[Meningeal irritation]. / Meningeale prikkeling.

Diagnosing meningitis requires the information from both history-taking and physical examination in its entirety. In adults with a history that makes meningitis a possibility, specific tests used to diagnose meningeal irritation, such as for Kernig or Brudzinski signs or nuchal rigidity, probably do not affect the reliability of the diagnosis. In small children and the elderly, Kernig and Brudzinski signs are also probably of little or no diagnostic value.

[The elderly patient]. / De oude patiënt.

Many elderly have mild physical disorders. It is difficult to differentiate between the physiological symptoms of ageing and disorders in the elderly patient. Many disorders present as non-specific signs or symptoms in the elderly. The relevance of an abnormality can be judged by comparing the patient's current state with his or her prior level of functioning: what aspect of his or her condition has changed? Attributing an abnormality to a disease instead of aging only makes sense if it has therapeutic consequences for the patient; in this respect, the patient's level of functioning is an important frame of reference.

[Physical examination of patients with acute abdominal pain]. / Onderzoek bij patiënten met een acute buik.

Reliable physical examination of patients presenting with acute abdominal pain and tenderness is necessary for identifying serious causes on the one hand, and for preventing further unnecessary imaging on the other. If acute appendicitis or peritonitis is suspected, positive palpatory findings like rigidity and guarding are helpful diagnostic indicators, whereas negative palpatory findings have little value in excluding these conditions. Physical examination is of limited predictive value in diagnosing cholecystitis. Visible peristalsis strongly argues for small bowel obstruction, but this sign is rarely present. Digital rectal examination appears to have no added diagnostic value for appendicitis, peritonitis, or small bowel obstruction.

[Examination of the shoulder]. / Onderzoek van de schouder.

Examination of the active and passive range of motion of the shoulder joint is of major importance when diagnosing shoulder disorders. Abduction and external exorotation movements of the shoulder joint can be judged reliably. Limitations in the range of abduction indicate subacromial pathology and limitations in the range of external exorotation indicate glenohumeral pathology. Other shoulder joint movement tests have only low inter-rater reliability. Palpation of the shoulder serves no useful purpose if inspection of the joint and examination of the active range of motion reveal no abnormal signs. The value of physical examination tests that identify impingement or stability of the shoulder joint has not been reliably demonstrated.

[Physical examination of the knee after trauma]. / Onderzoek van de knie na een trauma.

The practice guideline 'Traumatic knee complaints' from the Dutch College of General Practitioners is aimed at differentiating between intra-articular and extra-articular lesions. The diagnosis is based mainly on a combination of patient history and a limited physical examination of the knee. Specific tests for hydrarthrosis, injuries to the collateral or cruciate ligaments, and meniscal pathology have only a low diagnostic accuracy. Few reliable studies have been conducted into the diagnostic value of specific tests; most studies employed poor methodology, had considerable inter-observer variation and produced widely heterogenous results. Inspection of the knee can provide information regarding the presence of fluids in the knee (hydrarthrosis or haemarthrosis). A restricted active range of movement in flexion and extension may indicate osteoarthritis or arthritis.

[Physical examination of the lungs in suspected pneumonia]. / Onderzoek van de longen bij verdenking op een pneumonie.

Physical examination of the lungs is easy to perform, but the interobserver agreement is poor due to lack of standardisation in the findings. The use of an electronic stethoscope with computerised analysis of the lung sounds might improve diagnostic accuracy. General signs such as fever and an accelerated respiratory and pulse rate increase the probability of a pneumonia. Percussion dullness increases the probability of pneumonia, but its absence does not exclude a pneumonia. Bronchial or decreased breath sounds or crackles increase the probability of pneumonia, but their absence does not exclude a pneumonia. There are no physical diagnostic findings that have a very high predictive value for a pneumonia; all findings should therefore be combined.

[Auscultation of the abdomen]. / Auscultatie van de buik.

Normal bowel sounds vary considerably in intensity, pitch and frequency. Due to the wide range of physiological variation, the clinical significance of abdominal bowel sounds is limited. There is no clear evidence that very high-pitched bowel sounds have clinical pertinence. Small bowel obstruction is more commonly associated with hyperactive bowel sounds than with substantially diminished or absent bowel sounds. In 4-20% of young adults, systolic bruits are heard in the epigastric region that are not associated with abnormalities. There is no evidence that abdominal aortic aneurysms are associated with abdominal bruits. An abdominal bruit is indicative of renal artery stenosis when blood pressure control remains unsatisfactory, in particular when the bruit is also heard during diastole.

[Physical examination of the heart]. / Onderzoek van het hart.

Although almost every doctor daily carries out physical examination of the heart, there is little reliable research into the value of the conclusions. Inspection and palpation of the apex beat and percussion of the left heart border are important in diagnosing enlargement of the heart. If the dullness falls within the mid-clavicular line, cardiac enlargement is almost certainly excluded. The presence of an abnormal heart murmur indicates a high probability of a haemodynamically significant ventricular septal defect or valve deficiency. The absence of a murmur definitely does not exclude a serious valve deficiency. In case of abnormal heart sounds, such as irregular rhythms, splitting of heart sounds or extra sounds, further investigations are always necessary to determine the clinical importance.

[Examining the lymph nodes]. / Onderzoek van de lymfeklieren.

Enlarged lymph nodes occur frequently and imply a benign or systematic disorder. In primary care, only 1% of patients with an unexplained lymphadenopathy have a malignancy. In the case of unexplained lymphadenopathy the most important diagnostic dilemma is whether biopsy should be applied. In young patients the necessity of lymph node biopsy can be accurately predicted using the following parameters: abnormal chest X-ray; lymph node > 2 cm and ear, nose and throat symptoms. In adults the necessity of biopsy may be reliably predicted using the following parameters: age; lymph node tenderness; lymph node size; consistency, presence of supraclavicular lymph nodes and generalised pruritus.

[Physical diagnostic examination of dehydration]. / Onderzoek naar dehydratie.

Dehydration is an important cause of morbidity and mortality for children and the elderly. Acute loss of weight is the most reliable measure of dehydration. In addition, a range of physical diagnostic findings are used for measuring dehydration; separate clinical findings have very little predictive value. In clinical practice the need for further investigation and rehydration treatment can be assessed by combining history and physical examination.