Physical examination

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Physical examination or clinical examination is the process by which a health care provider 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.

Contents 1 Format and interpretation 2 Vital signs 3 Basic biometrics 3.1 Height 3.2 Weight 3.3 Pain 4 Structure of the written examination record 4.1 General appearance 4.2 Organ systems 5 See also 6 References 7 External links

[edit] Format and interpretation

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.

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 patients in hospital found that a quarter of them had signs identifiable on physical examination that were relevant to their diagnosis and treatment.^[1] Usually, patients are asked to remove their clothes and put on a gown.

[edit] Vital signs

The primary vital signs are:

• Temperature recording
• Blood pressure
• Pulse
• Respiratory rate

[edit] Basic biometrics

[edit] 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.

[edit] 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.

[edit] Pain

Because of the importance of pain to the overall wellness of the patient, subjective measurement is considered to be a vital sign. 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.

[edit] Structure of the written examination record

[edit] General appearance

Obvious apparent features as the patient enters the consulting room and in the course of taking the history (e.g. mobility problem or deafness)

• JACCOLD, a mnemonic for jaundice, suggestion of anaemia (pale colour of skin or conjunctiva), cyanosis (blue coloration of lips or extremities), clubbing of fingernails, oedema of ankles, lymph nodes of neck, armpits, groins and dehydration.

[edit] Organ systems

• Cardiovascular system
  • Blood pressure, pulse rate and rhythm.
  • Jugular venous pressure (JVP), peripheral oedema and evidence for pulmonary oedema.
  • Precordial exam (cardiac exam)
• Lungs
  • 4 parts: examination, auscultation, palpation, percussion
    • Examination involves observing the respiratory rate which should be in a ratio of 1:2 inspiration:expiration. 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. Also observe for retractions seen in asthmatics. 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.
  • There is always difficulty differentiating between pneumonia and pleural effusion based on just auscultation since both will have crackles or rhonchi. That is why such exams like palpation will help differentiate between the two. If there is pneumonia, palpation should reveal increased vibration and percussion should be increased (dullness sound). If there is pleural effusion, palpation should reveal decreased vibration and percussion will be increased.
• Breasts
• Abdomen
  • Abdominal examination notes in particular any tenderness, bloating, organ enlargement, or aortic aneurysm.
• Genitalia
• Musculoskeletal system
• Nervous system, including mental status
• Head and neck (HEENT)
• Skin
  • Check of the hair to see if the hair growth is receding (baldness) or there is loss of hair (alopecia).
  • Check of the skin will tell if there are marks such as hemangioma or strawberry marks or changes to the skin. Dark spots on the skin, nevi are also places where cancerous changes can appear because the face, head and neck are most usually sun exposed. Specific skin conditions (e.g. pyoderma gangrenosum, erythema nodosum, acanthosis nigricans) may be associated with specific diseases (ulcerative colitis, sarcoidosis and polycystic ovary syndrome, respectively).

Wikiversity has learning materials about Physical examination

[edit] See also

• Heart sounds
• Human weight
• Medical record
• Medical test
• Mental status examination

[edit] References

[edit] 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

v • d • e Medicine: physical examination Nervous system/head Neurology · Mental state · Eyes (Swinging-flashlight test) · Hearing (Weber, Rinne) · Jugular venous pressure Chest Respiratory system (Respiratory sounds) · Precordium (Heart sounds, Apex beat) Abdomen/pelvis Abdomen (Liver span) · Intimate (Pelvic, Rectal) · Hip Limbs Knee · GALS screen · Peripheral vascular (Ankle brachial pressure index) General Inspection · Auscultation · Palpation · Percussion

v • d • e Medical records Admission note H and P (history and physical): Chief complaint · History of the present illness (SAMPLE history, OPQRST) · Family history · Social history · Review of systems · Physical examination (Vital signs) other: Labs · Assessment and plan (Medical diagnosis, Differential diagnosis) Progress note SOAP note Medical privacy