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Master Thesis

Impact de la pratique échographique en médecine générale sur l'examen clinique du patient

Abstract : Introduction: Physical examination established by Hippocrate has been adapting and changing for centuries. It grew richer in the eighteenth century thanks to the anatomo-pathologic approach, which established a connection between the symptom put forward by the patient, the physical examination, and the lesion within an organ. The discovery of stethoscope in the nineteenth century by Laennec was an essential tool allowing to enrich the cardiologic and pneumologic semiologies. Since then, several tools have completed the medical instruments tool case. We focused on echography now used in the general practitioner office. Integrated within the physical examination, it is considerate as a diagnostic tool permitting visualization of direct or indirect pathological features inside the body. In this particularly case, refer to this as echoscopy. We evaluated how echography could modify the traditional physical examination and its consequences on medical uncertainty. Materials and method: We conducted a qualitative study from April to May 2019 using semi-directive interviews involving 15 general practitioners with specialties in echography. We first established a list of clinical situations where echoscopy could be relevant to the diagnostic. The main goal of the interviews was to compare for those situations the physical examination i.e. the way it was conducted before the echography tool and the way it is done since having integrated the echography tool. Results: Traditional physical examinations could be heterogeneous between GP. They generally report several situations where echography can be added within the physical examination. It becomes an next logical step in the physical examination, which then is modificated. The diagnostic uncertainty is always or often decreased depending on the situations. For thyroid, the majority do not trust their examination and directly use the echography tool. For pulmonary examination, most GPs add an additional step after the auscultation in order to validate a clinical hypothesis such as a pleural effusion or a pneumopathy, that last one being particularly interesting for children. Concerning abdominal pains, clinicians try to corroborate physical and echographical examinations. For instance, for gallbladder crisis or for appendicitis, clinical examination remains the same most of the time. Echoscopy then try to visualize directs and undirects signs of a lesion. Physical examination could also be shortened or cut out in the event of a suspicion of TVP, ascite, urinary retention, muscular lesion or popliteal cyst. Discussion: Echoscopy answers to a binary question during the examination and the medical reasoning. It could rule out or in a diagnostic hypothesis by visualizing patho-physiologic features in real time. When the accuracy of a physical examination is poor due to clinical signs not sensitive enough or specific, echoscopy could partially or totally substitute to the physical examination. When the clinician has moved forward into the diagnostic process thanks to a specific or sensitive semiology, echoscopy becomes a next logical step of the physical examination. It then allows either to establish an emergency level for patient care, or to remove the diagnostic uncertainty by showing the lesion to the clinician’s eye.
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Submitted on : Thursday, November 14, 2019 - 1:39:19 PM
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Isabelle Perez. Impact de la pratique échographique en médecine générale sur l'examen clinique du patient. Sciences du Vivant [q-bio]. 2019. ⟨dumas-02363367⟩



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