Chapter 4
The Physical Examination
Don’t touch the patient—state first what you see; cultivate your powers of observation.
Sir William Osler (1849–1919)
The Basic Procedures
In the previous chapters, the general rules for mastering the art of taking the history are discussed. The specific skills necessary to perform a proper physical examination are discussed in this chapter. The four principles of physical examination are as follows:
To achieve competence in these procedures, the student must, in the words of Sir William Osler, “teach the eye to see, the finger to feel, and the ear to hear.” The ability to coordinate all this sensory input is learned with time and practice.
Even though examiners do not use all these techniques for every organ system, they should think of these four skills before moving on to the next area to be evaluated.
Inspection
Inspection can yield an enormous amount of information. Proper technique requires more than just a glance. Examiners must train themselves to look at the body by using a systematic approach. All too often, the novice examiner rushes to use the ophthalmoscope, stethoscope, or otoscope before the naked eyes have been used for inspection.
An example of what is meant by “teaching the eye to see” can be demonstrated in the following exercise. Read the sentence in the box. Then count the number of “f’s” in the sentence.
How many did you count? The answer is given in a footnote at the end of this chapter. This example clearly shows that eyes have to be trained to see.1
While taking the history, the examiner should observe the following aspects of the patient:
The general appearance includes the state of consciousness and personal grooming. Does the patient look well or sick? Is he or she comfortable in bed, or does he or she appear in distress? Is the patient alert, or is he or she groggy? Does he or she look acutely or chronically ill? The answer to this last question is sometimes difficult to determine from inspection, but there are some useful signs to aid the examiner. Poor nutrition, sunken eyes, temporal wasting, and loose skin are associated with chronic disease. Does the patient appear clean? Although the patient is ill, he or she does not have to appear unkempt. Is his or her hair combed? Does he or she bite fingernails? The answers to these questions may provide useful information about the patient’s self-esteem and mental status.
Inspection can evaluate the state of nutrition. Does the patient appear thin and frail? Is the patient obese? Most individuals with chronic disease are not overweight; they are cachectic. Long-standing ailments such as cancer, hyperthyroidism, or heart disease can result in a markedly wasted appearance. See Chapter 29, Assessment of Nutritional Status, available online.
The body habitus is useful to observe, because certain disease states are more common in different body builds. The asthenic, or ectomorphic, patient is thin, has poor muscle development and small bone structure, and appears malnourished. The sthenic, or mesomorphic, patient is the athletic type with excellent development of the muscles and a large bone structure. The hypersthenic, or endomorphic, patient is a short, round individual with good muscle development but frequently has a weight problem.
Because the outward appearance of the body is symmetric, any asymmetry should be noted. Many systemic diseases provide clues that can be uncovered on inspection. For example, an obvious unilateral supraclavicular swelling or a less obvious unilateral miotic pupil is a clue that can aid the examiner in reaching a final diagnosis. A left supraclavicular swelling in a 61-year-old man may represent an enlarged supraclavicular lymph node and could be the only sign of gastric carcinoma. A miotic pupil in a 43-year-old woman may be a manifestation of interruption of the cervical sympathetic chain by a tumor of the apex of the lung. The recent onset of a left-sided varicocele in a 46-year-old man could be related to a left hypernephroma.
The patient is usually in bed when introduced to the examiner. If the patient were walking about, the examiner could use this time to observe the patient’s posture and gait. The ability to walk normally involves coordination of the nervous and musculoskeletal systems. Does the patient drag a foot? Is there a shuffling gait? Does the patient limp? Are the steps normal?
The examiner can learn much about the patient from his or her speech patterns. Is the speech slurred? Does the patient use words appropriately? Is the patient hoarse? Is the voice unusually high or low in pitch? Is the patient moving his or her face normally when speaking? If not, this could provide clues to some cranial nerve problems.
Is the patient oriented to person, place, and time? This can easily be evaluated by asking the patient, “Who are you?” “Where are you?” “What is the date, season, or month?” and “What is the name of the president of the United States?” These questions certainly do not have to be asked at the beginning, but they should be asked at some time during the interview and examination. These questions provide an insight into the mental status of the patient. The mental status examination is discussed further in Chapter 18, The Nervous System.
The examiner must be able to recognize the cardinal signs of inflammation: swelling, heat, redness, pain, and disturbance of function. Swelling results from edema or congestion in local tissues. Heat is the sensation resulting from an increased blood supply to the involved area. Redness is also a manifestation of the increased blood supply. Pain often results from the swelling, which exerts increased pressure on the nerve fibers. Because of the pain and swelling, a disturbance of function may occur.
Palpation
Palpation is the use of touch to determine the characteristics of an area of the body, such as skin elevation or depression, warmth, tenderness, pulses, crepitus, and sizes of organs or masses. For example, an abnormal impulse may be palpated in the right side of the chest and could be related to an ascending aortic aneurysm. A pulsatile mass palpated in the abdomen might be an abdominal aneurysm. An acutely tender mass palpated in the right upper quadrant of the abdomen that descends with inspiration is probably an inflamed gallbladder.
Percussion
Percussion relates to the tactile sensation and sound produced when a sharp blow is struck to an area being examined. One finger delivers a sharp tap to another finger of the other hand. This provides valuable information about the structure of the underlying organ or tissue. A difference from normal sensation may be related to fluid in an area that normally does not contain fluid. Collapse of a lung changes the percussion note, as does a solid mass in the abdomen. Percussion that produces a dull note in the midline of the lower abdomen in a man probably represents a distended urinary bladder.
Auscultation
Auscultation involves listening to sounds produced by internal organs. This technique furnishes information about an organ’s disease process. The examiner is urged to learn as much as possible from the other techniques before using the stethoscope. This instrument should corroborate the signs that were suggested by the other techniques. To examine the heart, chest, and abdomen, auscultation should be used, not alone, but together with inspection, percussion, and palpation. Listening for carotid, ophthalmic, or renal bruits can provide lifesaving information. The absence of normal bowel sounds could indicate a surgical emergency.
