General Principles of Physical Examination

Made Ratna SaraswatiInternal Medicine Department, Faculty of Medicine Udayana University/ Sanglah Hospital

Refference:Bates Guide to Physical Examination and History Taking 8th edition. Lynn S Bickley, Peter G. Szilagyi. Lippincott William & Wilkins, Philadelphia, 2003Textbook 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 physical 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.

1. The key to a thorough and accurate physical examination is developing a systemic sequence of examination.At first, you may need note to remember what to look for you as you examine each region of the body, but with a few months of practice you will acquire a routine sequence of your own. This sequence will become habit and often prompt you to return to an exam segment you may have inadvertently skipped, helping you to become thorough.2. 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. Some segments of physical examination are best obtained while the patient is sitting (such as examination of head, neck, thorax, and lung), others are best obtained supine (cardiovascular and abdominal examination.Most patients view the physical examination with at least some anxiety. They feel vulnerable, physically exposed, apprehensive about possible pain, and uneasy about what the clinician may find. At the same time, they appreciate the clinicians concern about their problems and respond to your attentiveness.With this consideration in mind, the skillful clinician is thorough without wasting time, systematic without being rigid, gentle yet not afraid to cause discomfort should this be required.Clinicians vary in where they place different segments of the examination, especially the examinations of the musculoskeletal system and the nervous system.

Beginning the examination: Setting the stagePreparing for the physical examination:Reflect on your approach to the patientDecide on the scope of the examinationChoose the examination sequenceAdjust the lighting and the environmentMake 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 patients welfare.

1. Approaching the patientWhen 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.

Approaching the patientWhen the first examining patients, feelings of insecurity are inevitable, but these will soon diminish with experience. Be straightforward.Let the patient know you are a student and try to appear calm, organized, and competent, even when you feel differently.If you forget to do part of the examination, this is not uncommon, especially at first!, simply examine those area out of sequence, but smoothly. It is not unusual to go back to the bedside and ask to check one or two items that you might have overlooked.As beginner, you will need to spend more time than experienced clinicians on selected portions of the examination, such as ophthalmoscopic examination or cardiac auscultation. To avoid alarming the patient, warn the patient ahead of time by saying, for example: I would like to spend extra time to listening to your heart sound, but this doesnt mean I hear anything wrong.As beginner, you should avoid interpreting your findings, You are not the patient primary caretaker, and your views may be conflicting or in error. As you grow in experience and responsibility, sharing finding will become more appropriate.Be selective, however-if you find an unexpected abnormality, you may wish you had kept a judicious silence. At times, you may discover abnormalities, such as an ominous or deep oozing ulcer. Always avoid showing distaste, alarm, or other negative reactions.

2. Decide on the scope of the examination: How complete should it be?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 sequenceThe sequence should maximize the patients comfort, avoid unnecessary changes in position, and enhance the clinicians 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 environmentAs 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 comfortableYour access to the patients 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 patients modesty but also help you to focus on the area being examined. Keep the patient informed, especially when you anticipate embarrassment or discomfort.

Make the patient comfortableYour access to the patients 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 patients modesty but also help you to focus on the area being examined. To help the patient prepare for segments that might be awkward, it is considerate to briefly describe your plans before starting the examination. As you proceed with the examination, keep the patient informed, especially when you anticipate embarrassment or discomfort.

Equipment for Physical Examination

Textbook of Physical Diagnosis, history and examination, 2nd edition. Mark H Swartz, WB Saunders, Philadelphia

Available in most patient care areasRequiredOptionalSphygmomanometerTongue bladeGlovesLubricant gelVaginal speculumStethoscopeOto/ophthalmoscopePenlightReflex hammerTuning fork 128 HzPinTape measureNasal IluminatorNasal speculumTuning fork 512 Hz

The four cardinal principles of physical examination:InspectionPalpationPercussion Auscultation

1. InspectionInspection can provide an enormous amount of information. Examiners must train themselves to look at the body using a systematic approach.

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

3. PercussionPercussion 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.

4. AuscultationAuscultation 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.

The ComprehensivePhysical examinationGeneral surveyVital signSkinHead, eyes, ears, nose, throat (HEENT)NeckBackSuperior thorax and lungsBreast, axillae, and epitrochlear nodesAnterior thorax and lungsCardiovascular systemAbdomenLower ExtremitiesNervous systemAdditional examinationrectal examination in mengenital and rectal examination in women

1. General surveyObserve the patients 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 patients facial expressions and note the manner, affect and reactions to person an things in the environment.Listen to the patients manner of speaking and note the state of awareness of level of consciousness.

2. Vital signThe 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. SkinObserve 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 patients hands. Continue your assessment of the skin as you examine the other body regions.

4. Head, eyes, ears, nose, throat 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.

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

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. NeckInspect 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 patients 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

Inspect and palpate the spine and muscles of the back

7. Superior thorax and lungsInspect 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 nodesThe patient is still sitting, move to the front againIn 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 nodesA 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.

Breast, axillae, and epitrochlear nodes(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 nodesA note on the musculoskeletal system: by this time you have made some preliminary observations of the musculoskeletal system. You have inspected the hands, surveyed the upper back, and at least in women, made a fair estimate of the shoulders range of motion. Use these to decide whether a full musculoskeletal examination is warranted. If indicated, with the patient still sitting, examine the hands, arms, shoulders, neck, and temporomandibular joints and check the range of motion

9. Anterior thorax and lungsThe patient position is supine, ask the patient to lie down, You should stand at the right side of the patients bed.Inspect, palpate, and percuss the chest.Listen to the breath sound, any adventitious sounds, and, if indicated transmitted voice sounds.

10. Cardiovascular systemElevated the head of the bed to about 30o. 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.

(Elevated the head of the bed to about 30o. 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 if 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 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.

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. AbdomenLower the head of the bed to the flat position, the patient should be supineInspect, 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

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 systemThe complete examination of the nervous system can also be done at the end of the examination. It consists of five segments: mental statuscranial nerves (including funduscopic examination)motor systemsensory systemreflexes.

14. Additional examinationRectal examination in men

The patient is lying on the left side or left lateral decubitusInspect 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 flexedExamine the external genitalia, vagina, and cervix. Obtain a Pap smear. Palpate the uterus and adnexa, Do a rectovaginal and rectal examination.

Recording your findingThe 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 patients 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

1. The key to a thorough and accurate physical examination is developing a systemic sequence of examination.At first, you may need note to remember what to look for you as you examine each region of the body, but with a few months of practice you will acquire a routine sequence of your own. This sequence will become habit and often prompt you to return to an exam segment you may have inadvertently skipped, helping you to become thorough.2. 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. Some segments of physical examination are best obtained while the patient is sitting (such as examination of head, neck, thorax, and lung), others are best obtained supine (cardiovascular and abdominal examination.Most patients view the physical examination with at least some anxiety. They feel vulnerable, physically exposed, apprehensive about possible pain, and uneasy about what the clinician may find. At the same time, they appreciate the clinicians concern about their problems and respond to your attentiveness.With this consideration in mind, the skillful clinician is thorough without wasting time, systematic without being rigid, gentle yet not afraid to cause discomfort should this be required.Clinicians vary in where they place different segments of the examination, especially the examinations of the musculoskeletal system and the nervous system.Approaching the patientWhen the first examining patients, feelings of insecurity are inevitable, but these will soon diminish with experience. Be straightforward.Let the patient know you are a student and try to appear calm, organized, and competent, even when you feel differently.If you forget to do part of the examination, this is not uncommon, especially at first!, simply examine those area out of sequence, but smoothly. It is not unusual to go back to the bedside and ask to check one or two items that you might have overlooked.As beginner, you will need to spend more time than experienced clinicians on selected portions of the examination, such as ophthalmoscopic examination or cardiac auscultation. To avoid alarming the patient, warn the patient ahead of time by saying, for example: I would like to spend extra time to listening to your heart sound, but this doesnt mean I hear anything wrong.As beginner, you should avoid interpreting your findings, You are not the patient primary caretaker, and your views may be conflicting or in error. As you grow in experience and responsibility, sharing finding will become more appropriate.Be selective, however-if you find an unexpected abnormality, you may wish you had kept a judicious silence. At times, you may discover abnormalities, such as an ominous or deep oozing ulcer. Always avoid showing distaste, alarm, or other negative reactions.Make the patient comfortableYour access to the patients 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 patients modesty but also help you to focus on the area being examined. To help the patient prepare for segments that might be awkward, it is considerate to briefly describe your plans before starting the examination. As you proceed with the examination, keep the patient informed, especially when you anticipate embarrassment or discomfort. Head, eyes, ears, nose, throat (HEENT)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 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.Breast, axillae, and epitrochlear nodes(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 nodesA note on the musculoskeletal system: by this time you have made some preliminary observations of the musculoskeletal system. You have inspected the hands, surveyed the upper back, and at least in women, made a fair estimate of the shoulders range of motion. Use these to decide whether a full musculoskeletal examination is warranted. If indicated, with the patient still sitting, examine the hands, arms, shoulders, neck, and temporomandibular joints and check the range of motion(Elevated the head of the bed to about 30o. 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 if 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 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.