Medicine Lecture 2

EXAMINATION 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 Exam
Ancillary Procedures
What is Physical Examination?
Process of gathering of medical information
with the use of the examiners sense of sight,
smell, touch and hearing
When does physical examination begin?
As soon as you greet the patient and begin
the interview
X After finishing the med interview
X After ROS
X As soon as you take the vital signs
Precautions against Infection
2 ways: from Doctor to patient
From Patient to doctor
2 important methods in the spread of pathogens:
Blood-borne diseases body fluids
Respiratory-borne pathogens
WHO:
Observe
guidelines
for
Precautions and Standard Precautions

Universal

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 welllighted 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
Head and
neck

Sitting/
reclining

Anterior
torso

Sitting

Posterior
torso

Sitting

Anterior
chest and
abdomen
Male
genitalia
Gait, station,
Coordination

Supine

Female
genitalia

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

Sitting

Standing
Variable
positions

Standing beside
the patient at
bedside
Standing in front
and then behind
the patient
Standing in front
and at sides of the
patient
Standing behind
and at sides of
patient
Besides the
patient
In front of the
patient
Standing in front,
sides, and behind
the patient
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 inspection
Head: face, eyes, ears, nose, mouth
Neck
Anterior and posterior trunk
Extremities
Patient is supine:
Thorax
Abdomen

Extremities
Pelvic and Rectal Examination
Modifications of PE techniques:
With disabilities
Mobility impairment
Sensory impairment
Techniques of PE:
Inspection (looking at the body)
Palpation (feeling the body with hands)
Percussion (producing sounds)
Auscultation (listening to sounds)
Inspection
Looking at the patient (or body part), is the 1 st
step in physical examination
To inspect, expose what you wish to see
Good lighting is important
The angle of light can be used to advantage
Things to inspect:
Color, skin, mucous membrane
Size and shape (or contour)
Anatomic
landmarks,
skin
lesions,
superficial vascularity, edema, muscular
or fat distribution
Symmetry of Lack of it
Deformity, generalized or localized bulging
or swelling
Movement
Muscles, joints, respiratory, vascular,
peristaltic
Position 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 distension
Symmetry or lack of it deformity, generalized
or localized, asymmetry
Obese abdomen
Hepatomegaly
Umbilical Hernia
Color skin, skin appendages, mucous
membrane
Size and shape (or contour) skin lesions,
edema
Symmetry 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 distribution
Symmetry 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
Palpation
Method of feeling with hands during PE
Further defines things we see size, shape,
symmetry,
movement,
and
position
(combined with inspection technique)
Reveal things we cant see
Data primarily revealed by palpation:
Tenderness superficial, deep, referred,
rebound
Tonus increased resistance, spasm, rigidity
Tumor (mass) like lymph nodes or
underlying organs that generally are felt but
not seen
Texture
Temperature
Moisture
Area of the hand used for palpation:
Fingertips: texture, size, shape, consistency,
pulsations
Back of fingers temperature
Palm (hypothenar area)
- movements (heaves), vibrations (thrills)
Techniques of palpation:
Based on the number of hands used:
1-hand technique
2=hand technique
Based on amount of force applied
Light palpation
Deep palpation
One hand light palpation of large portion of the
body:
Palpating for carotid pulsations
Palpating 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 artery
Palpating for brachial artery
Palpating for dorsalis pedis artery
Palpating for posterior tibial artery
Neck palpation: Two-hand technique:
Palpation of lymph nodes of the neck
Palpation of thyroid gland
Chest palpation: two-hand technique
Respiratory movements
Chest vibrations (fremitus)

Cardiac heaves and cardiac palpations

Abdominal palpations: two-hand technique
Bimanual
technique

Important:
hand
underneath
One 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 structures
Architecture size, shape, symmetry, surface
edge
Consistency (also include fluctuations)
Tenderness (and associated redness and heat)
Mobility and attachment
Pulsation
Percussion
Method 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 plexor
Direct percussion technique (Immediate / 1 hand
technique)
- uses only the plexor, that is the direct blow to
the area
Basic percussion notes:
1. tympanic
2. resonance
3. dull
4. flat
Technique of percussion:
Percussion technique to elicit tenderness
Direct or Indirect technique
Auscultation
Method used to listen to the sounds of the
body during physical exam
Usually performed by listening through a
stethoscope
Characteristics of a good stethoscope:
Head piece combined bell and diaphragm
Tubing 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
Pitch
Location

Intensity
Duration and Timing
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
Sphygmomanometer
Flashlight
Stethoscope
Lubricating jelly
Tape measure
Flexible ruler
Visual acuity chart
Thermometer
Otoscope
Ophthalmoscope
Monofilament
Tissues
Paper towels
Tongue depressors
Pocket
eye
chart
Tuning fork (128 Hz)
Rectal gloves
Percussion hammer
Vials of coffee & cinnamon
Alcohol
or
hand sanitizer
Surgical or N95 mask
Small leather
bag