General Physical Examination

Mr. Nasib Ur Rahman

Demonstrator Health Technology
Institute Of Paramedical Sciences (IPMS)
Khyber Medical University Peshawar
LECTURE OUT LINE

 Introduction
 Steps in preparing for the physical
examination
 Physical Examination Head - to - Toe
 Additional Examination
 References
 Introduction
Physical examination is the process of evaluating objective
anatomic findings through the use of Inspection,
palpation, percussion, and auscultation.
The information obtained must be thoughtfully
integrated with the patient's history and pathophysiology
Before you begin the adult physical examination, take time to
prepare for the tasks ahead. Think through your approach to the
patient, your professional demeanor, and how to make the
patient feel comfortable and relaxed.
Review the measures that promote the patient’s physical
comfort and make any adjustments needed in the environment
Steps In Preparing For The Physical
Examination
1. Reflect on your approach to the patient.
2. Adjust the lighting and the environment.
3. Check your equipment.
4. Make the patient comfortable.
5. Observe standard and universal precautions.
6. Choose the sequence, scope, and positioning of
examination.
 1. Reflect On Your Approach To
The Patient
As you greet the patient, identify yourself
E.g. ( I am Dr. ABC Designation)
It's common to forget parts of an exam initially. If needed, review
those areas out of sequence.
Don't hesitate to return to the patient later to check any missed
items.
Beginners need to spend more time than Experience
clinicians on selected portions of the examination, such as the
funduscopic examination or cardiac auscultation.
for example, “I would like to spend extra time listening to your heart
and the heart sounds, but this doesn’t mean I hear anything wrong.”
Patients often feel anxious during a physical exam, worrying about
being exposed or experiencing pain.
They value your care and attention. With this in mind, the skillful
clinician is thorough without wasting time, systematic but flexible
and gentle, yet not afraid to cause discomfort should this be
required.
The skillful clinician examines each region of the body, and at the
same time senses the whole patient, notes when the patient shows
signs of discomfort or concern, like a quick facial expression or look
of anxiety, and shares information that explains, and reassures.
As a beginner, avoid interpreting your findings:
You are not the primary caregiver, so your views might be premature
or incorrect. As you gain experience, sharing findings will be more
suitable. If the patient has concerns, talk to your teachers. If you
find serious issues, avoid showing shock or negative
reaactions.
 2. Adjust The Lighting And The Environment

 Several environmental factors affect the caliber of your examination.

For the best results, it is important to create the environment so that
both you and the patient are comfortable
 Adjust the bed to a good height and ask the patient to move or change
positions as needed to make the exam easier.
 Ensure the room is well-lit so you can see clearly. Minimize
distractions and make the space comfortable and private.
 This helps you perform a thorough examination and makes the patient
feel at ease.
 Good lighting and a quiet environment enhance what you see
and hear but may be hard to arrange.
 Do the best you can.
 3.Check Your Equipment
Equipment necessary for the physical examination includes the following
An ophthalmoscope and an otoscope. If you are examining children,
the otoscope could allow pneumatic otoscopy.
● A flashlight or penlight
● Tongue depressors
● A ruler and a flexible tape measure, preferably marked in
centimeters
● Thermometer
● A watch with a second hand
● A sphygmomanometer
● A stethoscope
● A visual acuity card
● A reflex hammer
● Tuning forks, both 128 Hz and 512 Hz
 CONTI…

● Cotton swabs
● Two test tubes (optional) for testing temperature
sensation
● Gloves and lubricant for oral, vaginal, and rectal
examinations
● Vaginal specula and equipment for cytologic and
bacteriologic studies
● Paper and pen or pencil, or desktop or laptop
computer
 4. Make The Patient Comfortable

Patient Privacy and Comfort

 Your access to the patient’s body is a unique and time-honored privilege of your
role as a clinician. Showing sensitivity to privacy and patient modesty must be
ingrained in your professional behavior and conveys respect for the patient’s
vulnerability.
 Close nearby doors, draw the curtains in the hospital or examining room,
and wash your hands carefully before the examination begins
 During the examination, be aware of the patient’s feelings and any
discomfort. Respond to the patient’s facial expressions and even
ask, “Are you okay” or “Is this painful” to elicit unexpressed
worries or sources of pain.
 Draping the Patient
 You will acquire the art of covering the patient with a gown or
sheet during an examination to ensure their privacy and comfort
while allowing access to the areas being examined.
 5. Observe Standard And Universal
Precautions
The Centers for Disease Control and Prevention (CDC) have issued
several guidelines to protect patients and examiners from
the spread of infectious disease.
Key situations where hand hygiene should be performed include:
A. Wear gloves before touching a patient.
B. Wash your hands before leaving the patient's area,
C. after touching the patient or their environment,
D. after contact with bodily fluids or wounds,
E. before doing tasks like setting up an IV, when moving
from a dirty to a clean area on the patient,
F. and after removing gloves.
Use soap and water when hands are visibly soiled (e.g., blood,
body fluids), or after caring for patients with known or suspected
infectious diarrhea
 Cardinal Techniques Of Examination
Inspection : systematic visual examination of a patient to detect any physical signs,
abnormalities. This involves looking at the patient's appearance, behavior, and the
condition of various body parts
Palpation: Use the pads of your fingers to feel for skin changes like bumps or
warmth, check lymph nodes, pulses, and the shape and size of organs and masses,
and feel for joint issues
Percussion: Use of the striking or plexor finger, usually the third, to
deliver a rapid tap or blow against the distal pleximeter finger, usually
the distal third finger of the left hand laid against the surface of the chest
or abdomen, to evoke a sound wave such as resonance or dullness from the
underlying tissue or organs. This sound wave also generates a tactile vibration
against the pleximeter finger.
• Auscultation:
• Use of the diaphragm and bell of the stethoscope to detect the
characteristics of heart, lung, and bowel sounds, including location,
timing, duration, pitch, and intensity.
• For the heart, this involves sounds from closure of the four valves, extra sounds
from blood flow into the atria and ventricles, and murmurs. Auscultation also
permits detection of bruits or turbulence over arterial vessels.
 6. Choose The Sequence, Scope, And Positioning Of The
Examination

Sequence of Examination
Organize your comprehensive or focused examination around three general goals:
■ Maximize the patient’s comfort.
■ Avoid unnecessary changes in position.
■ Enhance clinical efficiency
• In general, move from “head to toe.” Avoid examining the
patient’s feet, for example, before checking the face or mouth.
• You will quickly see that some segments of the examination are best
assessed when the patient is sitting, such as examination of the head
and neck and the thorax and lungs, whereas others are best obtained
with the patient supine, such as the cardiovascular and abdominal
examinations.
• Examining from the Patient’s Right Side:
• This is the standard position for the physical examination and has
several advantages compared with the left side
• for example,
 Estimates of jugular venous pressure are more reliable
 The palpating hand rests more comfortably on the apical impulse
 The right kidney is more frequently palpable than the left

• Examining the Patient at Bedrest:

• If you need to examine a patient at bedrest, especially in the hospital,
where patients frequently cannot sit up in bed or stand. This often dictates
changes in your sequence of examination. You can examine the head,
neck, and anterior chest with the patient lying supine.
• Then, roll the patient onto each side to listen to the lungs, examine the
back, and inspect the skin. Roll the patient back and finish the rest of the
examination with the patient again supine.
 Physical Examination “Head To
Toe’’
General Survey

Look at the patient’s overall health, height, body type, and sexual development.
Note posture, motor activity, and Manner of walking; dress, grooming, and personal
hygiene; and any odors of the body or breath.
Watch the patient’s facial expressions and note manner, affect, and reactions to
people and the environment. Listen to the patient’s speech, and note the state of
awareness or level of consciousness.
• Vital Signs

Measure the blood pressure. Count the pulse and respiratory rate. If indicated,
measure the body temperature.
• Skin
Observe the skin of the face and its characteristics. Assess skin moisture or
dryness and temperature. Identify any lesions, noting their location,
distribution, arrangement, type, and color. Inspect and palpate the hair
and nails. Study both surfaces of the patient’s hands. Continue your
assessment of the skin as you examine the other body regions
Head, Eyes, Ears, Nose, Throat (HEENT)
Head: Examine the hair, scalp, skull, and face.
Eyes: Check visual acuity and screen the visual fields.
 Note the position and alignment of the eyes.
Observe the eyelids and inspect the sclera and conjunctiva of
each eye. With oblique lighting, inspect each cornea, iris, and
lens. Compare the pupils, and test their reactions to light.
Assess the extraocular movements.
With an ophthalmoscope, inspect the ocular fundi.
 Ears: Inspect the auricles, canals, and drums. Check auditory acuity. If acuity is diminished,
check lateralization (Weber test) and compare air and bone conduction (Rinne test).

 Nose and sinuses: Examine the external nose; using a light and a nasal speculum, inspect the
nasal mucosa, septum, and turbinate's. Palpate for tenderness of the frontal and maxillary
sinuses.
 Throat (or mouth and pharynx): Inspect the lips, oral mucosa, gums, teeth, tongue, palate, tonsils,
and pharynx.
 Neck:
 Inspect and palpate the cervical lymph nodes. Note any masses or unusual pulsations in
the neck. Feel for any deviation of the trachea. Observe the sound and effort of the
patient’s breathing. Inspect and palpate the thyroid gland.
 Back:
 Inspect and palpate the spine and muscles of the back. Observe shoulder height for symmetry
 Posterior Thorax and Lungs:
 Inspect and palpate the spine and muscles of the upper back. Inspect, palpate, and percuss the
chest. Identify the level of diaphragmatic dullness on each side. Listen to the breath
sounds; identify any adventitious (or added) sounds, and, if indicated, listen to the transmitted
voice sounds
 Breasts, Axillae, and Epitrochlear Nodes:
 In a woman, inspect the breasts with her arms relaxed, then elevated, and
then with her hands pressed on her hips. In either sex, inspect the axillae and feel
for the axillary nodes. Feel for the Epitrochlear nodes.
 Anterior Thorax and Lungs
 Inspect, palpate, and percuss the chest. Listen to the breath sounds, any adventitious
sounds, and, if indicated, transmitted voice sounds.
 Cardiovascular System
 Observe the jugular venous pulsations and measure JVP in relation to the
sternal angle. Inspect and palpate the carotid pulsations. Listen for carotid
bruits.
 Elevate the head of the bed to ∼30º for the cardiovascular examination,
adjusting as necessary to see the jugular venous pulsations.
 Inspect and palpate the precordium . Note the location, diameter, amplitude, and
duration of the apical impulse.
 Listen at each auscultatory area with the diaphragm of the stethoscope.
Listen at the apex and the lower sternal border with the bell. Listen for the first
and second heart sounds and for physiologic splitting of the second heart sound. Listen
for any abnormal heart sounds or murmurs.
 Abdomen
 Inspect, auscultate, and percuss the abdomen. Palpate lightly, then
deeply. Assess the liver and spleen by percussion and then
palpation. Try to palpate the kidneys. Palpate the aorta and its
pulsations. If you suspect kidney infection, percuss posteriorly over
the costovertebral angles
 Lower Extremities

 Examine the legs, assessing three systems while the patient is still supine.
Each of these three systems can be further assessed when the patient
stands.
 With the patient supine:
 1.Peripheral vascular system. Palpate the femoral pulses and, if
indicated, the popliteal pulses. Palpate the inguinal lymph nodes.
Inspect for lower extremity edema, discoloration, or ulcers. Palpate for
pitting edema.
 2. Musculoskeletal system. Note any deformities or enlarged joints.
If indicated, palpate the joints, check their range of motion, and perform any
necessary maneuvers.
 3 Nervous system. Assess lower extremity muscle bulk, tone, and strength;
also assess sensation and reflexes. Observe any abnormal movements.
 With the patient standing:
 ■ Peripheral vascular system: Inspect for varicose veins.
 ■ Musculoskeletal system: Examine the alignment of the spine and its
range of motion, the alignment of the legs, and the feet.
 ■ Genitalia and hernias in men: Examine the penis and scrotal contents
and check for hernias.
 ■ Nervous system: Observe the patient’s gait and ability to walk heel-
to-toe, walk on the toes, walk on the heels, hop in place, and do shallow knee
bends. Do a Romberg test and check for pronator drift
Nervous System:
The complete examination of the nervous system can also be done
at the end of the examination. It consists of the five
segments:
(mental status, cranial nerves, motor system, sensory system, and
reflexes)
Mental Status: If indicated and not done during the interview,
assess the patient’s orientation, mood, thought process,
thought content, abnormal perceptions, insight and judgment,
memory and attention, information and vocabulary, calculating
abilities, abstract thinking, and constructional ability.
Cranial Nerves: If not already examined, check sense of
smell, strength of the temporal and masseter muscles,
corneal reflexes, facial movements, gag reflex, and
strength of the trapezia and sternocleidomastoid
muscles.
Motor System: Assess muscle bulk, tone, and strength of major
muscle groups..
Sensory System: Assess pain, temperature, light touch,
vibration, and discrimination.
Reflexes: Including biceps, triceps, brachioradialis,
patellar, Achilles deep tendon reflexes; also plantar
reflexes or Babinski response
 Additional Examinations
 The rectal and genital examinations are often performed at the
end of the physical examination. Patient positioning is as indicated
 Genital and Rectal Examination in Men:
 Inspect the sacrococcygeal and perianal areas. Palpate the anal canal,
rectum, and prostate. If the patient cannot stand, examine the genitalia
before doing the rectal examination.
 Genital and Rectal Examinations in Women:
 Examine the external genitalia, vagina, and cervix. Obtain a Pap smear.
Palpate the uterus and adjoining organ bimanually. Perform the rectal
examination if indicated

• Bates’ Guide to Physical Examination and History Taking ( PDF Drive )

Chapter No. 1 (Foundations for Clinical Proficiency )
Page No. (14 – 22)