| Physical examination | |
|---|---|
| Intervention | |
Examination room in Washington, DC, period of WWI. |
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| ICD-9-CM | 89.7 |
| MeSH | D010808 |
A physical examination, medical examination, or clinical examination (more popularly known as a check-up or medical) 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.
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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] In addition to the possibility of identifying signs of illness, it has been described as a ritual that plays a significant role in the doctor-patient relationship.[7] Physicians at Stanford University medical school have introduced a set of 25 key physical examination skills that were felt to be useful.[8]
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. A primary care physician will also generally examine the male genitals but may leave the examination of the female genitalia to a gynecologist.
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.
| Section | Sample text | Comments |
|---|---|---|
| General | "Patient in NAD. VS: WNL" | May be split on two lines. "WNL" = "within normal limits". |
| HEENT: | "NC/AT. PERRLA, EOMI. No cervical LAD, no thyromegaly, no bruit, no pallor, fundus WNL, oropharynx WNL, tympanic membrane WNL, neck supple" | "Neck" is sometimes split out from "Head". "Good dentition" may be noted. |
| Resp or "Chest" | "Nontender, CTA bilat" | More detailed examinations can include rales, rhonchi, wheezing ("no r/r/w"), and rubs. Other phrases may include "no cyanosis or clubbing" (if section is labeled "Resp" and not "Chest"), "fremitus WNL", and "no dullnes to percussion". |
| CV or "Heart" | "+S1, +S2, RRR, no m/r/g" | If "CV" is used instead of "heart", peripheral pulses are sometimes included in this section (otherwise, they may be in the extremities section) |
| Abd | "Soft, nontender, nondistended, no hepatosplenomegaly, NBS" | If lower back pain is involved, then the "Back" may become a primary section. Costovertebral angle tenderness may be included in the abdominal section if there is no back section. More detailed examinations may report "+psoas sign, +Rovsing's sign, +obturator sign". If tenderness was present, it might be reported as "Direct and rebound RLQ tenderness". "NBS" stands for "normal bowel sounds"; alternatives might include "hypoactive BS" or "hyperactive BS". |
| Ext | "No clubbing, cyanosis, edema" | Checking the fingers for clubbing and cyanosis is sometimes considered part of the pulmonary exam, because it closely involves oxygenation. Examinations of the knee may involve the McMurray test, Lachman test, and drawer test. |
| Neuro | "A&Ox3, CN II-XII grossly intact, Sensation intact in all four extremities (dull and sharp), DTR 2+ bilat, Romberg negative, cerebellar reflexes WNL, normal gait" | Sensation may be expanded to include dull, sharp, vibration, temperature, and position sense. A mental status exam may be reported at the beginning of the neurologic exam, or under a distinct "Psych" section. |
Depending upon the chief complaint, additional sections may be included. For example, hearing may be evaluated with a specific Weber test and Rinne test, or it may be more briefly addressed in a cranial nerve exam.
The primary vital signs are:
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