Physical examination

Physical examination or clinical examination is the process by which a health care provider investigates the body of a patient for signs of disease. It generally follows the taking of the medical history &mdash; an account of the symptoms as experienced by the patient. Together with the medical history, the physical examination aids in determining the correct diagnosis and devising the treatment plan. This data then becomes part of the medical record.

Although providers have varying approaches as to the sequence of body parts, a systematic examination generally starts at the head and finishes at the extremities. After the main organ systems have been investigated by inspection, palpation, percussion and auscultation, specific tests may follow (such as a neurological investigation, orthopedic examination) or specific tests when a particular disease is suspected (e.g. eliciting Trousseau's sign in hypocalcemia).

With the clues obtained during the history and physical examination the healthcare provider can now formulate a differential diagnosis, a list of potential causes of the symptoms. Specific diagnostic tests (or occasionally empirical therapy) generally confirm the cause, or shed light on other, previously overlooked, causes.

Whilst the format of examination as listed below is largely as taught and expected of students, a specialist will focus on their particular field and the nature of the problem described by the patient. Hence a cardiologist will not in routine practice undertake neurological parts of the examination other than noting that the patient is able to use all four limbs on entering the consultation room and during the consultation become aware of their hearing, eyesight and speech. Likewise an Orthopaedic surgeon will examine the affected joint, but may only briefly check the heart sounds and chest to ensure that there is not likely to be any contraindication to surgery raised by the anaesthetist. Non-specialists generally examine the genitals only upon request of the patient.

A complete physical examination includes evaluation of general patient appearance and specific organ systems. It is recorded in the medical record in a standard layout which facilitates others later reading the notes. In practice the Vital signs of Temperature examination, Pulse and Blood pressure are usually measured first.

==Essential Parts of Physical Examination    ==


 * Chief complaint: This is the most important part to determine the reason patient seeks care. Important to consider using the patient’s terminology. This almost always provides you a “title” for the encounter.
 * History of present illness: This provide a thorough description of the chief complaint and current problem. The suggested format is as follow: P-Q-R-S-T.
 * P: precipitating and palliative factors: It is essential to identify factors that make symptom worse and/or better; any previous self-treatment or prescribed treatment, and patient's response.
 * Q: quality and quantity descriptors: Allow her/him to identify own rating of symptom (e.g., pain on a 1–10 scale) and descriptors (e.g., numbness, burning sensation, stabbing).
 * R: region and radiation: Ask enough questions to identify the exact location of the symptom and any area of radiation
 * S: severity and associated symptoms: Try to identify the symptom’s severity (e.g., how bad at its worst) and any associated symptoms (e.g., presence or absence of nausea and vomiting, caused dyspnea, associated with chest pain).
 * T: timing and temporal descriptions: This helps to identify when complaint was first noticed; how it has changed/progressed since onset (e.g., remained the same or worsened/improved); whether onset was acute or chronic; whether it has been constant, intermittent, or recurrent.


 * Past medical history: Ask to identify past diagnoses, surgeries, hospitalizations [duration and nature (e.g., elective or urgent)], injuries, allergies, immunizations, current medications.
 * Habits: Smoking, alcohol use, therapeutic drugs, substance/drug abuse, sleep and exercise patterns [(e.g., tea and coffee consumption in the evening may aggravate frequency of urination at night (Differential diagnosis of nocturia should always kept in mind)].
 * Sociocultural: Be polite and careful. These questions will help to identify occupational and recreational activities and experiences, living environment, financial status/support as related to patient's health care, needs, travel, lifestyle, etc.
 * Family history: A carefully taken family history helps to identify potential sources of hereditary diseases. A genogram (if possible) is helpful; the minimum includes first degree relatives (parents, siblings, children), although 2–3 orders for each topics are helpful. Consider cardiovascular disorders, lung diseases (e.g., tuberculosis, asthma), skin lesions, allergies, food intolerance, history of oral and genital ulcerations etc.
 * Review of systems: Start from vital signs (regardless of the complaints) and review a list of possible symptoms that the patient may have noted in each of the body systems.

Temperature
Temperature recording gives an indication of core body temperature which is normally tightly controlled (thermoregulation) as it affects the rate of chemical reactions.

The main reason for checking body temperature is to solicit any signs of systemic infection or inflammation in the presence of a fever (temp > 101.4 F or sustained temp > 100.4 F). Other causes of elevated temperature include hyperthermia. Temperature depression (hypothermia) also needs to be evaluated. It is also noteworthy to review the trend of the patient's temperature. A patient with a fever of 101 F does not necessarily indicate an ominous sign if his previous temperature has been higher.

Blood pressure
The blood pressure is recorded as two readings, a high systolic pressure which is the maximal contraction of the heart and the lower diastolic or resting pressure. Usually the blood pressure is taken in the right arm unless there is some damage to the arm. The difference between the systolic and diastolic pressure is called the pulse pressure. The measurement of these pressures is now usually done with an aneroid or electronic sphygmomanometer. The classic measurement device is a mercury sphygmomanometer, using a column of mercury measured off in millimeters. In the United States and UK, the common form is millimeters of mercury, whilst elsewhere SI units of pressure are used. There is no natural 'normal' value for blood pressure, but rather a range of values that on increasing are associated with increased risks. The guideline acceptable reading also takes into account other co-factors for disease. Elevated blood pressure hypertension therefore is variously defined when the systolic number is persistently over 140-160 mmHg. Low blood pressure is hypotension. Blood pressures are also taken at other portions of the extremities. These pressures are called segmental blood pressures and are used to evaluate blockage or arterial occlusion in a limb (see Ankle brachial pressure index).

Pulse
The pulse is the physical expansion of the artery. Its rate is usually measured either at the wrist or the ankle and is recorded as beats per minute. The pulse commonly is taken is the radial artery at the wrist. Sometimes the pulse cannot be taken at the wrist and is taken at the elbow (brachial artery), at the neck against the carotid artery (carotid pulse), behind the knee (popliteal artery), or in the foot dorsalis pedis or posterior tibial arteries. The pulse rate can also be measured by listening directly to the heartbeat using a stethoscope. The pulse varies with age. A newborn or infant can have a heart rate of about 130-150 beats per minute. A toddler's heart will beat about 100-120 times per minute, an older child's heartbeat is around 90-110 beats per minute, adolescents around 80-100 beats per minute, and adults pulse rate is anywhere between 50 and 80 beats per minute. comment on pulse Rate 60-90 Rhythm regular-irregular force=systolic tension=diastolic volume=difference between the systolic & diastolic equality on both sides status of arterial wall

Respiratory rate
Varies with age, but the normal reference range is 16-20 breaths/minute.

Height
Height is the anthropometric longitudinal growth of an individual. A statiometer is the device used to measure height although often a height stick is more frequently used for vertical measurement of adults or children older than 2. The patient is asked to stand barefoot. Height declines during the day because of compression of the intervertebral discs. Children under age 2 are measured lying horizontally.

Weight
Weight is the anthropometric mass of an individual. A scale is used to measure weight.

Body mass index or BMI is used to calculate the relationship between healthy height and weight and obesity or being overweight or underweight.

Medical professionals generally prefer to use the SI unit of kilograms, and many medical facilities have ready-reckoner conversion charts available for professionals to use, when patients describe their weight in non-SI units. (In the US, pounds and ounces are common, while in the UK stones and pounds are frequently used; in most other countries the metric system predominates.)

Pain
Because of the importance of pain to the overall wellness of the patient, subjective measurement is considered to be a vital sign. Clinically pain is measured using a FACES scale which is a series of faces from '0' (no pain at all showing a normal happy face) to '5' (the worst pain ever experienced by the patient). There is also an analog scale from '0' to maximum '10'. It is important to allow patients to make their own choices on a pain scale. Physicians and health care workers frequently understate patient pain.

General appearance
Obvious apparent features as the patient enters the consulting room and in the course of taking the history (e.g. mobility problem or deafness)
 * JACCOL, a mnemonic for Jaundice, suggestion of Anaemia (pale colour of skin or conjunctiva), Cyanosis (blue coloration of lips or extremities), Clubbing of fingernails, edema of ankles, Lymph nodes of neck, armpits, groins.

Organ systems

 * Cardiovascular system
 * Blood pressure, pulse rate and rhythm.
 * Jugular venous pressure (JVP), peripheral oedema and evidence for pulmonary oedema.
 * Precordial exam (cardiac exam)
 * Lungs
 * Respiratory rate, chest expansion, lung auscultation
 * Breasts
 * Abdomen
 * Abdominal examination notes in particular any tenderness, bloating, organ enlargement, or aortic aneurysm.
 * No abdominal examination is complete without a Rectal examination
 * Genitalia
 * Musculoskeletal system
 * Nervous system, including mental status
 * Head and neck (HEENT)
 * Skin
 * Check of the hair to see if the hair growth is receding (baldness) or there is loss of hair (alopecia).
 * Check of the skin will tell if there are marks such as hemangioma or strawberry marks or changes to the skin. Dark spots on the skin, nevi are also places where cancerous changes can appear because the face, head and neck are most usually sun exposed. Specific skin conditions (e.g. pyoderma gangrenosum, erythema nodosum, acanthosis nigricans) may be associated with specific diseases (ulcerative colitis, sarcoidosis and polycystic ovary syndrome, respectively).
 * Check of the skin will tell if there are marks such as hemangioma or strawberry marks or changes to the skin. Dark spots on the skin, nevi are also places where cancerous changes can appear because the face, head and neck are most usually sun exposed. Specific skin conditions (e.g. pyoderma gangrenosum, erythema nodosum, acanthosis nigricans) may be associated with specific diseases (ulcerative colitis, sarcoidosis and polycystic ovary syndrome, respectively).

Video 1: Complete Physical Examination


Video 2: Complete Physical Examination


Video 3: Complete Physical Examination


Common Causes of Diagnostic Errors

 * Accepting previous diagnosis/explanation without exploring other possible explanations (e.g., diagnosis of chronic bronchitis as explanation of chronic cough in patient on ACE inhibitor).
 * Accepting the “horses” without even contemplating the “zebras”; contemplating “zebras” without adequately pursuing the possibility of a more common condition.
 * Accommodating patient wishes against clinician judgment (Be polite, do not hesitate to interrupt, but perform your art. As a physician you are the ruler during the examination).
 * Allowing other health care professionals to lead you down the wrong diagnosis path (Consider others perspective and be respectful to everybody's opinion, but have yourselves first).
 * Allowing the patient to make diagnosis for you (e.g., “I had sinusitis last year and the symptoms are exactly the same.”, "I had similar chest discomfort after a spicy meal"). Do not allow patient to make a diagnosis or get a conclusion. Do not forget you are the examiner.
 * Failing to consider medical conditions as the source of “psychiatric” symptoms and psychiatric conditions as the source of “medical” symptoms (At first, complete your history taking and physical examination, later on you will have enough time to make a decision).
 * Failure of memory, so only recognize what is memorized or recalled (ask for permission and take regular notes)
 * Focusing solely on the most obvious or likely explanation (always keep in mind that every patient has his/her own nature). Consider differential diagnosis and rule out every of them.
 * Ignoring basic findings, such as vital signs (Be prepared and follow the rules).
 * Jumping to conclusion without enough evaluation, being biased by an early finding (e.g., something in the patient’s past medical history or recheck from a previous visit).
 * Misinterpreting examination findings or using wrong data.
 * Performing skills improperly (wrong respiratory maneuvers order during auscultations, improper fundoscopic examinations, inadequate reflex evaluations).
 * Using a shotgun approach to assessment, without adequate focus on current problems.
 * Using the wrong rule, decision tree, or other resource to guide analysis or using the correct device incorrectly (Correct timing for endoscopic examinations, hormonal analysis in female patients).

Additional Readings

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History of Present Illness

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Vital Signs

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Head and Neck Exam

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The Lung Exam

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Exam of the Heart

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 * Wang C, Fitzgerald J, Schulzer M, Mak E, Ayas N. Does This Dyspneic Patient in the Emergency Department Have Congestive Heart Failure? JAMA 2005; 294: 1944 - 1956.


 * Westman EC, Matchar DB, Samsa GP, Mulrow CD, Waugh RA, Feussner JF. Accuracy and reliability of apical s3 gallop detection. Journal of General Internal Medicine 1995; 455-57.


 * Wolf PA, Kannel WB, Sorlie P, McNamara P. Asymptomatic carotid bruit and risk of stroke: The Framingham study. JAMA 1981; 245: 1442-45.

Exam of the Abdomen

 * Arnell TD, de Virgilio C, Donayre C, Grant E, Baker JD, White R. Abdominal aortic aneurysm screening in elderly males with atherosclerosis: The value of physical exam. The American Surgeon 1996; 62: 861-64.


 * Barkun AN, Camus M, Green L, Meagher T, Coupal L, de Stempel, Grover S. The bedside assessment of splenic enlargement. The American Journal of Medicine 1991; 91: 512-18.


 * Bickley LS. Bates' Guide to Physical Exam and History Taking. 7th edition, Philadelphia; Lippincott, 1999: 355-86.


 * Castell C. How big is the normal liver, indeed! Arch Intern Med 1979; 139: 968-9.


 * Castell DO. The spleen percussion sign: A useful diagnostic technique. Ann Intern Med 1967; 67: 1265-67.


 * Castell DO, O'Brien KD, Muench H, Chalmers TC. Estimation of liver size by percussion in normal individuals. Ann Intern Med 1969; 70: 1183-89.


 * Chervu A, Clagett P, Valentine J, Myers SI, Rossi PJ. Role of physical examination in detection of abdominal aortic aneurysms. Surgery 1995; 117: 454-57.


 * Cumings S, Papadakis M, Melnick J, Gooding GAW, Tierney LM. The predictive value of physical examinations for ascites. West J Med 1985; 142: 633-36.


 * Eippe DF, Gifford RW, Stewart BH, Alfidi RJ, McCormack LJ, Vidt DG. Abdominal bruits in renovascular hypertension. Am J of Cardioll 1976; 37: 48-52.


 * Ebaugh FG, McIntyre OR. Palpable spleens: Ten-year follow-up. Ann Intern Med 1979; 90: 130-31.


 * Fink HA, Lederle FA, Roth CS, Bowles C, Nelson DB, Haas MA. The accuracy of physical examination to detect abdominal aortic aneurysm. Arch Intern Med 2000; 160: 833-36.


 * Fuller GN, Hargreaves MR, King DM. Scratch test in clinical examination of liver. Lancet January 23, 1988; 181.


 * Goldberg BB, Clearfield HR, Goodman GA, Morales JO. Ultrasonic determination of ascites. Arch Intern Med 1973; 131: 217-20.


 * Grover SA, Barkun AN, Sackett DL. Does this patient have splenomegaly? JAMA 1993; 270: 2218-21.


 * Guarino JR. Auscultatory percussion to detect ascites. NEJM 1986; 315: 1555-56.


 * Julius S, Stewart BH. Diagnostic significance of abdominal murmurs. NEJM 1967; 276: 1175-78.


 * Kiev J, Eckhardt A, Kerstein MD. Reliability and accuracy of physical examination in detection of abdominal aortic aneurysms. Vascular Surgery 1997; 31: 143-46.


 * Lederle FA, Simel DL. Does this patient have abdominal aortic aneurysm? JAMA 1999; 281: 77-82.


 * Lederle FA, Walker JM, Reinke DB. Selective screening for abdominal aortic aneurysms with physical examination and ultrasound. Arch Intern Med 1988; 148: 1753-56.


 * McClouglin MJ, Colapinto RF, Hobbs BB. Abdominal bruits: Clinical and angiographic correlation. JAMA 1975; 232: 1238-42.


 * Naylor CD. Physical examination of the liver. JAMA 1994; 271: 1859-65.


 * Rivin AU. Abdominal vascular sounds. JAMA 1972; 221: 688-90.


 * Simon N, Franklin SS, Bleifer KH, Maxwell MH. Clinical characteristics of renovascular hypertension. JAMA 1972; 220: 1209-18.


 * Sapira JD. The Art and Science of Bedside Diagnosis. 1st edition, Baltimore; Williams and Wilkins 1990: 371-90.


 * Sapira JD, Williamson DL. How big is the normal liver? Arch Intern Med 1979; 139: 971-73.


 * Silen W. Cope's early diagnosis of the acute abdomen. 17th edition, New York; Oxford Press 1987.


 * Skrainka B, Stahlhut J, Fulbeck CL, Knight F, Holmes RA, Butt JH. Measuring liver span. J Clin Gastroenterol 1986; 8: 267-70.


 * Sullivan S, Krasner N, Williams R. The clinical estimation of liver size: A comparison of techniques and an analysis of the source of error. British Medical Journal 1976; 2: 1042-43.


 * Turnbull JM. Is listening for abdominal bruits useful in the evaluation of hypertension? JAMA 1995; 274: 1299-1301.


 * Wagner JM, McKinney P, Carpenter JL. Does this patient have appendicitis? JAMA 1996; 276: 1589-94.


 * Williams JW, Simel DL. Does this patient have ascites? JAMA 1992; 267: 2645-48.

The Breast Exam

 * Adams K. Lump detection in simulated human breasts. Perception and Psychophysicis   1976; 20: 163-7.


 * Baines C, Miller A, Bassett A. Physical examination. Its role as a single screening   modality in the Canadian national breast screening study. Cancer 1989; 63: 1816-22.


 * Baines CJ, Miller AB. Mammography versus clinical examination of the breasts.   J Natl Cancer Institute Monographs 1997; 22: 125-9.


 * Baines CJ. Physical examination   of the breasts in screening for breast cancer. J Gerontol 1992; 47: 63-7.


 * Barnes C. Breast palpation technique: what is the finer pad? J Chronic Disease   1987; 40: 361-2.


 * Barton M, Harris R, Fletcher S. Does this patient have berast cnacer?: The   screening clinical berast examination: Should it be done? How? JAMA 1999; 282:    1270-80.


 * Bickley LS. Bates' Guide to Physical Exam and History Taking. 9th edition,   Philadelphia; Lippincott 2007: 337-357.


 * Bloom HS, Criswell E, Pennypacker H. . Major stimulus dimensions determining   detection of simulated breast lesions. Perception and Psychophysiology 1982;    32: 251-60.


 * Campbell HS, Fletcher SW, Pilgrim CA, Morgan TM, Lin S. Improving physicians   and nurses clinical breast examination: A randomized controlled trial. Am J    Prev Med 1991; 7: 1-8.


 * Donegan W. Evaluation of a palpable breast mass. NEJM 1992; 327: 937-42.


 * Fletcher S, O'Malley M, Earp J, Morgan T, Lin S, Dengan D. How best to teach women breast self-examination: A randomized controlled trial. Ann Int Med 1990; 112: 772-9.


 * Gulay H, Bora S. Management of nipple discharge. J Am Coll Surg 1994; 178: 471-4.


 * Hall D, Goldstein M, Stein G. Progress in manual breast examination. Cancer 1977; 40: 364-70.


 * Hall D, Adams C, Stein G, Stephenson H, Goldstein M. Improved detection of human breast lesions following experimental training. Cancer 1980; 46: 408-14.


 * Kerlikowske K, Simth-Bindman R, Ljung B, Grady D. Evaluation of abnormal mammography results and palpable breast abnormalities. Ann Intern Med 2003; 139: 274-84


 * Love S, Gelman R, Silen W. Sounding board. Fibrocystic "disease of the breast - a nondisease? NEJM 1982; 307: 1010-4.


 * Mahoney L, Csima A. Efficiency of palpation in clinical detection of breast cancer. Can Med Assoc J 1982; 127: 729-30.


 * McDermott M, Dolan N, Huang J, Reifler D, Rademaker A. Lump detection is enhanced in silicone breast models stimulating postmenopausal breast tissue. JGen Intern Med 1996; 11: 112-4.


 * Mushlin A. Diagnostic tests in breast cancer. Clinical strategies based on diagnostic possibilities. Ann Int Med 1985; 103: 79-85.


 * Pilgrim C, Lannon C, Harris R, Cogburn W, Fletcher S. Improving clinical breast examination training in a medical school: A randomized trial. J of Gen Int Med   1993; 8: 685-8.


 * Sanders K, Pilgrim C, Pennypacker H. Increased proficiency of search in breast   self exam. Cancer 1986; 58: 2531-7.


 * Sapira JD. The Art and Science of Bedside Diagnosis. 1st edition, Baltimore;   Williams and Wilkins 1990: 239-43.


 * Screening for breast cancer; Summary of recomendations. U.S. Preventative Services   Task Force (USPSTF). 2002. http://www.ahrq.gov/clinic/uspstf/uspsbrca.htm


 * Stephenson HS, Adams CK, Hall DC, Pennypacker HS. Effects of certain training   parameters on detection of simulated breast cancer. Journal of Behavioral Medicine    1979; 2: 239-50.


 * Winchester D. Physical examination of the breast. Cancer 1992; 69: 1947-9.

Male Genital/Rectal Exam

 * Bickley LS. Bates' Guide to Physical Exam and History Taking. 7th edtion, Philadelphia; Lippincott, 1999: 387-403; 449-59.


 * Dixon JM, Elton RA, Rainey JB, Macleod DAD. Rectal examination in patients with pain in the right lower quadrant of the abdomen. British Medical Journal 1991; 302: 386-88.


 * Sapira JD. The Art and Science of Bedside Diagnosis. 1st edition, Baltimore; Williams and Wilkins 1990: 391-98, 411-14.


 * Wantz GE. A 65 year old man with an inguinal hernia. JAMA 1997; 277: 663-69.

The Upper Extremities

 * Bickley LS. Bates' Guide to Physical Exam and History Taking. 7th   edtion, Philadelphia; Lippincott, 1999: 461-68.


 * Dorrington KL. Skin turgor: Do we understand the clinical sign? Lancet January 31, 1981; 264-65.


 * Myers KA, Farquhar DRE. Does This Patient Have Clubbing? The Rational Clinical Examination. JAMA 2001; 286: 341-347.


 * Sapira JD. The Art and Science of Bedside Diagnosis. 1st edition, Baltimore; Williams and Wilkins 1990: 435-42.


 * Schriger DL, Baraff LJ. Capillary refill: Is it a useful predictor of hypovolemic states? Ann Emerg Med 1991; 20: 601-605.


 * Schriger DL, Baraff L. Defining normal capillary refill: Variation with age, sex and temperature. Ann Emerg Med 1988; 17: 932-35.


 * Shneerson JM. Digital clubbing and hypertrophic osteoarthropathy: The underlying mechanisms. Br J Dis Chest 1981; 75: 113-25.

The Lower Extremities

 * Anand SS, Wells PS, Hunt D, Brill-Edwards P, Cook D, Ginsberg JS. Does this patient have deep vein thrombosis? JAMA 1998; 279: 1094-99.


 * Barnes RW, Wu KK, Hoak JC. Fallibility of the clinical diagnosis of venous thrombosis. JAMA 1975; 234: 605-07.


 * Bickley LS. Bates' Guide to Physical Exam and History Taking. 7th Edtion, Philadelphia; Lippincott, 1999: 461-82.


 * Blankfield RP, Findelhor RS, Alexander JJ, Flocke SA, Maiocco J, Goodwin M, Zyzanski SJ. Etiology and diagnosis of bilateral leg edema in primary care.   American Journal of Medicine 1998; 105: 192-97.


 * Caputo GM, Cavanagh PR, Ulbrecht JS, Gibbons GW, Karchmer AW. Assessment and management of foot disease in patients with diabetes. NEJM 1994; 331: 854-60.


 * Cymet TC, Weisman DS. Lower leg ulcers. Hospital Physician July, 1997; 30-41.


 * Haeger K. Problems of acute deep venous thrombosis: The interpretation of signs and symptoms. Angiology 1969; 20: 219-223.


 * Hirsh J, Hull RD, Raskob GE. Clinical features and diagnosis of venous thrombosis.   J Am Coll Cardiol 1986; 8: 114B-127B.


 * Loscalzo J (editor). Vascular Medicine: A textbook of vascular biology and   diseases. 1st edition, Boston; Little, Brown and Compay 1992: 401-18.


 * Merli GJ, Spandorfer J. The outpatient with unilateral leg swelling. Medical   clinics of North America 1995; 79: 435-47.


 * Nelzen O, Bergqvist D, Lindhagen A. Venous and non-venous ulcers: Clinical   history and appearance in a population study. British Journal of Surgery 1995;    81: 182-87.


 * Sapira JD. The Art and Science of Bedside Diagnosis. 1st edition,   Baltimore; Williams and Wilkins 1990: 442-49.


 * Sumpio BE. Foot ulcers. NEJM 2000; 343: 787-92.


 * Vaughan BF. CT of swollen legs. Clinical Radiology 1990; 41: 24-30.


 * Wells PS, Hirsh J, Andeson DR, Lensing AWA, Foster G, Kearon C, Weitz J, D'Ovidio,   Cogo A, Prandoni P, Girolami A, Ginsberg JS. Accuracy of clinical assessment    of deep-vein thrombosis. Lancet 1995; 345: 1326-30.

The Mental Status Exam

 * Bickley LS. Bates' Guide to Physical Exam and History Taking. 7th   edtion, Philadelphia; Lippincott, 1999: 107-27.


 * Froehlich TE, Robison JT, Inouye SK. Screening for dementia in the outpatient   setting: The time and change test. J American Geriatrics Soc 1998; 46: 1506-11.


 * Hirschfeld RMA, Russell JM. Assessment and treatment of suicidal patients.   NEJM 1997; 337: 910-15.


 * Lipowski, ZJ. Delirium (acute confusional states). JAMA 1987; 258: 1789-92.


 * Lipowski ZJ. Delirium in the elderly patient. NEJM 1989; 320: 578-82.


 * Small SM. Outline for psychiatric examination: 6-21.


 * Sapira JD. The Art and Science of Bedside Diagnosis. 1st edition,   Baltimore; Williams and Wilkins 1990: 516-22.

Musculoskeletal Exam

 * Adkins S, Figler R. Hip pain in athletes. American Family Physician 2000; 61:   2109-20.


 * Anto C, Aradhya P. Clinical diagnosis of peripheral nerve compression in the   upper extremity. Orthopedic Clinics of North America 1996; 27: 227-236.


 * Baker D, Schumacher H. Acute monoarthritis. NEJM 1993; 329: 1013-20.


 * Bernstein J, Ivins D. Impingement syndrome: differential diagnosis and treatment   strategies. Hospital Medicine 1999 (Oct): 24-29.


 * Bickley LS. Bates' Guide to Physical Exam and History Taking. 7th edition,   Philadelphia; Lippincott 1999: 483-5532.


 * Boyd R. Evaluation of back pain. Primary Care Medicine (Goroll A, Editor),   3rd Edition, Philadelphia; Lippincott 1995: 742-51.


 * Burkhart S. A 26-year-old woman with shoulder pain. JAMA 2000; 284: 1559-67.


 * Campbell CS. Gamekeeper's Thumb. The Journal of Bone and Joint Surgery1955;   37B: 148-49.


 * Canale TS. Campbell's Operative Orthopaedics 10th Ed., Philadelphia; Mosby:   2180-2211.


 * Cardone D, Tallia A. Diagnostic and therapeutic injection of the elbow region.   American Family Physician 2002; 66: 2097-100.


 * Carragee E. Persistent low back pain. NEJM 2005; 352: 1891-98.


 * Chapman MW. Chapman's Orthopaedic Surgery 3rd Ed., Philadelphia; Lippincott:   2247-2265.


 * Chumbley E, O'Connor F, Nirschl R. Evaluation of overuse elbow injuries. American   Family Physician 2000; 61: 691-702.


 * Colman W, Strauch R. Physical examination of the elbow. Orthopedic Clinics   of North America 1999; 30: 15-20.


 * Daniels J, Zook E, Lynch J. Hand and wrist injuries: Part I. Non-emergent evaluation.   American Family Physician 2004; 69: 1941-48.


 * Daniels J, Zook E, Lynch J. Hand and wrist injuries: Part II. Emergent evaluation.   American Family Physician 2004; 69: 1949-56.


 * Deyo R, Rainville J, Kent D. What can the history and physical examination   tell us about low back pain? JAMA 1992; 268: 760-5.


 * Dickey P. Surgical management of disc disease of the lumbar spine. Resident   and Staff Physician 1997; 43: 41-50.


 * El-Gabalawy HS, Duray P, Goldbach-Mansky R. Evaluating patients with arthritis   of recent onset. JAMA 2000; 284: 2368-73.


 * El-Khoury G, Renfrew D. Percutaneous procedures for the diagnosis and treatment   of lower back pain: Diskography, facet-joint injection, and epidural injection.    American Journal of Rheumatology 1991; 157: 685-91.


 * Frymoyer J. Back pain and sciatica. NEJM 1988; 318: 291-300.


 * Felson D; Osteoarthritis of the knee. NEJM 2006 354: 841-8.


 * Garfin S, Herkowitz H, Mirkovic S. Spinal stenosis. The Journal of Bone and   Joint Surgery 1999; 81A: 572-86.


 * Jackson JL, O'Malley PG, Kroenke K. Evaluation of acute knee pain in primary   care. Annals of Int Med 2003; 139: 575-99.


 * Lonner JH. A 57-year-old man with osteoarthritis of the knee. JAMA 2003; 289:   1016-25.


 * Luime JJ, Verhagen AP, Miedema HS. Does this patient have an instability of   the shoulder or a labrum lesion? JAMA 2004; 292:1989-99.


 * Netter FH. Atlas of Human Anatomy, Summit, NJ; Ciba-Geigy Corporation 1989: 395-402, 476-80.


 * Nicholas JA. The upper extremity in sports medicine 2nd Ed, Philadelphia; Mosby 1995: 23-76.


 * Rectenwald, J. Stener lesion. E-Medicine 2005 http://www.emedicine.com/orthoped/topic313.htm.


 * Sapira JD. The Art and Science of Bedside Diagnosis. 1st edition, Baltimore; Williams and Wilkins 1990: 415-33.


 * Simon RR, Koenigsknecht SJ. Emergency Orthopedics, The Extremities, 3rd Ed, Stamford CT; Appleton and Lange 1996: 386-410, 437-60.


 * Skolnick AA. For some injuries, it's all in the name. JAMA 1998; 279: 572-73.


 * Smith CC. Evaluating the painful knee: A hands-on approach to acute ligamentous and meniscal injuries. Advanced Studies In Medicine 2004; 4: 362-69.


 * Snider RK. Essential of muscoskeletal care, 1st Ed. American Academy of Orthopedics 1997: 75-81, 311-9.


 * Solomon DH, Simel DL, Bates DW. Does this patient have a torn meniscus or ligament of the knee? JAMA 2001; 286: 1610-20.


 * Spiegel TM, Crues JV. The painful Shoulder: Diagnosis and treatment. Primary Care 1988; 15: 709-24.


 * Stener B. Displacement of the ruptured ulnar collateral ligament of the metarcarpo-phalangeal   joint of the thumb. Journal of Bone and Joint Surgery 1962; 44b: 869-79.


 * Woodward TW, Best TM. The painful shoulder: Part I clinical evaluation. Americal   Family Physician 2000; 61: 3079-88.


 * Sandler G. The importance of the history in the medical clinic and the cost   of unnecessary tests. American Heart Journal 1980; 100: 928-31.

Neurological Exam

 * Bickerstaff ER. Neurological Exam in Clinical Practice. 4th edition, London;   Blackwell Scientific Publications 1980.


 * Bickley LS. Bates' Guide to Physical Examination and History Taking. 7th edition,   Philadelphia; Lippincott 1999.


 * Caputo GM, Cavanagh PR. Assessment and management of foot disease in patients   with diabetes. NEJM 1994; 331: 854-60.


 * Chiles BW, Cooper PR. Acute spinal injury. NEJM 1996; 334: 514-20.


 * Clark CM, Lee A. Prevention and treatment of the complications of diabetes   mellitus. NEJM 1995; 332: 1210-17.


 * Cornbluth D. Peripheral neuropathy. NEJM 1982; 307: 1457.


 * D'Arcy C, McGee S.The Rational Clinical Examination: Does This Patient Have Carpal Tunnel Syndrome? JAMA 2000; 283: 3110-3117.


 * Dawson DM. Current concepts: Entrapment neuropathies of the upper extremities. NEJM 1993; 329: 2013-18.


 * Deyo R, Weinstein J. Low back pain. NEJM 2005; 344: 363-70.


 * Dyck PJ. Current concepts in nuerology. The causes, classification and treatment of peripheral neuropathy. NEJM 1982; 307: 283-86.


 * Furman JM, Cass SP. Primary care: Benign paroxysmal positional vertigo. NEJM 1999; 341: 1590-96.


 * Glick TH. Neurologic Skills: Examination and Diagnosis. Boston; Blackwell Scientific Publications 1993.


 * Gorson KC. Case 9-2001 - A 64 year old woman with peripheral neurophathy, paraproteinemia and lymphadenopathy. NEJM 2001; 344: 917-23.


 * Haerer AF. Dejong's: The Neurologic Examination. 5th Edition, New York; J B Lippincott; 1992.


 * Hotson JR, Baloh RW. Acute vestibular syndrome. NEJM 1998; 339: 680-85.


 * Katz JN, Simmons BP. Carpal tunnel syndrome. NEJM 2005; 346: 1807-11.


 * Lange AE, Lozano AM. Parkinson's disease - First of two parts. NEJM 1998; 339:1044-53.


 * Lessell S. Optic neuropathies. NEJM 1978; 299: 533-36.


 * Louis ED. Essential tremor. NEJM 2001; 345: 887-91.


 * Mancall E. Alpers and Mancall's Essentials of the Neurologic Examination. edition 2, Philadelphia; FA Davis Co; 1981.


 * Nathan DM. Medical progress: Long term complications of diabetes mellitus. NEJM 1993; 328: 1676-85.