PHYSICAL EXAMINATION AND COMPONENTS

Physical examination

Physical examination is the process of evaluating objective anatomic and physiologic findings
through the use of observation, palpation, percussion, and auscultation. It should focus on the
information obtained from medical history and must be thoughtfully integrated with the patient's
history and pathophysiology. It is important to proceed systematically and should not be directed
by a presumed diagnosis because if thoughtfully performed, physical examination should yield
20% of the data necessary for patient diagnosis and management.

Purpose of physical examination

The purpose of the physical examination is to discover any possible anatomic or physiologic
basis for the presenting complain.

Materials for physical examination.

The single most useful device for optimal performance of the physical examination is an
inquisitive and sensitive mind in addition to devices such as thermometer, stethoscope, timer,
sphygmomanometer, etc. Mastery of the techniques of observation, palpation, percussion, and
auscultation.

Techniques of Physical examination.

There are four main techniques in carrying out physical examination:

a) Inspection (looking at the body)

b) Palpation (feeling the body with fingers or hands)

c) Percussion (producing sounds, usually by tapping on specific areas of the body)

d) Auscultation (listening to sounds, usually with a stethoscope)

Inspection: Inspection involves observation for abnormal findings. A general inspection begins
the moment the patient walks into the room. For instance, are they limping or holding a body
part in pain? Is their gait abnormal, or are they shuffling their feet when they walk? Is there a
visible rash or loss of muscle mass or tissue that implies significant weight loss? Inspection
provides vital clues to a patient’s overall health.

Palpation: Palpation is the process of feeling a body part for abnormalities. Although the
abdomen is the most often part of the body palpated, abnormal or sustained beats felt in the area
above the heart, the contour of peripheral pulses, the temperature of the skin, or whether a lesion
is raised or flat are all examples of how palpation helps to narrow down a differential diagnosis.

Percussion: Percussion utilizes the resonant properties of different tissues to determine things
such as the presence or absence of fluids, solids, or air in a body cavity. This is done by striking
a hollow body surface with a finger, either directly, or by putting one hand on the surface and
striking that finger with a finger of the other hand. Mixtures of solids, fluids, and air conduct
sound at different frequencies. This produces different tones that can be distinguished with a
trained ear. Percussion is one of the more difficult physical exam skills for the early learner to
master. Even for experienced practitioners, it usually can only suggest rather than confirm a
diagnosis.

Auscultation: Auscultation uses a stethoscope to listen for the movements and sounds made by
internal organs – most commonly the heart, lungs, and abdomen. Normal sounds can be initially
quite difficult to distinguish from abnormal sounds; therefore, it is good to listen to as many
normal sounds as possible for a start. With experience, it will be to discover when something
deviates from the usual pattern.

Procedure for Physical examination.

1) The Patient’s comfort. It is of uttermost importance that the patient is in a relaxed

position, properly gowned or draped.
2) The optimal environment.
The examination surface should be at a height appropriate for the examiner. Light sources
and curtains should be optimally arranged. Television sets, radios, and other noisy
distractions should be eliminated.
3) Vital signs and general inspection
Evaluate the radial pulse for rate and rhythm. Measure brachial blood pressure. Inspect
nails, skin, and hair. Note the general appearance, body habitus, hair distribution, muscle
mass, movement coordination, odors, and breathing pattern.

4) Head

 Eyes: Examine the conjunctiva, sclera, cornea, and iris of each eye. Test pupils
for irregularity, accommodation, and reaction. Evaluate visual fields and visual
acuity (cranial nerve II). Assess extraocular movements (cranial nerves III, IV,
VI). Test the corneal reflex (cranial nerve V).

 Ears: Examine the pinnae and periauricular tissues.

 Ophthalmo-otoscopy: The ophthalmoscope can now be used after darkening the

room to examine the interior of the eye through the pupillary aperture. Particular
emphasis should be placed on the retina, optic disc, vessels, macula lutea, the
media, lens, and cornea. The opthalmoscope should be used to observe the
auditory canals and tympani.

 Nose: The nasal speculum should be connected to the otoscope so as to examine

the nares, taking note of the condition of the mucosa, septum and turbinates.

 Mouth: Examine the vermilion border, the oral mucosa, the tongue. Identify the
salivary duct papillae. Assess the dentition for decay, repair etc. View the
pharynx. Evaluate the function of cranial nerves IX, X, and XII. If appropriate,
evaluate sensory divisions of cranial nerves V, VII.

 Face: Evaluation of symmetry, smile, frown, and jaw movement will provide
information about motor divisions of cranial nerves V and VII.

5) Neck
Palpate the neck with emphasis on the salivary glands, lymph nodes, and thyroid. Look
for tracheal deviation. Identify the carotid arteries and auscultate for bruits. Note jugular
venous distention. Reexamine the thyroid from behind the patient. Test shoulder strength
of the sternocleidomastoid and trapezius muscles (cranial nerves XI and XII).
 6) Anterior torso
With the patient sitting, examine the epitrochlear and axillary nodes. Examine the breasts.
Examine the heart, having the patient lean forward if necessary.

7) Posterior torso
Observe for spinal curvature or chest deformity. Evaluate the vertebral column and the
costovertebral areas. Auscultate the posterior and lateral lung fields.

8) Completion of the "sitting" portion of the examination

Evaluate proximal and distal motor strength, deep tendon reflexes, distal pulses and
sensation.

9) With the patient supine

a. Thorax: Examine the breasts; reexamine the heart, turning the patient to the left
lateral decubitus position if appropriate. Auscultate the anterior lung structures.

b. Abdomen: After inspection, auscultate, listening for bowel sounds and bruits.
Next inspect, percuss, and palpate the abdomen, taking special notice of hepatic
or splenic enlargements.

c. Proximal lower extremities: Examine the inguinal, femoral, and popliteal regions
for adenopathy and pulses. Evaluate range of motion of hips, knees, and ankles.

10) With the patient standing

Examine external genitalia of the male and female. In females, the pelvic examination
should be performed on an examining table provided with stirrups. Rectal examination
and occult blood testing should be done simultaneously. In males, the rectal examination
is best performed with the patient in the bent forward position.

The physical examination is a key part of a continuum that extends from the history of the
present illness to the therapeutic outcome. If the history and physical examination are linked
properly by the physician's reasoning capabilities, laboratory tests should in large measure be
confirmation.

Types of physical exam

  Routine. This is a physical examination performed on an asymptomatic patient
for medical screening purposes.
 Comprehensive. Comprehensive physical exams, also known as executive physicals, in
addition to the physical examination typically include laboratory tests, chest x-rays,
pulmonary function testing, audiograms, full body CAT (Computed Axial Tomography)
scanning, EKGs or ECG (Electro Cardio Gram), heart stress tests, vascular age tests,
urinalysis, and mammograms or prostate exams depending on gender. It is a thorough
assessment designed to evaluate an individual's overall health. So, it helps to identify any
potential health risks early on.

 Pre-employment. Pre-employment examinations as the name implies are screening tests

which judge the suitability of a worker for hire based on the results of their physical
examination.

 Insurance. A physical examination may be provided under health insurance cover,

required of new insurance customers.

Uses of physical examination.

To enable the Doctor or a health care provider arrive at a diagnosis

To screen for diseases before such diseases occur.

To improve the Doctor-patient relationship.