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 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.
1. Before patient encounter
- 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.
- Disinfect any equipment you plan to use during the encounter (e.g., stethoscope, reflex hammer).
- Wash your hands with soap and water or topical disinfectant solution.
- Determine if any specific infection control precautions are needed for the clinical encounter (e.g., contact precautions) and obtain necessary protective equipment.
- 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.
2. Enter the room
- Knock on the door and ask permission to enter.
- Introduce yourself and your role.
3. Patient privacy
- 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.
- Ensure the exam room curtains are drawn and doors are closed.
- 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.
4. Consider your approach
- 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.
- 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.
- 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.
5. Patient attire
- Ensure the patient is dressed appropriately for the planned exam. If necessary, provide the patient with a gown and drape.
6. Other environmental considerations
- Adjust the height of the chair and exam table as needed to optimize your ability to perform maneuvers.
- Adjust lighting and ambient noise as able.
- The conventional approach to the examination places the examiner on the patient's right side.
7. Components of the exam
- 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.
- 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.
- Ask the patient's permission to proceed with the exam and at major transition points during the exam (e.g., "Now that I've explained what I am going to do, may I start the examination?" and "Next, I'd like to examine your heart.").
8. Clinical Reasoning
- 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.
- 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).
- 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.
9. Ending the examination
- Have the patient change back into regular clothing at the conclusion of the exam.
- It is optimal to wait until the patient is dressed again before offering your advice and opinions.
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!
Applications and Summary
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 valuable to optimize efficiency and the predictive value of the exam. An organized approach to the maneuvers being performed minimizes the need for unnecessary patient repositioning. The specific maneuvers to be performed vary based on the clinical circumstance, but an examiner's efforts to maintain clear communication with attention to patient comfort should not vary.
The physical examination has played a vital role in patient care for millennia and should continue to do so even in the face of technological advances. Over the past forty years, multiple studies in various clinical settings have demonstrated that history and physical alone allow physicians to arrive at the correct diagnosis a great majority of the time. In almost all other circumstances, the information gained at the bedside allows the clinician to utilize clinical reasoning to judiciously order and interpret tests to make diagnoses. Given the recent emphasis on medical cost containment, patient safety, and access to services, bedside diagnostics remain inexpensive, widely available, and carry little risk of adverse effects.