This part of the physical examination is usually only of practical use for the chest and abdomen. In the former case, its principal value is in establishing the nature of lung disorders. To give two examples: when one lung has collapsed suddenly, the percussion note over that side of the chest sounds more resonant than usual because of air in the pleural space between the lung and chest wall; and when one lung is consolidated (filled with fluid), as in pneumonia, the note is duller than usual. Usually, these findings are confirmed by an X-ray.
Bronchitis and asthma, however, are unlikely to be diagnosed solely by percussion. In the case of the abdomen, percussion may help in diagnosis of bowel obstruction. When the abdomen is swollen for this reason, the bowel contains much more gas than usual and the percussion-note is therefore very resonant (or tympanic – like a drum). If the distension of the abdomen is a result of fluid within v 7
At its simplest, palpation may simply amount to feeling the part of the body that is injured, or that the patient believes is abnormal in some way. An injured bone or joint may be palpated to discover any tenderness (pain on being touched or pressed); this may indicate a fracture, or damage to the ligament of a joint. A lump in the skin or elsewhere will be felt by the doctor and its consistency noted: a soft and pliable lump usually turns out to be a fluid-filled cyst, whereas a malignant tumour is usually noticeably hard; an abscess in the skin of the face may be accompanied by enlargement of the lymph-glands in the neck because of the spreading infection, so these will be palpated too.
Palpation is also an important part of examination of the various body systems. In assessing the condition of the heart, palpation of the pulse (usually felt at the wrist) is essential. The doctor notes the rate, the rhythm and the character of the beats. Similar observations are made on the pulses in the neck and legs – on both sides – and on the pulsation of the heart itself, often felt over the left side of the chest. In examining the abdomen, the doctor feels all the area to determine any tenderness and swelling. The liver, the kidneys and the spleen may be felt in their respective parts of the abdomen and any abnormal dimensions or consistencies noted. Finally, a rectal examination (examination of the back passage) may be made with a gloved finger. The lowest part of the bowel, the prostate gland in men and the neck of the womb in women, may be felt. In older girls and women a gynaecologist may make an internal examination by way of the vagina (front passage) to assess the womb and ovaries.
In general, a family doctor searching for a common diagnosis, for which he will prescribe conventional treatment, uses only a fraction of all these methods for carrying out the examination. The extent to which these techniques are taken depend on how much knowledge the doctor requires to advise therapy and return the patient to health. Many illnesses can be detected by the old-fashioned methods of inspection, auscultation, percussion and palpation alone. Because these methods are time-consuming, and because now there are many more examination methods available than previously, and also because there is a growing need to be certain of a diagnosis (in case the patient sues the doctor for malpractice), physical examination is sometimes replaced by laboratory tests and an X-ray photograph. This gives many patients increasingly the feeling that the doctor is not particularly concerned for them. Indeed, sometimes it is regrettable that medical science is seeming to rely more and more on laboratory results and less on physical examination.