Physical examination
Encyclopedia
Physical examination or clinical examination (more popularly known as a check-up) 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 symptom
s 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
.
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. 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. 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
, EliteHealth and Mount Sinai in New York City.
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.
In addition to the possibility of identifying signs of illness, it has been described as a ritual that plays a significant role in the doctor-patient relationship. Physicians at Stanford University medical school have introduced a set of 25 key physical examination skills that were felt to be useful.
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. A primary care physician will also generally examine the male genitals
but may leave the examination of the female genitalia to a gynecologist.
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.
Depending upon the chief complaint
, additional sections may be included. For example, hearing may be evaluated with a specific Weber test
and Rinne test
, or it may be more briefly addressed in a cranial nerve exam.
Patient
A patient is any recipient of healthcare services. The patient is most often ill or injured and in need of treatment by a physician, advanced practice registered nurse, veterinarian, or other health care provider....
for signs of disease
Disease
A disease is an abnormal condition affecting the body of an organism. It is often construed to be a medical condition associated with specific symptoms and signs. It may be caused by external factors, such as infectious disease, or it may be caused by internal dysfunctions, such as autoimmune...
. It generally follows the taking of the medical history
Medical history
The medical history or anamnesis of a patient is information gained by a physician by asking specific questions, either of the patient or of other people who know the person and can give suitable information , with the aim of obtaining information useful in formulating a diagnosis and providing...
— an account of the symptom
Symptom
A symptom is a departure from normal function or feeling which is noticed by a patient, indicating the presence of disease or abnormality...
s as experienced by the patient. Together with the medical history, the physical examination aids in determining the correct diagnosis
Medical diagnosis
Medical diagnosis refers both to the process of attempting to determine or identify a possible disease or disorder , and to the opinion reached by this process...
and devising the treatment plan. This data then becomes part of the medical record
Medical record
The terms medical record, health record, and medical chart are used somewhat interchangeably to describe the systematic documentation of a single patient's medical history and care across time within one particular health care provider's jurisdiction....
.
Medical uses
A physical examination may be provided under health insuranceHealth insurance
Health insurance is insurance against the risk of incurring medical expenses among individuals. By estimating the overall risk of health care expenses among a targeted group, an insurer can develop a routine finance structure, such as a monthly premium or payroll tax, to ensure that money is...
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. 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. The executive physical format was developed from the 1970s by the Mayo Clinic
Mayo Clinic
Mayo Clinic is a not-for-profit medical practice and medical research group specializing in treating difficult patients . Patients are referred to Mayo Clinic from across the U.S. and the world, and it is known for innovative and effective treatments. Mayo Clinic is known for being at the top of...
and is now offered by other health providers, including Johns Hopkins University
Johns Hopkins University
The Johns Hopkins University, commonly referred to as Johns Hopkins, JHU, or simply Hopkins, is a private research university based in Baltimore, Maryland, United States...
, EliteHealth and Mount Sinai in New York City.
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.
In addition to the possibility of identifying signs of illness, it has been described as a ritual that plays a significant role in the doctor-patient relationship. Physicians at Stanford University medical school have introduced a set of 25 key physical examination skills that were felt to be useful.
Format and interpretation
Although providers have varying approaches as to the sequence of body parts, a systematic examination generally starts at the headHuman head
In human anatomy, the head is the upper portion of the human body. It supports the face and is maintained by the skull, which itself encloses the brain.-Cultural importance:...
and finishes at the extremities
Limb (anatomy)
A limb is a jointed, or prehensile , appendage of the human or other animal body....
. After the main organ systems have been investigated by inspection
Inspection (medicine)
In medicine, 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:...
, palpation
Palpation
Palpation is used as part of a physical examination in which an object is felt to determine its size, shape, firmness, or location...
, percussion
Percussion (medicine)
Percussion is a method of tapping on a surface to determine the underlying structure, and is used in clinical examinations to assess the condition of the thorax or abdomen. It is one of the four methods of clinical examination, together with inspection, palpation and auscultation...
, and auscultation
Auscultation
Auscultation is the term for listening to the internal sounds of the body, usually using a stethoscope...
, specific tests may follow (such as a neurological
Neurology
Neurology is a medical specialty dealing with disorders of the nervous system. Specifically, it deals with the diagnosis and treatment of all categories of disease involving the central, peripheral, and autonomic nervous systems, including their coverings, blood vessels, and all effector tissue,...
investigation, orthopedic examination) or specific tests when a particular disease is suspected (e.g. eliciting Trousseau's sign
Trousseau sign of latent tetany
Trousseau sign of latent tetany is a medical sign observed in patients with low calcium. This sign may become positive before other gross manifestations of hypocalcemia such as hyperreflexia and tetany, but is generally believed to be more sensitive than the Chvostek sign for hypocalcemia.To...
in hypocalcemia).
With the clues obtained during the history and physical examination the healthcare provider can now formulate a differential diagnosis
Differential diagnosis
A differential diagnosis is a systematic diagnostic method used to identify the presence of an entity where multiple alternatives are possible , and may also refer to any of the included candidate alternatives A differential diagnosis (sometimes abbreviated DDx, ddx, DD, D/Dx, or ΔΔ) is a...
, 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. A primary care physician will also generally examine the male genitals
Sex organ
A sex organ, or primary sexual characteristic, as narrowly defined, is any of the anatomical parts of the body which are involved in sexual reproduction and constitute the reproductive system in a complex organism; flowers are the reproductive organs of flowering plants, cones are the reproductive...
but may leave the examination of the female genitalia to a gynecologist.
A complete physical examination includes evaluation of general patient appearance and specific organ systems. It is recorded in the medical record
Medical record
The terms medical record, health record, and medical chart are used somewhat interchangeably to describe the systematic documentation of a single patient's medical history and care across time within one particular health care provider's jurisdiction....
in a standard layout which facilitates others later reading the notes. In practice the vital signs of temperature examination, pulse
Pulse
In medicine, one's pulse represents the tactile arterial palpation of the heartbeat by trained fingertips. The pulse may be palpated in any place that allows an artery to be compressed against a bone, such as at the neck , at the wrist , behind the knee , on the inside of the elbow , and near the...
and blood pressure
Blood pressure
Blood pressure is the pressure exerted by circulating blood upon the walls of blood vessels, and is one of the principal vital signs. When used without further specification, "blood pressure" usually refers to the arterial pressure of the systemic circulation. During each heartbeat, BP varies...
are usually measured first.
Example
| Section | Sample text | Comments |
|---|---|---|
| General | "Patient in NAD. VS Vital signs Vital signs are measures of various physiological statistics, often taken by health professionals, in order to assess the most basic body functions. Vital signs are an essential part of a case presentation. The act of taking vital signs normally entails recording body temperature, pulse rate ,... : WNL" |
May be split on two lines. "WNL" = "within normal limits". |
| HEENT HEENT examination A HEENT examination is a portion of a physical examination; it principally concerns the Head, Ears, Eyes, Nose and Throat.Components of the exam may include:-Steps:* IPPA** Inspection of scars or skin changes... : |
"NC/AT. PERRLA PERRLA Perrla: Pupils equal, round & reactive to light & accommodationAccording to several articles Perrla is no longer used. Doctors don't find it valuable . According to Levin there are perils to using Perrla... , EOMI. No cervical LAD Lymphadenopathy Lymphadenopathy is a term meaning "disease of the lymph nodes." It is, however, almost synonymously used with "swollen/enlarged lymph nodes". It could be due to infection, auto-immune disease, or malignancy.... , no thyromegaly, no bruit Bruit Bruit is the term for the unusual sound that blood makes when it rushes past an obstruction in an artery when the sound is auscultated with the bell portion of a stethoscope.The term "bruit" simply refers to the sound... , no pallor Pallor Pallor is a reduced amount of oxyhaemoglobin in skin or mucous membrane, a pale color which can be caused by illness, emotional shock or stress, stimulant use, lack of exposure to sunlight, anaemia or genetics.... , fundus Fundus Fundus is an anatomical term referring to the portion of an organ opposite from its opening. Examples include:* Fundus * Fundus of gallbladder* Fundus * Fundus... WNL, oropharynx Oropharynx The Oropharynx reaches from the Uvula to the level of the hyoid bone.It opens anteriorly, through the isthmus faucium, into the mouth, while in its lateral wall, between the two palatine arches, is the palatine tonsil.... WNL, tympanic membrane WNL, neck supple" |
"Neck" is sometimes split out from "Head". "Good dentition Dentition Dentition pertains to the development of teeth and their arrangement in the mouth. In particular, the characteristic arrangement, kind, and number of teeth in a given species at a given age... " may be noted. |
| Resp Respiratory examination In medicine, the respiratory examination is performed as part of a physical examination, or when a patient presents with a respiratory problem or a history that suggests a pathology of the lungs... or "Chest" |
"Nontender, CTA bilat" | More detailed examinations can include rales Rales Crackles, crepitations, or rales are the clicking, rattling, or crackling noises that may be made by one or both lungs of a human with a respiratory disease during inhalation. They are often heard only with a stethoscope... , rhonchi Rhonchi Rhonchi is the coarse rattling sound somewhat like snoring, usually caused by secretion in bronchial airways. Rhonchi is the plural form of the singular word rhonchus.-Description:... , wheezing ("no r/r/w"), and rubs. Other phrases may include "no cyanosis or clubbing" (if section is labeled "Resp" and not "Chest"), "fremitus Fremitus Fremitus is a palpable vibration on the human body. In common medical usage, it usually refers to vocal fremitus, although there are several other types.-Pleural fremitus:... WNL", and "no dullnes to percussion". |
| CV Cardiovascular examination The Cardiovascular examination is a portion of the physical examination that involves evaluation of the cardiovascular system.It can involve a precordial examination and peripheral vascular examination.... or "Heart" |
"+S1, +S2, RRR, no m Heart murmur Murmurs are extra heart sounds that are produced as a result of turbulent blood flow that is sufficient to produce audible noise. Most murmurs can only be heard with the assistance of a stethoscope .... /r/g Gallop rhythm A gallop rhythm refers to a rhythm of the heart on auscultation. It includes three or four sounds, thus resembling the sounds of a gallop.... " |
If "CV" is used instead of "heart", peripheral pulses are sometimes included in this section (otherwise, they may be in the extremities section) |
| Abd Abdominal examination The abdominal exam, in medicine, is performed as part of a physical examination, or when a patient presents with abdominal pain or a history that suggests an abdominal pathology.The exam includes several parts:* Setting and preparation... |
"Soft, nontender, nondistended, no hepatosplenomegaly Hepatosplenomegaly Hepatosplenomegaly is the simultaneous enlargement of both the liver and the spleen . Hepatosplenomegaly can occur as the result of acute viral hepatitis or infectious mononucleosis, or it can be the sign of a serious and life threatening lysosomal storage disease... , NBS" |
If lower back pain is involved, then the "Back" may become a primary section. Costovertebral angle tenderness may be included in the abdominal section if there is no back section. More detailed examinations may report "+psoas sign Psoas sign The psoas sign is a medical sign that indicates irritation to the iliopsoas group of hip flexors in the abdomen, and consequently indicates that the inflamed appendix is retrocaecal in orientation... , +Rovsing's sign Rovsing's sign thumb|right|Rovsing's sign is pain in the [[RLQ]] experienced when the [[left lower quadrant|LLQ]] is palpated.Rovsing's sign, named after the Danish surgeon Niels Thorkild Rovsing, is a sign of appendicitis... , +obturator sign Obturator sign The obturator sign, also known as the Cope sign, is an indicator of irritation to the obturator internus muscle. The technique is carried out on each leg in succession. First the patient lies on his back with the right hip flexed at 90 degrees. The examiner then holds the patient's right ankle in... ". If tenderness was present, it might be reported as "Direct and rebound Rebound tenderness Rebound tenderness is a clinical sign that a doctor or other health care provider may detect in physical examination of a patient's abdomen. It refers to pain upon removal of pressure rather than application of pressure to the abdomen... RLQ tenderness". "NBS" stands for "normal bowel sounds"; alternatives might include "hypoactive BS" or "hyperactive BS". |
| Ext Extremities Extremities may refer to:* Extremities , a play by William Mastrosimone* Extremities , a film based on the play* limbs of the body, in medical terminology... |
"No clubbing, cyanosis Cyanosis Cyanosis is the appearance of a blue or purple coloration of the skin or mucous membranes due to the tissues near the skin surface being low on oxygen. The onset of cyanosis is 2.5 g/dL of deoxyhemoglobin. The bluish color is more readily apparent in those with high hemoglobin counts than it is... , edema Edema Edema or oedema ; both words from the Greek , oídēma "swelling"), formerly known as dropsy or hydropsy, is an abnormal accumulation of fluid beneath the skin or in one or more cavities of the body that produces swelling... " |
Checking the fingers for clubbing and cyanosis is sometimes considered part of the pulmonary exam, because it closely involves oxygenation. Examinations of the knee Knee The knee joint joins the thigh with the leg and consists of two articulations: one between the fibula and tibia, and one between the femur and patella. It is the largest joint in the human body and is very complicated. The knee is a mobile trocho-ginglymus , which permits flexion and extension as... may involve the McMurray test McMurray test The McMurray test, also known as the McMurray circumduction test is used to evaluate individuals for tears in the meniscus of the knee. It is a rotation test for demonstrating torn cartilage of the knee... , Lachman test, and drawer test Drawer test The drawer test is a test used by physicians to detect rupture of the cruciate ligaments in the knee. The patient should be supine with the hips flexed to 45 degrees, the knees flexed to 90 degrees and the feet flat on table. The examiner sits on the patient's feet and grasps the patient's tibia... . |
| Neuro | "A&Ox3, CN II-XII grossly intact, Sensation Sensation Sensation is the fiction-writing mode for portraying a character's perception of the senses. According to Ron Rozelle, “. . .the success of your story or novel will depend on many things, but the most crucial is your ability to bring your reader into it. And that reader will be most completely... intact in all four extremities (dull and sharp), DTR 2+ bilat, Romberg Romberg's test Romberg's test or the Romberg maneuver is a test used by doctors in a neurological examination, and also as a test for drunken driving. The exam is based on the premise that a person requires at least two of the three following senses to maintain balanced while standing:Proprioception ; Vestibular... negative, cerebellar reflexes WNL, normal gait Gait Gait is the pattern of movement of the limbs of animals, including humans, during locomotion over a solid substrate. Most animals use a variety of gaits, selecting gait based on speed, terrain, the need to maneuver, and energetic efficiency... " |
Sensation may be expanded to include dull, sharp, vibration, temperature, and position sense. A mental status exam may be reported at the beginning of the neurologic exam, or under a distinct "Psych" section. |
Depending upon the chief complaint
Chief complaint
The Chief Complaint formally known as CC in the medical field, or termed Presenting Complaint in the UK, is a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for a medicalencounter...
, additional sections may be included. For example, hearing may be evaluated with a specific Weber test
Weber test
The Weber test is a quick screening test for hearing. It can detect unilateral conductive hearing loss and unilateral sensorineural hearing loss...
and Rinne test
Rinne test
The Rinne test is a hearing test. It compares perception of sounds transmitted by air conduction to those transmitted by bone conduction through the mastoid...
, or it may be more briefly addressed in a cranial nerve exam.
Vital signs
The primary vital signs are:- Temperature recording
- Blood pressure
- PulsePulseIn medicine, one's pulse represents the tactile arterial palpation of the heartbeat by trained fingertips. The pulse may be palpated in any place that allows an artery to be compressed against a bone, such as at the neck , at the wrist , behind the knee , on the inside of the elbow , and near the...
- Respiratory rateRespiratory rateRespiratory rate is also known by respiration rate, pulmonary ventilation rate, ventilation rate, or breathing frequency is the number of breaths taken within a set amount of time, typically 60 seconds....
See also
- General medical examinationGeneral medical examinationIn medicine, the general medical examination is a common form of preventive medicine involving visits to a general practitioner by asymptomatic adults on a regular basis. This is generally yearly or less frequently...
- Heart soundsHeart soundsHeart sounds, or heartbeats, are the noises generated by the beating heart and the resultant flow of blood through it...
- Medical recordMedical recordThe terms medical record, health record, and medical chart are used somewhat interchangeably to describe the systematic documentation of a single patient's medical history and care across time within one particular health care provider's jurisdiction....
- Mental status examinationMental status examinationThe mental status examination in the USA or mental state examination in the rest of the world, abbreviated MSE, is an important part of the clinical assessment process in psychiatric practice...
External links
- Video Resource: General Practitioner examination videos by a consultant orthopaedic surgeon
- Connecticut Tutorials Physical Examination Video
- Physical examination of respiratory system video
- The Journal of Clinical Examination - A useful online source for evidence-based guidance on physical examination
- OSCE Skills - e-Learning Resources for Medical Students (free)