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General Principles of Physical examination

- Physical examination is taught in a formal way:
1. that ensures that examination is thorough & important signs are not overlooked because of haphazard method
2. the most convenient method for examining patients in bed & for particular conditions in various other postures
- Physical examination is divided into:
1. General examination (done first)
2. Systemic examination
- There is no local examination in medicine. We have general & systemic
- Patients are always examined from the right side of the bed
- You must write briefly
- You must follow a system
- Must examine the whole body
- Physical examination is done:
1. to pick up abnormalities that will help us make a diagnosis
2. confirm suspected diagnosis at history taking
3. look for other physical findings
- 90% of diagnosis can be made just from history  gives clues
- Some conditions are diagnosed only by:
 History like psychiatric diseases, migraine & angina pectoris
 Physical examination like hypertension (HTN) & mitral stenosis
 Investigations like arrhythmia (by ECG), diabetes & hyperlipidemia (high cholesterol)
- The system doctor Akhtar follows:
1. General appearance (can give clues to diagnosis)
2. Vital signs (pulse rate, respiratory rate, blood pressure & temperature)
♦ Doctor likes to start the physical examination starting w/ the head & ending w/ the toes
3. Examine the head, eyes, ears, nose, mouth, throat, neck then the hands. Others examine the hands & then the head & neck
4. Examine the chest: we divide the examination of the chest into 3 parts: examination of the heart, examination of the lungs, examination of the breast
5. examination of the abdomen
6. examination of the extremities
7. Neurological examination
- Each specialty has it’s own system in physical examination, but this is the backbone
- You examine the system that is involved in more detail, but the rest you just examine quickly
- Within each of the examining systems, one can describe 4 elements w/c compromise the main parts of physical examination: looking – inspection; feeling – palpation; tapping – percussion; & listening – auscultation. For many systems a 5th element, assessment of function, is added. Measuring is also relevant in some systems
- The first thing we do in general examination is that we see the patients general appearance
- General appearance:
▫ The patient is (young, middle-aged, old), (male, female), lying comfortably in bed.
▫ Well developed, well nourished
▫ Not in pain (known from patients face expression) or respiratory distress.
▫ Not connected to IV line or oxygen mask (any device or instrument e.g.: ECG, IV line, oxygen mask, chest tube or tube in the stomach, IV or nasal cannula).
▫ Conscious, alert & oriented.
♦ This stamp has to be mentioned in every general examination according to the patient current condition. However, in each system, certain points have to be particularly emphasized.
♦ If patient is abnormally tall we say he’s abnormally tall. If he’s abnormally short we say that he has short stature
♦ If patient is extremely thin we say that he’s emaciated or cachectic. If he’s overweight we say he’s obese
♦ If patient is laying down on his side instead of laying flat on his back you need to ask the patient to lay flat on his back, he might say that he cannot lie on his back and that he feels pain when he lays on his back  so this becomes an abnormal physical finding
- Proper position of patient:
 Patient & doctor should be comfortable
 Patient lays supine (flat on his back)
 When examining specific portions of the body, position may change (w/ comfort of patient) e.g. chest & lungs  patient sits up
- Vital signs:
 Radial pulse.
 Rate (normally: between 60 – 100).
 Rhythm (regular or irregular).
 Radiofemoral delay (if present: coarctation of aorta)
 Synchronization
 Volume
 Character
 Condition of vessel wall: not palpable normally
 Compare both sides
Pulse is 80 per minute, regular, synchronized with normal volume & character & the vessel wall is impalpable.
 Blood pressure
 Temperature
 Respiratory rate: hand on the abdomen & you count up movements (the normal is 12 – 18) (normally you don’t see normal respiration, but if you clearly see movements then patient is in mild respiratory distress
- Head:
 Eyes:
 Pallor (look for it in conjunctiva. Ask patient to look up & pull his eyelid down)
 Jaundice (look for it in sclera. Ask patient to look down & pull his eyelid up)
 Cyanosis
 Exophthalmos (proptosis): protrusion of the eyeball out of the orbit
 Do fundus examination of the eye
 Ears & nose
 Mouth:
 Hygiene (poor, average or good)
 Teeth
 Gums
 Tongue: central cyanosis in the floor of the mouth
 Lips
 Mucus membrane (look for ulcers)
 Throat: check oropharynx & tonsils
- Neck:
 Carotid arteries:
- Found medial to the sternocleidomastoid muscle
- Compare two sides
- Volume.
- Character of pulse: : can be bruit like murmur
- Condition of vessel wall.
 Jugular venous pressure:
- Found in between the two heads, behind & then anterior to the sternocleidomastoid muscle.

 Lymph nodes:
- Anterior cervical
- Posterior cervical
- Subclavicular
- Submental
- Submandibular
- Preauricular
- Postauricular
- Occipital (back of the neck)
 Thyroid: Enlargement (goiter).
 Inspection: Look at the front & sides of the neck & decide if there is localized or general swelling of the gland.
- Swelling (enhanced by asking the patient to swallow sips of water):
• Shape (nodular or diffuse).
• Movement during swallowing (only a goiter or thyroglossal cyst will rise during swallowing).
• Inferior border.
- Scars (thyroidectomy scar).
- Prominent veins (over the upper part of the chest, often accompanied by ↑ JVP. Suggest retrosternal extension of the goiter –thoracic inlet syndrome-).
- Erythema of skin (in case of suppurative thyroiditis).
There is diffuse thyroid swelling that moves freely with swallowing & its inferior border is visible.
No scars, prominent veins or erythema of skin.
 Palpatation: begun from behind.
- Size: look for the lower border, if absent, may be retrosternal extension).
- Site
- Shape:
• Diffuse enlargement.
• Solitary nodule:
• Location.
• Size.
• Consistency:
 Soft: simple goiter.
 Rubbery hard: Hashimoto’s thyroiditis.
 Stony hard node: carcinoma, calcification in a cyst, fibrosis, or Riedel’s thyroiditis.
• Tenderness.
• Mobility.
• Multinodular.
- Surface
- Temperature
- Tenderness
- Texture:
- Thrill: in thyrotoxicosis.
- Consistency: firm or stony hard.
- Relation to surrounding structures: tethering or fixation to overlying skin or underlying tissues in thyroid carcinoma.
- State of regional L.N: enlarged in carcinoma.
- State of local tissues (due to malignancy infiltration by thyroid carcinoma):
• Arteries: bruits over the carotids.
• Veins: venous hum

NOW, move to the front. Note the position of the trachea, which may displaced by a retrosternal gland.
 Percussion (only if enlarged): percuss the upper part of the manubrium from one side to the other. If percussion notes changed, this may indicate retrosternal extension.
♦ Rule for percussion: always from resonant to dull
 Auscultation:Listen for a bruit over each lobe which occur in:
- Thyrotoxicosis
- Hyperthyroidism.
- Using of antithyroid drugs.
- Hand:
 Palm:
 Warmth & moisture (thyrotoxicosis)
 Cold & clammy
 Pallor (anemia)
 Palmer erythema (Chronic liver disease, COPD, respiratory failure & thyrotoxicosis)
 Dupuytren’s contracture (in alcoholism & pancreatitis due to increased xanthine)
 Dorsum: muscle wasting
 Nail:
 Clubbing
 Pallor
 Cyanosis
 Leukonychia
 Koilonychia
 Tremors:
 Fine tremors
 Flapping tremors

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Comment by Dr Rajneesh Kumar Sharma MD(Hom) on November 6, 2010 at 6:30am
Thanks Dr. Hassan. Regards.

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