A physical examination, also known simply as a "physical," is a process in which a physician examines various organ systems and other parts of a patient's body. As the standard tool used to diagnose the source of pain and diseases - and to monitor overall health - it represents the cornerstone of preventive medicine. It is far better to prevent a disease or condition than to treat it, and better to treat it early before it becomes worse.

A physical examination is usually the first step in helping to find and treat the source of a patient's pain. The purpose of a physical is to determine if there are signs of illness that can be detected by simply looking, touching and listening to the patient. In the case of a serious illness, the physical findings and the medical history are important elements in making a diagnosis.

During a physical examination, the physician will assess a number of areas. For patients with pain complaints, the physician will focus on areas that may be of particular concern. Patients who visit a physician with complaints about pain will typically undergo a basic physical examination first. This type of examination is standard whenever a patient visits a physician and may include:

• Vital signs
• General appearance
• Eyes, ears, nose, throat and mouth
• Neck, particularly the thyroid gland and cervical lymph nodes
• Respiratory, cardiovascular and gastrointestinal systems (breathing, circulation and digestion)
• Breasts (women and men)
• Genitals (including men's prostate and women's pelvic area)
• Muscles, joints, bones and skin
• Neurological and psychiatric conditions

Patients who have persistent pain may also undergo one or more tests designed to help locate the source of their pain. Some sources of pain may be difficult to identify during a physical examination, which can be frustrating to patients. If a physician is unable to diagnose the source of a patient's pain - or believes the patient may simply benefit from another approach - the patient may be referred to a pain specialist with expertise in managing pain.

About the physical examination

Also known simply as a "physical," a physical examination is the process by which a physician inspects the patient's body for signs of illness and sources of pain. Along with taking a full medical history, this process is the most important strategy in identifying the source of a patient's pain. The physician uses a fairly structured process to conduct the exam. In general, the physical includes the following four elements:

• Inspection. After collecting information through a detailed medical history, the physician will look at various parts of the patient's body, with a focus on any regions of complaint. For example, physicians trying to locate the source of a patient's pain symptoms may observe a patient's gait or range of motion in moving a limb.
• Palpation. By gently pressing on the skin, a physician can identify areas of tenderness or swelling, as well as the size and texture of a growth, organ or other body part. For example, patients who complain of symptoms that indicate the chronic pain syndrome fibromyalgia are diagnosed with a technique in which a physician applies a certain amount of pressure to a tender point and observes any reaction that may indicate pain.
• Percussion. Most people have had their chest gently tapped by a physician's fingers. This is an example of percussion, or tapping on the chest or abdomen to gauge normal or abnormal responses. Different areas of the body elicit different responses, depending on the structures and tissues present. For instance, when tapping on the breastbone (sternum), the area should sound solid because the presence of hard bone. Differences in sound are due largely to the amount of fluid or air in the tissue or body cavity, which can be an important indicator of normal or abnormal functions.
• Auscultation. Using a stethoscope, the physician will listen to the heartbeat and other sounds within the body. Normal functions and many abnormal conditions have characteristic sounds that can be identified through this process.

Before the physical examination

A routine physical examination normally begins with a review of the patient's medical history by the physician. The physical examination offers an opportunity with which to speak to a physician about health concerns. Some patients find it helpful to bring a list of relevant questions for their physician to the appointment.

If there are no pressing concerns or current symptoms, no preparation is necessary prior to the exam. However, the physician may request that certain information be gathered before the appointment. A patient seeking help for a specific pain may want to detail the incidences of pain before the physical examination. A family medical history of close relatives (including parents, siblings, grandparents, aunts and uncles) may help a physician to be on guard for symptoms of conditions that may have a genetic component.

Also, if a patient reports certain symptoms when making the appointment, the physician may request certain items be prepared prior to the exam (e.g., a stool sample from a patient complaining of blood in the stool). If a patient will undergo diagnostic testing such as a blood test or urine test, it may be necessary to fast, adjust medication or make other preparations. The physician or office staff should inform the patient of any necessary steps.

Patients who report pain are likely to be asked a series of questions about their pain. This is known as a pain assessment. The more specifically and accurately the patient is able to describe the pain, the more likely it is that an accurate diagnosis will be made. For this reason, patients should be prepared to answer several questions. Prior to an appointment, it might help to keep a pain diary in which patients track their pain and record details about it.

Potential questions a physician may ask during a pain assessment include:

• Where does the pain occur and does it move around from place to place?
• Does pain occur in more than one area?
• How severe is the pain?
• When does the pain occur? Is it better or worse in the mornings? Does it come and go, or is it always present?
• How long does the pain last?
• Is the pain new? Has it ever occurred before?
• Does the pain prevent certain physical or mental activities?
• Does the pain interrupt sleep, change moods or affect appetite?
• Does anything make the pain better or worse?
• What medications or other techniques have been used to try to control the pain?

Patients are also often asked to describe their pain on a scale of zero to 10. In this measurement, zero represents "no pain" while 10 represents "the worst pain imaginable."

During the physical examination

Physical exams can range from simply measuring blood pressure and listening to a patient's heart to a more thorough exam, which usually includes:

• Measurements of height and weight.
• Vital statistics, including temperature, heart rate (pulse) and blood pressure.
• Examining the skin for any rashes, dryness, irritation, open sores, bleeding or abnormal pigments (e.g., jaundice) and checking moles for possible signs of skin cancer.
• Checking the spine for proper alignment and movement and for abnormal curvatures such as scoliosis.
• Examining joints and muscles for tenderness, swelling or motor difficulties such as gait disturbances. Crepitus (a crackling or grating sound) in a joint may indicate osteoarthritis.
• Listening to a patient's lungs to check for signs of fluid.
• Checking for signs of swelling around the eyes, or in the hands or feet.
• Checking the abdomen for tender areas, lumps or enlarged organs, as well as signs of swelling.
• Checking the eyes for clarity, movement and the pupils' response to light, as well as the back of the eye and any signs of vision changes.
• Examining the patient's ears and hearing.
• Looking at the teeth, gums and throat and asking about the patient's oral health habits.
• Checking the thyroid gland at the base of the neck while the patient swallows, as well as listening to the blood vessels in the neck.
• Feeling the lymph nodes under the arm and around the neck for any swelling or pain.

When a patient reports pain in a specific area (e.g., back or knees), the physician may conduct specific tests, such as walking or bending, to check functions in that area. The physician will also ask whether or not the patient has noticed other symptoms such as hoarseness, gastrointestinal bleeding, constipation, swallowing problems or coughing up blood. If the patient answers "yes" to any of these questions, the physician may request additional tests, such as blood tests or urine tests.

After the physical examination

Once the physical examination is complete, the physician may decide that additional evaluation of the patient is warranted to help locate the source of pain. The recommendation may be based on the patient's medical history and any findings during the physical, even if symptoms are not present. Additional tests, often referred to as screening and diagnostic tests, may be used to diagnose the source of pain. They include:

• Blood tests. Often used to screen for various illnesses. A complete blood count (CBC) is a test that measures the levels of red blood cells, white blood cells and platelets in a person's blood. It can provide important information on the types of blood cells present, their condition, number and percentage in relation to other cells. The results of a CBC can help diagnose many conditions and diseases.
• A sedimentation rate (sed rate) test measures the speed at which red blood cells settle at the bottom of blood in a glass tube. Certain proteins in the blood determine the rate. An elevated sed rate may be a sign of disease or inflammation. A C-reactive protein test can also reveal inflammation. A rheumatoid factor test is useful in diagnosing rheumatoid arthritis.
• In addition, glucose tests and cholesterol tests are often performed to screen people for diabetes and cholesterol problems.
• Urine tests. Used to help diagnose many conditions, including lupus, prostatitis, gout and blood in the urine (hematuria).
• X-ray. Uses low-dose radiation to create images of bones and internal organs. It can be used to reveal many conditions that might be the source of pain, including:
  • Fractures
  • Arthritis
  • Osteoporosis
  • Swallowed objects
  • Sinus infections
  • Sources of dental pain

• Bone scans. A type of radionuclide imaging used to look for bone abnormalities. Bone scans can be used to diagnose bone pain resulting from disorders such as cancer, arthritis or hidden fractures.
• Discogram. An x-ray examination of the intervertebral discs of the spine. This test can reveal damage to the discs that may be the source of pain. Damaged discs can cause pain in the neck, arms, back, abdomen or legs. In this test, dye is injected into the disc, helping to reveal any damage.
• ElectromyographyElectromyography (EMG). Uses a thin needle electrode to monitor tiny electrical discharges that take place in the muscles. EMG can evaluate and diagnose muscle and nerve disorders that may be causing pain, including pinched nerves.
• CAT scan (computed axial tomography). An imaging technique that uses x-rays to produce more detailed images of internal organs than traditional x-rays. CAT scans can help diagnose pain-causing disorders such as muscle and bone disorders, infections and internal bleeding or injuries.
• MRI (magnetic resonance imaging). Uses a magnetic field and radio waves to create cross-sectional images of the body. It can be used to diagnose a wide range of conditions that may cause pain, including bone and joint damage, damage to the heart or blood vessels, cancerous tumors, and many others.
• Arthrography. Injects a dye (contrast medium) into a joint to show damage.
• Ultrasound. Painlessly uses high-frequency sound waves to highlight internal structures.

In some cases, a physician may not be able to accurately diagnose the source of pain. Or, a physician may feel that another expert is better qualified to treat the pain after its source has been diagnosed. For example, patients may be referred to a pain specialist (a physician with extensive experience in diagnosing and treating pain) or rheumatologist (a physician who specializes in arthritis and other rheumatic diseases).