Physical examination

In medicine, the physical examination or clinical examination is the process by which the physician 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.

Although doctors 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 doctor 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.

Whilst the format of examination as listed below is largely as taught and expected of medical 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 there 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 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.

Vital Signs

Temperature

Temperature recording gives an indication of core body temperature which is normally tightly controlled (thermoregulation) as it affects the rate of chemical reactions. It does though vary with time of day and body conditions but prolonged significant temperature elevation (hyperthermia) or depression (hypothermia) are incompatible with life.

Blood pressure

The blood pressure is recorded as two readings, a high systolic pressure which is the maximal contraction of the heart and the lower diastolic or resting pressure. Usually the blood pressure is taken in the right arm unless there is some damage to the arm. The difference between the systolic and diastolic pressure is called the pulse pressure. The measurement of these pressures is now usually done with an aneroid or electronic sphygmomanometer. The classic measurement device is a mercury sphygmomanometer, using a column of mercury measured off in millimeters. In the United States and UK, the common form is millimeters of mercury, whilst elsewhere SI units of pressure are used. There is no natural 'normal' value for blood pressure, but rather a range of values that on increasing are associated with increased risks. The guideline acceptable reading also takes into account other co-factors for disease. Elevated blood pressure hypertension therefore is variously defined when the systolic number is persistently over 140-160 mmHg. Low blood pressure is hypotension. Blood pressures are also taken at other portions of the extremities. These pressures are called segmental blood pressures and are used to evaluate blockage or arterial occlusion in a limb (see Ankle brachial pressure index).

Pulse

The pulse is the physical expansion of the artery. Its rate is usually measured either at the wrist or the ankle and is recorded as beats per minute. The pulse commonly is taken is the radial artery at the wrist. Sometimes the pulse cannot be taken at the wrist and is taken at the elbow (brachial artery), at the neck against the carotid artery (carotid pulse), behind the knee (popliteal artery), or in the foot dorsalis pedis or posterior tibial arteries. The pulse rate can also be measured by listening directly to the heart beat using a stethescope.

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. The English system uses pounds and ounces; the SI system uses kilograms. Body mass index or BMI is used to calculate the relationship between healthy height and weight and obesity or being overweight or underweight.

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. Physicians and health care workers frequently understate patient pain.

Structure of the written examination record

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)
• JACCOL, 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.

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
  • Respiratory rate, chest expansion, lung auscultation
• Breasts
• Abdomen
  • Abdominal examination notes in particular any tenderness, bloating, organ enlargement, or aortic aneurysm.
  • No abdominal examination is complete without a Anus and rectum
• Genitalia
• Musculoskeletal system
• Nervous system, including mental status
• Head and neck (HEENT a menonic for head, eyes, ears, nose and throat.)
• Skin
  • Check of the hair to see if the hair growth is receding 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.

Special examinations

• Eye examination as performed by optometrists or ophthalmologists

See also:

• Eye examination
• Heart sounds
• Medical record
• Medical test