CHAPTER 4: Beginning the Physical Examination: General Survey, Vital Signs, and Pain

Intro

Introduction

Now that you have elicited the patient’s concerns and formed a trusting relationship, you are ready to begin the physical examination. At first you may feel unsure of your skills, but through study and repetition, the physical examination will soon flow more smoothly, and you will shift your attention from technique and how to handle instruments to what you hear, see, and feel (Fig. 4-1). Touching the patient’s body will seem more natural, and you will learn to minimize any discomfort to the patient (Fig. 4-2). As you gain proficiency, what once took between 1 and 2 hours will take considerably less time.

FIGURE 4-1 The physical examination flows more efficiently with practice.

The physical examination flows more efficiently with practice.

FIGURE 4-2 The clinician’s touch can reassure as well as assess.

The clinician's touch can reassure as well as assess.

This chapter introduces the sections of the regional examination chapters you will find throughout the book: The Health History of Common and Concerning Symptoms (in this chapter, these are common constitutional symptoms); Health Promotion and Counseling, which focuses in this chapter on lifestyle components such as weight, nutrition, and exercise; then, Techniques of Examination, which include the initial elements of the physical examination, the General Survey, Vital Signs, and assessment of pain; followed by Tables and the References. The regional examination chapters, Chapters 6 through 20, begin with an additional section, Anatomy and Physiology.

The Health History


Common or Concerning Symptoms

  • Fatigue and weakness
  • Fever, chills, night sweats
  • Weight change
  • Pain

Fatigue and Weakness

Fatigue is a nonspecific symptom with many causes. It refers to a sense of weariness or loss of energy that patients describe in various ways. “I don’t feel like getting up in the morning”…“I don’t have any energy”…“I can hardly get through the day”…“By the time I get to work, I feel as if I’ve done a day’s work.” Because fatigue is a normal response to hard work, sustained stress, or grief, elicit the life circumstances in which it occurs. Fatigue unrelated to such situations requires further investigation.


Fatigue is a common symptom of depression and anxiety, but also consider infections (such as hepatitis, infectious mononucleosis, and tuberculosis); endocrine disorders (hypothyroidism, adrenal insufficiency, diabetes mellitus); heart failure; chronic disease of the lungs, kidneys, or liver; electrolyte imbalance; moderate to severe anemia; malignancies; nutritional deficits; and medications.


Use open-ended questions to encourage the patient to fully describe what he or she is experiencing. Important clues about etiology often emerge from a good psychosocial history, exploration of sleep patterns, and a thorough review of systems.

Weakness is different from fatigue. It denotes a demonstrable loss of muscle power and will be discussed later with other neurologic symptoms (see p. 723).


Weakness, especially if localized in a neuroanatomical pattern, suggests possible neuropathy or myopathy.


Fever, Chills, and Night Sweats

Fever refers to an abnormal elevation in body temperature (see p. 133 for definitions of normal). Ask about fever if the patient has an acute or chronic illness. Find out if the patient has measured his or her temperature. Has the patient felt feverish or unusually hot, noted excessive sweating, or felt chilly and cold? Try to distinguish between feeling cold, and a shaking chill with shivering throughout the body and chattering of teeth.


Recurrent shaking chills suggest more extreme swings in temperature and systemic bacteremia.


Feeling cold, goosebumps, and shivering accompany a rising temperature, whereas feeling hot and sweating accompanies a falling temperature. Normally, the body temperature rises during the day and falls during the night. When fever exaggerates this swing, night sweats occur. Malaise, headache, and pain in the muscles and joints often accompany fever.


Feeling hot and sweating also accompany menopause. Night sweats occur in tuberculosis and malignancy.


Fever has many causes. Focus on the timing of the illness and its associated symptoms. Become familiar with patterns of infectious diseases that may affect your patient. Inquire about travel, contact with sick people, or other unusual exposures. Even medications may cause fever. By contrast, recent ingestion of aspirin, acetaminophen, corticosteroids, and nonsteroidal anti-inflammatory drugs may mask fever and affect the temperature recorded at the office visit.


In immunocompromised patients with sepsis, fever may be absent, low-grade, or drop below normal (hypothermia).


Weight Change

Weight change results from changes in body tissues or body fluid. Good opening questions include “How often do you check your weight?” “How is it compared to a year ago?” If there are changes, ask, “Why do you think it has changed?” “What would you like to weigh?” If weight gain or loss appears to be a problem, ask about the amount of change, its timing, the setting in which it occurred, and any associated symptoms.


Rapid changes in weight, over a few days, suggest changes in body fluid, not tissue.


Weight gain occurs when caloric intake exceeds caloric expenditure over time, and typically results in increased body fat. Weight gain can also reflect abnormal accumulation of body fluids, particularly when the gain is very rapid.


Edema from extravascular fluid retention is visible in heart failure, nephrotic syndrome, liver failure, and venous stasis.


Patients with a body mass index (BMI) of ?25 to 29 are defined as overweight; those with a BMI ?30 are considered obese. For these patients, plan a thorough assessment to avert the many associated risks of morbidity and mortality. Clarify the timing and evolution of the weight gain. Was the patient overweight as a child? Are the parents overweight? Ask about weight at life milestones like birth, kindergarten, high school or college graduation, military discharge, pregnancy, menopause, and retirement. Has a recent disability or surgery affected weight? What about depression or anxiety? Is there a change in sleep pattern or daytime drowsiness suspicious for sleep apnea?[1] Establish the level of physical activity and results of prior attempts at weight loss. Assess eating patterns and dietary preferences.


See Classification of Overweight and Obesity by BMI on p. 116.

See Table 4-1, Obesity-Related Health Conditions, p. 139, and discussion on pp. 114–118.


TABLE 4-1 Obesity-Related Health Conditions

Cardiovascular

? Hypertension
? Coronary artery disease
? Atrial fibrillation
? Heart failure
? Cor pulmonale
? Varicose veins

Endocrine

? Metabolic syndrome
? Type 2 diabetes
? Dyslipidemia
? Polycystic ovarian syndrome/androgenicity
? Amenorrhea/infertility/menstrual disorders

Gastrointestinal

? Gastroesophageal reflux disease (GERD)
? Nonalcoholic fatty liver disease (NAFLD)
? Cholelithiasis
? Hernias
? Cancer: colon, pancreas, esophagus, liver

Genitourinary

? Urinary stress incontinence
? Obesity-related glomerulopathy
? Hypogonadism (male)
? Cancer: breast, cervical, ovarian, uterine
? Pregnancy complications
? Nephrolithiasis, chronic renal disease

Integument

? Striae distensae (stretch marks)
? Status pigmentation of legs
? Lymphedema
? Cellulitis
? Intertrigo, carbuncles
? Acanthosis nigricans/skin tags

Musculoskeletal

? Hyperuricemia and gout
? Immobility
? Osteoarthritis (knees, hips)
? Low back pain

Neurologic

? Stroke
? Idiopathic intracranial hypertension
? Meralgia paresthetica

Psychological

? Depression/low self-esteem
? Body image disturbance
? Social stigmatization

Respiratory

? Dyspnea
? Obstructive sleep apnea
? Hypoventilation syndrome/Pickwickian syndrome
? Pulmonary embolism
? Asthma

Used with permission from Kushner RF. Roadmaps for Clinical Practice: Case Studies in Disease Prevention and Health Promotion—Assessment and Management of Adult Obesity: A Primer for Physicians. Chicago, IL: American Medical Association; 2003. © American Medical Association 2003. All Rights Reserved.

Review the patient’s medications.


Many drugs are associated with weight gain, such as: tricyclic antidepressants; insulin and sulfonylurea; contraceptives, glucocorticoids, and progestational steroids; mirtazapine and paroxetine; gabapentin and valproate; and propranolol.


Explore any clinically significant weight loss, defined as loss of 5% or more of usual body weight over a 6-month period. Mechanisms include decreased food intake due to anorexia, depression, dysphagia, vomiting, abdominal pain, or financial difficulties; defective gastrointestinal absorption or inflammation; and increased metabolic requirements. Ask about abuse of alcohol, cocaine, amphetamines, or opiates, or withdrawal from marijuana, all associated with weight loss. Heavy smoking also suppresses appetite.


Causes of weight loss include gastrointestinal diseases; endocrine disorders (diabetes mellitus, hyperthyroidism, adrenal insufficiency); chronic infections, HIV/AIDS; malignancy; chronic cardiac, pulmonary, or renal failure; depression; and anorexia nervosa or bulimia.

See Table 4-2, Eating Disorders and Excessively Low BMI, p. 140.


TABLE 4-2 Eating Disorders and Excessively Low BMI

 In the United States, an estimated 5 to 10 million women and 1 million men suffer from eating disorders. The lifetime prevalence estimates for anorexia nervosa, bulimia nervosa, and binge eating disorders are 0.9%, 1.5%, and 3.5%, respectively, among women; and 0.3%, 0.5%, and 2.0%, respectively, among men. These severe disturbances of eating behavior are often difficult to detect, especially in teens wearing baggy clothes or in individuals who binge and then induce vomiting or evacuation. Be familiar with the two principal eating disorders, anorexia nervosa and bulimia nervosa. Both conditions are characterized by distorted perceptions of body image and weight. Early detection is important because prognosis improves when treatment occurs in the early stages of these disorders.
Clinical Features
Anorexia Nervosa Bulimia Nervosa
  •  Refusal to maintain minimally normal body weight (or BMI above 17.5 kg/m2)
  •  Afraid of gaining weight or becoming fat
  •  Frequently starving but in denial; lacking insight
  •  Often brought in by family members
  •  May present as failure to make expected weight gains in childhood or adolescence, amenorrhea in women, loss of libido or potency in men
  •  Associated with depressive symptoms such as depressed mood, irritability, social withdrawal, insomnia, decreased libido
  •  Additional features supporting diagnosis: self-induced vomiting or purging, excessive exercise, use of appetite suppressants and/or diuretics
  •  ? Biologic complications
    •  Gynecological: amenorrhea
    •  Endocrine: hypercortisolemia, hypoglycemia, osteoporosis, euthyroid hypothyroxinemia
    •  Cardiovascular disorders: bradycardia, hypotension, arrhythmias, cardiomyopathy
    • Metabolic disorders: hypokalemia, hypochloremic metabolic alkalosis, increased blood urea nitrogen (BUN), edema
    •  Other: dry skin, dental caries, delayed gastric emptying, constipation, anemia, fatigue, weakness
  •  Repeated binge eating followed by self-induced vomiting, misuse of laxatives, diuretics or other medications, fasting, or excessive exercise
  •  Often with normal weight
  •  Overeating at least once a week during 3-month period; large amounts of food consumed in short period (?2 hrs)
  •  Preoccupation with eating; craving and compulsion to eat; lack of control over eating; alternating with periods of starvation
  •  Dread of fatness (usually leading to underweight)
  •  Subtypes of
    •  Purging: bulimic episodes accompanied by self-induced vomiting or use of laxatives, diuretics, or enemas
    •  Nonpurging: bulimic episodes accompanied by compensatory behavior such as fasting, or excessive exercising
    •  Biologic complications. See changes listed for anorexia nervosa, especially weakness, fatigue, mild cognitive disorder; also erosion of dental enamel, parotid gland swelling, pancreatitis, mild neuropathies, seizures, hypokalemia, hypochloremic metabolic acidosis, hypomagnesemia

Sources: Hudson JI, Hiripi E, Pope HG Jr The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biol Psychiatry. 2007;61:348; World Health Organization. The ICD-10 Classification of Mental and Behavioral Disorders: Diagnostic Criteria for Research. Geneva: World Health Organization, 1993; American Psychiatric Association. DSM-5: Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Association, 2013; Andersen AE. Eating Disorders: In: Sadock BJ, Sadock VA, Ruiz Peds. Kaplan and Sadock’s Comprehensive Textbook of Psychiatry. 9th ed. New York, NY: Wolters Kluwer; Lippincott Williams ; Wilkins, 2009.

Assess food intake. Has it been normal, dropped, or even increased?


Weight loss with relatively high food intake suggests diabetes mellitus, hyperthyroidism, or malabsorption. Consider also binge eating (bulimia) with clandestine vomiting.


Pursue a thorough psychosocial history. Who cooks and shops for the patient? Where does the patient eat? With whom? Are there any problems with obtaining, storing, preparing, or chewing food? Does the patient avoid or restrict certain foods for medical, religious, or other reasons?


Poverty, old age, social isolation, physical disability, emotional or mental impairment, lack of teeth, ill-fitting dentures, alcoholism, and drug abuse increase risk of malnutrition.


Check the medication history.


Drugs associated with weight loss include anticonvulsants, antidepressants, levodopa, digoxin, metformin, and thyroid medication.2


Be alert for symptoms and signs of malnutrition. These may be subtle and nonspecific, such as weakness, easy fatigability, cold intolerance, flaky dermatitis, and ankle swelling. Securing a good diet history of eating patterns and quantities is essential. Ask general questions about intake at different times throughout the day, such as “Tell me what you typically eat for lunch.” “What do you eat for a snack?” “When?”


See Table 4-3, Nutrition Screening, p. 141.


TABLE 4-3 Nutrition Screening

Nutrition Screening

Pain

Pain is one of the most common presenting symptoms in office practice. Each year, an estimated 100 million Americans experience chronic pain at a cost in medical care, disability, and work days lost of $560 to $635 million.[3],[4] Acute pain affects another 12% of Americans annually.[5] The most frequent causes are low back pain, headache or migraine, and knee and neck pain; prevalence varies by race, ethnicity, and socioeconomic status. Localizing symptoms, “the seven attributes of every symptom,” and the psychosocial history are essential to your physical examination, assessment, and a comprehensive management plan.


Turn to the section on Acute and Chronic Pain, pp. 134–137, at the end of this chapter for an approach to assessment and management.