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Physical examination

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In health care, the physical examination is a "systematic and thorough inspection of the patient for physical signs of disease or abnormality."[1] Textbooks are available that quantify the ability of physical examination.[2] [3]

Usually, before the physical examination, the health practitioner will have established the patient's chief complaint and taken a medical history.

The physical examination is an important part of the physician-patient relationship. It often helps the patient-physician relationship by being one of the few continuations of the "laying on of hands."

Importance of the physical examination

Contribution to diagnosis

The physical examination contributes to 9% to 17% of diagnoses.[4][5][6]

7% of medical inpatients had important physical examination findings that were the only evidence of an important underlying condition.[7]

Faulty physical examination may contribute to 5% to 10% of diagnostic errors.[8][9]

Physician-patient relationship

Patients' expections for the physical examination affect the physician-patient relationship.[10][11][12] Perception of missed components of the physical examination are among the most common missed expectations.[10][11][12]

Approaches to the physical examination

There are several ways to perform a basic review. In the "regional" approach, the patient is placed in positions suitable for specific examination. For example, several different methods, focused differently on the heart and lungs, might be most conveniently done together while the patient is sitting and facing the examiner.[13][14]

In the system-oriented approach, which may be slower but preferable when the examination is focused on a specific system, the examiner moves from position to position while focusing on one system at a time. This may encourage concentration on a system.

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

Many 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, [15], 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, as the examiner will listen 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.

Methods of the physical examination

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


Auscultation

For more information, see: Auscultation.

Auscultation is the "act of listening for sounds within the body." [16] Auscultation helps assess respiratory sounds[17], heart sounds[18], and heart murmurs[18].

Palpation

For more information, see: Palpation.

Palpation is the "application of fingers with light pressure to the surface of the body to determine consistence of parts beneath in physical diagnosis; includes palpation for determining the outlines of organs."[19]

Percussion

For more information, see: Percussion.

Percussion is the "act of striking a part with short, sharp blows as an aid in diagnosing the condition beneath the sound obtained."[20]

Research on the accuracy of the physical examination

Errors in the physical examination may be a cause diagnostic error.[21]

Guidelines have been proposed for reporting research on the physical examination.[22]

History of the physical examination

Auscultation prior to the stethoscope.

Walker has compiled the following dates in the development of the techniques for the physical examination.[23]

  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 concern that modern medicine overly relies on diagnostic tests and underutilizes medical history taking and physical examination. As an example, the rates of unnecessary appendectomy and appendicieal perforation have not improved over time[24][25] in spite of increased use of laboratory tests[25] and diagnostic imaging[26]. However, in general, medical history taking and physical examination contribute more to diagnosis than do diagnostic tests.[4][5][6] An aphorism among medical educators is "treat the patient, not the chart." Diagnostic imaging may produce false positives and false negatives, so that the patient receives unneeded treatment or fails to receive treatment for a disorder overlooked by diagnostic imaging. Concern about overdependence on diagnostic tests has created the acronym VOMIT: Victim of Modern Imaging Technology.[27]

Enhancing the examination with handheld tools

Hand held ultrasound, peak flow measurement, and echocardiography[28] may help.

"The rapid acquisition of images by skilled ultrasonographers who use PME yields accurate assessments of ejection fraction and some but not all cardiac structures in many patients". [29]

Use of chaperones

When patients are asked, some women prefer having a chaperone while other women do not want a chaperone during the pelvic examination.[30] The self-reported preference for a chaperone depends on the gender of the examiner. In one study, 4%[31] to 11%[30] do want a chaperone present and 34% would rather not have a chaperone.[30]

When health care providers are asked about chaperones, chaperones are more likely to be used when the examiner is male[32][33] and when nurses are available[32].

Some authors recommend routinely offering, but not requiring, chaperones.[30][34] The [35]

Examining techniques in complementary medicine

Some traditional and complementary disciplines, such as traditional Chinese medicine (TCM), often combine traditional and contemporary examination techniques.[36] For instance, Chinese manual "pulse diagnosis" uses three fingers over the radial artery of both wrists, applying different amounts of pressure in an effort to get a sense of the different qualities of the pulse as well as the heart rate. Western methods might instead use amplified or Doppler instruments, plesthymography, etc. Cardiologists and other specialists also will supplement basic pulse-taking with positional changes and different hand/probe positioning.

From an integrative medicine standpoint, these different techniques might actually be accessing similar information, possibly within a different paradigm. In other cases, they reveal information that is useful to both therapeutic models. It might be argued that manual pulse-taking by a cardiologist might be as different from the basic technique of a primary care physicians as is the technique of a TCM practitioner.

References

  1. Anonymous (2014), Physical examination (English). Medical Subject Headings. U.S. National Library of Medicine.
  2. McGee, Steven (2012-04-02). Evidence-Based Physical Diagnosis: Expert Consult - Online and Print, 3e, 3 edition. Philadelphia: Saunders. ISBN 9781437722079. 
  3. Simel, David (2008-08-25). The Rational Clinical Examination: Evidence-Based Clinical Diagnosis, 1 edition. New York: McGraw-Hill Professional. ISBN 9780071590303. 
  4. 4.0 4.1 Peterson MC, Holbrook JH, Von Hales D, Smith NL, Staker LV (February 1992). "Contributions of the history, physical examination, and laboratory investigation in making medical diagnoses". West. J. Med. 156 (2): 163–5. PMID 1536065. PMC 1003190[e]
  5. 5.0 5.1 Hampton JR, Harrison MJ, Mitchell JR, Prichard JS, Seymour C (May 1975). "Relative contributions of history-taking, physical examination, and laboratory investigation to diagnosis and management of medical outpatients". Br Med J 2 (5969): 486–9. PMID 1148666. PMC 1673456[e]
  6. 6.0 6.1 Sandler G (July 1979). "Costs of unnecessary tests". Br Med J 2 (6181): 21–4. PMID 466256. PMC 1595755[e]
  7. Reilly BM (2003). "Physical examination in the care of medical inpatients: an observational study.". Lancet 362 (9390): 1100-5. DOI:10.1016/S0140-6736(03)14464-9. PMID 14550696. Research Blogging.
  8. Graber ML, Franklin N, Gordon R (2005). "Diagnostic error in internal medicine.". Arch Intern Med 165 (13): 1493-9. DOI:10.1001/archinte.165.13.1493. PMID 16009864. Research Blogging.
  9. Schiff GD, Hasan O, Kim S, Abrams R, Cosby K, Lambert BL et al. (2009). "Diagnostic error in medicine: analysis of 583 physician-reported errors.". Arch Intern Med 169 (20): 1881-7. DOI:10.1001/archinternmed.2009.333. PMID 19901140. Research Blogging.
  10. 10.0 10.1 Kravitz RL, Callahan EJ (2000). "Patients' perceptions of omitted examinations and tests: A qualitative analysis.". J Gen Intern Med 15 (1): 38-45. PMID 10632832. PMC PMC1495321[e]
  11. 11.0 11.1 Kravitz RL, Callahan EJ, Paterniti D, Antonius D, Dunham M, Lewis CE (1996). "Prevalence and sources of patients' unmet expectations for care.". Ann Intern Med 125 (9): 730-7. PMID 8929006[e]
  12. 12.0 12.1 Bell RA, Kravitz RL, Thom D, Krupat E, Azari R (2002). "Unmet expectations for care and the patient-physician relationship.". J Gen Intern Med 17 (11): 817-24. PMID 12406352. PMC PMC1495125[e]
  13. Harrell, RA & GS Firestein (3rd edition, 1988), The Effective Scutboy: The Principles and Practice of Scut, Appleton & Lange
  14. (1990) “The Physical Examination”, Walker HK, Hall WD, Hurst JW: Clinical methods: the history, physical, and laboratory examinations (in English), 3rd. London: Butterworths. LCC RC71 .C63. ISBN 0-409-90077-X.  Library of Congress
  15. Especially when there is suspicion of cardiovascular disease, it is wise to take blood pressures on both arms, in sitting, standing, and lying positions
  16. Anonymous (2014), Auscultation (English). Medical Subject Headings. U.S. National Library of Medicine.
  17. (1990) “The Chest Examination”, Walker HK, Hall WD, Hurst JW: Clinical methods: the history, physical, and laboratory examinations (in English), 3rd. London: Butterworths. LCC RC71 .C63. ISBN 0-409-90077-X.  Library of Congress
  18. 18.0 18.1 (1990) “The cardiovascular System”, Walker HK, Hall WD, Hurst JW: Clinical methods: the history, physical, and laboratory examinations (in English), 3rd. London: Butterworths. LCC RC71 .C63. ISBN 0-409-90077-X.  Library of Congress
  19. Anonymous (2014), Palpation (English). Medical Subject Headings. U.S. National Library of Medicine.
  20. Anonymous (2014), Percussion (English). Medical Subject Headings. U.S. National Library of Medicine.
  21. Schiff, Gordon D.; Omar Hasan, Seijeoung Kim, Richard Abrams, Karen Cosby, Bruce L. Lambert, Arthur S. Elstein, Scott Hasler, Martin L. Kabongo, Nela Krosnjar, Richard Odwazny, Mary F. Wisniewski, Robert A. McNutt (2009-11-09). "Diagnostic Error in Medicine: Analysis of 583 Physician-Reported Errors". Arch Intern Med 169 (20): 1881-1887. DOI:10.1001/archinternmed.2009.333. Retrieved on 2009-11-10. Research Blogging.
  22. Simel DL et al. (2008). "The STARD Statement for Reporting Diagnostic Accuracy Studies: Application to the History and Physical Examination". J Gen Intern Med 23: 768–74. DOI:10.1007/s11606-008-0583-3. PMID 18347878. Research Blogging.
  23. Walker HK (1990). “The Origins of the History and Physical Examination”, Walker HK, Hall WD, Hurst JW: Clinical methods: the history, physical, and laboratory examinations, 3rd. London: Butterworths. ISBN 0-409-90077-X. 
  24. Flum DR et al. (October 2001). "Has misdiagnosis of appendicitis decreased over time? A population-based analysis". JAMA 286: 1748–53. PMID 11594900[e]
  25. 25.0 25.1 Scitovsky AA (1985). "Changes in the costs of treatment of selected illnesses, 1971-1981". Med Care 23: 1345–57. PMID 4087950[e]
  26. Perez J et al. (March 2003). "Liberal use of computed tomography scanning does not improve diagnostic accuracy in appendicitis". Am J Surg 185: 194–7. PMID 12620554[e]
  27. Arts, JA (December 11, 2006), VOMIT, Trauma & Critical Care Mailing List, Trauma.Org
  28. Cardim N, Fernandez Golfin C, Ferreira D, Aubele A, Toste J, Cobos MA et al. (2011). "Usefulness of a new miniaturized echocardiographic system in outpatient cardiology consultations as an extension of physical examination.". J Am Soc Echocardiogr 24 (2): 117-24. DOI:10.1016/j.echo.2010.09.017. PMID 21074362. Research Blogging.
  29. Liebo MJ, Israel RL, Lillie EO, Smith MR, Rubenson DS, Topol EJ (2011). "Is Pocket Mobile Echocardiography the Next-Generation Stethoscope? A Cross-sectional Comparison of Rapidly Acquired Images With Standard Transthoracic Echocardiography.". Ann Intern Med 155 (1): 33-8. DOI:10.1059/0003-4819-155-1-201107050-00005. PMID 21727291. Research Blogging.
  30. 30.0 30.1 30.2 30.3 Fiddes P, Scott A, Fletcher J, Glasier A (2003). "Attitudes towards pelvic examination and chaperones: a questionnaire survey of patients and providers.". Contraception 67 (4): 313-7. DOI:10.1016/S0010-7824(02)00540-1. PMID 12684154. Research Blogging.
  31. Baber JA, Davies SC, Dayan LS (2007). "An extra pair of eyes: do patients want a chaperone when having an anogenital examination?". Sex Health 4 (2): 89-93. PMID 17524285[e]
  32. 32.0 32.1 Price DH, Tracy CS, Upshur RE (2005). "Chaperone use during intimate examinations in primary care: postal survey of family physicians.". BMC Fam Pract 6: 52. DOI:10.1186/1471-2296-6-52. PMID 16371153. PMC PMC1360073. Research Blogging.
  33. Natasha R Johnson; Elliot H Philipson, Stephen L Curry (1999). "Chaperone Use by Obstetrician/Gynecologists". Obstetrical & Gynecological Survey 54 (11): 423-427.
  34. Penn MA, Bourguet CC (1992). "Patients' attitudes regarding chaperones during physical examinations.". J Fam Pract 35 (6): 639-43. PMID 1453147[e] Review in: J Fam Pract. 1993 Jun;36(6):597-8
  35. American Medical Association. Opinion 8.21 - Use of Chaperones During Physical Exams. In AMA's Code of Medical Ethics
  36. Chaitow L et al. (2003), Special Topic 11: Palpating the Traditional Chinese Pulses, Palpation and Assessment Skills: Assessment and Diagnosis Through Touch, Elsevier Health Sciences, ISBN 0443072183,, pp. 335-9
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