Introduction to Cardiac Physical Diagnosis

"Each of us should strive "to rise above the routines of the daily ward round and to see in every patient an opportunity not only to serve mankind in the best tradition of medical excellence, but to add to the store of medical knowledge." —A. McGehee Harvey (1973)

This section is dedicated to help and develop the skills of trainees in advanced cardiac physical diagnosis techniques and their application to patient care by demonstrating how to conduct attending rounds that include bedside teaching.

Physical examination or clinical examination is the process by which a doctor investigates the body of a patient for signs of disease. It generally follows the taking of the medical history — an account of the symptoms as experienced by the patient. Together with the medical history, the physical examination aids in determining the correct diagnosis and devising the treatment plan. This data then becomes part of the medical record.

Ten individuals are responsible for the development of modern physical diagnosis: Hippocrates, Vesalius, Morgagni, Sydenham, Auenbrugger, Corvisart, Laennec, Louis, Mueller, and Osler. Their accomplishments form a "golden thread [that runs] throughout the history of the world, consecutive and continuous, the work of the best men in successive ages" (Moxon, quoted by William Osler). The pool of information presented in this section of CardioNotebook.com has been created by the scholarship of these ten men. They were physicians going about the daily practice of medicine. The story of their achievements serves to stimulate the spirit of inquiry in each of us and underscores the obligation we have to add to this pool of knowledge.

Appropriate use of history and physical examination is essential to clinical practice. There is a renewed interest in physical examination skills and return to teaching rounds that include patients. There are many indications, however, that current medical students and medical residents are deficient in some aspects of physical diagnosis. For example, in site-specific studies and a national survey, the practice of cardiac auscultation, considered one of the keystones of physical examination, has been demonstrated to be lacking in medical residents.

Many faculty, trained in an era that de-emphasized bedside teaching, lack skills in physical diagnosis. In a study of faculty assessment, Noel, et al., demonstrated that attending physicians were often unable to detect both subtle and obvious mistakes made by students and residents in history and physical examinations. Many faculty also have not had role models for bedside teaching.

In addition to skills of history-taking and physical examination, one needs to consider medical literature evidence of accuracy in exam maneuvers, including sensitivity, specificity, and amount of contribution to patient diagnosis.

Physical diagnosis had its origins in Grecian medicine. Clinical medicine flourished before the Greeks, especially in Egypt, Crete, and Babylonia, and undoubtedly the Greeks were influenced by these earlier physicians. But writings from these countries did not become part of the mainstream of Western civilization, as did those of the Greeks. The following  two quotations llustrate the level of medicine practiced by the Greeks.

One should pay attention to the first day the patient felt weak; one should inquire why and when it began. These are the key points to keep in mind. After these questions have been cautiously considered, one should ask the patient how his head feels, or if he has any pain or if he feels heavy. … In regard to the chest, one should ask the patient if he has pain there and if he has a slight cough, with pain in the abdomen when he coughs (Littre's Translation of Hippocrates, 2, 436–40: Regimen in Acute Disease. Appendix #9).

They took a careful history and practiced direct auscultation. They were masters of observation: their descriptions of patients could fit modern texts without much change.

Seven crucial developments over the past 3000 years shaped physical diagnosis as we know it today. Hippocrates and his colleagues laid the foundations by establishing medicine as a profession and by declaring that it has a rational basis. The second development was the resumption of the dissection of human bodies for educational purposes, beginning in the thirteenth century in Italy. Vesalius was thereby able to publish an accurate human anatomy text in 1543, and Morgagni to establish morbid anatomy, or pathology, as a discipline in 1761. The third development was Sydenham's definition of disease between 1666 and 1683, leading to the nosological concept of disease. The actual beginnings of physical diagnosis occurred with the discovery of percussion by Auenbrugger in 1760, and its dissemination by Corvisart in 1808. Laennec invented the stethoscope in 1816, beginning a century of explosive development in physical diagnosis. The French School, exemplified by Pierre Louis, synthesized the previous developments and put physical diagnosis on a secure footing at the bedside and in the autopsy room during the period 1800 until 1850. The German School, epitomized by Johannes Mueller, laid the foundation for experimental laboratory science from 1830 until 1900. These six developments were applied to medical education by William Osler in the medical clinic at Johns Hopkins University in 1893, thereby revolutionizing medical education and the practice of medicine in America and the Western world.

There were a number of important developments in addition to the seven crucial ones outlined above: the model of bedside teaching developed by Boerhaave at Leyden about 1700; the development of precision instruments such as the thermometer, microscope, ophthalmoscope, kymograph, and sphygmomanometer; and the discovery of the x-ray. The urban migration in Europe in the late 1700s and early 1800s, coupled with the development of the French hospital system, made available to physicians a concentration of human illness never seen before. The ascendance of the German and American university had a profound influence on medicine. Once again, the genius of William Osler wove all these threads into the fabric that established clinical diagnosis and medical education as it exists today.

Crucial Developments in the History of Physical Diagnosis

Good Luck!

Dr. Subrahmanyam Karuturi