HOT OFF THE PRESS!

Originally published as an update to Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine

11th edition

Debra L. Beck

Eugene Braunwald, MD

Date Published: October 19, 2018

Time to add a fifth pillar to bedside physical examination: Inspection, palpation, percussion, auscultation, and insonation

Traditionally, the four pillars of bedside physical examination are inspection, palpation, percussion, and auscultation. In this paper, Drs. Narula, Chandrashekhar and Braunwald propose adding a fifth element—bedside ultrasound (or insonation). This is timely for several reasons, including that current physical examination skills in new trainees are often suboptimal and efforts to improve examination skills during medical training have not been particularly successful. Also, point-of-care handheld ultrasound systems are now available that make bedside insonation imminently feasible. The newest devices are handheld, in some cases wireless, compatible with smartphone technologies, and, in one case, costing less than $2000.

Detractors of bedside insonation have argued that it will diminish the primacy of physical examination even further. However, said the authors, “bedside imaging should not be thought of as replacing or even displacing current practice of physical examination but additive for understanding physiology and pathology and an internal validation of physical findings.” It should be considered “a complement to our senses” to aid in establishing a correct diagnosis rapidly and inexpensively. A further argument for bedside technology is that it may help with the patient-physician relationship in that it keeps the physician at the bedside for longer, and in direct contact with the patient.

In conclusion, said the authors, “We believe that the most practical enhancement to bedside physical examination could be provided by incorporating handheld ultrasound devices.”

Summary

The investigators concluded that many patients with severe asymptomatic primary MR may remain free of indications for surgery for long periods of time and can be actively monitored by experienced practitioners. In such patients, “active surveillance was associated with a favorable prognosis, resulting in timely referral to surgery, excellent long-term survival, and good surgical outcomes.” A randomized trial comparing active surveillance and early elective surgery is warranted.

Reference

1. J Narula, Y Chandrashekhar, E Braunwald: Time to Add a Fifth Pillar to Bedside Physical Examination: Inspection, Palpation, Percussion, Auscultation, and Insonation. JAMA Cardiol. 3(4): 346-350. 2018 Apr 1. PMID: 29490335

Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine features a unique update program by Dr. Braunwald, creating a “living textbook” by featuring weekly Hot off the Press, periodic Late-Breaking Clinical Trials (including links to authors’ presentation slides), and monthly Focused Reviews.

Learn more about Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine, 11th Edition. Download a free chapter here.