In an era of increasingly sophisticated testing, the
physical examination (or ‘laying on of hands’) is not
only about tradition—physical examination remains
a key element in the diagnostic and healing process.
Patients expect to be examined and this strengthens the
doctor–patient relationship.1,2 Even more importantly,
failing to examine remains a common reason avoidable
errors are made.1,2 You must learn to become an expert
in physical examination.
Students beginning their training in physical
examination will be surprised at the formal way this
examination is taught and performed.3,4 There are,
however, a number of reasons for this formal approach.
The first is that it ensures the examination is thorough
and that important signs are not overlooked because
of a haphazard method.5 The second is that the most
convenient methods of examining patients in bed, and
for particular conditions in various other postures, have
evolved with time. By convention, patients are usually
examined from the right side of the bed, even though
this may be more convenient only for right-handed
people. When students learn this, they often feel safer
huddling on the left side of the bed with their colleagues
in tutorial groups, but many tutors are aware of this
strategy, particularly when they notice all students
standing as far away from the right side of the bed as
possible.
It should be pointed out here that there is only
limited evidence-based information concerning the
validity of clinical signs. Many parts of the physical
examination are performed as a matter of tradition.
As students develop their examination skills, experience
and new evidence-based data will help them to refine
their use of examination techniques. We have included
information about the established usefulness of signs
where it is available, but have also included signs that
students will be expected to know about despite their
unproven value.
This formal approach to the physical examination
leads to the examination of the parts of the body
by body system. For example, examination of the
cardiovascular system, which includes the heart and
all the major accessible blood vessels, begins with
positioning the patient correctly. This is followed by
a quick general inspection and then, rather surprisingly
for the uninitiated, seemingly prolonged study of
the patient’s fingernails. From there, a set series of
manoeuvres brings the doctor to the heart. This type
of approach applies to all major systems, and is designed
to discover peripheral signs of disease in the system
under scrutiny. The attention of the examining doctor
is directed particularly towards those systems identified
in the history as possibly being diseased, but of course
proper physical examination requires that all the systems
be examined.
The danger of a systematic approach is that time
is not taken to stand back and look at the patient’s
general appearance, which may give many clues to
the diagnosis. Doctors must be observant, like a
detective (Conan Doyle based his character Sherlock
Holmes on an outstanding Scottish surgeon).6 Taking
the time to make an appraisal of the patient’s general
appearance, including the face, hands and body, conveys
the impression to the patient (and to the examiners)
that the doctor or student is interested in the person
as much as the disease. This general appraisal usually
occurs at the bedside when patients are in hospital,
but for patients seen in the consulting room it should