Physical Examination in the Current Era: A Case for Irfan’s sign

Physical examination has historically been an integral part of routine clinical encounter. Physical examination can help narrow the differential diagnosis and aid in the selection of judicious use of investigations.  More importantly,  a professional encounter, right at the outset, can build a strong rapport in building physician-patient relationship [1].  More recently, however,  physical examination has been considered to be a dying art where the physicians of recent generation increasingly rely on investigations. This has inverted the historical paradigm where doctors have a tendency to investigate first before even seeing the patient. Sadly, the concept of a “bed side diagnosis” is fading away with the passage of time [2].  Dr. Abraham Verghese of Stanford University has frequently commented on this declining art of the young generation of the physicians and has stated that some of the doctors review images of the patients first before even looking at the patient [3]. In the current issue of the journal,  Irfan Masood, a resident surgeon, has described a novel and conceptual physical exam finding in the intestinal perforation patients under his care [4]. A tympanic percussion note instead of a dull note in the mid clavicular line below the fifth intercostal space would suggest air under the diaphragm and hence suggest perforation. Given his initial description of the sign, it would be fair to label it as “Irfan’s sign”. Irfan’s sign once again reiterates the role of a physical exam in aiding diagnosis.  Larger studies are needed to assess the utility and validity of Irfan’s sign,  especially in resource limited settings.

1. Chi J, Verghese A. Improving communication with patients: learning by doing. 2013 Dec 4;310(21):2257-8.
2. Verghese A, Brady E, Kapur CC, Horwitz RI. The bedside evaluation: ritual and reason. Ann Intern Med.2011 Oct 18;155(8):550-3.
3. Chi J, Verghese A. Clinical education and the electronic health record: the flipped patient. 2014 Dec 10;312(22):2331-2.
4. Masood I. Description of a new clinical sign in evaluating the patients with gastro-intestinal perforation. J Pioneer Med Sci. 2015; 5(3):82