Physical examination

Examination room in Washington, DC, period of WWI.

Physical examination or clinical examination is the process by which a doctor investigates the body of a patient for signs of disease. It generally follows the taking of the medical history — an account of the symptoms as experienced by the patient. Together with the medical history, the physical examination aids in determining the correct diagnosis and devising the treatment plan. This data then becomes part of the medical record.

Uses of physical examinations

A physical examination may be provided under health insurance cover, required of new insurance customers, or stipulated as a condition of employment. In the United States, physicals are also marketed to patients as a one-stop health review, avoiding the inconvenience of attending multiple appointments with different healthcare providers.^[1][2] Comprehensive physical exams of this type are also known as executive physicals, and typically include laboratory tests, chest x-rays, pulmonary function testing, audiograms, full body CAT scanning, EKGs, heart stress tests, vascular age tests, urinalysis, and mammograms or prostate exams depending on gender.^{[3] [4]} The executive physical format was developed from the 1970s by the Mayo Clinic and is now offered by other health providers, including Johns Hopkins University, EliteHealth and Mount Sinai in New York City.

While elective physical exams have become more elaborate, in routine use physical exams have become less complete. This has led to editorials in medical journals about the importance of an adequate physical examination. ^[5][6]

Format and interpretation

Auscultation of a man in Vietnam

Although providers have varying approaches as to the sequence of body parts, a systematic examination generally starts at the head and finishes at the extremities. After the main organ systems have been investigated by inspection, palpation, percussion and auscultation, specific tests may follow (such as a neurological investigation, orthopedic examination) or specific tests when a particular disease is suspected (e.g. eliciting Trousseau's sign in hypocalcemia).

With the clues obtained during the history and physical examination the healthcare provider can now formulate a differential diagnosis, a list of potential causes of the symptoms. Specific diagnostic tests (or occasionally empirical therapy) generally confirm the cause, or shed light on other, previously overlooked, causes.

While the format of examination as listed below is largely as taught and expected of students, a specialist will focus on their particular field and the nature of the problem described by the patient. Hence a cardiologist will not in routine practice undertake neurological parts of the examination other than noting that the patient is able to use all four limbs on entering the consultation room and during the consultation become aware of their hearing, eyesight and speech. Likewise an Orthopaedic surgeon will examine the affected joint, but may only briefly check the heart sounds and chest to ensure that there is not likely to be any contraindication to surgery raised by the anaesthetist. Non-specialists generally examine the genitals only upon request of the patient.

A complete physical examination includes evaluation of general patient appearance and specific organ systems. It is recorded in the medical record in a standard layout which facilitates others later reading the notes. In practice the vital signs of temperature examination, pulse and blood pressure are usually measured first.

Evidence-based medicine

Most elements of the physical examination have not been subjected to clinical trials to test their usefulness in identifying signs of disease. A 2003 study of 100 patients in hospital found that 26% had signs identifiable on physical examination that led to important changes in clinical management. Of these 26, only 14 (54%) had conditions that could have been detected by laboratory testing or imaging.^[7]

Vital signs

The primary vital signs are:

• Temperature recording
• Blood pressure
• Pulse
• Respiratory rate
• Pain level assessment

Basic biometrics

Height

Height is the anthropometric longitudinal growth of an individual. A statiometer is the device used to measure height although often a height stick is more frequently used for vertical measurement of adults or children older than 2. The patient is asked to stand barefoot. Height declines during the day because of compression of the intervertebral discs. Children under age 2 are measured lying horizontally.

Weight

Weight is the anthropometric mass of an individual. A scale is used to measure weight.

Medical professionals generally prefer to use the SI unit of kilograms, and many medical facilities have ready-reckoner conversion charts available for professionals to use, when patients describe their weight in non-SI units. (In the US, pounds and ounces are common, while in the UK stones and pounds are frequently used; in most other countries the metric system predominates.)

Body mass index (BMI) or height-weight tables, may be used to compare the relationship between height and weight, and may suggest conditions such as obesity or being overweight or underweight.

Pain

Because of the importance of pain to the overall wellness of the patient, subjective measurement is considered by some to be a vital sign. However, some doctors have noted that pain is actually a subjective symptom, not an objective sign, and therefore object to this classification.^[8]

Clinically pain is measured using a FACES scale which is a series of faces from '0' (no pain at all showing a normal happy face) to '5' (the worst pain ever experienced by the patient). There is also an analog scale from '0' to maximum '10'. It is important to allow patients to make their own choices on a pain scale.

Structure of the written examination record

Organ systems

• Cardiovascular system
  • Blood pressure, pulse rate and rhythm.
  • Jugular venous pressure (JVP), peripheral oedema and evidence for ** **Precordial exam (cardiac exam)

• Respiratory system Lungs
  • 4 parts: observation, auscultation, palpation, percussion
    • Observation involves observing the respiratory rate which should be in a ratio of 1:2 inspiration:expiration. It is best to count the respiratory rate under pretext of some other exam, so that patient does not sub consciously increase his baseline respiratory rate. An acidotic patient will have more rapid breathing to compensate known as Kussmaul breathing. Another type of breathing is Cheyne-Stokes respiration, which is alternating breathing in high frequency and low frequency from brain stem injury. It can be seen in newborn babies which is sometimes physiological (normal). Also observe for retractions seen in asthmatics. Retractions can be supra-sternal, where the accessory muscles of respirations of the neck are contracting to aid inspiration. Retractions can also be intercostal, there is visible contraction of the inter costal muscles(between the ribs) to aid in respiration. This is a sign of repiratory distress. Observe for barrel-chest (increased AP diameter) seen in COPD. Observe for shifted trachea or one sided chest expansion, which can hint pneumothorax.
    • Lung auscultation is listening to the lungs bilaterally at the anterior chest and posterior chest. Wheezing is described as a musical sound on expiration or inspiration. It is the result of narrowed airways. Rhonchi are bubbly sounds similar to blowing bubbles through a straw into a sundae. They are heard on expiration and inspiration. It is the result of viscous fluid in the airways. Crackles or rales are similar to rhonchi except they are only heard during inspiration. It is the result of alveoli popping open from increased air pressure.
    • For palpation, place both palms or medial aspects of hands on the posterior lung field. Ask the patient to count 1-10. The point of this part is to feel for vibrations and compare between the right/left lung field. If the pt has a consolidation (maybe caused by pneumonia), the vibration will be louder at that part of the lung. This is because sound travels faster through denser material than air.
    • On percussion, you are testing mainly for pleural effusion or pneumothorax. The sound will be more tympanic if there is a pneumothorax because air will stretch the pleural membranes like a drum. If there is fluid between the pleural membranes, the percussion will be dampened and sound muffled.
  • If there is pneumonia, palpation may reveal increased vibration and dullness on percussion. If there is pleural effusion, palpation should reveal decreased vibration and there will be 'stony dullness' on percussion.

See also

• Evidence-based medicine
• General medical examination
• Heart sounds
• Human weight
• Medical record
• Medical test
• Mental status examination

References

External links

• Connecticut Tutorials Physical Examination Video
• UCSD school of medicine - guide to writing HPI and performing complete physical exam. Excellent for medical students
• Physical examination of respiratory system video
• The Journal of Clinical Examination - A useful online source for evidence-based guidance on physical examination