Introduction

As well as history taking, Physical Examination is an important part of patient management. The goal of the P/E is to obtain valid information concerning the health of the patient. The examiner must be able to identify , analyze and synthesize the accumulated information into a comprehensive assessment. The four principles of physical examination are the following: 1. Inspection can provide an enormous amount of information. You must train themselves to look at the body using a systematic approach. 2. Palpation is the use of the tactile sense to determine the characteristics of an organ system. 3. Percussion relates to the tactile sensation and sound produced when a sharp blow is struck to an area being examined. This provides valuable information about the structure of the underlying organ or tissue. 4. Auscultation involves listening to sounds produced by internal organs. This technique furnishes information about an organ’s pathophysiology.

To achieve competence in these procedures, the student must, "teach the eye to see, the finger to feel and the ear to hear" .

Note: These four principles have different value in different systems. For example, Inspection is more useful in general appearance, Palpation in abdominal examination, Percussion in organ size evaluation, and Auscultation in heart examination. In abdominal examination, Auscultation is first, since performing percussion or palpation, may alter the frequency of bowel sounds.

Preparing for the physical examination - Reflect on your approach to the patient - Decide on the scope of the examination - Adjust the lighting and the environment - Make the patient comfortable - Choose the examination sequence - Wash your hands in the presence of the patient - Describe your plans for the patient - Draped the patient. As you examine each segment, your goal is to visualize that area. For performing a brief, complete, easy general P/E with least discomfort for the patient, follow these sequence. A minimum number of position changes, is obviously desirable.

Sequence of Examination Step I Note the general appearance as you take the history and when initiating the physical examination, usually with the patient sitting. Vital signs may be taken at this time, and a survey of the skin may be started.

Step II Examine the head and neck, including cervical nodes. Thorax, breast, supraclavicular and axillary nodes, and initial cardiovascular examination, including upper extremity pulses and neck vein observation, are done next.

Step III Move to the rear and station yourself on the left. Examine the posterior lung fields and back. A posterior palpation of the thyroid gland is often done. Observe the skin of the back.

Step IV With the patient supine, station yourself on the right, and continue cardiac examination, including reexamination of the neck vein. Palpate the breasts. Examine the abdomen, including kidneys, and aorta. Palpate the inguinal nodes and femoral pulses. Observe the external genitalia. Peripheral pulses in the lower extremities and parts of the musculoskeletal examination are done in this position.

StepV With the patient again sitting, examine the remainder of the musculoskeletal system.

Step VI The patient stands for the rest of the neurologic examination. In men, examine the external genitalia, including hernia.

Step VII In women, the pelvic examination is done last, with the rectal conducted as part of this examination. In men, the rectal completes the physical. As you leave, wash your hands, clean your equipment, and dispose of any waste materials.

Precautions to take during the examination 1. The use of gloves should provide adequate protection when performing the physical examination. 2. Gloves should be worn when examining any individual with exudative lesions or weeping dermatitis. 3. Hands or other contaminated skin surfaces should be washed thoroughly and immediately if accidentally soiled with blood or other body fluids. 4. Areas that have been soiled with blood or other body fluids should be cleaned and decontaminated with an appropriate disinfectant. A patient may be in isolation or on special precautions, which indicates that he or she is suffering from a contagious disease. Consult the institutional infection control manual for guidelines regarding on entry into the patient’s room and protective attire. General Survey Note these characteristics: - Apparent state of health - Level of consciousness - Signs of distress - Weight, Hight, BMI - Skin color and obvious lesions - Dress and personal hygiene - Odors of the body and breath - Facial expression - Posture, Gait and motor Activity Vital signs 1. Insert oral thermometer 2. Count radial pulse and determine its rhythm, amplitude, and contour. 3. Observe the rate, rhythm, depth, effort of breathing and count the number. 4. Take blood pressure, both arms 5. Remove and read thermometer Skin Inspect and palpate the skin. Note these characteristics: - Color -Moisture - Temperature - Texture - Mobility and Turgor - Lesions and its description (size, shape, location, configuration, blanching, inflammation, tenderness, induration, discharge)

Nails Inspect and palpate the fingernails and toenails. Note their configuration, color, texture, condition, ridging, pitting and any lesions

Hair Palpate the hair for texture while at the same time inspecting it for color, distribution, and quantity. Head • Inspection (Note its Position, Shape, Size, Facial feathers, Asymmetry, Lesions, Masses) • Palpation - Hair - Temporal arteries - Solivery glands (if asymmetry or enlargment is noted) • Percussion (If sinusitis is suspicious) • Auscultation (If you suspect a vascular anomally of the brain listen for bruits over the skull and eyes).

Eye For eye examination check: - External eye - Pupils - Visual acuity - Extraocular movements - Visual field - Fundoscopy

Ear • External examination - Inspect and palpate the external ear structures • Otoscopic examination - Inspect the external canal - Inspect the tympanic membrane (T.M) - Determine the motility of the T.M • Auditory acuity testing (If hearing is diminished, check Weber’s and Rinne’s test)

Nose and Sinuses • External examination - Inspection (nose, external nares) - Test for nostril’s patency - Palpate deformity and sinuses • Internal examination - Inspection (position of the septum, mucous color and condition, discharge, size and color of inferior and middle turbinates).

- Palpate for sinus tenderness - Transilluminate the sinuses

Mouth and Pharynx • Inspection and palpation: - Lips - Buccal mucosa - Gingivae - Teeth - Tongue - Floor of the mouth - Hard and soft palate - Pharynx - Salivary glands - Cranial nerve XII

Neck • Inspection (symmetry, masses, scars, enlargment of the parotid or submandibular gland, visible lymph nodes) • Palpate the lymph nodes (preauricular, posterior auricular, occipital, tonsillar, submandibular, submental, superficial, posterior and deep cervical and supraclavicular) • Trachea and the thyroid gland - Inspect the trachea - Inspect and Palpate the thyroid gland • Carotid arteries and jugular veins Breast • Inspection - Arms at sides (appearance of the skin, size and symmetry, contour, characteristics of the nipple) - Arms over head, hands pressed against hips, leaning forward

• Palpation (for consistency, tenderness, nodules) - Lateral portion (Being in the axilla in a vertical strip) - Medial portion - Nipple Chest and lungs The following steps are performed with the patient sitting. 1. Inspect the chest, front and back, noting thoracic landmarks, for the following: - Size and shape (anteroposterior diameter compared with transverse diameter) - Symmetry - Color - Superficial venous patterns - Prominence of ribs 2. Evaluate respirations for the following: - Rate - Rhythm or pattern 3. Inspect chest movement with breathing for the following: - Symmetry - Bulging - Use of accessory muscles 4. Note any audible sounds with respiration (i.e., stridor or wheezes). 5. Palpate the chest for the following: - Symmetry - Thoracic expansion - Pulsations - Sensations such as crepitus, grating, vibrations - Tactile fremitus 6. Perform direct or indirect percussion on the chest, comparing sides, for the following: - Diaphragmatic excursion - Percussion tone intensity, pitch, duration, and quality 7. Auscultate the chest with the stethoscope diaphragm, from apex to base, comparing sides for the following: - Intensity, pitch, duration, and quality of expected breath sounds - Unexpected breath sounds (crackles, rhonchi, wheezes, friction rubs) - Vocal resonance Heart The following steps are performed with the patient sitting and leaning forward, supine, and in the left lateral recumbent positions; these positions are all used to compare findings or enhance the assessment. 1. Inspect the precordium for the following: - Apical impulse - Pulsations - Heaves or lifts 2. Palpate the precordium to detect the following: - Apical impulse - Thrills, heaves, or lifts 3. Percussion to estimate the heart size (optional). 4. Systematically auscultate in each of the five areas while the patient is breathing regularly and holding breath for the following: - Rate - S 1 - Rhythm - S 2 - Splitting - S 3 and/or S 4 - Extra heart sounds (snaps, clicks, friction rubs, or murmurs) 5. Assess the following characteristics of murmurs: - Timing and duration - Pitch - Intensity - Pattern - Quality - Location - Radiation - Variation with respiratory phase

Vascular system • Inspection - Symmetry of the extremities - Skin temperature - Varicosities • Examination of the arterial pulses (presence, contour, symmetry) - Radial pulse - Brachial pulse - Carotid artery - Coarctation of the aorta

- Abdominal aorta - Abdominal bruits - Femoral pulse - Popliteal pulse - Dorsalis pedis pulse - Posterior tibial pulse Lymphatic system Inspection and palpation, region by region • Head and neck - Parotid and retropharyngeal (tonsillar) - Submandibular - Sublingual (facial) - Occipital - Supraclavicular - Superficial anterior cervical - Superficial posterior cervical - Preauricular and postauricular

• Upper extremities - Axillary - Epitrochlear (cubital) • Lower extremities - Superficial superior inguinal - Occasionally, popliteal

Abdomen • Inspection - General appearance - Respiratory rate - Skin (scar, striae, dilated veins, rashes and lesions) - Umbilicus (contour, location, any signs of inflammation or hernia and eversion) - Contour of abdomen (shape [flat, rounded, protuberant, scaphoid], symmetry, visible organ or masses) - Peristalsis - Pulsation • Auscultation - Bowel sound - Rule out obstructed viscus - Rule out abdominal Bruits - Rule out peritoneal rubs • Percussion - Abdomen (presence of gas, any mass or enlarged organ) - Liver - Spleen - Rule out ascites • Palpation - Light palpation (for tenderness, spasm, rigidity) - Deep palpation (organ size, texture and abdominal masses) - Liver - Spleen - Kidney Note: Palpation may be prior to percussion

Rectal exam: Inspection - Anorectal cyst and sinus - Anal fissure - Pilonidal cyst and sinus - Hemorrhoids Palpation - Polyps of the rectum - Cancer of the rectum - Rectal shelf - Prostate gland Musculoskeletal • Inspection - Joint symmetry - Alignment - Bony deformities - Swelling or redness - Muscle atrophy or hypertrophy - Nodules • Palpation - Surronding tissues of major joint - Skin changes - Crepitus • Passive and active range of motion • Specific tests - Bulge sign (for minor effusion) - Balloon sign (for major effusion)

Neurologic • Mental status - Level of consciousness - Speech - Mood - Affect - Thought - Perceptions - Judgment - Cognitive function (orientation, attention, memory) - High cognitive functioning (calculation, abstract thinking, information, and constructional ability) • Cranial nerves I. Olfactory II. Optic III. Oculomotor: Ptosis, Pupillary reflexes III, IV, VI: Extraocular movements V. Trigeminal: muscle of mastication, devisions of sensation, corneal reflex VII. Facial: face observation, motor function VIII.Acoustic: hearing/vestibular: gait, nystagmus, caloric test, hallpike’s test (in positional vertigo) IX, X: Swallowing, gag reflex, observation of uvula, larynx examination XI: Trapezius and sternomastoid muscle XII: Articulation, tongue observation

• Motor - Observation (position, movements, symmetry, bulk, gait) - Muscle tone - Muscle strength • Coordination and gait - Rapid alternating movement - Point to point movements - Gait: walk and turn, walk heel-to-toes, walk on their toes and heels, hops in place • Reflexes - Deep tendon reflexes (Biceps, Tricepes, Brachioradialis, Knee, Achilles) - Plantar response or Babinski’s sign - Hoffmann’s sign - Oppenheim’s sign - Chaddock’s sign - Abdominal • Sensory - Dermatomal testing: Pain, temperature, light thouch, discrimination (graphesthesia, stereognosis, two point discremination) - Vibration - Proprioception - Subjective light touch