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The Lancet, Volume 362, Issue 9400, Page 2023, 13 December 2003
doi:10.1016/S0140-6736(03)15030-1Cite or Link Using DOI

Physical examination

We congratulate Brendan Reilly1 on his study describing the value of the rapidly dying art of physical examination in the management of patients. However, we believe that the high incidence (26%) of findings that changed management is far higher than that seen in actual practice, and that this exaggerated figure is largely due to the study design.
In Reilly's report, the examiner attending has the benefit of knowing the history and examination findings documented by the emergency department physicians, and is aware of the treatment given and the initial response to treatment. If there was no initial response, the examiner has the benefit of that knowledge and can focus on specific clues on physical examination, which will increase the yield of pivotal findings. Furthermore, it is not fair to compare the findings of the emergency department physicians, who work at odd hours, with a physician who works in day hours. Often patients come to the emergency department sick, and the initial priority is to stabilise the vital signs; a detailed physical examination is less of a concern at that stage. Besides, many physical findings can be missed during the acute presentation—eg, a jugular venous pulsation might be more apparent once the patient's tachypnoea improves.
Thus, the high incidence of pivotal findings is unlikely to translate into tangible gains in clinical practice. However, there are many advantages of a meticulous physical examination that might not be obvious in a study of this nature. A detailed physical examination instils confidence in the patient that the physician is thorough in his approach. The contact of a physician is often reassuring to an anxious patient. And finally, as any clinician will tell you, there are few things in clinical medicine that can give you as much satisfaction as detecting a subtle physical finding that can dramatically alter the diagnosis and the care of a patient.


1 Reilly BM. Physical examination in the care of medical inpatients: an observational study. Lancet 2003; 362: 1100-1105. Summary | Full Text | PDF(312KB) | PubMed
a Department of Medicine 2, Christian Medical College, Vellore 632004, Tamilnadu, India
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