Physical Examination

What is a Physical Examination?

A is a test done by healthcare practitioners to check a patient’s physical health. A practitioner may physically examine a patient even if they’re not in pain, sick, or injured.

Usually, a physical examination requires the health care professional to do the following four things:

• Inspection: This initial examination step involves the practitioner visually inspecting the patient's body part to identify any abnormalities, swelling, or other notable signs. It typically serves as the starting point of the examination process.
• Palpation: During this phase, the practitioner employs touch to assess the texture, location, tenderness, and other characteristics of the body part under examination.
• Auscultation: This refers to the process wherein the healthcare practitioner utilizes a stethoscope to listen to sounds originating from within the patient's body. Typically, they focus on examining the patient's heart, lungs, and intestines to assess the sounds' duration, frequency, and quality.
• Percussion: This technique involves the healthcare practitioner using their hands, fingers, or small instruments to tap on specific areas of the patient's body gently. The purpose is to assess the presence of gas, fluid, swelling, or other abnormalities within particular organs or body regions. By listening to the resulting sounds produced during percussion, the practitioner can determine if there are any underlying issues with the area under examination.

In addition to the tests mentioned above, healthcare practitioners may perform additional examinations tailored to the patient's age and sex. These may include skin exams, clinical breast exams, pelvic exams, laboratory tests, and imaging studies as deemed necessary.

As for the document where practitioners write down records, it’s primarily dependent on the practitioner conducting the test.

If you’re a practitioner and need an editable template when assessing your patient. We have a free physical examination template you can download and use. For instructions on how to grab a copy, proceed to the next section.

How Does it Work?

Step One. Download the Template

You can access and download a copy of our printable physical examination template by doing either of the following:

• Clicking the “Download this Template” or “Use this Template” button above
• Searching for “Physical Examination” in Carepatron’s template library on our website or app

Step Two. Interview Your Patient

Before you assess your patient, you must first write down the date and patient’s name and interview them to obtain information on their health history. Knowing your patient's background helps determine which areas require further examination.

You have the option to provide your patient with a physical examination template to document their responses, or they can choose to provide their answers verbally.

Step Three. Examine Your Patient

After interviewing your patient, it’s time to examine your patient. Following the inspection, palpation, auscultation, and percussion order is best. Don’t forget to fill out the results immediately after checking a part to prevent forgetting what you’ve found.

Step Four. Discuss the Results

You may immediately discuss the results with your patient after the exam. If you found any problems or concerns, It is advisable to deliver information to patients in a calm manner, using language that they can easily comprehend.

Remember to sign and have the patient sign the results to signify they’ve acknowledged and understood what you explained.

Step Five. Proceed with the Next Steps

The next steps will be dependent on the results. If the patient is healthy, you may schedule another physical examination in a few months as a check-up. On the other hand, if the patient needs further tests, procedures, etc., you may request that your patient do them before consulting you or a specialist on potential findings.

When Would You Use this Template?

While healthcare practitioners can employ the physical examination template in diverse scenarios, the following are typical instances when patient assessment is conducted:

• To ensure that the patient maintains a healthy diet and routine
• To check if the patient has any possible diseases, conditions, or issues that can be medical concerns in the future
• To update immunizations or check if any implants/transplants are functioning well
• To assess one’s health after treatment
• To determine if a patient needs to undergo further testing for anything
• To gather information and build a trusting relationship with the patient

Benefits

Early Detection and Prevention

As mentioned above, physical examinations help detect any possible conditions or diseases a patient may have. The purpose of having a template is to maintain a record that can serve as a foundation for conducting additional testing if any findings on a patient warrant further investigation.

Improves Monitoring Process

Having a template to document the progress of patients is beneficial for assessing the effectiveness of their medications, treatment, or overall health trajectory. It allows healthcare professionals to track and evaluate the impact of these factors on the patient's well-being.

Empowering

In some instances, a patient who wants to improve their health may be empowered to make healthier decisions upon seeing or hearing about unfavorable results.

Accessible

Our physical examination is free, making it accessible to individuals on a budget. Additionally, it can be easily edited and downloaded on any device you have at your disposal.

Research & Evidence

Every healthcare practitioner understands the significance of performing a thorough physical examination on their patients. However, as noted by Campbell and Lynn (1990), it is crucial that a physical examination is not conducted in a perfunctory or superficial manner.

Moreover, the true value of physical examinations lies in their integration with the patient's health history, the physician's clinical reasoning abilities, and the use of confirmatory laboratory tests in formulating an accurate diagnosis, management plan, or treatment approach. 

Additionally, Campbell and Lynn provided recommendations for reporting and interpreting physical findings, including emphasizing extreme physical signs and dichotomous variables, among others.

References

Campbell EW JR, Lynn CK. The Physical Examination. In: Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths; 1990. Chapter 4. Available from: https://www.ncbi.nlm.nih.gov/books/NBK361/