Chaperones
When asked in surveys, most patients of either sex and all ages report a lack of preference for a chaperone; it is not clear whether this response is their true feeling or a desire to give a “correct” response. Nevertheless, many adult women (29%) and adolescent girls (46%) do express a preference for a chaperone during a breast, pelvic, or rectal examination by a male physician (especially during their first examination). Examiners should offer patients the option of a chaperone, and a chaperone should be considered when the clinician and patient are of different genders. Many examiners prefer a chaperone to allay their own anxieties attributable to gender differences or to achieve a perceived need for protection should the patient become concerned during the procedure.
Vital SignsA nurse or assistant often obtains the vital signs. Vital signs include the pulse rate, blood pressure, respiratory rate, body temperature, and the patient's quantitative assessment of pain. Marked abnormalities require a rapid, focused evaluation that may take precedence over the typical structural approach to the remainder of the evaluation (Chapter 7).The pulse should be recorded as not just the rate but also the rhythm. Physicians may prefer to initiate the examination by holding the patient's hand while palpating the pulse. This nonthreatening initial contact with the patient allows the physician to determine whether the patient has a regular or irregular rhythm.When the blood pressure is abnormal, many physicians repeat the measurement. The instrument error that contributes to the greatest variability is the cuff size of the sphygmomanometer (Chapter 66). Many adults require a large adult cuff; using a narrow cuff can alter systolic/diastolic blood pressure by -8 to +10/+2 to +8 mm Hg. The appearance of repetitive sounds (Korotkoff sounds, phase 1) constitutes systolic pressure. After the cuff is inflated about 20 to 30 mm Hg above the palpated pressure, the Korotkoff sounds muffle and disappear as the pressure is released (phase 5). The level at which the sounds disappear is diastolic pressure. The American Heart Association recommends that each measure be rounded upward to the nearest 2 mm Hg.The respiratory rate should be assessed at the same time that the patient is observed to determine whether there is any respiratory discomfort (dyspnea) (Chapter 83). The subjective sensation of dyspnea is caused by an increased work of breathing. The examiner should decide whether patients have tachypnea (a rapid rate of breathing) or hypopnea (a slow or shallow rate of breathing). Tachypnea is not always associated with hyperventilation, which is defined by increased alveolar ventilation resulting in a lower arterial carbon dioxide level (Chapter 104). In the evaluation of patients suspected of having pneumonia, examiners agree on the presence of tachypnea only 63% of the time.The body temperature of adults is usually measured with an oral electric thermometer. These thermometers correlate well with the traditional mercury thermometer and are safer to use. Rectal thermometers reliably record temperatures 0.4° C higher than oral thermometers do. By comparison, newer tympanic thermometers may vary too much in comparison to oral thermometers (-1.2° C to +1.6° C vs. the oral temperature) to be reliable in hospitalized patients.The Joint Commission on Accreditation of Healthcare Organizations has been a leading advocate of the systematic measurement of self-assessed pain in all patients, typically rated on a scale of 0 to 10 (no pain to worst pain ever) (Chapter 28). The validity, usefulness, and value of the adopted scales as a screening tool for clinical diagnosis are uncertain, however.Head and NeckFaceWhen looking at the face, the examiner can simplify the assessment by carefully judging for symmetry. Asymmetrical facial features should be noted and explained. Examples of asymmetry include skin lesions (Chapter 462), cranial nerve palsies (Chapter 418), parotid enlargement (Chapter 451), or the ptosis of Horner's syndrome (Chapter 445). A variety of disorders may cause symmetrical, abnormal facies; examples include acromegaly (Chapter 242), Cushing's syndrome (Chapter 245), and Parkinson's disease (Chapter 433).EarsPhysicians may not recognize hearing loss unless they pay special attention (Chapter 454). When patients do not appreciate the whispered voice, the likelihood of hearing loss increases considerably (LR 6.0). Cerumen impaction is an easily treated cause of diminished hearing. Otoscopic evaluation of the tympanic membranes should reveal a translucent membrane and an obvious cone of light reflected where the eardrum meets the malleolus (see Fig. 452-6). Few data exist to determine observer variability in otoscopic examination of adult patients.NosePatients frequently have nasal symptoms, such as a self-diagnosis of sinusitis (Chapter 452) or snoring (Chapter 429). The nares should be examined for the presence of polyps, which can be seen as obstructing, glistening mucosal masses. Transillumination performed in a dark room is useful for diagnosing sinusitis, especially when combined with visualization of a purulent discharge, a patient's report of a poor response to decongestants or antihistamines, a maxillary toothache, and the presence of discolored rhinorrhea (Chapter 452). These patients have an LR greater than 6 for bacterial sinusitis.MouthThe quality of the patient's dentition directly affects nutrition. Generalist physicians can be confident that the patient requires dental care if periodontal disease or dental caries is detected (LR > 4.0). The need for dental care cannot be excluded even in the absence of such findings (LR 0.7), however, and all patients should be encouraged to seek regular dental evaluations. Premalignant oral lesions (e.g., leukoplakia [see Fig. 200-1], nodules, ulcerations) found by generalist physicians are usually verified by dentists (LR > 6.5) (Chapter 451). Patients who use smokeless tobacco products are at significantly increased risk for premalignant and malignant oral lesions (Chapter 30). Bimanual palpation of the cheeks and floor of the mouth facilitates identification of potentially malignant lesions (Chapter 451).EyesThe eye examination begins with simple visual inspection to look for symmetry in the lids, extraocular movements, pupil size and reaction, and the presence of redness (Chapters 449 and 450). Abnormalities in extraocular movements should be grouped into nonparalytic (usually chronic with onset in childhood) or paralytic (third, fourth, or sixth cranial nerve palsy) causes. Pupillary abnormalities may be symmetrical or asymmetrical (anisocoria). Red eyes should be categorized by the pattern of ciliary injection, presence of pain, effect on vision, and papillary abnormalities. When the eye examination is approached systematically, the generalist physician can evaluate the likelihood of conjunctivitis, episcleritis or scleritis, iritis, and acute glaucoma.Routine determination of visual acuity can help confirm or refute a patient's report of diminished vision but does not replace the need for formal ophthalmologic evaluation in patients with visual complaints (Chapter 449). Cataracts can be detected with direct ophthalmoscopy, but the generalist's proficiency in this evaluation is uncertain.After identifying the optic disc by ophthalmoscopy, the examiner should note the border of the disc for clarity, color, and the size of the central cup in relation to the total diameter (usually less than half the diameter of the disc). A careful observer sees spontaneous venous pulsations that indicate normal intracranial pressure. Abnormalities of the optic disc include optic atrophy (a white disc), papilledema (see Fig. 449-18) (blurry margins with a pink, hyperemic disc), and glaucoma (a large, pale cup with retinal vessels that dive underneath and that may be displaced toward the nasal side). The generalist's examination inadequately detects early glaucomatous changes, so high-risk patients should undergo routine ophthalmologic examination for glaucoma.After inspecting the disc, the examiner should examine the upper and lower nasal quadrants for the appearance of vessels and the presence of any retinal hemorrhages (see Fig. 449-17) or lesions. Proceeding from the nasal quadrants to the temporal quadrants decreases the risk of papillary constriction from the bright light focused on the fovea. Dilating the pupils leads to an improved examination. Despite the improved results in direct ophthalmoscopy after dilation, patients with diabetes (Chapter 247) should undergo routine examination by ophthalmologists to detect diabetic retinopathy because the sensitivity of a generalist's examination is not adequate to exclude diabetic retinopathy or monitor it over time.Neck Carotid PulsesThe carotid pulses should be palpated for contour and timing in relation to the cardiac impulse. Abnormalities in the carotid pulse contour reflect underlying cardiac abnormalities (e.g., aortic stenosis) but are generally appreciated only after detecting an abnormal cardiac impulse or murmur (Chapter 48).Many physicians listen for bruits over the carotid arteries because asymptomatic carotid bruits are associated with an increased incidence of cerebrovascular and cardiac events in older patients (Chapters 430 and 431). In asymptomatic patients, the presence of a carotid bruit increases the likelihood of a 70 to 90% stenotic lesion (LR 4 to 10), but the absence of a bruit is of uncertain value. Unfortunately, clinical data do not provide adequate data for judging the importance of detecting bruits in asymptomatic patients.ThyroidThe thyroid gland is felt best when standing behind the patient and using both hands to palpate the thyroid gland gently (Chapter 244). The palpatory examination is enhanced by asking the patient to swallow sips of water, which allows the thyroid to glide underneath the fingers, but the quantitative improvement achieved by this maneuver in detecting thyroid enlargement or nodules has not been evaluated rigorously. Inspection of the gland from the side is useful because lateral prominence of the thyroid between the cricoid cartilage and the suprasternal notch indicates thyromegaly. The generalist physician should estimate the size of the thyroid gland as normal or enlarged; the impression of an enlarged thyroid gland by a generalist physician has an LR of almost 4.0, whereas assessment that the gland is of normal size makes thyromegaly less likely (LR 0.4).Lymphatic SystemWhile palpating the thyroid, the examiner may also identify enlarged cervical lymph nodes (Chapter 174). In addition, lymph nodes can be palpated in the supraclavicular area, axilla, epitrochlear area, and inguinofemoral region. Simple lymph node enlargement confined to one region is common and as a single finding does not usually represent an important underlying disorder. Unexpected gross lymph node enlargement in a single area or diffuse lymph node enlargement is more important. Patients with febrile illnesses, underlying malignancy, or inflammatory diseases should routinely undergo an examination of each of the aforementioned areas for lymph node enlargement.ChestInspection of the patient's posture may reveal lateral curves in the back (scoliosis) or kyphosis that may be associated with loss of vertebral height from osteoporosis (Chapter 264). When patients have back pain, the spine and paravertebral muscles should be palpated in a search for spasm and tenderness (Chapter 423). The patient may be placed through maneuvers to assess loss of mobility associated with ankylosing spondylitis (Chapter 286), but a history of loss of lateral mobility may be just as efficient in the early stages of spondylitis.LungsExamination of the lungs begins with inspection of the shape of the chest, although a barrel chest, thought to be typical of obstructive airways disease, is present only in severely affected patients (Chapters 83 and 88). The incremental value of palpation and percussion of the chest to supplement the history, auscultation, and eventual chest radiograph is unknown. Medical students show more consistency than pulmonary specialists do in recording auscultatory abnormalities. The presence or absence of adventitial sounds (wheezes, crackles, or rubs) has good interobserver reliability (K = 0.30 to 0.70). The best piece of information for increasing the likelihood of chronic obstructive pulmonary disease is a history of more than 40 pack years of smoking (LR 19). The presence of wheezing or downward displacement of the larynx to within 4 cm of the sternum (distance between the top of the thyroid cartilage and the suprasternal notch) increases the likelihood of obstructive pulmonary disease (LR 4 for either).HeartThe patient should be examined in the sitting and lying positions (Chapter 48). Typically, the examination begins with auscultation of the precordium while the patient is sitting. Most examiners progress as follows: aortic area, pulmonic area, left sternal border, and apex. For auscultation over the aortic area, having the patient lean forward may increase the intensity of aortic murmurs. Palpation of the apical impulse when the patient lies down in the left lateral decubitus position helps detect a displaced apical impulse and can reveal a palpable S3. When the apical impulse is lateral to the midclavicular line, the likelihood of radiographic cardiomegaly and an ejection fraction less than 50% increases appreciably (LR about 3.5 and 6.0).A systematic approach to auscultation helps organize the examination. First, the physician should listen to the heart sounds and concentrate on their timing, intensity, and splitting with respiration. The first and second heart sounds are heard best with the diaphragm, as are pericardial rubs. Gallops (S3 and S4) are heard best with the stethoscope bell. Murmurs, depending on their origin, vary in pitch and may require switching from the diaphragm to the bell to assess their characteristics (see Table 48-6). The location, timing, intensity, radiation patterns, and respiratory variation of murmurs should be noted. Special maneuvers during auscultation (e.g., Valsalva, auscultation during sudden squatting/standing) do not usually need to be performed if the results of routine precordial examination are entirely normal.There is considerable concern about the reliability and accuracy of the cardiac examination. When performed on patients (as opposed to cardiac simulators), the reliability of perceiving an S3 or S4 is no better than chance, and agreement on the finding among examiners does not seem to improve with the examiner's experience. Nevertheless, the presence of an S3 on any examination is useful for detecting left ventricular systolic dysfunction (LR > 4.0 for identifying patients with an ejection fraction <30%). The presence of a systolic thrill (palpable murmur, LR 12) or a holosystolic murmur increases the likelihood of moderate to severe aortic stenosis or mitral regurgitation. Quiet systolic murmurs (LR 0.08) are much less likely to herald important cardiac abnormalities. A loud, early diastolic murmur (LR 4) or a diastolic murmur associated with an S3 suggests severe aortic regurgitation.BreastThe most important determinants of the accuracy of the breast examination are the duration of the examination; the patient's position; careful evaluation of the breast boundaries; the pattern of the examination; and the position, movement, and pressure of the examiner's fingers (Chapter 208). Interobserver variability is substantial (K about 0.3 to 0.6) because these aspects of the examination vary among physicians. To obtain the best sensitivity, the duration of the breast examination needs to be 5 to 10 minutes total time, but few generalist physicians perform such a lengthy examination. Clinicians should recognize that the examination may make them (or their patient) feel uncomfortable—the presence of a chaperone may give the clinician the confidence to perform an intensive examination.The patient should be examined with the pads of the fingers while she is supine, holding her hand first on her forehead (to flatten the lateral border of the breast) and then on her shoulder (to flatten the medial border). The examiner should make small circular motions with the fingers, moving up and down in parallel rows to span the entire breast-clavicle to the bra line. Cancerous breast lumps are difficult to distinguish from benign breast lumps on examination, but the presence of a fixed mass or a mass 2 cm in diameter has an LR of about 2 to 2.5 for cancer.AbdomenPalpation and percussion of the abdomen of patients with no symptoms or risk factors for an abdominal disorder rarely reveals important abnormalities (Chapter 134). The only caveat would be palpation of an older patient for asymptomatic widening of the abdominal aorta, which is useful when found (LR of 16 for detecting aneurysms >4 cm in diameter) but misses a substantial proportion of small to medium aneurysms (Chapter 78). After specific training in palpation techniques, general internists have good agreement on the presence or absence of an aortic aneurysm (K = 0.53).When patients have potential abdominal symptoms, the examination should be guided by the symptoms. If the history suggests an acute problem, the examination should focus initially on identifying patients who may require surgical evaluation.Auscultation of the abdomen in patients with acute symptoms is directed toward listening for bowel sounds to evaluate possible intestinal obstruction. For patients without gastrointestinal symptoms or abnormalities on palpation, auscultation for bruits is important primarily to detect renal bruits in patients with hypertension (Chapters 66 and 126). The presence of an abdominal bruit in a hypertensive patient, if heard in systole and diastole, strongly suggests renovascular hypertension (LR ≈ 40).LiverDetection of liver disease depends mostly on the history and laboratory evaluations (Chapter 149). By the time that signs are present on physical examination, the patient usually has advanced liver disease. The first abnormalities on physical examination associated with liver disease are extrahepatic. The clinician should assess the patient for ascites, peripheral edema, jaundice, or splenomegaly as signs of liver disease. In patients with an enlarged liver, palpation should begin at the liver edge, but palpation of the edge below the costal margin increases the likelihood of hepatomegaly only slightly (LR 1.7). The upper border of the liver may be detected by percussion, and a span of less than 12 cm reduces the likelihood of hepatomegaly. In the absence of a known diagnosis (e.g., a hepatoma, which may cause a hepatic bruit), auscultation of the liver rarely is helpful.SpleenExamination for splenomegaly in patients without findings suggestive of a disorder associated with splenomegaly almost always reveals nothing (Chapter 174). Approximately 3% of healthy teenagers may have a palpable spleen. The examination for an enlarged spleen begins first with percussion in the left upper quadrant to detect dullness. Percussion is performed over the lowest left anterior axillary line during inspiration and expiration while the patient is supine. In the absence of dullness, the results of palpation do not establish or exclude splenomegaly, so a radiographic image (ultrasound or nuclear scintigraphy) is required. The presence of a palpable splenic edge in patients with dullness to percussion and clinical suspicion of splenomegaly confirms enlargement. Palpation can be performed by any of the following three approaches (K about 0.2 to 0.4): palpating with the right hand while providing counterpressure with the left hand behind the spleen, palpating with one hand without counterpressure (with the patient in the right lateral decubitus position for both techniques), or placing the patient supine with the left fist under the left costovertebral angle while the examiner tries to hook the spleen with the hands.Musculoskeletal SystemThe musculoskeletal examination in adult patients is almost always driven by symptoms (Chapters 277 and 284). Regional musculoskeletal complaints are ubiquitous, and the limited formal clinical training that most physicians receive on the evaluation and management of such disorders belies their impact on the generalist's daily professional activities.Most patients have back pain at some point during their lives (Chapter 423). Back pain is second only to upper respiratory illness as a reason for seeking outpatient care. The goal is to be sure that the back pain is not representative of systemic disease and to exclude neurosurgical emergencies. The patient's history helps assess the likelihood of an underlying systemic disease (age, history of systemic malignancy, unexplained weight loss, duration of pain, responsiveness to previous therapy, intravenous drug use, urinary infection, or fever). The most important physical examination findings for lumbar disc herniation in patients with sciatica all have excellent reliability, including ipsilateral straight leg raising causing pain, contralateral straight leg raising causing pain, and ankle or great toe dorsiflexion weakness (all with K > 0.6).The generalist physician should evaluate an adult patient with knee discomfort for torn menisci or ligaments. The best maneuvers for demonstrating a tear in the anterior cruciate ligament is the anterior drawer or Lachman maneuver, in which the examiner detects the lack of a discrete end point as the tibia is pulled toward the examiner while the femur is stabilized. A variety of maneuvers that assess for pain, popping, or grinding along the joint line between the femur and tibia are used to evaluate for meniscal tears. As with many musculoskeletal disorders, no single finding has the accuracy of the orthopedist's examination, which factors in the history and a variety of clinical findings.The shoulder examination is directed toward determining range of motion, maneuvers that cause discomfort, and assessment of functional disability. Hip osteoarthritis is detected by evidence of restriction of internal rotation and abduction of the affected hip. Generalist physicians often rely on radiographs to determine the need for referral to orthopedic physicians, but routine radiographs are not needed early in the course of shoulder or hip disorders. The degree of pain and disability experienced by the patient may prompt confirmation of the diagnosis and referral to evaluate for surgery.The hands and feet may show evidence of osteoarthritis (local or as part of a systemic process) (Chapter 283), rheumatoid arthritis (Chapter 285), gout (Chapter 294), or other connective tissue diseases. In addition to regional musculoskeletal disorders, such as carpal tunnel syndrome, a variety of medical and neurologic conditions should prompt routine examination of the distal ends of the extremities to prevent complications (e.g., diabetes [neuropathy or ulcers] or hereditary sensorimotor neuropathy [claw toe deformity]).SkinThe skin should be examined systematically under good lighting (Chapter 462). It is best to ask the patient to point out any spots on the skin that concern them. Examiner agreement on some of the most important features of melanoma (asymmetry, haphazard color, border irregularity) is fair to moderate (Chapter 466). A lesion that is symmetrical, has regular borders, is only one color, is 6 mm or smaller, or has not enlarged in size is unlikely to represent a melanoma (LR 0.07). However, an increasing number of findings greatly enhances the likelihood of melanoma (LR 2.6 for two or more findings and LR 98 for the presence of all five findings) (Chapter 214).Basal cell carcinoma and squamous cell carcinoma occur even more frequently than melanoma (Chapter 214). These lesions can be detected during routine examination by paying careful attention to sun-exposed areas of the nose, face, forearms, and hands.Neurologic ExaminationFull details of the neurologic examination are given in Chapter 418.Psychiatric EvaluationDuring the general examination, much of the psychiatric assessment (including cognition) is accomplished while eliciting the routine history and performing the review of systems (Chapter 420). Observation of the patient's mannerisms, affect, facial expression, and behavior may suggest underlying psychiatric disturbances. When a screening survey and review of systems are obtained by a questionnaire completed by the patient, the clinician should review the responses carefully to determine whether the patient exhibits symptoms of depression. Specific questioning for symptoms of depression is appropriate for all adult patients.Genitalia and RectumPelvic ExaminationA complete examination should result in a description of the external genitalia, appearance of the vagina and cervix as seen through a speculum, and bimanual palpation of the uterus and ovaries (Chapters 209 and 254). The precision of the pelvic examination is uncertain. In the emergency setting there is poor agreement between resident physicians and emergency physicians on the presence of cervical motion tenderness, uterine tenderness, adnexal tenderness, and adnexal masses (K 0.2 to 0.25) (Chapter 307). Among gynecologists, assessment of uterine size by examination correlates reasonably well with measurement by pelvic ultrasound. In asymptomatic women, 10 to 15% have some abnormality on examination, and 1.5% have abnormal ovaries. Screening for ovarian cancer is limited by the low sensitivity of the physical examination for detecting early-stage ovarian carcinoma (Chapter 209).Male GenitaliaExamination of the male genitalia should begin with a description of whether the penis is circumcised and whether there are any visible skin lesions (e.g., ulcers or warts). Palpation should confirm the presence of bilateral testes in the scrotum. The epididymis and testes should be palpated for nodules. The low incidence of testicular carcinoma means than most nodules are benign (Chapter 210).The prostate should be examined in all quadrants with attention focused on surface irregularities or differences in consistency throughout the prostate (Chapter 211). An estimate of prostate size may be confounded by the size of the examiner's fingers. It may be best to estimate the size of the prostate in centimeters of width and height.RectumPatients can be examined while lying on their side, although this approach may place the examiner in an awkward stance (Chapters 134 and 148). The rectal examination in women can be performed as part of a bimanual examination, with the index finger in the vagina and the third finger in the rectum to permit palpation of the rectovaginal vault. Men may be asked to stand and lean over the examining table; alternatively, they may be examined while on their back with their hips and knees flexed. This latter maneuver is not used often, although it may facilitate examination of the prostate, which falls into the finger in this position.The rectal examination begins with inspection of the perianal area for skin lesions. A well-lubricated, gloved finger is placed on the anus, and while applying gentle pressure, the examiner asks that the patient bear down as though having a bowel movement. This maneuver facilitates entry of the finger into the rectum. A normal rectal response includes tightening of the anal sphincter around the finger. The examiner should palpate circumferentially around the length of the fully inserted finger for masses. On withdrawing the gloved finger, the finger should be wiped on a stool guaiac card for fecal blood testing to assess for acute blood loss. As a screening test for colorectal carcinoma (Chapter 203), digital examination does not replace the need for testing stool samples collected by the patient (or using alternative screening strategies, such as flexible sigmoidoscopy or colonoscopy).
When asked in surveys, most patients of either sex and all ages report a lack of preference for a chaperone; it is not clear whether this response is their true feeling or a desire to give a “correct” response. Nevertheless, many adult women (29%) and adolescent girls (46%) do express a preference for a chaperone during a breast, pelvic, or rectal examination by a male physician (especially during their first examination). Examiners should offer patients the option of a chaperone, and a chaperone should be considered when the clinician and patient are of different genders. Many examiners prefer a chaperone to allay their own anxieties attributable to gender differences or to achieve a perceived need for protection should the patient become concerned during the procedure.
Vital SignsA nurse or assistant often obtains the vital signs. Vital signs include the pulse rate, blood pressure, respiratory rate, body temperature, and the patient's quantitative assessment of pain. Marked abnormalities require a rapid, focused evaluation that may take precedence over the typical structural approach to the remainder of the evaluation (Chapter 7).The pulse should be recorded as not just the rate but also the rhythm. Physicians may prefer to initiate the examination by holding the patient's hand while palpating the pulse. This nonthreatening initial contact with the patient allows the physician to determine whether the patient has a regular or irregular rhythm.When the blood pressure is abnormal, many physicians repeat the measurement. The instrument error that contributes to the greatest variability is the cuff size of the sphygmomanometer (Chapter 66). Many adults require a large adult cuff; using a narrow cuff can alter systolic/diastolic blood pressure by -8 to +10/+2 to +8 mm Hg. The appearance of repetitive sounds (Korotkoff sounds, phase 1) constitutes systolic pressure. After the cuff is inflated about 20 to 30 mm Hg above the palpated pressure, the Korotkoff sounds muffle and disappear as the pressure is released (phase 5). The level at which the sounds disappear is diastolic pressure. The American Heart Association recommends that each measure be rounded upward to the nearest 2 mm Hg.The respiratory rate should be assessed at the same time that the patient is observed to determine whether there is any respiratory discomfort (dyspnea) (Chapter 83). The subjective sensation of dyspnea is caused by an increased work of breathing. The examiner should decide whether patients have tachypnea (a rapid rate of breathing) or hypopnea (a slow or shallow rate of breathing). Tachypnea is not always associated with hyperventilation, which is defined by increased alveolar ventilation resulting in a lower arterial carbon dioxide level (Chapter 104). In the evaluation of patients suspected of having pneumonia, examiners agree on the presence of tachypnea only 63% of the time.The body temperature of adults is usually measured with an oral electric thermometer. These thermometers correlate well with the traditional mercury thermometer and are safer to use. Rectal thermometers reliably record temperatures 0.4° C higher than oral thermometers do. By comparison, newer tympanic thermometers may vary too much in comparison to oral thermometers (-1.2° C to +1.6° C vs. the oral temperature) to be reliable in hospitalized patients.The Joint Commission on Accreditation of Healthcare Organizations has been a leading advocate of the systematic measurement of self-assessed pain in all patients, typically rated on a scale of 0 to 10 (no pain to worst pain ever) (Chapter 28). The validity, usefulness, and value of the adopted scales as a screening tool for clinical diagnosis are uncertain, however.Head and NeckFaceWhen looking at the face, the examiner can simplify the assessment by carefully judging for symmetry. Asymmetrical facial features should be noted and explained. Examples of asymmetry include skin lesions (Chapter 462), cranial nerve palsies (Chapter 418), parotid enlargement (Chapter 451), or the ptosis of Horner's syndrome (Chapter 445). A variety of disorders may cause symmetrical, abnormal facies; examples include acromegaly (Chapter 242), Cushing's syndrome (Chapter 245), and Parkinson's disease (Chapter 433).EarsPhysicians may not recognize hearing loss unless they pay special attention (Chapter 454). When patients do not appreciate the whispered voice, the likelihood of hearing loss increases considerably (LR 6.0). Cerumen impaction is an easily treated cause of diminished hearing. Otoscopic evaluation of the tympanic membranes should reveal a translucent membrane and an obvious cone of light reflected where the eardrum meets the malleolus (see Fig. 452-6). Few data exist to determine observer variability in otoscopic examination of adult patients.NosePatients frequently have nasal symptoms, such as a self-diagnosis of sinusitis (Chapter 452) or snoring (Chapter 429). The nares should be examined for the presence of polyps, which can be seen as obstructing, glistening mucosal masses. Transillumination performed in a dark room is useful for diagnosing sinusitis, especially when combined with visualization of a purulent discharge, a patient's report of a poor response to decongestants or antihistamines, a maxillary toothache, and the presence of discolored rhinorrhea (Chapter 452). These patients have an LR greater than 6 for bacterial sinusitis.MouthThe quality of the patient's dentition directly affects nutrition. Generalist physicians can be confident that the patient requires dental care if periodontal disease or dental caries is detected (LR > 4.0). The need for dental care cannot be excluded even in the absence of such findings (LR 0.7), however, and all patients should be encouraged to seek regular dental evaluations. Premalignant oral lesions (e.g., leukoplakia [see Fig. 200-1], nodules, ulcerations) found by generalist physicians are usually verified by dentists (LR > 6.5) (Chapter 451). Patients who use smokeless tobacco products are at significantly increased risk for premalignant and malignant oral lesions (Chapter 30). Bimanual palpation of the cheeks and floor of the mouth facilitates identification of potentially malignant lesions (Chapter 451).EyesThe eye examination begins with simple visual inspection to look for symmetry in the lids, extraocular movements, pupil size and reaction, and the presence of redness (Chapters 449 and 450). Abnormalities in extraocular movements should be grouped into nonparalytic (usually chronic with onset in childhood) or paralytic (third, fourth, or sixth cranial nerve palsy) causes. Pupillary abnormalities may be symmetrical or asymmetrical (anisocoria). Red eyes should be categorized by the pattern of ciliary injection, presence of pain, effect on vision, and papillary abnormalities. When the eye examination is approached systematically, the generalist physician can evaluate the likelihood of conjunctivitis, episcleritis or scleritis, iritis, and acute glaucoma.Routine determination of visual acuity can help confirm or refute a patient's report of diminished vision but does not replace the need for formal ophthalmologic evaluation in patients with visual complaints (Chapter 449). Cataracts can be detected with direct ophthalmoscopy, but the generalist's proficiency in this evaluation is uncertain.After identifying the optic disc by ophthalmoscopy, the examiner should note the border of the disc for clarity, color, and the size of the central cup in relation to the total diameter (usually less than half the diameter of the disc). A careful observer sees spontaneous venous pulsations that indicate normal intracranial pressure. Abnormalities of the optic disc include optic atrophy (a white disc), papilledema (see Fig. 449-18) (blurry margins with a pink, hyperemic disc), and glaucoma (a large, pale cup with retinal vessels that dive underneath and that may be displaced toward the nasal side). The generalist's examination inadequately detects early glaucomatous changes, so high-risk patients should undergo routine ophthalmologic examination for glaucoma.After inspecting the disc, the examiner should examine the upper and lower nasal quadrants for the appearance of vessels and the presence of any retinal hemorrhages (see Fig. 449-17) or lesions. Proceeding from the nasal quadrants to the temporal quadrants decreases the risk of papillary constriction from the bright light focused on the fovea. Dilating the pupils leads to an improved examination. Despite the improved results in direct ophthalmoscopy after dilation, patients with diabetes (Chapter 247) should undergo routine examination by ophthalmologists to detect diabetic retinopathy because the sensitivity of a generalist's examination is not adequate to exclude diabetic retinopathy or monitor it over time.Neck Carotid PulsesThe carotid pulses should be palpated for contour and timing in relation to the cardiac impulse. Abnormalities in the carotid pulse contour reflect underlying cardiac abnormalities (e.g., aortic stenosis) but are generally appreciated only after detecting an abnormal cardiac impulse or murmur (Chapter 48).Many physicians listen for bruits over the carotid arteries because asymptomatic carotid bruits are associated with an increased incidence of cerebrovascular and cardiac events in older patients (Chapters 430 and 431). In asymptomatic patients, the presence of a carotid bruit increases the likelihood of a 70 to 90% stenotic lesion (LR 4 to 10), but the absence of a bruit is of uncertain value. Unfortunately, clinical data do not provide adequate data for judging the importance of detecting bruits in asymptomatic patients.ThyroidThe thyroid gland is felt best when standing behind the patient and using both hands to palpate the thyroid gland gently (Chapter 244). The palpatory examination is enhanced by asking the patient to swallow sips of water, which allows the thyroid to glide underneath the fingers, but the quantitative improvement achieved by this maneuver in detecting thyroid enlargement or nodules has not been evaluated rigorously. Inspection of the gland from the side is useful because lateral prominence of the thyroid between the cricoid cartilage and the suprasternal notch indicates thyromegaly. The generalist physician should estimate the size of the thyroid gland as normal or enlarged; the impression of an enlarged thyroid gland by a generalist physician has an LR of almost 4.0, whereas assessment that the gland is of normal size makes thyromegaly less likely (LR 0.4).Lymphatic SystemWhile palpating the thyroid, the examiner may also identify enlarged cervical lymph nodes (Chapter 174). In addition, lymph nodes can be palpated in the supraclavicular area, axilla, epitrochlear area, and inguinofemoral region. Simple lymph node enlargement confined to one region is common and as a single finding does not usually represent an important underlying disorder. Unexpected gross lymph node enlargement in a single area or diffuse lymph node enlargement is more important. Patients with febrile illnesses, underlying malignancy, or inflammatory diseases should routinely undergo an examination of each of the aforementioned areas for lymph node enlargement.ChestInspection of the patient's posture may reveal lateral curves in the back (scoliosis) or kyphosis that may be associated with loss of vertebral height from osteoporosis (Chapter 264). When patients have back pain, the spine and paravertebral muscles should be palpated in a search for spasm and tenderness (Chapter 423). The patient may be placed through maneuvers to assess loss of mobility associated with ankylosing spondylitis (Chapter 286), but a history of loss of lateral mobility may be just as efficient in the early stages of spondylitis.LungsExamination of the lungs begins with inspection of the shape of the chest, although a barrel chest, thought to be typical of obstructive airways disease, is present only in severely affected patients (Chapters 83 and 88). The incremental value of palpation and percussion of the chest to supplement the history, auscultation, and eventual chest radiograph is unknown. Medical students show more consistency than pulmonary specialists do in recording auscultatory abnormalities. The presence or absence of adventitial sounds (wheezes, crackles, or rubs) has good interobserver reliability (K = 0.30 to 0.70). The best piece of information for increasing the likelihood of chronic obstructive pulmonary disease is a history of more than 40 pack years of smoking (LR 19). The presence of wheezing or downward displacement of the larynx to within 4 cm of the sternum (distance between the top of the thyroid cartilage and the suprasternal notch) increases the likelihood of obstructive pulmonary disease (LR 4 for either).HeartThe patient should be examined in the sitting and lying positions (Chapter 48). Typically, the examination begins with auscultation of the precordium while the patient is sitting. Most examiners progress as follows: aortic area, pulmonic area, left sternal border, and apex. For auscultation over the aortic area, having the patient lean forward may increase the intensity of aortic murmurs. Palpation of the apical impulse when the patient lies down in the left lateral decubitus position helps detect a displaced apical impulse and can reveal a palpable S3. When the apical impulse is lateral to the midclavicular line, the likelihood of radiographic cardiomegaly and an ejection fraction less than 50% increases appreciably (LR about 3.5 and 6.0).A systematic approach to auscultation helps organize the examination. First, the physician should listen to the heart sounds and concentrate on their timing, intensity, and splitting with respiration. The first and second heart sounds are heard best with the diaphragm, as are pericardial rubs. Gallops (S3 and S4) are heard best with the stethoscope bell. Murmurs, depending on their origin, vary in pitch and may require switching from the diaphragm to the bell to assess their characteristics (see Table 48-6). The location, timing, intensity, radiation patterns, and respiratory variation of murmurs should be noted. Special maneuvers during auscultation (e.g., Valsalva, auscultation during sudden squatting/standing) do not usually need to be performed if the results of routine precordial examination are entirely normal.There is considerable concern about the reliability and accuracy of the cardiac examination. When performed on patients (as opposed to cardiac simulators), the reliability of perceiving an S3 or S4 is no better than chance, and agreement on the finding among examiners does not seem to improve with the examiner's experience. Nevertheless, the presence of an S3 on any examination is useful for detecting left ventricular systolic dysfunction (LR > 4.0 for identifying patients with an ejection fraction <30%). The presence of a systolic thrill (palpable murmur, LR 12) or a holosystolic murmur increases the likelihood of moderate to severe aortic stenosis or mitral regurgitation. Quiet systolic murmurs (LR 0.08) are much less likely to herald important cardiac abnormalities. A loud, early diastolic murmur (LR 4) or a diastolic murmur associated with an S3 suggests severe aortic regurgitation.BreastThe most important determinants of the accuracy of the breast examination are the duration of the examination; the patient's position; careful evaluation of the breast boundaries; the pattern of the examination; and the position, movement, and pressure of the examiner's fingers (Chapter 208). Interobserver variability is substantial (K about 0.3 to 0.6) because these aspects of the examination vary among physicians. To obtain the best sensitivity, the duration of the breast examination needs to be 5 to 10 minutes total time, but few generalist physicians perform such a lengthy examination. Clinicians should recognize that the examination may make them (or their patient) feel uncomfortable—the presence of a chaperone may give the clinician the confidence to perform an intensive examination.The patient should be examined with the pads of the fingers while she is supine, holding her hand first on her forehead (to flatten the lateral border of the breast) and then on her shoulder (to flatten the medial border). The examiner should make small circular motions with the fingers, moving up and down in parallel rows to span the entire breast-clavicle to the bra line. Cancerous breast lumps are difficult to distinguish from benign breast lumps on examination, but the presence of a fixed mass or a mass 2 cm in diameter has an LR of about 2 to 2.5 for cancer.AbdomenPalpation and percussion of the abdomen of patients with no symptoms or risk factors for an abdominal disorder rarely reveals important abnormalities (Chapter 134). The only caveat would be palpation of an older patient for asymptomatic widening of the abdominal aorta, which is useful when found (LR of 16 for detecting aneurysms >4 cm in diameter) but misses a substantial proportion of small to medium aneurysms (Chapter 78). After specific training in palpation techniques, general internists have good agreement on the presence or absence of an aortic aneurysm (K = 0.53).When patients have potential abdominal symptoms, the examination should be guided by the symptoms. If the history suggests an acute problem, the examination should focus initially on identifying patients who may require surgical evaluation.Auscultation of the abdomen in patients with acute symptoms is directed toward listening for bowel sounds to evaluate possible intestinal obstruction. For patients without gastrointestinal symptoms or abnormalities on palpation, auscultation for bruits is important primarily to detect renal bruits in patients with hypertension (Chapters 66 and 126). The presence of an abdominal bruit in a hypertensive patient, if heard in systole and diastole, strongly suggests renovascular hypertension (LR ≈ 40).LiverDetection of liver disease depends mostly on the history and laboratory evaluations (Chapter 149). By the time that signs are present on physical examination, the patient usually has advanced liver disease. The first abnormalities on physical examination associated with liver disease are extrahepatic. The clinician should assess the patient for ascites, peripheral edema, jaundice, or splenomegaly as signs of liver disease. In patients with an enlarged liver, palpation should begin at the liver edge, but palpation of the edge below the costal margin increases the likelihood of hepatomegaly only slightly (LR 1.7). The upper border of the liver may be detected by percussion, and a span of less than 12 cm reduces the likelihood of hepatomegaly. In the absence of a known diagnosis (e.g., a hepatoma, which may cause a hepatic bruit), auscultation of the liver rarely is helpful.SpleenExamination for splenomegaly in patients without findings suggestive of a disorder associated with splenomegaly almost always reveals nothing (Chapter 174). Approximately 3% of healthy teenagers may have a palpable spleen. The examination for an enlarged spleen begins first with percussion in the left upper quadrant to detect dullness. Percussion is performed over the lowest left anterior axillary line during inspiration and expiration while the patient is supine. In the absence of dullness, the results of palpation do not establish or exclude splenomegaly, so a radiographic image (ultrasound or nuclear scintigraphy) is required. The presence of a palpable splenic edge in patients with dullness to percussion and clinical suspicion of splenomegaly confirms enlargement. Palpation can be performed by any of the following three approaches (K about 0.2 to 0.4): palpating with the right hand while providing counterpressure with the left hand behind the spleen, palpating with one hand without counterpressure (with the patient in the right lateral decubitus position for both techniques), or placing the patient supine with the left fist under the left costovertebral angle while the examiner tries to hook the spleen with the hands.Musculoskeletal SystemThe musculoskeletal examination in adult patients is almost always driven by symptoms (Chapters 277 and 284). Regional musculoskeletal complaints are ubiquitous, and the limited formal clinical training that most physicians receive on the evaluation and management of such disorders belies their impact on the generalist's daily professional activities.Most patients have back pain at some point during their lives (Chapter 423). Back pain is second only to upper respiratory illness as a reason for seeking outpatient care. The goal is to be sure that the back pain is not representative of systemic disease and to exclude neurosurgical emergencies. The patient's history helps assess the likelihood of an underlying systemic disease (age, history of systemic malignancy, unexplained weight loss, duration of pain, responsiveness to previous therapy, intravenous drug use, urinary infection, or fever). The most important physical examination findings for lumbar disc herniation in patients with sciatica all have excellent reliability, including ipsilateral straight leg raising causing pain, contralateral straight leg raising causing pain, and ankle or great toe dorsiflexion weakness (all with K > 0.6).The generalist physician should evaluate an adult patient with knee discomfort for torn menisci or ligaments. The best maneuvers for demonstrating a tear in the anterior cruciate ligament is the anterior drawer or Lachman maneuver, in which the examiner detects the lack of a discrete end point as the tibia is pulled toward the examiner while the femur is stabilized. A variety of maneuvers that assess for pain, popping, or grinding along the joint line between the femur and tibia are used to evaluate for meniscal tears. As with many musculoskeletal disorders, no single finding has the accuracy of the orthopedist's examination, which factors in the history and a variety of clinical findings.The shoulder examination is directed toward determining range of motion, maneuvers that cause discomfort, and assessment of functional disability. Hip osteoarthritis is detected by evidence of restriction of internal rotation and abduction of the affected hip. Generalist physicians often rely on radiographs to determine the need for referral to orthopedic physicians, but routine radiographs are not needed early in the course of shoulder or hip disorders. The degree of pain and disability experienced by the patient may prompt confirmation of the diagnosis and referral to evaluate for surgery.The hands and feet may show evidence of osteoarthritis (local or as part of a systemic process) (Chapter 283), rheumatoid arthritis (Chapter 285), gout (Chapter 294), or other connective tissue diseases. In addition to regional musculoskeletal disorders, such as carpal tunnel syndrome, a variety of medical and neurologic conditions should prompt routine examination of the distal ends of the extremities to prevent complications (e.g., diabetes [neuropathy or ulcers] or hereditary sensorimotor neuropathy [claw toe deformity]).SkinThe skin should be examined systematically under good lighting (Chapter 462). It is best to ask the patient to point out any spots on the skin that concern them. Examiner agreement on some of the most important features of melanoma (asymmetry, haphazard color, border irregularity) is fair to moderate (Chapter 466). A lesion that is symmetrical, has regular borders, is only one color, is 6 mm or smaller, or has not enlarged in size is unlikely to represent a melanoma (LR 0.07). However, an increasing number of findings greatly enhances the likelihood of melanoma (LR 2.6 for two or more findings and LR 98 for the presence of all five findings) (Chapter 214).Basal cell carcinoma and squamous cell carcinoma occur even more frequently than melanoma (Chapter 214). These lesions can be detected during routine examination by paying careful attention to sun-exposed areas of the nose, face, forearms, and hands.Neurologic ExaminationFull details of the neurologic examination are given in Chapter 418.Psychiatric EvaluationDuring the general examination, much of the psychiatric assessment (including cognition) is accomplished while eliciting the routine history and performing the review of systems (Chapter 420). Observation of the patient's mannerisms, affect, facial expression, and behavior may suggest underlying psychiatric disturbances. When a screening survey and review of systems are obtained by a questionnaire completed by the patient, the clinician should review the responses carefully to determine whether the patient exhibits symptoms of depression. Specific questioning for symptoms of depression is appropriate for all adult patients.Genitalia and RectumPelvic ExaminationA complete examination should result in a description of the external genitalia, appearance of the vagina and cervix as seen through a speculum, and bimanual palpation of the uterus and ovaries (Chapters 209 and 254). The precision of the pelvic examination is uncertain. In the emergency setting there is poor agreement between resident physicians and emergency physicians on the presence of cervical motion tenderness, uterine tenderness, adnexal tenderness, and adnexal masses (K 0.2 to 0.25) (Chapter 307). Among gynecologists, assessment of uterine size by examination correlates reasonably well with measurement by pelvic ultrasound. In asymptomatic women, 10 to 15% have some abnormality on examination, and 1.5% have abnormal ovaries. Screening for ovarian cancer is limited by the low sensitivity of the physical examination for detecting early-stage ovarian carcinoma (Chapter 209).Male GenitaliaExamination of the male genitalia should begin with a description of whether the penis is circumcised and whether there are any visible skin lesions (e.g., ulcers or warts). Palpation should confirm the presence of bilateral testes in the scrotum. The epididymis and testes should be palpated for nodules. The low incidence of testicular carcinoma means than most nodules are benign (Chapter 210).The prostate should be examined in all quadrants with attention focused on surface irregularities or differences in consistency throughout the prostate (Chapter 211). An estimate of prostate size may be confounded by the size of the examiner's fingers. It may be best to estimate the size of the prostate in centimeters of width and height.RectumPatients can be examined while lying on their side, although this approach may place the examiner in an awkward stance (Chapters 134 and 148). The rectal examination in women can be performed as part of a bimanual examination, with the index finger in the vagina and the third finger in the rectum to permit palpation of the rectovaginal vault. Men may be asked to stand and lean over the examining table; alternatively, they may be examined while on their back with their hips and knees flexed. This latter maneuver is not used often, although it may facilitate examination of the prostate, which falls into the finger in this position.The rectal examination begins with inspection of the perianal area for skin lesions. A well-lubricated, gloved finger is placed on the anus, and while applying gentle pressure, the examiner asks that the patient bear down as though having a bowel movement. This maneuver facilitates entry of the finger into the rectum. A normal rectal response includes tightening of the anal sphincter around the finger. The examiner should palpate circumferentially around the length of the fully inserted finger for masses. On withdrawing the gloved finger, the finger should be wiped on a stool guaiac card for fecal blood testing to assess for acute blood loss. As a screening test for colorectal carcinoma (Chapter 203), digital examination does not replace the need for testing stool samples collected by the patient (or using alternative screening strategies, such as flexible sigmoidoscopy or colonoscopy).
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