General principles of physical examination
The process of taking a history and conducting a physical examination is artificially separated in classical medical teaching, to encourage learners to develop a structured approach to information gathering. However, your physical assessment of patients undoubtedly begins as soon as you see them, and the astute clinician may notice signs of disease, such as subtle abnormalities of demeanour, gait or appearance, even before the formal consultation begins. The clinician can be likened to a detective, gathering clues, and the physical assessment of a patient can then be seen as the investigation itself!
Historically, great importance has been placed on the value of empirical observation of patients in the formulation of a differential diagnosis. Modern technological advances have increased the reliance on radiological and laboratory testing for diagnosis, sometimes even at the bedside (such as portable ultrasound or near-patient capillary blood ketone testing), and this has called into question the utility of systematic physical examination in modern practice. Nevertheless, the importance of performing a methodical and accurate physical examination cannot be overstated. The inconstancy of physical signs and the need to monitor patient progress by repeated bedside assessment, often conducted by different clinicians, mean that a standardised approach to physical examination resulting in reproducible findings is crucial. Additionally, the interpretation of many diagnostic investigations (such as detection of interstitial oedema on a chest X-ray in heart failure) is subject to variation between clinicians, as is the detection of physical signs (such as audible crackles on auscultating the lungs). Furthermore, the utility of many diagnostic investigations relies heavily on the pre-test probability (the likelihood of the disease being present prior to the test being performed; p. 362 ), which depends on information gathered during the history and examination. Finally, there are a number of conditions, or syndromes, that can be diagnosed only by the detection of a characteristic pattern of physical signs. Thus by mastering structured skills in physical examination, clinicians can improve the reliability and precision of their clinical assessment, which, together with the appropriate diagnostic investigations, lead to accurate diagnosis.
Preparing for physical examination
It is important to prepare both yourself and your patient for the physical examination. As a clinician, you must take reasonable steps to ensure you can give the patient your undivided attention, in an environment free from interruption, noise or distraction. Always introduce yourself to the patient, shake hands (which may provide diagnostic clues; Box 3.1 and see later) and seek permission to conduct the consultation. Make sure you have the relevant equipment available ( Box 3.2 ) and that you have observed local hand hygiene policies ( Fig. 3.1 ). As discussed on page 4 , privacy is essential when assessing a patient. At the very least, ensure screens or curtains are fully closed around a ward bed; where possible, use a separate private room to avoid being overheard. Seek permission from the patient to proceed to examination, and offer a chaperone where appropriate to prevent misunderstandings and to provide support and encouragement for the patient. Regardless of whether the patient is the same gender as the doctor or not, chaperones are always appropriate for intimate (breast, genital or rectal) examination. Chaperones are also advised if the patient is especially anxious or vulnerable, if there have been misunderstandings in the past, or if religious or cultural factors require a different approach to physical examination. Record the chaperone’s name and presence. If patients decline the offer, respect their wishes and record this in the notes. Tactfully invite relatives to leave the room before physical examination unless the patient is very apprehensive and requests that they stay. A parent or guardian should always be present when you examine children ( p. 307 ).
| Features | Diagnosis |
|---|---|
| Cold, sweaty hands | Anxiety |
| Cold, dry hands | Raynaud’s phenomenon |
| Hot, sweaty hands | Hyperthyroidism |
| Large, fleshy, sweaty hands | Acromegaly |
| Dry, coarse skin | Regular water exposure |
| Manual occupation | |
| Hypothyroidism | |
| Delayed relaxation of grip | Myotonic dystrophy |
| Deformed hands/fingers | Trauma |
| Rheumatoid arthritis | |
| Dupuytren’s contracture |
|
|
The room should be warm and well lit; subtle abnormalities of complexion, such as mild jaundice, are easier to detect in natural light. The height of the examination couch or bed should be adjustable, with a step to enable patients to get up easily. An adjustable backrest is essential, particularly for breathless patients who cannot lie flat. It is usual practice to examine a recumbent patient from the right-hand side of the bed. Ensure the patient is comfortably positioned before commencing the physical examination.
Seek permission and sensitively, but adequately, expose the areas to be examined; cover the rest of the patient with a blanket or sheet to ensure that they do not become cold. Avoid unnecessary exposure and embarrassment; a patient may appreciate the opportunity to replace their top after examination of the chest before exposing the abdomen. Remain gentle towards the patient at all times, and be vigilant for aspects of the examination that may cause distress or discomfort. Acknowledge any anxiety or concerns raised by the patient during the consultation.
Sequence for performing a physical examination
The purpose of the physical examination is to look for the presence, or absence, of physical signs that confirm or refute the differential diagnoses you have obtained from the history. The extent of the examination will depend on the symptoms that you are investigating and the circumstances of the encounter. Often, in a brief, focused consultation (such as a patient presenting to a general practitioner with headache), a single system (the nervous system in this case) will be examined. In other circumstances, however, a full integrated physical examination will be required and this is described in detail on page 362 .
There is no single correct way to perform a physical examination but standardised systematic approaches help to ensure that nothing is omitted. With experience, you will develop your own style and sequence of physical examination. Broadly speaking, any systematic examination involves looking at the patient (for skin changes, scars, abnormal patterns of breathing or pulsation, for example), laying hands on the patient to palpate (feel) and percuss (tapping on the body), and finally using a stethoscope, where appropriate, to listen to the relevant system (auscultate). This structured approach to the examination of the system can be summarised as:
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inspection
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palpation
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percussion
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auscultation.
Initial observations
The physical examination begins as soon as you see the patient. Start with a rapid assessment of how unwell the patient is, since the clinical assessment may have to be adjusted for a deteriorating or dying patient, and any abnormal physiology may need to be addressed urgently before the actual diagnosis is found ( pp. 341 and 348 ). Early warning scoring systems (which include assessment of vital signs: pulse, blood pressure, respiratory rate and oxygen saturations, temperature, conscious level and pain score) are used routinely to assess unwell patients and these clinical measurements aid decisions about illness severity and urgency of assessment ( p. 340 ). If your patient is distressed or in pain, giving effective analgesia may take priority before undertaking a more structured evaluation, although a concurrent evaluation for the cause of the pain is clearly important.
For the stable or generally well patient, a more measured assessment can begin. Observe the patient before the consultation begins. Do they look generally well or unwell? What is their demeanour? Are they sitting up comfortably reading or on the telephone to a relative, or do they seem withdrawn, distressed or confused?
Notice the patient’s attire. Are they dressed appropriately? Clothing gives clues about personality, state of mind and social circumstances, as well as a patient’s physical state. Patients with recent weight loss may be wearing clothes that look very baggy and loose. Are there signs of self-neglect (which may be underpinned by other factors such as cognitive impairment, immobility or drug or alcohol dependence) or inappropriate attire? For example, a patient with thyrotoxicosis may come to see you dressed for summer in the depths of winter due to heat intolerance.
Often there will be clues to the patient’s underlying medical condition either about the person (for example, they may be wearing a subcutaneous insulin pump to treat their type 1 diabetes, or carrying a portable oxygen cylinder if they have significant pulmonary fibrosis) or by the bedside (look on the bedside table for a hearing aid, peak flow meter or inhaler device, and note any walking aid, commode and wheelchair, which provide clues to the patient’s functional status). Patients may be wearing a medical identity bracelet or other jewellery alerting you to an underlying medical condition or life-sustaining treatment. Note any tattoos or piercings; as well as there being possible associated infection risks, these can provide important background information ( Fig. 3.2 ). Be sure to look for any venepuncture marks of intravenous drug use or linear (usually transverse) scars from recent or previous deliberate self-harm ( Figs 3.3 and 3.4 ).
Gait and posture
If patients are ambulant, watch how they rise from a chair and walk towards you. Are they using a walking aid? Is the gait normal or is there evidence of pain, immobility or weakness? Abnormalities of gait can be pathognomonic signs of neurological or musculoskeletal disease: for example, the hemiplegic gait after stroke, the ataxic gait of cerebellar disease or the marche à petits pas (‘walk of little steps’) gait in a patient with diffuse cerebrovascular disease or Parkinsonism (see Fig. 7.17D ). Notice any abnormal movements such as tremor (in alcohol withdrawal, for example), dystonia (perhaps as a side effect of neuroleptic therapy) or chorea (jerky, involuntary movements, characteristic of Huntington’s disease). Abnormalities of posture and movement can also be a clue to the patient’s overall wellbeing, and may represent pain, weakness or psychological or emotional disturbance.
Facial expression and speech
As with gait and posture, a patient’s facial expression and how they interact with you can provide clues to their physical and psychological wellbeing ( Box 3.3 ). Reluctance to engage in the consultation may indicate underlying depression, anxiety, fear, anger or grief, and it is important to recognise these emotions to ensure that both the physical and the emotional needs of the patient are addressed effectively. Some people conceal anxieties and depression with inappropriate cheerfulness. Illness itself may alter demeanour: frontal lobe disease or bipolar disorders may lead to animated disinhibition, whereas poverty of expression may occur in depression or Parkinson’s disease. Physical signs in the face that are associated with specific diagnoses are covered later (see Box 3.9 ).
Be vigilant for abnormalities in the character of speech, such as slurring (due to alcohol, for example, or dysarthria caused by motor neurone disease; p. 125 ), hoarseness (which can represent recurrent laryngeal nerve damage; p. 186 ) or abnormality of speech cadence (which could be caused by pressure of speech in hyperthyroidism or slowing of speech in myxoedema; p. 197 ).
Hands
Starting your physical contact with a patient with a handshake not only is polite but also may reveal relevant signs (see Box 3.1 ). The rare disease myotonic dystrophy (which is over-represented in candidate assessments) causes a patient to fail to release the handgrip (due to delayed muscle relaxation). A patient with neurological disease may be unable to shake your hand, or may have signs of muscle wasting or tremor. Detailed examination of the hands is described on page 265 but even a brief inspection and palpation may be very revealing.
Deformity
Deformity may indicate nerve palsies or arthritic changes (such as ulnar deviation at the metacarpophalangeal joints in longstanding rheumatoid arthritis; see Fig. 13.22 ). Arthritis frequently involves the small joints of the hands. Rheumatoid arthritis typically affects metacarpophalangeal and proximal interphalangeal joints (see Fig. 13.22 ), and osteoarthritis and psoriatic arthropathy affect the distal interphalangeal joints (see Fig. 13.8 ). Small-muscle wasting of the hands is common in rheumatoid arthritis, producing ‘dorsal guttering’ of the hands, and also occurs in cervical spondylosis with nerve root entrapment. In carpal tunnel syndrome, median nerve compression leads to wasting of the thenar muscles, also seen in damage affecting the T1 nerve root (see Fig. 13.23 ).
Dupuytren’s contracture is a thickening of the palmar fascia causing fixed flexion deformity, and usually affects the little and ring fingers ( Fig. 3.5 ). Arachnodactyly (long, thin fingers) is typical of Marfan’s syndrome (see Fig. 3.21B ). Trauma is the most common cause of hand deformity.
Colour
Colour changes in the hands may also be revealing. Look for peripheral cyanosis in the nail bed and tobacco staining of the fingers (see Fig. 5.8 ). Examine the skin creases for pigmentation, although pigmentation is normal in many non-Caucasian races ( Fig. 3.6 ).
Temperature
The temperature of the patient’s hand is a good guide to peripheral perfusion. In chronic obstructive pulmonary disease the hands may be cyanosed due to reduced arterial oxygen saturation but warm due to vasodilatation from elevated arterial carbon dioxide levels. In heart failure the hands are often cold and cyanosed because of vasoconstriction in response to a low cardiac output. If they are warm, heart failure may be due to a high-output state, such as hyperthyroidism.
Skin
Skin changes in the hands can indicate systemic disease, as in the coarse skin and broad hands of a patient with acromegaly (see Fig. 10.8 ), or the tight, contracted skin (scleroderma) and calcium deposits associated with systemic sclerosis (see Figs 3.30C and 13.6 ). Clues about lifestyle can also be seen in the hands: manual workers may have specific callosities due to pressure at characteristic sites, while disuse results in soft, smooth skin.
Nails
Nail changes occur in a wide variety of systemic diseases. Box 3.4 and Fig. 3.7 summarise nail changes seen on general examination that may indicate underlying systemic disease.
| Nail changes | Description of nail | Differential diagnosis |
|---|---|---|
| Beau’s lines | Transverse grooves (see Fig. 3.7B ) | Sequella of any severe systemic illness that affects growth of the nail matrix |
| Clubbing | Loss of angle between nail fold and nail plate (see Fig. 3.8 ) | Serious cardiac, respiratory or gastrointestinal disease (see Box 3.5 ) |
| Leuconychia | White spots, ridges or complete discoloration of nail (see Fig. 3.7C ) | Trauma, infection, poisoning, chemotherapy, vitamin deficiency |
| Lindsay’s nails | White/brown ‘half-and-half’ nails (see Fig. 12.7 ) | Chronic kidney disease |
| Koilonychia | Spoon-shaped depression of nail plate (see Fig. 3.7D ) | Iron deficiency anaemia, lichen planus, repeated exposure to detergents |
| Muehrcke’s lines | Narrow, white transverse lines (see Fig. 12.6 ) | Decreased protein synthesis or protein loss |
| Nail-fold telangiectasia | Dilated capillaries and erythema at nail fold (see Fig. 14.13B ) | Connective tissue disorders, including systemic sclerosis, systemic lupus erythematosus, dermatomyositis |
| Onycholysis | Nail separates from nail bed (see Fig. 3.7A ) | Psoriasis, fungal infection, trauma, thyrotoxicosis, tetracyclines (photo-onycholysis) |
| Onychomycosis | Thickening of nail plate with white, yellow or brown discoloration | Fungal infection |
| Pitting | Fine or coarse pits in nail (see Fig. 3.7A ) | Psoriasis (onycholysis, thickening and ridging may also be present), eczema, alopecia areata, lichen planus |
| Splinter haemorrhages | Small red streaks that lie longitudinally in nail plate (see Fig. 4.5B ) | Trauma, infective endocarditis |
| Yellow nails | Yellow discoloration and thickening (see Fig. 14.13C ) | Yellow nail syndrome |
Finger clubbing describes painless soft tissue swelling of the terminal phalanges and increased convexity of the nail ( Fig. 3.8 ). Clubbing usually affects the fingers symmetrically. It may also involve the toes and can be unilateral if caused by a proximal vascular condition, such as arteriovenous shunts for dialysis. It is sometimes congenital but in over 90% of patients it heralds a serious underlying disorder ( Box 3.5 ). Clubbing may recede if the underlying condition resolves.
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Look across the nail bed from the side of each finger. Observe the distal phalanges, nail and nail bed:
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Estimate the interphalangeal depth at the level of the distal interphalangeal joint (this is the anteroposterior thickness of the digit rather than the width). Repeat at the level of the nail bed.
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Assess the nail-bed (hyponychial) angle ( Fig. 3.9A ).
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