April 2015 Critical Care Case of the Month: Half-Sided Light House

Theodore Loftsgard APRN, ACNP, CCRN

Adam Frost RRT, CRT

Dacia Evans RN

Karen Kolbet PharmD, RPh

Division of Critical Care

Mayo Clinic

Rochester, Minnesota

History of Present Illness

A 55 year old woman was transferred to the ICU from the general medicine ward for tachycardia and acute hypoxic respiratory distress. She has multiple myeloma and had received cycle one of bortezomib, dexamethasone, thalidomide, cisplatin, doxorubicin, cyclophosphamide and etoposide (VDT-PACE) and radiotherapy to T7 for a pathologic compression. She was admitted for pain control from mucositis.

Past Medical History

In addition to the multiple myeloma she has a past medical history of asthma, ovarian cysts, diverticulitis, eczema, pneumonia, laparoscopic cholecystectomy, total abdominal hysterectomy with bilateral salpingo-oophorectomy, appendectomy, ectopic pregnancy in the past, and left Bell's palsy.

Current Medications

• Acyclovir 400 mg BID
• Albuterol 90 HFA prn
• Allopurinol 300 mg daily
• Fluconazole 200 mg BID
• Gabapentin 300 mg BID,
• Hydromorphone
• Levofloxacin 500 daily
• Morphine
• Omeprazole
• Bactrim 400-80 mg daily for PCP prophylaxis
• Thalomid 200 mg capsule daily
• Ativan 0.5 mg just prior to transfer

Physical Examination

• Vital Signs: temperature 36.4 °C, respiratory rate 24 breaths/minute, blood pressure 148/77 mm Hg, pulse 133/minute, SpO2 98% on oxygen at 4 L/min.
• General: Alert and follows commands. Slightly somnolent. In respiratory acute distress.
• Skin: Pink, warm and dry without acute rashes or lesions.
• Eyes: EOMs intact. Conjunctivae pink. Sclerae anicteric
• ENT: Neck supple. Trachea midline.
• Cardiac: S1, S2 irregular rate and rhythm without extra sounds, murmurs, rubs or gallops. Capillary refill 2 seconds.
• Lungs: Respirations with accessory muscle use, shallow. scattered crackles and equal to auscultation. Diminished bilateral bases.
• Abdomen: Soft. No abdominal tenderness. Non-distended. Bowel sounds present.
• Extremities: Peripheral pulses +2/4 throughout. 1+ peripheral edema.
• Neuro: GCS = 13, residual bell's palsy.

Pertinent Labs

• Sodium: 144 mmol/L
• Potassium: 4.2 mmol/L
• Chloride: 113 mmol/L *
• Bicarbonate,: 23 mmol/L
• Creatinine: 0.6 mg/dL
• Hematocrit: 20.5 %
• Leukocytes: 0.5 x10(9)/L
• Hemoglobin: 6.2 g/dL
• Platelet Count: 39 x10(9)/L
• Calcium, Ionized(S): 4.81 mg/dL
• pH (FOR CALCIUM, IONIZED [S]): 7.47
• INR: 1.5
• APTT(P): 29 sec

Her ECG (Figure 1) showed a tachycardia with a maximum heart rate was in the 170's.

Figure 1. Admission ECG to the ICU.

Her admission chest x-ray is shown in Figure 2.

Figure 2. Portable chest x-ray taken just after admission to the ICU.

Which of the following are true? (Click on the correct answer to proceed to the second of four panels)

1. The EKG shows atrial fibrillation with a rapid ventricular response
2. She should be immediately intubated for airway protection
3. The chest x-ray shows bilateral pleural effusions
4. 1 and 3
5. All of the above

Reference as: Loftsgard T, Frost A, Evans D, Kolbet K. April 2015 critical care case of the month: half-sided light house. Southwest J Pulm Crit Care. 2015;10(4):159-70. doi: http://dx.doi.org/10.13175/swjpcc031-15 PDF

March 2015 Critical Care Case of the Month: It’s Not Always Sepsis

Dionne Morgan, MD 

Carolyn H. Welsh, MD 

University of Colorado and the Eastern Colorado Veterans Affairs Medical Center

Department of Medicine

Division of Pulmonary Sciences and Critical Care Medicine

Denver, CO

History of Present Illness

A 57-year-old man with multiple co-morbidities including diabetes mellitus presented with wet gangrene of the right foot and hypotension.  He had diabetic ketoacidosis and acute kidney injury. He was admitted to the medical intensive care unit, given intravenous fluids and treated with insulin therapy, piperacillin/tazobactam and vancomycin. Initial blood cultures grew Methicillin-resistant Staphylococcus aureus (MRSA). The podiatry service performed a right transmetatarsal amputation. Subsequently, he did well and was transferred to a medical floor for further care. 

Three weeks later, following resolution of the initial sepsis, he developed persistently high fevers with hemodynamic instability despite continued antibiotic therapy. He was transferred back to the MICU for presumed sepsis.

Past Medical History, Social History and Family History

The past medical history was significant for diabetes, hypertension, COPD, coronary artery disease and hepatitis C. He did not smoke nor drink alcohol. Family history was non-contributory.

Physical Examination

On readmission to the medical intensive care unit, the patient was noted to have a generalized maculopapular rash on both upper and lower extremities, torso, palms and soles of his feet, associated with facial and periorbital edema (Figure 1). There was no mucosal membrane involvement or lymphadenopathy.  He was also febrile to 104^o F, hypotensive to 80/50 mm Hg and icteric.

Figure 1. Image of rash.

Laboratory Studies

Initial labs showed elevated leukocyte count, BUN and creatinine with anion-gap metabolic acidosis but a normal liver enzyme profile. Repeat labs on readmission to the medical ICU were significant for severe leukocytosis, with marked eosinophilia, atypical lymphocytes on blood smear, acute transaminitis and hyperbilirubinemia.

Admission labs: White blood cell count (WBC) 29.9 x 1000 cells/μL. Eosinophils 0.0% (Normal 0.0 - 0.7%), AST 28 U/L, ALT 15 U/L, ALP 162 U/L, total bilirubin 0.2 mg/dL.

Labs on ICU readmission: White blood cell count (WBC) 35.7 x 1000 cells/ μL. Eosinophils 2.3% (Normal 0.0 -0.7%), AST 486 U/L, ALT 288 U/L, ALP 749 U/L, total bilirubin 4.3 mg/dL.

Which are components of the SIRS criteria? (click on the correct answer to proceed to the second of 4 panels)

1. Elevated respiratory rate
2. Hypothermia
3. Leukocytosis
4. Tachycardia
5. All the above

Reference as: Morgan D, Welsh CH. March 2015 critical care case of the month: it's not always sepsis. Southwest J Pulm Crit Care. 2015;10(3):105-11. doi: http://dx.doi.org/10.13175/swjpcc029-15 PDF

Ultrasound for Critical Care Physicians: Now My Heart Is Even More Full

Bilal Jalil, MD

Michel Boivin, MD

Division of Pulmonary, Critical Care and Sleep Medicine

University of New Mexico School of Medicine

Albuquerque, NM

A 49-year-old man with type 2 diabetes, intravenous drug abuse and heart failure presented to the emergency room with 2 weeks of progressively worsening chest pain, lower extremity swelling and shortness of breath. The patient was found to have an elevated troponin as well as brain natriuretic peptide and the absence of ischemic electrocardiogram findings. The patient was admitted to the medical ICU for hypoxic respiratory failure and shock of uncertain etiology. Clinically he seemed to be in decompensated heart failure and a bedside echocardiogram was performed (Figures 1 and 2).

Figure 1. Parasternal short axis view at the level of the aortic valve

Figure 2. Apical 4 chamber view.

What is the best explanation for the echocardiographic findings shown above? (Click on the correct answer for the explanation)

1. Atrial myxoma
2. Cardiac amyloidosis
3. Cardiac lymphoma
4. Takotsubo cardiomyopathy
5. Tricuspid valve endocarditis

Reference as: Jalil B, Boivin M. Ultrasound for critical care physicians: now my heart is even more full. Souhtwest J Pulm Crit Care. 2015;10(2):83-6. doi: http://dx.doi.org/10.13175/swjpcc020-15 PDF

February 2015 Critical Care Case of the Month: A Bloody Mess

Mily Sheth, MD

Carmen Luraschi, MD

Matthew P. Schreiber, MD, MHS

University of Nevada School of Medicine: Las Vegas

Department of Internal Medicine

Division of Pulmonary/Critical Care

Las Vegas, NV

History of Presenting Illness:

A 23-year-old Ethiopian woman with a known history of systemic lupus erythematosus (SLE) but of unknown duration presented with the chief complains of cough and generalised weakness for 1 week. She had a recent history of travelling to Ethiopia 3 months ago for 3 weeks. She complained of subjective fevers and one episode of blood tinged sputum. She also complained of fatigue and an episode of syncope which prompted her hospitalization.

PMH, SH and FH:

The patient has a past medical history of SLE diagnosed in Ethiopia of which no records were available. She is a student and denied alcohol, smoking or drug abuse. She denied any family history of autoimmune disorders. She did not take any medications at home.

Physical Examination:

Initial admission vital signs were temperature of 100.5 F, heart rate of 130, respiratory rate of 30 and blood pressure of 92/48. Oxygen saturation was 96% on 2 L/min via nasal cannula.

She appeared to be in moderate distress but was speaking in full sentences. Skin examination revealed a malar rash on her face. Her upper and lower extremities had excoriated plaques. Her anterior chest had flat non blanchable, macular rash. CVS examination revealed tachycardia without any murmurs. Respiratory exam was positive for bilaterally diffuse bronchial breath sounds. The remainder of her exam was within normal limits.

Laboratory and Radiology:

CBC: WBC 6.7 million cells/mcL, hemoglobin 7.1 g/dL, hematocrit 20.9, platelet 160,000 cells/mcL

Renal panel: within normal limits.

Troponin 0.01, creatine kinase 457 U/L, lactic acid 1.1 mm/L, HIV non-reactive

Liver function tests: AST 288 U/L, ALT 93 U/L alkaline phosphatase 136 IU/L, total bilirubin 0.9 mg/dL

Radiography:

Her initial chest x-ray is shown in figure 1. It was interpreted as showing diffuse pulmonary infiltrates, right lung greater than left. No pleural effusions. No pneumothorax.

Figure 1. Initial chest x-ray.

In a patient with these characteristics, which other test(s) would you order? (Click on the correct answer to proceed to the second of five panels)

1. Arterial blood gases and lactic acid
2. Cardiac angiogram
3. Computed tomography (CT) of the chest without contrast
4. VATS lung biopsy
5. All of the above

Reference as: Sheth M, Luraschi C, Schreiber MP. February 2015 critical care case of the month: a blood mess. Southwest J Pulm Crit Care. 2015;10(2):63-9. doi: http://dx.doi.org/10.13175/swjpcc148-14 PDF

Physical Examination in the Intensive Care Unit: Opinions of Physicians at Three Teaching Hospitals

Rodrigo Vazquez, MD¹

Cristina Vazquez Guillamet, MD¹

Mohamed Adeel Rishi, MD²

Jorge Florindez, MD⁴

Priya S Dhawan, MD³

Sarah E. Allen, MD¹

Constantine A Manthous, MD⁵

Geoffrey Lighthall MD, PhD⁶

Affiliations: University of New Mexico School of Medicine¹ Albuquerque NM. McNeal Hospital², Berwyn Il. Mayo Clinic Arizona³, Scottsdale AZ. Bridgeport Hospital⁴, Bridgeport CT. Yale School of Medicine⁵, New Haven CT. Stanford University School of Medicine⁶, Stanford CA.

Study Sites: Stanford University Medical Center, Stanford CA. McNeal Hospital, Berwyn Il and Bridgeport Hospital, Bridgeport CT.

Abstract

Purpose: Technological advances in intensive care unit may lead physicians to question or omit portions of the physical exam. Our goal is to assess the opinions of intensive care unit physicians about physical examination in modern day medicine.

Methods: Subjects included physicians on medical intensive care unit teams at one university hospital and two university-affiliated teaching hospitals. Participants responded to an interview divided into two sections: (1) A semi-structured interview including open-ended questions on the management of four critical care scenarios and on the utility of physical exam; (2) Multiple-choice questions about physical exam.

Main Results: The response rate was 100%. A total of 122 individuals, 16(13%) attendings, 24(20%) fellows and 82(67%) residents, responded. Half 61 (50%) considered physical examination to be of limited utility in the intensive care unit. Fifteen percent of answers to the clinical scenarios were reasoned based on physical examination. Most extended the definition of physical examination to include data derived from monitoring 119(97%), life support 121(99%) and bedside imaging devices 112(92%). Residents 45(37%), students 35(29%) and nurses 35(29%) were recognized as the team members who examine patients the most.

Conclusion: Physical examination was considered useful by half of the physicians. Percussion is the least appreciated component. The role of nurses examining patients is recognized. A new definition of physical examination that extends beyond the patient to include monitoring, life support and bedside imaging is proposed to revitalize bedside clinical medicine.

For accompanying editorial click here.

Introduction

Physical examination is one of the mainstays of clinical activities at the bedside. The many maneuvers and signs of the physical exam were developed and described over the last two centuries when most patients presented in advanced states of disease with obvious physical examination findings (1). In the last few decades, advances in fields of imaging, laboratory and bedside monitoring technologies have increased expectations for early and accurate diagnoses, often before physical exam findings become apparent (2).

In Critical Care Units (ICU) patients have severe presentations of diseases, making it likely to encounter diagnostic physical examination findings; however ICUs have easy access to imaging and automated physiologic measurements that may lead physicians to question, or omit portions, of the physical examination.

In this context, we sought the opinions of physicians working in intensive care units about physical examination in modern day medicine.

Material and Methods

The study was divided into two sections. The first is based on mixed methods analysis (qualitative and quantitative) of semi-structured interviews with open-ended questions. The second is based on the quantitative analysis of multiple-choice questions.

Setting

The study was conducted in 2011, in three ICUs in three states.  One of three hospitals (Stanford) was a 32-bed closed medical-surgical unit in a university medical center hospital. The other two hospitals were 16-17 bed closed medical units at university-affiliated community teaching hospitals. All three hospitals had postgraduate residencies in Internal Medicine and Pulmonary and Critical Care Medicine, and were equipped with electronic medical records systems and computer acquisition and storage of bedside data. At the time of the study, Stanford had begun an initiative to increase the use and appreciation of physical examination in its medical school (3). No other confounding variables were apparent. The Investigational Review Boards of each center approved the protocol independently and waived the need for written consent.

Eligible subjects included residents, critical care fellows, and attending physicians on ICU rotations. Investigators approached all candidates for possible participation; subjects were informed that the study would evaluate their approach to diagnosis and treatment of ICU patients but not about its specific focus on physical examination.

Data collection

Demographic data collected included age, gender, type of specialty and subspecialty training, and level of training.

First section

Semi-structured interviews on how four hypothetical ICU clinical vignettes would be managed; questions were chosen by consensus of the authors and responses were open-ended.

Subjects were presented with this introductory statement: “I’m going to present you with four clinical scenarios. I would like you to explain how you would manage these clinical scenarios in real life. This is not an exam. We are just interested in how physicians practice.” The following four case scenarios were then introduced: “You have to manage an Intensive Care Unit patient with: 1) hypoxemia, 2) hypotension, 3) dyspnea and 4) oliguria. What would you do?”

After discussing management of the case scenarios, subjects were then asked: “What’s your opinion about the utility of physical exam in the ICU?”

Second section

Multiple-choice questions were then asked of each subject:

- How frequently do you examine your patients? Answer choices (or options): “Always, sometimes, never”

-Who do you think examines their patients the most? Answer choices: “Attendings, fellows, residents, students or nurses”

 -Which data obtained at the bedside should be included in an updated definition of physical exam in the ICU? Inspection? palpation? percussion? auscultation? venous lines? arterial line data? ventilator data?, bedside ultrasonography? Answer options: “Strongly agree, agree, disagree, strongly disagree”

The interview was pilot tested in six subjects to verify subjects had a clear understanding of the questions. Investigators performing the interviews were the same within each center and were trained prior to subject enrollment. Investigators read the questions in the same order. Subsequent questions were not revealed until the previous question had been answered. Responses were recorded and transcribed.

Analysis

Data analysis used a mixed-methods approach for the first section. The transcriptions were analyzed looking for key actions or ideas around which the rest of the response was organized, we called these “codes”. For example if an individual answered: “I would auscultate the lungs, order an arterial blood gas and a chest radiograph ” the codes would be lung auscultation, arterial blood gas and chest radiograph. After analyzing all the answers we decided to group “codes” into categories and report them as percentages of all the answers provided, four clinical scenarios per each of the 122 participants. For the previous example the categories would include: auscultation, laboratory test and radiology.

Mention of the physical exam was categorized as: a) mentions physical examination (e.g. “ I would examine the patient…”), b) mentions physical examination or the intention to go to the bedside, c) describes a reasoned physical examination (e.g.“ I would auscultate the lungs, if I heard wheezes then I would…”).

Illustrative comments were highlighted. The findings of each interviewer were checked against each other. In case of discrepancy, answers were compared to reach a consensus.

The analysis of the second section was quantitative.

We used the statistical package Stata 11. Chi² was used to compare rates. Factorial logistic regression and logistic regression were used to evaluate categorical and continuous data when appropriate. A p -value of <0.05 was considered significant.

Results

A total of 122 individuals were approached for study participation and all agreed to participate. The subjects included 16 (13%) attendings, 24 (20%) fellows and 82 (67%) residents. The average age was 32 years (range 24-65). There were 79 (65%) males. Most respondents had Internal Medicine training 116 (95%) and had attended medical school in the US 76 (62%).

First section

Clinical scenarios

Categories identified during the responses to the clinical scenarios are summarized in Table 1.

We report mention of the physical exam in three not mutually exclusive categories: a) mentions physical examination (e.g. “ I would examine the patient…”), b) mentions physical examination or the intention to go to the bedside, c) describes a reasoned physical examination (e.g.“ I would auscultate the lungs, if I heard wheezes then I would…”).

Answers to “What’s your opinion about the utility of physical exam in the ICU?” The physical exam was considered to be of “limited utility” by 61(50%) of the respondents. Table 2 includes answers that illustrate opinions for and against the utility of the physical exam.

According to the respondents, the components of the physical exam that remain useful in the intensive care unit are: a) general appearance; b) the neurological exam; c) abdominal exam since there are no adequate monitoring devices; d) anterior auscultation of the chest to detect pneumothoraces, effusions or cardiac murmurs; and e) examination of the skin.

Second section, multiple-choice questions

A. How frequently do you examine your patients?

Figure 1. Histogram with the percentages of each of the possible answers to question: How frequently do you examine your patients?

B. Who do you think examines patients the most? (Figure 2).

Figure 2. Histogram with the percentages for each of the possible answers to question: Who do you think examines patients the most?

C. Which data obtained at the bedside should be included in an updated definition of physical exam in the ICU?

At least 90% of the respondents agreed to include data obtained through inspection 112 (100%), auscultation 118 (97%), data from ventilators 121 (99 %), arterial lines 120 (98%), central lines 118 (97%), and bedside ultrasound 112(92%). Palpation 107(88%) and percussion 79 (65%) did not exceed the 90% threshold.

Besides the intergroup comparisons noted above, there were no statistically significant differences between responses based on level of training, age, gender, location of medical school training or hospital (p>0.05).

Discussion

We report the opinion of 122 physicians with regard to physical examination in the intensive care unit and the way they reported using the physical exam in four hypothetical clinical scenarios. We found that half of the physicians reported they considered physical exam useful, but only 15 percent mentioned physical exam in deducing answers to the clinical scenarios. Percussion was the least appreciated component of the physical exam. There was generalized agreement that the inclusion of data derived from bedside imaging, monitoring, and life support devices into an updated definition of physical examination would be valuable. Nurses and students were recognized as the team members who examined their patients the most. Study participants provided explanations behind their opinions.

The findings that only 50% of the physicians found the standard physical examination to be useful, and that only 15 % mentioned the physical exam in deducing their case scenario answers suggests a low appreciation for the standard physical exam. Available literature on the utility of the physical exam supports our current study findings. In one study the time spent at the bedside during clinical rounds was down to 11% from an historical 75%, with most of the time spent in hallways or conference rooms (4,5). In an ethnographic study, residents felt it was unnecessary to examine their patients in the ICU as long as they had monitoring and a good nurse (6).

Perceptions from patients and the general public support our findings that use of the physical exam is low. In a questionnaire to ambulatory patients, 56 patients perceived 113 omissions in their physician visit, the most common omissions being those related to what they felt were missed portions of the physical examination (7). Mass media has produced the following headlines: Physician revives a dying art: the physical; Is physical exam facing extinction? and Not on the Doctors’ checklist but touch matters (8-10).

Comments by our study participants help explain these findings. Participants had more confidence in the accuracy of data provided by monitoring devices and imaging than in findings of their physical exams.  Some participants mentioned that it was difficult to convince peers to change management based on physical examination findings alone. Participants also reported there was lack of role modeling physicians performing physical exams.

Attending and fellow physicians were perceived as the team members who examine their patients the least; Attending and fellows validated this perception in reporting examining their patients sometimes or never in more than half of the cases.

An alternative explanation for this perception about the senior team members could be related to differences in diagnostic reasoning between trainees and more experienced physicians (11). Students and residents probably relay more in hypothetic deductive reasoning and collect larger amounts of data, including a more detailed physical examination, to reach a diagnosis. As they become more experienced and start working as fellows and attendings the use of short cuts, heuristics, increases and they reach a diagnosis with smaller amounts of data. Time constraints also make them relay in the information relayed by more junior team members.

Whatever the reason for this perception about senior team members may be, it explains, at least in part, the atrophy of physical examination skills during residency training (12), and feeds a downward spiral with graduates that examine their patients less and less.

Residents, nurses and students on the other hand were recognized as the ones who examined their patients the most. This observation expands the role of nurses in the ICU, and if confirmed by others could change the allocation of responsibilities in the multidisciplinary ICU team.

Although until now our discussion portrays the current poor standings of physical examination in the ICU, we also found hope.

Despite the small proportion of participants basing their reasoning on physical examination during the clinical scenarios, most responses included going to the bedside and almost all participants agreed on extending the physical examination beyond the patient to include data derived from monitoring, life support and bedside imaging devices.

Just as Laennec revolutionized bedside diagnosis with the introduction of the stethoscope (13), a new standardized definition of physical examination including these new bedside diagnostic tools, has the potential to greatly enrich clinical medicine and would reflect the practice of modern medicine better (14,15). Critical care medicine is in a privilege position to lead this conceptual change and spread it to other specialties.

Our study has several limitations. First of all, it describes opinions and behaviors in theoretical scenarios and the answers provided may not correlate with true physician practices. The order and choice of the clinical scenarios and questions may have biased the respondents negatively against the physical exam. In support of our results, once the participants learned about the focus of the study one would have expected an attempt to offer better impressions of themselves with an “over reporting” bias towards the physical examination. However, our results pointed in the opposite direction. It does not correlate the use of physical examination to outcomes.

In regards to the composition of the respondents, residents conformed the great majority. Although one could argue that this limits the generalizability of the results, the proportion of residents, fellows and attending physicians mimics that found in the ICU teams at the participating institutions. Our findings may not be generalized to hospitals in areas with limited resources.

Finally its main limitation and at the same time its main virtue is the generation of new questions that will require new studies with direct observation of team practices and their correlation to patient outcomes.

Conclusion

Physical examination was considered useful by half of the physicians. Percussion is the least appreciated component. The role of nurses examining patients is recognized. A new definition of physical examination that extends to include monitoring, life support and bedside imaging is proposed to revitalize bedside clinical medicine.

Conflict of interests: The authors declare that they have no conflict of interest.

References

1. Walker HK, Hall WD, Hurst JW, Walker HK. The origins of the history and physical examination 3rd ed. Boston, MA: Butterworths; 1990.
2. Berenguer J, Bruguera M, Gervas J, et al. The Physician of the Future. El Metge del Futur. Fundacion Educaion Medica, Barcelona, Spain; 2009. Available at: http://www.econ.upf.edu/~ortun/publicacions/MedicoDelFuturo.pdf (accessed 1/6/15).
3. Verghese A, Horwitz RI. In praise of the physical examination. BMJ. 2009;339:b5448. [CrossRef] [PubMed]
4. LaCombe MA. On bedside teaching. Ann Intern Med. 1997;126(3):217-20. [CrossRef] [PubMed]
5. Miller M, Johnson B, Greene HL, Baier M, Nowlin S. An observational study of attending rounds. J Gen Intern Med. 1992;7(6):646-8. [CrossRef] [PubMed]
6. Bosk CL. Forgive and remember: managing medical failure. 2nd ed. Chicago, IL. University of Chicago Press; 2003. [CrossRef]
7. Kravitz RL, Callahan EJ. Patients' perceptions of omitted examinations and tests: A qualitative analysis. J Gen Intern Med. 2000;15(1):38-45. [CrossRef] [PubMed]
8. Knox R. The Fading Art Of The Physical Exam. National Public Radio. 2010. Available at: http://www.npr.org/player/v2/mediaPlayer.html?action=1&t=1&islist=false&id=129931999&m=129984296 (accessed 1/6/15).
9. Ofri D. Not on the doctor's checklist but touch matters. The New York Times. August 2, 2010.
10. Grady D. Physician revives a dying art: the physical. The New York Times. October 11, 2010. Available at: http://www.nytimes.com/2010/10/12/health/12profile.html?pagewanted=all&_r=0 (accessed 1/6/15).
11. Sackett DL, Tugwell P, Guyatt GH. Clinical epidemiology: a basic science for clinical medicine, 2nd ed. Boston: Little, Brown; 1991.
12. Mangione S, Nieman LZ. Cardiac auscultatory skills of internal medicine and family practice trainees. A comparison of diagnostic proficiency. JAMA. 1997;278(9):717-22. [CrossRef] [PubMed]
13. Laennec R. Traite de l’auscultation mediate. Bull Acad Natl Med. 1819;151:393-398.
14. COBATRICE Domain 2: diagnosis: assessment, investigation, monitoring and data interpretation. Available at: http://www.cobatrice.org/Data/ModuleGestionDeContenu/PagesGenerees/en/02-competencies/0B-diagnosis/8.asp (accessed 1/6/15).
15. American Association of Chest Physicians. Critical care ultrasonography. http://www.chestnet.org/Education/Advanced-Clinical-Training/Certificate-of-Completion-Program/Critical-Care-Ultrasonography (accessed 1/6/15).

Reference as: Vazquez R, Vazquez Guillamet C, Adeel Rishi M, Florindez J, Dhawan PS, Allen SE, Manthous CA, Lighthall G.  Physical examination in the intensive care unit: opinions of physicians at three teaching hospitals. Southwest J Pulm Crit Care. 2015;10(1):34-43. doi: http://dx.doi.org/10.13175/swjpcc165-14 PDF