Chapter 19
Putting the Examination Together
A physician is not only a scientist or a good technician. He must be more than that—he must have good human qualities. He has to have a personal understanding and sympathy for the suffering of human beings.
Albert Einstein (1879–1955)
The Techniques
The previous chapters dealt with the individual organ systems and the history and physical examinations related to each of them. The purpose of this chapter is to help the student assimilate each of the individual examinations into one complete and smoothly performed examination.
Ideally, a complete examination is performed in an orderly, thorough manner with as few movements as possible required of the patient. Most errors in performing a physical examination result from a lack of organization and thoroughness, not from a lack of knowledge. Evaluate each part of the examination carefully before moving on to the next part. The most common errors in performing the physical examination are related to the following:
Errors in technique are related to lack of order and organization during the examination, faulty equipment, and poor bedside etiquette. Errors of omission are common in examinations of the eye and nose; auscultation of the neck vessels, chest, and heart; palpation of the spleen; rectal and genital examinations; and the neurologic examination. Errors of detection are those in which the examiner fails to find abnormalities that are present. The most common errors of this type involve thyroid nodules, tracheal deviation, abnormal breath sounds, diastolic murmurs, hernias, and abnormalities of the extraocular muscles. Errors in interpretation of findings occur most commonly with tracheal deviation, venous pulses, systolic murmurs, fremitus changes, abdominal tenderness, liver size, eye findings, and reflexes. The most common types of recording errors are related to descriptions of heart size and murmurs, improper terminology, and obscure abbreviations.
In most situations, the hospitalized patient will be lying in bed when you arrive. After introducing yourself and documenting a complete history, you should inform the patient that you are ready to begin the physical examination. Always start by washing your hands.
The reader is advised now to watch the video presentation to review the complete physical examination of the man and the breast and pelvic examinations of the woman. The video will help you put the examination together.
Patient Lying Supine in Bed
General Appearance
Inspect the patient’s facial expression (see Chapters 10, The Chest; 11, The Heart; 14, The Abdomen; and 18, The Nervous System).
Have Patient Sit Up in Bed
Have Patient Turn and Sit with Legs Dangling off Side of Bed
Eyes (Chapter 7, The Eye)
Ears (Chapter 8, The Ear and Nose)
Mouth (Chapter 9, The Oral Cavity and Pharynx)
1. Inspect outer and inner surfaces of lips.
5. Observe Stensen’s and Wharton’s ducts, both sides.
9. Test hypoglossal nerve function (see Chapter 18, The Nervous System).
10. Palpate tongue.
13. Inspect tonsils, both sides.
14. Inspect posterior pharyngeal wall.
15. Observe uvula as patient says “Ah” (see Chapter 18, The Nervous System).
Posterior Chest (Chapter 10, The Chest)
2. Palpate back for tenderness, both sides.
3. Evaluate chest excursion, both sides.
4. Palpate for tactile fremitus, both sides.
6. Evaluate diaphragmatic excursion, right side.
7. Auscultate back, both sides.
8. Palpate for costovertebral angle tenderness, both sides (see Chapter 14, The Abdomen).
Have Patient Lie Supine with Head of Bed Elevated Approximately 30 Degrees
Heart (Chapter 11, The Heart)
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