Physical examination

Template:TOC-right In health care, the physical examination is a "systematic and thorough inspection of the patient for physical signs of disease or abnormality."

Components of the physical examination

For links to more information, see: Physical examination: Subtopics

It is usually wise to take the patient's history before performing the physical examination. Knowing the patient's chief complaint, and significant previous history, will guide the examination. If the examiner knows that one of the patient's eyes is prosthetic, it is not necessary to use the opthalmoscope to inspect the (nonexistent) internal eye structures. If a patient is complaining of knee pain, more attention should be given to that area and related topics such as observing the patient walk than, for example, examining the scalp.

There are several ways to perform a basic review; the important aspect is that there should be complete coverage. A common approach is "regional", in which the patient is placed in a series of positions and examining techniques best done in that position are done. Another approach can be slower but sometimes preferable, especially when the examination is focused on a specific system, is to move from position to position looking at aspects of one system at a time.

Regional method

The regional method can begin when the patient walks into the room, or is asked to walk across it.

Standing and walking

An examination often begins with taking the height and weight if this has not been done; this also gives the examiner to observe the patient's walking gait, apparent balance, and other movement-related signs.

Seated

A wide number of observations will be taken in a seated position. Depending on the layout of the examining room, the preference of the examiner, and the comfort of the patient, it may be useful to do some of these while the patient is in a chair, perhaps after the history has been taken from the comfortably seated patient. Some procedures, however, are best done when the patient is seated on the edge of the examining table, so it is simple to move between the patient's front and back. In the chair, a starting point is taking basic vital signs, , inspection of the face including fundoscopic viewing of the eyes and otoscopic viewing of the ears, etc.

Auscultation of the chest is usually easier with the patient sitting on the table, since the examiner will listed from the front and back. Examples of other tests conveniently done in this position include the patellar reflex, examination of the feet and ankles (e.g., skin state, edema, skin sensitivity such as testing for stocking and glove paresthesia).

Supine

When the patient is supine, this is the usual time to palpate the abdomen, testing the effect of leg raising in terms of range of motion and specific reactions such as Kernig's and Brudzinski's signs, etc.

System-oriented

This section deals with the level appropriate for a general examination. A focused neurological or pulmonary examination, for example, will involve many more specialized examining techniques, and perhaps instrumental tests done in the examining room.

Research on the accuracy of the physical examination

Guidelines have been proposed for conducting research on the physical examination.

History of the physical examination

Walker has compiled the following dates in the development of the techniques for the physical examination.

1. Hippocrates: A Rational Profession 460–370 b.c
2. Vesalius: Establishment of an Accurate Anatomy, 1543
3. Sydenham: The Nosology of Disease, 1666
4. Morgagni: The Foundation of Pathologic Anatomy, 1761
5. Auenbrugger: The Discovery of Percussion, 1761
6. Laennec: The Stethoscope and elaboration of the methods of auscultation 1816
7. Helmholtz: The ophthalmoscope, 1850
8. Carl Wunderlich: The thermometer, 1871
9. Erb and Westphal: The reflex Hammer, 1875
10. Riva Rocci: The Sphygmomanometer for measuring blood pressure, 1896

Evolution in mainstream medicine

While some of these innovators created fundamentally new ideas, the actual form of the technique may have changed substantially over the years. Some are matter of improving a device, for convenience of use, safety, or more efficient manufacturing. Early practical sphygnomanometers were built around a glass tube of mercury, but that is fragile, expensive, and both broken glass or spilled mercury are health hazards. Opthalmoscopes originally reflected a light, but even basic opthalmoscopes today use internal lamps, with specialized opthalmoscopes (e.g., the slit lamp) having more advanced optics.

In other cases, laboratory testing or medical examination have, at least, complemented the original methods. The stethoscope remains a basic symbol of the examination, but the finding of preliminary abnormalities is sensitive but not selective. Particular sounds, such as rales and rhonchi from the chest, or a heart murmur, call for such studies as X-ray or ultrasonography.

There is, indeed, mainstream opinion that some patients would better be served by more thought about the results of the medical history and physical examination, rather than overdependence on technology. A widespread aphorism among medical educators is "treat the patient, not the chart." Imaging may produce false positives and false negatives, so that the patient is subjected to an unneeded treatment risk or fails to receive treatment for a real disorder not detected by the particular imaging technique; especially among specialists in trauma, the concern over overdependendce created the informal term VOMIT: Victim of Modern Imaging Technology.

Examining techniques in complementary medicine

Some methods, such as acupuncture, often combine traditional and contemporary methods.

External links

• The Rational Clinical Examination Series