physical exam

Physical examination

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.

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.

Whilst 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.

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.

The main reason for checking body temperature is to solicit any signs of systemic infection or inflammation in the presence of a fever (temp > 38.5°C or sustained temp > 38°C). Other causes of elevated temperature include hyperthermia. Temperature depression (hypothermia) also needs to be evaluated. It is also noteworthy to review the trend of the patient's temperature. A patient with a fever of 38°C does not necessarily indicate an ominous sign if his previous temperature has been higher.

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 heartbeat using a stethoscope. The pulse varies with age. A newborn or infant can have a heart rate of about 130-150 beats per minute. A toddler's heart will beat about 100-120 times per minute, an older child's heartbeat is around 90-110 beats per minute, adolescents around 80-100 beats per minute, and adults pulse rate is anywhere between 50 and 80 beats per minute.

Respiratory rate

Varies with age, but the normal reference range is 16-20 breaths/minute.

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.

Body mass index, or BMI, is used to calculate the relationship between healthy height and weight and obesity or being overweight or underweight.

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.)

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.

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)

Organ systems

  • Cardiovascular system
  • 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 airays. 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
  • Genitalia
  • Musculoskeletal system
  • Nervous system, including mental status
  • Head and neck (HEENT)
  • Skin

See also

References

External links

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