How Reliable are Bedside Physical Signs in the Diagnosis of Cardiac Disease?
Item
- Title
- How Reliable are Bedside Physical Signs in the Diagnosis of Cardiac Disease?
- Date
- 1989
- extracted text
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BACKGROUND PAPER-II
XV
COMMUNITY HEALTH CELL
47/1,(First Hoor)St. Marks Hoad
BANjitO
5G'j U01
ANNUAL MEET OP MEDICO FRIEND CIRCLE
HOW REL-H.BLE ARE BEDSIDE PHYSICAL SIGNS IN THE
DIAGNOSIS OF CARDIAC f>ISEASE?
We come across one article, on the reliability of bedside
clinical signs in cardiac diseases.' Thbugh this article on
the utility of cardiac signs appeared in 1978, the collective
experience of authors in clinical cardiology(over 60 years)
and their critical assessment of these signs makes us quote
some of their vi ws in verbatim.
On the arterical pulse?
*
Superflouous terms such as dichrctic,anachrotic,bisferiens
and water hammer should be avoided. These abnormalities are
difficult to- recognise, unreliable and contribute nothing to
diagnosis. They should betrar be replaced by description of
type of the pulse based on pulse volume and characters The large
volume and sharp upstroke pulse, the large volume and blunt
upstroke pulse, the small volume and blunt upstroke pul..a and
the small volumeand sharp upstroke pulse.
*
These pulse abnormalities are found only when the valve
lesion is at least moderately severe.
*
Evaluating ths state of the radial artery wall contributes
nothing of v ilue to an assessment of thestate of the pi-culation
locally or in more important vascular beds.
On Jugular Venous Pulse;
*
Apart from the systolic surge (V wave) -in tricuspid
incompetence, and 'a1 wave cr cannon waves, other abnormalities
in JVP are difficult to recognise, and rarely provide information
that can not be more readily obtained by other means.
On Apex Beat;
*
The term 'tapping' apex beat causes confusion, sines it
does not represent right ventricular hypertrophy but a j o ud and
palpable first heart sound.
■‘k
No attempt should be made to t-ach students to recognise
a right ventricular apex, because even the trained cardiologist
can not recognise it.
On Left parasternal impulse?
*
r ’ " ’
.............
_
Differentiating
..betwe-n the parasternal
impulse of mitral
regurgitation and th.„t of a right" ventricular abnormality
requires exceptional experience.
On murmur s:
Although the classic distinction between ejection and
pansystolic murmers should b.taught, it should be made clear' that
it is impossible to categorise all systolic murmers in this way
at the bedside.
Other points?
Thrills; These are often of little value and are often
reported erroneously by students.
Percussion; This
7"
'
__ limited value that it his no
is
of such
place in the routine cardiac examination.
2.
The authors conclude that in the basic teaching of
students, and in revision courses for non-cardiologists,
the emphasis should be placed on those signs which .are of
the greatest value. To go much beyond this is likely to be
counterproductive.
Instead of using a chest X-ray as a"gold standard to
assess reliability of clinical signs, we decided to examine
how far an echocardiogram influences.diagnosis and management.
The following are the conslu s-ions from 3 different studies;
(i)
The influence of echocardiogram is greater for diagnosis
than for patient management.22
(ii) The value of ech-cardiogram is obvious when assessing
the patients for invasive investigations or when proper
treatment or adequate reassurance are impeded by
diagnostic doubt, when the aim is to rule out disease,
however, an' expert cardiologist1 s opinion 'would-..often
be more appropriate than an echocardiogram.3
(iii) If an -echocardiogram, is used blindly, i.e. as a primary
means-of diagnosis rath r than of confirmation of clinical
impressions, very few positive results--will be obtained.
The investigation rarely reveals totally unsuspected
information. It is in tile assessment of known cardiac
disease that the investigation is more likely to b.i of
;
greater value in the future. It can cut short the bomber
of routine cardiac catherrisations of many patients with
known valvular diseases.4
HOW RELIABLE IS BEDSIDE DIAGNOSIS IN RESPIRATORY DISEASE?
. Inter-observer variation in detection of respiratory signs
is well known. The value of a sign in reaching a dj clinical
diagnosis i s dependent on whether its pr sence, often in
conjunction with other signs, discriminate between diseases;
and on the consistency with which observers agree on its
presence or absence. An attempt to. rank the order of r -'.liability
with which chest signs are .-.licited was undertaken by Bpiteri
M .a. et al (1983)5
comparing clinical findings (History of
patient was not consid- red ) with the true diagnosis confirmed
by chest radiography, pulmonary function tests, arterial blood
gas measurements and CT scans. Their conclusions were?-
1.
The complete agreement about particular respiratory
sign was found 55% of the. time. The amount of agreement
was greatest for percussion note, wheezing, pleural rub,
clubbing and reduced breath sounds, where as signs such
as whispering pectoriloguy was rated totally unreliable.
2.
In 28%, clinical diagnosis was incorrect.
However, this study docs not tell us whether incorrect
structural diagnosis(say fibrosis,pleural effusion,pneumonia,
cavity etc) necessarily lead to incorrect etiological probability
and thus to incorrect management. Nor it tells us when should
we rely on bedside diagnosi.' and what are-the guidelines for
investigating patient further.
We did a study at M.G.I.M.S.,Sewagram,6 comparing bedside
diagnosis with ehest radiograph in lower respiratory tract
diseases with aim to tailor the utility of chest radiography.
Our conclusions are;-
3.
1.
'When the d-agnosis of respiratory disease rests on
interpretation of crepitation as the only detectable
sign, chest radiograph offers useful clue to the etiologi- ■
cal probability. With other- florid-signs, bedside diag
nosis correlated very well with chest radiography. In
such circumstances - chest radiography.does not add much
to etiological diagnosis.
2.
Those patients where symptoms strongly suggest r rspiratory
tract disease but there arc no bediside signs demonstrable,
chest radiograph is indicated.
3.
In a case of pleural effusion where chest radiograph is
ncn-committ-nt about etiological probability, intercostal
tenderness was a definite sign- of empyema.
4;
In absence of respiratory sign and symptoms, chest radio
graphy helps in detecting etiological probability in
systemic disorders like P .U .0.(5%)and T.E. M.(33%)„
/
REFERENCES?
1.
Finlaysin,JK et al. Cardiac signs for students? separating
wheat from chaff. 3MJ 1978? 1? 1471-73.
2.
Goldman et al. clinical impact of echocardiogram .Lm»J .Med.
1983, 75? 49-56.
3.
4.
5.
6.
McDonald et al. J_. Clin. Epidemiol.’ 198’8 ? 4 ? 151-161.
Grimmer etnl. Lancet. 1982? 1? 440-41.
Spitsri M.A. et -1 Th..- Lanc~t? 1988? 1? 873-875.
Subhbdh Mohan? Efficacy of clinical evaluation and role
of ehest radiography in the diagnosis of lower respiratory
tract disorders? Post-graduate thesis 1987,Nagupur
University, Nagpur.
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