Physical examination before diagnostic ultrasonography: Alive and kicking or a relic of the past?

Objectives	To investigate how often physicians perform physical examination prior to referring patients for diagnostic ultrasonography (US). To investigate whether its omission affects clinical reasoning quality or diagnostic yield.
Authors	Andreea M Pavel, Yuki Arita, Ömer Kasalak, Thomas C Kwee.
Journal	Eur J Radiol. 2025 Dec;193:112431. doi: 10.1016/j.ejrad.2025.112431.
Methods	Prospective study. Patients who underwent diagnostic US at the department of radiology of the University Medical Centre Groningen (a tertiary care academic centre in the Netherlands) between 5 December 2024 and 10 April 2025, were asked whether their referring physician had performed a physical examination. Patient demographics, referring specialty, healthcare professional, US indication, and anatomical region were recorded. Clinical reasoning quality was defined as the alignment between clinically suspected and US findings. US outcomes were classified as positive, negative, or indeterminate. Associations with omission of physical examination were analysed using multivariate regression.
Results	302 patients were included (median age: 56 years; 48 % male). Physical examination was omitted in 168 cases (55.6 %). Of all exams, 51 % were positive. Omission was less likely in referrals from surgical specialties (OR 0.490, P = 0.032), family medicine (OR 0.253, P = 0.016), and residents (OR 0.303, P < 0.001), as well as in cases of new complaints (OR 0.226, P < 0.001) and head and neck US (OR 0.261, P < 0.001). Omission was marginally associated with lower clinical reasoning scores on univariate analysis (P = 0.050), but not after adjustment. Omission of physical examination showed a trend toward lower diagnostic yield (P = 0.059), but was not significant after adjustment.
Conclusions	Physical examination was frequently omitted before US referral. While initially linked to reduced clinical reasoning and diagnostic yield, these associations did not remain significant after adjustment, suggesting no clear impact on diagnostic outcomes.
Key points	Physical examination before US is omitted in more than half of the cases, challenging the traditional view of physical assessment as a diagnostic cornerstone. This omission physical examination does not necessarily compromise diagnostic reasoning or reduce the detection of relevant pathology. The diagnostic utility of physical examination may be low in some clinical contexts, allowing physicians to omit it. The higher rates of physical examination appear on specific settings: Patients with new complaints likely due to the greater diagnostic uncertainty in these cases. Head and neck US probably due to the physical accessibility of this region. Here, prior physical examination were significantly associated with higher clinical reasoning quality probably because here, physical findings are the reason to request the US.
Link (DOI)	https://dx.doi.org/10.1016/j.ejrad.2025.112431
Ultrasound speciality	Physical Exams

Short-Review by:

Prof. Dr. Jose Luis del Cura
Department of Radiology
Donostia University Hospital
Spain

Strengths:

Prospective. Topic that everyone talks about informally but that has rarely been studied. Include a multivariate regression addressing all the relevant potential confounders.

Weaknesses:

Small series. Performed in only one centre, and specifically in a radiology department, which could mean that its conclusions are not valid in other settings, and especially for POCUS exams. Data were based on patient self-reporting, which may be subject to recall bias. The quality and thoroughness of the physical examinations performed were not assessed.

Personally thinking:

Although probably biased and probably not generalizable to other healthcare settings or populations, the study addresses a topic that has rarely been studied but is relevant to the organization and protocols of healthcare services.

The results suggest that:

Previous physical exam can be omitted as a requisite to perform US.
US has evolved from a tool used to assess previous findings in the patient’s history or physical examination to a routine stage of triage for any patient. Kind of screening tool to be performed in every case sometimes without an specific aim. Therefore, any effort aimed at limiting the workload by reducing the number of scans by acting on the indications for ultrasound is doomed to failure.

Andreea M Pavel, Yuki Arita, Ömer Kasalak, Thomas C Kwee. Andreea M Pavel, Yuki Arita, Ömer Kasalak, Thomas C Kwee.