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The Screening Physical Examination
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In our era of high technology, the continued need for the performance of a proper physical examination may surprise the uninformed [Sackett DL. The science of the art of the clinical examination. JAMA. 1992;267:2650–2652 [PubMed: 1573756]; Adolph RJ, Reilly BM. Physical examination in the care of medical inpatients: An observational study. Lancet. 2003;362:1100–1105].

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The importance of a systematic history and physical examination is best understood by considering the following points. (1) Attention to the story of the patient's illness and thoughtful performance of the physical examination (the “laying on of hands”) establishes a personal relationship of trust and respect between the patient and clinician which is necessary for a good medical care. (2) Performing laboratory tests and imaging studies without diagnostic hypotheses generated from the history and physical examination is expensive and often produces false-positive results, delaying proper diagnosis. (3) Conclusions drawn from the results of blood tests, imaging procedures, and even biopsy material are based upon the pretest probability of the various diagnoses under consideration. The pretest probability is derived from the history, physical examination, and knowledge of disease prevalence. (4) Additionally, many studies have shown that the history and physical examination are more sensitive and specific than imaging tests in most difficult diagnostic situations [Kirch W, Schafi C. Misdiagnosis at a university hospital in 4 medical eras. Medicine (Baltimore). 1996;75:29–40 [PubMed: 8569468].

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Each physical examination is an opportunity to train the four senses: sight, touch, hearing, and smell. With reflective practice and knowledge of anatomy, physiology, and pathology, you will perceive abnormalities in structure and function overlooked by an untrained examiner. The physiologic and disease hypotheses generated during the history and physical examination are tested in the various laboratories leading to precise diagnosis with an economical use of resources.

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We use each of our four senses to elicit signs of disease: inspection (sight and smell), palpation (touch), percussion (touch and hearing), and auscultation (hearing). Only minimal manual dexterity is required for percussion and palpation. Remember to be gentle on initiation of the examination; forceful palpation and percussion are rarely necessary and will cause the patient to become tense and resist your examination.

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With experience, you will be able to assess the severity of illness and the urgency for treatment. To become a skillful diagnostician, you must constantly reflect on the findings from your examination, the correlations between your examination and the laboratory and imaging studies, and the accuracy of your findings and hypotheses based upon the final confirmed diagnoses. In short, you must practice and study. No one started as an expert history taker, physical examiner, or diagnostician. The experts are those who have learned from their experience and refined their senses and skills through repetition, reflection and correlation of their physical findings with the results of imaging and laboratory tests.

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