Physical Examination

Nicholas K. Birech

March, 2006

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.  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.  

Methods of clinical examination

1. Inspection

Inspection  is the thorough and unhurried visualization of the client. This requires the use of the naked eye. During inspection, the examiner observes:

    External signs:

·         Body features and symmetry appearance

·         Nutritional state or weight

·         Skin color

·         Frequency and volume of breaths during respiration

·         Movement of the abdomen and each side of the chest during respiration

·         Hair distribution

·         Gait (particular way or manner of moving on foot) and manner of speaking

    Gross Deviation:

·         Abnormal contour

·         Scars and striae(striae are most commonly seen as stretch marks on the skin with a silvery white hue.)

·         Visible masses

·         Discoloration

·         Swelling

·         Tremor (Tremor is the rhythmic, oscillating shaking movement of the whole body or just a certain part of it, caused by problems of the neurons responsible from muscle action.)

    In medical practice, inspection is however not limited to visual information alone. Inspection also involves:

·         Listening to any sounds emanating from the patient

·         Odors that may be present

2. Auscultation

Auscultation is the technical term for listening to the internal sounds of the body, usually using a stethoscope. Auscultation is normally performed for the purposes of examining the cardiovascular system and respiratory systems (heart and lung sounds), as well as the gastrointestinal system (bowel sounds).

3. Percussion

Percussion is a method used by a doctor to find out about the changes in the thorax or abdomen. It is done by tapping on a surface to determine the underlying structure.  It is done with the middle finger of right hand tapping on the middle finger of the left hand, which is positioned with the whole palm on the body. The presence of a solid mass underneath the surface will produce a dull sound. Hollow, air-containing structures will lead to a more sonore sound.

4. Palpation

Palpation is s a method of examination in which the examiner feels the size or shape or firmness or location of something (of body parts when the examiner is a health professional). Palpation is used by  doctors for particularly for thoracic and abdominal examinations, but also for examination of edema( swelling of any organ or tissue due to accumulation of excess fluid) and palpation of pulses.  

Physical Examination Evaluation

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, then the basic biometrics of height, weight and pain are done.

·         Temperature Recording

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 : also known as heat stroke or sunstroke, is an acute condition which occurs when the body produces or absorbs more heat than it can dissipate) or depression (hypothermia : a medical condition in which the victim's core body temperature has dropped to significantly below normal and normal metabolism begins to be impaired) are incompatible with life.

·         Blood Pressure Recording

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.

 

·         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.

 

·         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. 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'.

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(is yellowing of the skin, sclera (the white of the eyes) and mucous membranes caused by increased levels of bilirubin in the human body), suggestion of Anaemia (pale colour of skin or conjunctiva), Cyanosis (blue coloration of lips or extremities), Clubbing of nails (deformity of the fingers 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 mnemonic for head, eyes, ears, nose and throat.)
• 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).

   

References and Links  

http://www.meddean.luc.edu/lumen/meded/MEDICINE/PULMONAR/PD/contents.htm 

http://medicine.ucsd.edu/clinicalmed/introduction.htm

http://www.nlm.nih.gov/medlineplus/ency/article/002274.htm

http://en.wikipedia.org/wiki/Medical_examination

http://medicine.osu.edu/exam/

http://www.ohsaa.org/medicine/physicalform.pdf

http://omeweb2.ucdavis.edu/doctoring/doctoring/