Physical examination

Physical examination
Intervention

An examination room in Washington, DC, during the first World War
ICD-9-CM 89.7
MeSH D010808
MedlinePlus 002274

A physical examination, medical examination, or clinical examination (more popularly known as a check-up) is the process by which a medical professional investigates the body of a patient for signs of disease. It generally follows the taking of the medical history—an account of the symptoms as experienced by the patient. Together with the medical history, the physical examination aids in determining the correct diagnosis and devising the treatment plan. This data then becomes part of the medical record.

A Cochrane Collaboration meta-study found that routine annual physicals did not measurably reduce the risk of illness or death, and conversely, could lead to over-diagnosis and over-treatment. The authors concluded that routine physicals were unlikely to do more good than harm.[1]

Types

A resident physician at the Granada Relocation Center, examining a patient's throat

Routine physicals

Routine physicals are physical examinations performed on asymptomatic patients for medical screening purposes. These are normally performed by a pediatrician, family practice physician, physician assistant, a certified nurse practitioner or other primary care provider. This routine physical exam usually includes the HEENT evaluation. Nursing professionals such as Registered Nurse, Licensed Practical Nurses develop a baseline assessment to identify normal versus abnormal findings.[2] These are reported to the primary care provider.

Comprehensive physicals

Comprehensive physical exams, also known as executive physicals, typically include laboratory tests, chest x-rays, pulmonary function testing, audiograms, full body CAT scanning, EKGs, heart stress tests, vascular age tests, urinalysis, and mammograms or prostate exams depending on gender.[3]

Pre-employment examinations

Pre-employment examinations are screening tests which judge the suitability of a worker for hire based on the results of their physical examination.[4] This is also called pre-employment medical clearance. Many employers believe that by only hiring workers whose physical examination results pass certain exclusionary criteria, their employees collectively will have fewer absences due to sickness, fewer workplace injuries, and less occupational disease.[4]

A small amount of low-quality evidence in medical research supports the idea that pre-employment physical examinations can actually reduce absences, workplace injuries, and occupational disease.[4]

Employers should not routinely request that workers x-ray their lower backs as a condition for getting a job.[5] Reasons for not doing this include the inability of such testing to predict future problems, the radiation exposure to the worker, and the cost of the exam.[5]

Insurance exams

These are physicals performed as a condition of buying health insurance or life insurance.

Uses

Diagnosis

Physical examinations are performed in most healthcare encounters. For example, a physical examination is performed when a patient visits complains of flu-like symptoms. These diagnostic examinations usually focus on the patient's chief complaint.

Screening

General health checks, including physical examinations performed when the patient reported no health concerns, often include medical screening for common conditions, such as high blood pressure. A Cochrane review found that general health checks did not reduce the risk of death from cancer, heart disease, or any other cause, and could not be proved to affect the patient's likelihood of being admitted to the hospital, becoming disabled, missing work, or needing additional office visits. The study found no effect on the risk of illness, but did find evidence suggesting that patients subject to routine physicals were diagnosed with hypertension and other chronic conditions at a higher rate than those who were not. Its authors noted that studies often failed to consider or report possible harmful outcomes (such as unwarranted anxiety or unnecessary follow-up procedures), and concluded that routine health checks were "unlikely to be beneficial" in regards to lowering cardiovascular and cancer morbidity and mortality.[1]

Establishing doctor-patient relationship

In addition to the possibility of identifying signs of illness, it has been described as a ritual that plays a significant role in the doctor-patient relationship that will provide benefits in other medical encounters.[6]

Format and interpretation

Auscultation of a man in Vietnam

A physical examination may include checking vital signs, including temperature examination, Blood pressure, pulse, and respiratory rate. The healthcare provider uses the senses of sight, hearing, touch, and sometimes smell (e.g., in infection, uremia, diabetic ketoacidosis). Taste has been made redundant by the availability of modern lab tests. Four actions are taught as the basis of physical examination: inspection, palpation (feel), percussion (tap to determine resonance characteristics), and auscultation (listen).

What is checked

While elective physical exams have become more elaborate, in routine use physical exams have become less complete. This has led to editorials in medical journals about the importance of an adequate physical examination.[7][8]

Although providers have varying approaches as to the sequence of body parts, a systematic examination generally starts at the head and finishes at the extremities. After the main organ systems have been investigated by inspection, palpation, percussion, and auscultation, specific tests may follow (such as a neurological investigation, orthopedic examination) or specific tests when a particular disease is suspected (e.g. eliciting Trousseau's sign in hypocalcemia).

With the clues obtained during the history and physical examination the healthcare provider can now formulate a differential diagnosis, a list of potential causes of the symptoms. Specific diagnostic tests (or occasionally empirical therapy) generally confirm the cause, or shed light on other, previously overlooked, causes.

Physicians at Stanford University medical school have introduced a set of 25 key physical examination skills that were felt to be useful.[9]

Example

A doctor using a stethoscope to listen to a 15-month-old's abdomen

While the format of examination as listed below is largely as taught and expected of students, a specialist will focus on their particular field and the nature of the problem described by the patient. Hence a cardiologist will not in routine practice undertake neurological parts of the examination other than noting that the patient is able to use all four limbs on entering the consultation room and during the consultation become aware of their hearing, eyesight and speech. Likewise an Orthopaedic surgeon will examine the affected joint, but may only briefly check the heart sounds and chest to ensure that there is not likely to be any contraindication to surgery raised by the anaesthetist. A primary care physician will also generally examine the male genitals but may leave the examination of the female genitalia to a gynecologist.

A complete physical examination includes evaluation of general patient appearance and specific organ systems. It is recorded in the medical record in a standard layout which facilitates others later reading the notes. In practice the vital signs of temperature examination, pulse and blood pressure are usually measured first.

Section Sample text Comments
General "Patient in NAD. VS: WNL" May be split on two lines. "WNL" = "within normal limits"
HEENT: "NC/AT. PERRLA, EOMI. No cervical LAD, no thyromegaly, no bruit, no pallor, fundus WNL, oropharynx WNL, tympanic membrane WNL, neck supple" "Neck" is sometimes split out from "Head". "Good dentition" may be noted.
Resp or "Chest" "Nontender, CTA bilat" Chest expansion test, normal breathing with little effort, absence of wheezing, rhonchi and crackles. More detailed examinations can include rales, rhonchi, wheezing ("no r/r/w"), and rubs. Other phrases may include "no cyanosis or clubbing" (if section is labeled "Resp" and not "Chest"), "fremitus WNL", and "no dullnes to percussion".
CV or "Heart" "+S1, +S2, RRR, no m/r/g" If "CV" is used instead of "heart", peripheral pulses are sometimes included in this section (otherwise, they may be in the extremities section)
Abd "Soft, nontender, nondistended, absence of pain, no hepatosplenomegaly, NBS" If lower back pain is involved, then the "Back" may become a primary section. Costovertebral angle tenderness may be included in the abdominal section if there is no back section. More detailed examinations may report "+psoas sign, +Rovsing's sign, +obturator sign". If tenderness was present, it might be reported as "Direct and rebound RLQ tenderness". "NBS" stands for "normal bowel sounds"; alternatives might include "hypoactive BS" or "hyperactive BS".
Ext "No clubbing, cyanosis, edema" Checking the fingers for clubbing and cyanosis is sometimes considered part of the pulmonary exam, because it closely involves oxygenation. Examinations of the knee may involve the McMurray test, Lachman test, and drawer test.
Neuro "A&Ox3, CN II-XII grossly intact, Sensation intact in all four extremities (dull and sharp), DTR 2+ bilat, Romberg negative, cerebellar reflexes WNL, normal gait" Sensation may be expanded to include dull, sharp, vibration, temperature, and position sense. A mental status exam may be reported at the beginning of the neurologic exam, or under a distinct "Psych" section.

Depending upon the chief complaint, additional sections may be included. For example, hearing may be evaluated with a specific Weber test and Rinne test, or it may be more briefly addressed in a cranial nerve exam. To give another example, a neurological related complaint might be evaluated with a specific test, such as the Romberg maneuver.

History

The executive physical format was developed from the 1970s by the Mayo Clinic and is now offered by other health providers, including Johns Hopkins University, EliteHealth and Mount Sinai in New York City. Executive physicals are also the primary service of concierge doctors, who say that they do a more thorough examination for a cash premium on top of the insurance coverage.[10]

Society and culture

A physical examination may be provided under health insurance cover, required of new insurance customers. This is a part of insurance medicine. In the United States, physicals are also marketed to patients as a one-stop health review, avoiding the inconvenience of attending multiple appointments with different healthcare providers.[11][12]

See also

References

  1. 1 2 Krogsbøll, Lasse T; Karsten Juhl Jørgensen; Christian Grønhøj Larsen; Peter C Gøtzsche; Lasse T Krogsbøll (2012). "General health checks in adults for reducing morbidity and mortality from disease". doi:10.1002/14651858.CD009009.pub2.
  2. ↑ Schreiber, Mary L. Evidence-Based Practice. Neurovascular Assessment: An Essential Nursing Focus. MEDSURG Nursing (MEDSURG NURS), Jan/Feb2016; 25(1): 55-57. ISSN 1092-0811
  3. ↑ "Johns Hopkins Executive Health Program".
  4. 1 2 3 Mahmud, Norashikin; Schonstein, Eva; Schaafsma, Frederieke; Lehtola, Marika M; Fassier, Jean-Baptiste; Reneman, Michiel F; Verbeek, Jos H; Mahmud, Norashikin (2010). "Pre-employment examinations for preventing occupational injury and disease in workers". doi:10.1002/14651858.CD008881.
  5. 1 2 American College of Occupational and Environmental Medicine (February 2014), "Five Things Physicians and Patients Should Question", Choosing Wisely: an initiative of the ABIM Foundation, American College of Occupational and Environmental Medicine, retrieved 24 February 2014, which cites
    • Talmage, J; Belcourt, R; Galper, J; et al. (2011). "Low back disorders". In Kurt T. Hegmann. Occupational medicine practice guidelines : evaluation and management of common health problems and functional recovery in workers (3rd ed.). Elk Grove Village, IL: American College of Occupational and Environmental Medicine. pp. 336, 373, 376–377. ISBN 978-0615452272.
  6. ↑ Verghese A, Brady E, Kapur CC, Horwitz RI (October 2011). "The bedside evaluation: ritual and reason". Ann. Intern. Med. 155 (8): 550–3. doi:10.1059/0003-4819-155-8-201110180-00013. PMID 22007047.
  7. ↑ Flegel KM (November 1999). "Does the physical examination have a future?". Canadian Medical Association Journal. 161 (9): 1117–8. PMC 1230732Freely accessible. PMID 10569087.
  8. ↑ McAlister FA, Straus SE, Sackett DL (February 2000). "High marks for the physical exam". Canadian Medical Association Journal. 162 (4): 493. PMC 1231165Freely accessible. PMID 10701381.
  9. ↑ Verghese A, Horwitz RI (2009). "In praise of the physical examination" (PDF). BMJ. 339: b5448. doi:10.1136/bmj.b5448. PMID 20015910.
  10. ↑ Executive physicals Physical Exam in NYC
  11. ↑ Brink, Susan (18 February 2008). "$2,000 physicals for busy execs". Los Angeles Times. Retrieved 16 July 2009.
  12. ↑ Armour, Lawrence A. (21 July 1997). "2,500 executives flock to Rochester, Minn., for a deluxe, soup-to-nuts physical at the Mayo clinic. Our man went for a tune-up to find out why". CNN.com. Retrieved 16 July 2009.
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