The how-to of physical examination in cardiology

Clinical and instrumental diagnosis. Recent technological advances have profoundly changed the diagnostic process in cardiology, as can be clearly seen fromthe role played by echocardiography, hemodynamic investigations, electrocardiographic recording techniques, and the assaying of a variety of substances in everyday clinical practice. It is therefore understandable that physicians increasingly rely on instrumental and biohumoral investigations. However, this leads to greater healthcare costs, which may become unsustainable for poorer countries and less wealthy categories. Furthermore, unless supported by a sound clinical approach, potentiating investigational diagnostics risks dehumanising patient-doctor relationships and increasing the number of inappropriate examinations. My aim in writing this brief manual is to underline the role of clinical diagnostics in cardiology by concentrating on the information that can be obtained from meeting and physically examining a patient. Why examine a patient with heart disease? Fortunately, most physicians still find this question absurd but, because of their increasing work load, some of them are tempted to shorten and simplify the diagnostic process by combining the taking of a summary history with the directed use of advanced technologies: in practice, skipping physical examination. However, no technology has such a high cost/efficacy ratio as a complete physical examination, which can also lead to the emergence of other anomalies involving organs and apparatuses that may otherwise go unrecognised; they may simply be due to the heart disease itself, but may also signal the presence of another systemic disease of which the heart disease is merely a part. Furthermore, a physical examination can be repeated at even short intervals, and it seems likely that the appropriateness of using technological investigations increases if the diagnostic queries arise from an anamnesis and careful physical examination. Last but not least, a physical examination establishes a sort of physical relationship between patient and doctor, and patients usually appreciate the fact that their doctor considers them as a person rather than just a series of data and images. How accurate is a clinical diagnosis? In order to answer this question, it is useful to look at some other branches of medicine. One study has shown that the sensitivity and specificity of Emergency Department physicians in recognising the presence of fever, anemia and jaundice by means of a physical examination was about 70% in comparison with gold standard rectal temperature measurements and biohumoral examinations carried out immediately afterwards [1]. Another study evaluated the accuracy of abdominal palpation in formulating a diagnosis of asymptomatic aortic aneurysm [2]: the diagnosis of abdominal aortic aneurysm was based on palpation in 38% of 243 patients undergoing surgery, whereas the remaining 62% were diagnosed on the basis of radiological investigations even though the aneurysm was actually palpable in more than half of the latter cases: i.e. a further 38% of the patients as a whole. Amore recent study published in The Lancet [3] compared the admission diagnosis with the discharge diagnosis made in the medical ward, and then assessed the contribution to the final diagnosis of the physical examination carried out in the ward. Surprisingly, the diagnosis was modified on the basis of the findings of the physical examination made upon admission to the ward in 26% of the cases. As far as cardiology is concerned, it is enough to think of the role played by the physical variables codified in the four Killip classes of patients with acutemyocardial infarction: their classification in one of these classes is capable of predicting the prognosis in cases with or without ST-segment elevation [4, 5]. However, the role of making a clinical diagnosis in modern cardiology has not been recently investigated.