Introduction to Physical Examination

Dr. Gwen Hollaar

Dr. Lanice Jones

Dr. Robert Lee

September 2006 Lao Project

Outline

General Observations

Vital Signs

General Approach to physical examination

General surface anatomy

Examination of Head and Neck

Examination of Lymph nodes

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

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

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

Radial Pulse

Notice:

1. Pulse Rate

2. Pulse Regularity

3. Pulse Volume

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

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.

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’

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.

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)

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

Surface Anatomy: Head

Surface Anatomy: Neck

Spinous process of C-spine

Posterior cervical

Location of Cervical lymph nodes

Surface Anatomy: Thyroid

Location of Thyroid

Surface Anatomy: Anterior Chest

Surface Anatomy: Anterior Chest

Surface Anatomy: Cardiac

Right 2nd Interspace Left 2nd Interspace

Right 5th Interspace Left 5th Interspace

Surface Anatomy: Posterior Chest

Surface Anatomy: Abdomen

Abdominal Lines

Linea alba

Arcuate lineAnterior superior iliac spine

Surface Anatomy: Abdominal Organs

LiverSpleen

Appendix

Surface Anatomy: Abdominal Organs

Musculo-Skeletal Surface Anatomy: Knee (as one example)

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

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

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

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

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

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

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

Head and Neck Examination: Mouth

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)

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

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

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

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

Questions?