Strolling through the halls of a busy medical ward, Dr. Peter Sullivan stops outside of a patient’s room and turns to the group of medical students following closely behind, “Wait here.” The students were familiar with the routine. And by now, in his eighth year teaching the physical diagnosis elective course, so was Sullivan. He would disappear into the patient’s room, confirm their findings were of interest to the group, and then ask the patient for permission to bring the group of students in to see them. “I can’t remember the last time a patient said no,” remarks Sullivan. “Most patients want to help students learn. “ Once inside the patient’s room, the education begins.

Among the students in the room that day was Dr. André Mansoor, who now teaches the course alongside Drs. Sullivan and Lynn Loriaux. He recalls, “We started off by commenting on the patient’s ill appearance and elevated respiratory rate, and then we started to look more closely at his neck.” Turning to the group, Sullivan remarked “There is much that can be learned about the heart by evaluating the neck veins.”

Sullivan then led the students through a basic evaluation of the patient’s central venous pressure, teaching them how to use the height of the jugular venous pulse to estimate right atrial pressure. “It was elevated, but there was more to it” recalls Mansoor. “Pete also pointed out how the descents (the inward movements of the jugular venous waveform) were unusually sharp and deep.” To the astute clinician, changes in the jugular venous waveform can serve as clues to an underlying condition.

What happened next was an epiphany for Mansoor, who at that point in his career was not fully acquainted with the power of physical examination. Sullivan turned to the patient and, with confidence, asked him, “When did you have radiation therapy to your chest?” Surprised, the patient responded with a question of his own, “How did you know I had radiation therapy?” Sullivan had noticed small blue dots arranged in a square-pattern on the patient’s chest. These blue dots were tattoo markers, used by radiation-oncology physicians to mark the radiation field.

In a similar way, Sullivan went on to uncover more clues, like the presence of Kussmaul’s sign (the paradoxical inspiratory rise in jugular venous pressure), as well as an extra heart sound known as a pericardial knock. Putting all of the clues together to create a cohesive story, the patient was diagnosed with constrictive pericarditis related to radiation therapy. According to Mansoor, that experience showed him the power of physical examination, and he has believed in it ever since.

Now colleagues, Mansoor and Sullivan teach the same physical diagnosis course together, now in its twentieth year as of July, 2020.

When I came to OHSU as a medical student in 2005 I was introduced to Dr. Lynn Loriaux for the first time. But I had not yet met him, you see. No, I was introduced first to his legend. It was said that, among other things, he needed only a handshake in order to make a diagnosis. Now, of course behind every legend there is a man. Often, they are worlds apart. Rarely, they are similar. And very very rarely does the man exceed the legend. And when I met the man himself for the first time, it quickly became apparent to me that he was a rarity. And that he far exceeded his legend.

-Mansoor on Dr. Lynn Loriaux, June 9th, 2013.

The legend Lynn Loriaux using a wine glass to teach students the art of percussion during our physical diagnosis course. 2019.

Loriaux, Sullivan, and Mansoor continue to teach physical diagnosis at Oregon’s academic medical center. They have always thought about ways to reach a wider audience. “We gotta make a website” Mansoor remembers telling Sullivan many years back. The problem? Neither are proficient with computers.

“And then Joe walked into our lives”. Literally. Mansoor met Joseph Nugent, a medical student, while leading a “ward walk,” an activity designed to bring first- and second-year students – typically preoccupied with lecture-based teaching at that point of medical school – into the hospital to see patients, sometimes for the first time. Joe had the computer knowledge Mansoor and Sullivan lacked. The Physical Diagnosis PDX team became complete with the arrival of Ishita Sharma, a doctor from the Seattle area, who met Mansoor during a shadowing experience. Sharma was trained in India, where there is a particular emphasis on physical examination. The team hopes PDX PDX will illustrate the importance of physical examination to a worldwide audience. With a wealth of physical findings at their fingertips, students no longer have to “wait here.”

Ever since Sullivan first mentioned it to him, Mansoor has been fascinated by phonocardiography, a technique used in decades past to record and illustrate heart sounds using a phonocardiograph machine. The sounds are recorded and then illustrated on a strip of paper. It is the method of choice for illustrating heart sounds in medical textbooks. But where have all the phonocardiographs gone? Mansoor searched and searched but could not seem to locate any machines. It was as if they had disappeared from the face of the earth. But he continued to try to find a machine because he thought it would be an outstanding teaching tool. Instead of relying solely on auditory input, students could have both auditory and visual inputs to help them learn heart sounds. Finally, some time in 2015, the day came. He found a phonocardiograph machine for sale online. It was made by Burdick in 1958. He asked the seller about the condition and whether it still worked. 

“I just sell antique medical equipment, I am not a doctor and I don’t know if most of this stuff still works,” the merchant warned. Mansoor bought it anyway. When it arrived, he found a small carrying case, built almost like a treasure chest. And when he opened it, he was greeted with an aroma that suggested this was the first time anyone had done so since 1958. Astonishingly, inside the chest Mansoor found a phonocardiograph machine in apparent perfect condition, along with the original instructions manual and a Burdick product catalogue. Mansoor could see how the machine recorded heart sounds with a microphone attachment, but he could not figure out how to get it to display the audio output. Reading the instructions manual, he realized that the phonocardiograph machine was made to connect with a Burdick electrocardiogram (EKG) machine, which was responsible for printing the phonocardiograms. Luckily, Mansoor was able to locate and purchase a compatible Burdick EKG machine from the same era. There was one more problem. The original mercury battery that the machine needed for power was obsolete. After talking to an electrical engineer, Mansoor was able to locate an alkaline battery that “should” work with the machine. He ordered it. One day he found himself with the phonocardiograph machine, the 1950s EKG machine, and the alkaline battery. Mansoor connected the three components and like any good old school physician, he tested his new (old) device on himself. Amazingly, the old machine recorded and produced each new S1 and S2 sounds from his heart in perfect execution.

Mansoor has since used the machine to teach cardiac auscultation to medical students. He has also used it for published case reports, such as Pericardial Knock and Mitral Stenosis.

Medical students practicing percussion skills in the halls of the hospital in 2014. Finding wall studs can be a great way to practice. As an added benefit your students will appear rather unhinged to the non-medical passerby.

Mansoor talking about the importance of physical examination

Demonstrating to a group of students how the digital stethoscope records sound, Mansoor began tapping rhythmically on the diaphragm and showed how the corresponding phonocardiogram was being generated on the attached phone screen. Sullivan quipped, “So that’s how you record these sounds? Think the journals are gonna catch on?”

An inside look at Nugent’s laboratory. All of our audio recordings and videos spend time in the lab under Joe’s care before becoming the content you see on the site today.