Interactive Guide to Physical Examination


ability to learn new information: A patient should be able to recall several unrelated words strung together after an interval of three to five minutes. The mini mental state exam (MMSE - see link at the bottom of the page) provides specific tasks to test this. New learning may be impaired in dementia, delirium, anxiety, depression, and other conditions. Go to page

abnormal response to proprioceptive testing: Normally, patients can tell if a joint is being moved upwards or downwards. If they are unable to tell, or choose the incorrect direction, this is suggestive of posterior column disease or a lesion of a peripheral nerve or root. Vibratory sense may also be impaired in these situations. Go to page

abstract thinking: To evaluate abstract thinking, ask the patient to explain similarities ("What do a cat and a dog have in common?") and differences ("What is the difference between a pond and an ocean?"). Alternatively, you can ask the patient to interpret a proverb ("What does it mean when people say, 'Don't count your chickens before they've hatched'?"). Evaluate the relevance of the patient's responses and whether they are concrete or abstract. In the setting of delirium or dementia the patient's response is more likely to be concrete. Responses to these questions can depend on an individual's formal education and life experience. Go to page

achilles tendon: The achilles tendon is prone to injury if not warmed up properly before activity. Achilles tendonitis is characterized by tenderness over the tendon. To test for achilles rupture, squeeze the calf firmly. Foot plantarflexion, the normal response, is absent if the achilles is not intact.

acromegaly: In acromegaly there is increased production of growth hormone (most commonly secondary to an anterior pituitary adenoma) with resultant enlargement of bone and soft tissue. In the face, there is a prominence of the forehead and enlargement of the ears, nose, lips and tongue as well as enlargement of the jaw (macrognathia). Facial features often appear more coarse than normal. There may be enlargement of the soft tissue of the hands and feet. Go to page

affect: Affect refers to the patient's emotional tone as expressed through demeanor, facial expressions, or tone of voice. It is important to note if the affect is congruent with what the patient is conveying. For example, when discussing emotionally distressing topics the patient's affect should reflect a compatible emotion. Go to page

anisocoria: Inequality of pupillary diameter is termed anisocoria. If unequal pupils react equally to direct light, this is most likely normal physiological anisocoria. Although common, is not seen in a majority of adults. If the reaction is unequal, diagnostic considerations include trauma, glaucoma, tonic pupil, oculomotor nerve paralysis or Horner's syndrome. Go to page

ankylosing spondylitis: Ankylosing spondylitis is a systemic rheumatic disorder characterized by inflammation of large peripheral joints and the axial skeleton. There may be diffuse costovertebral involvement with some degree of bony fixation such that thoracic expansion is limited. Go to page

aortic aneurysm: Aortic aneurysm is dilation of the aorta due to weakening of the wall either from atherosclerosis, infection, or trauma. The normal size of the aorta in the abdomen is 1.4 to 3.0 centimeters in diameter. A diameter greater than 3.0 centimeters is considered aneurysmal. An abdominal aortic aneurysm may be visible or palpable as an expansile mass in the abdomen. Go to page

aortic insufficiency: Aortic regurgitation is due to inadequate closure of the leaflets of the aortic valve. As a result a portion of the left ventricular stroke volume leaks back into the left ventricle. This volume overload then causes ventricular hypertrophy and eventually enlargement. Causes include aortic root dilatation or aneurysm, or damage to the aortic valve from infection, calcification, degeneration, or systemic disease. Go to page

aortic stenosis: Aortic stenosis may be due to a great number of causes. Some of the most common include congenital malformations of the valve (e.g. bicuspid valve), rheumatic fever, calcification of the valve, or atherosclerosis of the valve. Obstruction to ventricular outflow due to the diseased aortic valve results in a systolic murmur. The murmur of aortic stenosis is classically heard best at the base of the heart with the diaphragm of the stethoscope. The sound of this murmur is rather harsh. During standing or with the strain of the valsalva maneuver, there is diminished left ventricular volume and thus less blood ejected into the aorta. As a result, the intensity of the murmur of aortic stenosis decreases during these maneuvers. In contrast, squatting (or release of the valsalva maneuver) results in an increased left ventricular volume and thus more blood ejected into the aorta. The murmur of aortic stenosis therefore increases in intensity during these murmurs. Go to page

apical impulse: The apical impulse is normally at, or medial to, the midclavicular line, in the 4th or 5th intercostal space. You may see the brief impulse in the supine patient or when your patient is in the left lateral decubitus position. Feel for the impulse with the flats of your fingertips. If you can not find the apical impulse in the supine position, have your patient roll into the left lateral decubitus position, and try again, while asking your patient to exhale and hold his breath. The apical impulse may be difficult to find in patients with an increased anteroposterior diameter of the chest, with obesity, or in those with a thick muscular chest. In women, the apical impulse is generally under the breast. You will therefore need to displace the breast gently upwards. Go to page

amplitude: The amplitude of the apical impulse refers to the vigor of the impulse. The normal apical impulse feels like a gentle, brief, tap. The amplitude may be increased and in these instances is characterized as "hyperdynamic". This may be seen in healthy young adults if they are overly anxious or just after exercise. It is generally correlated with an increase stroke volume or volume overload (e.g. mitral regurgitation) of the left ventricle without associated left ventricular hypertrophy or diminished ejection fraction. Go to page

duration: The duration of the apical impulse is one of the hardest characteristics for learners to assess. You need to auscultate, listening to S1 and S2, while you feel the apical impulse. Estimate the proportion of systole occupied by the apical impulse. Normally, the apical impulse takes up only 2/3 or less of systole. A sustained apical impulse (one that lasts greater than 2/3 of systole) is suggestive of ventricular hypertrophy from pressure overload such as in patients with left ventricular outflow obstruction or severe hypertension. Go to page

location: The apical impulse is normally found in the 4th or 5th intercostal space, in or medial to, the midclavicular line with the patient in the supine position. With the patient in the left lateral decubitus position, the apical impulse will be slightly displaced to the left however should not be normally found lateral to the midclavicular line. With left ventricular hypertrophy the apical impulse may be displaced laterally. In addition, with left ventricular enlargement the impulse may be displaced inferiorly. Occasionally in thin individuals with a long torso the apical impulse will be close to the left sternal border. Go to page

size: The diameter of the normal apical impulse is approximately 2-3 centimeters or the size of a quarter. It generally occupies one interspace. A diameter greater than 3 centimeters suggests left ventricular enlargement. Go to page

articulation: In evaluating your patient's articulation, note if speech is clear and distinct. Dysarthria refers to speech that sounds slurred or indistinct and is related to defects in the muscular control of speech. Go to page

ascites: Ascites is free fluid in the abdomen. The cause may be diseases of the thorax, such as congestive heart failure, or diseases of the abdomen or pelvis. The etiology may be infectious, inflammatory, anatomic, or neoplastic.

ataxia: The ataxic gait is characterized by staggering, wavering, or lurching during walking. This may occur in all directions, or only toward an affected side. The underlying problem is dysfunction of the cerebellum due to diffuse disease processes or focal lesions. Go to page

atelectasis: Atelectasis is created by airlessness in a lung or portion of lung that was once expanded. The cause may be due to prolonged recumbency, or an obstructed bronchus (such as with a mucous plug). The percussion note over the atelectatic area will be dull. There may be diminished or absent breath sounds, as well as absent tactile and vocal fremitus over this area. Go to page

athetoid movements: Athetoid movements are slow, writhing movements like a snake. Go to page

attention: Normally, patients should be able to demonstrate focused attention and concentration. When this ability is in question, the mini-mental state examination provides specific tasks for testing attention (see link at the bottom of the page regarding the MMSE). Poor performance may suggest an underlying delirium, dementia, anxiety disorder or depression, but limited formal education may also cause errors in these tasks. Go to page