Physical examination

# Overview
Physical examination or clinical examination is the process by which a health care provider 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.
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.
Whilst 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.  Non-specialists generally examine the genitals only upon request of the patient.
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.
The physical examination can be therapeutic.

# Essential Parts of History Taking     
- Chief complaint: This is the most important part to determine the reason patient seeks care. Important to consider using the patients terminology. This almost always provides you a title for the encounter.
- History of present illness: This provide a thorough description of the chief complaint and current problem. The suggested format is as follow: P-Q-R-S-T.
- P: precipitating and palliative factors: It is essential to identify factors that make symptom worse and/or better; any previous self-treatment or prescribed treatment, and patient's response.
- Q: quality and quantity descriptors: Allow her/him to identify own rating of symptom (e.g., pain on a 110 scale) and descriptors (e.g., numbness, burning sensation, stabbing).
- R: region and radiation: Ask enough questions to identify the exact location of the symptom and any area of radiation
- S: severity and associated symptoms: Try to identify the symptoms severity (e.g., how bad at its worst) and any associated symptoms (e.g., presence or absence of nausea and vomiting, caused dyspnea, associated with chest pain).
- T: timing and temporal descriptions: This helps to identify when complaint was first noticed; how it has changed/progressed since onset (e.g., remained the same or worsened/improved); whether onset was acute or chronic; whether it has been constant, intermittent, or recurrent.
- Another mnemonic used sometimes is 'SOCRATES' with questions Site, onset, character, radiation, association, timing of complaint, Exacerbating and alleviating factor and severity.
- Past medical history: Ask to identify past diagnoses, surgeries, hospitalizations , injuries, allergies, immunizations, current medications.
- Habits: Smoking, alcohol use, therapeutic drugs, substance/drug abuse, sleep and exercise patterns .
- Sociocultural: Be polite and careful. These questions will help to identify occupational and recreational activities and experiences, living environment, financial status/support as related to patient's health care, needs, travel, lifestyle, etc.
- Family history: A carefully taken family history helps to identify potential sources of hereditary diseases. A genogram (if possible) is helpful; the minimum includes first degree relatives (parents, siblings, children), although 23 orders for each topics are helpful. Consider cardiovascular disorders, lung diseases (e.g., tuberculosis, asthma), skin lesions, allergies, food intolerance, history of oral and genital ulcerations etc.
- Review of systems: Start from vital signs (regardless of the complaints) and review a list of possible symptoms that the patient may have noted in each of the body systems.

# Vital Signs

## Temperature
Temperature recording gives an indication of core body temperature which is normally tightly controlled (thermoregulation) as it affects the rate of chemical reactions.
The main reason for checking body temperature is to solicit any signs of systemic infection or inflammation in the presence of a fever (temp > 101.4 F or sustained temp > 100.4 F). Other causes of elevated temperature include  hyperthermia. Temperature depression (hypothermia) also needs to be evaluated. It is also noteworthy to review the trend of the patient's temperature. A patient with a fever of 101 F does not necessarily indicate an ominous sign if his previous temperature has been higher.

## Blood Pressure
The blood pressure is recorded as two readings, a high systolic pressure which is the maximal contraction of the heart and the lower diastolic or resting pressure. Usually the blood pressure is taken in the right arm unless there is some damage to the arm. The difference between the systolic and diastolic pressure is called the pulse pressure. The measurement of these pressures is now usually done with an aneroid or electronic sphygmomanometer. The classic measurement device is a mercury sphygmomanometer, using a column of mercury measured off in millimeters. In the United States and UK, the common form is millimeters of mercury, whilst elsewhere SI units of pressure are used. There is no natural 'normal' value for blood pressure, but rather a range of values that on increasing are associated with increased risks.  The guideline acceptable reading also takes into account other co-factors for disease.  Elevated blood pressure hypertension therefore is variously defined when the systolic number is persistently over 140-160 mmHg. Low blood pressure is hypotension. Blood pressures are also taken at other portions of the extremities. These pressures are called segmental blood pressures and are used to evaluate blockage or arterial occlusion in a limb (see Ankle brachial pressure index).

## Pulse
The pulse is the physical expansion of the artery. Its rate is usually measured either at the wrist or the ankle and is recorded as beats per minute. The pulse commonly is taken is the radial artery at the wrist. Sometimes the pulse cannot be taken at the wrist and is taken at the elbow (brachial artery), at the neck against the carotid artery (carotid pulse), behind the knee (popliteal artery), or in the foot dorsalis pedis or posterior tibial arteries. The pulse rate can also be measured by listening directly to the heartbeat using a stethoscope. The pulse varies with age. A newborn or infant can have a heart rate of about 130-150 beats per minute. A toddler's heart will beat about 100-120 times per minute, an older child's heartbeat is around 90-110 beats per minute, adolescents around 80-100 beats per minute, and adults pulse rate is anywhere between 50 and 80 beats per minute.
comment on pulse
Rate 60-90
Rhythm regular-irregular
force=systolic
tension=diastolic
volume=difference between the systolic & diastolic
equality on both sides
status of arterial wall

## Respiratory Rate
Varies with age, but the normal reference range is 16-20 breaths/minute.

# Basic Biometrics

## Height
Height is the anthropometric longitudinal growth of an individual. A statiometer is the device used to measure height although often a height stick is more frequently used for vertical measurement of adults or children older than 2. The patient is asked to stand barefoot. Height declines during the day because of compression of the intervertebral discs. Children under age 2 are measured lying horizontally.

## Weight
Weight is the anthropometric mass of an individual. A scale is used to measure weight.
Body mass index or BMI is used to calculate the relationship between healthy height and weight and obesity or being overweight or underweight.
Medical professionals generally prefer to use the SI unit of kilograms, and many medical facilities have ready-reckoner conversion charts available for professionals to use, when patients describe their weight in non-SI units. (In the US, pounds and ounces are common, while in the UK stones and pounds are frequently used; in most other countries the metric system predominates.)

## Pain
Because of the importance of pain to the overall wellness of the patient, subjective measurement is considered to be a vital sign. Clinically pain is measured using a FACES scale which is a series of faces from '0' (no pain at all showing a normal happy face) to '5' (the worst pain ever experienced by the patient). There is also an analog scale from '0' to maximum '10'. It is important to allow patients to make their own choices on a pain scale. Physicians and health care workers frequently understate patient pain.

# Structure of the Written Examination Record

## General Appearance
Obvious apparent features as the patient enters the consulting room and in the course of taking the history (e.g. mobility problem or deafness)
- JACCOL, a mnemonic for Jaundice, suggestion of Anaemia (pale colour of skin or conjunctiva), Cyanosis (blue coloration of lips or extremities), Clubbing of fingernails, edema of ankles, Lymph nodes of neck, armpits, groins.

## Organ Systems
- Cardiovascular system
Blood pressure, pulse rate and rhythm.
Jugular venous pressure (JVP), peripheral oedema and evidence for pulmonary oedema.
Precordial exam (cardiac exam)
- Blood pressure, pulse rate and rhythm.
- Jugular venous pressure (JVP), peripheral oedema and evidence for pulmonary oedema.
- Precordial exam (cardiac exam)
- Lungs
Respiratory rate, chest expansion, lung auscultation
- Respiratory rate, chest expansion, lung auscultation
- Breasts
- Abdomen
Abdominal examination notes in particular any tenderness, bloating, organ enlargement, or aortic aneurysm.
No abdominal examination is complete without a Rectal examination
- Abdominal examination notes in particular any tenderness, bloating, organ enlargement, or aortic aneurysm.
- No abdominal examination is complete without a Rectal examination
- Genitalia
- Musculoskeletal system
- Nervous system, including mental status
- Head and neck (HEENT)
- Skin
Check of the hair to see if the hair growth is receding (baldness) or there is loss of hair (alopecia).
Check of the skin will tell if there are marks such as hemangioma or strawberry marks or changes to the skin. Dark spots on the skin, nevi are also places where cancerous changes can appear because the face, head and neck are most usually sun exposed. Specific skin conditions (e.g. pyoderma gangrenosum, erythema nodosum, acanthosis nigricans) may be associated with specific diseases (ulcerative colitis, sarcoidosis and polycystic ovary syndrome, respectively).
- Check of the hair to see if the hair growth is receding (baldness) or there is loss of hair (alopecia).
- Check of the skin will tell if there are marks such as hemangioma or strawberry marks or changes to the skin. Dark spots on the skin, nevi are also places where cancerous changes can appear because the face, head and neck are most usually sun exposed. Specific skin conditions (e.g. pyoderma gangrenosum, erythema nodosum, acanthosis nigricans) may be associated with specific diseases (ulcerative colitis, sarcoidosis and polycystic ovary syndrome, respectively).

# Video 1: Complete Physical Examination

# Video 2: Complete Physical Examination

# Video 3: Complete Physical Examination

# Common Causes of Diagnostic Errors
- Accepting previous diagnosis/explanation without exploring other possible explanations (e.g., diagnosis of chronic bronchitis as explanation of chronic cough in patient on ACE inhibitor).
- Accepting the horses without even contemplating the zebras; contemplating zebras without adequately pursuing the possibility of a more common condition.
- Accommodating patient wishes against clinician judgment (Be polite, do not hesitate to interrupt, but perform your art. As a physician you are the ruler during the examination).
- Allowing other health care professionals to lead you down the wrong diagnosis path (Consider others perspective and be respectful to everybody's opinion, but have yourselves first).
- Allowing the patient to make diagnosis for you (e.g., I had sinusitis last year and the symptoms are exactly the same., "I had similar chest discomfort after a spicy meal"). Do not allow patient to make a diagnosis or get a conclusion. Do not forget you are the examiner.
- Failing to consider medical conditions as the source of psychiatric symptoms and psychiatric conditions as the source of medical symptoms (At first, complete your history taking and physical examination, later on you will have enough time to make a decision).
- Failure of memory, so only recognize what is memorized or recalled (ask for permission and take regular notes)
- Focusing solely on the most obvious or likely explanation (always keep in mind that every patient has his/her own nature). Consider differential diagnosis and rule out every of them.
- Ignoring basic findings, such as vital signs (Be prepared and follow the rules).
- Jumping to conclusion without enough evaluation, being biased by an early finding (e.g., something in the patients past medical history or recheck from a previous visit).
- Misinterpreting examination findings or using wrong data.
- Performing skills improperly (wrong respiratory maneuvers order during auscultations, improper fundoscopic examinations, inadequate reflex evaluations).
- Using a shotgun approach to assessment, without adequate focus on current problems.
- Using the wrong rule, decision tree, or other resource to guide analysis or using the correct device incorrectly (Correct timing for endoscopic examinations, hormonal analysis in female patients).