Routine Physical Examinations
Your doctor uses the routine physical examination to assess your current physical condition and to identify any undiagnosed disorders. A routine physical examination also helps your doctor become familiar with you and your health risks or medical problems. The frequency with which you see the doctor for a routine checkup varies, depending upon your age and whether you already have a medical condition. Before beginning the examination, the doctor will take a complete medical history by asking you a series of questions about your lifestyle habits, general health, and family health history (see page 80). Taking a thorough medical history often takes as long as the physical examination itself but is just as important.
When you go to the doctor’s ofﬁce for a routine physical examination, a nurse or other healthcare worker will weigh you and take your temperature to ﬁnd out if you have a fever, which could signal an infection. He or she also will take your blood pressure, using an inﬂatable cuff, pressure gauge, and stethoscope. A blood pressure reading measures how forcefully your circulating blood pushes against the walls of the blood vessels with each contraction of your heart. The reading records the pressure in the vessels both when the heart pumps blood (the systolic pressure) and when it rests (the diastolic pressure). The reading is expressed in two numbers in millimeters of mercury (mmHg)—for example, 120/80 mmHg, which is a reading within the normal range. The ﬁrst number indicates the systolic pressure; the second number, the diastolic pressure. The higher the pressure in your blood vessels, the higher the reading.
You will be asked to undress and put on a cloth or paper gown. The doctor will begin by examining your skin, checking for any paleness, ﬂushing, yellow- ish or bluish cast, rashes, dryness, bruising, or broken capillaries (tiny blood ves- sels). He or she will examine your face, which can display a number of unusual signs, such as puffy eyes, and your neck, checking for swollen glands or an enlarged thyroid (a gland just below your larynx—your voice box—that has an important role in controlling the chemical processes in your body).
Next, your doctor will look inside your mouth with a small ﬂashlight and a tongue depressor to examine your tongue, teeth, and gums. The condition of your mouth can reveal a number of clues about your general health. For example, red, cracking areas on your lips can signal a vitamin B deﬁciency. The doctor also will check your throat as far back as possible. By using an illuminated instrument called an ophthalmoscope, he or she will look into your eyes to see the retina lining the back of your eyes. Another lighted instrument, known as an otoscope, helps your doctor peer into your ears, to check for any inﬂammation or a possible perforation of the eardrum.
Listening to your chest with a stethoscope allows your doctor to assess not only the nature of your heartbeat but also the condition of your lungs. Any abnor- mal heart sounds will alert your doctor to the possibility of an enlarged heart, poor blood ﬂow through the heart, or a disorder of the heart valves. When lis- tening to your breathing with the stethoscope, the doctor listens for wheezing, crackling, or other sounds that could signal the presence of a lung disorder such as asthma. The doctor will probably also tap your chest and place his or her hands against your chest and ask you to cough so he or she can detect any ﬂuid in the chest. This process is called percussion. Taking your pulse is an important part of the examination because your heart rate can reveal heart or circulation problems.
The doctor will want to examine your abdomen, feeling and tapping it to detect any tenderness, abnormal masses, or ﬂuid accumulation. He or she will continue to press on different parts of your abdomen and ask you to respond if you feel any tender areas. The doctor is also checking for the correct positioning of the spleen and the liver. As part of his or her examination of your digestive system, the doctor will probably perform a rectal examination. Your doctor will ﬁrst cover his or her hands with disposable plastic gloves and lubricate the area to be examined with a cream or jelly. The doctor will gently and carefully place his or her ﬁngers inside your rectum to feel for any tumors in the rectum or prostate. Many prostate tumors are ﬁrst detected in this way.
If the doctor notices any signs that indicate that you may have a disorder of the nervous system, he or she will assess your motor ability, or ability to move, by observing the way you walk. He or she may also ask you to move your arms and legs in various ways to see whether there is a difference in movement between the two sides of your body. Testing the reﬂexes at your wrists, knees, ankles, and soles of your feet will also tell your doctor important information about the proper functioning of your nervous system.
To complete the physical examination, the doctor may order blood, urine, stool, or other tests (see next page) to help detect any abnormal conditions. Typical blood tests include the complete blood cell count, cholesterol testing, and a blood glucose test. The collected body ﬂuids are sent to a laboratory for analysis. The doctor may also order X rays or other scans, depending on your condition.
After your doctor examines you, he or she will write down his or her ﬁndings, along with the information obtained during the medical history, in your medical record. The doctor will also write down his or her orders to other healthcare workers in the ofﬁce about your medications, diet, tests, and recommended treat- ments. Your medical record serves as a means of communication for all of the doctors, specialists, nurses, therapists, and other healthcare workers who care for you. It is a conﬁdential and legal document maintained by professional records management workers. If you would like to have a copy of your medical record, contact the medical records department of your doctor’s ofﬁce or hospital.
Common Screening Tests
Sometimes a physical examination of your body is not enough to tell your doc- tor the full condition of your health. In such cases the doctor may order a num- ber of common screening tests. Blood tests and urinalysis help the doctor ﬁnd out if all of the components of your blood or urine are at normal levels. Scanning techniques such as X rays, magnetic resonance imaging (MRI), ultrasound scan- ning, and computed tomography (CT) scanning produce pictures of the inside of your body without surgery to give your doctor important information about your overall health. If your doctor has ordered one of these tests for you and you don’t understand what exactly is going to happen, ask questions so you can feel more comfortable about having the procedure. Diagnostic techniques are changing rapidly, and newer techniques will undoubtedly be available in the near future.
A sample of your blood can provide many clues about the quantity and quality of the individual blood cells and whether your blood can clot normally. To obtain a sample of your blood, a medical technician will draw blood with a needle and syringe from your forearm and send it to a laboratory. At the laboratory, your blood will be analyzed in several ways. Tests will be done to check the number of your red blood cells and the concentration of hemoglobin inside them. Hemo- globin is the substance in red blood cells that carries oxygen throughout the body. A low red blood cell count or too little hemoglobin indicates anemia. Blood tests also will be conducted to detect the number of white blood cells, which have a major part in defending the body against infection. If an infection is present, the number of white blood cells in your blood will rise. The appear- ance of your blood cells is also important. Abnormally shaped red or white blood cells can signal the presence of diverse conditions such as sickle-cell disease, leukemia, or mononucleosis. Finally, your blood will be checked to see how well it clots by examining the number of blood cells called platelets, which help stop bleeding.
Cholesterol Levels Elevated levels of the fats known as cholesterol in your blood increase your risk for heart disease. When the excess fats build up inside the walls of your arteries, they narrow the arteries, obstructing blood ﬂow to your heart. When the heart receives less blood, it gets less oxygen, which is trans- ported by red blood cells. Your heart sends out warning signals in the form of pain and discomfort known as angina. When the blockage in the arteries supply- ing blood to your heart causes severe obstruction, resulting in a heart attack (see page 207), the heart muscle can become permanently damaged.
Cholesterol comes in two forms: low-density lipoprotein (LDL), the “bad” cholesterol, and high-density lipoprotein (HDL), the “good” cholesterol. Some- what like a delivery truck, LDL cholesterol carries most of the fat in your blood and deposits the excess inside your artery walls. Like a garbage truck, HDL cholesterol removes fat from your blood, preventing it from building up in your arteries. When testing your cholesterol levels, your doctor measures your total blood cholesterol as well as your LDL and HDL levels by taking a sample of your blood and having it analyzed in a laboratory.
A desirable total blood cholesterol level falls under 200 milligrams per deciliter of blood. Doctors consider cholesterol levels above 200 to be high. One in ﬁve Americans has a total cholesterol level of 240 or greater, placing that per- son at risk of a heart attack. Your LDL cholesterol levels should be under 100, and HDL levels should be 40 or higher. The higher your HDL level, the lower your risk for heart disease.
All men over 20 years of age should have their total cholesterol levels checked at least once every 5 years. Your level of LDL cholesterol also should be tested if your HDL is less than 40 or if your total cholesterol is 240 or higher—200 if you have two or more risk factors for heart disease. Talk to your doctor about your personal risk factors for heart disease. Don’t hesitate to ask him or her anything you do not understand about cholesterol testing.
Your urine provides crucial information about the presence of any disorders of the kidneys or bladder. If your doctor orders a urinalysis, you will be asked to pass some urine and collect a midstream sample (urinate for several seconds before collecting the sample of urine) in a small container, either at home or in the doctor’s ofﬁce. If you are uncircumcised, you should pull back your foreskin and wash the tip of your penis with soap and water before urinating to ensure that your urine remains sterile. Your urine may be tested in a laboratory or in the doctor’s ofﬁce, using special strips that the doctor can dip into the urine to test for any abnormalities. The presence of particular substances such as blood or sugar in the urine can indicate certain diseases. For example, the presence of pro- tein in the urine can signal some types of kidney disease.
The most common scanning test is the X ray, in which electromagnetic radia- tion passes through a body part to produce a picture of internal structures on ﬁlm. X rays are a good way of showing dense areas of the body, such as bones or a tumor, that allow only a few rays to pass through. These dense areas show up as white areas on the ﬁlm. Doctors use X rays to examine the chest, skull, and spine and to view a bone that may have been fractured. Even organs ﬁlled with ﬂuid, gas, or air—such as the arteries, colon, or bladder—can be viewed with X rays if the organs are ﬁrst enhanced with a special liquid dye called a contrast medium. The contrast medium is injected, swallowed, or inserted through the anus; then the doctor or technician takes a series of X rays as the contrast medium moves through the organ to facilitate viewing. Getting an X ray is safe because today’s X-ray equipment minimizes your exposure to radiation.
Magnetic resonance imaging (MRI) uses a magnetic ﬁeld and radio waves to produce a picture of the inside of the body. When you undergo an MRI, you lie on a table that slides into a rounded scanner containing a doughnut-shaped mag- net that creates a magnetic ﬁeld. Radio waves are sent to the part of your body to be viewed. The atoms in your body respond by emitting energy, and a magnetic ﬁeld detector measures this energy and sends it to a computer, which translates the signal and creates a picture that your doctor can read. The procedure can take from 30 to 90 minutes and is painless, but the magnetic ﬁeld can interfere with a pacemaker, hearing aid, or metal implants, so your doctor needs to know if you have any of these devices in your body. MRI scanning poses no known health risks.
Ultrasound scanning uses sound waves to produce pictures of internal body structures. Doctors often use an ultrasound scan to diagnose disorders of the heart, kidneys, bladder, gallbladder, and pancreas. If your doctor orders an ultra- sound scan, you will be asked to lie on a table, and the ultrasound technician will spread a gel on your skin over the area to be scanned. The technician will then move a handheld instrument called a transducer over the area, sending sound waves into your body. The sound waves bounce off of your internal organs, and the transducer transforms the waves into an image on a screen or on paper. Ultra- sound is risk-free and is not painful.
Computed tomography (CT) scans take hundreds of X-ray images of the body from different directions that a computer then converts into cross-sectional pictures on a screen. CT scans can pick up details of abnormalities that a
conventional X ray cannot detect. Doctors often order a CT scan to check for tumors or other abnormalities in the brain, liver, spleen, lungs, kidneys, pelvis, or lymph nodes (a part of the body’s immune system). During a CT scan, you lie on a table that moves into a circular machine. A tube revolves around the machine, taking multiple, low-dose X-ray images from many angles. The proce- dure takes about 20 minutes. Although a CT scan takes a vast number of images, the amount of radiation generated in a CT scan can be the same as or even less than that from a traditional X ray.
In addition to the tests and screenings that your doctor performs during routine checkups, there are two important self-examinations that you should do regularly to detect any early signs of cancer. The testicle self-examination can help you identify any early signs of cancer of the testicle, and the skin self-examination will aid you in spotting early signs of skin cancer.
Examining your testicles once a month will help you to become familiar with their normal appearance so you can tell if something unusual turns up. A small, hard, painless lump on or enlargement of a testicle could be a sign of cancer. This type of cancer usually affects young men between the ages of 15 and 35. If another man in your family had cancer of the testicle, your risk is higher than normal. Early detection and treatment of cancer of the testicle is crucial because the cure rate is very high (about 90 percent) when the disorder is found and treated early.
The best time to examine your testicles is after a shower or a bath, when the muscles in your scrotum are relaxed. To examine your testicles, follow these steps:
• While standing in front of a mirror, look for any swelling on the surface of the scrotum.
• Using both hands, examine each testicle by placing your index and middle ﬁngers underneath the testicle with the thumbs placed on top. Gently roll the testicle between the thumbs and ﬁngers. One testicle may seem slightly larger than the other, but that is usually normal.
• Feel for abnormal lumps, about the size of a pea, on the sides or front of each testicle. Abnormal lumps are usually painless. Do not confuse the epididymis (the soft, tubelike structure on top of and behind the testicle) with a lump.
If you ﬁnd a lump, call your doctor right away. The lump may be an infection that requires treatment, or it may be cancer. You should also contact your doctor if one of your testicles has not descended from the abdomen, if you have pain or swelling in your scrotum, or if you feel a collection of veins above one of your testicles. These signs do not indicate the presence of cancer of the testicle but may point to another disorder of the testicles. Only a physician can make an accurate diagnosis. Be sure to see your physician regularly in addition to per- forming routine self-examinations. Your doctor should examine your testicles during a checkup. He or she also can check the way you perform a testicle self- examination.
Examining your own skin is the best way to ﬁnd skin cancer in the early stages, when it is most treatable. This is especially true of malignant melanoma, the most virulent and sometimes deadly form of skin cancer. A skin self-examination should be a regular part of your health routine. To identify abnormal-looking moles, look for the following signs of skin cancer:
One half of the mole is a differ- ent size or shape than the other half.
The edges of the mole are irregu- lar, notched, or blurred.
The color may be uneven, con- taining shades of brown, black, white, blue, pink, or red.
The mole is typ- ically larger than a pencil eraser (half an inch).
Malignant melanoma may also cause a mole to change in a number of ways, becoming scaly or crusted; oozing; or becoming harder or softer. The mole might change in size, or the skin around the mole could redden, swell, bleed, or itch. A red, scaly patch or a red or ﬂesh-colored nodule could also develop next to the mole. A change in any mole is an important warning sign.
Carefully examine your skin from head to toe every month, including your scalp, the soles of your feet, and between your toes. Use a mirror to check your back, or ask someone else to check it for you. If you see anything unusual, con- tact your doctor, even if you think it is nothing. Remember that skin cancer is most easily cured when detected early.