Physical examination: Difference between revisions
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In health care, the '''physical examination''' is a "systematic and thorough inspection of the patient for physical [[Sign (medical)|sign]]s of disease or abnormality."<ref>{{MeSH}}</ref> | In health care, the '''physical examination''' is a "systematic and thorough inspection of the patient for physical [[Sign (medical)|sign]]s of disease or abnormality."<ref>{{MeSH}}</ref> | ||
Usually, the physical examination | Usually, before the physical examination, the health practitioner will have established the patient's [[chief complaint]] and taken a [[Medical history taking|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." | 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." | ||
==Approaches to the physical examination== | ==Approaches to the physical examination== | ||
There are several ways to perform a basic review. In the "regional" approach, the patient is placed in | 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.<ref name=Scut>{{citation | ||
| title = The Effective Scutboy: The Principles and Practice of Scut | | title = The Effective Scutboy: The Principles and Practice of Scut | ||
| first1 = | | first1 = RA |last1 = Harrell | first2=GS | last2 = Firestein | ||
| date = 3rd edition, 1988 | | date = 3rd edition, 1988 | ||
| publisher = Appleton & Lange}}</ref><ref name="isbn0-409-90077-X">{{cite book |author= |authorlink= |editor=Walker HK, Hall WD, Hurst JW |others= |title=Clinical methods: the history, physical, and laboratory examinations |edition=3rd |language=English |publisher=Butterworths |location=London |year=1990 |origyear= |pages= |quote= |isbn=0-409-90077-X |oclc= |doi= |url=http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=cm|chapter=The Physical Examination|chapterurl=http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=cm&part=A245#A251 |accessdate=|id={{LCC|RC71 .C63}} }} [http://lccn.loc.gov/87013782 Library of Congress]</ref> | | publisher = Appleton & Lange}}</ref><ref name="isbn0-409-90077-X">{{cite book |author= |authorlink= |editor=Walker HK, Hall WD, Hurst JW |others= |title=Clinical methods: the history, physical, and laboratory examinations |edition=3rd |language=English |publisher=Butterworths |location=London |year=1990 |origyear= |pages= |quote= |isbn=0-409-90077-X |oclc= |doi= |url=http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=cm|chapter=The Physical Examination|chapterurl=http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=cm&part=A245#A251 |accessdate=|id={{LCC|RC71 .C63}} }} [http://lccn.loc.gov/87013782 Library of Congress]</ref> | ||
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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. | 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==== | ====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 sign]]s, <ref>Especially when there is suspicion of cardiovascular disease, it is wise to take blood pressures on both arms, in sitting, standing, and lying positions</ref>, inspection of the face including [[fundoscope|fundoscopic]] viewing of the eyes and [[otoscope|otoscopic]] viewing of the ears, etc. | In the chair, a starting point is taking basic [[vital sign]]s, <ref>Especially when there is suspicion of cardiovascular disease, it is wise to take blood pressures on both arms, in sitting, standing, and lying positions</ref>, inspection of the face including [[fundoscope|fundoscopic]] viewing of the eyes and [[otoscope|otoscopic]] viewing of the ears, etc. | ||
[[Auscultation]] of the chest is usually easier with the patient sitting on the table, | [[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==== | ====Supine==== | ||
When the patient is [[supine]], this is the usual time to [[palpation|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. | When the patient is [[supine]], this is the usual time to [[palpation|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. | ||
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==Research on the accuracy of the physical examination== | ==Research on the accuracy of the physical examination== | ||
Guidelines have been proposed for reporting research on the physical examination.<ref name="pmid18347878">{{cite journal |author=Simel DL | Guidelines have been proposed for reporting research on the physical examination.<ref name="pmid18347878">{{cite journal |author=Simel DL ''et al.'' |title=The STARD Statement for Reporting Diagnostic Accuracy Studies: Application to the History and Physical Examination |journal=J Gen Intern Med |volume=23 |pages=768–74 |year=2008 |pmid=18347878 |doi=10.1007/s11606-008-0583-3 |url=http://dx.doi.org/10.1007/s11606-008-0583-3 |issn=}}</ref> | ||
==History of the physical examination== | ==History of the physical examination== | ||
| Line 67: | Line 68: | ||
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 [[Sensitivity and specificity|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]]. | 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 [[Sensitivity and specificity|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 test]]s and underutilizes [[medical history taking]] and physical examination. As an example, the rates of unnecessary [[appendectomy]] and appendicieal perforation have not improved over time<ref name="pmid11594900">{{cite journal |author=Flum DR | There is concern that modern medicine overly relies on [[diagnostic test]]s and underutilizes [[medical history taking]] and physical examination. As an example, the rates of unnecessary [[appendectomy]] and appendicieal perforation have not improved over time<ref name="pmid11594900">{{cite journal |author=Flum DR ''et al.'' |title=Has misdiagnosis of appendicitis decreased over time? A population-based analysis |journal=JAMA |volume=286 |pages=1748–53 |year=2001 |month=October |pmid=11594900 |doi= |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=11594900 |issn=}}</ref><ref name="pmid4087950">{{cite journal |author=Scitovsky AA |title=Changes in the costs of treatment of selected illnesses, 1971-1981 |journal=Med Care |volume=23 |pages=1345–57 |year=1985 |pmid=4087950 |doi= |url= |issn=}}</ref> in spite of increased use of laboratory tests<ref name="pmid4087950">{{cite journal |author=Scitovsky AA |title=Changes in the costs of treatment of selected illnesses, 1971-1981 |journal=Med Care |volume=23 |pages=1345–57 |year=1985 |pmid=4087950 |doi= |url= |issn=}}</ref> and [[diagnostic imaging]]<ref name="pmid12620554">{{cite journal |author=Perez J ''et al.''|title=Liberal use of computed tomography scanning does not improve diagnostic accuracy in appendicitis |journal=Am J Surg |volume=185 |pages=194–7 |year=2003 |month=March |pmid=12620554 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0002961002013648 |issn=}}</ref>. However, in general, [[medical history taking]] and physical examination contribute more to diagnosis than do [[diagnostic test]]s.<ref name="pmid1536065">{{cite journal |author=Peterson MC, Holbrook JH, Von Hales D, Smith NL, Staker LV |title=Contributions of the history, physical examination, and laboratory investigation in making medical diagnoses |journal=West. J. Med. |volume=156 |issue=2 |pages=163–5 |year=1992 |month=February |pmid=1536065 |pmc=1003190 |doi= |url= |issn=}}</ref><ref name="pmid1148666">{{cite journal |author=Hampton JR ''et al.'' |title=Relative contributions of history-taking, physical examination, and laboratory investigation to diagnosis and management of medical outpatients |journal=Br Med J |volume=2 |pages=486–9 |year=1975 |month=May |pmid=1148666 |pmc=1673456 |doi= |url= |issn=}}</ref><ref name="pmid466256">{{cite journal |author=Sandler G |title=Costs of unnecessary tests |journal=Br Med J |volume=2 |issue=6181 |pages=21–4 |year=1979 |month=July |pmid=466256 |pmc=1595755 |doi= |url= |issn=}}</ref> 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.<ref name=>{{citation | ||
| url = http://www.trauma.org/index.php/community/list/url/http:list.ftech.net/pipermail/trauma-list/2006-December/034324.html | | url = http://www.trauma.org/index.php/community/list/url/http:list.ftech.net/pipermail/trauma-list/2006-December/034324.html | ||
|title = VOMIT | |title = VOMIT | ||
| first = | | first = JA | last = Arts | ||
| date= December 11, 2006 | publisher = Trauma & Critical Care Mailing List, Trauma.Org}}</ref> | | date= December 11, 2006 | publisher = Trauma & Critical Care Mailing List, Trauma.Org}}</ref> | ||
| Line 77: | Line 78: | ||
| url = http://books.google.com/books?id=7KPPXqI2rEQC&pg=RA1-PA335&lpg=RA1-PA335&dq=TCM+pulses&source=web&ots=dL2iuYP5rv&sig=E2rC0xV3NW7usblwmVL85Nnd-gU&hl=en&sa=X&oi=book_result&resnum=10&ct=result#PRA1-PA335,M1 | | url = http://books.google.com/books?id=7KPPXqI2rEQC&pg=RA1-PA335&lpg=RA1-PA335&dq=TCM+pulses&source=web&ots=dL2iuYP5rv&sig=E2rC0xV3NW7usblwmVL85Nnd-gU&hl=en&sa=X&oi=book_result&resnum=10&ct=result#PRA1-PA335,M1 | ||
| title = Palpation and Assessment Skills: Assessment and Diagnosis Through Touch | | title = Palpation and Assessment Skills: Assessment and Diagnosis Through Touch | ||
| author = | | author = Chaitow L ''et al.'' | ||
| publisher = Elsevier Health Sciences | year = 2003 | | publisher = Elsevier Health Sciences | year = 2003 | ||
| contribution = Special Topic 11: Palpating the Traditional Chinese Pulses | | contribution = Special Topic 11: Palpating the Traditional Chinese Pulses | ||
|ISBN=0443072183, | |ISBN=0443072183, | ||
}}, pp. 335- | }}, pp. 335-9</ref> 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. | 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. | ||
Revision as of 14:09, 14 February 2009
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."[1]
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."
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.[2][3]
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, [4], 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
Auscultation is the "act of listening for sounds within the body." [5] Auscultation helps assess respiratory sounds[6], heart sounds[7], and heart murmurs[7].
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."[8]
Percussion
Percussion is the "act of striking a part with short, sharp blows as an aid in diagnosing the condition beneath the sound obtained."[9]
Research on the accuracy of the physical examination
Guidelines have been proposed for reporting research on the physical examination.[10]
History of the physical examination
Walker has compiled the following dates in the development of the techniques for the physical examination.[11]
- Hippocrates: A Rational Profession 460–370 b.c
- Vesalius: Establishment of an Accurate Anatomy, 1543
- Sydenham: The Nosology of Disease, 1666
- Morgagni: The Foundation of Pathologic Anatomy, 1761
- Auenbrugger: The Discovery of Percussion, 1761
- Laennec: The Stethoscope and elaboration of the methods of auscultation 1816
- Helmholtz: The ophthalmoscope, 1850
- Carl Wunderlich: The thermometer, 1871
- Erb and Westphal: The reflex Hammer, 1875
- 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[12][13] in spite of increased use of laboratory tests[13] and diagnostic imaging[14]. However, in general, medical history taking and physical examination contribute more to diagnosis than do diagnostic tests.[15][16][17] 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.[18]
Examining techniques in complementary medicine
Some traditional and complementary disciplines, such as traditional Chinese medicine (TCM), often combine traditional and contemporary examination techniques.[19] 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
- ↑ Anonymous (2024), Physical examination (English). Medical Subject Headings. U.S. National Library of Medicine.
- ↑ Harrell, RA & GS Firestein (3rd edition, 1988), The Effective Scutboy: The Principles and Practice of Scut, Appleton & Lange
- ↑ (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
- ↑ Especially when there is suspicion of cardiovascular disease, it is wise to take blood pressures on both arms, in sitting, standing, and lying positions
- ↑ Anonymous (2024), Auscultation (English). Medical Subject Headings. U.S. National Library of Medicine.
- ↑ (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
- ↑ 7.0 7.1 (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
- ↑ Anonymous (2024), Palpation (English). Medical Subject Headings. U.S. National Library of Medicine.
- ↑ Anonymous (2024), Percussion (English). Medical Subject Headings. U.S. National Library of Medicine.
- ↑ 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.
- ↑ 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.
- ↑ Flum DR et al. (October 2001). "Has misdiagnosis of appendicitis decreased over time? A population-based analysis". JAMA 286: 1748–53. PMID 11594900. [e]
- ↑ 13.0 13.1 Scitovsky AA (1985). "Changes in the costs of treatment of selected illnesses, 1971-1981". Med Care 23: 1345–57. PMID 4087950. [e]
Cite error: Invalid
<ref>tag; name "pmid4087950" defined multiple times with different content - ↑ 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]
- ↑ 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]
- ↑ Hampton JR et al. (May 1975). "Relative contributions of history-taking, physical examination, and laboratory investigation to diagnosis and management of medical outpatients". Br Med J 2: 486–9. PMID 1148666. PMC 1673456. [e]
- ↑ Sandler G (July 1979). "Costs of unnecessary tests". Br Med J 2 (6181): 21–4. PMID 466256. PMC 1595755. [e]
- ↑ Arts, JA (December 11, 2006), VOMIT, Trauma & Critical Care Mailing List, Trauma.Org
- ↑ 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