Physical examination

Definition

A physical examination is the evaluation of a body to determine its state of health. The techniques of inspection include palpation (feeling with the hands and/or fingers), percussion (tapping with the fingers), auscultation (listening), and smell. A complete health assessment also includes gathering information about a person's medical history and lifestyle, conducting laboratory tests, and screening for disease. These elements constitute the data on which a diagnosis is made and a plan of treatment is developed.

Purpose

The term annual physical examination has been replaced in most health care circles by periodic health examination. The frequency with which it is conducted depends on factors such as the age, gender, and the presence of risk factors for disease in the person being examined. Health-care professionals often use guidelines that have been developed by organizations such as the United States Preventative Services Task Force. Organizations such as the American Cancer Society or American Heart Association, which promote detection and prevention of specific diseases, generally recommend more intensive or frequent examinations, or suggest that examinations be focused on particular organ systems of the body.

Comprehensive physical examinations provide opportunities for health care professionals to obtain baseline information about individuals that may be useful in the future. They also allow health care providers to establish relationships before problems occur. Physical examinations are appropriate times to answer questions and teach good health practices. Detecting and addressing problems in their early stages can have beneficial long-term results.

Every person should have periodic physical examinations. These occur frequently (monthly at first) in infants and gradually reach a frequency of once per year for adolescents and adults.

Description

A complete physical examination usually starts at the head and proceeds all the way to the toes. However, the exact procedure will vary according to the needs of the person being examined and the preferences of the examiner. An average examination takes about 30 minutes. The cost of an examination will depend on the charge for professional time and any tests that are included. Most health plans cover routine physical examinations, including some tests.

The examination

Before examiners question the patient, they will observe a person's overall appearance, general health, and behavior. Measurements of height and weight are made. Vital signs such as pulse, breathing rate, body temperature, and blood pressure are recorded.

With the person being examined in a sitting position, the following systems are reviewed:

• Skin. The exposed areas of the skin are observed; the size and shape of any lesions are noted.
• Head. The hair, scalp, skull, and face are examined.
• Eyes. The external structures are observed. The internal structures can be observed using an ophthalmoscope (a lighted instrument) in a darkened room.
• Ears. The external structures are inspected. A lighted instrument called an otoscope may be used to inspect internal structures.
• Nose and sinuses. The external nose is examined. The nasal mucosa and internal structures can be observed with the use of a penlight and a nasal speculum.
• Mouth and pharynx. The lips, gums, teeth, roof of the mouth, tongue, and pharynx are inspected.
• Neck. The lymph nodes on both sides of the neck and the thyroid gland are palpated.
• Back. The spine and muscles of the back are palpated and checked for tenderness. The upper back, where the lungs are located, is palpated on the right and left sides and a stethoscope is used to listen for breath sounds.
• Breasts and armpits. A woman's breasts are inspected with the arms relaxed and then raised. In both men and women, the lymph nodes in the armpits are felt with the examiner's hands. While the person is still sitting, movement of the joints in the hands, arms, shoulders, neck, and jaw can be checked.

While the person is lying down on the examining table, the examination includes:

• Breasts. The breasts are palpated and inspected for masses.
• Front of chest and lungs. The area is inspected with the fingers, using palpation and percussion. A stethoscope is used to listen to internal breath sounds.

The head should be slightly raised to examine:

• Heart. A stethoscope is used to listen to the heart's rate and rhythm. The blood vessels in the neck are observed and palpated.

The person being examined should lie flat for an examination of the:

• Abdomen. Light and deep palpation is used on the abdomen to feel the outlines of internal organs, including the liver, spleen, kidneys, and aorta, a large blood vessel.
• Rectum and anus. With the person lying on the left side, the outside areas are observed. An internal digital examination (using a gloved finger), is usually done for persons over 40 years old. In men, the prostate gland is also palpated.
• Reproductive organs. The external sex organs are inspected and the area is examined for hernias. In men, the scrotum and testicles are palpated. In women, a pelvic examination is completed using a speculum and a sample for a Papanicolaou test (Pap test) may be taken.
• Legs. While lying flat, the legs are inspected for swelling, and pulses in the knee, thigh, and foot area are found. The groin area is palpated for the presence of lymph nodes. The joints and muscles are observed.
• Musculoskeletal system. With the person standing, the straightness of the spine and the alignment of the legs and feet is noted.
• Blood vessels. The presence of any abnormally enlarged veins (varicose), usually in the legs, is noted.

In addition to evaluating a person's alertness and mental ability during the initial conversation, inspection of the nervous system may include:

• Neurologic screen. The person's ability to take a few steps, hop, and do deep knee bends is observed. The strength of the handgrip is felt. While sitting in an upright position, the reflexes in the knees and feet can be tested with a small hammer. The sense of touch in the hands and feet can be evaluated by testing reaction to pain and vibration.
• The 12 nerves in the head (cranial) that are connected directly to the brain. They control the senses of smell and taste, strength of muscles in the head, reflexes in the eye, facial movements, gag reflex, vision, hearing, and muscles in the jaw. General muscle tone and coordination, and the reaction of the abdominal area to stimulants like pain, temperature, and touch may also be evaluated.

Diagnosis/Preparation

The individual being examined should be comfortable and treated with respect throughout the examination. As the examination continues, examiners should explain what they are doing and share any relevant findings. Using language appropriate to the person being examined improves the effectiveness of communications and ultimately fosters better relations between examiners and examinees.

Before visiting a health care professional, individuals should write down important facts and dates about their own medical history, as well as those of family members. There should be a complete listing of all medications and their dosages. This list should include over-the-counter preparations, vitamins, and herbal supplements. Some people bring their bottles of medications with them. Any questions or concerns about medications should be written down.

Before the physical examination begins, the bladder should be emptied. A urine specimen is usually collected in a small container at this time. The urine is tested for the presence of glucose (sugar), protein, and blood cells. For some blood tests, individuals may be told ahead of time not to eat or drink for 12 hours prior to the test.

Individuals being examined usually remove all clothing and put on a loose-fitting hospital gown. An additional sheet is provided to keep persons covered and comfortable during the examination.

Aftercare

Once a physical examination has been completed, the person being examined and the examiner should review what laboratory tests have been ordered, why they have been selected, and how and with whom the results will be shared. A health professional should discuss any recommendations for treatment and follow-up visits. Special instructions should be put in writing. This is also an opportunity for persons to ask any remaining questions about their own health concerns.

Risks

There are virtually no risks associated with a physical examination. Complications with the process of a physical examination are unusual. Occasionally, a useful piece of information or data may be overlooked. More commonly, results of associated laboratory tests compel physicians to recheck an individual or reexamine portions of the body already reviewed. In a sense, complications may arise from the findings of a physical examination. These usually trigger further investigations or initiate treatment. They are really more beneficial than negative, as they often begin a process of treatment and recovery.

Normal results

Normal results of a physical examination correspond to the healthy appearance and normal functioning of the body. For example, appropriate reflexes will be present, no suspicious lumps or lesions will be found, and vital signs will be normal.

Abnormal results of a physical examination include any findings that indicate the presence of a disorder, disease, or underlying condition. For example, the presence of lumps or lesions, fever, muscle weakness or lack of tone, poor reflex response, heart arrhythmia, or swelling of lymph nodes will indicate possible health problems.

Resources

books

bickley, l. s., p. g. szilagyi, and j. g. stackhouse. bates' guide to physical examination & history taking, 8th edition. philadelphia: lippincott williams & wilkins, 2002.

chan, p. d., and p. j. winkle. history and physical examination in medicine, 10th edition. new york: current clinical strategies, 2002.

seidel, henry m. mosby's physical examination handbook, 4th edition. st. louis, mo: mosby-year book, 2003.

swartz, mark a., and william schmitt. textbook of physical diagnosis: history and examination, 4th edition. philadelphia: saunders, 2001.

periodicals

ahmed, a. m. "deficiencies of physical examination among medical students." saudi medical journal, 24, no.1 (2003): 108–111.

organizations

american academy of family physicians. 11400 tomahawk creek parkway, leawood, ks 66211-2672. (913) 906-6000. e-mail: <fp@aafp.org>. <http://www.aafp.org>.

american academy of pediatrics. 141 northwest point boulevard, elk grove village, il 60007-1098. (847) 434-4000; fax: (847) 434-8000. e-mail: <kidsdoc@aap.org>. <http://www.aap.org/default.htm>.

american college of physicians. 190 n independence mall west, philadelphia, pa 19106-1572. (800) 523-1546, x2600, or (215) 351-2600. <http://www.acponline.org>.

american medical association. 515 n. state street, chicago, il 60610. (312) 464-5000. <http://www.ama-assn.org>.

other

karolinska institute. [cited march 1, 2003]. <http://isp.his.ki.se/text/physical.htm>.

loyola university chicago stritch school of medicine. [cited march 1, 2003]. <http://www.meddean.luc.edu/lumen/meded/medicine/pulmonar/pd/pdmenu.htm>.

national library of medicine. [cited march 1, 2003]. <http://www.nlm.nih.gov/medlineplus/ency/article/002274.htm>.

review of systems school of medical transcription. [cited march 1, 2003]. <http://www.mtmonthly.com/studentcorner/cpe.htm>.

L. Fleming Fallon, Jr. MD, DrPH

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

A physical examination is best performed by a trained physician. Other health care professionals such as physician assistants and nurse practitioners have similar but limited training. Examinations are usually performed in professional medical offices or hospitals. Occasionally, they may be performed in private homes or in the field.

QUESTIONS TO ASK THE DOCTOR

• What are my results, both normal and abnormal?
• What has changed since the last physical examination?
• What do you recommend as a result of the findings of this physical examination?
• When do you want to repeat the physical examination?

Physical Examination

Definition

A physical examination is an evaluation of the body and its functions using inspection, palpation (feeling with the hands), percussion (tapping with the fingers), and auscultation (listening). A complete health assessment also includes gathering information about a person's medical history and lifestyle, doing laboratory tests, and screening for disease.

Purpose

The annual physical examination has been replaced by the periodic health examination. How often this is done depends on the patient's age, sex, and risk factors for disease. The United States Preventative Services Task Force (USPSTF) has developed guidelines for preventative health examinations that health care professionals widely follow. Organizations that promote detection and prevention of specific diseases, like the American Cancer Society, generally recommend more intensive or frequent examinations.

A comprehensive physical examination provides an opportunity for the healthcare professional to obtain baseline information about the patient for future use, and to establish a relationship before problems happen. It provides an opportunity to answer questions and teach good health practices. Detecting a problem in its early stages can have good long-term results.

Precautions

The patient should be comfortable and treated with respect throughout the examination. As the examination procedes, the examiner should explain what he or she is doing and share any relevant findings.

Description

A complete physical examination usually starts at the head and proceeds all the way to the toes. However, the exact procedure will vary according to the needs of the patient and the preferences of the examiner. An average examination takes about 30 minutes. The cost of the examination will depend on the charge for the professional's time and any tests that are done. Most health plans cover routine physical examinations including some tests.

The examination

First, the examiner will observe the patient's appearance, general health, and behavior, along with measuring height and weight. The vital signs—including pulse, breathing rate, body temperature, and blood pressure—are recorded.

With the patient sitting up, the following systems are reviewed:

• Skin. The exposed areas of the skin are observed; the size and shape of any lesions are noted.
• Head. The hair, scalp, skull, and face are examined.
• Eyes. The external structures are observed. The internal structures can be observed using an ophthalmoscope (a lighted instrument) in a darkened room.
• Ears. The external structures are inspected. A lighted instrument called an otoscope may be used to inspect internal structures.
• Nose and sinuses. The external nose is examined. The nasal mucosa and internal structures can be observed with the use of a penlight and a nasal speculum.
• Mouth and pharynx. The lips, gums, teeth, roof of the mouth, tongue, and pharynx are inspected.
• Neck. The lymph nodes on both sides of the neck and the thyroid gland are palpated (examined by feeling with the fingers).
• Back. The spine and muscles of the back are palpated and checked for tenderness. The upper back, where the lungs are located, is palpated on the right and left sides and a stethoscope is used to listen for breath sounds.
• Breasts and armpits. A woman's breasts are inspected with the arms relaxed and then raised. In both men and women, the lymph nodes in the armpits are felt with the examiner's hands. While the patient is still sitting, movement of the joints in the hands, arms, shoulders, neck, and jaw can be checked.

Then while the patient is lying down on the examining table, the examination includes:

• Breasts. The breasts are palpated and inspected for lumps.
• Front of chest and lungs. The area is inspected with the fingers, using palpation and percussion. A stethoscope is used to listen to the internal breath sounds.

The head should be slightly raised for:

• Heart. A stethoscope is used to listen to the heart's rate and rhythm. The blood vessels in the neck are observed and palpated.

The patient should lie flat for:

• Abdomen. Light and deep palpation is used on the abdomen to feel the outlines of internal organs including the liver, spleen, kidneys, and aorta, a large blood vessel.
• Rectum and anus. With the patient lying on the left side, the outside areas are observed. An internal digital examination (using a finger), is usually done if the patient is over 40 years old. In men, the prostate gland is also palpated.
• Reproductive organs. The external sex organs are inspected and the area is examined for hernias. In men, the scrotum is palpated. In women, a pelvic examination is done using a speculum and a Papamnicolaou test (Pap test ) may be taken.
• Legs. With the patient lying flat, the legs are inspected for swelling, and pulses in the knee, thigh, and foot area are found. The groin area is palpated for the presence of lymph nodes. The joints and muscles are observed.
• Musculoskeletel system. With the patient standing, the straightness of the spine and the alignment of the legs and feet is noted.
• Blood vessels. The presence of any abnormally enlarged veins (varicose), usually in the legs, is noted.

In addition to evaluating the patient's alertness and mental ability during the initial conversation, additional inspection of the nervous system may be indicated:

• Neurologic screen. The patient's ability to take a few steps, hop, and do deep knee bends is observed. The strength of the hand grip is felt. With the patient sitting down, the reflexes in the knees and feet can be tested with a small hammer. The sense of touch in the hands and feet can be evaluated by testing reaction to pain and vibration.
• Sometimes additional time is spent examining the 12 nerves in the head (cranial) that are connected directly to the brain. They control the sense of smell, strength of muscles in the head, reflexes in the eye, facial movements, gag reflex, and muscles in the jaw. General muscle tone and coordination, and the reaction of the abdominal area to stimulants like pain, temperature, and touch would also be evaluated.

Preparation

Before visiting the health care professional, the patient should write down important facts and dates about his or her own medical history, as well as those of family members. He or she should have a list of all medications with their doses or bring the actual bottles of medicine along. If there are specific concerns about anything, writing them down is a good idea.

Before the physical examination begins, the bladder should be emptied and a urine specimen can be collected in a small container. For some blood tests, the patient may be told ahead of time not to eat or drink after midnight.

The patient usually removes all clothing and puts on a loose-fitting hospital gown. An additional sheet is provided to keep the patient covered and comfortable during the examination.

Aftercare

Once the physical examination has been completed, the patient and the examiner should review what laboratory tests have been ordered and how the results will be shared with the patient. The medical professional should discuss any recommendations for treatment and follow-up visits. Special instructions should be put in writing. This is also an opportunity for the patient to ask any remaining questions about his or her own health concerns.

Normal results

Normal results of a physical examination correspond to the healthy appearance and normal functioning of the body. For example, appropriate reflexes will be present, no suspicious lumps or lesions will be found, and vital signs will be normal.

Abnormal results

Abnormal results of a physical examination include any findings that indicated the presence of a disorder, disease, or underlying condition. For example, the presence of lumps or lesions, fever, muscle weakness or lack of tone, poor reflex response, heart arhythmia, or swelling of lymph nodes will point to a possible health problem.

Resources

BOOKS

Bates, Barbara. A Guide to Physical Examination and History Taking. Philadelphia: Lippincott Co., 1995.

KEY TERMS

Auscultation— The process of listening to sounds that are produced in the body. Direct auscultation uses the ear alone, such as when listening to the grating of a moving joint. Indirect auscultation involves the use of a stethoscope to amplify the sounds from within the body, like a heartbeat.

Hernia— The bulging of an organ, or part of an organ, through the tissues normally containing it; also called a rupture.

Inspection— The visual examination of the body using the eyes and a lighted instrument if needed. The sense of smell may also be used.

Ophthalmoscope— Lighted device for studying the interior of the eyeball.

Otoscope— An instrument with a light for examining the internal ear.

Palpation— The examination of the body using the sense of touch. There are two types: light and deep.

Percussion— An assessment method in which the surface of the body is struck with the fingertips to obtain sounds that can be heard or vibrations that can be felt. It can determine the position, size, and consistency of an internal organ. It is done over the chest to determine the presence of normal air content in the lungs, and over the abdomen to evaluate air in the loops of the intestine.

Reflex— An automatic response to a stimulus.

Speculum— An instrument for enlarging the opening of any canal or cavity in order to facilitate inspection of its interior.

Stethoscope— A Y-shaped instrument that amplifies body sounds such as heartbeat, breathing, and air in the intestine. Used in auscultation.

Varicose veins— The permanent enlargement and twisting of veins, usually in the legs. They are most often seen in people with occupations requiring long periods of standing, and in pregnant women.

physical examination see diagnosis .