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Physical Examination: Systematic and thorough inspection of the patient for physical signs of disease or abnormality.
 Science Education: Essentials of Physical Examinations I

Proper Adjustment of Patient Attire during the Physical Exam

JoVE Science Education

Source: Jaideep S. Talwalkar, MD, and Joseph Donroe, MD, Internal Medicine and Pediatrics, Yale School of Medicine, New Haven, CT

In order to optimize the predictive value of the physical examination, the provider must perform maneuvers correctly. The proper use of drapes is an important component of correctly performing physical examination maneuvers. Skin lesions are missed when "inspection" occurs through clothing, crackles are erroneously reported when the lungs are examined through a t-shirt, and subtle findings on the heart exam go undetected when auscultation is performed over clothing. Accordingly, the best practice standards call for examining with one's hands or equipment in direct contact with the patient's skin (i.e., do not examine through a gown, drape, or clothing). In addition to its clinical value, the correct draping technique is important for improving the patient's comfort level during the encounter. Like all other aspects of the physical exam, it takes deliberate thought and practice to find the right balance between draping, which is done to preserve patient modesty, and exposure, which is necessary to optimize access to the parts that need examination. Individual provider styles in the use of gowns and drapes vary consider

 Science Education: Essentials of Physical Examinations II

Abdominal Exam I: Inspection and Auscultation

JoVE Science Education

Source: Alexander Goldfarb, MD, Assistant Professor of Medicine, Beth Israel Deaconess Medical Center, MA

Gastrointestinal disease accounts for millions of office visits and hospital admissions annually. Physical examination of the abdomen is a crucial tool in diagnosing diseases of the gastrointestinal tract; in addition, it can help identify pathological processes in cardiovascular, urinary, and other systems. As physical examination in general, the examination of the abdominal region is important for establishing physician-patient contact, for reaching the preliminary diagnosis and selecting subsequent laboratory and imaging tests, and determining the urgency of care. As with the other parts of a physical examination, visual inspection and auscultation of the abdomen are done in a systematic fashion so that no potential findings are missed. Special attention should be paid to potential problems already identified by the patient's history. Here we assume that the patient has already been identified, and has had history taken, symptoms discussed, and areas of potential concern identified. In this video we will not review the patient's history; instead, we will go directly to the physical examination. Before we get to the examination, let's briefly review s

 Science Education: Essentials of Physical Examinations I

General Approach to the Physical Exam

JoVE Science Education

Source: Jaideep S. Talwalkar, MD, Internal Medicine and Pediatrics, Yale School of Medicine, New Haven, CT

The examination of the body is fundamental to the practice of medicine. Since the Roman Empire, physicians have described the connection between alterations in function of specific parts of the body and specific disease states and have sought to further scientific understanding to improve bedside diagnosis. However, in this modern age of increasing technology within medical diagnostics, it is important to consider the role that physical examination plays today. It is misguided to believe that physical examination holds all the answers, and much has been written about the questionable utility of certain maneuvers previously held in high regard. It is equally misguided to suggest that physical examination plays little role in the modern patient encounter. Physical examination remains a valuable diagnostic tool; there are many diagnoses that can only be made by physical examination. A diagnosis made by labs or imaging is rarely done in the absence of findings detectable at the bedside. As the provider conducts a history and physical, they are actively generating and testing hypotheses to explain the patient's condition. The information one gathers may not replace the need

 JoVE Bioengineering

Training Persons with Spinal Cord Injury to Ambulate Using a Powered Exoskeleton

1Department of Veterans Affairs (VA) Rehabilitation Research and Development National Center of Excellence for the Medical Consequences of Spinal Cord Injury, James J. Peters VA Medical Center, 2Department of Veterans Affairs (VA) Spinal Cord Injury Service, James J. Peters VA Medical Center


JoVE 54071

 JoVE Medicine

Multimodal Quantitative Phase Imaging with Digital Holographic Microscopy Accurately Assesses Intestinal Inflammation and Epithelial Wound Healing

1Department of Medicine B, University Hospital Münster, 2Institute of Palliative Care, University Hospital Münster, 3Biomedical Technology Center, University of Münster, 4Department of Gastroenterology, Klinikum Bielefeld


JoVE 54460

 Science Education: Essentials of Physical Examinations II

Male Rectal Exam

JoVE Science Education

Source: Joseph Donroe, MD, Internal Medicine and Pediatrics, Yale School of Medicine, New Haven, CT

While its usefulness in cancer screening is debated, the male rectal examination remains an important part of the physical exam. The exam is indicated in selected patients with lower urinary tract symptoms, urinary and/or fecal incontinence or retention, back pain, anorectal symptoms, abdominal complaints, trauma patients, unexplained anemia, weight loss, or bone pain. There are no absolute contraindications to the rectal exam; however, relative contraindications include patient unwillingness to undergo the exam, severe rectal pain, recent anorectal surgery or trauma, and neutropenia. When performing the rectal exam, the examiner should conceptualize the relevant anatomy. The external anal sphincter is the most distal part of the anal canal, which extends three to four centimeters before transitioning into the rectum. The prostate gland lies anterior to the rectum, just beyond the anal canal. The posterior surface of the prostate, including its apex, base, lateral lobes, and median sulcus, can be palpated through the rectal wall (Figure 1). The normal consistency of the prostate is similar to the thenar eminence when the hand is in a tight fist. The thumb knuckle is representativ

 Science Education: Essentials of Physical Examinations I

Palpation

JoVE Science Education

Source: Jaideep S. Talwalkar, MD, Internal Medicine and Pediatrics, Yale School of Medicine, New Haven, CT

The physical examination requires the use of all of the provider's senses to gain information about the patient. The sense of touch is utilized to obtain diagnostic information through palpation.

The specific parts of the examiner's hand used for palpation differ based on the body part being examined. Because of their dense sensory innervation, the finger pads are useful for fine discrimination (e.g., defining the borders of masses, lymph nodes) (Figure 1). The dorsal surface of the hand provides a rough sense of relative temperature (Figure 2). The palmar surfaces of the fingers and hands are most useful for surveying large areas of the body (e.g., abdomen) (Figure 3). Vibration is best appreciated with the ulnar surface of the hands and 5th fingers (e.g., tactile fremitus) (Figure 4). While palpation is fundamental to the diagnostic aspect of the physical exam, it is also important to acknowledge the role that touch plays in communicating caring and comfort during the patient encounter. Patients generally perceive to

 Science Education: Essentials of Physical Examinations II

Abdominal Exam III: Palpation

JoVE Science Education

Source: Alexander Goldfarb, MD, Assistant Professor of Medicine, Beth Israel Deaconess Medical Center, MA

Abdominal palpation, if performed correctly, allows for examination of the large and relatively superficial organs; for a skilled examiner, it allows for assessment of the smaller and deeper structures as well. The amount of information that can be obtained by palpation of the abdominal area also depends on the anatomical characteristics of the patient. For example, obesity might make palpation of internal organs difficult and require that additional maneuvers be performed. Abdominal palpation provides valuable information regarding localization of the problem and its severity, as abdominal palpation identifies the areas of tenderness as well as presence of organomegaly and tumors. The specific focus of palpation is driven by the information collected during history taking and other elements of the abdominal exam. Palpation helps to integrate this information and develop the strategy for subsequent diagnostic steps.

 Science Education: Essentials of Physical Examinations II

Abdominal Exam IV: Acute Abdominal Pain Assessment

JoVE Science Education

Source: Joseph Donroe, MD, Internal Medicine and Pediatrics, Yale School of Medicine, New Haven, CT

Abdominal pain is a frequent presenting concern in both the emergency department and the office setting. Acute abdominal pain is defined as pain lasting less than seven days, while an acute abdomen refers to the abrupt onset of severe abdominal pain with features suggesting a surgically intervenable process. The differential diagnosis of acute abdominal pain is broad; thus, clinicians must have a systematic method of examination guided by a careful history, remembering that pathology outside of the abdomen can also cause abdominal pain, including pulmonary, cardiac, rectal, and genital disorders. Terminology for describing the location of abdominal tenderness includes the right and left upper and lower quadrants, and the epigastric, umbilical, and hypogastric regions (Figures 1, 2). Thorough examination requires an organized approach involving inspection, auscultation, percussion, and palpation, with each maneuver performed purposefully and with a clear mental representation of the anatomy. Rather than palpating randomly across the abdomen, begin palpating remotely from the site of tenderness, moving systematically toward the tender region, and thi

 Science Education: Essentials of Physical Examinations I

Observation and Inspection

JoVE Science Education

Source: Jaideep S. Talwalkar, MD, Internal Medicine and Pediatrics, Yale School of Medicine, New Haven, CT

Observation and inspection is fundamental to physical examination and begins at the first point of contact with a patient. While observation and inspection are often used interchangeably, observation is a general term that refers to the careful use of one's senses to gain information. Inspection is an act limited to what one can observe visually, and when referring to physical examination, typically refers to findings on the surface of the body, rather than to behaviors. Skilled clinicians utilize all of their senses to assist with gaining an understanding of their patients, relying on vision, touch (percussion and palpation), and hearing (percussion and auscultation) primarily. Smell can also provide important diagnostic information during the patient encounter (e.g., personal hygiene, substance use, or metabolic diseases). Fortunately the sense of taste is largely a historical relic in medicine, though it is interesting to note that diabetes mellitus was diagnosed for many centuries by the sweet taste of the urine. Through experience, clinicians develop an important sixth sense - the gut instinct - that can only be gained through deliberate practice of clinical skills on thousands of pati

 Science Education: Essentials of Physical Examinations I

Percussion

JoVE Science Education

Source: Jaideep S. Talwalkar, MD, Internal Medicine and Pediatrics, Yale School of Medicine, New Haven, CT

Simply stated, percussion refers to the striking of one object against another to produce sound. In the early 1700s, an Austrian inn-keeper's son, named Leopold Auenbrugger, discovered that he could take inventory by tapping his father's beer barrels with his fingers. Years later, while practicing medicine in Vienna, he applied this technique to his patients and published the first description of the diagnostic utility of percussion in 1761. His findings faded into obscurity until the prominent French physician Jean-Nicolas Corvisart rediscovered his writings in 1808, during an era in which great attention was focused on diagnostic accuracy at the bedside.1 There are three types of percussion. Auenbrugger and Corvisart relied on direct percussion, in which the plexor (i.e. tapping) finger strikes directly against the patient's body. An indirect method is used more commonly today. In indirect percussion, the plexor finger strikes a pleximeter, which is typically the middle finger of the non-dominant hand placed against the patient's body. As the examiner's finger strikes the pleximeter (or directly against the surface of the patient's body)

 Science Education: Essentials of Physical Examinations I

Peripheral Vascular Exam

JoVE Science Education

Source: Joseph Donroe, MD, Internal Medicine and Pediatrics, Yale School of Medicine, New Haven, CT

The prevalence of peripheral vascular disease (PVD) increases with age and is a significant cause of morbidity in older patients, and peripheral artery disease (PAD) is associated with cardiovascular and cerebrovascular complications. Diabetes, hyperlipidemia, hypertension, and tobacco use are important disease risk factors. When patients become symptomatic, they frequently complain of limb claudication, defined as a cramp-like muscle pain that worsens with activity and improves with rest. Patients with chronic venous insufficiency (CVI) often present with lower extremity swelling, pain, skin changes, and ulceration. While the benefits of screening asymptomatic patients for PVD are unclear, physicians should know the proper exam technique when the diagnosis of PVD is being considered. This video reviews the vascular examination of the upper and lower extremities and abdomen. As always, the examiner should use a systematic method of examination, though in practice, the extent of the exam a physician performs depends on their suspicion of underlying PVD. In a patient who has or is suspected to have risk factors for vascular disease, the vascular exam should be thorough, beginning with inspection, fo

 Science Education: Essentials of Physical Examinations II

Lymph Node Exam

JoVE Science Education

Source: Richard Glickman-Simon, MD, Assistant Professor, Department of Public Health and Community Medicine, Tufts University School of Medicine, MA

The lymphatic system has two main functions: to return extracellular fluid back to the venous circulation and to expose antigenic substances to the immune system. As the collected fluid passes through lymphatic channels on its way back to the systemic circulation, it encounters multiple nodes consisting of highly concentrated clusters of lymphocytes. Most lymph channels and nodes reside deep within the body and, therefore, are not accessible to physical exam (Figure 1). Only nodes near the surface can be inspected or palpated. Lymph nodes are normally invisible, and smaller nodes are also non-palpable. However, larger nodes (>1 cm) in the neck, axillae, and inguinal areas are often detectable as soft, smooth, movable, non-tender, bean-shaped masses imbedded in subcutaneous tissue. Lymphadenopathy usually indicates an infection or, less commonly, a cancer in the area of lymph drainage. Nodes may become enlarged, fixed, firm, and/or tender depending on the pathology present. For example, a soft, tender lymph node palpable near the angle of the mandible may indicate an infected tonsil, whereas a firm, enlarged, non-tender lymph

 Science Education: Essentials of Physical Examinations I

Peripheral Vascular Exam Using a Continuous Wave Doppler

JoVE Science Education

Source: Joseph Donroe, MD, Internal Medicine and Pediatrics, Yale School of Medicine, New Haven, CT

Peripheral vascular disease (PVD) is a common condition affecting older adults and includes disease of the peripheral arteries and veins. While the history and physical exam offer clues to its diagnosis, Doppler ultrasound has become a routine part of the bedside vascular examination. The video titled "The Peripheral Vascular Exam" gave a detailed review of the physical examination of the peripheral arterial and venous systems. This video specifically reviews the bedside assessment of peripheral arterial disease (PAD) and chronic venous insufficiency using a handheld continuous wave Doppler. The handheld Doppler (HHD) is a simple instrument that utilizes continuous transmission and reception of ultrasound (also referred to as continuous wave Doppler) to detect changes in blood velocity as it courses through a vessel. The Doppler probe contains a transmitting element that emits ultrasound and a receiving element that detects ultrasound waves (Figure 1). The emitted ultrasound is reflected off of moving blood and back to the probe at a frequency directly related to the velocity of blood flow. The reflected signal is detected and transduced to an audible sound with a frequen

 JoVE Medicine

Fundus Photography as a Convenient Tool to Study Microvascular Responses to Cardiovascular Disease Risk Factors in Epidemiological Studies

1Environmental Risk and Health, Flemish Institute for Technological Research (VITO), 2Centre for Environmental Sciences, Hasselt University, 3Transportation Research Institute, Hasselt University, 4Department of Public Health, Occupational and Environmental Medicine, Leuven University


JoVE 51904

 JoVE Immunology and Infection

Cutaneous Leishmaniasis in the Dorsal Skin of Hamsters: a Useful Model for the Screening of Antileishmanial Drugs

1Program for the Study and Control of Tropical Diseases -PECET-School of Medicine, University of Antioquia, 2School of Agrarian Sciences, University of Antioquia


JoVE 3533

 Science Education: Essentials of Physical Examinations I

Auscultation

JoVE Science Education

Source: Jaideep S. Talwalkar, MD, Internal Medicine and Pediatrics, Yale School of Medicine, New Haven, CT

Through auscultation, the clinician is able "to eavesdrop on the workings of the body" to gain important diagnostic information.1 Historically, the term "auscultation" was synonymous with "immediate auscultation," in which the examiner's ear was placed directly against the patient's skin. Although this was standard practice for centuries, the method proved inadequate in nineteenth-century France, due to social norms and suboptimal diagnostic yield. This led René Laënnec to invent the first stethoscope in 1816 (Figure 1), a tool that has since become inseparable from auscultation in modern clinical practice, and patients hold it as a symbol of honor and trustworthiness among those who carry them.2 Figure 1. A representative illustration of the first stethoscope invented by René Laënnec. The stethoscope has undergone many technologic advances since Laënnec's initial hollow wooden tube. Practically speaking, the provider mus

 Science Education: Essentials of Physical Examinations I

Respiratory Exam I: Inspection and Palpation

JoVE Science Education

Source: Suneel Dhand, MD, Attending Physician, Internal Medicine, Beth Israel Deaconess Medical Center

Disorders of the respiratory system with a chief complaint of shortness of breath are among the most common reasons for both outpatient and inpatient evaluation. The most obvious visible clue to a respiratory problem will be whether the patient is displaying any signs of respiratory distress, such as fast respiratory rate and/or cyanosis. In a clinical situation, this will always require emergent attention and oxygen therapy. Unlike pathology in other body systems, many pulmonary disorders, including chronic obstructive pulmonary disease (COPD), asthma, and pneumonia, can be diagnosed by careful clinical examination alone. This starts with a comprehensive inspection and palpation. Keep in mind that in non-emergency situations the patient's complete history will have been taken already, gaining important insight into exposure histories (e.g., smoking), which could give rise to specific lung diseases. This history can then confirm physical findings as the examination is performed.

 JoVE Engineering

In Situ Neutron Powder Diffraction Using Custom-made Lithium-ion Batteries

1School of Chemistry, University of Sydney, 2Institute for Superconducting & Electronic Materials, University of Wollongong, 3Australian Synchrotron, 4Australian Nuclear Science and Technology Organisation, 5School of Mechanical, Materials, and Mechatronic Engineering, University of Wollongong, 6School of Chemistry, University of New South Wales


JoVE 52284

 JoVE Medicine

Adapting Human Videofluoroscopic Swallow Study Methods to Detect and Characterize Dysphagia in Murine Disease Models

1Department of Otolaryngology - Head and Neck Surgery, University of Missouri, 2Department of Communication Science and Disorders, University of Missouri, 3Department of Medicine, University of Missouri


JoVE 52319

 Science Education: Essentials of Physical Examinations II

Pelvic Exam I: Assessment of the External Genitalia

JoVE Science Education

Source:
Alexandra Duncan, GTA, Praxis Clinical, New Haven, CT
Tiffany Cook, GTA, Praxis Clinical, New Haven, CT
Jaideep S. Talwalkar, MD, Internal Medicine and Pediatrics, Yale School of Medicine, New Haven, CT

The pelvic exam can feel invasive to patients, so it is important to do everything possible to make patients feel comfortable and empowered, rather than vulnerable. Clinicians should be aware of how they are communicating, both verbally and nonverbally, and should give their patients control whenever possible. There are many ways to do this, from how the exam table is positioned to how the patient is engaged throughout the exam. As many as 1 in 5 patients may have experienced sexual trauma; therefore, it is important to avoid triggering those patients, but it's not always possible to know who they are. The exam in this video demonstrates neutral language and techniques that can be employed with all patients to create the best experience possible. It's important to keep the patient covered wherever possible and to minimize extraneous contact. A clinician should be careful to tuck fingers that aren't being used to examine the patient to avoid accidental contact with the clitoris or anus. Before performing the pelvic e

 Science Education: Essentials of Physical Examinations II

Abdominal Exam II: Percussion

JoVE Science Education

Source: Alexander Goldfarb, MD, Assistant Professor of Medicine, Beth Israel Deaconess Medical Center, MA

Medical percussion is based on the difference in pitch between the sounds elicited by tapping on the body wall. The auditory response to tapping depends on the ease with which the body wall vibrates, and is influenced by underlying organs, strength of the stroke, and the state of the body wall. There are three main medical percussion sounds: resonance (heard over lungs), tympany (heard over the air-filled bowel loops), and dullness (heard over fluid or solid organs). The contrast between dullness vs. tympany or resonance allows for determination of the size and margins of organs and masses, as well as identification of fluid accumulation and areas of consolidation. Percussion remains an intricate part of the physical diagnosis since it was first introduced more than 200 years ago, and is especially useful in examination of the lungs and abdomen. As a part of an abdominal examination, percussion follows visual inspection and auscultation. The examiner should first percuss over each of the nine abdominal regions (epigastric region, right hypochondriac region, left hypochondriac region, umbilical region, right lumbar region, left lumbar region, hypogastric region, right inguinal region, and left

 JoVE Behavior

Examination of Rapid Dopamine Dynamics with Fast Scan Cyclic Voltammetry During Intra-oral Tastant Administration in Awake Rats

1Interdepartmental Neuroscience Program, Yale University, 2Department of Biotechnical and Clinical Laboratory Sciences, School of Medicine and Biomedical Sciences, University at Buffalo, 3Department of Psychiatry, Yale School of Medicine, 4Department of Cellular and Molecular Physiology, Yale School of Medicine


JoVE 52468

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