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Physical examination

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Physical examination
An examination room in Washington, DC, during the first World War
ICD-9-CM89.7
MeSHD010808
MedlinePlus002274

In a physical examination, medical examination, clinical examination, or medical checkup, a medical practitioner examines a patient for any possible medical signs or symptoms of a medical condition. It generally consists of a series of questions about the patient's medical history followed by an examination based on the reported symptoms. Together, the medical history and the physical examination help to determine a diagnosis and devise the treatment plan. These data then become part of the medical record.[citation needed]

Types

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A doctor using a stethoscope to listen to a 15-month-old's abdomen

Routine

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The routine physical, also known as general medical examination, periodic health evaluation, annual physical, comprehensive medical exam, general health check, preventive health examination, medical check-up, or simply medical, is a physical examination performed on an asymptomatic patient for medical screening purposes. These are normally performed by a pediatrician, family practice physician, a physical therapist, physician assistant, a certified nurse practitioner or other primary care provider. This routine physical exam usually includes the HEENT evaluation. Nursing professionals such as Registered Nurse, Licensed Practical Nurses can develop a baseline assessment to identify normal versus abnormal findings.[1] These are reported to the primary care provider. If necessary, the patient may be sent to a medical specialist for further, more detailed examinations.

The term is generally not meant to include visits for the purpose of newborn checks, Pap smears for cervical cancer, or regular visits for people with certain chronic medical disorders (for example, diabetes).[2] The general medical examination generally involves a medical history, a (brief or complete) physical examination and sometimes laboratory tests. Some more advanced tests include ultrasound and mammography.

If done for a group of people the routine physical is a form of screening, as the aim of the examination is to detect early signs of diseases to prevent them.[3]

Evidence

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Although annual medical examinations are a routine practice in several countries, examinations performed on an asymptomatic patient are poorly supported by scientific evidence in the majority of the population. A Cochrane Collaboration meta-study found that routine annual physicals did not measurably reduce the risk of illness or death, and conversely, could lead to overdiagnosis and over-treatment; however, this article does not conclude that being in regular communication with a doctor is not important, simply that an actual physical examination may not be necessary.[4]

Some notable general health organisations recommend against annual examinations, and propose a frequency adapted to age and previous examination results (risk factors).[5][6][7] The specialist American Cancer Society recommends a cancer-related health check-up annually in men and women older than 40, and every three years for those older than 20.[8]

A systematic review of studies until September 2006 concluded that the examination does result in better delivery of some other screening interventions (such as Pap smears, cholesterol screening, and faecal occult blood tests) and less patient worry.[2] Evidence supports several of these individual screening interventions.[9][10][11] The effects of annual check-ups on overall costs, patient disability and mortality, disease detection, and intermediate end points such a blood pressure or cholesterol, are inconclusive.[2] A recent study found that the examination is associated with increased participation in cancer screening.[12]

Some employers [where?] require a mandatory health checkup before hiring a candidate, even though it is now well known that some of the components of the prophylactic annual visit may actually cause harm. For example, lab tests and exams that are performed on healthy patients (as opposed to people with symptoms or known illnesses) are statistically more likely to be "false positives"—that is, when test results suggest a problem that does not exist.[13] Disadvantages cited include the time and money that could be saved by targeted screening (health economics argument),[14] increased anxiety over health risks (medicalisation), overdiagnosis, wrong diagnosis (for example athletic heart syndrome misdiagnosed as hypertrophic cardiomyopathy) and harm, or even death, resulting from unnecessary testing to detect or confirm, often non-existent, medical problems or while performing routine procedures as a followup after screening.[15][16][17]

A resident physician at the Granada Relocation Center, examining a patient's throat

The lack of good evidence contrasts with population surveys showing that the general public is fond of these examinations, especially when they are free of charge.[18] Despite guidelines recommending against routine annual examinations, many family physicians perform them.[19] A fee-for-service healthcare system has been suggested to promote this practice.[20] An alternative would be to tailor the screening interval to the age, sex, medical conditions and risk factors of each patient.[6][21][22] This means choosing between a wide variety of tests.[23]

Prevalence

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The routine physical is commonly performed in the United States and Japan, whereas the practice varies among South East Asia and mainland European countries. In Japan it is required by law for regular working employees to have a health check once a year.[24]

History

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The roots of the periodic medical examination are not entirely clear. They have been referenced as early as 1671.[25] They have also been advocated for since the 1920s.[26] Some authors point to pleads from the 19th and early 20th century for the early detection of diseases like tuberculosis, and periodic school health examinations.[27] The advent of medical insurance and related commercial influences seems to have promoted the examination, whereas this practice has been subject to controversy in the age of evidence-based medicine.[20][27][28][29][30] Several studies have been performed before current evidence-based recommendation for screening were formulated, limiting the applicability of these studies to current-day practice.[2][31][32]

Comprehensive

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Comprehensive physical exams, also known as executive physicals, typically include laboratory tests, chest x-rays, pulmonary function testing, audiograms, full body CAT scanning, EKGs, heart stress tests, vascular age tests, urinalysis, and mammograms or prostate exams depending on gender. It is a thorough assessment designed to evaluate an individual's overall health. So, it helps to identify any potential health risks early on. [33]

Pre-employment

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Pre-employment examinations are screening tests which judge the suitability of a worker for hire based on the results of their physical examination.[34] This is also called pre-employment medical clearance. Some employers believe that by only hiring workers whose physical examination results pass certain exclusionary criteria, their employees collectively will have fewer absences due to sickness, fewer workplace injuries, and less occupational disease.[34] A small amount of low-quality evidence in medical research supports this idea.[34] Furthermore, the cost of staff health insurance will be lower. However, certain exams or tests that are requested by employers, such as a baseline low back x-ray, should not be performed, according to the American College of Occupational and Environmental Medicine. Reasons for this include the legality and medical necessity of the test as well as the inability of such testing to predict future problems, the radiation exposure to the worker, and the cost of the exam.[35]

Insurance

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A physical examination may be provided under health insurance cover, required of new insurance customers. This is a part of insurance medicine. In the United States, physicals are also marketed to patients as a one-stop health review, avoiding the inconvenience of attending multiple appointments with different healthcare providers.[36][37]

Uses

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A medical doctor examines a young girl, Guinea-Bissau, 1974

Diagnosis

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Physical examinations are performed in most healthcare encounters. For example, a physical examination is performed when a patient visits complaining of flu-like symptoms. These diagnostic examinations usually focus on the patient's chief complaint.[citation needed]

Screening

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General health checks, including physical examinations performed when the patient reported no health concerns, often include medical screening for common conditions, such as high blood pressure. A Cochrane review found that general health checks did not reduce the risk of death from cancer, heart disease, or any other cause, and could not be proved to affect the patient's likelihood of being admitted to the hospital, becoming disabled, missing work, or needing additional office visits. The study found no effect on the risk of illness, but did find evidence suggesting that patients subject to routine physicals were diagnosed with hypertension and other chronic conditions at a higher rate than those who were not. Its authors noted that studies often failed to consider or report possible harmful outcomes (such as unwarranted anxiety or unnecessary follow-up procedures), and concluded that routine health checks were "unlikely to be beneficial" in regards to lowering cardiovascular and cancer morbidity and mortality.[4]

Doctor-patient relations

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Main article: Doctor-patient relationship

Physical examination has been described as a ritual that plays a significant role in the doctor-patient relationship that will provide benefits in other medical encounters.[38] When a physical exam is expected by the patient but is not performed by the provider, patients may express concern for the lack of depth of investigation into their illness, the validity of treatment plans and exclusions, and the doctor-patient relationship.[39]

Other uses

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By extension, the term "health check" is also used for routing checks on the working of equipment [40] or business operations or solvency.[41]

Format and interpretation

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Auscultation of a man in Vietnam

A physical examination may include checking vital signs, including temperature examination, blood pressure, pulse, and respiratory rate. The healthcare provider uses the senses of sight, hearing, touch, and sometimes smell (e.g., in infection, uremia, diabetic ketoacidosis). Taste has been made redundant by the availability of modern lab tests. Four actions are taught as the basis of physical examination: inspection, palpation (feel), percussion (tap to determine resonance characteristics), and auscultation (listen).[42]

Scope

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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 and includes evaluation of general patient appearance and specific organ systems. 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).[citation needed]

While 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. A primary care physician will also generally examine the male genitals but may leave the examination of the female genitalia to a gynecologist.

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. The physical exam is then recorded in the medical record in a standard layout which facilitates billing and other providers later reading the notes.

A doctor examining a pediatric patient in hospital

While elective physical exams have become more elaborate, in routine use physical exams have become less complete. This has led to editorials in medical journals about the importance of an adequate physical examination.[43][44] Physicians at Stanford University medical school have introduced a set of 25 key physical examination skills that were felt to be useful.[45]

Recording

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Section Sample text Comments
General "Patient in NAD. VS: WNL" May be split on two lines. "WNL" = "within normal limits"
HEENT: "NC/AT. PERRLA, EOMI. No cervical LAD, no thyromegaly, no bruit, no pallor, fundus WNL, oropharynx WNL, tympanic membrane WNL, neck supple" "Neck" is sometimes split out from "Head". "Good dentition" may be noted.
Resp or "Chest" "Nontender, CTA bilat" Chest expansion test, normal breathing with little effort, absence of wheezing, rhonchi and crackles. More detailed examinations can include rales, rhonchi, wheezing ("no r/r/w"), and rubs. Other phrases may include "no cyanosis or clubbing" (if section is labeled "Resp" and not "Chest"), "fremitus WNL", and "no dullness to percussion".
CV or "Heart" "+S1, +S2, RRR, no m/r/g" If "CV" is used instead of "heart", peripheral pulses are sometimes included in this section (otherwise, they may be in the extremities section)
Abd "Soft, nontender, nondistended, absence of pain, no hepatosplenomegaly, NBS" If lower back pain is involved, then the "Back" may become a primary section. Costovertebral angle tenderness may be included in the abdominal section if there is no back section. More detailed examinations may report "+psoas sign, +Rovsing's sign, +obturator sign". If tenderness was present, it might be reported as "Direct and rebound RLQ tenderness". "NBS" stands for "normal bowel sounds"; alternatives might include "hypoactive BS" or "hyperactive BS".
Ext "No clubbing, cyanosis, edema" Checking the fingers for clubbing and cyanosis is sometimes considered part of the pulmonary exam, because it closely involves oxygenation. Examinations of the knee may involve the McMurray test, Lachman test, and drawer test.
Neuro "A&Ox3, CN II-XII grossly intact, Sensation intact in all four extremities (dull and sharp), DTR 2+ bilat, Romberg negative, cerebellar reflexes WNL, normal gait" Sensation may be expanded to include dull, sharp, vibration, temperature, and position sense. A mental status exam may be reported at the beginning of the neurologic exam, or under a distinct "Psych" section.

Depending upon the chief complaint, additional sections may be included. For example, hearing may be evaluated with a specific Weber test and Rinne test, or it may be more briefly addressed in a cranial nerve exam. To give another example, a neurological related complaint might be evaluated with a specific test, such as the Romberg maneuver.

History

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The Old Testament makes provision for persons in the Israelite community with leprosy to be examined by a priest: if the presenting sore was white and appeared to go beyond the depth of the skin, it was to be treated as a ritually defiling condition.[46] A further examination was to take place seven days later.[47]

The medical history and physical examination were supremely important to diagnosis before advanced health technology was developed, and even today, despite advances in medical imaging and molecular medical tests, the history and physical remain indispensable steps in evaluating any patient. Before the 19th century, the history and physical examination were nearly the only diagnostic tools the physician had, which explains why tactile skill and ingenious appreciation in the exam were so highly valued in the definition of what made for a good physician. Even as late as 1890, the world had no radiography or fluoroscopy, only early and limited forms of electrophysiologic testing, and no molecular biology as we know it today. Ever since this peak of the importance of the physical examination, reviewers have warned that clinical practice and medical education need to remain vigilant in appreciating the continuing need for physical examination and effectively teaching the skills to perform it; this call is ongoing, as the 21st-century literature shows.[48][49]

Society and culture

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People may request modesty in medical settings when the health care provider examines them.

In many Western societies, a physical exam is required to participate in extracurricular sporting activities. During the physical examination, the doctor will examine the genitals, including the penis and testicles. The doctor may ask the teenager to cough while examining the scrotum. Although this can be embarrassing for an adolescent male, it is necessary to help evaluate the presence of inguinal hernias or tumors.[50]

See also

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Wikimedia Commons has media related to Physical examinations.

References

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  1. ^ Schreiber, Mary L. Evidence-Based Practice. Neurovascular Assessment: An Essential Nursing Focus. MEDSURG Nursing (MEDSURG NURS), Jan/Feb2016; 25(1): 55-57. ISSN 1092-0811
  2. ^ a b c d Boulware LE, Marinopoulos S, Phillips KA, et al. (February 2007). "Systematic review: the value of the periodic health evaluation". Ann. Intern. Med. 146 (4): 289–300. doi:10.7326/0003-4819-146-4-200702200-00008. PMID 17310053. S2CID 1683342.
  3. ^ Raffle AE, Muir Gray JA (2007). Screening: Evidence and practice. Oxford University Press. doi:10.1093/acprof:oso/9780199214495.001.0001. ISBN 978-0-19-921449-5.
  4. ^ a b Krogsbøll LT, Jørgensen KJ, Gøtzsche PC (31 January 2019). "General health checks in adults for reducing morbidity and mortality from disease". The Cochrane Database of Systematic Reviews. 1 (1): CD009009. doi:10.1002/14651858.CD009009.pub3. ISSN 1469-493X. PMC 6353639. PMID 30699470.
  5. ^ US Preventive Services Task Force. Guide to Clinical Preventive Services: Report of the Preventive Services Task Force 2nd ed. Baltimore, Md: Williams & Wilkins; 1996.
  6. ^ a b "Periodic health examination: a guide for designing individualized preventive health care in the asymptomatic patients. Medical Practice Committee, American College of Physicians". Ann. Intern. Med. 95 (6): 729–32. December 1981. doi:10.7326/0003-4819-95-6-729. PMID 7305155.
  7. ^ Hayward RS, Steinberg EP, Ford DE, Roizen MF, Roach KW (May 1991). "Preventive care guidelines: 1991. American College of Physicians. Canadian Task Force on the Periodic Health Examination. United States Preventive Services Task Force". Ann. Intern. Med. 114 (9): 758–83. doi:10.7326/0003-4819-114-9-758. PMID 2012359.
  8. ^ Mettlin C, Dodd GD (1991). "The American Cancer Society Guidelines for the cancer-related checkup: an update". CA Cancer J Clin. 41 (5): 279–82. doi:10.3322/canjclin.41.5.279. PMID 1878784.
  9. ^ Screening for Lipid Disorders in Adults, Topic Page. June 2008. U.S. Preventive Services Task Force. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/clinic/uspstf/uspschol.htm Archived 2011-05-23 at the Wayback Machine
  10. ^ Screening for Colorectal Cancer, Topic Page. July 2002. U.S. Preventive Services Task Force. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/clinic/uspstf/uspscolo.htm Archived 2011-05-23 at the Wayback Machine
  11. ^ Screening for Cervical Cancer, Topic Page. January 2003. U.S. Preventive Services Task Force. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/clinic/uspstf/uspscerv.htm Archived 2015-11-27 at the Wayback Machine
  12. ^ Fenton JJ, Cai Y, Weiss NS, et al. (March 2007). "Delivery of cancer screening: how important is the preventive health examination?". Arch. Intern. Med. 167 (6): 580–5. doi:10.1001/archinte.167.6.580. PMC 3443471. PMID 17389289.[permanent dead link‍]
  13. ^ "A checkup for the checkup: Do you really need a yearly physical? - Harvard Health Blog". Harvard Health Blog. 2015-10-23. Retrieved 2015-11-02.
  14. ^ Yarnall KS, Pollak KI, Østbye T, Krause KM, Michener JL (April 2003). "Primary care: is there enough time for prevention?". Am J Public Health. 93 (4): 635–41. doi:10.2105/AJPH.93.4.635. PMC 1447803. PMID 12660210.
  15. ^ Yahr E (2015-01-28). "What went wrong with Joan Rivers's last medical procedure: lawsuit". The Washington Post. ISSN 0190-8286. Retrieved 2015-11-08.
  16. ^ "Minnesota teen Sydney Galleger dies after dental procedure". www.cbsnews.com. 16 June 2015. Retrieved 2015-11-08.
  17. ^ "Three Georgia boys die unexpectedly after dental procedure". www.cbs46.com. Archived from the original on 2018-05-25. Retrieved 2015-11-08.
  18. ^ Oboler SK, Prochazka AV, Gonzales R, Xu S, Anderson RJ (May 2002). "Public expectations and attitudes for annual physical examinations and testing". Ann. Intern. Med. 136 (9): 652–9. doi:10.7326/0003-4819-136-9-200205070-00007. PMID 11992300. S2CID 46398009.
  19. ^ Prochazka AV, Lundahl K, Pearson W, Oboler SK, Anderson RJ (June 2005). "Support of evidence-based guidelines for the annual physical examination: a survey of primary care providers". Arch. Intern. Med. 165 (12): 1347–52. doi:10.1001/archinte.165.12.1347. PMID 15983282.
  20. ^ a b Gordon PR, Senf J (May 1999). "Is the annual complete physical examination necessary?". Arch. Intern. Med. 159 (9): 909–10. doi:10.1001/archinte.159.9.909. PMID 10326933. Archived from the original on 2012-02-13.
  21. ^ Lawrence RS, Mickalide AD (April 1987). "Preventive services in clinical practice: designing the periodic health examination". JAMA. 257 (16): 2205–7. doi:10.1001/jama.257.16.2205. PMID 3560403.
  22. ^ Frame PS, Carlson SJ (February 1975). "A critical review of periodic health screening using specific screening criteria. Part 1: Selected diseases of respiratory, cardiovascular, and central nervous systems". J Fam Pract. 2 (1): 29–36. PMID 1123583.
  23. ^ Beck LH (November 1999). "Periodic health examination and screening tests in adults". Hosp Pract (Minneap). 34 (12): 117–8, 121–2, 124–6. doi:10.3810/hp.1999.11.175. PMID 10616549.
  24. ^ "Home | OECD iLibrary". www.oecd-ilibrary.org. Retrieved 2023-10-22.
  25. ^ Smith JE (2011). Divine machines: Leibniz and the sciences of life. Princeton: Princeton University Press. ISBN 978-0-691-14178-7.
  26. ^ Emerson H (1923). "Periodic medical examinations of apparently healthy persons". JAMA. 80 (19): 1376–1381. doi:10.1001/jama.1923.26430460003011.
  27. ^ a b Han PK (November 1997). "Historical changes in the objectives of the periodic health examination". Ann. Intern. Med. 127 (10): 910–7. doi:10.7326/0003-4819-127-10-199711150-00010. PMID 9382370. S2CID 20210491.
  28. ^ Charap MH (December 1981). "The periodic health examination: genesis of a myth". Ann. Intern. Med. 95 (6): 733–5. doi:10.7326/0003-4819-95-6-733. PMID 7030166.
  29. ^ Davis AB (1981). "Life insurance and the physical examination: a chapter in the rise of American medical technology". Bull Hist Med. 55 (3): 392–406. PMID 7037084.
  30. ^ Jureidini R, White K (2000). "Life insurance, the medical examination and cultural values". J Hist Sociol. 13 (2): 190–214. doi:10.1111/1467-6443.00113. PMID 18383634.
  31. ^ Olsen DM, Kane RL, Proctor PH (April 1976). "A controlled trial of multiphasic screening". N. Engl. J. Med. 294 (17): 925–30. doi:10.1056/NEJM197604222941705. PMID 1256483.
  32. ^ Knox EG (December 1974). "Multiphasic screening". Lancet. 2 (7894): 1434–6. doi:10.1016/S0140-6736(74)90086-5. PMID 4140342.
  33. ^ "Johns Hopkins Executive Health Program". Archived from the original on 2009-12-24. Retrieved 2009-07-16.
  34. ^ a b c Schaafsma FG, Mahmud N, Reneman MF, Fassier JB, Jungbauer FH (2016-01-12). "Pre-employment examinations for preventing injury, disease and sick leave in workers". The Cochrane Database of Systematic Reviews. 2016 (1): CD008881. doi:10.1002/14651858.CD008881.pub2. ISSN 1469-493X. PMC 7163410. PMID 26755127.
  35. ^ American College of Occupational and Environmental Medicine (February 2014), "Five Things Physicians and Patients Should Question", Choosing Wisely: an initiative of the ABIM Foundation, American College of Occupational and Environmental Medicine, retrieved 24 February 2014, which cites
    • Talmage J, Belcourt R, Galper J, et al. (2011). "Low back disorders". In Kurt T. Hegmann (ed.). Occupational medicine practice guidelines : evaluation and management of common health problems and functional recovery in workers (3rd ed.). Elk Grove Village, IL: American College of Occupational and Environmental Medicine. pp. 336, 373, 376–377. ISBN 978-0615452272.
  36. ^ Brink S (18 February 2008). "$2,000 physicals for busy execs". Los Angeles Times. Retrieved 16 July 2009.
  37. ^ Armour LA (21 July 1997). "2,500 executives flock to Rochester, Minn., for a deluxe, soup-to-nuts physical at the Mayo clinic. Our man went for a tune-up to find out why". CNN.com. Retrieved 16 July 2009.
  38. ^ Verghese A, Brady E, Kapur CC, Horwitz RI (October 2011). "The bedside evaluation: ritual and reason". Ann. Intern. Med. 155 (8): 550–3. CiteSeerX 10.1.1.692.177. doi:10.7326/0003-4819-155-8-201110180-00013. PMID 22007047. S2CID 24847029.
  39. ^ Kravitz RL, Callahan EJ (January 2000). "Patients' Perceptions of Omitted Examinations and Tests". Journal of General Internal Medicine. 15 (1): 38–45. doi:10.1046/j.1525-1497.2000.12058.x. ISSN 0884-8734. PMC 1495321. PMID 10632832.
  40. ^ Microsoft, How to use the PC Health Check app, accessed 16 November 2023
  41. ^ Insolvency Service, Company health check: keeping your business on track, accessed 16 November 2023
  42. ^ Campbell EW, Lynn CK (1990), Walker HK, Hall WD, Hurst JW (eds.), "The Physical Examination", Clinical Methods: The History, Physical, and Laboratory Examinations (3rd ed.), Butterworths, ISBN 978-0-409-90077-4, PMID 21250202, retrieved 2019-12-02
  43. ^ Flegel KM (November 1999). "Does the physical examination have a future?". Canadian Medical Association Journal. 161 (9): 1117–8. PMC 1230732. PMID 10569087.
  44. ^ McAlister FA, Straus SE, Sackett DL (February 2000). "High marks for the physical exam". Canadian Medical Association Journal. 162 (4): 493. PMC 1231165. PMID 10701381.
  45. ^ Verghese A, Horwitz RI (2009). "In praise of the physical examination". BMJ. 339: b5448. doi:10.1136/bmj.b5448. PMID 20015910. S2CID 5371569. Archived from the original (PDF) on 2016-08-04. Retrieved 2012-12-17.
  46. ^ Leviticus 13:3
  47. ^ Leviticus 13:5–6
  48. ^ Natt B, Szerlip HM (2014), "The lost art of the history and physical", Am J Med Sci, 348 (5): 423–425, doi:10.1097/MAJ.0000000000000326, PMID 25247755.
  49. ^ Guadalajara Boo JF (2015), "Auscultation of the heart: an art on the road to extinction." (PDF), Gac Med Mex, 151 (2): 260–265, PMID 25946538.
  50. ^ "Physical Examination: Adolescent Male". Children's Hospital of Philadelphia. 23 August 2014.
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