Transcript Introduction to the Physical Examination

Introduction to the Physical
Examination
Today’s Agenda
• Overview of course
• Exam techniques and use of equipment
• Vital signs
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
IMP is a two year course
• IMP I
• IMP II
• Primary Care
Externship
• Communication and
Interviewing
• Physical Examination
• Clinical Decision
Making - EBM
• Adv. Communication
and Interviewing
• Physical Diagnosis
• Radiology, Laboratory
and problem-solving
• Clinical Decision
Making-EBM
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
Expectations
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Attendance
Participation
Professionalism
Honesty
Feedback
Attitude
Physical Examination
• Lecture series
• Small group session
• CSTAC
Assessment
• Multiple choice examination
• Practical examination
– History
– Physical examination
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
“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
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
Physical Examination:
Two Tiers of Investigation
• Extended or Problem-Focussed Examination
– Physician follows leads
– Usually involves an extended assessment of a
system or region
Physical Examination
• Knowledge Base
• Perceptual Skills
– Sensory
• Technical Skills
– Exam skills
– Use of equipment
• Interpretation
• Communication Skills
• Interpersonal Skills
Knowledgebase
 Normal examination
 Anatomy
 Physiology
 Techniques
 Equipment
 Expected normal findings
 Normal variations
 Changes with age
 Extrapolation to common abnormalities
Learning the Physical Examination
• A key to a thorough and accurate physical
examination is developing a systematic
sequence of examination
Learning the Physical Examination
• An important goal is to minimize the
number of times you ask the patient to
change positions
Learning The Physical
Examination
 Systems Approach  Regional Approach
• Small group sessions with preceptor
• Lecture series
• Reading Bates
• Practice
• Review session with SPs
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
The Syllabus
INTRODUCTION TO THE MEDICAL PROFESSION
(MD 811: 2006)
MODULE III:
Physical Examination
Module Coordinator: David Rudy, MD
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Outline
Pages
Lecture schedule
Small group sessions
Explanation of course
Objectives for each section
Practice Questions
Systems Checklist
Regional Checklist
2
3
4-8
9-18
19-31
32-37
38-48
Lecture Schedule
Physical Examination Lecture and Test Schedule
Date
Time
Room
Feb 15
1-2
MN 263
2-3
Feb 22
1-2
MN 263
1-2
MN 263
2-3
Mar 15
1-2
MN 263
2-3
Mar 22
1-3
MN 263
Mar 29
1-3
MN 263
Apr 5
1-2
MN 263
2-3
Apr 12
Apr 19
Apr 26
TBA
1-2
2-3
1-3
Introduction to PE Module
PE Lecture #1 – General
Appearance and Vital Signs
Dr. David Rudy
PE Lecture #2 – ENT Exam
Dr. Valentino
Reading
Assignments
(Bates 9th Edition)
p. 11-14
Chapter 4: p. 89-113
Chapter 6: p. 153170, 177-200, 212,
229
PE Lecture #3 –Eye Exam
2-3
Feb 27Mar 3
Mar 8
Topic
MN 263
MN 263
MN 263
CSTAC
SPRING BREAK
Chapters 1-20
PE Lecture #4 – Introduction to the
Pulmonary Exam
Dr. Steve Kraman
Chapter 7: p.241266, 274-277
PE Lecture #5 – The Peripheral
Vascular Exam – Dr. David Rudy
PE Lecture #6 – The
Cardiovascular Exam
Chapter 14: p. 473478, 481-488, 491
Chapter 8: p. 279292, 302-316, 328,
330
Chapter10: p.359361,374-387,
Chapter 17: p. 595606, 610-639
Chapter 15: 497-501,
507-555
PE Lecture #7 – The Abdominal
Exam – Dr. Chipper Griffith
PE Lecture # 8– The Neurological
Exam – Dr. Robin Meek
PE Lecture #9 – The
Musculoskeletal Exam –
Dr. Todd Milbrandt
PE Lecture #10 – The Pediatric
Exam – Dr. Chipper Griffith
PE Lecture # 11- The Dermatologic
Exam- Dr. Rudy
PE Lecture #12 – The Geriatric
Exam – Dr. Stiles
PE Lecture – Review
Review
Written Exam
PE Clinical Performance Exam
Day & Time to be assigned
Chapter 18: skim p.
671-698
Chapter 5: p.121131, 143,
Chapter 20: 839-847,
851-852,
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
Practice Questions
1. Tangential lighting enhances observation of:
A. Color
B. Mobility
C. Texture
D. Contour
2. Which part of the examiner’s hand is best for palpating vibration?
Ulnar surface
Finger pads
Finger tips
Dorsal surface
3. Percussion of body tissue makes sounds that are:
A. Soft over fluid
B. Loud over air
C. Dull over lungs
D. Flat over gastric air bubble
4. Percussion is best sequenced from:
A. Upper to lower body parts
B. Resonant to dull areas
C. Round to flat surfaces
D. Soft to hard surfaces
Checklist
1.
2.
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6.
7.
8.
9.
A. PRELIMINARY Washes hands before starting examination (in front of patient)
B. VITAL SIGNS Blood pressure done - 1 arm
Systolic BP estimated by palpation of brachial or radial arteries with BP cuff
BP done correctly (not over clothing, cuff tight, arm correct relaxed position, etc.)
Patient seated with back supported and both feet flat on ground
Blood pressure taken with the bell of the stethoscope
Heart rate - at least 15 seconds checking radial pulse with fingers, not thumb
Respiratory rate - inconspicuously watching chest movement (at least 20-30 seconds)
Temperature (done correctly – will beep when done if electronic)
Checklist Explained
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.
Learning Resources:
Required Textbook: Bates. . A Guide
to Physical Exam and History Taking. 9th ed.
Philadelphia: Lippincott, 2005
Examination Techniques and
Equipment
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
Examination Techniques:
 Inspection
 Percussion
• Palpation
• Auscultation
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
How to Observe
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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
Finished files are the result of years of scientific study combined with
the experience of years.
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
“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.
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
“Don’t touch the patient - state first what you
see; cultivate your powers of observation.”
Sir William Osler
“The student must teach the eye to see,
the fingers to feel, and the ear to hear.”
Sir William Osler
Observation:
• What you see
– Know what to look for
• What you hear
(listening)
• Olfactory diagnosis
• What you feel
emotionally
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
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
Inspection: General Appearance
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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
Dress, grooming, and personal
hygiene
Inspection: General Appearance
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State of nutrition
Body habitus
Symmetry
Stated age vs. physiologic age
Mood, attitude, affect
Speech
Olfactory diagnosis
Bodily excretions (Effuvia)
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
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
Inspection: Olfactory Diagnosis:
Diagnosis of certain
diseases
 Fruity; acetone like =
Diabetic ketoacidosis
 Urine-like = Uremia
 Inborn errors of
metabolism
Detection of
ingestions or
toxins
 Alcohol
 Tobacco
 Toluene
 Cyanide
Detection of certain
infections
 Anaerobic
 Necrotic material
Inspection: Bodily Excretions
(Effluvia)
• Video
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
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
Percussion
“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.”
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
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 nondominate hand as the PIP joint is pressed firmly against the
area to be percussed (pleximeter)
Percussion Tones
 Tympany
 Hyperresonace
 Resonance
 Dullness
 Flatness
Gastric air bubble
Emphysemic lung
Healthy lung
Liver
Muscle, thigh
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
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
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
Special Methods of Palpation
Light palpation – up to 1 cm
Deep palpation – up to 4 cm
Ballottement
Fluid wave
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
Instruments
 Stethoscope
 Ophthalmoscope
 Otoscope
 Near vision chart
 Tuning forks
 Reflex hammer
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
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.
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
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
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
Otoscope
 Speculum narrows and directs the beam of light
 Glass plate magnifying glass
 Pneumatic attachment - TM mobility
 May be used for nasal examination
Tuning Forks
 Auditory - 500 to 1000 HZ
 Vibratory - 100 to 400 HZ
Reflex Hammer
• Tomahawk
• Babinski
• Neurologic hammer
Other
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Safety pins
Pen light
Tape measure
Ruler
Q-tips
Tongue blades
Near vision chart
Near Vision Chart
Vital Signs
Vital Signs
Equipment Needed
 A Stethoscope
 A Blood Pressure Cuff
 A Watch Displaying Seconds
 A Thermometer
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
97.6F/36.3C)
 Rectal or "core" with a glass or electronic thermometer
(normal 99.6F/37.7C)
 Aural (the ear) with an electronic thermometer (normal
99.6F/37.7C)
• Of these, axillary is the least and rectal is the most
accurate.
Temperature:
Fever (pyrexia): elevated body temperature
Hyperpyrexia: extreme fever, > 106F/41.1C
Hypothermia: extremely low temperature<
95F/35C
False measurements:
Patient smoking or drinking hot or cold
liquids
Rapid respiratory rate
Failure to use thermometer correctly
Recording:
Temperature in degrees
Which scale?
Location,
(Type of thermometer)
ex: 106F, axillary, (glass)
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.
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.
Pulse: Interpretation
 A normal adult heart rate is between 50 and 100
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.
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?
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 14-20 breaths/minute. Rapid respiration is
called tachypnea.
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."
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
Blood Pressure:
• Hypertension
– For adults >140/90
– Graded by severity
– Malignant hypertension = acute target organ damage
• Hypertension is a risk factor
Blood Pressure Classification
BP Classification SBP
mmHg
DBP
mmHg
Normal
Prehypertension
<120
120–139
and
or
<80
80–89
Stage 1
Hypertension
140–159
or
90–99
Stage 2
Hypertension
>160
or
>100
Sphygmomanometers
Types
Mercury-gravity
Aneroid
Automated
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
THE BLOOD PRESSURE CUFF
BLADDER
CUFF
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
Technique of Blood Pressure
Measurement:
Be aware of conditions which may alter BP
• Dialysis fistula
• Lymphedema
• Atherosclerosis
• Anxiety (white coat hypertension)
• Circadian variation
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 170 - 150
CAVALLINI MC ANN INTERN MED 124:887-883;1996
BATES GUIDE TO THE PHYSICAL EXAMINATION 8TH ED.
Phases of the Korotkoff Sounds
Phase 1
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
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
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.
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.
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.
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).
Errors in BP Measurement
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Cuff too small
Cuff too large
Arm held below heart
Loose cuff
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
CIRCADIAN PATTERNS OF BLOOD PRESSURE
NORMALLY BLOOD PRESSURE FALLS AT NIGHT AND EARLY
MORNING.
NEJM 347:778-779;2002
Next Week
• ENT
• Eye