2Today’s Agenda Overview of course Exam techniques and use of equipment Vital signs
3Introduction to the Medical Profession Not an introduction, but a beginningA new type of learning experienceThe study of the patientThe study of illness as opposed to disease
4IMP is a two year course IMP I IMP II Primary Care Externship Communication and InterviewingPhysical ExaminationClinical Decision Making - EBMIMP IIAdv. Communication and InterviewingPhysical DiagnosisRadiology, Laboratory and problem-solvingClinical Decision Making-EBM
5Student Goals:To understand the underlying anatomy and physiology of the normal physical examinationTo be able to perform a complete screening physical examination in a logical fashion with minimal discomfort to the patient.To be able to recognize normal findings on the physical examination
7Physical ExaminationLecture seriesSmall group sessionCSTAC
8Assessment Multiple choice examination Practical examination History Physical examination
9Basic Clinical Skills 70% of diagnosis can be based on history alone 90% of diagnosis can be made when the physical examination is addedExpensive tests often confirm what is found in the H&P
10“The major effort in becoming a diagnostician consists in acquiring the intellectual background to make his or her perceptions meaningful - in short, he or she must practice and study.”DeGowin and DeGowin
11Physical Examination: Two Tiers of Investigation Screening or Comprehensive ExaminationThe foundation of clinical skillsUsesUndifferentiated patientNew patientPt wishing a “complete” H&P
12Physical Examination: Two Tiers of Investigation Extended or Problem-Focussed ExaminationPhysician follows leadsUsually involves an extended assessment of a system or region
13Physical Examination Knowledge Base Technical Skills Perceptual Skills Exam skillsUse of equipmentPerceptual SkillsSensoryInterpretationCommunication SkillsInterpersonal Skills
14Knowledgebase Normal examination Anatomy Physiology Techniques EquipmentExpected normal findingsNormal variationsChanges with ageExtrapolation to common abnormalities
15Learning the Physical Examination A key to a thorough and accurate physical examination is developing a systematic sequence of examination
16Learning the Physical Examination An important goal is to minimize the number of times you ask the patient to change positions
17Learning The Physical Examination Systems Approach Regional ApproachSmall group sessions with preceptorLecture seriesReading BatesPracticeReview session with SPs
18Format of Small Group Sessions: Read material ahead of timeUse objectives as a guideDo the practice questions and review with preceptorPractice exam techniquesUse checklist as a guideline
26Examination Techniques and Equipment Objectives for each section:General AppearanceAppreciate the importance of observationExam techniquesInspectionList what some examples of what to look for in general observationList a few conditions that are diagnosed from general inspectionThe type of lighting is best for observing couturePercussionDefinition of percussionTypes of percussionUses of percussionThe technique of percussionBe able to perform direct and indirect percussionThe percussion notes and what they indicateRecognize percussion notesBe able to interpret physical exam findings based on percussion
28Observation (Inspection): Least mechanical part of the physical examinationHardest to learnYields the most physical signsMore diagnoses are made by inspection than all others combinedDepends upon the knowledge of the observer
29How to Observe Keep your eyes open Keep an open mind Ask questions Learn what to observeReflect on what you have observed and look for what you may have missed
30Finished files are the re- sult of years of scientif-ic study combined withthe experience of years.
31Observation“Never mind,” said Holmes, laughing; “it is my business to know things. Perhaps I have trained myself to see what others overlook. If not, why should you come to consult me?”“A case of Identity” from Adventures of Sherlock Holmes
32“The precise and intelligent recognition and appreciation of minor differences is the real essential factor in all successful medical diagnosis” - Joseph Bell, MD (1890)The character of Sherlock Holmes was based on Dr. Bell, an English surgeon who taught Arthur Conan Doyle during medical school.
33Enhancing Your Powers of Observation Learning physical examination techniques is all about becoming a better observerA skilled clinician has enhanced powers of observation and the knowledge to use these observations in the care of patients
34“Don’t touch the patient - state first what you see; cultivate your powers of observation.” Sir William Osler
35“The student must teach the eye to see, the fingers to feel, and the ear to hear.” Sir William Osler
37Observation: What you see What you hear (listening) Know what to look forWhat you hear (listening)Olfactory diagnosisWhat you feel emotionally
38Observation: Inspection Least mechanical aspect of the physical examinationHardest to learnYields the most physical signsMore diagnosis are made by inspection than all other techniques combinedDepends upon the knowledge of the observer
39InspectionBegins when you first see the patient and ends when they leaveSystematic part of each component of the physical examinationPart of the mental status examinationSubtle observations probably account for “the sixth sense” of astute clinicians
40Inspection: General Appearance State of consciousnessSigns of distress (sick or not sick?)Apparent state of healthSkin:discoloration or obvious lesionsDress, grooming, and personal hygieneFacial expressionGait and postureMotor activity
42Inspection: General Appearance State of nutritionBody habitusSymmetryStated age vs. physiologic ageMood, attitude, affectSpeechOlfactory diagnosisBodily excretions (Effuvia)
43Olfactory Diagnosis:“Medical olfaction can often be an important aspectof clinical examination if clinicians approach patientencounters with an “open nose” as well as an openmind.”Hayden, GF: Olfactory diagnosis in medicine, Post Graduate Medicine,1980
44Olfactory Diagnosis: “Characteristic patient odors accompany many diseases and intoxications, and theirrecognition can provide diagnostic clues,guide the laboratory evaluation, and affect thechoice of immediate therapy.”Hayden, GF: Olfactory diagnosis in medicine, Post Graduate Medicine,1980
45Inspection: Olfactory Diagnosis: Detection of ingestions or toxinsAlcoholTobaccoTolueneCyanideDetection of certain infectionsAnaerobicNecrotic materialDiagnosis of certain diseasesFruity; acetone like = Diabetic ketoacidosisUrine-like = UremiaInborn errors of metabolism
47Inspection: Bodily Excretions (Effluvia) Urine, stool, sputum, vomitus, exudates, sweatColor, odor, constancy, or smellExamples:Acholic (clay colored) stool of biliary obstruction“Coffee ground” emesis of upper gastrointestinal hemorrhage“Rusty sputum” of pneumococcal pneumoniaMelena the black tarry stool from an upper gastrointestinal hemorrhage has a distinct odor“Uremic frost” of severe renal failure
60Recording General Observations: Consider the patient with lung cancer with a superimposed pneumonia:A brief statement at the beginning of the physical examination:“A cachextic cyanotic white male sitting upright on the edge of the bed in moderate reparatory distress”During the vital signs: Respiratory rate 24 and labored with use of accessory musclesDuring parts of the physical examination:HEENT: Temporal wastingChest: Barrel chestedSkin: Cyanotic and diaphoretic
61Percussion surface of the body is struck to emit sounds that “Method of physical examination in which thesurface of the body is struck to emit sounds thatvary in quality according to the density of theunderlying tissues.”
62PercussionVibration produced by impact of the finger against underlying tissueSound waves (resonance) arise from vibrations 4 to 6 cm deep in the body tissueThe more dense the material, the quieter the tone
63Techniques of Percussion DirectStriking finger, hand, or lunar aspect of fist directly against the body.IndirectOne finger tip (dominate middle finger) used as a hammer (plexar)To strike the PIP joint of the middle finger of the non-dominate hand as the PIP joint is pressed firmly against the area to be percussed (pleximeter)
65Uses of Percussion Sonorous percussion – determine density Definitive percussion – mapping extent of border of an areaEx: liverIt is easier to hear the change from resonance to dullness – so proceed with percussion from areas of resonance to areas of dullnessDetection of areas of tendernessEx: flank percussion in pyleonephritis
66Palpation Sensitive parts of the hand Tactile sense – finger pads more sensitive than finger tipsVibratory sense – ulnar aspect of hands, palmer metacarpalphalangeal jointsPosition and consistency – grasping fingersTemperature – dorsum of hand
67Qualities Elicited by Palpation: Texture – skin and hairMoisture – skinTemperature – skinMassesSize, shape, consistency, motility, pulsatilePrecordial cardiac thrustCrepitusTendernessVocal Fremitus
68Special Methods of Palpation Light palpation – up to 1 cmDeep palpation – up to 4 cmBallottementFluid wave
69AuscultationHeartMurmurs, clicks, opening snap, gallops, pericardial friction rubs and knocksLungsBreath sounds, whispers, voice, crackles (rales), pleural friction rubsAbdomenBowel sounds, bruitsNeckBruits – carotid, thyroidHeadBruit of AV fistulaJointsCrepitusScrotumBowel sounds from hernia
70Instruments Stethoscope Ophthalmoscope Otoscope Near vision chart Tuning forksReflex hammer
71StethoscopeConveys a vibrating column of air from the body wall to the earsDoes not amplify, but sounds may be alteredExcludes extraneous noises
72StethoscopeHeart and lung sounds have a frequency between 60 and 3000 cycles per secondHearing range in a young person is 30 to 20,000 cycles per second, but is dependent upon intensity.At low intensity range is 70 to 150 cycles per second. Therefore some low-pitched sounds may be near the limits of auscultation.
73Components of the stethoscope Chest pieceBell pieceTransmits all soundsLow pitches are transmitted wellLightly touch testShould have rubber edgeDiaphragmFilters out low pitched soundsIsolates high pitched soundsPress firmlyHold between second and third fingers
74Components of the stethoscope Rubber tubingThick walled, stiff, and heavy30 to 40 cm (12 to 18 inches)Angled BiauralsPoint ear pieces towards the noseEar piecesSnugComfortable
75Ophthalmoscope Lenses and mirrors -20 to +40 diopters Light source Various aperturesSmall - small pupilsRed free filter - green beam, optic disc pallor and minute vessels changesSlit - Anterior eye, elevation of lesionsGrid - size of fundal lesions
89Vital Signs Equipment Needed A Stethoscope A Blood Pressure Cuff A Watch Displaying SecondsA Thermometer
90Temperature Temperature can be measured is several different ways: Oral with a glass, paper, or electronic thermometer (normal 98.6F/37C)Axillary with a glass or electronic thermometer (normal F/36.3C)Rectal or "core" with a glass or electronic thermometer (normal 99.6F/37.7C)Aural (the ear) with an electronic thermometer (normal F/37.7C)Of these, axillary is the least and rectal is the most accurate.
91Temperature: Fever (pyrexia): elevated body temperature Hyperpyrexia: extreme fever, > 106F/41.1CHypothermia: extremely low temperature< 95F/35C
92False measurements: Patient smoking or drinking hot or cold liquids Rapid respiratory rateFailure to use thermometer correctly
93Recording: Temperature in degrees Which scale? Location, (Type of thermometer)ex: 106F, axillary, (glass)
94Pulse Sit or stand facing your patient. Grasp the patient's wrist with your free (non-watch bearing) hand (patient's right with your right or patient's left with your left). There is no reason for the patient's arm to be in an awkward position, just imagine you're shaking hands.Compress the radial artery with your index and middle fingers.
95Pulse Note whether the pulse is regular or irregular: Regular - evenly spaced beats, may vary slightly with respirationRegularly Irregular - regular pattern overall with "skipped" beatsIrregularly Irregular - chaotic, no real pattern, very difficult to measure rate accuratelyCount the pulse for 15 seconds and multiply by 4.Count for a full minute if the pulse is irregular.Record the rate and rhythm.
96Pulse: Interpretation A normal adult heart rate is between 50 and beats per minuteA pulse greater than 100 beats/minute is defined to be tachycardia. Pulse less than 60 beats/minute is defined to be bradycardia.Tachycardia and bradycardia are not necessarily abnormal. Athletes tend to be bradycardic at rest (superior conditioning). Tachycardia is a normal response to stress or exercise.
97RespirationBest done immediately after taking the patient's pulse. Do not announce that you are measuring respirations.Without letting go of the patients wrist begin to observe the patient's breathing. Is it normal or labored?
98RespirationCount breaths for 15 seconds and multiply this number by 4 to yield the breaths per minute.In adults, normal resting respiratory rate is between breaths/minute. Rapid respiration is called tachypnea.
99Measurement of Blood Pressure “Although the arterial blood pressure is measured many time a day by doctors all over the world, few physicians have devoted much thought to the problems and principles involved in measuring blood pressure accurately…From the very beginning, students must learn to record the blood pressure properly. Accurate blood pressure recording will then become a habit that will remain with the physician for a lifetime."
100Blood Pressure: Systolic = highest BP in the cycle Diastolic = lowest BP in the cyclePulse pressure = difference between systolic and diastolicMean arterial pressure = (1/3)(SBP – DBP) + DBP
101Blood Pressure: Hypertension Hypertension is a risk factor For adults >140/90Graded by severityMalignant hypertension = acute target organ damageHypertension is a risk factor
103Sphygmomanometers Types Mercury-gravity Aneroid Automated Components: Components:Pressure manometerInflatable rubber bladder within an inelastic coveringSize is importantWidth - 40% arm circumferenceLength – 80% arm circumferenceMost are markedRubber hand bulb and pressure control valve
105Technique of Blood Pressure Measurement: The patientNot smoking, ingesting caffeine, or vigorous activity for 30 min priorRest sitting comfortably for 5 – 10 minRoom quiet and warmArm rested and free of clothing
106Technique of Blood Pressure Measurement: Be aware of conditions which may alter BPDialysis fistulaLymphedemaAtherosclerosisAnxiety (white coat hypertension)Circadian variation
112THE AUSCULTATORY GAPTHE DISAPPERANCE OF THE PHASE 1 KOROTKOFF SOUNDS IN SYSTOLE WITH REAPPEARANCE ABOVE THE DIASTOLIC PRESSURE.AVOID BY PALPATING THE DISTAL PULSE UNTIL IT DISAPPEARS DURING CUFF INFLATION.MECHANISM UNKNOWN ?ATHEROSCLEROTIC PLAQUE.20% OF ELDERLY PATIENTS.MAY LEAD TO INACCURATE SYSTOLIC AND DIASTOLIC READING. FALSELY LOW SBP OR FALSELY HIGH DBP.150/98200/98 WITH AN AUSCULTATORY GAP BETWEENCAVALLINI MC ANN INTERN MED 124: ;1996BATES GUIDE TO THE PHYSICAL EXAMINATION 8TH ED.
113Phases of the Korotkoff Sounds Starts with a loud “thud”Recorded at level when 2 beats heard in a rowSystolicThere may be an auscultatory gapPhase 2A blowing or swishing soundPhase 3Softer thud than phase 1Still crispPhase 4MuffingSofter blowing sounds that disappearsPhase 5SilenceDiastolic
114Diastolic Blood Pressure: Special Considerations:Some controversy if phase 4 or phase 5 is DBPRecorded at phase 5, disappearance of soundsUsually phase 4 and 5 are close, < 5 mm HgIf more than 10 mm Hg apartRecord as:160/90/68In some patients, ex: Aortic regurgitation, sounds never disappear.Record as: 150/70/0
115Blood Pressure1. Position the patient's arm so the anticubital fold is level with the heart. Support the patient's arm with your arm or a bedside table.2. Center the bladder of the cuff over the brachial artery approximately 2.5 cm above the anticubital fold. Proper cuff size is essential to obtain an accurate reading. Be sure the index line falls between the size marks when you apply the cuff. Position the patient's arm so it is slightly flexed at the elbow.
116Blood Pressure3. Palpate the radial pulse and inflate the cuff until the pulse disappears. This is a rough estimate of the systolic pressure.4. Place the stethoscope over the brachial artery.
117Blood Pressure5. Inflate the cuff to 30 mmHg above the estimated systolic pressure. Release the pressure slowly, no greater than 5 mmHg per second. The level at which you consistently hear beats is the systolic pressure.
118Blood Pressure6. Continue to lower the pressure until the sounds muffle and disappear. This is the diastolic pressure. Record the blood pressure as systolic over diastolic ("120/70" for example).
119Errors in BP Measurement Cuff too smallCuff too largeArm held below heartLoose cuff
120Accurate BP Measurements Proper patient conditions - Sitting, relaxed, no caffeine or smoking, etcErrors in measurement – Cuff size, technique“White coat” hypertensionPseudohypertensionHome BP measurements24 hour ambulatory measurements
121CIRCADIAN PATTERNS OF BLOOD PRESSURE NORMALLY BLOOD PRESSURE FALLS AT NIGHT AND EARLY MORNING.NEJM 347: ;2002