CLINICAL METHODS I

B.Sc. Physician Assistantship – Medical

ROUTINE PHYSICAL EXAMINATION

BY
EBENEZER KISSI OWUSU
 THE FORMAT OF THE
EXAMINATION

The examination techniques in medicine may seem

forced and unnaturally formulaic at first, but these
routines ensure that no part of the examination is
missed.
THE RIGHT APPROACH
One important rule is that you should always stand at
the patient's right hand side.

This gives them a feeling of control over the situation

(most people are right handed).

All the standard examination techniques are formulated

with this orientation in mind.
 THE SYSTEMS EXAMINATIONS

• The physical examination can be broken into body

systems.

• You often need to examine several systems at a time

and it is then that you must combine your learnt
techniques.
For example, you may wish to examine the patient's
thorax with a view to the cardiovascular and
respiratory systems, listening for both heart and
breath sounds during your auscultation stage rather
than completing the heart exam and then returning
to examine the chest.
 THE EXAMINATION FRAMEWORK
Each system examination is divided into the following
categories: (Vol. 1 pp 52)

• Inspection (looking).
• Palpation (feeling).
• Percussion (tapping).
• Auscultation (listening).
In addition, there may be special tests and other added
categories.
 Principles of Examination of the Systems

After the general examination of the patient, one is now

ready to examine the patient system by system. Irrespective
of the system one is examining one must go through four
basic processes in the correct sequence.

If one does this all the time one is unlikely to miss any
important findings.
The processes are:-

1. INSPECTION
2. PALPATION
3. PERCUSSION
4. AUSCULTATION
 Scheme for Routine
Examination
GENERAL

o General appearance
o Gait
o Hair
o Eyes
o Face
o Mouth and pharynx
o Neck
o Upper limbs
o Lower limbs
o Spine and joints
o Thorax (anteriorly, laterally and posteriorly)
o Abdomen
o Examination of Pelvic and Rectal (excreta)
 General
o General appearance (does the patient look healthy,
unwell or ill, well cared for or infected)

o Intelligence and educational level

o Mental state

o Expression and emotional state

o Build and posture

o Nutrition, Obesity, Oedema

o Skin colour, cyanosis, anaemia, jaundice, pigmentation,

o Skin eruptions, petechiae, spider naevi, vitiligo

(luecoderma)

o Body hair

o Deformities, swelling

o Temperature, pulse, respiration rate

Features of endocrine disease e.g. hyperlipidaemia,
acromegaly, Cushing’s syndrome

Hair

o Texture, colour, distribution

Eyes

o Simple test of visual acuity

o Exophthalmus or enophthalmus

o Ptosis
o Oedema of the lids

o Conjunctivae: anaemia, jaundice, inflammation

o Pupils: size, equality, regularity, reaction to light,

accommodation.

o Eye movement: nystagmus, strabismus

o Ophthalmoscopic examination of the fundi and ocular

chambers

o Face
Faces

o Jaws movements

o Facial symmetry or asymmetry

o Rash

o Features of endocrine disease or hyperlipidaemia

Mouth and pharynx

o Breath odours

o Lips; colour and eruptions

o Tongue; protrusion and appearance

o Teeth and gums; Dentures – Cosmetics? Meals?

o Buccal mucous membrane; colour and pigmentation

Pharynx
o Movement of the soft palate
o State of tonsils
Neck
o Movement, pain, range
o Veins
o Lymphatic glands
o Thyroid
o Carotid pulses and bruits
 Upper limbs

o General Examination of the arms and hands

o Fingernails; clubbing or koilonychias

Spine and joints

o Pulse; rate, rhythm, volume, and character

o State of arterial wall of radials and brachials

o Axillae; lymph glands

o Blood pressure
o Muscles; muscle wasting, fasciculation

o Test for power, tone, reflexes and coordination

o Cutaneous sensation; check all modalities to

exclude root or nerves lesions

o Joint; movement, pain, and swelling, rheumatoid

nodules and xanthelasma at elbows.
Lower limbs

o General Examination of the legs and feet

o Stance, balance and gait

o Oedema of feet, ankles

o Varicose vein

o Muscles; muscles wasting, fasciculation

o Test for power, tone, reflexes (including plantar response)

and coordination
o Joints; movement, pain and swelling

o Peripheral pulses

o Temperature of feet

Examination of excreta

o Urine, sputum, stool, vomitus: examination by

naked eyes, and measure or estimate amount.

o Test urine for SG, sugar, protein, blood.

THANK YOU
Cardiovascular System
Examination
Presenting Complaint
• Chest pain
• Shortness of breath
• Ankle swelling
• Palpitations
• Syncope
• Intermittent claudication
Chest Pain
• Character of pain • Relieving factors
• Severity • Worse on taking a deep
• Duration breath (pleuritic)
• Radiation • Worse on movement
• At rest or on exertion • Autonomic symptoms
• Sweating
• Previous episodes
• Nausea
Causes of Chest Pain
• Cardiovascular • Chest wall
• Angina • Coughing
• Stable
• Intercostal muscle strain/myositis
• Unstable
• Myocardial infarction • Herpes zoster
• Aortic dissection • Viral pleurodynia
• Myocarditis • Thoracic radiculopathy
• Pleuropericardial • Rib fracture
• Pericarditis • Rib tumour
• Pleurisy • Costochondritis
• Pneumothorax
• Gastrointestinal
• Gastro-oesophageal reflux
• Oesophageal spasm
Dyspnoea
• Unexpected awareness of breathing
• At rest or on exertion
• Quantify exercise tolerance (yards walked, stairs climbed)
• Orthopnoea = shortness of breath on lying supine
• Number of pillows
• Paroxysmal nocturnal dyspnoea
Causes of Dyspnoea
• Airways disease
• COPD • Chest wall
• Chronic bronchitis • Pleural effusion
• Emphysema • Rib fracture
• Asthma • Kyphoscoliosis
• Bronchiectasis • Neuromuscular
• Cystic fibrosis • Cardiac
• Parenchymal disease • Left ventricular failure
• Pneumonia • Mitral valve disease
• Pulmonary fibrosis • Cardiomyopathy
• Tumour • Pericardial effusion
• Pneumothorax • Other
• Pulmonary vasculature • Anaemia
• Pulmonary embolism • Acidosis
• Pulmonary hypertension • Psychogenic
Pulmonary Oedema

Normal Chest Pulmonary

Radiograph Oedema
Ankle Swelling
• Unilateral or bilateral • Drugs
• Proximal extent of oedema • Calcium channel blockers

• Pitting/non-pitting • Other
• Cirrhosis
• Cardiac • Nephrotic syndrome
• Congestive cardiac failure • Protein-losing enteropathy
• Right ventricular failure • Deep vein thrombosis
• Cor pulmonale • Hypothyroidism
• Constrictive pericarditis • Lymphoedema
Palpitations
• = Unexpected awareness of heartbeat • Sinus tachycardia
• Ask patient to tap palpitations on • Ventricular extrasystoles
chest • Atrial fibrillation
• Slow or fast • Atrial flutter
• Regular or irregular • Supraventricular tachycardia
• Duration • Ventricular tachycardia
• Speed of onset or offset
• Relieving manoeuvres
Syncope
• = Transient loss of consciousness due to cerebral
hypoperfusion
• What was the patient doing at the time?
• Standing for prolonged period
• Standing up suddenly (postural hypotension)
• Coughing
• Prodromal symptoms
• Abnormal movements (epilepsy)
• Sensation of room spinning (vertigo)
Intermittent Claudication
• Pain in one or both calves, thighs or buttocks
• Brought on by walking a certain distance (claudication distance)
• Worse on walking uphill
• Relieved by rest
• Suggests peripheral vascular disease
 Risk factors for Ischaemic Heart
Disease
1. Hyperlipidaemia
2. Diabetes mellitus
3. Smoking
4. Hypertension
5. Obesity
6. Family history
Past Medical History
• Rheumatic fever
• Previous cardiac investigations
• Previous myocardial infarction
• Coronary angioplasty + stent insertion
• Coronary artery bypass grafting
• Pacemaker insertion
Medications
• Anti-anginal agents
• Use of sublingual nitrate spray
• Antihypertensive agents
• Anti-arrhythmics
• Statins
• Platelet inhibitors, e.g., Aspirin
• Anticoagulants, e.g., Warfarin
• Allergies
• NB Document in front of chart and inform nurses
Social History
• Occupation
• e.g., train driver, long distance truck driver
• Smoking
• Number of pack years
• Alcohol intake
• Stairs at home
Family History
• Ischaemic heart disease
• Angina
• MI
• CABG
• Hypertrophic obstructive cardiomyopathy
• Dilated cardiomyopathy
HOCM
Physical Examination
• General • Precordium
• Hands • Inspection
• Palpation
• Pulse • Percussion
• Blood pressure • Auscultation
• Face • Back
• Neck • Abdomen
• Jugular venous pressure • Lower limbs
• Other
Examination - General
• Position patient at 45 degrees
• Respiratory rate
• Cachexia
• Marfan’s syndrome
• Down’s syndrome
Did Abraham Lincoln have Marfan’s Syndrome?

High arched
palate
Examination - Hands
• Clubbing
• Splinter haemorrhages (infective endocarditis)
• Osler’s nodes (tender)
• Janeway lesions (non-tender)
• Xanthomata (Hyperlipidaemia)
 Splinter
Haemorrhages

Clubbing
Splinter Haemorrhages
Splinter Haemorrhages
Janeway lesions
Janeway
lesions
Osler’s nodes
Examination - Pulse
• Character and volume assessed
• Radial artery from carotid artery
• Rate (normal = 60-100) • Collapsing pulse (aortic
• Bradycardia (<60) regurgitation)
• Tachycardia (>100)
• Pulsus alternans (left ventricular
• Rhythm failure)
• Regular
• Irregular
• Pulse deficit (atrial fibrillation)
• Radiofemoral delay (coarctation of the
aorta)
Examination - Blood Pressure
• Sphygmomanometer • Deflate at 4 mmHg/s
• Systolic/diastolic pressure • Difference between arms of
• Normal <140/90 mmHg <10 mmHg
(lower in diabetes) • Pulsus paradoxus =
• Korotkoff sounds exaggerated reduction in BP
with inspiration (>10
• Use larger cuff width for mmHg)
large arms
• Postural hypotension
Examination – Face and Neck
• Jaundice • Central cyanosis
• Xanthelasmata • Carotid pulse character
• Corneal arcus • Slow rising (AS)
• Bisferiens (AS + AR)
• Malar flush (mitral • Collapsing (AR)
stenosis) • Alternans (LVF)
• High arched palate • Jerky (HOCM)
(Marfan’s syndrome) • Carotid bruit
• Dental caries (infective
endocarditis)
Eye signs in Hyperlipidaemia

CORNEAL XANTHELASMATA
ARCUS
Jugular Venous Pressure
• Patient at 45 degrees • Fills from above
• Good lighting • Hepatojugular reflux
• Internal jugular vein • Abnormal if >3 cm above zero
• Reflects right atrial pressure point:
• RV failure
• Zero point = sternal angle • RV infarct
• Visible but not palpable • Tricuspid stenosis
• Tricuspid regurgitation
• Complex wave form (a, c, v
waves) • Pericardial effusion
• SVC obstruction
• Decreases on inspiration • Fluid overload
Precordium - Inspection
• Scars
• Median sternotomy
• CABG
• Valve replacement
• Lateral thoracotomy Sternotomy
scar
• Infraclavicular (pacemaker)
• Pectus excavatum
Pectus
• Pacemaker box excavatum
• Apex beat
Precordium - Palpation
• Apex beat
• Location
• Character
• Heaving
• Thrusting
• Double
• Tapping
• Paradoxical
• Left parasternal heave
• Thrills (palpable murmurs)
• Systolic
• Diastolic
• Palpable P2 (pulmonary hypertension)
• Pacemaker box
Precordium – Auscultation
Heart Sounds
• Bell – low pitched sounds
• Diaphragm – high pitched sounds
• Mitral  Tricuspid  Pulmonary
 Aortic areas
• S1 (first heart sound)
• S2 – Splitting (A2, P2)
Precordium – Auscultation
Murmurs
• Timing of murmur
• Pitch
• Systolic
• Diastolic • Radiation
• Continuous • Dynamic manoeuvres
• Site of maximal intensity • Respiration
• Left-sided  on exp.
• Loudness • Right-sided  on insp.
• Grades I-VI • Valsalva
• Thrill • Squatting (exaggerated)
The intensity or loudness of murmur is graded over a
scale of 4.

• Grade 1 The murmur is heard quietly in an ordinary

room.
• Grade 2 The murmur is moderately loud.
• Grade 3 The murmur is loud and it is also accompanied
by a thrill.
• Grade 4 The murmur is audible even without a
stethoscope.
Grade 1: A quiet murmur that can be heard only after
careful auscultation over a localised area.
Grade 2: A quiet murmur that is heard immediately once
the stethoscope is placed over its localised
PMI.
Grade 3: A moderately loud murmur.
Grade 4: A loud murmur heard over a widespread area,
with no thrill palpable.
Grade 5: A loud murmur with an associated precordial
thrill.
Grade 6: A murmur sufficiently loud that it can be heard
with the stethoscope raised just off the chest
surface.
Heart Murmurs
• Systolic
• Pansystolic • Diastolic
• Mitral regurgitation • Early diastolic
• Tricuspid regurgitation • Aortic regurgitation
• Ventricular septal defect • Pulmonary regurgitation
• Ejection systolic • Mid-diastolic
• Aortic stenosis • Mitral stenosis
• Pulmonary stenosis • Tricuspid stenosis
• HOCM • Atrial myxoma
• Atrial septal defect • Continuous
• Late systolic • Patent ductus arteriosus
• Mitral valve prolapse • Arteriovenous fistula
• Pericardial friction rub
Examination – Back
• Percuss and auscultate lung bases
• Left ventricular failure
• Pleural effusion
• Sacral pitting oedema
• Right heart failure
Examination - Abdomen
• Patient lying with one pillow (if tolerated)
• Tender hepatomegaly
• Pulsatile liver (tricuspid regurgitation)
• Ascites
• Splenomegaly
• Abdominal aortic aneurysm
Examination – Lower Limbs
• Peripheral oedema
• Palpate arteries
• Pitting/non-pitting
• Femoral
• Upper level
• Popliteal
• Achilles tendon • Posterior tibial
xanthomata • Dorsalis pedis
• Capillary return • Buerger’s test (peripheral vascular
disease)
• Trophic skin changes
Peripheral Pulses

Dorsalis pedis Posterior tibial

pulse pulse
Examination - Other
• Urinalysis
• Haematuria (infective endocarditis)
• Fundi
• Hypertensive retinopathy
• Roth spots (infective endocarditis)
• Temperature chart
• Infective endocarditis
THE END
 CLINICAL METHODS I

B.Sc. Physician Assistantship – Medical

ROUTINE PHYSICAL EXAMINATION

BY
EBENEZER KISSI OWUSU
 Examination of the
RESPIRATORY SYSTEM
(Chest and Lungs)

Physical Exam Techniques

• Inspection

• Palpation

• Percussion

• Auscultation
1. The patient must be properly undressed and gowned
for this examination.

2. Ideally the patient should be sitting on the end of an

exam table.

3. The examination room must be quiet to perform

adequate percussion and auscultation.
4. Try to visualize the underlying anatomy as you
examine the patient.
Thorax (anteriorly and laterally)
1. Type of chest, asymmetry if any

2. Breast and nipples

3. Respiration; rate, depth and character

4. Pulsation

5. Dilated vessels

6. Position of trachea by palpation

7. Look for and palpate apex beat

8. Palpate over precordium for thrills

9. Palpate cervical and axillary glands

10. Palpate respiratory movement

11. Estimate tactile vocal fremitus

12. Percuss the lungs

13. Auscultate the heart/breath sounds

14. Perform Egophony

15. Perform Whispered Pectoriloquy

16. Estimate vocal resonance,

Chest Topography:
Anterior Chest
Chest Topography:
Lateral Chest
Chest Topography:
Posterior Chest
Fissures:
Location of
Lobes
5. Observe the patient for
general signs of
respiratory disease (finger
clubbing, cyanosis, air
hunger, etc.).
Schamroth’s Sign
Observation: Clubbing
Observation:
Breathing Patterns
• Eupnea

• Tachypnoea/Bradypnoea

• Biot’s

• Cheynes-Stokes

• Kussmaul
Inspection
1. Observe the rate, rhythm, depth, and effort of breathing.
Note whether the expiratory phase is prolonged.

2. Listen for obvious abnormal sounds with breathing such

as wheezes.

3. Observe for retractions and use of accessory muscles

(sternomastoids, abdominals).
Observation: Thoracic Contour (cont.)
• Pectus Excavatum

• Pectus Carinatum

• Kyphosis

• Scoliosis

• Kyphoscoliosis

• Symmetry of chest movement

Observation:
Thoracic Contour
4. Observe the chest for asymmetry, deformity, or
increased anterior-posterior (AP) diameter.

5. Confirm that the trachea is near the midline?

6. Check for presence of clubbing and cyanosis.

Palpation: Tracheal
Alignment
Tracheal Alignment Abnormalities

• Pneumothorax – shifts to unaffected side

• Pleural Effusion – shifts to unaffected side

• Fibrosis or Atelectasis – shifts towards affected side

• Pulmonary consolidation – no shift

Posteriorly (patient sitting)

 Inspect and palpate respiratory movement

 Estimate tactile vocal fremitus

 Percuss the lungs resonance

 Auscultate the breath sounds

 Estimate vocal resonance, cervical and axillary glands

 Palpate from behind; cervical glands, thyroid

 Look for sacral oedema

Anterior Chest
Tactile fremitus
• Apices to MCL
• Side to side
• Symmetry expected
Palpate chest wall
Palpation: Vocal Fremitus
• BILATERAL comparison of
vocal vibrations
• Increased with alveolar
consolidation
• Decreased with increased
distance between lung
and chest wall
• Pneumothorax, Pleural
effusion
ESTIMATION OF CHEST EXPANSION
Palpation : Chest
Excursion
 Palpation
1. Identify any areas of tenderness or deformity by
palpating the ribs and sternum.

2. Assess expansion and symmetry of the chest by

placing your hands on the patient's back, thumbs
together at the midline, and ask them to breath
deeply.

3. Check for tactile fremitus.

Percussion
• Assess density of underlying tissue
Percussion – (Proper
Technique)
1. Hyperextend the middle finger of one hand and place
the distal interphalangeal joint firmly against the
patient's chest.

2. With the end (not the pad) of the opposite middle

finger, use a quick flick of the wrist to strike first finger.

3. Categorize what you hear as normal, dull, or hyper-

resonant.
4. Practice your
technique until you
can consistently
produce a "normal"
percussion note on
your (presumably
normal) partner
before you work with
patients.
Objective Data-Anterior Chest
Percussion
• Dullness over breast tissue, liver,
cardiac borders
• Tympany over gastric
Auscultation
• Displace breast and listen over
chest wall
Posterior Chest
Percussion
• Find predominant note
over lung fields
• Begin at apices
• Use same pathway side to
side
 Percussion Notes
• Resonance – normal

• Dullness – increased density

• Atelectasis, alveolar filling/consolidation, pleural effusion,
fibrosis

• Hyperresonance – decreased density

• Hyperinflation (COPD), Pneumothorax
Lung Percussion Sounds
• Resonance: non-musical; healthy lung
• Hyper-resonance: slightly musical; too much air, i.e.
emphysema/pneumothorax
• Dull: muffled; organ or abnormal density, i.e.
pneumonia
• Flat: soft thud; i.e. muscle mass, bone
 Auscultation of the
Chest
• Auscultation of the chest is part of every chest
examination but it is the data collected during
inspection, palpation, and percussion that alert the
clinician what to listen for during auscultation in order
to identify the correct diagnosis most effectively
The stethoscope is an instrument
that does not significantly
amplify sound, but, more
important, acts as a selective
filter of sound.
• Briefly, the bell filters high-frequency sounds greater
than 1500 cycles per second and therefore should be
used to detect low-frequency sounds.

• On the other hand, the diaphragm selectively filters low-

frequency sounds. Since sounds produced by breathing
tend to be of relatively high pitch, the chest is
auscultated with the diaphragm.
Anterior Chest
Auscultation
• Use diaphragm of
stethoscope; place
firmly
• One full breath at each
position
• Use same pathway
– side to side
comparison
Posterior Chest
Auscultation
• Use diaphragm of stethoscope;
place firmly
• One full breath at each position
• Use same pathway
• side to side comparison
Breath Sounds
• Bronchial
• Loud, harsh sounds over trachea
• Bronchovesicular
• Moderate, mixed sounds over bronchi
• Vesicular
• Soft, rustling sounds over periphery
Decreased or Absent
Obstruction
• Secretions, mucus plug, foreign body
Emphysema
• Loss of elasticity; air already in lungs
Silent chest
• No air is moving in or out of lungs; ominous sign
Increased Sounds
Bronchial sounds heard over wrong area
• Solid tissue conducts sounds to surface better
• Found in pneumonia with consolidation or fluid
in intra-pleural space
 Adventitious Sounds
Crackles (Rales): Fine
• Fine, discontinuous high-pitched,
short crackling sound on inspiration
which are not cleared by
coughing. (Roll a strand of hair at
ear)
• Found in pneumonia and heart failure
Adventitious Sounds

Crackles: Coarse
• Loud, low-pitched bubbling or gurgling
sounds
• Start in inspiration, may be in expiration
• Decrease with coughing, but comes back
• Found in pulmonary oedema and
terminally ill with suppressed cough reflex
 Adventitious Sounds
Wheeze: High pitch
• High-pitched, musical squeaking
sound that predominates with
expiration
• Indicates narrowed passageway
• Obstruction from acute asthma or
chronic emphysema
Adventitious Sounds

Wheeze Low-pitch
• Single note which is more prominent
on expiration
• Air flow obstruction
• bronchitis or tumor
Adventitious Sounds
Stridor
• High-pitched, crowing sound with inspiration
• Louder in neck
• Upper airway obstruction
• Croup, acute epiglottis, or foreign body
inhalation
Objective Data-Anterior Chest
Inspect
• Shape and configuration
• Facial expression
• Level of consciousness
• Color and condition
• Respiration rate/quality
Anterior Chest
Symmetric chest
expansion
• Place hands at costal
margins
• Equal movement of
thumbs with inhaling
Questions?