Purpose of the examination (one or more of the following)
Patient population and context
Pediatric
Adolescent
Young adult
Adult
Geriatric
Pregnant
Detect conditions that require immediate treatment
Neck rigidity and petechia in a patient with fever and vomiting (bacterial meningitis)
Mood disorder (depression)
Orthostatic hypotension and smell of acetone in a patient with abdominal pain and polyuria (diabetic acidosis)
Tracheal deviation and hyperresonance on chest percussion in a patient with respiratory distress and chest pain (pneumothorax)
Pallor and pulselessness in a patient with sudden limb pain (arterial occlusion)
High blood pressure in a patient with seizures (eclampsia)
Test diagnostic hypotheses in patients with focal complaints (e.g., chest pain and dysuria)
Tonsillar exudates and cervical adenopathy in a patient with fever, sore throat but no cough (strep tonsillitis)
Blurred sinus transillumination in a patient with colored nasal discharge (sinusitis)
Tenderness at the costovertebral angle in a patient with fever and dysuria (pyelonephritis)
Muscle weakness and ptosis in a patient with diplopia and difficulty in swallowing (myasthenia gravis)
Reduced diaphragmatic motion and absent cardiac dullness in a patient with chronic shortness of breath (emphysema)
Leg muscle weakness, reduced patellar reflex, and pain on leg elevation in a patient with back pain(sciatic nerve compression)
Search for a cue for diagnosis in patients with nonspecific complaints (e.g., fatigue, confusion, loss of weight, and fever) without focal symptoms
Bulging tympanic membranes in a patient with fever (otitis media)
Dilated pupils, tachycardia, and hypertension in a confused patient (sympathomimetic toxidrome)
Goiter and exophthalmus in a patient with weight loss (hyperthyroidism)
Splenomegaly and splinter hemorrhages in a patient with fever and a heart murmur (bacterial endocarditis)
Dullness on percussion and bronchial breathing in a patient with sudden confusion (lobar pneumonia)
Jaundice and petechia in a patient with vomiting (acute fatty liver)
Monitoring a known disease and detection of complications
Loss of weight in a patient with gluten sensitivity
Changes in weight in an obese patient
Retinopathy in a diabetic patient
High blood pressure in a hypertensive patient
Shortness of breath, hepatomegaly and abdominal jugular reflux in a patient with chronic left ventricular failure
Fetal growth, premature labor, and abruptio placenta in a diabetic patient
Health promotion and case finding in asymptomatic patients
Failure to gain weight (malnutrition)
Alcohol abuse (alcoholism)
Smoking (tobacco dependence)
High blood pressure (hypertension)
Loss of hearing (otosclerosis)
Leg edema and high blood pressure (pre-eclampsia)
The need to consider the patient’s specific clinical contexts implies that textbooks of physical diagnosis and teaching programs should be restructured by the various clinical contexts (Table 10.1), rather by organ systems, as they are today. Each section would consist of the diagnostic hypotheses to be tested, e.g., “Does this patient have ascites?” and would provide answers based on selected physical signs that have been shown to be reproducible, sensitive, and specific enough to change the probability of a diagnosis [17].
Consideration of Patients’ Expectations
A reflective PE should be guided not only by the doctor’s diagnostic hypotheses but also by the patient’s expectations.
Students should communicate with patients throughout the PE and, if appropriate, explain the purpose of PE, and ask for patients’ consent to any part of the PE that may not seem to be related to their complaints.
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