Goal of the Physical Examination

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The goal of the physical examination is to obtain valid information concerning the health of the patient. The examiner must be able to identify, analyze, and synthesize the accumulated information into a comprehensive assessment.

The validity of a physical finding depends on many factors. Clinical experience and reliability of the examination techniques are most important. False-positive or false-negative results reduce the precision of the techniques. Variance can occur when techniques are performed by different examiners, with different equipment, on different patients. The concepts of validity and precision are discussed further in Chapter 27, Diagnostic Reasoning in Physical Diagnosis.

Unconscious bias is an important concept to understand. It is well known that unconscious bias in an examiner can influence the evaluation of a physical finding. For example, in patients with rapid atrial fibrillation, the ventricular rate is irregular and varies from 150 to 200 beats per minute. The radial pulse rate is significantly lower, owing to a pulse deficit (explained in Chapter 14, The Heart). If examiners record the apical heart rate first, they find that the rate varies from 150 to 200 beats per minute. If they then check the radial pulse, they detect a faster pulse rate than if they had measured the radial pulse first. The first observation, therefore, biases the second observation. Alternatively, if examiners determine the radial pulse first and the heart rate second, the apical heart rate appears slower, but the chance of bias is lower because observer error is less at the apex (Chalmers, 1981).

It is important to review the concepts of sensitivity and specificity. Sensitivity is the frequency of a positive result of a test or technique in individuals with a disease or condition. Specificity is the frequency of a negative result of a test or technique in individuals without a disease or condition. Sensitivity and specificity refer to properties of the test or technique, whereas the health-care provider is interested in properties or characteristics of the patient, which are characterized by the predictive values. The positive predictive value is the frequency of disease in patients with positive test results. The negative predictive value is the frequency of lack of disease in patients with negative test results. The question, ''What is the possibility that a woman with a stony-hard breast mass has cancer?'' addresses the positive predictive value. Predictive value depends on the prevalence of disease in the respective population, as well as the sensitivity and specificity of the test. In an individual from a population with a low prevalence of disease, a positive test result still yields a low positive predictive value.

For example, eliciting the presence of shifting dullness is a highly sensitive technique for detecting ascites. Thus, an examiner who does not detect shifting dullness in the abdomen of a patient can be reasonably sure that this negative finding rules out ascites. In contrast, the finding of microaneurysms in the macular area of the retina is a highly specific finding for diabetes. Thus, an examiner who finds microaneurysms at the macula can be reasonably confident that this finding confirms diabetes, because normal individuals without diabetes do not have macular microaneurysms; that is, the finding of microaneurysms at the macula has a high degree of specificity. Unfortunately, a technique is rarely both very sensitive and very specific. Several techniques must be applied together to make an appropriate assessment.

In summary:

1. A technique or test with high sensitivity can be used confidently to rule out disease for a patient with a negative finding.

2. A technique or test with high specificity can be used confidently to confirm disease for a patient with a positive finding.

These concepts are discussed in more detail in Chapter 27, Diagnostic Reasoning in Physical Diagnosis.

Useful Vocabulary

The vocabulary of medicine is difficult and broad. Memorizing a term is less useful than being able to determine the meaning by understanding its etymology, or roots. The spelling of terms will also be easier.

Listed here are some general prefixes, roots, and suffixes that are important to understand. At the end of each chapter in Section 2 is a list of terminology for that area of the body. The following list should not be memorized at this time. It should be referred to in conjunction with the lists in subsequent chapters.

Prefix/Root/ Suffix

Pertaining to

Example

Definition

ab-

away from

abduction

Away from the body

ad-

toward

adduction

Toward the body

aden-

gland

adenopathy

Glandular disease

an-

without

anosmia

Without the sense of smell

aniso-

unequal

anisocoria

Unequal pupils

asthen-

weak

asthenopia

Eye fatigue

contra-

against; opposite

contralateral

Pertaining to the opposite side

diplo-

double

diplopia

Double vision

duc-

lead

abduction

Turning outward

dys-

bad; ill

dysuria

Painful urination

eso-

in

esotropia

Eye deviated inward

eu-

good; advantageous

ewpnea

Easy breathing

exo-

out

exotropia

Eye deviated outward

hemi-

half

hemiplegia

Paralysis of one side of the body

hydro-

water

hydrophilic

Readily absorbing water

hyper-

beyond; greater than normal

hyperemia

Excess of blood

hypno-

sleep

hypnotic

Inducing sleep

hypo-

below

hypodermic

Below the skin

idio-

separate; distinct

idiopathic

Of unknown cause

infra-

below

infrahyoid

Below the hyoid gland

intra-

within

intracranial

Within the skull

Prefix/Root/ Suffix

Pertaining to

Example

Definition

ipsi-

self

ipsilateral

Situated on the same side

iso-

equal

isotonic

Equal tension

leuko-

white

leukocyte

White blood cell

lith-

stone

lithotomy

Incision of an organ to remove a stone

macro-

larger than normal

macrocephaly

Abnormally large head

micro

smaller than normal

microcephaly

head size smaller than normal

neo-

new

neoplasm

Abnormal new growth

pedia-

child

pediatrics

Branch of medicine treating diseases of children

peri-

around

pericardium

Sac around heart

poly-

many

polycystic

Many cysts

presby-

old

presbyopia

Impairment of vision as a result of advancing age

retro-

situated behind

retrobulbar

Behind the eye

soma-

body

somatic

Pertaining to the body

sten-

narrowed

stenosis

Narrowed

trans-

through

transurethral

Through the urethra

-dynia

pain

cephalodynia

Headache

-ectomy

removal of

appendectomy

Removal of the appendix

-gnosis

recognition

stereognosis

Recognizing an object by touch

-gram

something written

myelogram

X-ray film of the spinal cord

-ism

state; condition

gigantism

State of abnormal overgrowth

-itis

inflammation of

colitis

Inflammation of the colon

-kinesia

movement

bradykinesia

Abnormal slow movement

-lysis

dissolution

hemolysis

Liberation of hemoglobin into solution

-malacia

softening

osteomalacia

Softening of bones

-megal-

enlargement

cardiomegaly

Cardiac enlargement

-mycosis

fungus

blastomycosis

A specific fungal infection

-oid

resembling

human oid

Resembling a human

Continued

Continued

Useful Vocabulary—cont'd

Prefix/Root/ Suffix

Pertaining to

Example

Definition

-ologist

specialist in study of

cardiologist

A specialist in heart disease

-oma

tumor; growth

fibroma

A tumor of fibrous tissue

-osis

diseased state

endometriosis

Disease state of abnormally located uterine tissue

-otomy

cutting; incision

gastrotomy

Incision of the stomach

-pathy

disease

uropathy

Disease of the urinary tract

-phobia

fear; pain; intolerance

photophobia

Abnormal intolerance of light

-plasty

repair

valvuloplasty

Surgical repair of a valve

-plegia

paralysis

hemiplegia

Paralysis of one half of the body

-ptosis

drooping

blepharoptosis

Drooping eyelids

-rrhagia

hemorrhage

otorrhagia

Hemorrhage from the ear

-rrhaphy

suture; repair

herniorrhaphy

Repair of a hernia

-rrhexis

rupture

gastrorrhexis

Rupture of stomach

-scope

instrument for

ophthalmoscope Instrument for examination of the eye

-spasmos

spasm

blepharospasm

Twitching of the eyelids

-stom-

opening

ileostomy

Surgical creation of an opening into the ileum

-tome

cut

microtome

An instrument for cutting thin slices

Bibliography

Advisory Committee on Immunization Practices: Recommended immunization schedule: United States,

October 2007-September 2008. Ann Intern Med 147:725. Bolyard EA, Tablan OC, Williams WW, et al: Guideline for infection control in health care personnel, 1998.

Infect Control Hosp Epidemiol 19:493, 1998. Centers for Disease Control and Prevention. Recommended adult immunization schedule—United States.

October 2007-September 2008. MMWR Morb Mortal Wkly Rep 56(Q1), 2007. Chalmers TC: The clinical trial. Milbank Mem Fund Q 59:324, 1981.

Panlilio AL, Cardo DM, Grohskopf LA, et al: Updated U.S. Public Health Service guidelines for the management of occupational exposures to HIV and recommendations for postexposure prophylaxis. MMWR Morb Mort Wkly Rep 54(RR-9):1, 2005. Siegel JD, Rhinehart E, Jackson M, et al: 2007 Guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. June 2007. (Available at: http://www.cdc.gov/ncidod/dhqp/pdf/ isoiation2007.pdf; accessed June 5, 2008.)

There are six "f's" in the sentence in the box. Go back and count them. Most individuals count only three, neglecting to include the ''f's'' in the three instances of ''of.''

CHAPTER 8

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