Physical Examination

September 23, 2011

┬áThe concept of the adult physical examination has changed significantly in the past several years. As compared to many years ago when having a “physical” meant an annual hour-long history and physical examination, medical care has changed to consist of a series of visits where a broad array of issues are addressed. The care is tailored to the patient’s gender, health history, and family history. Screening for illnesses for which she is at risk, counseling for problems that she is at risk of, and immunizations are addressed during the visits. The extent of the physical examination is based on the clinical situation. The purpose of the physical examination is to allow the patient to express concerns and explain symptoms she is experiencing. It allows the physician to investigate physical complaints further as he or she examines the patient, and in some cases to establish a baseline of normal physical findings. It is an opportunity to obtain not only further history but to share a multitude of information between the patient and the physician.

WHAT IS A COMPREHENSIVE EXAMINATION?

A critical part of every physical examination is an assessment of the vital signs. This includes the pulse, respiratory rate, and blood pressure. Blood pressure is a very important part of any physical examination and if there are symptoms, it is important to check the temperature. An elevated blood pressure of greater than 140 systolic should be repeated with the patient at rest for 5 min. Antihypertensive medication should not be started based on a single high reading. At least three abnormal readings should be obtained before starting the medication. The blood pressure should be repeated to confirm that it is real and not due to anxiety.

Any skin lesions should be assessed and if the patient has any complaints regarding her hair or scalp, a thorough examination of the entire scalp, skull, and face should be done. A comprehensive examination of the eyes is generally done in an ophthalmologist’s or optometrist’s office. The primary care provider, however, does need to assess the position of the eyes and the health of the eyelids and conjunctiva of each eye.

Examination of the ears allows one to inspect the eardrums, canals, and external ears. The nose and sinuses are examined by palpating the areas above the eyebrows in the midline (frontal sinus) and the maxillary sinuses (below each eye). Palpation may reveal tenderness and provide clues to the presence of infection. Examination of the mouth and throat includes a check of the lips, oral mucosa, gums, teeth, and tongue. Lymph nodes are present in the neck, both in the front and the back of the neck and are referred to as anterior and posterior cervical lymph nodes. The thyroid gland rests in the middle of the neck in the midline and is palpated to check for enlargement or nodules. Examination of the chest is done using visual inspection, palpation of the chest wall, and listening with the stethoscope. The purpose of listening with the stethoscope is to identify any abnormal sounds that might indicate bronchospasm (wheezing) or crackling sounds that would be consistent with fluid in the lungs or infection. Examination of the breasts is done usually with the patient’s arms relaxed and then elevated. It is also helpful to bring her hands to her hips and ask her to press down on the hips so that it may make any abnormalities more prominent.

The musculoskeletal system examination includes assessment of the arms, legs, shoulders, neck, and the temporomandibular joint, where the mandible (or jaw) connects with the skull. It is important that any painful joints be palpated and an evaluation of the range of motion of the joint be done.

In order to fully evaluate the heart, it is important to look at and palpate the carotids that are the large arteries in the neck. One may listen for carotid bruits that are muffled sounds indicating possible obstruction in the vessels. Examination of the heart is done by listening to all areas of the heart that coincide with the four heart valves. When examining the abdomen it is important to first look then listen for the presence of bowel sounds. After bowel sounds are identified, it is appropriate to percuss the abdomen to identify the span of the liver. At this point, the examiner can examine lightly and then more deeply with the fingers. The genital and rectal examination in women is performed with the woman in the stirrups. The external genitalia are examined along with the vagina and cervix. A Pap smear is obtained; palpation of the uterus and the annexa (ovaries) is done.

The examination of the legs includes palpation to check for swelling in the legs, also known as edema. The pulse on the top of the foot is known as the dorsalis pedis and is one way to assess the adequacy of blood flow to the feet.

A neurologic examination assesses the health of the cranial nerves, which are the nerves that supply the face, head, and neck. The cranial nerves can be checked by looking for the patient’s sense of smell, strength of the jaw muscles, corneal reflexes that are the reflexes of the eye when touched, facial movements, the gag reflex, and the strength of the muscles in the neck. Muscle strength testing is part of the neurologic examination, as is sensation and the evaluation of balance to further assess the cerebellar system.

WHAT IS THE APPROPRIATE DEPTH OF A PHYSICAL EXAMINATION?

This clearly must be based upon the patient’s age, her known health problems, and her complaints. The depth of an examination for a healthy 40-year-old with no symptoms is very different from the depth of an examination given to a 30-year-old with severe illnesses. In general, what has been described above is a very comprehensive examination and not necessarily what is indicated for each patient at each visit.

It is important to realize that a physical examination provides an assessment of the person’s physical status at the time of the examination. For example, a normal physical examination is no guarantee of normal health as it simply allows the physician to evaluate that person on that day. Taking a good history and doing a good examination so that appropriate testing may be ordered allows the physician to evaluate any symptoms that the patient may be having. However, unfortunately, it does occur that a person with no symptoms can become ill shortly after having a normal physical examination. This makes the point that a physical examination is no guarantee of sound health, but it is a great opportunity to identify and evaluate symptoms.

The frequency of the examination depends on the health status of each person. A well woman with no physical problems may go for a long period of time between physical examinations.

However, special populations do exist that do require much more compulsive care in order to prevent physical abnormalities in the future. Diabetic women require much closer monitoring of many aspects of their health, in addition to monitoring of their glucose levels. Because diabetics suffer from a certain set of illnesses, very specific examinations need to be done on a regular basis. Diabetes can cause retinal damage and result in blindness. Thus, it is very important for diabetic patients to have routine eye examinations by an ophthalmologist or optometrist. The blood pressure must be monitored and maintained within a very safe level. A foot examination utilizing a sensitive test called a monofilament examination is used to identify decreased sensation. By identifying women with decreased sensation in the feet, they can be targeted for interventions by the podiatrist to maintain healthy feet and reduce the risk of amputation that accompanies sensory loss. With regard to lab work, diabetic patients require routine monitoring of their glycosylated hemoglobin levels. This level indicates the overall control of the diabetes. Other routine monitoring that must be done is measurement of kidney function, evaluation and management of high cholesterol, and checks for protein in the urine.

There are other populations of patients who are disadvantaged, either due to homelessness, mental illness, or being in abusive situations. Many times these patients have difficulty keeping appointments, thus, when they do present for care, as much care should be given to them as possible.

SEE ALSO: Preventive care

Suggested Reading

  • Barker, L. R., Burton, J. R., & Zieve, P. D. (Eds.). (2003). Principles of ambulatory medicine (6th ed.). Philadelphia: J.B. Lippincott.
  • Bates, B. (1995). A guide to physical examination and history taking (6th ed.). Philadelphia: J.B. Lippincott.
  • Carlson, K. J., Eisenstat, S. A., Frigoletto, F. D., Jr., & Shift, I. (1995). Primary care of women. St. Louis, MO: C.V. Mosby.

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