Garden Advances in Psychiatric Treatment (2005), vol.

11, 142–149

Physical examination in psychiatric practice

Gill Garden

Abstract Physical disease is more prevalent in people with mental disorder than in the general population. It is
important for psychiatrists to maintain skills in physical examination to ensure that physical illness is
diagnosed and treated appropriately. A sound knowledge of medical illness ensures that examination
is targeted at the relevant diseases. Mental health units should provide adequate facilities and equipment.
All detailed examinations should be undertaken in the presence of a chaperone. Opportunities for
psychiatrists to refresh their knowledge and skill are suggested.

The literature on physical examination in psy- have shown that, in many cases, physical diseases
chiatric practice is sparse, much is dated and from will not be diagnosed and treated when a patient is
overseas, and so of limited use in extrapolation to admitted to a psychiatric unit (Felker et al, 1996; Moos
current practice in the UK. British studies have & Mertens, 1996), which has potentially serious
reported the recording of physical examination implications for patients’ overall health, delaying
carried out on admission by psychiatric trainees to recovery and increasing length of stay. Consequently,
be ‘uniformly poor’ (Rigby & Oswald, 1986) or an important aspect of psychiatric evaluation is
‘variable’ (Hodgson & Adeyemo, 2004). The earlier differentiating organic disease from ‘functional’
study found that significant positive findings were psychiatric disorders. A competent assessment of
unrecorded, especially in the neurological and patients’ physical health also helps to tailor drug
locomotor systems. The recent study showed little use and reduce the risk of side-effects. Additionally,
progress, with under 60% of patients having a it gives a clear baseline for comparison, should a
comprehensive central nervous system (CNS) patient’s physical state change, thus informing the
examination. clinician of the severity of the effect of a drug and of
the need for action.
Therefore, there appears to be compelling evidence
Why should psychiatrists be able that care of people with mental illnesses should
to do a physical examination? encompass physical as well as mental healthcare.
How can this be achieved and what barriers are
Age-adjusted annual death rates from all causes there to overcome?
among psychiatric patients are 2–4 times higher than
in the general population (Harris & Barraclough,
1998), with higher rates of physical disorder across Barriers to overcome
the entire range of mental disorders. Attitudes
The risks of reliance on the belief that the patient’s
general practitioner or other referring doctor will Many psychiatrists have not used a stethoscope, let
have done a thorough examination have been alone done a physical examination, for many years.
emphasised (Sternberg, 1986). It has been reported Past surveys reported that most psychiatrists did
that between 6 and 20% of patients with physical not examine their patients routinely (McIntyre &
illness are misdiagnosed as having mental disorder Romano, 1977; Summers et al, 1981; Krummel &
(Koranyi, 1979; Koran et al, 1989). This discrepancy Kathol, 1987) and that a third had little confidence
may be due to the fact that patients who are mentally in their ability to do so (McIntyre & Romano, 1977),
disturbed may be unable to give a clear account of or believed that it should be done by a physician
their symptoms, even in the presence of a life- other than a psychiatrist (Victoroff et al, 1979). There
threatening disorder (Kampmeier, 1977). Studies is little evidence to show that the situation has

Gill Garden is a consultant psychiatrist at Pilgrim Hospital (Sibsey Road, Boston PE21 9QS, UK. E-mail:
[email protected]). She trained in medicine, passing the membership examinations for the Royal College of Physicians
before changing to psychiatry. She is a member of the Objective Structured Clinical Examination (OSCE) panel and an
examiner for Part I of the Royal College of Psychiatrists’ membership examinations.

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 Physical examination in psychiatric practice

changed. Thus, it is likely that many psychiatrists Table 1 Equipment

practice without any clear knowledge of their
Essential Desirable
patients’ physical health and its impact on mental
health or vice versa. Examination couch Auroscope
Stethoscope Alcometer
Sphygmomanometer Oximeter
Isolation from acute health services Thermometer Neurological testing pins
Tendon hammer Snellen chart
At present, national policy is for mental health Tuning fork (256 Hz) Height measure
services to be managed separately from other Weighing scales Disposable gloves
health services. The establishment of small in- Urinalysis sticks
patient units in the community is likely to lead to
physical estrangement from medical colleagues and
investigative support services, which are usually history help in focusing the physical examination.
based in acute hospitals. As a consequence, service The essence of a skilled physical examination is not
level agreements between acute and mental health an immaculate examination of the various organs
trusts, which were designed to offer reciprocal in isolation from each other. Rather, it is that
and complementary services, may no longer be clinicians use their knowledge selectively to inform
practicable. an efficient search for signs from different systems
to confirm or support a diagnosis.
Training
Equipment and environment
With the exception of vocational training in general
practice, postgraduate medical training programmes Essential to a good physical examination are
are increasingly focused on specialty, which may privacy, peace, light, warmth and good equipment
be to the detriment of holistic patient care. As a (Table 1). Unfortunately, many psychiatrists work
consequence, the mental disorders of mentally ill in offices or wards without examination couches
patients may deter clinicians in acute hospitals from and without basic equipment such as stethoscopes,
adequately managing medical illness, and diagnosis sphygmomanometers or ophthalmoscopes.
and treatment of a physical disorder may be over-
looked by their counterparts in psychiatric services
(Bunce et al, 1982).
Chaperones
Anything more than cursory examination of
appearance, pulse or blood pressure should be
The MRCPsych Part I conducted with a chaperone. A female member of
staff should always accompany male doctors when
The Royal College of Psychiatrists has been
examining a female patient. It is my view that the
proactive in placing greater emphasis on retention
advice to be chaperoned should equally apply to
of the skills of physical examination. The objective
female psychiatrists examining male patients, not
structured clinical examination (OSCE) in Part I of
just to prevent allegations of assault on the patient,
the College’s membership examinations (the
but also to avoid assault by the patient. This
MRCPsych) has at least one physical examination
precaution is of particular relevance when patients
station in each circuit. As the bank of stations
are intoxicated with alcohol or other substances or
increases, there will be greater opportunity to assess
are elated, and as a consequence may be sexually
skills in physical examination, with an emphasis
disinhibited.
on trainees demonstrating their ability to elicit signs
from a number of systems in order to substantiate a
clinical diagnosis. Timing
Ideally, physical examination should be carried out
The general physical examination as part of the admission procedure. A survey of
physical examination suggested that there is often
Physical examination should not be conducted in a delay, with a mean of 62 h after admission and as
isolation from systemic enquiry. Just as a good long as 612 h (25.5 days) in some cases (Hodgson &
psychiatric history informs our examination of Adeyemo, 2004). Although delay may be justified
mental state, so a good working knowledge of because of the patient’s mental state, reasons for the
internal medicine, systemic enquiry and medical delay should be recorded clearly.

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Garden

Observation Examination of the hands and arms can also be

informative. Although possession of a tattoo is
Knowledge of a patient’s weight is extremely increasingly prevalent in the British population,
important. It is obviously vital in anorexia nervosa, certain types of tattoo, in particular letters over the
but it also helps to confirm the extent of weight knuckles and collars around the neck, are commonly
loss due to neglect in a patient with psychosis believed to have an association with psychopathy
and of weight variation in depression. Furthermore, (Macleod, 1983). These should alert the clinician to
a weight chart provides an important indicator of look for signs of substance misuse, such as needle
weight gain due to psychotropic drugs or dietary tracks, to take particular care with venesection and
intake during admission. to gain corroboration of the history. Splinter
Presence or absence of cyanosis should be noted. haemorrhages are rare, but should also raise concern
Although peripheral cyanosis is not unusual in in the intravenous drug misuser. Palmar erythema,
patients with chronic cardiac or respiratory Dupuytren’s contractures and clubbing should all
disorders, central cyanosis should alert the raise suspicion of liver disease in a patient with
clinician to serious underlying physical problems depression or psychosis who professes abstinence
and the need for urgent medical intervention. A or moderation. The development of clubbing in a
foreign body should be suspected, especially in the patient who is a heavy smoker may suggest a lung
elderly, those with swallowing disorders, con- cancer and the need for an urgent chest X-ray and
ditions such as Huntington’s chorea and patients possible referral.
on neuroleptics. Rapid diagnosis in such circum- Examination of the oral cavity is important in
stances is vital. patients with mental illnesses, since dental hygiene
Anaemia as suggested by pallor of palmar creases and need for treatment are commonly neglected.
and subconjunctiva may be seen in patients with a
history of chronic self-neglect and poor dietary iron
or folate intake due to illnesses such as depression, Palpation
schizophrenia and anorexia nervosa. Very occasion-
ally, anaemia in a patient with dementia results from A handshake is not only a mark of courtesy, but also
vitamin B12 deficiency, which may be associated a potential source of information. A warm, sweaty
with other signs of autoimmune disorder such as palm may give some clues about endocrine disorders
vitiligo, alopecia and thyroid disease. such as thyroid disease or acromegaly. A fine tremor
Complexion, a feature rarely mentioned in helps to add weight to a clinical diagnosis of
mental health texts, is often altered in depression, thyrotoxicosis, whereas cold tremulous hands are
when it may appear sallow and grey. Plethora, seen in anxiety disorders. Tremor may be caused by
while explicable in a landworker exposed to the medication such as lithium and neuroleptics. A
elements, should alert the clinician to the possi- symmetrical coarse tremor associated with the latter,
bility of alcohol misuse, and thus prompt a search together with bradykinesia and rigidity, suggest
for associated physical signs and mental health iatrogenic parkinsonism. Asymmetric signs, in the
symptoms. Rashes due to medication are common, absence of medication, point to primary Parkinson’s
either as predictable responses such as photo- disease, which is commonly associated with
sensitivity to chlorpromazine or idiosyncratic depressive disorder, but may also be associated with
responses to drugs such as fluoxetine. A true Lewy body dementia, especially if there are signs of
butterfly rash is rare. Its presence in association autonomic instability.
with an unusual mental health picture should Lymphadenopathy is not common in patients
prompt the clinician to look for other physical signs with mental health problems. However, it can be a
of systemic lupus erythematosus, a condition which feature of tuberculosis, to which people with mental
is confirmed readily by investigation and is health problems may be susceptible on account of
responsive to steroids, rather than psychotropics self-neglect and living in institutional settings. Both
alone. Jaundice may be due to liver disease second- tuberculosis and lymphoma are complications of
ary to alcohol misuse, but can arise from use of a HIV infection, which is known to be associated with
variety of psychotropic agents, some of which cognitive impairment, especially in the later stages
cause hepatitis, whereas others, such as chlor- of the illness. An enlarged supraclavicular lymph
promazine, cause cholestasis (British Medical node in a patient who smokes should raise suspicion
Association & Royal Pharmaceutical Society of of a bronchogenic carcinoma, and should indicate
Great Britain, 2004). A lemon tinge to the skin may close examination of the chest and chest X-ray.
be seen in a patient with dementia secondary to Axillary lymphadenopathy may be a sign of
vitamin B12 deficiency, and a bronze complexion is metastatic breast disease. Examination of the breasts
classically associated with haemochromatosis. is an important part of the physical examination.

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 Physical examination in psychiatric practice

Examination of individual commonly considered, especially in patients with

panic disorder who have resorted to alcohol to
systems reduce anxiety. Urinary glucose may suggest a
Cardiovascular examination phaeochromocytoma, although 24-hour urinary
adrenaline and noradrenaline are the definitive tests.
Observation of the jugular venous pressure (JVP) is Hypotension is seen in anorexia nervosa and
a conventional part of the cardiovascular exam- Addison’s disease. Postural hypotension is seen in
ination, and should be carried out with the patient autonomic dysfunction associated with diabetes
lying at an angle of 45°. In normal circumstances the mellitus and Lewy body dementia, as well as being
venous pulse should be seen just above the clavicle, an unwanted side-effect of chlorpromazine and
and will become more prominent with the patient tricyclic antidepressant treatment.
lying flatter or with pressure placed over the right A swinging blood pressure, particularly in
upper quadrant of the abdomen. Patients with association with tachycardia and pyrexia, should
congestive cardiac failure, other causes of right heart raise the possibility of either acute intermittent
failure or vena caval obstruction will have a raised porphyria or neuroleptic malignant syndrome.
jugular venous pressure. Fortunately, both are extremely uncommon. In the
Presence of oedema should be noted: it is an former, there is association with abdominal pain
important sign in congestive cardiac failure, but also and darkening of urine left to stand. The latter
may be due to hypoalbuminaemia resulting from usually occurs with neuroleptic treatment, particu-
liver disease. Rarely, it is seen in anorexia nervosa. larly with rapid escalation of dose, and is also
The importance of the baseline pulse, its rate and associated with muscle rigidity and raised creatine
rhythm, and of blood pressure cannot be overstated. kinase levels.
These simple measures often give valuable infor- The apical beat is best felt with the patient leaning
mation about the patient’s physical well-being and forward. A thrusting beat should alert the clinician
provide comparators, should the patient’s health to the possibility of established hypertensive left
suddenly deteriorate. The nature of the pulse is ventricular hypertrophy or, more rarely, cardio-
particularly important in a number of conditions myopathy. Heart sounds and added sounds or
(Table 2). Blood pressure is also an essential baseline murmurs should be noted. In particular, a mid-
measurement. However, high readings seen on diastolic murmur due to mitral stenosis, with or
admission may be due to heightened arousal, and without atrial fibrillation, is an important finding if
it is appropriate to monitor the blood pressure over a vascular dementia is suspected, since further
a number of days before instituting medication or a vascular events may be reduced by anticoagulation
referral for advice. Hypertension is usually essential, and control of the rhythm disturbance. Murmurs
but it is also associated with alcohol misuse, thyroid may also be heard in bacterial endocarditis, which
disorder, clozapine therapy or high doses of should be suspected in pyrexial patients with
venlafaxine, and renal failure. The latter should be splinter haemorrhages, clubbing and a history of
considered if a patient on long-term lithium therapy intravenous drug misuse.
develops hypertension, and proteinuria is a Last, and of particular importance when a
particularly ominous sign, but easy to detect with vascular aetiology is suspected, peripheral pulses
dipsticks. should be systematically palpated and the perfusion
Phaeochromocytoma, a much loved subject of of the extremities should be observed. This cannot
multiple choice questions, is extremely rare, but be done through socks. As I have already said,
patients with mental illnesses neglect themselves.
Table 2 Importance of pulse An aversion to smelly socks is not an excuse for
failing to examine the feet, which may be unkempt
Sign Potential association and simply in need of a chiropodist, or may have
Sinus tachycardia Infection, hyperthyroidism, evidence of ischaemia. The presence of bruits,
autonomic instability and especially in the carotid and femoral arteries, should
arousal, neuroleptic be sought if there is suspicion of a vascular disease.
malignant syndrome
Bradycardia Clozapine therapy, anorexia
nervosa, hypothyroidism, Respiratory examination
tricyclic antidepressants
Atrial fibrillation Hyperthyroidism, vascular A history of smoking, cough, recurrent respiratory
dementia tract infections, purulent sputum or haemoptysis
Arrhythmias Tricyclic antidepressants,
should prompt the clinician to do a thorough
some antipsychotics, lithium
examination of the chest. Tracheal deviation,

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symmetry of chest expansion and percussion, breath conscious state change. The Glasgow Coma Scale
sounds and added sounds should all be recorded. (Teasdale & Jennett, 1974) is easy to use and widely
Abnormalities should be followed up by chest accepted throughout the UK (Table 3). Memory and
X- ray. intellectual function will influence the reliability
of a history and ability to cooperate with further
examination.
Gastrointestinal system Speech is another important baseline assessment,
Examination of the abdomen should always be as symptoms cannot be communicated readily
carried out with the patient lying flat, unless they without it. Dysphasia, be it receptive or expressive,
suffer from cardiac failure. Abdominal examination is a key localising sign. However, it is important to
is important when alcohol misuse is suspected. establish whether the patient is right- or left-handed,
Distended veins around the umbilicus (caput as this helps to determine cerebral dominance and
medusae) are an uncommon finding, but suggest the location of speech areas. Conventional neuro-
portal hypertension due to cirrhosis. The abdomen leptics can cause dysarthria, as can anticonvulsants
itself may be distended owing to ascites, which can in high doses. Cerebrovascular disease, multiple
be confirmed by dullness on percussion in the flanks sclerosis, cerebellar disease and tardive dyskinesia
which shifts if the patient moves onto one side. The may also be associated with dysarthria.
liver, which should normally extend to a finger- Full neurological examination, which takes about
breadth below the costal margin, may be enlarged 40 min, should be conducted in a systematic manner,
and tender in the early stages of cirrhosis, or hard starting with examination of the cranial nerves, then
and shrunken once the disorder is established. Other sensation, then the motor system and coordination.
signs of portal hypertension are splenomegaly and Reflexes are usually tested at the end. Although full
haemorrhoids. neurological examination might be desirable, it is
often not done, even in specialist settings. In practice,
particularly in the out-patient clinic, a brief assess-
Neurological examination ment is all that is possible. The next section presents
an assessment that can be performed in about 3 min,
The principle objective of a neurological examination
as long as the method is understood. Once this
is localisation. A working knowledge of neuro-
assessment has been done, there can be reasonable
anatomy greatly helps the clinician in conducting
certainty that there is no major brain pathology.
the examination. Neurological and mental state
examination overlap, in that conscious level,
The 3-minute neurological examination
orientation, memory, higher intellectual function
and speech are common to both. The conscious level The examination begins with Romberg’s test
on admission should be recorded in all cases, as this (steps 1 and 2 in Box 1). It is usual for normal people
gives an important baseline should the patient’s to waver slightly when their eyes are closed.
Some patients may wobble a great deal with this
Table 3 The Glasgow Coma Scale (Teasdale & test. A number of these people have non-organic
Jennett, 1974) disease and usually perform the tandem test (heel–
toe) without difficulty.
Item Patient’s response Score
Walking on the heels and then the toes (steps 3
Eye opening Spontaneous 4 and 4) is a useful test of plantar and dorsiflexion.
To speech 3 With the drift test (steps 5 and 6), normal people
To pain 2 are able to hold their pronated arms outstretched
None 1
and in the same position. Patients with a left-
Best verbal response Oriented 5 hemisphere lesion may show flexion of the right arm.
Confused 4 If there is neglect, there may be downward drift.
Inappropriate words 3 In testing light touch and coordination (step 7),
Incomprehensible the patient’s index finger on one hand and the
sounds 2 middle finger on the other should be touched, and
None 1
then the patient should be asked to touch their nose
Best motor response Obeying commands 6 with the tip of each of these fingers.
Localising pain 5 Fine finger movement is a useful test of extra-
Withdrawing to pain 4 pyramidal function.
Flexing to pain 3 Rapid tapping movements (step 8) are a good
Extending to pain 2 screen for ataxia. If the patient has difficulties in
None 1
doing this, you can then test the more difficult way

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 Physical examination in psychiatric practice

Rapid tongue movements (steps 12 and 13) test

Box 1 Quick neurological examination for presence of pseudobulbar palsy.
The patient should be asked to do the following: The first part of step 14 (wiggling a finger in the
outer quadrants to the left and then to the right of
1 Stand with feet together the head) achieves adequate visual-field screening.
2 Close eyes The second part of step 14 (wiggling a finger on
3 Open eyes and walk heel to toe in a straight both sides of the head at the same time) tests for
line forwards and backwards inattention. If any abnormality is observed, the
4 Walk on tiptoes and then on heels visual fields must be assessed more thoroughly
5 Hold their arms outstretched with palms using a red pin by the standard confrontation
facing upwards method described by Macleod (1983).
6 Hold this position for a few seconds Step 15 tests for occulomotor palsies (cranial
7 With eyes closed, touch the nose with the nerves III, IV and VI) and nystagmus.
tip of the index finger that the examiner has Reflexes should be tested while the patient’s limbs
just lightly touched. Then touch the nose are in a relaxed position (step 16). Lateralising signs
with the tip of the middle finger that the indicating an upper (increased reflexes) or lower
examiner has just lightly touched (diminished reflexes) motor neurone problem
8 Pretend to play the piano with the arms still should be looked for.
outstretched Step 17 looks for papilloedema, optic atrophy
9 Pat the back of each hand with the opposite and system vascular disease (e.g. diabetes or
palm hypertension).
10 While facing the examiner, screw eyes tight If the 3-minute neurological examination is
11 Give a grin performed, it is important to follow up any
12 Protrude the tongue abnormality with a more detailed neurological
13 Wiggle the tongue examination pertaining to it. Macleod (1983) and
14 Stare at the examiner’s face and, as the specialist neurological texts (Bickerstaff & Spillane,
examiner wiggles one finger in each outer 1989; Kaufman, 1995; Malhi et al, 2000) give excellent
quadrant on the left, then on the right and descriptions of appropriate methodology.
then wiggles one finger on the left and right
at the same time, the patient should point to
The extrapyramidal system
the moving fingers
15 Follow the examiner’s finger, with head still: Specific attention should be paid to the extra-
the finger should move across the mid-line pyramidal system. Abnormality on inspection
to shoulder width on either side and then (abnormal movements and poverty of movement),
move up and down; this procedure should testing of tone (lead pipe or cogwheel rigidity) and
be repeated on the opposite side assessment of gait (festinant) should all be noted.
16 Sit on the examining couch while the Abnormal involuntary movements and general
examiner tests the patient’s reflexes neurological impairment have been reported in
17 Allow the examiner to examine the fundi neuroleptic-naïve patients (Manschreck et al, 1990;
with an ophthalmoscope Ismail et al, 2001). The presence of extrapyramidal
signs seems to predict acute extrapyramidal side-
effects of typical neuroleptic drugs, such as rigidity,
by asking them to tap rapidly and alternately the tremor, akathisia and dystonia (Chatterjee et al, 1995).
back and palm of each hand with the back and palm Hyperkinetic signs in neuroleptic-naïve patients,
of the opposite hand (step 9). Most people perform in addition to abnormalities of manual dexterity and
this test better with their dominant hand. coordination, may prove useful in assessing
Asking the patient to close their eyes, bury their vulnerability to tardive dyskinesia (Sanders et al,
eyelashes and then to give a grin (steps 10 and 11) 2003).
can be used to assess muscles innervated by the
facial nerve. The patient’s face should be watched The sensory system
closely for signs of asymmetry. On opening the eyes,
it should be noted whether the pupils constrict. The Examination of the sensory system needs a lot of
presence of Horner’s syndrome can be checked by cooperation from the patient and is less objective, as
looking for signs of ptosis, a slightly quizzical it depends on patient report rather than the
raising of the eyebrow and a constricted pupil. The clinician’s observations. Sensation is conventionally
latter is better seen in a darkened rather than bright tested in two anatomical groups. Neurons conduc-
room. ting sensations of vibration and proprioception are

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situated in the dorsal columns. These tracts are neuron lesions. Absent reflexes are seen with lower
affected in vitamin B12 deficiency and syphilis. motor neuron lesions or peripheral neuropathy,
Vibration is also affected in diabetic neuropathy. such as that associated with diabetes mellitus and
Sensation of pain, pinprick and light touch is alcohol misuse. Plantar reflexes should also be
conducted in the spinothalamic tracts. It is helpful tested; an upgoing plantar (Babinski’s sign)
to know where each dermatome is located, as this indicates upper motor neuron pathology, which
can help with localisation. It is also a useful way of may be located in the spinal cord or brain.
discriminating between functional and organic
lesions, since the former may not follow a recognised
dermatomal pattern. The uncooperative patient
The motor system Lack of facilities, time and poor cooperation are
common reasons for failure to examine patients in
In examining the motor system, attention should be psychiatric units. However, external inspection can
paid to the pattern of any weakness, as opposed to be carried out in environments with minimal facili-
its extent or severity, because this is more likely to ties, with little or no cooperation from the patient,
indicate the origin of the weakness. There are three and it provides opportunity to learn about the
essential patterns: physical state and what systems may be of particu-
1 weakness on one side of the body (hemiplegia) lar importance when more comprehensive physical
is indicative of contralateral brain damage; examination and investigation is permitted. Both in
2 weakness of both legs (paraparesis) suggests physical medicine specialties and in psychiatry,
spinal cord damage or, rarely, a parasagittal examination should start as soon as the patient is
meningioma; met. The cleanliness and state of clothing may give
3 weakness limited to the distal portions of the clues about the level of self-care. Dentition can
limbs is a feature of damage to the peripheral usually be seen without physical examination, and
nervous system rather than to the central obvious neglect in this area should prompt the
nervous system. clinician to examine visual acuity, hearing and foot
care, when the patient permits. Observation should
Hoover’s sign is particularly useful in patients also give some clue as to the nutritional status of the
with medically unexplained hemiparesis. While patient, although baggy or eccentric clothing may
lying supine on a couch, the patient is first asked to mask emaciation. A bulge in the neck and exoph-
raise the affected leg as the examiner holds a hand thalmos might indicate thyroid disease. Facial
under the heel of the opposite leg. The examiner expression, although an integral part of the mental
should be able to raise the heel of the affected leg state examination, may also point to underlying
because the patient is exerting so little downward physical problems such as endocrine disorders,
force with this leg. The patient is then asked to raise Parkinson’s disease and other neurological illness.
the unaffected leg while the examiner holds a hand Tardive dyskinesia or other extrapyramidal signs are
under the heel of the ‘paralysed’ leg. Intact strength often evident at initial assessment. Observations of
in the affected leg is revealed as it is unconsciously gait may also indicate neurological or psychomotor
forced down. disturbance and, in particular, the effect on function.
If the patient is standing upright, is shouting or
Reflexes able to talk without becoming breathless, the airway
The tendon reflexes should be graded (Table 4). is probably intact, he or she is not likely to be
Sluggish reflexes, particularly with a delayed severely hypotensive and is likely to have reasonable
relaxation phase, should prompt tests for hypo- respiratory function.
thyroidism. Hyperreflexia is seen with upper motor
How to maintain skills
Table 4 Grading of tendon reflexes
However detailed a text on physical examination
Tendon reflex Grade may be, it is no substitute for observation of clinical
Very brisk +++ examination being performed by an expert, either in
Brisk ++ person or on video. It is my view that every training
Normal + scheme should invest in audio-visual aids on
Absent 0 physical examination for trainees, or should invite
Present with reinforcement +/– a local physician to conduct a session during which
Clonus cl
trainees can both observe and be observed.

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 Physical examination in psychiatric practice

What about more senior clinicians? At present Sanders, R. D., Keshavan, M. S. & Goldstein, G. (2003)
Clinical utility of the neurological examination in
there is no consensus on how to maintain compe- psychosis. Psychiatric Annals, 33, 195–200.
tence in physical examination, and there are no Sternberg, D. E. (1986) Testing for physical illness in
guidelines either. Competence in basic resuscitation, psychiatric patients. Journal of Clinical Psychiatry, 47, 3–9.
Summers, W. K., Munoz, R. A. & Read, M. R. (1981) The
a core medical skill, falls far short of requirement to Psychiatric Physical Examination – Part I: Methodology.
conduct competently a physical examination. Journal of Clinical Psychiatry, 42, 95–97.
Attendance at medical case presentations is a useful Teasdale, G. & Jennett, B. (1974) Assessment of coma and
impaired consciousness: a practical scale. Lancet, 2, 81–84.
way of refreshing knowledge. However, it does not Victoroff, V. M., Mantel Jnr, S. J., Bailetti, A., et al (1979)
maintain examination skills, and the only way to Physical examinations in psychiatric practice in Ohio.
do so is to perform physical examinations regularly. Hospital and Community Psychiatry, 30, 536–540.

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