A guide to PHYSICAL EXAMINATION

This lecture deals with matters belonging to the art of medicine As a logical first step in preparation for a career in health care, you study the biological science and then follow with the acquisition of new attitudes, skills, and knowledge that extend your capabilities beyond an understanding of biological systems and disease processes. Finally, you must develop your understanding and action capabilities relative to the emotional components of human illness and the attitudes and behavior that inevitably influence the patient-physician relationship.

General Objective
After completing a skill practice of physical examination on adult, the student will be able to perform general physical examination technique correctly

Step I

: Development of data base History Physical examination Laboratory studies Special studies

Step II

: Making the problem list Assessment

Step III : Selection of significant data Step IV : Creation of hypotheses

Step V

: Testing validity of hypotheses Does diagnosis fit findings ? Are expected findings present ? Diagnostic Therapeutic Educational

Step VI : Making a plan

Step VII : Recording the progress Subjective Objective Assessment Plan

Specific Objectives
At the end of skill practice, the student will be able to :
Perform measurement of blood pressure Perform measurement of pulse rate Perform measurement of respiratory rate Perform measurement of body temperature Perform physical examination of the head Perform physical examination of the neck Perform physical examination of the thorax Perfom physical examination of the abdomen Perform physical examination of the extremities

An approach to symptoms General symptoms : BW, fatigue, weakness, fever The skin The head The eyes The ear, nose and sinuses The mouth, throat and neck The breasts The chest The gastrointestinal tract The genital system The peripheral vascular system The musculoskeletal system The nervous system The hematologic system The endocrine system
Chapter 2

Perform physical examination of Genitourinary Perform Speculum examination Perform Vaginal examination Perform Vaginal examination

Head:

Neck :

Eyes : signs of anemia, icteric

Masses in the neck, lymph node

Chest : Shape, symmetry, movement, spider naevi, tumor Breast : Size, contour, masses, nipples, discharge

Lungs : Respiratory movement, resonance, percussion (sonor, dull), vocal fremitus Breath sound, effort

Cardiovascular : Heart : size, apex impulse (location,character), thrill, enlargement, rate, rhythm, sounds (intensity, quality, murmurs, gallops, clicks) Peripheral vascular : Character and quality of pulse, bruits

Abdomen : Shape, liver, spleen Masses (location, size,consistency, mobility, tenderness, rebound tenderness, rigidity) Uterus (in obstetrics : fundal height; gynecologic: enlargement - description as mass)
Lymph node : Inguinal lymph node

Examination
Observe patient's appearance :
level of consciousness general health measure height and weigth

Vital sign:
Blood pressure Pulse rate Respiratory rate Body temperature

Mental status Component of mental functions : Level of consiousness (attention, orientation, memory) - Normal - Drowsiness or obtundation - Stupor - Coma The Glasgow Coma Scale (score 3 to 15) : opening of the eyes, verbal responses and motor responses Thought processes

Physical examination General survey : - Apparent state of health - Sign of distress - Skin color and possible lesions - Stature and habitus height - Sexual development - Weight - Posture, gait and motor activity - Odors of body or breath - Facial expression - speech Vital sign : BP, pulse & resp. rate, the body temperature Inspect, palpate, percuss and ausculate. Depends on the organ system. Note : anatomy & physiology
Chapter 4 & 5

The body temperature The average oral temperature : 37oC - In the early morning hours : 35,8oC - In the late afternoon or evening : 37,3oC Rectal temperatures average 0,4 0,5oC higher than oral readings

Chapter 4

TECHNIQUES OF EXAMINATION The arterial pulse :

- Rate : when the rhythm is irregular heart rate - Rhythm : regular or irregular ? - Amplitude and contour : These are best assessed in the carotic or brachial arteries (fig.280) Try to assess : 1. The amplitude of the pulse (small, weak pulses & large) 2. The contour of the pulse wave (the speed of its upstroke, the duration of its summit, and the speed of its downstroke). 3. Any variation in amplitude a. From beat to beat (pulsus alternans, bigeminal) b. With respiration (paradoxical) - Bruit and thrills
Chapter 9

 The arterial pulse : - Rate : when the rhythm is irregular heart rate - Rhythm : regular or irregular ? - Amplitude and contour - Bruit and thrills

Definition of Blood Pressure

Pressure against arterial wall when the heart pumps the blood to the whole body Pressure is determined by:
Force and blood volume Size and flexibility of artery

Principal of blood pressure measurement

Recording not the blood pressure directly in the artery, but the arterial counter pressure by squeezing the artery on which the pressure is measured

Bladder Size
Must be adapted with the arm circumference Width must be equal at least 40% of the arm circumference:
Arm circumference: 30 cm bladder: 12 cm

Children: 9 cm Adult: 12 cm Obese: 15 cm

Technique of blood pressure measurement

Difference
Systolic blood pressure
Underestimate 10 mmHg

Diastolic blood pressure:

Overestimate 10 mmHg

Blood Pressure: 140/90 mmHg Arterial Pressure?

THE SKIN Inspect & palpate Color : - Increased or loss of pigmentation, redness, pallor, cyanosis & yellowing of the skin - Peripheral cyanosis (the nails & skin of extrimities) anxiety, cold exposure, venous obstruction - Central cyanosis (the lips, buccal mucosa & tongue) CHD, abN hemoglobins & advanced lung disease Moisture : dryness (hypothyroidism), sweating, oiliness (acne) Temperature Mobility & turgor Lesions : location, distribution, grouping & type of lesions and color Nails Hair Chapter 6

KEPALA DAN LEHER Penderita menunjukan daerah yang sakit Inspeksi dan palpasi daerah temporomandibula Inspeksi : dicatat adanya kelainan : - perubahan bentuk/ deformitas - perubahan warna kulit, dll Palpasi : Dipalpasi sendi temporomandibula Pemeriksa berdiri di depan penderita, dengan jari telunjuk diletakkan didepan telinga penderita Jari akan masuk ke rongga sendi, saat penderita membuka mulut Dinilai juga lingkup gerak sendi Raba adanya pembengkakan, atau nyeri tekan : >>>> arthritis

THE HEAD AND NECK Inspect & palpate The head : - Hair - Face - Eyes - Sinuses - Nose - Ears - Lips - Mouth - Tongue - Pharynx The neck : - Lymph node - Thyroid gland : isthmus & lateral lobes - Trachea - Jugular Vein
Chapter 7

EYE : Edema ? exophthalmus ? Or ptosis ? Madarosis ? Icterus konjunctiva : anemia, cyanosis, pigmentation, ptecheae, Sinus : Press and percussion on sinus paranasalis area Pain pathologi Sinusitis >>> Nose : Form, smell, Obstruction Pain ?

MOUTH : Tongue : Form and characteristic color Atrophy ( sliding ), geoghrafic / scrotal Teeth: Caries, distance , prothese, Abnormality of Gums : Hypertrophy, hemorhagic LIPS : Cyanosis

NECK : Trigonum anterior Trigonum posterior Submandibula Regio Supraclavikula Regio v.jugularis

Trachea Thyroid

Inspeksi : Pada leher terhadap adanya deformitas dan posisi abnormal Palpasi : Processus spinosus cervical dan jaringan lunak sekitarnya meliputi otot trapezius, sternocleidomastoidie Catat apabila ada kelainan atau nyeri Periksa lingkup gerak sendi leher ( posisi O dengan pandangan kedepan ) flexi : gerak dahu menyentuh dada Normal 40o Rotasi : gerak dahu menyentuh bahu Normal 70o Lateral : gerak telinga menyentuh bahu tanpa menaikkan bahu Normal 40o Extensi : gerak kepala ke belakang N : 55o

Pada ankylosing spoylotis : leher kaku/ tak bisa bergerak dengan deformitas khas

Kelainan yang sering ditemukan pada wajah : Acromegali : Kepala memanjang dengan tonjolan tulang dahi Hidung, dan rahang bawah Myxedem : Muka sembab, udem sekitar mata, rambut alis lateral rontok, non pitting edem kulit kasar kering Sindroma nefrotik : Muka edem, pucat, sembab di sekitar mata Sindroma cushing : moon face, pipi kemrehan kadang rambut muka bertambah

Pembesaran kelanjar parotis, Cretinisme, SLE, CRF, Sianosis

Jugular venous pressure and pulses Important determinants of systemic venous pressure : 1. blood volume 2. venous tone 3. the capacity of the right heart to receive blood and to eject it onward into the pulmonary arterial system
-The pressure in jugular veins, which reflects right atrial pressure, can be estimated clinically. The best estimate is made form the internal jugular veins. These are impossible the external jugular vein The usual zero point for this estimate is the sternal angle (5 cm above the RA) Elevating the head of the bed to about 150 to 300 from the horizontal for most normal people. (fig. 276)

THE ABDOMEN
Anatomy and physiology
(fig. 339-341)

Techniques of examination General approach 1. Supine position 2. Should not have a full bladder 3. Should keep arm 4. Ask the pts to point to any areas of pain 5. Have warm hands, a warm stethoscope and short fingernails 6. Approach slowly, avoid quick 7. Distract the pts if necessary with conversation 8. Very frightened ? Begin palpation with his or her own hand 9. Watching the patientss face for signs or discomfort

Chapter 11

THE ABDOMEN
Inspection The skin : Scars Striae : pink purple striae of Cushings syndrome Dilated veins : hepatic cirrhosis, inferior vena cava obstruction Rashes and lesions The umbilicus Contour and location Any sign of inflammation Hernia The contour of abdomen : flat ? Peristalsis Pulsations : aortic aneurysm, increased pulse pressure
Chapter 11

THE ABDOMEN
Palpation Light palpation (fig 350) Deep palpation (fig 351) Assessment for peritoneal irritation (rebound tenderness) The liver (fig 352) The spleen (fig 354, 355) The kidneys : (fig 356) A normal left kidney is rarely palpable Causes of kidney enlargement : hydronephrosis, cysts, tumors polycystic (bilateral enlargement) Kidney tenderness : costovertebral angle (fig 357) The aorta : pulsation (fig 358)
Chapter 11

THE ABDOMEN
Special maneuvers 1. To Assess possible ascites : Test for shifting dullness Test for a fluid wave (fig 359) (fig 360)

2. To identify an organ or a mass in an ascitic abdomen Try to ballotte the organ or mass

3. To assess possible appendicitis

4. To assess possbile acute cholescystitis (Murphys sign) 5. To assess ventral hernias 6. To distinguish an abdominal mass from a mass in the abdominal wall
Chapter 11

THE ABDOMEN
Percussion The liver The spleen Ascitic Fluid (fig 347, 348) (fig 349)

Solid or fluid-filled masses

Air in the stomach and bowel Auscultation Bowel sounds Bruits (fig 346)

Chapter 11

II. Ekstrimitas atas a. Tangan dan pergelangan tangan a. Periksa lingkup gerak sendi jari2 dari pergelangan tangan dengan menyuruh penderita mengepalkan tangan dan kemudian dibuka dan diekstensikan. Normal : dapat menggenggam dan membuka dengan mudah Abnormal : Arthritis, tenosytis, contracture b. Pergelangan tangan ( tangan dan lengan bawah dalam satu garis) Periksa lingkup gerak sendi pergelangan tangan Fleksi : gerak tangan ke arah ventral N : 90o Extensi : gerak tangan kearah dorsal N : 70o Radiasi deviasi : gerak tangan kearah radius N 20o Ulnar deviasi : gerak tangan kea rah ulnar N 35o Inspeksi : tangan dan pergelangan tangan, catat apabila adanya pembengkakkan, eritema, nodul, deformitas ataupun atrophi otot.

Kelainan kelainan : BEHERDENS Node : Nodul keras pada bagian dorsolateral dari distal sendi interphalangeal Terdapat pada Osteo arthritis Pada rheumatoid artritis biasanya mengenai sendi yang proksimal

Siku ; Pemeriksaan lingkup gerak sendi siku Posisi siku lurus Plexi : gerak tangan kearah bahu N 160o Ekstensi : gerak berlawanan dengan fleksi N 0 5o Pronasi dan supinasi dari lengan bawah pada sendi radioulnaris Supinasi : gerakan palmar marnus ke atas N 90o Pronasi : gerakan palmar marnus ke arah bawah N 90o Inspeksi dan palpasi siku Permukaan extensor ulna dan processus olecranon Catat bila ada pembengkakan atau nyeri Kelainan : Olecranon bursitis : student below Rheumatoid nodulus Arthritis Lateral epicondylitis : Tenis elbow

EKSTRIMITAS BAWAH Penderita diperiksa dalam keadaan tidur terlentang

A. Kaki dan pergelangan kaki Inspeksi : seluruh kaki dan pergelangan kaki deformormitas, nodul, benjolan, pembengkakan calus Acute gouty arthritis : Sering pada sendi metacorpophalangeal : bengkak, nyeri, panas, nodus uricemi Hallus valgus : Ibu jari abduksi pada sendi metatarso -phalangeal pertama

Palpasi : dengan ibu jari dipalpasi bagian depansendi pergelangan kaki Catat : nyeri, edem atau lainnya Sepanjang tendo achiles diraba, Apakah ada nyeri, pembengkakan, nodul >> rheumatoid nodule, achiles tendinitis, bursitis

B. LUTUT melibatkan tulang patela, femur, dan tibis Titik yang perlu diketahui : condylus tibia lateral condylus tibia medial tuberositas tibia epicondylus femus lateral epicondylus femur medial Patela tendon patela Ligamentum coloterale lateral dan medial Ligamentum crucial anterior dan posterior

Perform physical examination of Genitourinary :

Inspect ulcers, warts, swelling, redness, other lessions including skin irritation, vaginal introitus

Perform Speculum examination :

Vagina : examine the entire wall and fornices for masses, other lessions Portio/uterine ostium : discharge, bleeding, size and lession of portio Colposcopic examination : for early cervical neoplasia/malignancy

Perform Vaginal examination :

Palpate any swelling or masses, give further description about location, size, consistency, pain or contact bleeding, also bulging and tenderness of fornices Define the size and consistency of portio, palpate any mass/enlargement Define the size, consistency, alignment of uterus, any mass in or originating from the uterus. Give detail descriptions Palpate any mass in the adnexal area, give further description if exists, tenderness

Perform Rectovaginal toucher :

Describe the condition of hymen (if necessary), identify or confirm pelvic masses
Rectovaginal toucher is the key in physical diagnosis for pelvic masses when vaginal toucher is not enabled, this also helps in identifying the pelvic organs. Give further details of the mass. Identify any tenderness