A physical examination is an evaluation of the body and its functions using inspection, palpation (feeling with the hands), percussion (tapping with the fingers), and auscultation (listening). A complete health assessment also includes gathering information about a person's medical history and lifestyle, doing laboratory tests, and screening for disease.
Description
A complete physical examination usually starts at the head and proceeds all the way to the toes. However, the exact procedure will vary according to the needs of the patient and the preferences of the examiner. An average examination takes about 30 minutes. The cost of the examination will depend on the charge for the professional's time and any tests that are done. Most health plans cover routine physical examinations including some tests.
The examination
First, the examiner will observe the patient's appearance, general health, and behavior, along with measuring height and weight. The vital signs—including pulse, breathing rate, body temperature, and blood pressure— are recorded.
With the patient sitting up, the following systems are reviewed:
Skin. The exposed areas of the skin are observed; the size and shape of any lesions are noted.
Head. The hair, scalp, skull, and face are examined.
Eyes. The external structures are observed. The internal structures can be observed using an ophthalmoscope (a lighted instrument) in a darkened room.
Ears. The external structures are inspected. A lighted instrument called an otoscope may be used to inspect internal structures.
Nose and sinuses. The external nose is examined. The nasal mucosa and internal structures can be observed with the use of a penlight and a nasal speculum.
Mouth and pharynx. The lips, gums, teeth, roof of the mouth, tongue, and pharynx are inspected.
Neck. The lymph nodes on both sides of the neck and the thyroid gland are palpated (examined by feeling with the fingers).
Back. The spine and muscles of the back are palpated and checked for tenderness. The upper back, where the lungs are located, is palpated on the right and left sides and a stethoscope is used to listen for breath sounds.
Breasts and armpits. A woman's breasts are inspected with the arms relaxed and then raised. In both men and women, the lymph nodes in the armpits are felt with the examiner's hands.While the patient is still sitting, movement of the joints in the hands, arms, shoulders, neck, and jaw can be checked.
Then while the patient is lying down on the examining table, the examination includes:
Breasts. The breasts are palpated and inspected for lumps.
Front of chest and lungs. The area is inspected with the fingers, using palpation and percussion. A stethoscope is used to listen to the internal breath sounds.
The head should be slightly raised for:
Heart. A stethoscope is used to listen to the heart's rate and rhythm. The blood vessels in the neck are observed and palpated.
The patient should lie flat for:
Abdomen. Light and deep palpation is used on the abdomen to feel the outlines of internal organs including the liver, spleen, kidneys, and aorta, a large blood vessel.
Rectum and anus. With the patient lying on the left side, the outside areas are observed. An internal digital examination (using a finger), is usually done if the patient is over 40 years old. In men, the prostate gland is also palpated.
Reproductive organs. The external sex organs are inspected and the area is examined for hernias. In men, the scrotum is palpated. In women, a pelvic examination is done using a speculum and a Papamnicolaou test (Pap test) may be taken.
Legs. With the patient lying flat, the legs are inspected for swelling, and pulses in the knee, thigh, and foot area are found. The groin area is palpated for the presence of lymph nodes. The joints and muscles are observed.
Musculoskeletel system. With the patient standing, the straightness of the spine and the alignment of the legs and feet is noted.
Blood vessels. The presence of any abnormally enlarged veins (varicose), usually in the legs, is noted.
In addition to evaluating the patient's alertness and mental ability during the initial conversation, additional inspection of the nervous system may be indicated:
Neurologic screen. The patient's ability to take a few steps, hop, and do deep knee bends is observed. The strength of the hand grip is felt. With the patient sitting down, the reflexes in the knees and feet can be tested with a small hammer. The sense of touch in the hands and feet can be evaluated by testing reaction to pain and vibration.
Sometimes additional time is spent examining the 12 nerves in the head (cranial) that are connected directly to the brain. They control the sense of smell, strength of muscles in the head, reflexes in the eye, facial movements, gag reflex, and muscles in the jaw. General muscle tone and coordination, and the reaction of the abdominal area to stimulants like pain, temperature, and touch would also be evaluated.
Who Performs the Procedure and Where Is It Performed?
A physical examination is best performed by a trained physician. Other health care professionals such as physician assistants and nurse practitioners have similar but limited training. Examinations are usually performed in professional medical offices or hospitals. Occasionally, they may be performed in private homes or in the field.
Questions to Ask the Doctor
What are my results, both normal and abnormal?
What has changed since the last physical examination?
What do you recommend as a result of the findings of this physical examination?
When do you want to repeat the physical examination?
Definition
A physical examination is the evaluation of a body to determine its state of health. The techniques of inspection include palpation (feeling with the hands and/or fingers), percussion (tapping with the fingers), auscultation (listening), and smell. A complete health assessment also includes gathering information about a person's medical history and lifestyle, conducting laboratory tests, and screening for disease. These elements constitute the data on which a diagnosis is made and a plan of treatment is developed.
Purpose
The term annual physical examination has been replaced in most health care circles by periodic health examination. The frequency with which it is conducted depends on factors such as the age, gender, and the presence of risk factors for disease in the person being examined. Health-care professionals often use guidelines that have been developed by organizations such as the United States Preventative Services Task Force. Organizations such as the American Cancer Society or American Heart Association, which promote detection and prevention of specific diseases, generally recommend more intensive or frequent examinations, or suggest that examinations be focused on particular organ systems of the body.
Comprehensive physical examinations provide opportunities for health care professionals to obtain baseline information about individuals that may be useful in the future. They also allow health care providers to establish relationships before problems occur. Physical examinations are appropriate times to answer questions and teach good health practices. Detecting and addressing problems in their early stages can have beneficial long-term results.
Every person should have periodic physical examinations. These occur frequently (monthly at first) in infants and gradually reach a frequency of once per year for adolescents and adults.
Description
A complete physical examination usually starts at the head and proceeds all the way to the toes. However, the exact procedure will vary according to the needs of the person being examined and the preferences of the examiner. An average examination takes about 30 minutes. The cost of an examination will depend on the charge for professional time and any tests that are included. Most health plans cover routine physical examinations, including some tests.
The Examination
Before examiners question the patient, they will observe a person's overall appearance, general health, and behavior. Measurements of height and weight are made. Vital signs such as pulse, breathing rate, body temperature, and blood pressure are recorded.
With the person being examined in a sitting position, the following systems are reviewed:
Skin. The exposed areas of the skin are observed; the size and shape of any lesions are noted.
Head. The hair, scalp, skull, and face are examined.
Eyes. The external structures are observed. The internal structures can be observed using an ophthalmoscope (a lighted instrument) in a darkened room.
Ears. The external structures are inspected. A lighted instrument called an otoscope may be used to inspect internal structures.
Nose and sinuses. The external nose is examined. The nasal mucosa and internal structures can be observed with the use of a penlight and a nasal speculum.
Mouth and pharynx. The lips, gums, teeth, roof of the mouth, tongue, and pharynx are inspected.
Back. The spine and muscles of the back are palpated and checked for tenderness. The upper back, where the lungs are located, is palpated on the right and left sides and a stethoscope is used to listen for breath sounds.
Breasts and armpits. A woman's breasts are inspected with the arms relaxed and then raised. In both men and women, the lymph nodes in the armpits are felt with the examiner's hands. While the person is still sitting, movement of the joints in the hands, arms, shoulders, neck, and jaw can be checked.
While the person is lying down on the examining table, the examination includes:
Breasts. The breasts are palpated and inspected for masses.
Front of chest and lungs. The area is inspected with the fingers, using palpation and percussion. A stethoscope is used to listen to internal breath sounds.
The head should be slightly raised to examine:
Heart. A stethoscope is used to listen to the heart's rate and rhythm. The blood vessels in the neck are observed and palpated.
The person being examined should lie flat for an examination of the:
Abdomen. Light and deep palpation is used on the abdomen to feel the outlines of internal organs, including the liver, spleen, kidneys, and aorta, a large blood vessel.
Rectum and anus. With the person lying on the left side, the outside areas are observed. An internal digital examination (using a gloved finger), is usually done for persons over 40 years old. In men, the prostate gland is also palpated.
Reproductive organs. The external sex organs are inspected and the area is examined for hernias. In men, the scrotum and testicles are palpated. In women, a pelvic examination is completed using a speculum and a sample for a Papanicolaou test (Pap test) may be taken.
Legs. While lying flat, the legs are inspected for swelling, and pulses in the knee, thigh, and foot area are found. The groin area is palpated for the presence of lymph nodes. The joints and muscles are observed.
Musculoskeletal system. With the person standing, the straightness of the spine and the alignment of the legs and feet is noted.
Blood vessels. The presence of any abnormally enlarged veins (varicose), usually in the legs, is noted.
In addition to evaluating a person's alertness and mental ability during the initial conversation, inspection of the nervous system may include:
Neurologic screen. The person's ability to take a few steps, hop, and do deep knee bends is observed. The strength of the handgrip is felt. While sitting in an upright position, the reflexes in the knees and feet can be tested with a small hammer. The sense of touch in the hands and feet can be evaluated by testing reaction to pain and vibration.
The 12 nerves in the head (cranial) that are connected directly to the brain. They control the senses of smell and taste, strength of muscles in the head, reflexes in the eye, facial movements, gag reflex, vision, hearing, and muscles in the jaw. General muscle tone and coordination, and the reaction of the abdominal area to stimulants like pain, temperature, and touch may also be evaluated.
Diagnosis/Preparation
The individual being examined should be comfortable and treated with respect throughout the examination. As the examination continues, examiners should explain what they are doing and share any relevant findings. Using language appropriate to the person being examined improves the effectiveness of communications and ultimately fosters better relations between examiners and examinees.
Before visiting a health care professional, individuals should write down important facts and dates about their own medical history, as well as those of family members. There should be a complete listing of all medications and their dosages. This list should include over-the-counter preparations, vitamins, and herbal supplements. Some people bring their bottles of medications with them. Any questions or concerns about medications should be written down.
Before the physical examination begins, the bladder should be emptied. A urine specimen is usually collected in a small container at this time. The urine is tested for the presence of glucose (sugar), protein, and blood cells. For some blood tests, individuals may be told ahead of time not to eat or drink for 12 hours prior to the test.
Individuals being examined usually remove all clothing and put on a loose-fitting hospital gown. An additional sheet is provided to keep persons covered and comfortable during the examination.
Aftercare
Once a physical examination has been completed, the person being examined and the examiner should review what laboratory tests have been ordered, why they have been selected, and how and with whom the results will be shared. A health professional should discuss any recommendations for treatment and follow-up visits. Special instructions should be put in writing. This is also an opportunity for persons to ask any remaining questions about their own health concerns.
Risks
There are virtually no risks associated with a physical examination. Complications with the process of a physical examination are unusual. Occasionally, a useful piece of information or data may be overlooked. More commonly, results of associated laboratory tests compel physicians to recheck an individual or reexamine portions of the body already reviewed. In a sense, complications may arise from the findings of a physical examination. These usually trigger further investigations or initiate treatment. They are really more beneficial than negative, as they often begin a process of treatment and recovery.
Normal Results
Normal results of a physical examination correspond to the healthy appearance and normal functioning of the body. For example, appropriate reflexes will be present, no suspicious lumps or lesions will be found, and vital signs will be normal.
Abnormal results of a physical examination include any findings that indicate the presence of a disorder, disease, or underlying condition. For example, the presence of lumps or lesions, fever, muscle weakness or lack of tone, poor reflex response, heart arrhythmia, or swelling of lymph nodes will indicate possible health problems.
Resources
Books
Bickley, L. S., P. G. Szilagyi, and J. G. Stackhouse. Bates'Guide to Physical Examination & History Taking, 8th edition. Philadelphia: Lippincott Williams & Wilkins, 2002.
Chan, P. D., and P. J. Winkle. History and Physical Examination in Medicine, 10th edition. New York: Current Clinical Strategies, 2002.
Seidel, Henry M. Mosby's Physical Examination Handbook, 4th edition. St. Louis, MO: Mosby-Year Book, 2003.
Swartz, Mark A., and William Schmitt. Textbook of PhysicalDiagnosis: History and Examination, 4th edition. Philadelphia: Saunders, 2001.
Periodicals
Ahmed, A. M. "Deficiencies of Physical Examination Among Medical Students." Saudi Medical Journal, 24, no.1 (2003): 108–111.
Organizations
American Academy of Family Physicians. 11400 Tomahawk Creek Parkway, Leawood, KS 66211-2672. (913) 906-6000. E-mail: fp@aafp.org. http://www.aafp.org.
American Academy of Pediatrics. 141 Northwest Point Boulevard, Elk Grove Village, IL 60007-1098. (847) 434-4000; Fax: (847) 434-8000. E-mail: kidsdoc@aap.org. http://www.aap.org/default.htm.
American College of Physicians. 190 N Independence Mall West, Philadelphia, PA 19106-1572. (800) 523-1546, x2600, or (215) 351-2600. http://www.acponline.org.
American Medical Association. 515 N. State Street, Chicago, IL 60610. (312) 464-5000. http://www.ama-assn.org.
1. Direct physical inspection of an object. It is necessary, for example, to do a physical examination of bridge structures at periodic intervals to ensure that they are structurally sound and not presenting a public hazard.
2. Medical examination performed on people, called a physical.
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.
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 and EliteHealth.
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]
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]
Height is the anthropometriclongitudinal 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 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.
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.
^McAlister FA, Straus SE, Sackett DL (February 2000). "High marks for the physical exam". CMAJ : Canadian Medical Association Journal = Journal De l'Association Medicale Canadienne162 (4): 493. PMID10701381.
^Reilly BM (October 2003). "Physical examination in the care of medical inpatients: an observational study". Lancet362 (9390): 1100–5. doi:10.1016/S0140-6736(03)14464-9. PMID14550696.
