The Ultrasound-Assisted Physical Examination in the Periodic Health Evaluation of the Elderly

Journal of Family Practice, July, 2000 by Timothy Siepel, David S. Clifford, Paul A. James, Timothy M. Cowan

* BACKGROUND Except for specific procedures such as blood pressure measurement, the conventional physical examination (PE) does not have sufficient sensitivity to be useful as part of the periodic health evaluation. Ultrasound has demonstrated greater sensitivity and specificity in numerous studies but has been too expensive to be widely employed in health screening. The purpose of our study was to determine whether an examination in which conventional and ultrasound techniques are blended and applied by a primary care physician might be feasible and useful in the periodic health evaluations of senior citizens.

* METHODS Seventy-two patients presenting to a community-based family physician for periodic health evaluations received an ultrasound-assisted physical examination (USA-PE) from a second family physician. The results were reported to the primary physician, and the outcomes were tracked for periods of up to 2 years.

* RESULTS Twenty-two of the 72 patients (31%) had abnormalities found by the USA-PE that were not apparent during the conventional PE. Five of these patients (7%) had serious conditions that received prompt treatment with apparent benefit. Findings included endometrial carcinoma, abdominal aortic aneurysm, carotid stenosis, hydronephrosis, and urinary retention.

* CONCLUSIONS The USA-PE found more abnormalities in this group of patients than conventional PE. Whether it can improve outcomes for senior citizens undergoing periodic health evaluations in a cost-effective manner is yet to be determined.

* KEY WORDS Ultrasonography; physical examination; aged. (J Fam Pract 2000; 49:628-632)

The traditional physical examination (PE) has been limited to the use of the eyes, ears, and hands of the examiner and has excluded technological enhancement beyond the use of simple instruments. The value of the PE in the periodic health evaluation, however, has been called into question.[1-6] Except for a few specific segments of the head-to-toe examination, the evidence suggests that it does not detect enough conditions in time to have a favorable impact on the outcome of patients' health. The US Preventive Services Task Force[7] does not list the PE among its recommended interventions for screening of the general or elderly population.

One possible reason for the failure of the PE to have a positive impact as a screening examination is that it is not sensitive enough to detect many diseases in their early stages, when intervention might have more benefit. For example, the PE is relatively insensitive and inaccurate, when compared with ultrasound, in the detection of carotid stenoses, thyroid nodules, various cardiac abnormalities, abdominal aortic aneurysms, renal cancers, hydronephroses, gallstones, and cancers of the uterus, ovaries, and urinary bladder. Ultrasound has demonstrated efficacy in the detection of these conditions in screening studies[8-31] but has not been widely employed, primarily because of the cost of formal specialist-performed studies. We hypothesize that blending real-time diagnostic ultrasound into the PE performed by the primary care physician can increase its diagnostic yield with little additional cost. We call this amalgamation of physical and ultrasound examinations the ultrasound-assisted physical examination (USA-PE).

METHODS

Study Population

New patients aged 65 years and older who presented to the office of a family physician in western New York for periodic health evaluations were informed about the study and offered the opportunity to participate. Seventy-two patients participated in the study. The study sample predominantly included middle-class suburban white people who had been under regular medical care with other physicians in recent years. We limited our study to seniors in anticipation that they might have a higher incidence of findings and to new patients so that fewer diagnostic tests might have been completed previously.

The Ultrasound-Assisted Physical Examination

Patients who agreed to participate were asked to return for an ultrasound-assisted examination by a family physician who had passed the registry examinations as a registered diagnostic medical sonographer (the examination used to certify ultrasound technicians). Most of the USA-PEs were conducted within 1 month of enrollment and the initial PE. The examinations were performed between October 1, 1996, and June 9, 1998. The Medison 4800 (Medison Co, Ltd, Seoul, Korea), an office-type real-time ultrasonic diagnostic scanner, was used in all USA-PE examinations. This machine has 7.5 and 3.5 mhz probes with duplex pulse-wave Doppler capability.

Before performing the USA-PE, the physician-sonographer reviewed the patient's history and medical record. A conventional screening PE was performed; pelvic and rectal examinations were not repeated in our study. The diagnostic ultrasound machine was then used to screen the carotid arteries, the thyroid, the heart (assessed with 2 dimensional sonography only), the abdomen, and the penis. In total the USA-PEs, including both conventional PE and ultrasound-assisted components, took approximately 15 minutes each.