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The basics of examination

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First things first …

The majority of a diagnosis is formulated from what is

ascertained from the history and should be taken prior to

examinations and investigations.

In preparing for any examination or procedure - think about

UNIVERSAL PRECAUTIONS. Which precautions are most

appropriate ?

(Don’t forget HAND WASHING before and after

patient contact!)

What equipment (if any) is required ?

On approaching the patient introduce yourself explain who

you are and why your there and gain INFORMED consent

for the examination

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General

Remember to use an appropriate environment-

Warm enough? Private? Light enough?

The distinction between history and examination is

arbitrary and artificial in relation to diagnosis

Examination starts as the doctor or patient enters a

room

A handshake can welcome the patient and can

point to a variety of clinical conditions

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Basics of Examination

The basic elements of examinations are -

Inspection

Palpation

Percussion

Auscultation

Not every component is used in every

examination and may be used to a greater or

lesser degree

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Inspection (to look)

General overall impression way a person walks (gait ,posture), talks, looks

(demeanour, expression, colour)

Specific inspection of the hands moving up to the face etc. swellings, defects, paralysis, rashes, tremor, scars

Specific abnormalities relating to system to be examined GIT (gastro intestinal tract ) - abdominal distension

CVS (cardio vascular system) / RS (respiratory system) – cyanosis

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Palpation (to feel)

Using hands with appropriate pressure to assess both

normal and abnormal tissues

A range of palpation techniques could be used e.g.

superficial, deep, balloting

Can be used to describe the physical characteristics of

both normal and abnormal tissues

Always observe your patient for signs of discomfort

during palpation.

Palpating appropriate lymph node groups is required.

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Percussion (tapping)

The technique of

tapping with a

fingertip over an

area of the body

to elicit a sound-

described as

“resonant” or

“dull”

Used to indicate

presence or

absence of:

Air = Resonant

Solid = Dull

Fluid = Stony dull

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Percussion technique 1

Place the middle finger of

the examining hand on

the area you want to

percuss

If this area is the chest

wall the middle finger

should be placed

between the intercostal

spaces

Striking

handExamining hand

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Percussion technique 2

Use the tip of the

middle finger of

your striking hand

to elicit the sound

by……………

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Percussion technique 3

Striking the middle phalanx firmly using a sharp tapping movement (preferably using sharp palmer flexion of the wrist joint)

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Percussion technique 4

Remove the

striking finger

sharply

Two or three taps

in any one site is

sufficient

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Poor percussion technique? THINK:

Finger nails must be short to ensure the

very tip of the striking finger is used

All the fingers of the examining hand must

be splayed apart to avoid dampening the

sound

The finger to be percussed (tapped) must

be in firm contact with the patient

(particularly the middle phalanx)

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Clinical practice

You may see other methods used in practice

This is the “text book” method and is the method you will be expected to demonstrate

Direct percussion of the chest wall is possible only over the clavicles. In all other sites you should percuss on to the fingers of the examining hand firmly applied to the surface to be percussed always comparing right to left when possible

Assess areas of altered resonance by percussing from areas of normal resonance around the abnormality to determine extent

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Auscultation

LISTENING

Use a CLEAN stethoscope

Bell

Diaphragm

Used to listen to

heart sounds

lung sounds

bowel sounds

Arterial bruits

other sounds

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Revision of stethoscope

Bell - best for low pitched

sounds

Diaphragm - best for high

pitched sounds

Ear pieces should be

angled forwards

Spring should retain the

ear pieces in the ear

comfortably

Ensure the hole is

aligned with the part

being used to listen

Ears

Active

Off

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Special

Use of various techniques and procedures

to extend the examination beyond

superficial tissues e.g.

Ophthalmoscopy retinal examination

Otoscopy ear examination

Proctoscopy anal canal

Torches assess pupil reflexes

transillumination of swellings