Vital Signs
In a clinic or office-based medical practice, the physical examination may begin with a nurse or medical assistant measuring the patient's vital signs—temperature, respiration, pulse, and blood pressure. Temperature is measured using a thermometer. Normal oral temperature (measured by mouth) is 98.6 degrees Fahrenheit or 37 degrees Celsius. Temperature also may be measured rectally, under the arm (axillary), or aurally with an electronic thermometer placed in the ear. Temperatures measured aurally or rectally are normally higher (approximately 99.6 degrees F/37.7 degrees C) than axillary or oral temperatures.
Respiration is measured by observing the patient's rate of breathing. In addition to determining the rate of respiration (normal for an adult is twelve to twenty breaths per minute), the practitioner also notes any difficulties in breathing.
Pulse rate and rhythm are assessed by compressing the resting patient's radial artery at the wrist. The normal resting pulse rate is between sixty and one hundred beats per minute, and the rhythm should be regular, with even spaces between beats. Pulse rates higher than one hundred beats per minute are called tachycardia, and rates lower than sixty beats per minute are called bradycardia. Some variations in pulse rates are considered normal and do not signify disease. Athletes who engage in high levels of physical conditioning often have pulse rates of less than sixty beats per minute at rest. Similarly, pulse rates increase naturally in response to exercise or emotional stress.
Blood pressure is measured using an inflatable blood pressure cuff, also known as a sphygmomanometer. The cuff is wrapped around the patient's upper arm, slightly above the elbow level, and as it deflates, the practitioner uses a stethoscope to listen to beats of the brachial artery. Blood pressure is measured in millimeters of mercury (mm Hg). Two readings are recorded—systolic pressure is the top number of a blood pressure reading and represents the pressure at which beats are first heard in the artery. The bottom number is the pressure at which the beats can no longer be heard; it is called diastolic pressure.
As with pulse rates, blood pressure varies in response to exercise and emotional stress. Normally, the systolic blood pressure of an adult is less than 140 mm Hg and diastolic blood pressure is less than 90 mm Hg. Repeated blood pressure readings higher than 140/90 mm Hg lead to a diagnosis of hypertension (high blood pressure).
Head and Neck
Physical examination of the head and neck involves inspection of the head (including skin and hair), ears, nose, throat, and neck. An instrument called an otoscope is used to examine the ear canal and tympanic membrane. Ears and nose are examined for swelling, redness, lesions, drainage, discharge, or deformity. Inspecting the throat, the practitioner looks for abnormalities and, by depressing the tongue, can inspect the mouth, oropharynx, and tonsils.
The practitioner notes any scars, asymmetry, or masses (lumps or thickenings) in the neck and systematically palpates (presses) to examine the chains of lymph nodes (also known as "lymph glands," clusters of cells that filter fluid known as lymph) that run in front and behind the ear, near the jaw, and at the base of the neck. The practitioner also inspects and palpates the thyroid gland (the largest gland in the endocrine system, located where the larynx and trachea meet).
Eye Examination
An eye examination consists of a vision test and visual inspection of the eye and surrounding areas for abnormalities, deformities, and signs of infection. Two numbers describe visual acuity (vision). The first number is the distance (in feet) that the patient is standing from the test chart, and the second number is the distance from which the eye can read a line of letters from the test chart. Because 20/20 is considered normal vision, a person with 20/60 vision can read a line of letters from 20 feet away that a person with normal vision could read from a distance 60 feet away from the test chart.
Using an ophthalmoscope, the practitioner examines the inner structures of the eye by looking through the pupil.
Chest and Lungs
Examination of the chest and lungs focuses on identifying disorders of breathing by observing for structural symmetry, listening for abnormal breath sounds and unusual effort during breathing, and noting the rate and rhythm of breathing. Breathing consists of inspiration and expiration (inhaling and exhaling), and changes in the length of either action could be a sign of disease. For example, prolonged expiration may be the result of the airway obstruction of asthma.
Percussion is a tapping technique used to produce sounds on the chest wall that may be distinguished as normal, dull, or hyperresonant. Dull sounds may indicate the presence of pneumonia (infection of the lungs), whereas hyperresonant sounds may be signs of a collapsed lung (pneumothorax) or emphysema (a disease in which the alveoli—microscopic air sacs—of the lung are destroyed).
The practitioner listens to breath sounds with a stethoscope. Listening with the stethoscope is called auscultation. Decreased breath sounds may be signs of emphysema or pneumothorax, whereas high-pitched wheezes are associated with asthma. Another device used to monitor the breathing of patients with asthma is a peak flow meter. After taking a deep breath, the patient exhales into the peak flow meter and it measures the velocity of exhaled breath.
Back and Extremities
The examination of the back and extremities (arms and legs) focuses on the anatomy of the musculoskeletal system. The practitioner looks for symmetry, swelling, color (redness may be a sign of infection; blueness may indicate inadequate blood supply), deformity, and loss of function. Major muscle groups and all joints are examined. The upper-body extremities include the fingers, thumbs, wrists, forearms, elbows, and shoulders. The lower extremities consist of hips, knees, ankles, feet, and toes. All joints and the spine are observed as the patient moves to determine stability and range of motion, and each is palpated to watch for pain, tenderness, or weakness.
Pulses on the arms, legs, and feet (radial, posterior tibial, and dorsalis pedis respectively) are checked to be certain blood flow to the extremities is adequate. Monitoring capillary refill time is another way to assess the adequacy of blood flow. To do this, the practitioner presses the patient's fingernail or toenail until it pales and then observes how long it takes to regain color once the pressure is released. Greater than average capillary refill time may be a sign of peripheral vascular disease or blocked arteries.
Cardiovascular System
The examination of the cardiovascular system focuses on the rate and rhythm of radial and carotid artery pulses (located at the wrist and neck), blood pressure, and the sounds associated with blood flow through the carotid arteries and the heart. After measuring and recording the rate and rhythm of radial and carotid pulses, the practitioner may listen with a stethoscope for abnormal sounds in the carotid arteries. Rushing sounds, called "bruits," may indicate narrowing of the arteries and an increased risk for stroke.
Examination also entails assessment of jugular vein pressure and listening (auscultation) with a stethoscope to heart sounds. Heart murmurs, clicks, and extra sounds are abnormal heart sounds associated with the functioning of heart valves. Some murmurs are considered "innocent" (normal variations), whereas others are indicators of serious malfunctioning of heart valves.
Abdominal Examination
Inspection of the abdomen focuses on the shape and movement of the abdomen and the presence of scars, lesions, rashes, and hernias (protrusion of an organ through a wall that usually encloses it). Using a stethoscope, the practitioner listens to the arteries that supply blood to the kidneys, listens to the aorta (the main artery that supplies blood to all the organs except the lungs), and listens for bowel sounds.
Percussion of the abdomen that produces a dull sound may indicate an abnormality, such as an abdominal mass. Percussion also is used to determine the size of the liver (the largest gland in the body, which produces bile to aid in the digestion of fats) that measures 6–12 cm in a healthy adult. An expanse of dullness around the liver or spleen (an organ on the left side of the body, below the diaphragm, that filters and stores blood) may indicate that these organs are enlarged.
A healthy liver is not tender or painful; palpation of the liver is used to check for pain or tenderness. The aorta may be palpated in the midline of the abdomen, and its pulse may be felt. The spleen is not usually palpable in healthy adults.
Breast and Pelvic Examination
Visual inspection of the breast focuses on symmetry, dimpling, swelling or discoloration of skin, and position of the nipple. Manual breast examination is performed by slowly and methodically palpating breast tissue in overlapping vertical strips using small circular movements from the midline to the axilla (armpit). The practitioner presses the nipple to observe whether there is any discharge (fluid) and also palpates the axilla for the presence of lymph nodes.
Annual (or more frequent) manual examination of the breast by a health practitioner supplements, but does not replace, monthly breast self-examination and regular mammography (breast x-rays able to detect tumors too small to be felt during manual examination) as recommended by a physician or other health care practitioner.
Pelvic examination often is performed after the breast examination, during a woman's physical examination by a primary care physician (doctor specializing in general practice, family practice, or internal medicine), an obstetrician–gynecologist (a physician specializing in women's reproductive health), a nurse-midwife, or nurse practitioner (also known as advance practice nurses, who have additional professional training, expertise, and certification).
With the patient lying down with her heels in stirrups and knees apart, the health care practitioner inspects the genitalia for redness, swelling, and infection. Using an instrument called a speculum, which is inserted into the vagina, the practitioner is able to view the cervix (opening of the uterus) and vaginal walls. At this time, a sample of tissue usually is obtained for a Papanicolaou (Pap) smear, which is examined microscopically for cervical cancer cells in the cytology laboratory.
Pelvic examination also involves manual palpation of the cervix to assess its shape, size, and mobility and to examine the uterus and ovaries. A rectal examination, during which the practitioner inserts a gloved finger into the rectum to check for polyps (protruding growths), also may be performed during this examination.
Neurologic and Mental Status Examinations
Neurologic examination considers mental status, cranial nerves (the twelve cranial nerves are olfactory, optic, oculomotor, trochlear, trigeminal, abducens, facial, acoustic, glossopharyngeal, vagus, accessory, and hypoglossal), muscle strength, coordination and gait, reflexes, and the senses. When a comprehensive neurologic examination is performed independent of a complete physical examination, it includes an eye examination to test visual acuity, visual fields, the reaction of the pupils to light, and extraocular muscles. However, when neurologic evaluation is performed as part of a complete physical examination, the eye examination usually has been performed prior to the neurologic examination.
Generally, the cranial nerves are assessed by observation as the health care practitioner asks the patient to demonstrate their use. For example, the facial nerve may be tested by watching patients open their mouths and clench their teeth. The practitioner also tests sensation to the parts of the face supplied by branches of the trigeminal nerve by applying sharp and dull objects to these areas and asking the patient to distinguish between them. Finally, the practitioner touches the patient's cornea lightly to observe whether the patient blinks—the corneal reflex is present if the patient blinks normally in response to the stimulation.
Evaluating the motor system involves assessment of muscle symmetry, tone, strength, gait, and coordination. Patients are observed performing different skills and walking. Reflexes also are tested and graded as "normal," "hypoactive," or "hyperactive." An example of reflex testing is when the practitioner strikes the patellar tendon just below the kneecap to observe contraction of the quadriceps muscle in the thigh and extension of the knee.
The sensory system is tested to determine whether there is loss of sensation in any body part. The practitioner may use light touch; the vibrations from a tuning fork; or hot, cold, or sharp objects to evaluate patients' abilities to perceive sensation accurately. The practitioner also may test discrimination—the ability to accurately interpret touch and position—by tracing a number on the patient's palm and asking the patient to name the number.
A preliminary evaluation of mental status aims to determine the patient's orientation, immediate and short-term memory, and ability to follow simple verbal and written commands. Patients are considered "oriented" if they can identify time, place, and person accurately. Immediate and short-term memories are tested when the practitioner poses simple questions for the patient to answer, and one's ability to follow commands is assessed by observing patients perform tasks in response to verbal or written instructions.
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