1. Introduction to the Physical Examination

2. Today’s Agenda Overview of course Exam techniques and use of equipment
Vital signs

3. Introduction to the Medical Profession
Not an introduction, but a beginning
A new type of learning experience
The study of the patient
The study of illness as opposed to disease

4. IMP is a two year course IMP I IMP II Primary Care Externship
Communication and Interviewing
Physical Examination
Clinical Decision Making - EBM
IMP II
Adv. Communication and Interviewing
Physical Diagnosis
Radiology, Laboratory and problem-solving
Clinical Decision Making-EBM

5. Student Goals:
To understand the underlying anatomy and physiology of the normal physical examination
To 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

6. Expectations Attendance Participation Professionalism Honesty Feedback
Attitude

7. Physical Examination
Lecture series
Small group session
CSTAC

8. Assessment Multiple choice examination Practical examination History
Physical examination

9. Basic Clinical Skills 70% of diagnosis can be based on history alone
90% of diagnosis can be made when the physical examination is added
Expensive 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

11. Physical Examination: Two Tiers of Investigation
Screening or Comprehensive Examination
The foundation of clinical skills
Uses
Undifferentiated patient
New patient
Pt wishing a “complete” H&P

12. Physical Examination: Two Tiers of Investigation
Extended or Problem-Focussed Examination
Physician follows leads
Usually involves an extended assessment of a system or region

13. Physical Examination Knowledge Base Technical Skills Perceptual Skills
Exam skills
Use of equipment
Perceptual Skills
Sensory
Interpretation
Communication Skills
Interpersonal Skills

14. Knowledgebase Normal examination Anatomy Physiology Techniques
Equipment
Expected normal findings
Normal variations
Changes with age
Extrapolation to common abnormalities

15. Learning the Physical Examination
A key to a thorough and accurate physical examination is developing a systematic sequence of examination

16. Learning the Physical Examination
An important goal is to minimize the number of times you ask the patient to change positions

17. Learning The Physical Examination
Systems Approach  Regional Approach
Small group sessions with preceptor
Lecture series
Reading Bates
Practice
Review session with SPs

18. Format of Small Group Sessions:
Read material ahead of time
Use objectives as a guide
Do the practice questions and review with preceptor
Practice exam techniques
Use checklist as a guideline

19. The Syllabus

20. Lecture Schedule

21. Small Group Sessions: 1.Getting started 2. HEENT, neck, lymph nodes
3. Cardiovascular, peripheral vascular
4. Chest, pulmonary
5 Abdomen
6 Neurological
7. Musculoskeletal
8.&9.Putting it all together
10.Patients

22. Practice Questions

23. Checklist

24. Checklist Explained
Applying the cuff
Correct setting for patient as above
Palpate brachial (or radial) artery
Position arm so brachial artery is at heart level
4th intercostal space at its junction with the sternum
Center bladder over brachial artery
Cuff’s lower boarder 2.5 cm above antecubical crease
Secure cuff snugly
Slightly flex arm at elbow
Estimating Systolic Pressure
Inflate cuff until pulse is no longer palpable
Read this pressure
Deflate cuff
Systolic blood pressure should be estimated the first time a patient's blood pressure is taken. This is done by palpating the brachial or radial arteries; after the pulse is palpated, slowly inflate the blood pressure cuff and note the blood pressure at which the pulse is no longer palpable.

25. Learning Resources: Required Textbook: Bates. . A Guide
to Physical Exam and History Taking. 9th ed.
Philadelphia: Lippincott, 2005

26. Examination Techniques and Equipment

27. Examination Techniques and Equipment
Objectives for each section:
General Appearance
Appreciate the importance of observation
Exam techniques
Inspection
List what some examples of what to look for in general observation
List a few conditions that are diagnosed from general inspection
The type of lighting is best for observing couture
Percussion
Definition of percussion
Types of percussion
Uses of percussion
The technique of percussion
Be able to perform direct and indirect percussion
The percussion notes and what they indicate
Recognize percussion notes
Be able to interpret physical exam findings based on percussion

28. Examination Techniques:
Inspection
Percussion
Palpation
Auscultation

29. Observation (Inspection):
Least mechanical part of the physical examination
Hardest to learn
Yields the most physical signs
More diagnoses are made by inspection than all others combined
Depends upon the knowledge of the observer

30. How to Observe Keep your eyes open Keep an open mind Ask questions
Learn what to observe
Reflect on what you have observed and look for what you may have missed

31. Finished files are the re-
sult of years of scientif-
ic study combined with
the experience of years.

32. Observation
“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

33. “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.

34. Enhancing Your Powers of Observation
Learning physical examination techniques is all about becoming a better observer
A skilled clinician has enhanced powers of observation and the knowledge to use these observations in the care of patients

35. “Don’t touch the patient - state first what you see; cultivate your powers of observation.” Sir William Osler

36. “The student must teach the eye to see, the fingers to feel, and the ear to hear.” Sir William Osler

38. Observation: What you see What you hear (listening)
Know what to look for
What you hear (listening)
Olfactory diagnosis
What you feel emotionally

39. Observation: Inspection
Least mechanical aspect of the physical examination
Hardest to learn
Yields the most physical signs
More diagnosis are made by inspection than all other techniques combined
Depends upon the knowledge of the observer

40. Inspection
Begins when you first see the patient and ends when they leave
Systematic part of each component of the physical examination
Part of the mental status examination
Subtle observations probably account for “the sixth sense” of astute clinicians

41. Inspection: General Appearance
State of consciousness
Signs of distress (sick or not sick?)
Apparent state of health
Skin:discoloration or obvious lesions
Dress, grooming, and personal hygiene
Facial expression
Gait and posture
Motor activity

42. Dress, grooming, and personal hygiene

43. Inspection: General Appearance
State of nutrition
Body habitus
Symmetry
Stated age vs. physiologic age
Mood, attitude, affect
Speech
Olfactory diagnosis
Bodily excretions (Effuvia)

44. Olfactory Diagnosis:
“Medical olfaction can often be an important aspect
of clinical examination if clinicians approach patient
encounters with an “open nose” as well as an open
mind.”
Hayden, GF: Olfactory diagnosis in medicine, Post Graduate Medicine,
1980

45. Olfactory Diagnosis: “Characteristic patient odors accompany many
diseases and intoxications, and their
recognition can provide diagnostic clues,
guide the laboratory evaluation, and affect the
choice of immediate therapy.”
Hayden, GF: Olfactory diagnosis in medicine, Post Graduate Medicine,
1980

46. Inspection: Olfactory Diagnosis:
Detection of ingestions or toxins
Alcohol
Tobacco
Toluene
Cyanide
Detection of certain infections
Anaerobic
Necrotic material
Diagnosis of certain diseases
Fruity; acetone like = Diabetic ketoacidosis
Urine-like = Uremia
Inborn errors of metabolism

47. Inspection: Bodily Excretions (Effluvia)
Video

48. Inspection: Bodily Excretions (Effluvia)
Urine, stool, sputum, vomitus, exudates, sweat
Color, odor, constancy, or smell
Examples:
Acholic (clay colored) stool of biliary obstruction
“Coffee ground” emesis of upper gastrointestinal hemorrhage
“Rusty sputum” of pneumococcal pneumonia
Melena the black tarry stool from an upper gastrointestinal hemorrhage has a distinct odor
“Uremic frost” of severe renal failure

62. Recording 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 muscles
During parts of the physical examination:
HEENT: Temporal wasting
Chest: Barrel chested
Skin: Cyanotic and diaphoretic

63. Percussion surface of the body is struck to emit sounds that
“Method of physical examination in which the
surface of the body is struck to emit sounds that
vary in quality according to the density of the
underlying tissues.”

64. Percussion
Vibration produced by impact of the finger against underlying tissue
Sound waves (resonance) arise from vibrations 4 to 6 cm deep in the body tissue
The more dense the material, the quieter the tone

65. Techniques of Percussion
Direct
Striking finger, hand, or lunar aspect of fist directly against the body.
Indirect
One 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)

66. Percussion Tones Tympany Gastric air bubble
Hyperresonace Emphysemic lung
Resonance Healthy lung
Dullness Liver
Flatness Muscle, thigh

67. Uses of Percussion Sonorous percussion – determine density
Definitive percussion – mapping extent of border of an area
Ex: liver
It is easier to hear the change from resonance to dullness – so proceed with percussion from areas of resonance to areas of dullness
Detection of areas of tenderness
Ex: flank percussion in pyleonephritis

68. Palpation Sensitive parts of the hand
Tactile sense – finger pads more sensitive than finger tips
Vibratory sense – ulnar aspect of hands, palmer metacarpalphalangeal joints
Position and consistency – grasping fingers
Temperature – dorsum of hand

69. Qualities Elicited by Palpation:
Texture – skin and hair
Moisture – skin
Temperature – skin
Masses
Size, shape, consistency, motility, pulsatile
Precordial cardiac thrust
Crepitus
Tenderness
Vocal Fremitus

70. Special Methods of Palpation
Light palpation – up to 1 cm
Deep palpation – up to 4 cm
Ballottement
Fluid wave

71. Auscultation
Heart
Murmurs, clicks, opening snap, gallops, pericardial friction rubs and knocks
Lungs
Breath sounds, whispers, voice, crackles (rales), pleural friction rubs
Abdomen
Bowel sounds, bruits
Neck
Bruits – carotid, thyroid
Head
Bruit of AV fistula
Joints
Crepitus
Scrotum
Bowel sounds from hernia

72. Instruments Stethoscope Ophthalmoscope Otoscope Near vision chart
Tuning forks
Reflex hammer

73. Stethoscope
Conveys a vibrating column of air from the body wall to the ears
Does not amplify, but sounds may be altered
Excludes extraneous noises

74. Stethoscope
Heart and lung sounds have a frequency between 60 and 3000 cycles per second
Hearing 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.

75. Components of the stethoscope
Chest piece
Bell piece
Transmits all sounds
Low pitches are transmitted well
Lightly touch test
Should have rubber edge
Diaphragm
Filters out low pitched sounds
Isolates high pitched sounds
Press firmly
Hold between second and third fingers

76. Components of the stethoscope
Rubber tubing
Thick walled, stiff, and heavy
30 to 40 cm (12 to 18 inches)
Angled Biaurals
Point ear pieces towards the nose
Ear pieces
Snug
Comfortable

77. Ophthalmoscope Lenses and mirrors -20 to +40 diopters Light source
Various apertures
Small - small pupils
Red free filter - green beam, optic disc pallor and minute vessels changes
Slit - Anterior eye, elevation of lesions
Grid - size of fundal lesions

84. Otoscope Speculum narrows and directs the beam of light
Glass plate magnifying glass
Pneumatic attachment - TM mobility
May be used for nasal examination

86. Tuning Forks
Auditory to 1000 HZ
Vibratory to 400 HZ

87. Reflex Hammer
Tomahawk
Babinski
Neurologic hammer

88. Other Safety pins Pen light Tape measure Ruler Q-tips Tongue blades
Near vision chart

89. Near Vision Chart

90. Vital Signs

91. Vital Signs Equipment Needed A Stethoscope A Blood Pressure Cuff
A Watch Displaying Seconds
A Thermometer

92. Temperature 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.

93. Temperature: Fever (pyrexia): elevated body temperature
Hyperpyrexia: extreme fever, > 106F/41.1C
Hypothermia: extremely low temperature< 95F/35C

94. False measurements: Patient smoking or drinking hot or cold liquids
Rapid respiratory rate
Failure to use thermometer correctly

95. Recording: Temperature in degrees Which scale? Location,
(Type of thermometer)
ex: 106F, axillary, (glass)

96. Pulse 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.

97. Pulse Note whether the pulse is regular or irregular:
Regular - evenly spaced beats, may vary slightly with respiration
Regularly Irregular - regular pattern overall with "skipped" beats
Irregularly Irregular - chaotic, no real pattern, very difficult to measure rate accurately
Count the pulse for 15 seconds and multiply by 4.
Count for a full minute if the pulse is irregular.
Record the rate and rhythm.

98. Pulse: Interpretation
A normal adult heart rate is between 50 and beats per minute
A 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.

99. Respiration
Best 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?

100. Respiration
Count 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.

101. Measurement 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."

102. Blood Pressure: Systolic = highest BP in the cycle
Diastolic = lowest BP in the cycle
Pulse pressure = difference between systolic and diastolic
Mean arterial pressure = (1/3)(SBP – DBP) + DBP

103. Blood Pressure: Hypertension Hypertension is a risk factor
For adults >140/90
Graded by severity
Malignant hypertension = acute target organ damage
Hypertension is a risk factor

104. Blood Pressure Classification
BP Classification
SBP mmHg
DBP mmHg
Normal
<120
and
<80
Prehypertension
120–139 or
80–89
Stage 1 Hypertension
140–159 or
90–99
Stage 2 Hypertension
>160 or
>100

105. Sphygmomanometers Types Mercury-gravity Aneroid Automated Components:
Components:
Pressure manometer
Inflatable rubber bladder within an inelastic covering
Size is important
Width - 40% arm circumference
Length – 80% arm circumference
Most are marked
Rubber hand bulb and pressure control valve

106. THE BLOOD PRESSURE CUFF
BLADDER
CUFF

107. Technique of Blood Pressure Measurement:
The patient
Not smoking, ingesting caffeine, or vigorous activity for 30 min prior
Rest sitting comfortably for 5 – 10 min
Room quiet and warm
Arm rested and free of clothing

108. Technique of Blood Pressure Measurement:
Be aware of conditions which may alter BP
Dialysis fistula
Lymphedema
Atherosclerosis
Anxiety (white coat hypertension)
Circadian variation

114. THE AUSCULTATORY GAP
THE 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.
150/98
200/98 WITH AN AUSCULTATORY GAP BETWEEN
CAVALLINI MC ANN INTERN MED 124: ;1996
BATES GUIDE TO THE PHYSICAL EXAMINATION 8TH ED.

115. Phases of the Korotkoff Sounds
Starts with a loud “thud”
Recorded at level when 2 beats heard in a row
Systolic
There may be an auscultatory gap
Phase 2
A blowing or swishing sound
Phase 3
Softer thud than phase 1
Still crisp
Phase 4
Muffing
Softer blowing sounds that disappears
Phase 5
Silence
Diastolic

116. Diastolic Blood Pressure:
Special Considerations:
Some controversy if phase 4 or phase 5 is DBP
Recorded at phase 5, disappearance of sounds
Usually phase 4 and 5 are close, < 5 mm Hg
If more than 10 mm Hg apart
Record as:160/90/68
In some patients, ex: Aortic regurgitation, sounds never disappear.
Record as: 150/70/0

117. Blood Pressure
1. 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.

118. Blood Pressure
3. 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.

119. Blood Pressure
5. 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.

120. Blood Pressure
6. 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).

121. Errors in BP Measurement
Cuff too small
Cuff too large
Arm held below heart
Loose cuff

122. Accurate BP Measurements
Proper patient conditions - Sitting, relaxed, no caffeine or smoking, etc
Errors in measurement – Cuff size, technique
“White coat” hypertension
Pseudohypertension
Home BP measurements
24 hour ambulatory measurements

123. CIRCADIAN PATTERNS OF BLOOD PRESSURE
NORMALLY BLOOD PRESSURE FALLS AT NIGHT AND EARLY MORNING.
NEJM 347: ;2002

124. Next Week
ENT
Eye