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Chapter 4
53
Physical examination
skills and leads
Physical examination skills 54
The general examination 55
Plan of the general physical examination 56
Cardiovascular system 57
Respiratory system 58
Alimentary and genitourinary systems 59
Nervous system 60
The full neurological assessment 62
Mental status examination 65
Writing out the examination findings 66
The problem list and positive-finding summary 67
Looking up the lead 68
Red pharynx and tonsils 68
The working diagnoses 69
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CHAPTER 4 Physical examination skills and leads
54
Physical examination skills
At the end of the history in the previous chapter the patient was thought
to have
- ? Viral pharyngitis
- ? Infectious mononucleosis
- ? Acute follicular tonsillitis
- ? Agranulocytosis due to carbimazole
- ?? Meningococcal meningitis
- Inadequate domestic support currently for acute illness
- ?? Undiscovered type 2 diabetes mellitus
Recall what you imagined after the history. Give a subjective impression of
how well the patient appears to be on a spectrum from being completely
fit and well, being unwell to some degree, to moribund. Be prepared to
respond appropriately.
An ability to make a subjective diagnosis of degrees of well-being and
imminent outcome depends on experience of observing a large number
of patients and knowing what happened to them. There are early warning
scores that you may be expected to use in some centers based on pulse,
respiratory rate, and other factors.
When you are being assessed by an examiner, do things deliberately so
that you can be clearly seen to be doing the right thing. Students and
many doctors are being assessed continuously during their day-to-day
work, so there is much to be said for doing everything in a deliberate and
transparent way at all times.
The techniques of the physical examination are not covered in detail
in this Oxford American Handbook of Clinical Diagnosis. However, the
sequences of examination and documentation are described here. The
skills themselves are best learned by watching experts, copying them, and
practicing as much as possible. Consult books that specialize in describing
practical examination techniques in detail.
Watch others, read other books, and choose your own sequences.
Write out your chosen sequence on the blank pages provided here and
inside the front cover of this book if you wish. Write out your findings in
the patient’s record in the same order, to reduce the chance of forgetting
something. However, in some centers you will be provided with a stan-
dardized form, which you will be expected to use.
THE GENERAL EXAMINATION1
55
The general examination
Before examining the patient, look for other clues, e.g., state of dress,
nebulizer masks, sputum cups, medication packets, etc. The general
examination is directed mainly at assessing the patient’s appearance,
demeanor, and state of distress; often, the skin and lymph nodes are
considered here as well. Abnormal odors are also noted at this time,
such as fruity breath in diabetic ketoacidosis, alcohol on the breath, the
odors of urine or stool in incontinent patients.
During the history, the order of questioning could be decided entirely
by thought processes (for example, probing indirectly for a symptom to
chase up a diagnostic possibility that comes to mind), but the physical
examination is different. It is more efficient to adopt a routine that is
smooth and quick and not to jump about looking for physical signs that
might support the diagnostic idea of that moment.
You have already been looking at the patient’s face, general appearance,
and immediate vicinity (e.g., walking stick, medication packets, etc.) when
taking the history, so for the general examination, begin with the hands
and work your way up by inspecting (and, when appropriate, palpating)
the arms to the shoulders. Examine the patient’s scalp, ears, eyes, cheeks,
nose, and lips. Take the patient’s temperature. Examine inside the patient’s
mouth, then the neck, breasts, axillae, and then the skin of the abdomen,
legs, and feet.
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CHAPTER 4 Physical examination skills and leads
56
Plan of the general physical
examination
General exam
- Appearance
- Level of distress
- Odors
Hands, arms, and shoulders
- Fingernails
- Clubbing
- Finger nodules
- Finger joints deformity
- Rashes
- Pain and stiffness in the elbow, shoulder, neck
Head and neck
- Neck stiffness
- Patchy hair loss
- Eardrum redness
- Perforated eardrum
Eyes, face, and neck
- Facial redness, general appearance
- Red eye
- Iritis
- Conjunctival pallor
- Temperature—high or low
- Mouth lesions
- Lumps in the following areas:
- Face
- Submandibular region
- Anterior neck
- Anterior triangle of neck
- Posterior triangle
- Supraclavicular region
Trunk
- Breast discharge
- Nipple eczema
- Breast lumps
- Gynecomastia in males
- Axillary lymphadenopathy
- Sparse body hair
- Hirsutism
- Scar pigmentation
- Abdominal striae
Legs
- Inguinal and generalized lymphadenopathy
- Sacral, leg, and heel sores
CARDIOVASCULAR SYSTEM1
57
Cardiovascular system
Think first of cardiac output and inspect and feel the hands for warmth
or coldness. Feel the radial pulse, take the blood pressure and check the
other pulses in the arms and neck. Next think of venous return and look
at the jugular venous pressure (JVP). Then examine the heart itself (pal-
pate, percuss, and then listen to it). Finally, consider cardiac output and
venous return by feeling skin temperature, palpating pulses, and looking
for congestion and edema of the legs, liver, and lungs.
Cardiac output
- Peripheral cyanosis
- Radial pulse
- Rate
- Rhythm (compare cardiac apex rate if irregular)
- Amplitude
- Vessel wall
- Compare pulses for volume and synchrony
- Radial, brachial, carotid (femoral, popliteal, posterior and
anterior tibials after examining the heart)
- Blood pressure (BP) standing and lying in right arm; repeat on left
Venous return
- Jugular venous pressure (JVP)
The heart itself
- Trachea displaced?
- Apex beat displaced?
- Parasternal heave
- Palpable thrill
- Auscultation
- Rate, rhythm
- Extra heart sounds
—Gallops (S3, S4)
—Systolic murmurs
—Diastolic murmurs
—Friction rubs
Cardiac output and venous return
- Skin temperature
- Posterior and anterior tibials, popliteal, femoral pulses
- Venous skin changes
- Vein abnormalities
- Calf swelling
- Leg edema
- Sacral edema
- Liver enlargement and hepatojugular reflux
- Basilar lung crackles
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CHAPTER 4 Physical examination skills and leads
58
Respiratory system
Think of general respiratory structure and function. Inspect and think of
oxygen and carbon dioxide levels, then the ventilation process, which
depends on the chest wall and its movement. Palpate by feeling for tactile
vocal fremitus. Percuss and then auscultate. Listen for wheezes and rhon-
chi, thus assessing airways from small (high pitched) to large (low pitched).
General inspection
- Tremor and muscle twitching
- Cyanosis of the tongue and lips
- Clubbing
Chest inspection
- Respiratory rate and depth
- Distorted chest wall
- Poor expansion
- Paradoxical movement
Palpation
- Mediastinum
- Position of trachea
- Position of apex beat
Tactile vocal fremitus
- Present or absent (or increased)
- Symmetry
Percussion
- Hyperresonant, resonant, normal, dull, or stony dull
Auscultation
- Diminished breath sounds
- Bronchial breathing
- Crackles
- Rubs
- Wheezes, rhonchi (high or low pitched or polyphonic, during
inspiration or expiration or both)
ALIMENTARY AND GENITOURINARY SYSTEMS1
59
Alimentary and genitourinary systems
Think first of metabolic issues related to general nutrition (obese, average,
thin, cachexia) and ensure that the patient is weighed. Check the mucous
membranes, e.g., for signs of vitamin deficiency. Look for nongastrointestinal
(e.g., skin, eye) signs of hypovolemia and liver disease. Next turn your mind
to anatomical aspects of the gastrointestinal (GI) and genitourinary (GU)
systems together by inspecting, palpating, and auscultating. Finally, perform
examinations (when indicated) that need special equipment.
Inspection
- Obesity
- Cachexia
- Oral lesions
- Jaundice
- Hepatic skin stigmata
- Loss of skin turgor
- Low eye tension
Palpation
- Supraclavicular nodes
Inspection of the abdomen
- Abdominal scars
- Veins
- General distension
- Visible peristalsis
- Poor movement
Palpation
- General tenderness
- Localized tenderness
- Hepatic enlargement
- Splenic enlargement
- Renal enlargement
- Abdominal masses
Percussion
- Dull or resonant
- Shifting dullness
Auscultation
- Silent abdomen
- Tinkling bowel sounds
- Bruits
Inspection and palpation again
- Groin lumps (lymph nodes?)
- Scrotal masses
- Rectal abnormalities
- Prostate exam
- Melena, fresh blood
- Vaginal and pelvic abnormalities
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CHAPTER 4 Physical examination skills and leads
60
Nervous system
If there are no neurological symptoms or signs detected up to this point,
then it is customary to perform an abbreviated examination. Comment
on the fact that the patient was conscious and alert, speech was normal,
and there were no cranial nerve abnormalities noted when looking at the
face during the history and general examination. Also, you should be able
to note the patient’s gait and movements around the hospital bed or
consultation room. According to the GALS system, note and record the
Gait, appearance, and movement of the Arms, Legs and Spine.
If the patient was not conscious and alert, then the level of conscious-
ness should be addressed with the Glasgow Coma Scale (GCS).
The brief neurological examination consists of checking coordination
and reflexes (thus testing sensory and motor function of the nerves
and central connections involved). The findings may be recorded as in
Box 4.1.
Box 4.1 Short CNS examination
- Conscious and alert
- Speech normal
- Facial appearance and movement normal
- Finger–nose pointing normal
- Hand tapping and rotating normal
- Heel–toe test normal (ran heel from opposite knee to toe and back)
- Foot tapping (examiner’s hand) normal
Reflexes Right Left
Biceps normal
Supinators normal
Triceps normal
Knees normal
Ankles normal
Plantars normally flexor
+
+
+
+
+
d
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