 1966; 34: 795-806.
45. McGee SR, Boyko EJ. Physical examination and chronic lower-extremity ischaemia. A Critical review. Arch Intern Med 1998; 158: 1357-64.
46. Christensen JH, Freundlich M, Jacobsen BA, Falstie-Jensen N. Clinical relevance of pedal pulse palpation in patients suspected of peripheral arterial insufficiency. J Intern Med 1989; 226: 95-9.
47. Criqui MH, Fronek A, Klauber MR, Barrett-Connor E, Gabriel S. The sensitivity, specificity and predictive value of traditional clinical evaluation of peripheral arterial disease: results from noninvasive testing in a defined population. Circulation 1985; 71: 516-22.
48. Stoffers HEJH, Kester ADM, Saiser V, Rindens PELM, Knottnerus JA. Diagnostic value of signs and symptoms associated with peripheral arterial occlusive disease seen in general practice: a multivariable approach. Med Decis Making 1997; 17: 61-70.
49. Boyko EJ, Ahroni JH, Davignon D, Stensel V, Prigeon RL, Smith DG. Diagnostic utility of the history and physical examination for peripheral vascular disease among patients with diabetes mellitus. J Clin Epidem 1997; 50: 659-68.
50. Metlay JP, Kapoor WN, Fine MJ. Does this patient have community acquired pneumonia? Diagnosing pneumonia by history and physical examination. JAMA 1997; 278: 1440-45.
51. Holleman DR Jr, Simel DL, Goldberg JS. Diagnosis of obstructive airways disease from the clinical examination. J Gen Intern Med 1993; 8: 63-8.
52. Schapira RM, Schapira MM, Funahashi A, McAuliffe TL, Varkey B. The value of forced expiratory time in the physical diagnosis of obstructive airways disease. JAMA 1993; 270: 731-6.
53. Badgett RG, Tanaka DJ, Hunt DK, Jelley MJ, Feinberg LE, Steiner JF et al. Can moderate chronic obstructive pulmonary disease be diagnosed by historical and physical findings alone? Am J Med 1993; 94: 188-96.
54. Nairn JR, Turner-Warwick M. Breath sounds in emphysema. Br J Dis Chest 1969; 63: 29-37.
55. Mulrow CD, Dolmatch BL, Delong ER, Feussner JR, Benyunes MC, Diets JL et al. Observer variability in the pulmonary examination. J Gen Intern Med 1986; 1: 364-7.
56. Anand SS, Wells PS, Hunt D, Brill-Edwards P, Cook D, Ginsberg JS. Does this patients have deep vein thrombosis? JAMA 1998; 279: 1094-9.
57. Hirsh J, Hull RD, Raskob GE. Clinical features and diagnosis of venous thrombosis. J Am Coll Cardiol 1986; 8 (6 Suppl. B): 114B-27B.
58. Wheeler HB. Diagnosis of deep vein thrombosis. Review of clinical evaluation and impedance plethysmography. Am J Surg 1985; 150: 7-13.
59. Johnson WC. Evaluation of newer techniques for the diagnosis of venous thrombosis. J Surg Res 1974; 16: 473-81.
60. O'Donnell TF, Abbott WM, Athanasoulis CA, Millan VG, Callow AD. Diagnosis of deep venous thrombosis in the out patient by venography. Surg Gynaecol Obstet 1980; 150: 69-74.
61. Naffalis J, Leevy CM. Clinical examination of liver size. Am J Dig Dis 1963; 8: 236-43.
62. Ralphs DNL, Venn G, Kan O, Palmer JG, Cameron DE, Hobsley M. Is the undeniably palpable liver ever 'normal'? Ann R Coll Surg Engl 1983; 65: 159-60.
63. Sullivan S, Krasner N, Williams R. The clinical estimation of liver size: a comparison of techniques and an analysis of the source of the error. Br Med J 1976; 2: 1042-3.
64. Halpern S, Coel M, Ashburn W, Alazraki N, Littenburg R, Hurwitz S et al. Correlation of liver and spleen size: determinations by nuclear medicine studies and physical examination. Arch Intern Med 1974; 134: 123-4.
65. Rosenfeld AT, Laufer I, Schneider PB. The significance of a palpable liver. Am J Roentgenol Radiat Ther Nucl Med 1974; 122: 313-17.
66. Naylor CD. Physical examination of the liver. JAMA 1994; 271: 1859-65.
67. Theodossi A, Knill-Jones RP, Skene A, Lindberg G, Bjerregaard B, Holst-Christensen J et al. Inter-observer variation of symptoms and signs in jaundice. Liver 1981; 1: 21-32.
68. Meyhoff HH, Roder O, Anderson B. Palpatory estimation of liver size. Acta Chir Scand 1979; 145: 479-81.
69. Espinoza P, Ducot B, Pelletier G, Attali P, Buffet C, David B et al. Interobserver agreement in the physical diagnosis of alcoholic liver disease. Dig Dis Sci 1987; 32: 244-7.
70. Cummings S, Papadakis M, Melnick J, Gooding GA, Tierney LM Jr. The predictive value of physical examination for ascites. West J Med 1985; 142: 633-6.
71. Cattau EL, Benjamin SB, Knuff TE, Castell DO. The accuracy of physical examination in the diagnosis of suspected ascites. JAMA 1982; 247: 1184-6.
72. Sullivan S, Williams R. Reliability of clinical techniques for detecting splenic enlargement. BMJ 1976; 2: 1043-4.
73. Barkun AN, Camus M, Meagher T, Green L, Coupal L, De Stempel J et al. Splenic enlargment and Traube's space: how useful is percussion? Am J Med 1989; 87: 562-6.
74. Grover SA, Barkun A, Sackett DL. Does this patient have splenomegaly? JAMA 1993; 270: 2218-21.
75. Barkun AN, Camus M, Green L, Meagher T, Coupal L, De Stempel J et al. The bedside assessment of splenic enlargement. Am J Med 1991; 91: 512-18.
76. Gross F. The Emporer's Clothes syndrome. N Engl J Med 1971; 285: 863.
77. Van Gijn J, Bonke B. Interpretation of plantar reflexes: biasing effect of other signs and symptoms. J Neurol Neurosurg Psychiatry 1977; 40: 787-9.
78. Hansen M, Sindrup SH, Christensen PB, Olsen NK, Kristensen O, Friis ML. Interobserver variation in the evaluation of neurological signs: observer dependent factors. Acta Neurol Scand 1994; 90: 145-9.
79. Maher J, Reilly M, Hutchinson M. Planter Power: reproducibility of the planter response. BMJ 1992; 304: 482.
80. Shinar D, Gross CR, Mohr JP, Caplan LR, Price TR, Wolf PA et al. Interobserver variability in the Assessment of Neurologic History and Examination in the Stroke Data Bank. Arch Neurol 1985; 42: 557-65.
81. Manschot S, van Paseel L, Buskens E, Algra A, van Gijn J. Mayo and NINDS scales for assessment of tendon reflexes: between observer agreement and implications for communication. J Neurol Neurosurg Psychiatry 1998; 64: 253-5.
82. Litvan I, Mangone CA, Werden W, Bueri JA, Estol CJ, Garcea DO et al. Reliability of the NINDS Myotactic Reflex Scale. Neurology 1996; 47: 969-72.
83. George JH, Doto FX. A simple five-step method for teaching clinical skills. Fam Med 2001; 33: 577-8.
84. Koran LM. The reliability of clinical methods data, judgments (second of two parts). N Engl J Med 1975; 293: 695-701.
85. Sackett DL, Renniwe D. The science of the art of clinical examination. JAMA 1992; 267: 2650-2.
86. Miller M, Johnson B, Greene HL, Baier M, Nowlin S. An observational study of attending rounds. J Gen Intern Med 1992; 7: 646-8.
87. LaCombe M. On bedside teaching. Ann Intern Med 1997; 126: 217-20.
88. Mangoine S, Nieman LZ. Pulmonary auscultatory skills during training in internal medicine and family practice. Am J Respir Crit Care Med 1999; 159: 1119-24.
89. Mangione S, Nieman LZ. Cardiac auscultatory skills of internal medicine and family practice trainees: a comparison of diagnostic proficiency. JAMA 1997; 278: 717-22.
90. Mangione S, Loudon RG, Fiel SB. Lung auscultation during internal medicine and pulmonary training: a nationwide survey. Chest 1993; 104: 70S.
91. Mangione S, Nieman LZ, Gracely E, Kaye D. The teaching and practice of cardiac auscultation during internal medicine and cardiology training: a nationwide survey. Ann Intern Med 1993; 119: 47-54.
92. Wray NP, Freidland JA. Detection and correction of house staff error in physical diagnosis. JAMA 1987; 249: 1035-7.
93. Perloff D, Grim C, Flack J, Frolich ED, Hill M, McDonald M et al. Human blood pressure determination by sphygmomanometry. Circulation 1993; 88: 2460-67.
94. Cicuttini FM, Baker J, Hart DJ, Spector TD. Relation between Heberden's nodes and distal interphalangeal joint osteophytes and their role as markers of generalized disease. Ann Rheum Dis 1998; 57: 246-8.
95. Siminoski K. Does this patient have a goiter? JAMA 1995; 273: 813-37.
96. Espinoza P, Ducot B, Pelletier G, Attali P, Buffet C, David B et al. Interobserver agreement in the physical diagnosis of alcoholic liver disease. Dig Dis Sci 1987; 32: 244-7.
97. Meade TW, Gardner MJ, Cannon P, Richardson PC. Observer variability in recording the peripheral pulses. Br Heart J 1968; 30: 661-5.
98. Gadsboll N, Hoilund-Carlsen PF, Nielsen GG, Berning J, Bruun NE, Hein E. Interobserver agreement and accuracy of bedside estimation of right and left ventricular ejection fraction in acute myocardial infarction. Am J Cardiol 1989; 63: 1301-7.
99. Berton MB, Harris R, Fletcher SW. The rational clinical examination: does this patient have breast cancer? The screening clinical breast examination: should it be done? How? JAMA 1999; 282: 1270-80.
100. Ishmail AA, Wing S, Ferguson J, Hutchinson TA, Magder S, Flegel KM. Interobserver agreement by auscultation in the presence of the third heart sound in patients with congestive heart failure. Chest 1987; 91: 870-73.
101. Ellen SD, Crawford MH, O'Rourke RA. Accuracy of precordial palpation for detecting increased left ventricular volume. Ann Intern Med 1983; 99: 628-30.
102. Hoagland PM, Cook EF, Wynne J, Goldman L. Value of noninvasive testing in adults with suspected aortic stenosis. Am J Med 1986; 80: 1041-50.
103. Patel R, Bushnell DL, Sobotka PA. Implications of an audible third heart sound in evaluating cardiac function. West J Med 1993; 158: 606-9.
104. Forssell G, Jonassen R, Orinius E. Identifying severe aortic valvular stenosis by bedside examination. Acta Medica Scandinavica 1985; 218: 397-400.
105. Gillam PMS, Deliyannis AA, Mounsey JPD. The left parasternal impulse. Br Heart J 1964; 26: 726-36.
106. Adedeji OA, McAdam WA. Murphy's sign, acute cholecystitis and elderly people. J R Coll Surg Edinb 1996; 41: 88-9.
107. Singer AJ, McCracken G, Henry MC, Thode HC Jr, Cabahug CJ. Correlation among clinical, laboratory and hepatobiliary scanning findings in patients with suspected acute cholecystitis. Ann Emerg Med 1996; 28: 267-72.
108. Singh A, Bagga SP, Jindal VP, Singh K, Rato SS. Gall bladder disease: an analytical report of 250 cases. J Indian Med Assoc 1989; 87: 253-6.
109. Kuschner SH, Ebramzadeh E, Johnson D, Brien WW. Sherman Tinel's sign and Phalen's test in carpal tunnel syndrome. Orthopaedics 1992; 15: 1297-1302.
110. Stewart JD, Eisen A. Tinel's sign and the carpal tunnel syndrome. BMJ 1978; 2: 1125-6.
111. Katz JN, Larson MG, Sabra A, Krarup C, Stirrat CR, Sethi R et al. The carpal tunnel syndrome: diagnostic utility and physical examination findings. Ann Intern Med 1990; 112: 321-7.
112. Gelmers HJ. The significance of Tinnel's sign in the diagnosis of carpal tunnel syndrome. Acta Neurochirurgica (Wien) 1979; 49: 225-58.
113. Thomas KE, Hasbun R, Jekel J, Quagliarello VJ. The diagnostic accuracy of Kernig's sign, Brudzinski's sign and nuchal rigidity in adults with suspected meningitis. Clin Infect Dis 2002; 35: 46-52.
114. Raftery EB, Holland WW. Examination of the Heart: an investigation into variation. Am J Epidemiol 1967; 85: 438-44.
115. Tomasello F, Mariani F, Fieschi C, Argentino C, Bono G, De Zanche L et al. Assessment of interobserver differences in the Italian multicenter study on reversible cerebral ischaemia. Stroke 1982; 13: 32-5.
116. Vogel H-P. Influence of additional information on interrater reliability in the neurologic examination. Neurology 1992; 42: 2076-81.
117. Ramani S, Orlander JD, Strunin L, Barber TW. Whither bedside teaching? A focus-group study of clinical teachers. Acad Med 2003; 78: 384-90.
118. Friedman RC, Bigger JT, Koranfield DS. The intern and sleep loss. N Engl J Med 1971; 285: 201-3.
119. Stockler M, Tannock I. Comment on Angulo et al.: 'A Man's Got To Know His Limitations'. Urol Oncol 1995; 1: 206-7.
120. McAlister FA, Straus SE, Sackett DL. Why we need large, simple studies of the clinical examination: the problem and a proposed solution. CARE-COAD1 group. Clinical Assessment of the Reliability of the Examination-Chronic Obstructive Airways Disease Group. Lancet 1999; 354: 1721-4.
121. Straus SE, McAlister FA on behalf of the CARE Group. Collaborative Studies of the Accuracy and Precision of the Clinical Examination. Toronto: University of Toronto [updated Dec 2004; cited 24 Jul 2003]. Available from: http://www.carestudy.com