Name: why physical exams still matter
Uploaded: 2023-04-30T06:35:19.000Z
Duration: 5 min 21 s
Channel: JoVE

K12 Standards

new-york-state-science-learning-standards

New York State Science Learning Standards

High School

Life Science

Structure and Function

HS-LS1-3.

General Approach to the Physical Exam

1. Before patient encounter
<ol>
	<li>Prepare the exam room for the patient by disinfecting surfaces touched by the previous patient (e.g., exam table); this is typically done by support staff.</li>
	<li>Disinfect any equipment you plan to use during the encounter (e.g., stethoscope, reflex hammer).</li>
	<li>Wash your hands with soap and water or topical disinfectant solution.</li>
	<li>Determine if any specific infection control precautions are needed for the clinical encounter (e.g., contact precautions) and obtain necessary protective equipment.</li>
	<li>Attempt to calm your own anxieties, as the patient may be feeling vulnerable due to illness. The patient is likely to feel much more at ease if you appear calm.</li>
</ol>
2. Enter the room
<ol>
	<li>Knock on the door and ask permission to enter.</li>
	<li>Introduce yourself and your role.</li>
</ol>
3. Patient privacy
<ol>
	<li>Ask family members who have accompanied the patient to step out of the room. This provides an important opportunity to speak to the patient alone. Requests by patients to have family members remain present should generally be respected.</li>
	<li>Ensure the exam room curtains are drawn and doors are closed.</li>
	<li>Determine if a chaperone will be present during the exam, which is fine if either the patient or provider feels it necessary. This is often done standardly for genitourinary, rectal, and female breast exams.</li>
</ol>
4. Consider your approach
<ol>
	<li>Determine what aspects of the examination you plan to perform. This can range from a comprehensive assessment, as one might do during a preventive visit, to a more focused examination based on patient complaints and your clinical suspicion for specific diseases.</li>
	<li>Whether focused or comprehensive, the exam should be performed in a deliberate, active way, with constant attention given to what one is seeking, rather than through solely a rote/automatic process. Achieving the state in which one is able to focus on the findings, rather than just the process, takes much practice.</li>
	<li>Plan your sequence of examination to optimize efficiency and patient comfort. You should strive to minimize patient repositioning by grouping maneuvers together that need to be performed in a particular position. It is helpful to have a plan in mind before starting the examination.</li>
</ol>
5. Patient attire
<ol>
	<li>Ensure the patient is dressed appropriately for the planned exam. If necessary, provide the patient with a gown and drape.</li>
</ol>
6. Other environmental considerations
<ol>
	<li>Adjust the height of the chair and exam table as needed to optimize your ability to perform maneuvers.</li>
	<li>Adjust lighting and ambient noise as able.</li>
	<li>The conventional approach to the examination places the examiner on the patient&#39;s right side.</li>
</ol>
7. Components of the exam
<ol>
	<li>The physical examination is subdivided into the following regional/anatomic components: general survey; vital signs; head, eyes, ear, nose, throat (HEENT); neck; chest; cardiovascular; back; abdomen; extremities; neurologic; musculoskeletal; skin; breast; genitourinary; rectal; lymph nodes; mental status. There is substantial overlap between components.</li>
	<li>Each component exam consists of maneuvers employing the techniques of inspection, percussion, palpation, and auscultation, each of which is explored in detail in separate videos. Newer modalities, such as bedside diagnostic ultrasound, are increasingly incorporated into the physical examination.</li>
	<li>Ask the patient&#39;s permission to proceed with the exam and at major transition points during the exam (e.g., &#34;Now that I&#39;ve explained what I am going to do, may I start the examination?&#34; and &#34;Next, I&#39;d like to examine your heart.&#34;).</li>
</ol>
8. Clinical Reasoning
<ol>
	<li>The examiner must actively weigh how the presence or absence of particular findings affects disease probability. Experienced clinicians do this in real time during the examination.</li>
	<li>Modify the initial plan of approach based on findings encountered during the exam. For example, while one may have only planned to perform simple auscultation of the lungs, the presence of decreased breath sounds in a given area may prompt the examiner to utilize specialized techniques (e.g., egophony, vocal fremitus).</li>
	<li>The consolidation of information obtained during history (symptoms) and physical (signs) informs the next steps in management. Treatment may be initiated if the probability of a particular disease is high enough, or additional testing may be requested in a deliberate and judicious manner.</li>
</ol>
9. Ending the examination
<ol>
	<li>Have the patient change back into regular clothing at the conclusion of the exam.</li>
	<li>It is optimal to wait until the patient is dressed again before offering your advice and opinions.</li>
</ol>
<div class="chapter_text" id="script_0">
	Physical examination has been fundamental to the practice of medicine for centuries. Despite substantial advancement in medical instrumentation, physical examination remains a valuable diagnostic tool, and its importance cannot be overstated. As physicians assess history and conduct a physical, they gather information leading to a firm hypothesis, which promotes a more judicious approach to ordering tests and analysis of those tests. This, in turn, has the potential to reduce patient risk and health care costs. 
	This video will illustrate some of the important steps that every physician must take to ensure that the physical exam is carried out in a safe and sensitive manner.
</div>
<div class="chapter_text" id="script_1">
	A physical exam can be comprehensive or specific, but the overall steps before and during each exam remain the same. Let's review these steps in detail. 
	First, the exam room should be prepared for the patient by disinfecting surfaces to be used during the examination. In addition, a physician should disinfect equipment like the stethoscope or the reflex hammer, which may be used during the exam. Before every exam, wash your hands with soap and water or apply topical disinfectant solution. If the patient is suffering from a known specific infection, then control precautions should be taken by obtaining the necessary protective equipment. Make sure that cuffs of the gloves cover the gown so that no skin is exposed. 
	Once the patient is seated in the room, knock on the door and ask for patient's permission to enter the room. Introduce yourself and your role. Request the family members or friends who have accompanied the patient to step out of the room. This provides an important opportunity to speak to the patient alone. Ensure that the exam room curtains are drawn and doors are closed. While talking to the patient, general observations should be made regarding the patient's health. These include, appearance consistency with the stated age, overall health, alertness, affect, thought content and organization, and perception. 
	After this initial conversation, determine what aspects of the examination are necessary. Ensure the patient is dressed appropriately for the planned exam. If necessary, provide the patient with a gown and drape and give them some time to change. After some time, knock on the door and ask for the patient's permission to enter the room. Request the patient to occupy the exam table. Adjust the back of the exam table as needed to optimize your ability to perform maneuvers. The physical examination can be subdivided into the following components: general survey, measuring vital signs, examination of the neurologic functioning and mental status, examination of the head, eyes, ears, nose, throat, chest, lungs, lymph nodes, cardiovascular, abdomen, musculoskeletal, skin, genitourinary, and rectal. A chaperone may be necessary if a sensitive exam like genitourinary, rectal, or breast exams is to be conducted. 
	Explain the patient the physical exam that is going to be conducted and ask for their permission to proceed with the exam. "Now that I've explained what I am going to do, may I proceed with the examination?" Each exam consists of maneuvers employing the techniques of inspection, percussion, palpation, and auscultation, each of which is explored in detail in separate videos of this collection. You should strive to minimize patient repositioning by grouping maneuvers together that need to be performed in a particular position. After the exam is complete, request the patient to change back to regular clothing. It is optimal to wait until the patient is dressed again before offering advice and opinion. Subsequently, weighing how the presence or absence of particular findings affects disease probability and consolidating the information obtained from patient's history and physical exam, one may decide to initiate a therapy or order additional testing in a deliberate and judicious manner. 
</div>
<div class="chapter_text" id="script_2">
	You have just watched JoVE's video on general approach to the physical examination. 
	This video reviewed the importance of physical examination in the modern patient encounter and demonstrated some critical steps to ensure the exam is carried out in a safe and sensitive manner. Important preparatory steps before the examination help to reduce risk of infection, and an organized approach to the maneuvers being performed minimizes the need for unnecessary patient repositioning. 
	Given the recent emphasis on medical cost containment, patient safety, and access to services, physical examination remains inexpensive, widely available, and carries little risk of adverse effects. As always, thanks for watching!
</div>

This video demonstrates the role that physical examination plays in the modern patient encounter and has reviewed some critical steps to ensure the exam is carried out in a safe and sensitive manner. Important preparatory steps before the examination help to reduce risk of infection as well as patient and provider anxiety. Ensuring patient privacy and using gowns and drapes in a sensitive manner also makes patients feel more comfortable. A deliberate approach to the examination that is grounded in clinical reasoning is v...

general approach to the physical exam

Source: <a href="https://www.jove.com/author/Jaideep+S._Talwalkar">Jaideep S. Talwalkar</a>, 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&#39;s condition. The information one gathers may not replace the need for testing, but having firm hypotheses in place allows the provider to order tests more judiciously and ask better questions of those tests. This, in turn, has the potential to reduce risk to the patient and save cost for the health care system. Finally, physical examination plays a critical role in the therapeutic relationship. By engaging in the time-honored ritual of physical examination, the clinician has the opportunity to develop rapport (by demonstrating attention and sensitivity) and promote healing through the deliberate and responsible use of touch.

Source: Jaideep S. Talwalkar, MD, Internal Medicine and Pediatrics, Yale School of Medicine, New Haven, CT
The examination of the body is fundamental to ...

Physical examination has been fundamental to the practice of medicine for centuries. Despite substantial advancement in medical instrumentation, physical examination remains a valuable diagnostic tool, and its importance cannot be overstated. As physicians assess history and conduct a physical, they gather information leading to a firm hypothesis, which promotes a more judicious approach to ordering tests and analysis of those tests. This, in turn, has the potential to reduce patient risk and health care costs. This video will illustrate some of the important steps that every physician must take to ensure that the physical exam is carried out in a safe and sensitive manner.A physical exam can be comprehensive or specific, but the overall steps before and during each exam remain the same. Let's review these steps in detail. First, the exam room should be prepared for the patient by disinfecting surfaces to be used during the examination. In addition, a physician should disinfect equipment like the stethoscope or the reflex hammer, which may be used during the exam. Before every exam, wash your hands with soap and water or apply topical disinfectant solution. If the patient is suffering from a known specific infection, then control precautions should be taken by obtaining the necessary protective equipment. Make sure that cuffs of the gloves cover the gown so that no skin is exposed. Once the patient is seated in the room, knock on the door and ask for patient's permission to enter the room. Introduce yourself and your role. Request the family members or friends who have accompanied the patient to step out of the room. This provides an important opportunity to speak to the patient alone. Ensure that the exam room curtains are drawn and doors are closed. While talking to the patient, general observations should be made regarding the patient's health. These include, appearance consistency with the stated age, overall health, alertness, affect, thought content and organization, and perception. After this initial conversation, determine what aspects of the examination are necessary. Ensure the patient is dressed appropriately for the planned exam. If necessary, provide the patient with a gown and drape and give them some time to change. After some time, knock on the door and ask for the patient's permission to enter the room. Request the patient to occupy the exam table. Adjust the back of the exam table as needed to optimize your ability to perform maneuvers. The physical examination can be subdivided into the following components: general survey, measuring vital signs, examination of the neurologic functioning and mental status, examination of the head, eyes, ears, nose, throat, chest, lungs, lymph nodes, cardiovascular, abdomen, musculoskeletal, skin, genitourinary, and rectal. A chaperone may be necessary if a sensitive exam like genitourinary, rectal, or breast exams is to be conducted. Explain the patient the physical exam that is going to be conducted and ask for their permission to proceed with the exam. "Now that I've explained what I am going to do, may I proceed with the examination?" Each exam consists of maneuvers employing the techniques of inspection, percussion, palpation, and auscultation, each of which is explored in detail in separate videos of this collection. You should strive to minimize patient repositioning by grouping maneuvers together that need to be performed in a particular position. After the exam is complete, request the patient to change back to regular clothing. It is optimal to wait until the patient is dressed again before offering advice and opinion. Subsequently, weighing how the presence or absence of particular findings affects disease probability and consolidating the information obtained from patient's history and physical exam, one may decide to initiate a therapy or order additional testing in a deliberate and judicious manner. You have just watched JoVE's video on general approach to the physical examination. This video reviewed the importance of physical examination in the modern patient encounter and demonstrated some critical steps to ensure the exam is carried out in a safe and sensitive manner. Important preparatory steps before the examination help to reduce risk of infection, and an organized approach to the maneuvers being performed minimizes the need for unnecessary patient repositioning. Given the recent emphasis on medical cost containment, patient safety, and access to services, physical examination remains inexpensive, widely available, and carries little risk of adverse effects. As always, thanks for watching!

Education

JoVE Science Education

Clinical Skills

Physical Examinations I

why physical exams still matter

Physical examination remains an important part of medicine. Doctors have used the body exam for centuries to connect changes in body function with disease. Even with modern imaging and lab tests, the bedside exam still helps clinicians understand what may be happening in the patient.

Physical examination is not a replacement for tests, and it does not answer every question. Some maneuvers that were once highly valued may have limited usefulness. Still, many conditions can only be found through physical examination, and diagnoses made with labs or imaging usually begin with findings from the bedside.

As a provider performs the history and physical, they form and check ideas, or hypotheses, about the patient’s condition. These ideas help guide which tests to order and which questions to ask next. That can make testing more focused, reduce risk for the patient, and help lower health care costs.

The physical exam also supports the therapeutic relationship. By using careful and respectful touch, the clinician can show attention and sensitivity. This process can build rapport and may help promote healing during the patient encounter.

Why Physical Exams Still Matter

Physical examination remains an important part of medicine. Doctors have used the body exam for centuries to connect changes in body function with disease. Even with modern imaging and lab tests, the bedside exam still helps clinicians understand what may be happening in the patient. Physical examination is not a replacement for tests, and it does not answer every question. Some maneuvers that were once highly valued may have limited usefulness. Still, many conditions can only be found through...

observation and inspection

Clinical Observation in Physical Exam

Clinical observation is the starting point of a physical examination and begins at the first contact with a patient. Observation is a broad term for using the senses carefully to gather information. Inspection is a narrower term. It refers to what can be seen with the eyes, especially on the surface of the body, rather than to behavior. Skilled clinicians use more than sight when they examine a patient. They also rely on touch, through palpation and percussion, and on hearing, through...

palpation

How Hand Position Guides Palpation

Palpation uses touch to collect diagnostic information during the physical exam. It is one of the ways a healthcare provider uses the senses to learn more about a patient. The part of the hand used for palpation changes depending on the body area being examined. Finger pads are best for fine detail. Their dense sensory nerves help the examiner feel small features, such as the borders of masses or lymph nodes. The back of the hand, also called the dorsal surface, gives a rough sense of relative...

percussion

Clinical Percussion and Body Sound

Clinical percussion uses tapping to create sound and help assess what lies beneath the body surface. It is a simple bedside technique that depends on the way sound changes when it travels through different tissues. The method began with Leopold Auenbrugger, an Austrian inn-keeper's son, who found that tapping beer barrels could help him take inventory. He later applied the same idea to patients in Vienna and published the first description of its diagnostic use in 1761. Jean-Nicolas Corvisart...

auscultation

Stethoscope Sounds in Clinical Exam

Auscultation is a clinical exam method that lets a provider listen to sounds inside the body. Doctors use it to gather important diagnostic information from the chest, heart, abdomen, and blood vessels. For many years, auscultation meant immediate auscultation. In that method, the examiner placed an ear directly on the patient's skin. This approach was used for centuries, but it became less useful in nineteenth-century France because of social norms and poor diagnostic yield. René Laënnec...

proper adjustment of patient attire during the physical exam

proper-adjustment-of-patient-attire-during-the-physical-exam

Draping for a Better Physical Exam

Draping is an important part of a careful physical exam. It helps the provider examine the right body area while also protecting patient modesty. Good draping takes practice because the examiner must balance exposure with comfort. Correct technique also improves the accuracy of the exam. Skin lesions can be missed if inspection is done through clothing. Lung crackles may be reported by mistake when the chest is examined through a T-shirt, and subtle heart findings can be missed when...

blood pressure measurement

Manual Blood Pressure Reading Steps

Blood pressure reading uses an indirect method to measure the pressure of blood against vessel walls. Blood pressure, or BP, is a vital sign that is checked routinely in hospital and outpatient settings. It is one of the most common medical assessments performed around the world. The indirect method is non-invasive, safe, and easily reproducible, so it is used most often. BP can be measured automatically by oscillometry or manually by auscultation. Auscultation uses a sphygmomanometer, which...

measuring vital signs

Vital Sign Ranges and Patient Status

Vital signs are objective measurements that show a patient’s clinical status. The commonly accepted vital signs are blood pressure, heart rate, temperature, respiratory rate, and oxygen saturation. In many practices, pain is also treated as the sixth vital sign and is documented with the others. Pain is different from the other vital signs because it is a subjective measurement. That means the pain scale can vary from one patient to another. A vital signs assessment includes heart rate, blood...

respiratory exam i: inspection and palpation

respiratory-exam-i-inspection-and-palpation

Checking Breathing Distress by Exam

Respiratory exam starts with looking for breathing distress and feeling the chest. Shortness of breath is a common reason for both outpatient and inpatient evaluation. Early inspection can reveal fast breathing or cyanosis, which is a bluish color change that can signal low oxygen. If a patient shows respiratory distress, the situation needs urgent attention and oxygen therapy. In many cases, careful clinical examination can help identify lung problems without relying only on tests. This is...

respiratory exam ii: percussion and auscultation

respiratory-exam-ii-percussion-and-auscultation

Respiratory Exam: Lung Sounds and Percussion

Respiratory exam skills include percussion and auscultation of the lungs. These techniques help identify lung problems during a physical exam. Percussion uses tapping to assess the chest, and auscultation uses a stethoscope to listen for breath sounds. Percussion is a useful skill that is often skipped in routine clinical practice. When it is done correctly, it can help a physician detect underlying lung pathology. Auscultation can also give an almost immediate clue to several acute pulmonary...

cardiac exam i: inspection and palpation

Cardiac Exam I: Checking the Chest First

Cardiac exam inspection and palpation are the first steps in a careful heart assessment. These steps help a physician gather useful information before using a stethoscope. They are part of the core examination performed when a patient is first seen. Heart and circulatory disorders are common reasons for hospital admission. They can include conditions such as myocardial infarction and congestive heart failure. Because of this, learning a complete cardiac examination is important for any...

cardiac exam ii: auscultation

Listening for Normal and Abnormal Heart Sounds

Heart auscultation uses a stethoscope to listen to heart sounds and check for normal and abnormal patterns. For physicians, knowing how to hear these sounds and tell them apart is an essential skill. The sound heard at each spot on the chest relates to the closing of specific heart valves. The heart has two main sounds, called S1 and S2. S1 happens when the mitral and tricuspid valves, which are the atrioventricular valves, close after blood enters the ventricles. This marks the start of...

cardiac exam iii: abnormal heart sounds

Heart Murmurs and Gallop Sounds

Heart murmurs and gallop sounds are abnormal heart sounds that can be heard during auscultation, or listening to the heart with a stethoscope. A good understanding of normal heart sounds is the first step in telling normal sounds apart from abnormal ones. Murmurs usually have a swishing quality and point to turbulent blood flow across a heart valve. Murmurs can happen because a valve is too narrow, which is called stenosis, or because blood leaks backward across the valve, which is called...

peripheral vascular exam

Assessing PAD and Venous Signs

Peripheral vascular disease can affect blood flow in the arms and legs, and careful exam steps help reveal signs of disease. Peripheral artery disease (PAD) is linked to cardiovascular and cerebrovascular complications. Risk factors include diabetes, hyperlipidemia, hypertension, and tobacco use. Symptoms may appear as limb claudication, which is cramp-like muscle pain that gets worse with activity and better with rest. Chronic venous insufficiency (CVI) can cause lower extremity swelling,...

peripheral vascular exam using a continuous wave doppler

peripheral-vascular-exam-using-a-continuous-wave-doppler

Bedside Doppler for Leg Blood Flow Checks

Peripheral vascular disease affects the arteries and veins outside the heart, and it is common in older adults. History and physical exam can suggest the diagnosis, but Doppler ultrasound is now a routine part of the bedside vascular exam. This lesson focuses on bedside assessment of peripheral arterial disease and chronic venous insufficiency with a handheld continuous wave Doppler. A handheld Doppler is a simple tool that sends and receives ultrasound at the same time. It detects changes in...

physical examinations i

This collection provides a foundation for performing physical exams; with techniques ranging from measuring blood pressure or vital signs, to key pulmonary and cardiovascular physical examinations. 

Learn why the physical exam remains a key part of medicine, from bedside diagnosis and hypothesis testing to building patient trust and rapport.

Why Physical Exams Still Matter | JoVE K12

Jaideep Talwalkar

Internal Medicine

Yale School of Medicine

Overview

General Steps During Any Physical Examination

Summary

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drosophila-melanogaster-embryo-and-larva-harvesting-and-preparation

Drosophila melanogaster Embryo and Larva Harvesting and Preparation

Drosophila melanogaster embryos and larvae are easy to manipulate and develop rapidly by mechanisms that are analogous to other organisms, including ...

Construct an explanation based on evidence for how the structure of DNA determines the structure of proteins which carry out the essential functions of life through systems of specialized cells.

HS-LS1-1.

Why Physical Exams Still Matter

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