The Patient Was…

When something is “Time-Honored,” it often suggests that its value is largely historical. It’s important because it’s been around for a long time. We may render an approving nod and then ignore it. Many things in medicine are like that: long-standing practices, now largely neglected.

Annual physical examinations are largely such time-honored traditions and are often neglected. They deserve more serious consideration.

The “annual” part is, of course, arbitrary. Like a list of the year’s best movies. or books, or songs, or almost anything defined primarily by the yearly calendar, the annual aspect is simply a convenient means of periodic assessment of things that exist pretty much in a continuum.

Health and medical care don’t restart annually. Blood pressure doesn’t reset yearly. Elevated cholesterol doesn’t revert to lower levels every twelve months. Organ dysfunction doesn’t magically normalize according to the calendar.

Periodic  —  call it annual for its time-honored tradition —  medical reexamination is an important part of maintaining health and managing illness. Note that it’s not just a “physical” that is important. It is an in-depth evaluation of symptoms, concerns, lifestyle, and findings on physical examination that are the hallmarks of a meaningful medical assessment. (Medicare, interestingly, does not cover annual physical examinations, but it does cover annual “wellness” visits where personalized health plans are developed for an individual. The subtleties of how to qualify for this benefit are beyond the scope of this article.)

Time constraints on medical visits, and the mandate to use electronic health records (EHRs), make detailed conversations between patients and physicians more difficult. Instead of face-to-face with the patient, the physician is often face-to-computer screen. But the even more neglected part of medical evaluations today is the careful physical examination, and that is what I want to focus on in this article.

A older colleague of mine, an internal medicine specialist, when asked by a patient what an internist actually did, responded, “I take care of the skin and its contents.” In other words, total care, total responsibility for the patient.

It is impossible, I maintain, to examine a patient thoroughly if the patient remains fully clothed.  And it is unfortunately commonplace, today, for patients not to disrobe during physical examinations. I’m thrilled when my own doctors use their stethoscopes as medical instruments rather than neck ornaments, but I’m dismayed when they listen to my lungs and heart through my clothing.

You should wear an examination gown that can be decorously and appropriately opened and closed, when being examined. Your own clothing hinders and prevents careful physical examination.

Checking so-called “vital signs” is a good starting point in an examination. These signs include blood pressure (ideally checked in both arms to rule out a blockage in the blood flow to one arm), pulse rate and rhythm, and respiratory (breathing) rate. Height and weight should be recorded because changes in these over time can be significant in many ways.

Beginning with examination of your skin, it’s literally impossible to examine if it’s not bared. I recall finding a concerning spot on a patient’s back for which I referred her to a dermatologist. The spot I worried about was nothing of consequence, but another lesion that concerned the dermatologist turned out to be a melanoma, the deadliest of skin cancers. Fortunately, it was still superficial and easily cured by excision. You can’t see covered skin!

Most comprehensive physical examinations proceed in an orderly fashion from head to foot. In this way, nothing is missed. With the head part are the eyes, ears, nose and throat. Simple ophthalmic examination can reveal abnormalities in blood vessels  —  you can actually see the blood vessels within the eye  —  and possible distortion of the optic disc which is actually the head of the optic nerve. Simple maneuvers can give a rough estimate of hearing. And within the nose and throat, nasal septum abnormalities including deviations and perforations, and lesions in the throat, are easily visualized.

Moving down, your neck is a complicated structure. Abnormal lymph nodes can be felt, if present, pointing to infectious, inflammatory, or cancerous possibilities. Distention of the veins may suggest early congestion of the vascular system. Abnormal sounds in the carotid arteries heard with a    stethoscope can indicate circulatory blockages in blood flow to the brain. And careful palpation of the thyroid gland can detect enlargement or lumps.

Auscultation (meaning listening to sounds) of the lungs is a mainstay of physical examination. Instead of normal breath sounds a doctor might detect various abnormalities, including things called rales, rhonchi, rubs, and even the absence of breath sounds. Each of these conveys different information and suggests different diagnoses. If your lungs are examined through your clothing, the rubbing of fabric against the stethoscope can mimic or obscure some of these findings.

Examination of the heart can be extremely detailed and time-consuming, especially when cardiac disease is suspected and a cardiologist is asked to perform the evaluation. At least four steps are traditionally involved: inspection, palpation, percussion, and auscultation. Inspection looks for abnormal cardiac pulsations visible on the chest; palpation feels for the  movement of the heart beneath the chest wall; percussion is a manual technique to help determine heart size and position; auscultation listens for heart murmurs and other abnormal sounds including rubs, knocks, and gallops. While many of these maneuvers are quite specialized, a routine cardiac examination on a periodic medical evaluation should, as a minimum, listen for murmurs and other abnormal sounds, which might point to heart valve problems or heart failure.

Examination of the abdomen is mainly a manual exercise where doctors use their hands to feel for organ enlargement such as the liver or spleen, abnormal masses, vascular abnormalities, or areas of tenderness. Feeling the width of the aorta, the largest artery in the body, as it traverses the abdominal cavity, might detect an aneurysm (abnormal bulging) of that blood vessel which might need careful surveillance or even active treatment. Listening with the stethoscope to sounds within the abdomen might detect vascular narrowings of clinical importance.

The inguinal region (groin area) lies between the lower abdomen and upper thigh and it is a “busy” one, containing nerves, arteries, veins, and lymph glands. It is easy to feel the pulse of the femoral artery, which is the main conduit for blood flow to the legs, to assure no obstruction to blood flow.  Enlarged lymph glands may be felt, pointing to one or more important conditions. An inguinal hernia, a protrusion of a segment of intestine through a defect in the abdominal cavity lining, may be seen or felt. The legs themselves should be checked at least for signs of impaired blood flow in both arteries and veins.

In patients with suspected neurological diseases or impairments, neurologists may perform detailed and extensive examinations. But even on a routine periodic examination, a physician can easily test strength, sensation, and mobility in arms and legs. And so-called deep tendon reflexes are easily tested by tapping on a tendon to elicit a muscle contraction. I once diagnosed a spinal cord tumor simply by finding a marked difference in the reflex response of one ankle compared to the other.

Pelvic and genital examinations represent a special situation, special because of their “sensitive” nature. Many women have gynecologists who perform pelvic examinations, so a general physician doesn’t need to. But if your female patient does not see a gynecologist, a pelvic examination should be done with appropriate regard for privacy and decorum. Breast examination should be performed by some physician, be it a gynecologist or primary doctor. In men, manual testicular examination should be done. In addition, rectal examination is vital, especially as rectal cancer is increasing in frequency.

Several laboratory tests should be periodically checked. Perhaps primary among them is a CBC (Complete Blood Count), which analyzes the cellular components of the blood, including red blood cells (RBCs), white blood cells (WBCs) and platelets. Excess or deficiency in any cellular component of the blood requires a search for the cause. Other routine periodic blood tests look at kidney and liver function, diabetes, cholesterol and other blood lipids (fatty molecules), and electrolytes like sodium and potassium. Routine urinalysis checks for sugar, blood, protein and possibly other urinary abnormalities. Examination of the stool for blood can be done on rectal examination or at home with simple test kits. Additional diagnostic tests such as x-rays, electrocardiograms, and other modalities, may be part of periodic examinations by some physicians.

All this may sound complicated, but it really isn’t. Everything described here is familiar to physicians and can generally be done efficiently. Routine annual or periodic examinations have fallen into disuse, partly because technology has replaced clinical evaluations and partly because the “yield” (positive findings) is low. The yield, however, may be low because the examination is performed in a superficial and perfunctory manner. But, if the examination is done thoroughly, and nothing abnormal is found, that should provide great reassurance to both patient and physician.