A systematic history and physical exam is the foundation of the diagnostic process. Likewise, the screening physical exam is foundational to the clinician–patient relationship. Laying on of hands is symbolic of the trusting, respectful relationship between clinician and patient necessary for good care. The hands-on physical examination by an experienced clinician is frequently undervalued.
The exam imprints an image of the person in their nonidealized normal state while screening for signs of unsuspected disease or developmental abnormalities. All four senses are used during the physical exam: inspection uses sight and smell, palpation is systematic touch and feel, percussion uses hearing and feel, and auscultation uses hearing. Each physical exam is an opportunity to further train these senses. Deliberate practice, study, and experience improve the ability to detect structural and functional changes overlooked by inexperienced examiners. Skill is achieved by routinely comparing exam findings to laboratory and imaging studies. If discrepancies are observed, repeat the exam. Experts have refined their senses and skills through repetition and reflection and learned from experience.
METHODS FOR PHYSICAL EXAMINATION
Observation using sight and smell is both simple and difficult. Simple because sight and smell are continuous during wakefulness; hard because learning to see actively, rather than passively, is a skill acquired by deliberate practice. Attention is unconsciously selective so that what we see and consciously remember is biased toward what is expected and known. The ability to see the unexpected or unknown is acquired by deliberate practice, not just by doing many exams; remember, sight is a faculty, seeing is an art. Consequently, inspection depends entirely on the observer’s knowledge, expectations, and training. This is epitomized in maxims such as “We see what’s behind the eyes” (Wintrobe), “The examination does not wait the removal of the shirt” (Waring), and “Was Man Weiss, Man sieht” (Goethe: “What one knows, one sees”). The layperson sees someone who looks peculiar. The expert physician sees enlarged supraorbital ridges, widely spaced teeth, large tongue, and wide hands and feet; he sees acromegaly.
Smells are impossible to describe, only experience provides a context for interpretation. The body odors of poor hygiene, the fetor of advanced liver disease, the putrid smell of anaerobic infections, the smell of alcohol or acetone on the breath, and many others are useful diagnostic clues to a trained observer.
General visual inspection
The physical exam begins by inspecting the whole person at first contact. If possible, watch how the patient walks into the exam room. Note how he is dressed and groomed, whether eye contact is established, the tone and pattern of speech, how he moves and changes position, his facial expression, skin type, overall body form and proportions, deformities or asymmetry of face, limbs, or trunk, nutrition, specific behaviors, presence of tremor, and signs of pain. Bear ...