BATESVISUALGUIDETOPHYSICALEXAMINATION

Vol.1:HeadtoToeAssessment:Adult

GoodmorningMr.Morris.
Goodmorning.
ImDr.Bickley
Typically,youwillperformacomprehensivephysicalexaminationonnewpatientsorpatientsbeing
admittedtothehospital.Thisprovidesfundamentalknowledgeaboutthepatientandhelpsidentifyor
ruleoutphysicalcausesrelatedtoyourpatientshealthconcerns.
Askilledheadtotoeexaminationofadultpatientsrequiresathoroughknowledgeofthetechniquesof
examinationforeachregionofthebody.Youshouldbepreparedtodetectnormalvariationsand
abnormalfindings.

ImportanceofPatientComfort
Thepatientshealthandwellbeingshouldbetheprimaryfocusoftheexamination,butyoumust
promotethepatientspersonalcomfort,aswell.
Taketimetoadjusttheexaminingroomsenvironmentpriortotheexaminationmakingchangesin
lighting,sound,orprivacy,forexample.Bydemonstratingrespectforthepatient,youpromotethe
patientscomfortandrelaxation,whichhelpsensureasuccessfulexamination.
Anotherkeytopatientcomfortisyourattentiontoproperdrapingduringtheexamination,combined
withcommunicationaboutyourintentionsasyoumovefromoneregionalexaminationtothenext.
Yourpatientswillappreciateknowingwhyyouareadjustingtheirgownorcausingthemevenminor
discomfort.
Minimizethenumberoftimesyouaskthepatienttochangepositionsfromsittingtosupine,orfrom
supinetostanding,forexample,toassurepatientcomfort.
Developingasystematicsequenceofexaminationgreatlyaidsyourabilitytoconductanaccurate
physicalexaminationwiththoroughnessandefficiency.Withexperience,youwillacquirearoutinethat
workswellforyouandforthepatient.

GeneralSurvey&VitalSigns
Withthepatientshealthhistoryinmind,andaftergoodhandhygiene,youarereadyforthephysical
examination.

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Forahealthypatient,acompleteheadtotoeassessmentshouldtakebeginningstudentsabout2030
minutes.Withthepatientsitting,beginyourassessmentwithageneralsurvey,inspectingthepatient
closelyliterally,fromheadtotoeinordertoformimpressionsforyourlater,writtenassessment.
Notecharacteristicssuchasapparentstateofhealth,easeofbreathing,height,build,andsexual
development.
Obtainthepatientsweight.Noteposture,motoractivity,andgait,aswellasdress,grooming,personal
hygiene,andanyodorsofthebodyorbreath.
Observethepatientsfacialexpressions,andlistentothepatientsmannerofspeakingasyounotehis
orherstateofawareness.
Nowmeasurevitalsigns.
Whenmeasuringbloodpressure,selectacuffoftheappropriatesizeandpositionthepatientsarm
properly,atheartlevel.Thiswillhelpensureanaccuratereading.
Recordthepatientsheartratebycheckingtheradialorinolderadults,theapicalpulse.
Next,checkrespiration.Listentothenumberofrespirationsperminutebysubtlyplacingthe
stethoscopeoverthepatientstrachea.
Next,checkthepatientstemperature.Threemethodsarecommonlyused:oral...
...viathetympanicmembrane...
...or,attimes,rectal.
Oraltemperaturesarethemostcommon,butshouldnotbeusedforpatientswhoareunconscious,
restless,orunabletoclosetheirmouths.

TheSkin
Begininspectionofthepatientsskinbyobservingthepatientsface.Assessthefacialexpression,skin
moistureordryness,anyfacialswellingorasymmetry,andcheckforanycyanosisinthelips.
Inspectandpalpatethepatientsfingernails,lookingespeciallyforanyclubbingorcyanosis.
Continueyourassessmentoftheskinasyouexaminetheotherbodyregions.Notecolor,pigmentation,
texture,hairdistributionandthickness,andanylesions.
Lookfornevi,scars,orotherdistinguishingcharacteristics,notingtheirplacementanddimensions.
Whenyouseeneviormoles,assessformelanomasusingtheABCDEmethod...
InspectforAsymmetry...irregularBorders...Colorvariationorchange,especiallyblueorblack...Diameter
largerthan6millimeters...andElevation.

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Ifanyofthesefiveaspectsispresent,considerreferringthepatienttoadermatologistforfurther
evaluation.
Insunexposedareasflakingulceratedlesionsaresuspiciousforasquamouscellcarcinoma,andshiny
raisedlesions,forabasalcellcarcinoma.

HEENT
Next,assessthehead,eyes,ears,nose,andthroat.
Palpatethescalp,lookingforanydepressionsoftheskull,whichmightindicateheadtraumaorprevious
surgery.Inspectthehairanditstexture,lookingfornevi,lesions,orevenlice.
Inspecttheface.Notewhetherthefacialexpressionsandeyebrowsaresymmetric.
SoImgoingtoturnthelightsoutandweregoingtocheckyourpupils,okay?
Checkthecoloroftheconjunctivaandsclera,lookingforpallorintheconjunctivaoricterusinthe
sclera.Inspecteachcornea,iris,andlens,notinganyinjectionofthecornea,especiallyaroundtheiris.
Comparethepupils,andtesttheirreactionstolightandaccommodation.
Withanophthalmoscope,inspecttheocularfundi,checkingcarefullyforsharpnessofthediscmargins
andespeciallyanyblurringofthemarginssuggestingpapilledema,shownhere.
Next,examinetheearcanalanddrum,usingyourlargestearspeculumandholdingtheotoscopeatan
upwardangle.
Checkauditoryacuity.Ifacuityisdiminished,checklateralizationusingtheWebertest.
AndcompareairandboneconductionwithaRinnetest.
Next,inspecttheanteriorandinferiorsurfacesofthenose.Noteanyasymmetryordeformity.
Theninspecttheinsideofthenasalpassageswithanotoscope.
Palpateforsinustendernessbypressinguponthefrontalsinusesfromunderthebonybrows...then
pressuponthemaxillarysinuses.
Okay,Imgoingtocheckyourmouth,yourlips
Inspectthemouth,observingthesymmetry,color,andmoistureofthelips,andnoteanymasses,
ulcers,cracking,orscaliness.
Inspecttheoralmucosa,andnotethecolorofthegums,normallypink.Inspectthegummarginsand
theinterdentalpapillaeforswellingorulceration.Inspectthepatientsteethandlookforabnormalities.
Inspectthehardandsoftpalates,theuvula,tongue,andotherstructuresofthemouth.Payparticular
attentiontothefloorofthemouthandthesidesandundersurfaceofthetongue,forhereiswhere
leukoplakiaorcancerscandevelop.

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NervousSystem:CranialNerves
Next,youmaywishtoperformabriefassessmentofthetwelvecranialnerveswhilethepatientis
sittingandfacingyou.CranialNerveI,theolfactorynerve,istypicallynottestedunlessaneurological
problemissuspected.
Intheheadtotoeassessment,CranialNerveII,theopticnerve,canbeassessedwithatestforvisual
acuitybyusingaSnelleneyechart.Pupillaryresponsewastestedearlier.
CranialNervesIII,IV,andVIcontrolextraocularmovement.
Idlikeyoutolookstraightaheadjustrightovermyshoulder.AndthenIwantyoutofollowmyfinger.
Okay?
Excellent.
Next,testfortheseveralcomponentsofCranialNerveV,whichincludesmotorresponse,sensory
response,andthecornealreflex.
Alright,Idlikeyoutojustclenchyourjawforme.Alright,goodandthenImjustgoingtochecksharp
anddull,sotellmeifyourefeelinganythingbrushyourskin.Justsayyesorno.
Yes.
CranialNerveVIIisassessedbyinspectingthepatientsmovementsoffacialexpression.
Raiseyoureyebrowsforme.Goodandrelax.Squeezeyoureyestightshut.Good.Andpuffyourcheeks,
relax.Andshowmeyourteeth.Excellent.
Next,assessCranialNerveVIII,whichisresponsibleforhearing.Testoneearatatime.
Imgoingtowhisperinyourear.Andtellmewhatyouhear.[WHISPERING]Twentyone.
Twentyone.
Excellent.[WHISPERING]Fourteen.
Fourteen.
Verygood.
AssessCranialNervesIXandXbylisteningtothepatientsvoice.Isithoarse,ordoesithaveanasal
quality?
HereyoullalsoaskthepatienttosayAhortoyawnasyouwatchforsymmetricmovementofthesoft
palate,uvulaandtheinteriorandposteriorpillars,andpharynx.
ForCranialNervenumberX,warnthepatientthatyouaregoingtotestthegagreflex.Then,stimulate
thebackofthethroatlightlyoneachsideinturn.

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AssessCranialNerveXIfrombehindthepatient.Lookforatrophyorfasciculationsinthetrapezius
muscles.Askthepatienttoshrugbothshouldersupwardagainstyourhands.Notethestrengthofthe
trapezius.
Fromthefront,askthepatienttoturnhisheadtoeachsideagainstyourhand,observethecontraction
andforceoftheoppositesternomastoidandnotetheforceofthemovementagainstyourhand.Assess
the12thCranialNervebyinspectingthepatientstongueforatrophyorfasciculations.
Alright,Idlikeyoutostickoutyourtongueforme.
Then,withthepatientstongueprotruded,lookforasymmetryanddeviationfromthemidline.

TheNeck
Onceyouhavecompletedanyassessmentofthetwelvecranialnerves,inspecttheneck,bypalpating
theanteriorandposteriorcervicallymphnodes.Foreachnode,noteitssize,mobility,andany
tenderness.Noteanymassesorunusualpulsationsintheneck.
Next,palpateinthesternalnotchtocheckthepositionofthetrachea.Itshouldbemidline.
Askthepatienttotakeasipofwaterandinspectforthethyroidglandasthepatienttipshisheadback,
thenswallows.
Frominfrontofthepatient,inspectandpalpatetheregionbelowthecricoidcartilageforthethyroid
isthmusandforanyglandularenlargement.Repeatstandingbehindthepatient.

Back,PosteriorThorax,andLungs
Positionedbehindthepatient,continuebyinspectingthemusclesoftheupperback.Observeshoulder
heightforsymmetry.
Then,palpatethespineandmusclesoftheupperback.
checkyourspine.Anysorenessthereortenderness?
No,itsfine.
Inspect,palpateandpercussthechestandlungs.Percussthelungsinaladderpattern,goingfromside
tosideasyoumovedownthethoraxfromtheapicestothebasesofthelungs.Normallungsare
resonant.Locateanyareaswhereyouhearabnormalnotes.
Next,usepercussiontoidentifythelevelofdiaphragmaticdullnessandmeasuredescentofthe
diaphragm.
Toassessrespiratoryexcursion,placeyourthumbsclosetothepatientsspineatthelevelofthetenth
ribsandspreadyourhandslightlyoverthelowerthorax.

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Askthepatienttoinhaledeeplyandexhalefullywhileyouwatchthedivergenceofyourthumbsand
feelfortherangeandsymmetryofmovementofthethorax.
Usingthediaphragmofthestethoscope,observetherate,rhythm,depth,andeffortofbreathing...and
listenforadventitioussoundsthatmayindicateabnormalrespiratoryconditions.Listentoatleastone
entirebreathingcycleateachlocation,includingovertherightmiddlelobeundertheaxilla.

UpperExtremities
Onceyouhavealreadyexaminedthepatientshandsandupperback,youmaydecide,basedonyour
observations,thatamoreextensivemusculoskeletalexaminationiswarranted.
Ifso,whilethepatientremainssittingupright,inspectandpalpatethetemporomandibularjoints,
hands,wrists,elbows,shoulders,andneck.Inspectandpalpatethejoints;thenchecktheirrangeof
motion.
Fortheshoulders,assessexternalandinternalrotation.
Withthepatientstillseated,youcanperformaneurologicalexaminationofthepatientsupper
extremity.First,visuallyassessthepatientsmusclebulk.Thencheckmuscletone.
Nowtestmusclestrength.Askthepatienttosqueezeyourfingersashardashecan.
Next,testthepatientsbiceps.Thentestthetriceps...andrepeatontheotherside.
Okay,withyoureyesopen,touchmyfinger.
Next,checkforpointtopointmovement.
Andassessrapidalternatingmovements.Together,theseexerciseshelpyouassessthepatientsupper
extremitystrengthandcoordination.

Breasts
Examinationofthebreastsisimportantforbothfemaleandmalepatients.Whilethetechniquesof
examinationformenandwomenpatientsaresimilar,thefemalebreastisusuallymoredenseandits
examinationshould,therefore,bemorethorough.
Palpateinasmoothrotarymotionassessingthebreasttissueforconsistency,tenderness,andnodules
ormasses.
Inthewoman,tobegintheexamination,visuallyinspectthebreastswiththepatientseatedandher
armsathersides
Inspectthebreastswithherarmsraised.
Andwithherhandsplacesonherhips.

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Ineithersex,inspecttheaxillae,andfeelfortheaxillarynodes.Feelfortheepitrochlearnodesaswell.
Althoughexaminationofthemalebreastsmaybebrief,itshouldnotbeomitted.
Inspectforsymmetryandsize,andpalpateeachnipple,areolaandbreastfornodules.

AnteriorThoraxandLungs
Toexaminetheanteriorthorax,havethepatientremainsupineandbreathingnormally.
Observetheconditionoftheskinandinspectthechestfordeformities,asymmetry,andrespiratory
movement.
Next,palpatethechestwalltolocateanyareasoftendernessortoassessanylesionsorabnormalities.
Next,percusstheanteriorthoraxinsymmetricalareas,proceedingfromthesupraclavicularareadown
tothesixthriborbelow.Again,comparebothsides.Identifyyourpercussionnotesandtheirlocations.
Usingthediaphragmofyourstethoscope,youshouldhearbreathsoundsovertheanteriorlungfields.

CadiovascularSystem
Withthepatientsupineandelevatedtoa30degreeangle,beginthecardiacexamination.Often,the
firststepinyourcardiovascularassessmentisestimatingthejugularvenouspressure,orJVP.Measure
theJVPinrelationtothesternalangle.
Next,inspectandpalpatethecarotidpulsation.Thiswillincludebothpalpationandlisteningforbruits.
Inspectandpalpatetheprecordium.Notethelocation,diameter,amplitudeanddurationoftheapical
impulse.
Listenateachauscultatoryareainsixpositions.
Startwiththediaphragmofthestethoscopeattherightuppersternalborderandtheleftupper
sternum.
Listenattheleftlowersternalborderandtheapexwiththebell.
S1islouderattheapexandS2islouderatthebase.ListenforphysiologicsplittingofS2attheleftupper
sternalborder.Alsolistenforanyabnormalheartsoundsormurmurs.

Abdomen
Lowerthetableflat.Exposethesupinepatientsabdomen,drapingthelowerabdomenatthesupra
pubiclevel.First,listenforactivebowelsounds.
Imgoingtolistentoyourabdomen.

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Palpatelightly,thendeeply.
Assesstheliverandspleenbypercussionandthenpalpation.Trytofeelthekidneysandpalpatethe
aortaanditspulsations.

PeripheralVascularSystem
Examinetheperipheralvascularsystembypalpatingthefemoralpulses,thenthepoplitealpulses.
Palpatetheinguinallymphnodes.Inspectforlowerextremityedema,discoloration,orulcers.Palpate
forpittingedema.Assessthepedalpulses.Withthepatientstanding,inspectforanyvaricoseveins.
Withthepatientremainingsupine,youmaywishtocompletethemusculoskeletalexamination.
Examinethehips,legs,knees,ankles,andfeet.Inspectandpalpatetheseareasfortenderness,
deformities,nodules,swelling,corns,orcalluses.

LowerExtremities
Tocompletetheneurologicalexamination,assesslowerextremitystrength,bulk,tone,sensation,
reflexes,andBabinskistocompleteyourexaminationofthenervoussystem.
Inspectthepatientsmusculoskeletalsystembothsupineandstanding.
Withthepatientstanding,examinethealignmentofthespineanditsrangeofmotion,aswellasthe
alignmentofthelegsandfeet.
Observethepatientsgaitandabilitytowalkheeltotoeandwalkonthetoes,theheels,hopinplace
anddoshallowkneebends.DoaRombergtestandcheckforpronatordrift.

NervousSystem
Acompleteexaminationofthenervoussystemcanbedoneatthispointifnotdoneearlier.Itconsists
offivesegments.

Mentalstatus

Cranialnerves

Motorsystem

Sensorysystem

Reflexes

Thementalstatusisdeterminedbyassessingthepatientsorientation,mood,thoughtprocessand
content,abnormalperceptions,insight,andjudgment.

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Aspreviouslyoutlined,thetwelvecranialnervesmaybeexaminedhere.
Themotorsystemconsistsofexaminationofmusclebulk,tone,andtestsofstrengthofmajormuscle
groupsoftheupperandlowerextremities.
Assessmentofthesensorysystemevaluatespain,andifindicated,temperature,lighttouch,vibration,
proprioception,anddiscrimination.
Testthereflexesofbiceps,triceps,brachioradialis,patellar,andAchillesdeeptendonreflexesandthe
Babinskis.
Genitalandrectalexaminationsareoftenperformedattheendoftheheadtotoeexamination.

GenitalandRectal
Theexaminationofmalepatientsbeginswithinspectionofthegenitalia...continueswithinspectionof
thesacrococcygealandperianalareas...andincludespalpationoftheanalcanal,rectum,andprostate.
Genitalandrectalexaminationsoffemalepatientsbeginwithinspectionoftheexternalgenitalia,and
continueswithaspeculumexaminationofthevaginaandcervix,includingapapsmearandculturesif
indicated.
Theclinicianmayalsoperformabimanualexaminationoftheuterusandadnexa...followedbythe
rectovaginal...andrectalexaminationsifindicated.
Payparticularattentiontodrapingduringtheseexaminations,andwheneverpossible,continueto
minimizethepatientsexposure.

RecordingYourFindings
Rememberthataclear,wellorganizedclinicalrecordemployinglanguagethatisneutral,professional,
andsuccinctisoneofthemostimportantadjunctstopatientcare.
[TYPING]Thepatientisofmediumheightandweight.Middleaged,andresponsiveofthequestions.He
isrelaxed.Hisskiniswarmandmoist.Heiswellgroomed

Summary
Afterpracticeandfurtherreviewofthisvideo,makesureyouhavemasteredtheimportantlearning
objectivesforexaminingthepatientheadtotoe.
Themoreadeptyouareattheprincipalsofclinicalreasoning,patientinterviewingandtherapeutic
supportthemoreeffectiveyourphysicalexaminationwillbetothewellbeingofyourpatient.

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