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 activity
Anxiety or Depression
Skin
Pale
Jaundice
Dress or hygiene
Preparation / Draping
Prior to beginning formal physical examination:
Explain to patient what you will be doing
Make sure patient feels comfortable and provide
privacy
Ask patient to remove clothing so that you can do
proper physical examination
Give patient sheet/gown to cover herself
Uncover only the area that you are presently examining
to keep patient comfortable
In general, examine from head to toe
During examination make as few position changes
as possible
Vital Signs
Height and Weight
Temperature
Usually oral or rectal thermometer
Respiratory Rate
Have student count for 30 seconds
Have student also observe character of respirations
Pulse
Can be done on any pulse, but radial pulse is usually used
Need to teach how to assess rate AND quality of pulse
Blood pressure
Need to teach students the steps involved in taking BP
Radial Pulse
Notice:
1. Pulse Rate
2. Pulse Regularity
3. Pulse Volume
Blood Pressure Measurement
3 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 Technique
Now 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 patient
Vital signs
include observation of the hands
Head Examination
Examine the eyes & mouth
Examine ears, sinus, scalp as needed
Neck Examination
Central (thyroid), anterior triangle, posterior triangle
Patient sitting – Physician stands behind patient
Examine posterior chest (Respiratory)
Patient sitting – Physician stands in front of patient
Exam anterior chest (Respiratory and Cardiac)
Patient Lying down
Finish cardiac examination
Do abdominal Examination
Genitourinary exam and rectal exam as indicated
MSK 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
Location of Cervical lymph nodes
Posterior cervical
Spinous process of C-spine
Surface Anatomy: Thyroid
Location of Thyroid
Surface Anatomy: Anterior Chest
Surface Anatomy: Anterior Chest
Surface Anatomy: Cardiac
Right 2nd Interspace
Right 5th Interspace
Left 2nd
Interspace
Left 5th Interspace
Surface Anatomy: Posterior Chest
Surface Anatomy: Abdomen
Abdominal Lines
Linea alba
Anterior superior
iliac spine
Arcuate line
Surface Anatomy: Abdominal Organs
Spleen
Liver
Appendix
Surface Anatomy: Abdominal Organs
Musculo-Skeletal Surface Anatomy:
Knee (as one example)
General Inspection
Skin
Colour
Capillary refill
Presence of skin lesions (i.e. nevi, skin
cancers)
Nail
Colour of nailbed
Shape of nail (clubbing)
Hair (head and body)
Character (fine / course)
Distribution
Head and Neck Examination: Eye
Eyelids
Check for eyelid
swelling
Check 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
Eyelashes
Infection 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
Conjuctiva
Gently 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
Cornea
Look for haziness of cornea and engorgement
of blood vessels and eccentric pupil as these
are features of glaucoma
Look for corneal abrasion
Ophthalmoscopic examination of fundus
Look at:
Optic disc
Arteries and veins
Fundus background
Macula and surroundings
Head and Neck Examination: Ears
Look at external ear
Do auriscopic examination
Pull 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
Lips
Look at colour (i.e. cyanosis)
Look for cracking of the lips or non-healing lesions
Look for painful cracks at the corners of the mouth
Teeth
Look at dental hygiene
Gums
Look for areas where gums may be swollen or infected
Tongue
Look at tongue size and movement
Look at tongue mucosa (top and bottom of tongue)
Colour
Atrophy 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
Palate
Look at mucosa and make sure there is no mucosal
lesion or deformity
Tonsils and pharynx
Have patient protrude tongue, say ‘ah’, and place tongue
depressor over tongue
Look for swollen gland or red mucosa or exudate
Salivary glands
Palpate 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 molars
Submandibular 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 front
Can 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 lobe
Feel for firmness, tenderness, nodules, or enlargement
Ask patient to swallow as you palpate each lobe
Auscultate over the thyroid gland
May 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 nodes
Palpate on medial aspect of elbow)
Axillary lymph nodes
Slightly abduct arm, have patient keep arm relaxed,
and slide your hand up into the axilla and palpate
along the chest wall
Femoral lymph nodes
Palpate over the area of the femoral artery and vein
in the groins
Questions?