Difference Between Review of Systems and Physical Examination

Definition

Physical examination is the process of evaluating objective anatomic findings through the apply of observation, palpation, percussion, and auscultation. The information obtained must be thoughtfully integrated with the patient's history and pathophysiology. Moreover, it is a unique situation in which both patient and physician understand that the interaction is intended to be diagnostic and therapeutic. The physical test, thoughtfully performed, should yield xx% of the data necessary for patient diagnosis and management.

The Context

Virtually without exception, some medical history about the patient is bachelor at the fourth dimension of the physical examination. Rarely, there may be no history, or at best brief recordings of acute events. Data pertinent to the physical exam can be learned from ascertainment of speech, gestures, habits, gait, and manipulation of features and extremities. Interactions with relatives and staff are oft revealing. Pigmentary changes such equally cyanosis, jaundice, and pallor may be noted. Diaphoresis, blanching, and flushing may provide clues about vasomotor tone related to mood or physiologic abnormalities. Aspects of patient habits, interests, and relationships can be ascertained from pictures, books, magazines, and personal objects at the bedside.

The Physician–Patient Interaction

Aside from the infirmary room and part, physical examination may occur in a variety of other settings where it is difficult to establish privacy and quiet. The best resource available to the physician to set the stage for the physical examination is to communicate respect and a genuine interest in the patient's welfare. The patient should be addressed politely and asked to perform the required maneuvers of the examination, a technique far preferable to imperative language such equally, "I desire y'all to. …" Patients should be prepared for unpleasant portions of the examination.

Aside from explanations and reassurance, information technology is not necessary to maintain a continuous chat with the patient during the examination. Avert embarrassing the patient. Be sure that draping material is used accordingly and that personal areas are not subjected to undue exposure. An examination that ends abruptly may diminish the value of the doctor–patient relationship and may destroy its therapeutic content. The patient may benefit from a brief summary of relevant findings and may require reassurance nigh what has and has non been found.

The Materials

The single well-nigh useful device for optimal performance of the physical examination is an inquisitive and sensitive mind. Adjacent virtually useful is mastery of the techniques of observation, palpation, percussion, and auscultation. Less of import are the tools required for the examination (Table 4.1).

Tabular array 4.1

Equipment Required for the Concrete Examination.

The Examination

As the environment affects the quality of the physical examination, information technology is wise to accommodate for repose and privacy, darkening the room for parts of the examination, and comfort for the patient and examiner.

The complete test should proceed in an orderly style with a minimum of required position shifts by the patient (Table 4.2). On the other hand, the physician must be able to ascertain the integrity of the various organ systems from regional examinations. For instance, from examination of the caput and neck, the physician must identify the vascular, neurologic, lymphatic, skeletal, and integumentary components and must chronicle them to their complements in other body regions. It would be deadening, past dissimilarity, to examine the vascular system in its entirety, followed by a complete neurologic examination and the other organ systems each in turn. When examining an anatomic region, the observer must be alert to the advent of any abnormality and question at the time the morphologic aspects of the aberration and its clinical significance.

Table 4.2

Positions of Patient and Examiner during the Concrete Examination.

The full general physical exam can accept many forms depending upon circumstances. Virtually often, the examiner evaluates torso regions in a general way, looking for abnormalities. Clues derived from the history signal the need for a more than precise and detailed test of a given organization. A thorough physical examination often includes the sequence presented in Table 4.3.

The clinically significant concrete examination is a flexible entity that should vary with the needs of the patient. Periodic examinations for health assessment demand to be comprehensive, as exercise about hospital access examinations. In contrast, it will non be toll effective to undertake a complete physical test in almost patients presenting with symptoms of an upper respiratory tract infection or a urinary tract infection.

Conclusion

The physical examination is a key office of a continuum that extends from the history of the present illness to the therapeutic effect. If the history and physical examination are linked properly by the physician's reasoning capabilities, laboratory tests should in large measure be confirmatory. The physical examination, however, can be the weak link in this chain if it is performed in a perfunctory and superficial manner. Agreement the pathophysiologic mechanism of a physical abnormality is essential for right diagnosis and direction. For example, the failure to discriminate between and know the origin of carotid bruits and transmitted sounds of valvular origin can have critical significance.

As cognition of disease changes, the techniques of concrete examination become augmented. The astute physician constantly reviews and adds to the repertoire of techniques for physical examination.

Evaluation of the concrete examination in terms of sensitivity and specificity is difficult. Interpretation of isolated physical findings is often influenced past the presence or absence of historical information and circumstantial physical findings. For instance, the cess of whether clubbing of the fingers is nowadays or absent-minded has significant interobserver variability and has been demonstrated to be influenced by the clinical appearance of the patient.

A number of studies accept attempted to wait at the validity of the physical exam every bit a diagnostic tool. The concept of interobserver and intraobserver variability has been introduced when looking at specific isolated findings. For example, judging the presence or absenteeism of râles is more probable to be agreed upon by several observers and on repeated exams by a single blinded observer, than is the graded intensity of jiff sounds. The presence or absence of ascites in patients with known liver affliction has been shown to exist difficult to determine when using physical exam techniques alone. The bedside measurement of forced expiratory time by auscultation however, has been shown to accept a small interobserver variability in trained observers and to accept clinical value in post-obit the degree of airway obstacle.

Considering of the large caste of variability in observing many physical signs, the post-obit recommendations can be fabricated when reporting and interpreting concrete findings.

1. Emphasis should be placed on dichotomous variables (i.e., presence or absence of râles) rather than on graded variables (i.eastward., intensity of jiff sounds).

2. Some physical signs (i.due east., clubbing of the fingers) represent a continuum from obviously normal to obviously abnormal. Accent should exist placed on those findings which represent the extremes rather than the "deadline" cases.

3. Recognition of those physical findings which have a high caste of interobserver variability is of import. Good examples of this include detection of moderate or small amounts of ascitic fluid and detection of diaphragmatic movement by percussion. These findings should be deemphasized in favor of those with amend reproducibility.

4. It is benign to use the body's "symmetry" to reward. Differences auscultated in breath sounds between similar area of the right and left lung are far more clinically important than an overall subtract in jiff sounds.

If these points are kept in mind, the physical examination will fill its proper role in the care of the patient. That is as an adjunct to a thorough history and equally a way for the physician to interact physically with the patient.

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Source: https://www.ncbi.nlm.nih.gov/books/NBK361/