Introduction to the Physical Examination

Today’s Agenda

• Overview of course

• Exam techniques and use of equipment

• Vital signs

Introduction to the Medical Profession

• Not an introduction, but a beginning

• A new type of learning experience

• The study of the patient

• The study of illness as opposed to disease

IMP is a two year course

• IMP I • Primary Care

Externship• Communication and

Interviewing• Physical Examination• Clinical Decision

Making - EBM

• IMP II• Adv. Communication

and Interviewing• Physical Diagnosis• Radiology, Laboratory

and problem-solving• Clinical Decision

Making-EBM

Student Goals:

To understand the underlying anatomy and physiology of the normal physical examination

To be able to perform a complete screening physical examination in a logical fashion with minimal discomfort to the patient.

To be able to recognize normal findings on the physical examination

Expectations

• Attendance• Participation• Professionalism• Honesty• Feedback• Attitude

Physical Examination

• Lecture series

• Small group session

• CSTAC

Assessment

• Multiple choice examination

• Practical examination– History– Physical examination

Basic Clinical Skills

• 70% of diagnosis can be based on history alone

• 90% of diagnosis can be made when the physical examination is added

• Expensive tests often confirm what is found in the H&P

“The major effort in becoming a diagnostician consists in acquiring the intellectual background to make his or her perceptions meaningful - in short, he or she must practice and study.”

DeGowin and DeGowin

Physical Examination:Two Tiers of Investigation

• Screening or Comprehensive Examination– The foundation of clinical skills– Uses

• Undifferentiated patient

• New patient

• Pt wishing a “complete” H&P

Physical Examination:Two Tiers of Investigation

• Extended or Problem-Focussed Examination– Physician follows leads– Usually involves an extended assessment of a

system or region

Physical Examination

• Knowledge Base

• Technical Skills– Exam skills

– Use of equipment

• Perceptual Skills– Sensory

• Interpretation • Communication Skills• Interpersonal Skills

Knowledgebase

Normal examination Anatomy Physiology Techniques Equipment Expected normal findings Normal variations Changes with age Extrapolation to common abnormalities

Learning the Physical Examination

• A key to a thorough and accurate physical examination is developing a systematic sequence of examination

Learning the Physical Examination

• An important goal is to minimize the number of times you ask the patient to change positions

Learning The Physical Examination

Systems Approach Regional Approach

• Small group sessions with preceptor

• Lecture series

• Reading Bates

• Practice

• Review session with SPs

Format of Small Group Sessions:

Read material ahead of time

Use objectives as a guide

Do the practice questions and review with preceptor

Practice exam techniques

Use checklist as a guideline

The SyllabusINTRODUCTION TO THE MEDICAL PROFESSION

(MD 811: 2006)

MODULE III: Physical Examination

Module Coordinator: David Rudy, MD

Outline Pages Lecture schedule 2 Small group sessions 3 Explanation of course 4-8 Objectives for each section 9-18 Practice Questions 19-31 Systems Checklist 32-37 Regional Checklist 38-48

Lecture SchedulePhysical Examination Lecture and Test Schedule

Date Time Room Topic Reading Assignments

(Bates 9th Edition) Feb 15 1-2

2-3

MN 263 Introduction to PE Module PE Lecture #1 – General Appearance and Vital Signs Dr. David Rudy

p. 11-14 Chapter 4: p. 89-113

Feb 22 1-2

2-3

MN 263 PE Lecture #2 – ENT Exam Dr. Valentino PE Lecture #3 –Eye Exam

Chapter 6: p. 153- 170, 177-200, 212, 229

Feb 27-Mar 3

SPRING BREAK Chapters 1-20

Mar 8 1-2

2-3

MN 263 PE Lecture #4 – Introduction to the Pulmonary Exam Dr. Steve Kraman PE Lecture #5 – The Peripheral Vascular Exam – Dr. David Rudy

Chapter 7: p.241-266, 274-277 Chapter 14: p. 473-478, 481-488, 491

Mar 15 1-2

2-3

MN 263 PE Lecture #6 – The Cardiovascular Exam PE Lecture #7 – The Abdominal Exam – Dr. Chipper Griffith

Chapter 8: p. 279-292, 302-316, 328, 330 Chapter10: p.359-361,374-387,

Mar 22 1-3 MN 263 PE Lecture # 8– The Neurological Exam – Dr. Robin Meek

Chapter 17: p. 595-606, 610-639

Mar 29 1-3 MN 263 PE Lecture #9 – The Musculoskeletal Exam – Dr. Todd Milbrandt

Chapter 15: 497-501, 507-555

Apr 5 1-2

2-3

MN 263 PE Lecture #10 – The Pediatric Exam – Dr. Chipper Griffith PE Lecture # 11- The Dermatologic Exam- Dr. Rudy

Chapter 18: skim p. 671-698 Chapter 5: p.121-131, 143,

Apr 12 1-2

2-3

MN 263 PE Lecture #12 – The Geriatric Exam – Dr. Stiles PE Lecture – Review

Chapter 20: 839-847, 851-852,

Apr 19 1-3 MN 263 Review Apr 26 MN 263 Written Exam TBA CSTAC PE Clinical Performance Exam

Day & Time to be assigned

Small Group Sessions:

1.Getting started2. HEENT, neck, lymph nodes3. Cardiovascular, peripheral vascular4. Chest, pulmonary5 Abdomen6 Neurological7. Musculoskeletal8.&9.Putting it all together10.Patients

Practice Questions 1. Tangential lighting enhances observation of:

A. Color B. Mobility C. Texture D. Contour

2. Which part of the examiner’s hand is best for palpating vibration?

Ulnar surface Finger pads Finger tips Dorsal surface

3. Percussion of body tissue makes sounds that are:

A. Soft over fluid B. Loud over air C. Dull over lungs D. Flat over gastric air bubble

4. Percussion is best sequenced from:

A. Upper to lower body parts B. Resonant to dull areas C. Round to flat surfaces D. Soft to hard surfaces

Checklist

1. A. PRELIMINARY Washes hands before starting examination (in front of patient) 2. B. VITAL SIGNS Blood pressure done - 1 arm 3. Systolic BP estimated by palpation of brachial or radial arteries with BP cuff 4. BP done correctly (not over clothing, cuff tight, arm correct relaxed position, etc.) 5. Patient seated with back supported and both feet flat on ground 6. Blood pressure taken with the bell of the stethoscope 7. Heart rate - at least 15 seconds checking radial pulse with fingers, not thumb 8. Respiratory rate - inconspicuously watching chest movement (at least 20-30 seconds) 9. Temperature (done correctly – will beep when done if electronic)

Learning Resources:

Required Textbook: Bates. . A Guideto Physical Exam and History Taking. 9th ed.Philadelphia: Lippincott, 2005

Examination Techniques and Equipment

Examination Techniques and EquipmentObjectives for each section:General AppearanceAppreciate the importance of observationExam techniquesInspectionList what some examples of what to look for in general observationList a few conditions that are diagnosed from general inspectionThe type of lighting is best for observing couturePercussionDefinition of percussionTypes of percussionUses of percussionThe technique of percussionBe able to perform direct and indirect percussionThe percussion notes and what they indicateRecognize percussion notesBe able to interpret physical exam findings based on percussion

Examination Techniques:

Inspection

Percussion

• Palpation

• Auscultation

Observation (Inspection):

Least mechanical part of the physical examination

Hardest to learnYields the most physical signsMore diagnoses are made by inspection than all others combined

Depends upon the knowledge of the observer

How to Observe

• Keep your eyes open• Keep an open mind• Ask questions• Learn what to observe• Reflect on what you

have observed and look for what you may have missed

Finished files are the re-

sult of years of scientif-

ic study combined with

the experience of years.

Observation

• “Never mind,” said Holmes, laughing; “it is my business to know things. Perhaps I have trained myself to see what others overlook. If not, why should you come to consult me?”

• “A case of Identity” from Adventures of Sherlock Holmes

“The precise and intelligent recognition and appreciation of minor differences is the real essential

factor in all successful medical diagnosis”- Joseph Bell, MD (1890)

• The character of Sherlock Holmes was based on Dr. Bell, an English surgeon who taught Arthur Conan Doyle during medical school.

Enhancing Your Powers of Observation

• Learning physical examination techniques is all about becoming a better observer

• A skilled clinician has enhanced powers of observation and the knowledge to use these observations in the care of patients

“Don’t touch the patient - state first what you see; cultivate your powers of observation.”

Sir William Osler

“The student must teach the eye to see, the fingers to feel, and the ear to hear.”

Sir William Osler

Observation:

• What you see– Know what to look for

• What you hear (listening)

• Olfactory diagnosis• What you feel

emotionally

Observation: Inspection

• Least mechanical aspect of the physical examination

• Hardest to learn• Yields the most physical signs• More diagnosis are made by inspection than

all other techniques combined• Depends upon the knowledge of the observer

Inspection

• Begins when you first see the patient and ends when they leave

• Systematic part of each component of the physical examination

• Part of the mental status examination

• Subtle observations probably account for “the sixth sense” of astute clinicians

Inspection: General Appearance

• State of consciousness• Signs of distress (sick or not sick?)• Apparent state of health• Skin:discoloration or obvious lesions• Dress, grooming, and personal hygiene• Facial expression• Gait and posture• Motor activity

Dress, grooming, and personal hygiene

Inspection: General Appearance

• State of nutrition• Body habitus• Symmetry• Stated age vs. physiologic age• Mood, attitude, affect• Speech• Olfactory diagnosis• Bodily excretions (Effuvia)

Olfactory Diagnosis:

“Medical olfaction can often be an important aspect

of clinical examination if clinicians approach patient

encounters with an “open nose” as well as an open

mind.”

Hayden, GF: Olfactory diagnosis in medicine, Post Graduate Medicine,

1980

Olfactory Diagnosis:

“Characteristic patient odors accompany manydiseases and intoxications, and theirrecognition can provide diagnostic clues,guide the laboratory evaluation, and affect thechoice of immediate therapy.”

Hayden, GF: Olfactory diagnosis in medicine, Post Graduate Medicine,1980

Inspection: Olfactory Diagnosis:

Diagnosis of certain diseases

Fruity; acetone like = Diabetic ketoacidosis

Urine-like = Uremia Inborn errors of

metabolism

Detection of ingestions or toxins

Alcohol Tobacco Toluene Cyanide

Detection of certain infections

Anaerobic Necrotic material

Inspection: Bodily Excretions (Effluvia)

• Video

Inspection: Bodily Excretions (Effluvia)

Urine, stool, sputum, vomitus, exudates, sweatColor, odor, constancy, or smell

Examples: Acholic (clay colored) stool of biliary obstruction “Coffee ground” emesis of upper gastrointestinal

hemorrhage “Rusty sputum” of pneumococcal pneumonia Melena the black tarry stool from an upper

gastrointestinal hemorrhage has a distinct odor “Uremic frost” of severe renal failure

Recording General Observations:

Consider the patient with lung cancer with a superimposed pneumonia:

A brief statement at the beginning of the physical examination:

“A cachextic cyanotic white male sitting upright on the edge of the bed in moderate reparatory distress”

During the vital signs: Respiratory rate 24 and labored with use of accessory muscles

During parts of the physical examination: HEENT: Temporal wasting Chest: Barrel chested Skin: Cyanotic and diaphoretic

Percussion

“Method of physical examination in which the

surface of the body is struck to emit sounds that

vary in quality according to the density of the

underlying tissues.”

Percussion

Vibration produced by impact of the finger against underlying tissue

Sound waves (resonance) arise from vibrations 4 to 6 cm deep in the body tissue

The more dense the material, the quieter the tone

Techniques of Percussion

Direct Striking finger, hand, or lunar aspect of fist directly against

the body.

Indirect One finger tip (dominate middle finger) used as a hammer

(plexar) To strike the PIP joint of the middle finger of the non-

dominate hand as the PIP joint is pressed firmly against the area to be percussed (pleximeter)

Percussion Tones

Tympany Gastric air bubble

Hyperresonace Emphysemic lung

Resonance Healthy lungDullness LiverFlatness Muscle, thigh

Uses of Percussion

Sonorous percussion – determine density Definitive percussion – mapping extent of border of

an area Ex: liver It is easier to hear the change from resonance to dullness –

so proceed with percussion from areas of resonance to areas of dullness

Detection of areas of tenderness Ex: flank percussion in pyleonephritis

Palpation

Sensitive parts of the hand Tactile sense – finger pads more sensitive than

finger tips Vibratory sense – ulnar aspect of hands, palmer

metacarpalphalangeal joints Position and consistency – grasping fingers Temperature – dorsum of hand

Qualities Elicited by Palpation:

Texture – skin and hairMoisture – skinTemperature – skinMasses• Size, shape, consistency, motility, pulsatilePrecordial cardiac thrustCrepitusTendernessVocal Fremitus 

Special Methods of Palpation

Light palpation – up to 1 cm

Deep palpation – up to 4 cm

Ballottement

Fluid wave

Auscultation

HeartMurmurs, clicks, opening snap,

gallops, pericardial friction rubs and knocks

 LungsBreath sounds, whispers, voice,

crackles (rales), pleural friction rubs

 AbdomenBowel sounds, bruits 

NeckBruits – carotid, thyroid HeadBruit of AV fistula JointsCrepitus ScrotumBowel sounds from hernia

Instruments

Stethoscope Ophthalmoscope Otoscope Near vision chart Tuning forks Reflex hammer

Stethoscope

Conveys a vibrating column of air from the body wall to the ears

Does not amplify, but sounds may be altered Excludes extraneous noises

Stethoscope

Heart and lung sounds have a frequency between 60 and 3000 cycles per second

Hearing range in a young person is 30 to 20,000 cycles per second, but is dependent upon intensity.

At low intensity range is 70 to 150 cycles per second. Therefore some low-pitched sounds may be near the limits of auscultation.

Components of the stethoscope

Chest piece

Bell piece

Transmits all sounds

Low pitches are transmitted well

Lightly touch test

Should have rubber edge

Diaphragm

Filters out low pitched sounds

Isolates high pitched sounds

Press firmly

Hold between second and third fingers

Components of the stethoscope

Rubber tubing

Thick walled, stiff, and heavy

30 to 40 cm (12 to 18 inches)

Angled Biaurals

Point ear pieces towards the nose

Ear pieces

Snug

Comfortable

Ophthalmoscope• Lenses and mirrors -20 to +40 diopters• Light source• Various apertures• Small - small pupils• Red free filter - green beam, optic disc

pallor and minute vessels changes• Slit - Anterior eye, elevation of lesions• Grid - size of fundal lesions

Otoscope

Speculum narrows and directs the beam of light Glass plate magnifying glass Pneumatic attachment - TM mobility May be used for nasal examination

Tuning Forks

Auditory - 500 to 1000 HZVibratory - 100 to 400 HZ

Reflex Hammer

• Tomahawk

• Babinski

• Neurologic hammer

Other

• Safety pins

• Pen light

• Tape measure

• Ruler

• Q-tips

• Tongue blades

• Near vision chart

Near Vision Chart

Vital Signs

Vital Signs

Equipment Needed A Stethoscope A Blood Pressure Cuff A Watch Displaying Seconds A Thermometer

Temperature• Temperature can be measured is several different

ways: Oral with a glass, paper, or electronic thermometer (normal

98.6F/37C)

Axillary with a glass or electronic thermometer (normal 97.6F/36.3C)

Rectal or "core" with a glass or electronic thermometer (normal 99.6F/37.7C)

Aural (the ear) with an electronic thermometer (normal 99.6F/37.7C)

• Of these, axillary is the least and rectal is the most accurate.

Temperature:

Fever (pyrexia): elevated body temperature

Hyperpyrexia: extreme fever, > 106F/41.1C

Hypothermia: extremely low temperature< 95F/35C

False measurements:

Patient smoking or drinking hot or cold liquids

Rapid respiratory rate

Failure to use thermometer correctly

Recording:

Temperature in degrees

Which scale?

Location,

(Type of thermometer)

ex: 106F, axillary, (glass)

 

Pulse

– Sit or stand facing your patient.

– Grasp the patient's wrist with your free (non-watch bearing) hand (patient's right with your right or patient's left with your left). There is no reason for the patient's arm to be in an awkward position, just imagine you're shaking hands.

– Compress the radial artery with your index and middle fingers.

Pulse

– Note whether the pulse is regular or irregular:

Regular - evenly spaced beats, may vary slightly with respiration

Regularly Irregular - regular pattern overall with "skipped" beats

Irregularly Irregular - chaotic, no real pattern, very difficult to measure rate accurately

– Count the pulse for 15 seconds and multiply by 4.

– Count for a full minute if the pulse is irregular.

– Record the rate and rhythm.

Pulse: Interpretation

A normal adult heart rate is between 50 and 100 beats per minute

A pulse greater than 100 beats/minute is defined to be tachycardia. Pulse less than 60 beats/minute is defined to be bradycardia.

Tachycardia and bradycardia are not necessarily abnormal. Athletes tend to be bradycardic at rest (superior conditioning). Tachycardia is a normal response to stress or exercise.

Respiration

– Best done immediately after taking the patient's pulse. Do not announce that you are measuring respirations.

– Without letting go of the patients wrist begin to observe the patient's breathing. Is it normal or labored?

Respiration

– Count breaths for 15 seconds and multiply this number by 4 to yield the breaths per minute.

– In adults, normal resting respiratory rate is between 14-20 breaths/minute. Rapid respiration is called tachypnea.

Measurement of Blood Pressure

“Although the arterial blood pressure is measured many time a day by doctors all over the world, few physicians have devoted much thought to the problems and principles involved in measuring blood pressure accurately…From the very beginning, students must learn to record the blood pressure properly. Accurate blood pressure recording will then become a habit that will remain with the physician for a lifetime."

Blood Pressure:

• Systolic = highest BP in the cycle• Diastolic = lowest BP in the cycle• Pulse pressure = difference between systolic and

diastolic • Mean arterial pressure = (1/3)(SBP – DBP) + DBP

Blood Pressure:

• Hypertension– For adults >140/90– Graded by severity– Malignant hypertension = acute target organ damage

• Hypertension is a risk factor

Blood Pressure Classification

Normal <120 and <80

Prehypertension 120–139 or 80–89

Stage 1 Hypertension

140–159 or 90–99

Stage 2 Hypertension

>160 or >100

BP Classification SBP mmHg

DBP mmHg

SphygmomanometersTypesMercury-gravityAneroidAutomated Components:Pressure manometerInflatable rubber bladder within an inelastic coveringSize is importantWidth - 40% arm circumferenceLength – 80% arm circumferenceMost are markedRubber hand bulb and pressure control valve 

CUFFBLADDER

THE BLOOD PRESSURE CUFF

Technique of Blood Pressure Measurement:

The patient

Not smoking, ingesting caffeine, or vigorous activity for 30 min prior

Rest sitting comfortably for 5 – 10 min

Room quiet and warm

Arm rested and free of clothing

Technique of Blood Pressure Measurement:

Be aware of conditions which may alter BP

• Dialysis fistula

• Lymphedema

• Atherosclerosis

• Anxiety (white coat hypertension)

• Circadian variation

 

THE AUSCULTATORY GAP

THE DISAPPERANCE OF THE PHASE 1 KOROTKOFF SOUNDS IN SYSTOLE WITH REAPPEARANCE ABOVE THE DIASTOLIC PRESSURE.

AVOID BY PALPATING THE DISTAL PULSE UNTIL IT DISAPPEARS DURING CUFF INFLATION.

MECHANISM UNKNOWN ?ATHEROSCLEROTIC PLAQUE.

20% OF ELDERLY PATIENTS.

MAY LEAD TO INACCURATE SYSTOLIC AND DIASTOLIC READING. FALSELY LOW SBP OR FALSELY HIGH DBP.

150/98

200/98 WITH AN AUSCULTATORY GAP BETWEEN 170 - 150

CAVALLINI MC ANN INTERN MED 124:887-883;1996

BATES GUIDE TO THE PHYSICAL EXAMINATION 8TH ED.

Phases of the Korotkoff Sounds

Phase 1

Starts with a loud “thud”

Recorded at level when 2 beats heard in a row

Systolic

There may be an auscultatory gap

Phase 2

A blowing or swishing sound

Phase 3Softer thud than phase 1Still crispPhase 4MuffingSofter blowing sounds that

disappearsPhase 5 SilenceDiastolic

Diastolic Blood Pressure: Special Considerations: Some controversy if phase 4 or phase 5 is DBPRecorded at phase 5, disappearance of soundsUsually phase 4 and 5 are close, < 5 mm HgIf more than 10 mm Hg apart Record as:160/90/68In some patients, ex: Aortic regurgitation, sounds never

disappear.Record as: 150/70/0 

Blood Pressure1. Position the patient's arm so the anticubital fold is

level with the heart. Support the patient's arm with your arm or a bedside table.

2. Center the bladder of the cuff over the brachial artery approximately 2.5 cm above the anticubital fold. Proper cuff size is essential to obtain an accurate reading. Be sure the index line falls between the size marks when you apply the cuff. Position the patient's arm so it is slightly flexed at the elbow.

3. Palpate the radial pulse and inflate the cuff until the pulse disappears. This is a rough estimate of the systolic pressure.

4. Place the stethoscope over the brachial artery.

Blood Pressure

Blood Pressure

5. Inflate the cuff to 30 mmHg above the estimated systolic pressure. Release the pressure slowly, no greater than 5 mmHg per second. The level at which you consistently hear beats is the systolic pressure.

Blood Pressure

6. Continue to lower the pressure until the sounds muffle and disappear. This is the diastolic pressure. Record the blood pressure as systolic over diastolic ("120/70" for example).

Errors in BP Measurement

• Cuff too small

• Cuff too large

• Arm held below heart

• Loose cuff

Accurate BP Measurements

• Proper patient conditions - Sitting, relaxed, no caffeine or smoking, etc

• Errors in measurement – Cuff size, technique

• “White coat” hypertension• Pseudohypertension• Home BP measurements• 24 hour ambulatory measurements

CIRCADIAN PATTERNS OF BLOOD PRESSURE

NORMALLY BLOOD PRESSURE FALLS AT NIGHT AND EARLY MORNING.

NEJM 347:778-779;2002

Next Week

• ENT

• Eye