Medicine Lecture 2EXAMINATION TECHNIQUES

Physical Diagnosis- Process of collecting medical information,

organize them and come up with an analysis (hypothesis) of the disease process affecting the patient

- Gathering medical data + diagnostic reasoning

Methods of Gathering Medical Information:Medical Interview (history taking)

- Gather symptoms: clinical manifestations of diseases told by the patient; subjective medical data (something that the patient tells the doctor)

Physical Examination- Gather signs of diseases: clinical

manifestations of diseases that the doctor gathered

Laboratory ExamAncillary Procedures

What is Physical Examination? Process of gathering of medical information with the use of the examiner’s sense of sight, smell, touch and hearing

When does physical examination begin?As soon as you greet the patient and begin

the interviewX After finishing the med interviewX After ROSX As soon as you take the vital signs

Precautions against Infection

2 ways: from Doctor to patientFrom Patient to doctor

2 important methods in the spread of pathogens:Blood-borne diseases – body fluidsRespiratory-borne pathogens

WHO: Observe guidelines for Universal Precautions and Standard Precautions

Bodily Fluids requiring Universal Precautions:Blood, semen, vaginal secretions, synovial fluid, amniotic fluid, CSF, pleural fluid, peritoneal fluid, pericardial fluid

Bodily Fluids not requiring Universal Precautions:

Feces, nasal secretions, urine, vomitus, perspiration, sputum, saliva

Protective clothing may include but is not limited to:

Hospital or barrier gowns, medical gloves, eyewear (goggles or glasses), face shields, hair nets, shoe coverings, surgical mask, N95 respiratory

Respiratory hygiene/cough etiquette Hand washing and instrument infection

Starting a Physical Examination Examine the patient in a quiet and well-

lighted private room Ask permission of the patient before

beginning Explain the procedure to the patient

Address the patient politely, communicate respect and a genuine interest in the patient welfare

Make the patient as comfortable as possible, properly draped and positioned

Only the region or part of the body under study is adequately exposed

Every effort is made to assure privacy and decency of patient

Avoid embarrassing the patient Proceed with the exam in an orderly and

systematic manner

Vital signs, general inspections

Sitting/ reclining

Standing beside the patient at bedside

Head and neck

Sitting Standing in front and then behind the patient

Anterior torso

Sitting Standing in front and at sides of the patient

Posterior torso

Sitting Standing behind and at sides of patient

Anterior chest and abdomen

Supine Besides the patient

Male genitalia

Standing In front of the patient

Gait, station, Coordination

Variable positions

Standing in front, sides, and behind the patient

Female genitalia

Reclining on examining table, draped, knees flexed, legs adducted, feet in stirrups

Sitting in stool at times or standing

Steps in Physical Examination with Reference to Body Parts:

General Examination General Survey Vital Signs

Regional Exam (by area or by system) Skin HEENT Thorax

Breast Respiratory Cardiovascular

Abdomen Extremities

Steps in Physical Examination with Reference to patient position:

Patient is standing: Station and gait

Patient is seated:Vital signs and general inspectionHead: face, eyes, ears, nose, mouthNeckAnterior and posterior trunkExtremities

Patient is supine:ThoraxAbdomenExtremities

Pelvic and Rectal Examination

Modifications of PE techniques:With disabilitiesMobility impairmentSensory impairment

Techniques of PE:Inspection (looking at the body)Palpation (feeling the body with hands)Percussion (producing sounds)Auscultation (listening to sounds)

InspectionLooking at the patient (or body part), is the 1st

step in physical examinationTo inspect, expose what you wish to seeGood lighting is importantThe angle of light can be used to advantage

Things to inspect:Color, skin, mucous membraneSize and shape (or contour)

Anatomic landmarks, skin lesions, superficial vascularity, edema, muscular or fat distribution

Symmetry of Lack of itDeformity, generalized or localized bulging or swelling

Movement Muscles, joints, respiratory, vascular,

peristalticPosition and Posture

Gait

2 reference points to follow: Anatomy Compare one side of the body with the other

(symmetry)

Color: skin, skin appendages, mucous membrane

Ex: jaundice, cyanosis Color

Size and shape (or contour), skin lesions, edema

Ex: gangrene, ulcer Color

Size and shape (contour) - Superficial Vascularity, muscular or fat distribution

Ex: Spider Angiomata (liver cirrhosis)Muscle wasting

Symmetry or lack of it - thoracic deformities:Pectus excavatum – congenital disorder; in

growing sternum inside the chest

Pectus carinatum Size and shape (or contour) – dimension of body

structures or body parts, bulging or distensionSymmetry or lack of it – deformity, generalized or localized, asymmetry

Obese abdomenHepatomegalyUmbilical Hernia

Color – skin, skin appendages, mucous membraneSize and shape (or contour) – skin lesions, edemaSymmetry or lack of it – generalized, or localized asymmetry

Cellulitis – punctuate yellowish discoloration; postules; orange peel appearance

Lymphedema

Size and shape (or contour) – superficial vascularity, muscle or fat distributionSymmetry or lack of it – asymmetry, generalized or localized

Caput medusae (venous collaterals) – superficial veins portal hypertension

Gynecomastia Movement – muscle, joints, respiratory,

vascular, peristaltic Position and Posture

Gait: propulsive gait Scissors gait Spastic gait Steppage gait Waddling gait

PalpationMethod of feeling with hands during PEFurther defines things we see – size, shape, symmetry, movement, and position (combined with inspection technique)Reveal things we can’t see

Data primarily revealed by palpation:Tenderness – superficial, deep, referred, reboundTonus – increased resistance, spasm, rigidityTumor (mass) – like lymph nodes or underlying organs that generally are felt but not seenTextureTemperatureMoisture

Area of the hand used for palpation:Fingertips: texture, size, shape, consistency, pulsationsBack of fingers – temperaturePalm (hypothenar area)

- movements (heaves), vibrations (thrills)

Techniques of palpation:Based on the number of hands used:

1-hand technique2=hand technique

Based on amount of force appliedLight palpationDeep palpation

One hand light palpation of large portion of the body:

Palpating for carotid pulsationsPalpating for cardiac heaves (palm)Palpating for apex beat (fingertips)

One hand deep palpation of large portion of the body

One hand palpation of peripheral structures:Palpating for radial arteryPalpating for brachial arteryPalpating for dorsalis pedis arteryPalpating for posterior tibial artery

Neck palpation: Two-hand technique:Palpation of lymph nodes of the neckPalpation of thyroid gland

Chest palpation: two-hand techniqueRespiratory movementsChest vibrations (fremitus)Cardiac heaves and cardiac palpations

Abdominal palpations: two-hand techniqueBimanual technique – Important: hand

underneathOne hand over the other technique

Side by side technique Abdominal two hand deep palpation technique

Deep palpation of the liver Abdominal Palpitation: Hooking technique Peripheral Palpation: two-hand technique

Palpation of popliteal artery

Tumors or masses should be evaluated for:Location and relationship to other structuresArchitecture – size, shape, symmetry, surface edgeConsistency (also include fluctuations)Tenderness (and associated redness and heat)Mobility and attachmentPulsation

PercussionMethod of tapping body parts with fingers, hands, or small instruments, as part of a PE. What we do in effect is to produce sound vibrations and listen to what it sounds like. The purpose is to evaluate the size, consistency, borders, and presence and absence of fluid in body organs

Indirect percussion technique (Mediate / 2 hand technique)- uses pleximeter hand and plexorDirect percussion technique (Immediate / 1 hand technique)- uses only the plexor, that is the direct blow to

the area

Basic percussion notes:1. tympanic2. resonance3. dull4. flat

Technique of percussion:Percussion technique to elicit tendernessDirect or Indirect technique

AuscultationMethod used to listen to the sounds of the

body during physical examUsually performed by listening through a stethoscope

Characteristics of a good stethoscope:Head piece – combined bell and diaphragmTubing – thick-walled, diameter of internal

bore (5-6mm), ideal length (12-15 inches)

Earpieces – selected to fit comfortably the external auditory canals, the axis of each earpiece should parallel to the long axis of the auditory canal

Properties of Sound:Quality IntensityPitch Duration and TimingLocation Radiation

Special Maneuvers A procedure that is performed by examiner with or without the participation of the patient in order to elicit a response (sign or symptoms or its absence), that indicates a particular or a group of disease(s)Ex: Abdominal fluid wave Shifting dullness

Romberg test Tinels sign

Anterior and posterior drawer, etc

Equipments for Physical Examination:Cotton wisp

SphygmomanometerFlashlight StethoscopeLubricating jelly Tape measureFlexible ruler Visual acuity chartThermometer OtoscopeOphthalmoscope MonofilamentTissues Paper towelsTongue depressors Pocket eye chartTuning fork (128 Hz) Rectal glovesPercussion hammerVials of coffee & cinnamon Alcohol or hand sanitizerSurgical or N95 mask Small leather bag