• Clinical science

Physical examination

Summary

The physical examination is typically the first diagnostic measure performed after taking the patient's history. It allows for an initial assessment of symptoms and is crucial for determining the differential diagnoses and further steps. Ideally, a complete physical examination should be performed for every patient. In practice, the physical examination is usually tailored to specific patient concerns. Sensitivity and specificity of physical examination findings vary widely. In some cases, a diagnosis is possible on the basis of the physical examination alone. This article covers the basics of the physical examination and links out to other articles for more specific examinations, including:

Approach

Objectives

  • Determine a working diagnosis or differentials, and further diagnostic and management steps.
  • Adjust approach from full to focused physical examination as needed based on medical history, patient condition, and findings.

Preparing for the examination [1][2][3]

  • Provide optimal conditions for the examination:
    • Find a comfortable and quiet place.
    • Ensure privacy: Ask other patients and possibly even family members (depending on patient preference and extent of exam) to leave the room.
  • Disinfect hands prior to touching the patient.
  • Introduce yourself and your title and explain the procedure.
  • Always address patient by his/her name (ask first if it is unknown).
  • During the examination, inform the patient about further steps.
  • Examination tools include:
    • Pens
    • Stethoscope
    • Penlight
    • Tongue depressor
    • Reflex hammer
    • If necessary, otoscope and ophthalmoscope

Basic techniques

  • Inspection
  • Palpation
  • Percussion
  • Auscultation
  • Functional examination

Sequence

Approaches to the physical examination vary greatly and depend on a number of factors, including personal, specialty, and institutional preferences, as well as the reason for the visit or patient's chief concerns, condition, medical history, frequency of past visits, and time available. An example of a full exam sequence could consist of:

The physical examination should be tailored to the purpose of visit, patient history, and allotted time in a focused assessment by body systems.

Systems

The following sections provide an overview of all the parts of a physical examination that should be considered, including:

In some cases, more details can be found in the links provided.

General appearance

  • Assess physical, behavioral, and emotional state, including:
    • Physical characteristics: body type, distinguishing characteristics or abnormal formations/symmetry, development, race
    • Behavior: alert, active, lethargic, calm, agitated, combative, compliant
    • Wellness: well, unwell
    • Color: rosy, pale, flushed, jaundice
    • Grooming
    • Posture and movement

Vital signs and measurements

Skin and nails

Head, eyes, ears, nose, throat (HEENT)

Lymphatics

  • Examine different locations (cervical, axillary, and groin areas)
  • Inspection: look for visible enlargement
  • Palpation of lymph nodes for:
    • Swelling
    • Tenderness
    • Mobility
    • Irregularity
  • See lymph node examination.

Heart

Lungs and chest wall

  • Inspection: breathing pattern, shape of thorax, sputum
  • Palpation: tenderness, symmetry, tactile fremitus (“ninety-nine”)
  • Percussion: hyperresonant or dull
  • Auscultate (would be enough if the case is not pulmonary)
  • Egophony (auscultate with ee-aa)
  • See pulmonary examination for a thorough examination.

Abdomen

Pelvic

  • Female
    • External genital exam: check for any abnormalities of the vulva, labia (e.g., swelling, irritation, ulcers)
    • Internal genital exam: includes the sterile speculum exam, cervicovaginal swab
    • Bimanual pelvic exam: by introducing two fingers of one hand in the patient's vagina while pressing on the abdomen with the other hand the physician to examine patient's uterus and adnexa (e.g., their localization, size, tenderness during manipulation, presence of masses)
    • Rectovaginal pelvic exam: allows for the palpation of the rectovaginal septum palpation in patients with suspected pelvic masses (e.g., colorectal cancer)
    • For other common instrumental diagnostic procedures used for the examination of an OB/GYN patient, see diagnostic procedures in gynecology.
  • Male

As a student, you should only perform breast, pelvic, and prostate exams under the supervision of a senior physician!

Neurological

Musculoskeletal

Breast

last updated 06/24/2020
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