The Physical Examination
The physical examination looks for the same conditions sought
by the history. However, the Rule of Threes indicates the three aspects of the physical
examination (airway, cardiovascular, and lung) that may augment, or be better than,
the history for detecting the presence of undiagnosed disease or a condition that
may affect perioperative outcome; other aspects to be explored include those specific
to the patient's condition or planned procedure, such as a sensory nerve examination
if a regional block is planned.
The physical examination consists of the following processes:
- • Determination of arterial blood pressure in both arms, and in at least
one arm 2 minutes after the patient assumes the upright position after lying down.
- • Examination of the pulses and of the chest for heaves, thrusts, pulsations,
murmurs, and gallops (third and fourth heart sounds). (Some believe that obtaining
ankle blood pressure is useful in assessing the risk for cardiovascular disease,
[97]
[98]
but this
process is not routine.)
- • Examination of the carotid and jugular pulses. (I have found that patients
expect to be partially undressed for this exam and consider the examiner unprofessional
if he or she does not auscultate blood pressure sounds using a bell or diaphragm
held to the skin.)
- • Examination of the chest and auscultation of the bases of the heart for
subtle rales suggestive of congestive heart failure, or for rhonchi, wheezes, and
other sounds indicative of lung disease. (Although history-taking may detect these
symptoms that point to lung disease as accurately as auscultation, the patient expects
a "good" physician to auscultate his or her lungs preoperatively. Thus, this part
of the physical examination also helps increase patient confidence.)
- • Observation of the patient's walk for signs of neurologic disease and to
assess back mobility and general health.
- • Examination of the eyes for abnormal movement and, along with the skin,
for signs of jaundice, cyanosis, nutritional abnormalities, and dehydration.
- • The fingers are checked for clubbing.
- • Examination of the airway and mouth for neck mobility, tongue size, oral
lesions, and ease of intubation (see Chapter
42
).
- • Functional evaluation of cardiovascular risk by observing vigor and stamina
in walking. (I frequently take the pulse of the patient and myself prior to and
after climbing two flights of stairs with the patient, while we talk about other
subjects. My own pulse change acts as a control, alerting me when to be concerned
about the patient's exercise capacity: if the patient's pulse rate exceeds an increase
of 40 beats per minute after climbing two flights [twice my usual pulse change],
I worry that the patient cannot do much more than 4 METs of activity [see Table
25-4
].)
- • Examination of the legs for bruising, edema, clubbing, mobility, sensation,
and adequacy of hair growth (or skin texture) as signs of circulatory competence.
Although these portions of the history-taking and physical examination
are routine, they are usually not recorded. Because the Health Care Financing Administration
(HCFA) has insisted on recording of procedures as proof of their performance, it
is advisable to use information system processes to document what has been done (see
later).
