Physical examination - approach and overview
Examination techniques and equipment
Examination techniques
a. Inspection
b. Palpation
c. Percussion
d. Auscultation
Measurement of vitals
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Pulse
Respirations
Blood pressure
Height and weight
Pulse oximetry.
Equipment
 Stethoscope
 Blood pressure cuff
 Cardiac monitor
 Pulse oximetry
 Peak flow meter
 Capnometry
General approach
o Examine the patient systematically
o Place special emphasis on areas suggested by the present illness and
chief complaint
o Keep in mind that most patients view a physical exam with
apprehension and anxiety
o they feel vulnerable and exposed
Overview of a advanced examination
The categories of a physical exam should include:
 Mental status
 General survey
 Vital signs
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 Skin
 HEENT
o Head
o Eyes
o Ears
o Nose
o Throat
 Neck
 Chest
 Abdomen
 Posterior body
 Extremities
o Peripheral vascular
o Musculoskeletal
 Neurologic exam.
Mental status
A. Appearance and behavior
1. Level of consciousness:
 Alertness
 Response to verbal stimuli
 Response to touch or shake of shoulder (tactile)
 Response to painful stimuli
 Unresponsive.
Possible findings:
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Normal
Drowsy
Coma ( State of profound unconsciousness -Absence of spontaneous
eye movements - No response to verbal or painful stimuli - Patient
cannot be aroused by any stimuli).
2. Posture and motor behavior
Abnormal posture
 Purposeful
 Non purposeful
Appropriateness of movement (Normal – Restlessness – Agitation - Bizarre
postures - Immobility - Involuntary movements).
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3. Dress, grooming, and personal hygiene (Fastidiousness - Neglect)
4. Facial expression
( Anxiety - Depression - Anger - Response to imaginary people or objects –
Withdrawal).
Speech and language:
1. Assess- Quantity - Rate - Loudness – Fluency
Possible findings
 Aphasia
 Dysphonia
 Dysarthria
 Changes with mood disorders
Mood
1. Assess
Stability of abnormal mood - Risk of suicide
Possible findings
 Happiness
 Elation
 Depression
 Anxiety
 Anger
 Indifference
Orientation
1. Assess ( Time - Place - Person)
Possible findings (Disorientation)
 Assess remote memory (i.e., birthdays)
 Assess recent memory (i.e., events of the day)
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General survey
Cardiorespiratory insufficiency
 Labored breathing
 Wheezing
 Cough
 Pain
Anxiety
Apparent state of health
Skin color and obvious lesions
 Pallor
 Cyanosis
 Jaundice
 Rashes
 Bruises - ecchymosis
 Scars
 Discoloration
Weight
 Emaciated
 Obese
 Recent history of weight gain or loss
Posture, gait, and motor activity
Preferred posture
o Tripodal
o Paralysis
o Limpness
o Ataxia
o Restless or quiet
o Involuntary motor activity
o Ease of walking ( Balance Limp - Discomfort - Fear of falling Abnormal motor pattern)
Dress, grooming, and personal hygiene
 How is the patient dressed ( Appropriate for temperature and weather –
Clean)
 . Odors of breath
 . Facial expression
 . Observe expression (At rest, during conversation, and during the
examination)
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Vital signs
. Blood pressure
. Respirations
. Pulse
Temperature
. Pulse oximetry
. Blood glucose monitor
. Cardiac monitor
Anatomical regions
Skin
1. Techniques of exam
 Inspect and palpate the skin
 Note the following characteristics
 Color
The red color of oxyhemoglobin and pallor due to lack of oxygen are
best seen where the epidermis is thinnest
The fingernails and lips and the mucous membranes of the mouth and
palpebral conjunctiva
In dark skinned persons, the palms and the soles may also be useful
 Moisture
 Temperature
 Texture
 Mobility and turgor
 Lesions
Inspect the fingernails
Note their color
 Abnormalities
 Color
 Temperature
 Condition
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Head, ears, eyes, nose, and throat
1. Techniques of examination
Head
The scalp
(a) Inspect and palpate for evidence of trauma
Skull
(a) Inspect and palpate, note any tenderness or deformities
Face
(a) Note the facial expression and contours
(b) Observe for asymmetry, involuntary movements, and edema
(c) Inspect and palpate, note any tenderness or deformities
(Skin
(a) Note color, temperature, and condition
Eyes
(1) Position and alignment
 Stand in front of the patient and survey the patient’s eyes
 Assess for conjugate gaze
Eyelids
 Inspect the eyelids for any evidence of trauma
Conjunctiva and sclera
 Inspect for discoloration
Pupils
 Inspect the size, shape, and symmetry of the pupils
 Test the pupillary reactions to light
Look for Direct reaction- Consensual reaction.
c. Ears
The auricle
 Inspect each auricle and surrounding tissue for deformities,
 drainage, tenderness, and erythema
Mastoid
 Discoloration
 Tenderness
Nose
Inspect the anterior and inferior surface of the nose
 Asymmetry
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 Deformity
 Foreign bodies
Palpate for tenderness
Mouth and pharynx
 Inspect the lips, observe color, moisture, or cracking
 Note the color of the gums
 Inspect the teeth
 Inspect the tongue
Neck
 Inspect the neck, noting its symmetry and any masses or scars
 Inspect and palpate the trachea for any deviation
 Inspect for jugular venous distention
The cervical spine
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Inspection
Palpation( Tenderness – Deformities).
Chest
Techniques of examination
 Inspect
 Palpate
 Percuss
 Auscultate
 Compare side to side
Examination of the thorax and ventilation
 Observe rate, rhythm, depth, and effort of breathing
 Check for cyanosis
 Listen to the patient’s breathing
 Observe the shape of the chest
Examination of the anterior and posterior chest
inspect
(a) Any deformities or asymmetry
 Barrel chest
 Traumatic flail chest
 Open wounds
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 Other evidence of trauma
(b) Abnormal retractions
(c) Impairment of respiratory movement
Palpate
o Any tenderness
o Assessment of observed abnormalities
o Further assessment of respiratory expansion
Percuss in symmetrical locations noting Any area of abnormal percussion
 Dullness
 Resonance
 Hyperresonance
Auscultate breath sounds
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Vesicular - Bronchiovesicular - Bronchial - Tracheal
Added sounds (adventitious lung sounds)
(crackles - Wheezes - Rhonchi- Diminished or absent)
Effusion
Consolidation
Cardiovascular system
Techniques of examination
a. Arterial pulse
 Heart rate
 Rhythm
 Amplitude
 Abnormal findings
b. Blood pressure
 Abnormal findings
Inspection and palpation of the chest
Auscultation-Listen for the heart tones
Locate the point of maximum impulse (PMI) and assess apical
pulse
Listen for distant or muffled heart tones
Abdomen
Techniques of examination
a. General approach
 Place the patient in a supine position
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Before palpation ask the patient to point out any areas of pain examine
these areas last.
 Approach slowly and avoid quick, unexpected movements
 Distract the patient as needed with conversation
 Proceed in an orderly manner
Inspection
Inspection of the abdomen, including the flanks, noting
Skin
Scars - Rashes and lesions - Discoloration - Ascites
The contour of the abdomen
 Bulges
 Flat
 Rounded
 Protuberant
 Scaphoid
 Bulges at the flanks
 Hernias
 Symmetry
 Pulsations
 Ascites.
Palpation
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Muscle guarding
Rigidity
Large masses
Tenderness
Female genitalia
Techniques of examination
a. General approach
 This may be awkward or uncomfortable for the patient and the provider
 Male examiners are customarily attended by female assistants
 Female examiners may choose to work alone
Examination
(1) Inspect the external genitalia
(2) Note any ( Inflammation - Discharge and bleeding - Swelling).
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Male genitalia
Techniques of examination
a. General approach
 This may be awkward or uncomfortable for the patient and the provider
 Female examiners are customarily attended by male assistants
 Male examiners may choose to work alone
Examination
(1) Inspect the external genitalia
(2) Note any( Inflammation- Discharge and bleeding - Swelling Hematomas)
Extremities
Techniques of examination
a. General approach
Direct your attention to function as well as structure
Assess general appearance, bodily proportions and ease of movement
 Note particularly( Limitation in the range of motion - Unusual
Increase in the mobility of a joint)
 Signs of inflammation (Swelling - Tenderness - Increased heat Redness )
 Decreased function
 Crepitus
 Deformities
 Muscular strength
 Symmetry
 Atrophy
 Pain
 Tenderness
 Peripheral pulses
 Motor function
 Sensory function
Peripheral vascular system
Techniques of examination
The arms
Inspection from fingertips to shoulders noting
 Size
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Symmetry
Swelling
Color of the skin and nail beds
Texture of the skin
Palpation
 If you suspect arterial insufficiency, feel for the brachial pulse
 Compare ampitude of pulses.
Legs
 Patient should be lying down
 Successful examination cannot be completed with socks or stockings
on
 Inspect from the groin and buttocks to the feet
• Size
• Symmetry
• Swelling
• Rashes
• Scars
• Ulcers
• Color and texture of the skin
Palpate the pulses in order to assess arterial circulation
 Femoral pulse
 Popliteal pulse
 Dorsalis pedis pulse
 Posterior tibial pulse
 Note the temperature of the feet and legs
 Look for edema
• Check for pitting edema( Press firmly but gently with your thumb for at
least 5 seconds
Over the dorsum of each foot - Behind each medial malleolus - Over the
shins).
Nervous system
Techniques of examination
a. General approach
 Are right and left-sided findings symmetrical
 Is this a peripheral or central nervous system problem
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 Detail of an appropriate neurological exam varies greatly
 Components of the neurological exam may be completed during other
assessments
 It may be best to organize your findings into three categories
• Mental status and speech
• Motor system
• Sensory system
The motor system
Body position( Observe the position during movement and at rest)
 Involuntary movements: Watch for involuntary movements.
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Muscle tone( Feel the resistance to passive stretch)
Muscle strength( Ask the patient to move actively against your
resistance)
No muscular contraction detected
A barely detectable flicker or trace of contraction
Active movement of the body part with gravity eliminated
Active movement against gravity
Active movement against gravity and some resistance
Active movement against full resistance without evident
fatigue - this is normal muscle tone
 Test flexion
 Test extension
 Test the grip
 Test finger abduction
 Test dorsiflexion
 Test plantar flexion
Coordination Rapid alternating movements.
Sensory system
General approach
 Compare symmetrical areas on the two sides of the body
 When testing pain, temperature, and touch, compare distal and
proximal areas
 Pain
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