Manual procedures
The physical examination continues the diagnostic process, adding information obtained by inspection, palpation, percussion, and auscultation. When data accumulated from the history and physical examination are complete, a working diagnosis is established, and tests are selected that will help to retain or exclude that diagnosis.
Patients are usually apprehensive and anxious when being examined because they feel exposed, vulnerable, and afraid of discomfort. The physician attempts to allay that anxiety by explaining which examinations are to be performed and the degree of discomfort they will entail. Throughout the examination, concern for the patient’s dignity must be maintained.
Inspection
A wide array of sophisticated instruments are available to assist with examinations, but a well-performed visual inspection can often reveal more information. Osler admonished physicians to closely observe patients before touching them, to cultivate the power of observation, as it is one of the greatest diagnostic tools. Thus, inspection should begin with the patient’s general appearance, state of nutrition, symmetry, and posture. Wasting and hallmarks of poor nutrition may indicate chronic disease; poor grooming or slack posture may suggest depression or low self-esteem. The physician then proceeds to more specific examination of the skin—looking for redness or other signs of infection, hair loss, nail thickening, and moles or other areas of pigmentation—and inquires about any recent changes in skin lesions that could indicate early cancer. Inspection also should encompass, in particular, areas that the patient normally would not be able to see, such as the scalp, the back, and the buttocks.
The nails and the skin are particularly important in making a diagnosis. Examination of the nails can provide important clues about systemic disease. Clubbing of the nails (broadening of the nailbeds, with curved and shiny nails) may indicate congenital heart disease, chronic obstructive pulmonary disease, bronchogenic carcinoma, or another cardiac or pulmonary condition. Pitting of the nails occurs in about 50 percent of patients with psoriasis. The skin should always be inspected for cancer, though it is sometimes difficult to differentiate a benign mole (nevus) from a cancer.
The most dangerous skin cancer, malignant melanoma, occurs in about 1 in 10,000 people and can spread readily throughout the body. A squamous-cell carcinoma also may spread but is slow to do so and can be completely cured by early detection and removal. Basal-cell cancer is the most common form of skin cancer, and, though it is locally invasive, it almost never spreads distantly to other parts of the body. Suspicious lesions are those that have recently enlarged, started to bleed, become darker, or developed an irregular outline. Most skin cancers occur on areas of the body that have been exposed to the sun; they are more common in light-skinned individuals with blond hair and blue eyes who sunburn easily.
The most common premalignant (precancerous) skin lesion is actinic keratosis, a rough, scaling, red or brown papule that appears on sun-exposed areas such as a bald scalp, ears, the forehead, and the back of the hands. These lesions can be easily removed by cryotherapy (therapeutic use of cold), electrodesiccation (dehydration of tissue by electric current), or surgical excision. Some skin lesions, including melanoma, are treated with local excision.
Palpation
Palpation is the act of feeling the surface of the body with the hands to determine the characteristics of the organs beneath the surface. It can be performed with one hand or two and can be light or deep. Light palpation is used to detect tenderness, muscle spasm, or rigidity of the abdomen. If abdominal pain is present, gentle palpation begins farthest away from the pain to localize the point of maximum tenderness. Acute inflammation in the abdomen, as in acute appendicitis, causes peritoneal irritation, resulting in not only localized tenderness in the right lower abdomen but also a guarding reaction (tightening and rigidity) by the muscles in that area to protect the inflamed organ from the external pressure. Deep palpation of the abdomen is used to determine the size of the liver, spleen, or kidneys and to detect an abnormal mass. An abdominal aortic aneurysm can be detected by palpating a pulsatile mass in the upper abdomen. An acutely tender mass in the right upper abdomen that is more painful on inspiration is probably an inflamed gallbladder. An unexplained nontender abdominal mass could be as nonthreatening as a hard stool or as serious as a tumour.
Palpation also is used to detect and evaluate abnormal lesions in the breast, the prostate gland, the lymph nodes, or the testes. Proper breast examination includes frequent (at least monthly) self-examinations and an annual examination by a physician. Palpation should be methodical and performed over the entire breast; it is done either in concentric circles or outward from the nipple, using a spokes-of-a-wheel approach. Suspicious breast lesions are hard and fixed rather than movable. Skin retraction or breast asymmetry can indicate an underlying, potentially serious lesion. Cancers are usually not tender, and benign lesions are more likely to be round, elastic or firm, movable, and well-defined. Similarly, suspicious prostate lesions are hard irregular nodules within the prostate, whereas benign prostatic hyperplasia (BPH) is a soft symmetrical enlargement of the gland.
Palpation also can detect cardiac enlargement if the point of maximal impulse (PMI) of the heart is farther to the left than normal. Other cardiac abnormalities can be suspected if a thrill is felt from light palpation over the chest wall. A thrill is a vibratory sensation felt on the skin overlying an area of turbulence and indicates a loud heart murmur usually caused by an incompetent heart valve.
Percussion
Percussion is a diagnostic procedure used to determine the density of a part by tapping the surface with short, sharp blows and evaluating the resulting sounds. In the abdomen it can be used to detect fluid (ascites), a gaseous distention of the intestine as occurs in bowel obstruction, or an enlargement of the liver. It is used most often to evaluate the chest. Percussion produces a resonant note when the area over a healthy lung is struck; a dull sound, however, will emanate if the lung contains fluid, as in pneumonia, or when a region over a solid mass such as the heart is tapped. A lung that is diseased with emphysema contains more air than a healthy lung and produces hyperresonance. A stomach distended with air will produce a high-pitched, hollow tympanic sound.
Auscultation
Auscultation is performed with a stethoscope to evaluate sounds produced by the heart, the lungs, the blood vessels, or the bowels. The lack of bowel sounds indicates a nonfunctioning or paralyzed bowel, and high-pitched “tinkling” bowel sounds suggest bowel obstruction. The “growling” of the stomach is an accentuation of these sounds during periods of bowel hyperactivity.
Bruits are blowing vascular sounds resembling heart murmurs that are perceived over partially occluded blood vessels. When detected over the carotid arteries, a bruit may indicate an increased risk of stroke; when produced by the abdomen, it may indicate partial obstruction of the aorta or other major arteries such as the renal, iliac, or femoral arteries.
Listening to the sound of air passing in and out of the lungs can be useful in detecting an obstruction, as in asthma, or an inflammation, as in bronchitis or pneumonia. Adventitious sounds are those heard in addition to normal breathing sounds and include crackles, wheezes, and rubs. Crackles (also called rales) resemble the sound made by rubbing hair between the fingers next to the ear. They are caused by fluid in the small passageways that adheres to the walls during respiration. Crackles are heard in congestive heart failure and pneumonia. Wheezes, musical sounds heard mostly during expiration, are caused by rapid airflow through a partially obstructed airway, as in asthma or bronchitis. Pleural rubs sound like creaking leather and are caused by pleural surfaces roughened by inflammation moving against each other, which occurs in patients with pneumonia and pulmonary infarction.
Cardiac auscultation is the evaluation of the sounds made by the heart valves—namely, the aortic, the pulmonary, the tricuspid, and the mitral—for murmurs that may be due to turbulent blood flow or vibrations from a heart valve deformity. Murmurs may be physiological (unimportant clinically) or pathological, indicating a problem that needs attention, especially if they reflect obstruction of normal blood flow. Heart murmurs vary according to their timing in the cardiac cycle (i.e., during systole, the period of contraction when blood is pumped from the heart ventricles, or diastole, the period of filling of the right and left ventricles between contraction), location, duration, intensity, pitch, and quality. Intensity is graded on a scale from 1 to 6, with 6 being the loudest. Heart murmurs are described, for example, as “grade 2/6”—the numerator representing the intensity of the murmur, and the denominator indicating the highest grade of the scale being used. However, the intensity of the murmur alone provides little information about the clinical severity of the problem. Depending on its cause, an ejection murmur caused by turbulence across the aortic valve during systole can be either serious or nonthreatening, even though the intensity of the murmur may be the same. Therefore, the pitch and quality of the murmur also are described. Pitch is usually reported as high or low, and quality is described as harsh, soft, blowing, musical, or rumbling. For example, the murmur of mitral stenosis may be described as a grade 3/6, low-pitched, rumbling, presystolic murmur heard best at the apex and having an increased first heart sound at the apex.
Special examinations
Emergency
Of greatest importance in an emergency is the evaluation of systems that are essential to sustaining life—namely, the circulatory, respiratory, and central nervous systems. A person in distress should be checked to determine whether breathing is normal or at least whether there is adequate exchange of air to ensure oxygenation of the blood. If the person is unconscious and normal breathing and circulation have stopped, cardiopulmonary resuscitation, or CPR, is an immediate procedure that can be used to provide temporary artificial respiration and blood circulation. CPR buys time for the trauma victim by supplying life-sustaining oxygen to the brain and other vital organs until fully equipped emergency medical personnel have arrived on the scene.
In an emergency situation, circulation is evaluated by medical personnel to determine whether the person’s cardiac output is adequate to provide oxygenated blood to the tissues. Circulation can be compromised by excessive bleeding or other conditions. A blood pressure greater than 100/60 millimetres of mercury (mm Hg) indicates adequate perfusion. However, when blood pressure falls to extremely low levels, shock occurs. The underlying cause of this precipitous drop characterizes shock; for example, hypovolemic shock is caused by inadequate blood volume, cardiogenic shock is caused by reduced heart function, and neurogenic shock and septic shock are caused by malfunction of the vascular system. This malfunction, which can be caused by severe allergic reaction such as anaphylaxis or by drug overdose, results in severely reduced peripheral vascular tone, in vasodilation, and in pooling of the blood. Signs of shock include a rapid and weak pulse, pale complexion, sweating, and confusion. Organs particularly sensitive to injury if the shock is not corrected are the brain, the heart, the lungs, the kidneys, and the liver.
An unconscious person may not respond to external stimulation, in which case the person would be in a coma, or the patient may exhibit varying levels of unconsciousness, responding only to painful stimuli (deep level of unconsciousness) or when called by name (light level). Pupil size and reactivity to light can provide clues to the status of the nervous system. Bilateral dilated pupils that do not contract when a light is placed on one of them indicate death or severe damage to the nervous system. Small pupils that do react to light are seen in narcotic overdose. If one pupil is larger than the other, a brain lesion or hemorrhage on one side should be suspected.
Pediatric
Examinations to assess the well-being of children begin at birth. The Apgar Score System, named for American physician and anesthesiologist Virginia Apgar, is obtained at one and five minutes after birth and indicates the condition of the newborn. A score of 0 (absent), 1, or 2 is given for each of the five parameters, which are heart rate, respiratory effort, muscle tone, reflex irritability, and colour. Infants scoring between 7 and 10 at one minute will likely do well with no special treatment; those scoring between 4 and 6 may require stimulation or brief respiratory support; those scoring 3 or below will probably need extended resuscitative efforts. Infants who have a score of 7 or above at five minutes will continue to do well. The Apgar score is usually reported as two numbers, from 1 to 10, that are separated by a virgule, the first number being the score at one minute, the second the score at five minutes.
Developmental assessment is measured with growth charts. A child’s length (height) and weight are plotted over time on standard graphs constructed from data gathered from a large number of average-sized children. The average length of a newborn infant is 50 cm (20 inches). The length has increased by 50 percent at 12 months of age and has doubled to 100 cm when the child is 4 years old. The average weight at birth is 3.4 kg (7.5 pounds), which doubles in 4 to 5 months and has tripled when the child is 12 months old. After 2 years of age, height increases by 5 cm (2 inches) and weight increases by 2.3 kg (5 pounds) per year until the growth spurt during adolescence.
Psychosocial development can be measured with the Denver Developmental Screening Test, or Denver Scale. This test, which was developed at the University of Colorado in the United States in the late 1960s, is used today in multiple countries, including Canada and the United Kingdom. The test evaluates motor, language, and social development skills in children up to age six. The test was modified in the 1990s to better detect symptoms of a group of conditions known as pervasive developmental disorders (PDDs), which includes autism, Asperger syndrome, and Rett syndrome. PDDs collectively affect an estimated 30 in every 10,000 children worldwide. Although there are no curative treatments for these disorders, early intervention, such as with speech therapy and behaviour modification therapy, may alleviate some of the social and behavioral symptoms.
The adolescent growth spurt is closely associated with the development of the reproductive system. In developed countries, where the majority of children consume diets fulfilling or exceeding the basic nutrient requirements for physical development, puberty occurs in girls starting, on average, at age 10 or 11 and in boys at age 11. In developing countries, puberty occurs anywhere between ages 12 and 16, depending on dietary factors. In girls the first sign of puberty is the breast bud, followed by breast and pubic hair development. In boys it is growth of the testes with reddening and wrinkling of the scrotum. Pubic hair appears within six months of these first signs of puberty, followed in another six months or so by enlargement of the penis. The full development of the male genitalia may take between 2 and 5 years. In girls the interval from the first indication of puberty to complete maturity may vary from 18 months to 6 years.
Hearing is evaluated early, and a disorder should be suspected if speech is delayed or abnormal. Vision testing is begun in the newborn to detect strabismus (misalignment of the eyes) and other congenital abnormalities. Visual acuity can be evaluated in children when they reach age 2 or 3. Dental appointments should begin when the child is 2 or 3, because the eruption of primary teeth is usually complete by age 2. Permanent teeth begin erupting about age 6 and are all in place by age 12 or 13.
Geriatric
Worldwide, in the 20th and early 21st centuries the number of people who survived to age 65 and over increased significantly. As the body ages, there is a steady loss in organ reserve (ability to function beyond the level normally required, which may be called upon in an emergency), which leads to decreasing functional capacity and increasing vulnerability to disease and disability. Age-related changes include the following:
- Cellular changes occur, including decreased function and number.
- Increased collagen results in greater stiffness and decreased tissue elasticity.
- Muscle mass decreases, as does the mass of the liver, brain, and kidneys.
- Cardiac output is reduced; the ability to respond to stress diminishes; and blood flow to the kidneys and other organs decreases.
- Pulmonary function decreases because the number of alveoli lessens, expiratory muscles weaken, and there is a reduction in elastic recoil.
- Gastrointestinal changes occur, including decreased secretion of stomach acid; decreased intestinal motility, resulting in constipation and dehydration of the stools; slower metabolism of drugs by the liver; increased incidence of gallstones; and loss of teeth, impairing proper chewing and digestion. Diverticulosis, in which the inner lining of the large intestine protrudes out through the surrounding muscular layer, occurs in more than 50 percent of persons by age 80.
- Excretory function diminishes because of a decrease in kidney mass and in the number of functioning nephrons.
- Endocrine changes are noted and can include decreased functioning of the thyroid gland and the adrenal gland and decreased insulin production by the pancreas along with increasing insulin resistance that can result in type II diabetes mellitus.
- Height decreases because of narrowing of the intervertebral disks and narrowing of the vertebrae, resulting in the loss of 5 cm (2 inches) by age 70.
Osteoporosis, which is the demineralization of bone and loss of bone mass, results in an increased risk of fracture, especially of the hip, the wrist, and the spine. Bone loss is accelerated in women during menopause but can be prevented by administration of estrogen and calcium. Progesterone is added to prevent uterine cancer if the uterus is still present. Cancers, including uterine cancer, occur most frequently in the elderly. Carcinoma of the colon is predominantly a disease of the geriatric population.
Dementia (loss of intellectual function) is common among the elderly, and Alzheimer disease is thought to account for more than 60 percent of these cases. Alzheimer disease is characterized by a slowly progressive cognitive decline in the absence of other causes of dementia. In the most common form, typically called late-onset Alzheimer disease, symptoms usually appear around age 60. The risk of the disease increases with age.