physical examination

PhysicalPhysical ExaminationExamination

Grzegorz Chodkowski (MD)Grzegorz Chodkowski (MD)

Riga, Radisson SAS

2009

• Stethoscope

• Pen-torch

• Measuring tape

• Ophthalmoscope

• Sphygmomanometer

• Tendon hammer

• Tuning fork

• Cotton wool

• Disposable Neurotips

• Wooden spatula

• Magnifying glass

• Disposable gloves, lubricant jelly and a proctoscope may also be required

• Facilities for obtaining blood samples, urinalysis and faecal occult blood testingshould be available

• Accurate weighing scales and a height-measuring device(preferably a Harpenden stadiometer)

Equipment required Equipment required

The sequence of examination is:

• Inspection

• Palpation

• Percussion

• Auscultation

SequenceSequence

• Handshake and introduction

• Note general appearances while talking:

- does the patient look well?

- any immediate and obvious clues, e.g. obesity, plethora, breathlessness

- complexion

• Hands and radial pulse

• Face

• Mouth

• Neck

• Thorax:

- breasts

- heart

- lungs

• Abdomen

• Lower limbs:

- oedema

- circulation

- locomotor function and neurology

• Upper limbs:

- movement and neurology

• Cranial nerves, including fundoscopy

• Blood pressure

• Height and weight

• Urinalysis

How to?How to?

Dupuytren's contracture

Rheumatoid arthritis

Deformed hands/fingers

Myotonic dystrophyDelayed relaxation of grip

Regular water exposure

Manual occupation

Hypothyroidism

Dry, coarse skin

AcromegalyLarge, fleshy, sweaty hands

HyperthyroidismHot, sweaty hands

Raynaud's phenomenonCold, dry hands

AnxietyCold, sweaty hands

DiagnosisFeatures

Information from a HandshakeInformation from a Handshake

• Level of consciousness, signs of distress, apparent state of health

• Facial expression

• Height, build, and weight

• Posture, gait, and motor activity

• Dress, grooming, and personal hygiene

GeneralGeneral AppearanceAppearance

• blood pressure,

• heart rate (radial and apical)

• respiratory rate

• and temperature

ObtainingObtaining VitalsVitals

Start

D: Ok. Mr. Sampson now I would like to do a physicalexamination on you. For that I need to untie your gown. Is that ok. with you?

P: Yes, it’s ok.

D: Thank you

If the patient resists , then you have to explain theimportance of this:

Mr. Sampson. I can understand your feelings but to be ableto identify the problem I have to do this examination. It won’t take more than a minute (long). Don’t worry. I amhere to assist you. I will tell you whatever I am going to do.

Respiratory Examination

Ideally the patient should be sitting on the end of the

axamination couch.

D: Now I would like to examine your chest, is that

Ok. with you?

D: I would like to palpate your chest. Let me know if it hurts.

D: Now I am going to tap on your lungs to look for any fluid or

excess air.

D: Now I would like to listen to your lungs. Can you take some

nice big breaths for me, please?

D: Can you please say „ninety-nine” repeatedly for me?

Cardiovascular System

Always examine the patient’s right side

D: Ok. Mr Sampson, now I would like to examine your heart. First, in a sitting position, then lying down and finally in a sitting position again.

D: I need to check your pulse

D: I need to check your heart. Could youplease lie down for me, please?I will pull out the leg extension to make it a littlemore comfortable for you

D: Now I would like to listen to your heart.

Abdominal Examination

The patient should be lying supine on the examination couchand be appropriately draped.

D: I am now looking at your belly for anygross abnormalities.

D: Now I would like to listen to your bowelsounds.

D: Now I would like to tap on your belly.

D: Now I would like to press on your belly firstlightly and then deeply (firmly). Please let me know if it hurts ( you get any pain / becomespainful)

Rebound tenderness

• This is a test for peritoneal irritation

• Tell the patient what you are about to do:„No I would like to press in and release. Please let me know if it hurts when I pressin or let go”

• Press deeply on the abdomen with your hand. Aftera moment quickly release the pressure.

• If it hurts more when you release, the patient has gotrebound tenderness

Neurologic Examination

Always consider left to right symmetry

Organize your thinking into 7 categories:

1. Mental Status

2. Cranial Nerves

3. Motor System

4. Coordination and Gait

5. Reflexes

6. Sensory System

7. Special Tests

Sample Questions

D: Hello Mr. Sampson. Can you hear me?

If you hear me. Can you smile for me?

D: Can you please frown for me?

D: Can you please raise your eyebrows for me?

D: I will try to open your eyes. Don’t let me open.

D: Now I need to examine your eyes.

Can you please count my fingers?

D: Can you please show me your teeth

D: I would like to check your muscle strength/power

Musculoskeletal

D: Can you please pull in (elbow) and pull

out

D: Can you pull your thighs together?

D: Can you please push down?

D: Can you please walk a few steps for me,

please?

ThankThank YouYou!!

AnyAny QuestionsQuestions??