Physical Address

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Mental Status

The mental status portion of the neurologic examination is a complex process. Mental status is the total expression of a person’s emotional responses, mood, cognitive functioning (ability to think, reason, and make judgments), and personality. A major focus of the examination is the identification of the individual’s strengths and capabilities for interaction with the environment. This chapter focuses on the mental status evaluation of the individual’s…

Vital Signs and Pain Assessment

The vital signs include assessment of temperature, pulse, respiration, and blood pressure. They are considered the baseline indicators of a patient’s health status. Pain assessment is considered the fifth vital sign. Pain is a subjective unpleasant symptom of many conditions and injuries. The pain experience, its characteristics, and intensity are unique for each person. The Joint Commission (2017) requires healthcare facilities to make pain assessment and…

The Health Record

After performing the history and physical examination, the healthcare clinician must organize, synthesize, and record the data along with the problems identified and the rationale for the diagnostic evaluation and plan of care. This cognitive effort goes well beyond simply transcribing or importing data that may exist from other sources or completing prescribed templates. The information in the patient’s health record must enable you and your…

Taking the Next Steps: Clinical Reasoning

Clinical reasoning is the process by which the information gathered from the history and physical examination is merged with clinical knowledge, experience, and the current best evidence to formulate the next steps in patient care—development of the diagnostic and management plans. Critical reflection involves thinking through the reasoning for these decisions. This reflection can help you progress from rote decision making to clinical reasoning. The Clinical…

Examination Techniques and Equipment

This chapter provides an overview of the techniques of inspection, palpation, percussion, and auscultation that are used throughout the physical examination. In addition, general use of the equipment for performing physical examination is discussed ( Box 3.1 ). Specific details regarding techniques and equipment as they relate to specific parts of the examination can be found in the relevant chapters. This chapter also addresses special issues…

The History and Interviewing Process

This chapter discusses the development of relationships with patients and the building of histories or healthcare narratives. We write of it as “building” a history rather than “taking” one because you and your patient are involved in a joint effort, a partnership, which should have, among other outcomes, a history that truly reflects the patient’s perspectives and unique status ( Haidet, 2010 ; Haidet and Paterniti,…

Cultural Competency

Achieving cultural competence is a learning process that requires self-awareness, reflective practice, and knowledge of core cultural issues. It involves recognizing one’s own culture, values, and biases and using effective patient-centered communication skills. A culturally competent healthcare provider adapts to the unique needs of patients of backgrounds and cultures that differ from their own. This adaptability, coupled with a genuine curiosity about a patient’s beliefs, values,…

The Extremities and Peripheral Vascular Exam

In Medicine it is always necessary to start with the observation of the sick and to always return to this as this is the paramount means of verification. Observe methodically and vigorously without neglecting any exploratory procedure, using all that can be provided by physical examination. –Antoine B.J. Marfan Generalities 1. What is the role of the extremities’ exam? Often examined last, the extremities can still…

The Musculoskeletal System

Generalities This is a difficult area of physical exam, but one necessary in ambulatory medicine and often rewarding. One of ten patients presenting to a primary care office will do so because of musculoskeletal complaints. Most of these can be diagnosed through a thorough exam, specific maneuvers ( Table 18.1 ), and a proper knowledge of joints’ anatomy and physiology. 1. What are the cardinal signs…

The Neurologic System

Generalities In times of magnetic resonance imaging (MRI) and computed tomography (CT), the neurologic exam may seem almost anachronistic. Yet, as the leading British neurologist McDonald Critchley (1900–1997) once said during one of his United States visits, “CT scanning will take away the shadows of neurology, but the music will still remain.” Indeed, the neurologic exam remains the most sophisticated part of physical diagnosis, still able…

Lymph Nodes

A General Considerations Lymph nodes are important. A methodical search may yield invaluable clues in cancer or systemic disease. Some “sentinel” nodes have even entered medical folklore, forever linked by eponyms to the physicians who first described them. 1. Which nodes are normally palpable in the healthy individual? Out of a total of 600, only the submandibular, axillary , or inguinal nodes may at times be…

Female Genitalia and the Pelvis

1. What is the role of the pelvic exam? To provide an essential component of the female exam, which, when well performed, allows for “low-tech” cancer screening plus the detection of various obstetric-gynecologic conditions – including pregnancy. 2. How can I make my patient as comfortable as possible during the pelvic exam? By following a few simple steps: Suggest she void prior to the exam. Raise…

Male Genitalia, Hernias, and Rectal Exam

Generalities Examination of male genitalia and the rectum is an important but often overlooked part of the physical examination, usually conducted rather quickly at the end. There is no gain in being prudish about it (or, even worse, skipping it altogether, while documenting in the chart: patient refused ). In fact, a wealth of information can be garnered. If your patient is transgender or gender fluid,…

The Abdomen

Generalities Conventional teaching has long recognized the abdomen as “the grave of the internist,” since in contrast to the chest, this cavity has been quite unyielding to physical exam. Although maneuvers devised by generations of physicians to unlock the secrets of its many organs have been for the most part wanting, there are still a few golden nuggets worth learning about. This chapter reviews sequentially the…

Lung Auscultation

Generalities Lung auscultation has long suffered from a complex and onomatopoeic terminology that goes back to the original stethoscope and its inventor. Recent application of computer technology has rekindled this art by facilitating acoustic analysis. Still, its major difficulty lies not in the identification of sounds (which is much easier than for cardiac sounds and murmurs), but in their interpretation. And despite recent attempts at standardization,…

Chest Inspection, Palpation, and Percussion

Generalities Chest inspection, palpation, and percussion are the foundations of physical exam. Percussion is 15 years older than the United States, the brainchild of an Austrian innkeeper’s son who figured out that patients’ chests could behave like barrels of wine. Although rather “ancient,” these maneuvers retain considerable value. Their skilled use may in fact still provide key pieces to our diagnostic mosaic. Indeed, bedside diagnosis of…

The Cardiovascular Exam

Generalities Cardiovascular examination is centered around five main components – all essential for making a diagnosis. In this section we shall discuss inspection , palpation , and percussion . Next we shall address auscultation, first with heart sounds and extra heart sounds, followed by murmurs. The chapter concludes with a discussion on cardiac POCUS and its role in augmenting the five traditional components of the cardiovascular…

The Breast

Generalities The clinical breast examination (CBE) as screening tool for breast cancer is a controversial, changing field; it has mostly been studied in conjunction with screening mammography. (1) Inspection 1. Which areas should be examined? Breast tissue is contained in an imaginary pentagon, whose lateral border follows the midaxillary line, from the middle of the axilla down to the inframammary (or bra) line (fifth to sixth…

The Thyroid

Generalities The thyroid may not be the most important organ in a busy general practice, but in physical diagnosis it is second only to the heart in number of examination errors and lack of physician’s confidence. This is unfortunate, as better skills may guide a more intelligent use of costly scans and better assessment of the likelihood of hyperthyroidism in anxious young patients. A Anatomic Review…