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General Principles of

Physical Examination

General Principles of Physical Examination Made Ratna Saraswati Internal Medicine Department, Faculty of Medicine Udayana University/
General Principles of Physical Examination Made Ratna Saraswati Internal Medicine Department, Faculty of Medicine Udayana University/

Made Ratna Saraswati

Internal Medicine Department, Faculty of Medicine Udayana University/

Sanglah Hospital

Refference:

Refference:  Bates’ Guide to Physical Examination and History Taking 8th edition. Lynn S Bickley, Peter
  • Bates’ Guide to Physical Examination and History

Taking 8th edition. Lynn S Bickley, Peter G. Szilagyi. Lippincott William & Wilkins, Philadelphia

  • Textbook of Physical Diagnosis, history and

examination, 2nd edition. Mark H Swartz, WB Saunders, Philadelphia

On most new patients or patients being admitted to the hospital, you will conduct a comprehensive

On most new patients or patients being

admitted to the hospital, you will conduct a comprehensive physical examination.

The key to a thorough and accurate physical examination is developing a systemic sequence of examination.

The key to a thorough and accurate physical

examination is developing

a systemic sequence of examination.

As you develop your own sequence of examination, an important goal is to minimize the number of times you ask the patient to change position from supine to sitting, or standing to lying supine.

Beginning the examination:

Setting the stage

Beginning the examination: Setting the stage Preparing for the physical examination: 1. Reflect on your approach

Preparing for the physical examination:

1. Reflect on your approach to the patient

  • 2. Decide on the scope of the examination

  • 3. Choose the examination sequence

  • 4. Adjust the lighting and the environment

  • 5. Make the patient comfortable

Make sure that you wash your hands in the presence of the patient before beginning the examination, this is a

subtle yet much appreciated gesture of concern for the

patient’s welfare.

1. Approaching the patient

1. Approaching the patient  When the first examining patients, feelings of insecurity are inevitable. 
  • When the first examining patients, feelings of insecurity are inevitable.

  • Be straightforward. Let the patient know you are a student and try to appear calm, organized, and competent.

  • If you forget to do part of the examination, simply examine those area out of sequence, but smoothly.

  • Avoid interpreting your findings, your views may be conflicting or in error.

  • Always avoid showing distaste, alarm, or other negative reactions.

2. Decide on the scope of the examination:

How complete should it be?

2. Decide on the scope of the examination: How complete should it be?  No simple
  • No simple answer

  • As a general principle: a new patient warrants a complete examinations, regardless of chief complain or setting. You may choose to abbreviate the examination for patients making routine office visits or seeking urgent care. A more limited examination may also appropriate for patients with symptoms restricted to a specific body system or with patients you know well.

3. Choose the examination sequence

3. Choose the examination sequence  The sequence should maximize the patient’s comfort, avoid unnecessary changes
  • The sequence should maximize the patient’s

comfort, avoid unnecessary changes in position,

and enhance the clinician’s efficiency. In general,

move from head to toe.

  • An important goal for you as a student is to develop your own sequence of examination with this principles in mind

4. Adjusting the lighting and the environment

4. Adjusting the lighting and the environment  As the examiner, you will find that awkward
  • As the examiner, you will find that awkward positions impair the quality of your observations. Take the time to adjust the bed to a convenient height (but be sure to lower it when finished) and ask patient to move toward you if this makes it easier to examine a region of the body more carefully.

  • Good lighting and a quiet environment make important contribution to what you see and hear.

5. Make the patient comfortable

5. Make the patient comfortable  Your access to the patient’s body is a unique and
  • Your access to the patient’s body is a unique and time-honored privilege of your role as a clinician.

  • Be sure to close nearby doors and draw the curtains in the hospital or examining room before the examination begins.

  • Your goal is to visualize one area of the body at a time. This preserves the patient’s modesty but also

help you to focus on the area being examined.

  • Keep the patient informed, especially when you

anticipate embarrassment or discomfort.

Equipment for Physical Examination

Equipment for Physical Examination Available in most patient care areas Required Optional Sphygmomanometer Stethoscope Nasal Iluminator

Available in most patient care areas

Required

Optional

Sphygmomanometer

Stethoscope

Nasal Iluminator

Tongue blade

Oto/ophthalmoscope

Nasal speculum

Gloves Lubricant gel

Penlight Reflex hammer

Tuning fork 512 Hz

Vaginal speculum

Tuning fork 128 Hz

Pin

Tape measure

The four cardinal principles of physical examination:

The four cardinal principles of physical examination: 1. Inspection 2. Palpation 3. Percussion 4. Auscultation

1.

Inspection

2.

Palpation

3.

Percussion

4.

Auscultation

The four cardinal principles of physical examination: 1. Inspection 2. Palpation 3. Percussion 4. Auscultation

1. Inspection

1. Inspection Inspection can provide an enormous amount of information. Examiners must train themselves to look

Inspection can provide an enormous amount of information. Examiners must train themselves

to look at the body using a systematic

approach.

OBSERVATION

OBSERVATION WEALTH OF INFORMATION!!!!

WEALTH OF INFORMATION!!!!

VISUAL INSPECTION

VISUAL INSPECTION  INSPECT CAREFULLY ALL AREAS OF EXAM  DOCUMENT BOTH NORMAL AND ABNORMAL FINDINGS
  • INSPECT CAREFULLY ALL AREAS OF EXAM

  • DOCUMENT BOTH NORMAL AND ABNORMAL FINDINGS

2. Palpation

2. Palpation Palpation is the use of tactile sense to determine the characteristics of an organ

Palpation is the use of tactile sense to determine the characteristics of an organ system.

PALPATION

PALPATION  TEXTURE  SIZE  CONSISTENCY  CREPITUS  MASSES  EXAMPLE – TAKING A
  • TEXTURE

  • SIZE

  • CONSISTENCY

  • CREPITUS

  • MASSES

  • EXAMPLE TAKING A PULSE, HEAD AND NECK EXAM

3. Percussion

3. Percussion Percussion relates to the tactile sensation and sound produced when a sharp blow is

Percussion relates to the tactile sensation and sound produced when a sharp blow is struck to an area being examined.

Provide valuable information about the structure

of the underlying organ or tissue.

PERCUSSION

PERCUSSION
PERCUSSION

4. Auscultation

4. Auscultation Auscultation involves listening to sounds produced by internal organs. This instrument should corroborate the

Auscultation involves listening to sounds

produced by internal organs. This instrument should corroborate the signs that were suggested the other techniques.

Auscultation should be not used alone to

examine the heart, chest, and abdomen.

This technique should be used together with inspection, percussion, and palpation.

AUSCULATION

AUSCULATION
AUSCULATION

The Comprehensive

Physical examination

The Comprehensive Physical examination  General survey  Vital sign  Skin  Head, eyes, ears,
  • General survey

  • Vital sign

  • Skin

  • Head, eyes, ears, nose, throat (HEENT)

  • Neck

  • Back

  • Superior thorax and lungs

  • Breast, axillae, and epitrochlear nodes

  • Anterior thorax and lungs

  • Cardiovascular system

  • Abdomen

  • Lower Extremities

  • Nervous system

  • Additional examination

    • rectal examination in men

    • genital and rectal examination in women

1. General survey

1. General survey  Observe the patient’s general state of health, height, build and sexual development.
  • Observe the patient’s general state of health, height, build and sexual development.

  • Obtain the patient weight.

  • Note posture, motor activity, and gait; dress, grooming, and personal hygiene; and any odors of the body or breath.

  • Watch the patient’s facial expressions and note the manner, affect and reactions to person an things in the environment.

  • Listen to the patient’s manner of speaking and note the state of awareness of level of consciousness.

GENERAL SURVEY

GENERAL SURVEY  Exam begins the minute you first see the patient  Exam continues throughout
  • Exam begins the

minute you first see the patient

  • Exam continues

throughout your

patient interaction

GENERAL SURVEY  Exam begins the minute you first see the patient  Exam continues throughout

HEALTH STATUS

HEALTH STATUS
HEALTH STATUS

BREATH/ODOR

BREATH/ODOR
BREATH/ODOR

2. Vital sign

2. Vital sign The patient is sitting on the edge of the bed or examining table,

The patient is sitting on the edge of the bed or

examining table, unless this position is contraindicated. You should be standing in

front of the patient, moving to either side if

needed.

  • Measure height, weight.

  • Measure blood pressure.

  • Count the pulse and respiratory rate.

  • If indicated, measure the body temperature.

3. Skin

3. Skin  Observe the skin of the face and its characteristics.  Identify any lesions,
  • Observe the skin of the face and its characteristics.

  • Identify any lesions, noting their location, distribution, arrangement, type, and color.

  • Inspect and palpate the hair and nails. Study the patient’s hands.

  • Continue your assessment of the skin as you examine the other body regions.

4. Head, eyes, ears, nose, throat

4. Head, eyes, ears, nose, throat  Head: examine the hair, scalp, skull and face. 
  • Head: examine the hair, scalp, skull and face.

  • Eyes: check visual acuity and screen the visual fields. Note the position and alignment of the eyes. Observe the eyelids and inspect the sclera and conjunctiva of each eye. With oblique lighting, inspect each cornea, iris, and lens. Compare the pupils and test their

reactions to light. Assess the extraocular movement. With ophthalmoscope inspect the ocular fundi.

 Ears: inspect the auricles, canals, and drums. Check auditory acuity. If acuity is diminished, check
  • Ears: inspect the auricles, canals, and drums. Check auditory acuity. If acuity is diminished, check lateralization (Weber test), and compare air and bone conduction (Rinne test).

  • Nose and sinuses: Examine the external nose; using a light and a nasal speculum, inspect the nose mucosa,

septum and turbinates. Palpate for tenderness of the frontal and maxillary sinuses.

  • Throat (or mouth and pharynx): inspect the lips, oral mucosa, gums, teeth, tongue, palate, tonsils, and

pharynx.

  • You may wish to assess the cranial nerves during this portion of examination.

5. Neck

5. Neck  Inspect and palpate the cervical lymph nodes. Note any masses or unusual pulsation
  • Inspect and palpate the cervical lymph nodes. Note any masses or unusual pulsation in the neck. Feel for any deviation of the trachea. Observe sound and effort of the patient’s breathing. Inspect and palpate the thyroid gland. (move behind the sitting patient to feel the thyroid gland and to examine the back, posterior thorax , and the lung)

6. Back

6. Back  Inspect and palpate the spine and muscles of the back
  • Inspect and palpate the spine and muscles of the back

7. Superior thorax and lungs

7. Superior thorax and lungs  Inspect and palpate the spine and muscles of the upper
  • Inspect and palpate the spine and muscles of the upper back.

  • Inspect, palpate and percuss the chest. Identify the level of diaphragmatic dullness on each side. Listen to the breath sound; identify any adventitious (or added) sounds, and if indicated, listen to the transmitted voice sounds.

8. Breast, axillae, and epitrochlear nodes

8. Breast, axillae, and epitrochlear nodes The patient is still sitting, move to the front again

The patient is still sitting, move to the front again

  • In woman, inspect the breast with her arms relaxed, then elevated, and then with her hands pressed on her hip.

  • In either sex, inspect the axillae and feel for the axillary nodes. Feel the epitrochlear nodes

  • A note on the musculoskeletal system: by this time you have made some preliminary observations of the musculoskeletal system. Use these to decide whether a full musculoskeletal examination is warranted.

9. Anterior thorax and lungs

9. Anterior thorax and lungs The patient position is supine, ask the patient to lie down,

The patient position is supine, ask the patient to lie

down, You should stand at the right side of the

patient’s bed.

  • Inspect, palpate, and percuss the chest.

  • Listen to the breath sound, any adventitious sounds, and, if indicated transmitted voice sounds.

10. Cardiovascular system

10. Cardiovascular system Elevated the head of the bed to about 30 . Ask the patient

Elevated the head of the bed to about 30 o . Ask the patient to roll partly onto the left side while you listen at the apex, then have the patient roll back to the supine position while you listen to

the rest of the heart. The patient should sit, lean

forward, and exhale while you listen for the murmur of aortic regurgitation.

  • Observe the jugular venous pulsations, and measure the jugular venous pressure in relation to the sternal angle.

 Inspect and palpated the carotid pulsation.  Listen for carotid bruits.  Inspect and palpate
  • Inspect and palpated the carotid pulsation.

  • Listen for carotid bruits.

  • Inspect and palpate the precordium. Note the location, diameter, amplitude, and duration of the apical impulse. Listen at the apex and the lower sternal border with the bell of the sthetoscope. Listen at the auscultatory area with the diaphragm. Listen to the first and second sound. Listen for any abnormal heart sounds or murmurs.

11. Abdomen

11. Abdomen Lower the head of the bed to the flat position, the patient should be

Lower the head of the bed to the flat position, the

patient should be supine

  • Inspect, auscultate, and percuss the abdomen. Palpate lightly, the deeply.

  • Assess the liver and spleen by percussion and then

palpation.

  • Try to feel the kidneys, and palpate the aorta and its pulsations. If you suspect kidney infection, percuss posteriorly over the costovertebral angles.

12. Lower Extremities

12. Lower Extremities  Examine the legs, assessing three systems while the patient is still supine.
  • Examine the legs, assessing three systems while the patient is still supine. Each of these three systems can be further assessed when the patient stands.

13. Nervous system

13. Nervous system  The complete examination of the nervous system can also be done at
  • The complete examination of the nervous system

can also be done at the end of the examination. It

consists of five segments:

  • mental status

  • cranial nerves (including funduscopic examination)

  • motor system

  • sensory system

  • reflexes.

14. Additional examination

14. Additional examination  Rectal examination in men The patient is lying on the left side

Rectal examination in men

The patient is lying on the left side or left lateral decubitus

Inspect the sacrococcygeal and perianal areas. Palpate the anal canal, rectum, and prostate. If the patient cannot stand, examine the genitalia before doing the rectal examination.

Genital and rectal examination in women

Lithotomy position: lying supine with hips flexed, abducted, and externally rotated and knees flexed

Examine the external genitalia, vagina, and cervix. Obtain a

Pap smear. Palpate the uterus and adnexa, Do a

rectovaginal and rectal examination.

Recording your finding

Recording your finding  The history and physical examination form the database for your subsequent assessment
  • The history and physical examination form the

database for your subsequent assessment of the patient and your plan with the patient for management and next steps.

  • Your written record organizes the information from the history and physical examination and should

clearly communicate the patient’s clinical issues to all

members of the health care team.

  • You should write the record as soon as possible before the data fade from your memory.

Vital Sign Measurement
Vital Sign Measurement

Vital Sign Measurement