The Physical Exam

First of all, I wanted to thank those of you who have left some kind comments about my blog. I want to hear from more of you about what types of things you like hearing about. Do you prefer hearing more of my stories and less of the science behind medicine? I thought that I might spend one blog describing a specific drug, how it works, and why it has certain side effects. Or maybe pick a study that is in the popular press and describe the real significance of it. Tell me what you guys want.

Anyway, for this post, I thought I'd explain how a physical exam is done.

Everyone who has seen a doctor has had a physical exam in some form or another. But I would bet that hardly anybody has ever had a proper thorough examination. A true physical exam done carefully should take over half an hour. But they don't because physicians don't have that much time, so they only examine the pertinent parts of the body.

The truth is that most physical exams are normal. Most of the information that doctors use to diagnose illnesses comes from the history, or the story. Where is the pain? When did the pain start? What makes the pain better? Have you ever had this pain before? 80% of diagnoses can be made by history alone. So the interview is the most important part of each encounter. The physical exam is used mostly to confirm what is learned from the history. More importantly, the physical exam is used to make the patient feel comfortable with the physician.

There are very few professions where you are allowed to physically touch people. And as physicians, we use that to our advantage. We use the power of touch to make people feel like we are special people. We give patients confidence in our ability and make them feel like they are being taken care of. When I listen to people's hearts and lungs, I always put my arm on the patient's shoulder. It may seem like I am trying to stabilize myself while listening, but I am really trying to make a connection with my patient.


Even though the physical exam is a secondary part of each encounter, it can truly be crucial to making certain diagnoses. A careful clinician can tell subtle differences in the way somebody is talking and diagnose a stroke. Or listen to the heart and diagnose a faulty heart valve. Or push on somebody's belly and tell whether a person is bleeding internally or just constipated. It is a difficult skill that takes years of experience to get good at. So here's how you do it:

The physical exam starts the second you walk into the room and introduce yourself.

Observe the patient. Are they sitting quietly or are they bouncing around the room like a bipolar maniac? Is their speech slurred from a stroke? Is their face drooping from Bell's palsy? There are many things that you can tell just by looking at a patient. Even race can play an important role in making a diagnosis since most ethnicities have diseases more common to them. It's very important to get an overall picture of who your patient is.

After the initial introduction, most physicians will sit down and just talk to the patient and get some history. After the history is taken, comes the formal physical exam.

I like to do my physical exams starting from the head and working my way down to the toes. I use a methodical approach so that I don't forget anything. When you examine a body part, you always start with observation (just like how you started the entire encounter).

When you examine the head, you start out by just looking at it. Are there deformities? Does the patient have a cleft palate? Does the patient have a bleeding laceration across their face? Are the creases in the face symmetric? (Asymmetry of the folds around the lips may be a subtle sign of a facial droop which may indicate a neurologic impairment like stroke).

Then I start with the eyes. I tell the patient to keep their head facing ahead and follow my finger with their eyes only. Then I hold up my index finger about a foot in front of their face and start moving it around. Meanwhile I observe the movement of the patients eyes. Certain neurological conditions will cause paralysis of the muscles which control the movement of the eyes. If the patient has a brain tumor pinching off a certain nerve, a patient might not be able to move one eye in one direction. Or if the patient is having vertigo, they may have nystagmus, which is a twitching movement of the eye.


Of course one of the most important tests of the eyes is whether or not they can see. But presumably you tested this when you walked into the room and decided if the patient was blind. So next you can test the visual fields. A patient may be able to see right in front of them, but certain types of brain tumors can pick off the peripheral eye fields. So when you put up 2 fingers at the edge of somebody's view, they might not be able to see it. This is typically tested by comparing the patient's visual fields with your own. So you stand facing the patient and hold up your fingers right at the edge of your visual field, an equal distance from the patient. Theoretically this should be the edge of the patient's visual field as well. So you ask them how many fingers you are holding up and test whether or not they can see that area of their visual field.

An important part of the eye exam which is hardly ever done is called the fundoscopic exam. This involves a special light and magnifying lens that looks at the back of the eye, the fundus. The fundus is actually the retina, where the nerves of the eye pick up light and turn them into electrical signals that your brain can interpret. The retina also has many tiny blood vessels which can tell you about the patient's cardiovascular system. Patients with high blood pressure may have certain changes on their blood vessels which can be determined on the fundoscopic exam. People who get "red-eye" when they have photographs taken of them are getting red eyes because the camera is picking up portions of the patient's fundus which is red from all of the blood vessels. Swelling of the brain can also be diagnosed by looking at the back of the eye since nerves can be seen which connect the eye with the brain.

The reason why the fundoscopic exam is hardly ever done is that it is incredibly hard to do proficiently. To do it properly, a light must be shined into the patient's eye and the scope must be placed right up against the physician's face and then the other end of the scope is placed right up against the patient's face. In the end, the doctor and patient's faces are practically touching with a little lighting instrument held in between. The fundoscope must be held very precisely and with little movement to see all the parts of the fundus. This exam is always done when you go to the eye doctor, but most primary care doctors wont bother with it unless there is a specific reason.

I realize that this post (like all my other posts) is getting kind of long already, so I'll continue the post next week and describe more of the physical exam.

Let me know if you want to hear more of it or if you want me to abandon this topic and move onto something else.