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Introduction to Physical Examination
Dr. Gwen Hollaar
Dr. Lanice Jones
Dr. Robert Lee
September 2006 Lao Project
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Outline
General Observations
Vital Signs
General Approach to physical examination
General surface anatomy
Examination of Head and Neck
Examination of Lymph nodes
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Physical Examination begins with observing the patient
Many observations can be made while the patient walks into the examination room or as you approach the patient
Level of Consciousness Alert or decreased level of consciousness
Apparent State of Health: Acutely ill or chronically ill (i.e. emaciated)
Signs of Distress Sweating / Diaphoresis Dyspnea / Wheeze / Cough Pain
Posture, gait, or motor activityAnxiety or Depression Skin
PaleJaundice
Dress or hygiene
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Preparation / Draping
Prior to beginning formal physical examination:Explain to patient what you will be doingMake sure patient feels comfortable and provide privacyAsk patient to remove clothing so that you can do proper physical examination
Give patient sheet/gown to cover herselfUncover only the area that you are presently examining to keep patient comfortable
In general, examine from head to toeDuring examination make as few position changes as possible
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Vital Signs
Height and WeightTemperature
Usually oral or rectal thermometer
Respiratory Rate Have student count for 30 secondsHave student also observe character of respirations
Pulse Can be done on any pulse, but radial pulse is usually usedNeed to teach how to assess rate AND quality of pulse
Blood pressureNeed to teach students the steps involved in taking BP
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Radial Pulse
Notice:
1. Pulse Rate
2. Pulse Regularity
3. Pulse Volume
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Blood Pressure Measurement3 Cuff Sizes:
1. Pediatric
2. Adult Regular to 32 – 35 cm arm circumference
3. Adult Large
TOO SMALL A CUFF ARTIFICIALLY ELEVATES BP!
Brachial artery on ulnar side of biceps tendon
Place BP cuff marker over brachial artery
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BP Measurement Technique
Expose the arm.Put cuff on upper arm with mark over brachial artery.Place stethoscope in your ears.Raise the patient’s arm so that the brachial artery is approximately at the same height as the heart.
The arm should remain relaxed. Place diaphragm of stethoscope over brachial artery.Pump the bulb until you have generated 150 mmHg on the manometer. Listen.If you immediately hear sound, you have underestimated the systolic blood pressure and will need to pump up an additional 20 mmHg and repeat.
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BP Measurement TechniqueNow slowly deflate the blood pressure cuff. The first sound that you hear is systolic blood pressure.
You are hearing blood that has started to flow through the artery as you release pressure of the cuff.
The diastolic blood pressure is measured when the sound completely disappears.
This is the point when the pressure within the vessel is greater then that supplied by the cuff, allowing the free flow of blood without turbulence and thus no audible sound.
The sound between the systolic and diastolic pressure are known as the ‘sounds of Korotkov’
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BP measurement-
-Repeat the measurement on the patient's other arm.
-The two readings should be within 10-15 mm Hg of each other.
- Differences greater then this imply that there is a different blood flow to each arm, which most frequently occurs in the setting of subclavian artery stenosis.
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General approach to a physical examination
Patient sitting – Physician stands in front of patientVital signs
include observation of the handsHead Examination
Examine the eyes & mouthExamine ears, sinus, scalp as needed
Neck ExaminationCentral (thyroid), anterior triangle, posterior triangle
Patient sitting – Physician stands behind patient Examine posterior chest (Respiratory)
Patient sitting – Physician stands in front of patientExam anterior chest (Respiratory and Cardiac)
Patient Lying downFinish cardiac examinationDo abdominal Examination
Genitourinary exam and rectal exam as indicatedMSK as indicated (lying, sitting, and standing)
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Surface Anatomy
Why do we have students study surface anatomy?
Students need to make practical their knowledge of anatomy
Students need to understand body landmarks in order to describe their observations
You should teach surface anatomy for every body system
We will now cover some examples
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Surface Anatomy: Head
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Surface Anatomy: Neck
Spinous process of C-spine
Posterior cervical
Location of Cervical lymph nodes
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Surface Anatomy: Thyroid
Location of Thyroid
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Surface Anatomy: Anterior Chest
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Surface Anatomy: Anterior Chest
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Surface Anatomy: Cardiac
Right 2nd Interspace Left 2nd Interspace
Right 5th Interspace Left 5th Interspace
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Surface Anatomy: Posterior Chest
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Surface Anatomy: Abdomen
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Abdominal Lines
Linea alba
Arcuate lineAnterior superior iliac spine
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Surface Anatomy: Abdominal Organs
LiverSpleen
Appendix
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Surface Anatomy: Abdominal Organs
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Musculo-Skeletal Surface Anatomy: Knee (as one example)
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General Inspection
SkinColourCapillary refillPresence of skin lesions (i.e. nevi, skin cancers)
Nail Colour of nailbedShape of nail (clubbing)
Hair (head and body)Character (fine / course)Distribution
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Head and Neck Examination: Eye
EyelidsCheck for eyelid swellingCheck for eyelid retraction (sclera is very visible above the iris when the patient looks forward)Check for lid lag (delay in downward movement of the upper eyelid when the patient is instructed to look down)
Eyelid retraction and lid lag are associated with eye proptosis which can be seen in hyperthyroidism
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Head and Neck Examination: Eye
EyelashesInfection at edge of eyelid is often due to a staphylococcal infection of hair follicle
Look for ectropion (eversion) or entropion (inversion) of eyelids
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Head and Neck Examination: Eye
ConjuctivaGently evert the lower eyelid and have patient look up
Gently evert the upper eyelid and have patient look down
Look for:Redness
Purulent exudate
Edema
Subconjuctival hemorrhage
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Head and Neck Examination: Eye
CorneaLook for haziness of cornea and engorgement of blood vessels and eccentric pupil as these are features of glaucomaLook for corneal abrasion
Ophthalmoscopic examination of fundusLook at:
Optic discArteries and veinsFundus backgroundMacula and surroundings
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Head and Neck Examination: Ears
Look at external ear
Do auriscopic examinationPull the outside ear up and slightly lateral and look at:
External meatus
Tympanum– The ear drum is normally grey in colour
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Head and Neck Examination: Nose and Sinuses
Test patency of each nostril by closing one nostril with your finger and asking patient to breathe through their other nostril with their mouth closed
Look up each nostril with nasal speculum to see appearance of mucosa and inferior nasal turbinates
Can tap over frontal and maxillary sinuses to test for tenderness
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Head and Neck Examination: Mouth
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Head and Neck Examination: Mouth
LipsLook at colour (i.e. cyanosis)Look for cracking of the lips or non-healing lesionsLook for painful cracks at the corners of the mouth
TeethLook at dental hygiene
GumsLook for areas where gums may be swollen or infected
TongueLook at tongue size and movementLook at tongue mucosa (top and bottom of tongue)
ColourAtrophy or smooth mucosa (i.e. associated with iron or vitamin B12 deficiency)Look for tongue lesions or non-healing ulcers (i.e. tongue cancer)
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Head and Neck Examination: Mouth
PalateLook at mucosa and make sure there is no mucosal lesion or deformity
Tonsils and pharynxHave patient protrude tongue, say ‘ah’, and place tongue depressor over tongueLook for swollen gland or red mucosa or exudate
Salivary glandsPalpate over parotid and submandibular salivary glands feeling for masses or tenderness (i.e. parotid gland may be enlarged from mumps, plugged salivary duct from stone, or tumor)Look at ductal openings in mouth
Parotid duct openings are located opposite the second upper molarsSubmandibular duct openings are located near the midline in the sublingual region
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Head and Neck Examination: Cervical Lymph Nodes
Inspect and palpate all the cervical lymph node areas:
Preauricular
Submental
Submandibular
Anterior cervical chain
Posterior cervical chain
Supraclavicular
Posterior cervical
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Head and Neck Examination: Thyroid
Inspect from the frontCan palpate from the front or the back (often easier from the back)
Place fingers over each lobe of the thyroid (below the thyroid cartilage and above the jugular notch)Stabilize one side while examining the opposite lobeFeel for firmness, tenderness, nodules, or enlargementAsk patient to swallow as you palpate each lobe
Auscultate over the thyroid glandMay hear a bruit in conditions of hyperthyroidism
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Examination of Lymph Nodes
Need to examine all major areas of lymph nodes
Cervical lymph nodes(Discussed already on neck examination)
Epitrochlear lymph nodesPalpate on medial aspect of elbow)
Axillary lymph nodesSlightly abduct arm, have patient keep arm relaxed, and slide your hand up into the axilla and palpate along the chest wall
Femoral lymph nodesPalpate over the area of the femoral artery and vein in the groins
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Questions?