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Author: Kanchan Ganda, M.D.
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1. Introduction

The physical examination complements the history, in the sequence of the patient work-up. The patient is examined from head to toe, thus ensuring thoroughness and screening for abnormalities. Also, any specific physical findings which are suggestive because of history findings, are looked for. Thus, the history serves to focus and provide emphasis to the physical examination.

Following is an outline of the components of the physical examination in sequential order.

1.1. General appearance

Note mental status, interactiveness, speech pattern, neatness, etc.

1.2. Vital signs

Pulse
Note rate, rhythm, volume, and regularity. If an irregularity exists, note if the irregularity is regular or irregular. Establish the pulse rate/min.

Pulse

Respiration
Note respiratory pattern while taking the pulse. Do not announce it to the patient that you are taking the respiratory rate! Establish the respiratory rate/min. Normal respiratory rate is 12-18/min.
Blood pressure
Take the blood pressure in both arms during patient's first visit. Normal blood pressure reading is usually 120/80 mm Hg or less.
Blood Pressure Monitoring
Always obtain two blood pressure readings at the first visit of the patient. If the blood pressure obtained is high, take two more readings at the next visit. Average of the four readings will determine the blood pressure of the patient. When monitoring the blood pressure, always make sure that the patient has rested sufficiently in the chair. Certain physiological situations can raise the blood pressure erroneously. Example: stress, caffeine intake, improper positioning of the arm, improper cuff size, etc.
Method of Recording
Fasten the cuff over the arm snugly such that the lower border of the cuff is about one quarter to one half inch above the elbow crease. Place the tubes over the brachial artery. For a seated patient, place the patient's arm on the armchair. For a patient lying down, place the arm to the side of the patient. Always make sure that the cuff is at the cardiac level. Place your fingers on the radial pulse. Pump up the pressure in the cuff and monitor the dial. You will lose the pulse at a particular pressure level. Make a note of that reading. Keep your fingers on the pulse and continue to raise the pressure to 200 mm Hg. Now gradually start bringing the pressure down. You will at one point start feeling the radial pulse again. Note that pressure reading. Bring the pressure down to 0 mm Hg. The point where the radial pulse disappears and then reappears again is the rough systolic pressure. Now place your stethoscope on the brachial artery. Raise the pressure to 30-40 mm above the rough systolic pressure. Now gradually start bringing the pressure down. The point where you start hearing the tapping sounds (Korotkoff's sounds) is the true systolic pressure and the point where the tapping sounds disappear is the true diastolic pressure. Always raise the pressure to 200 mm Hg initially because in some hypertensives there exists what is called the auscultatory gap (see graph below). The tapping sounds will begin at an elevated systolic level, disappear temporarily and reappear again to disappear finally at the true diastolic pressure. The reappearance of the tapping sounds may be thought of as the start of the tapping sounds if you do not raise the pressure to 200 mm Hg.

Blood Pressure Monitoring

Height and weight
Note any irregularities.

1.3. Skin examination

Note the color of skin, temperature, turgor and skin lesions.

1.4. Head

Note hair (coarse and dry or thin and sparse), facial symmetry, any facial edema, butterfly rash, etc.

1.5. Ears

External ear infection is referred to as otitis externa. Gently pull on the earlobe for the ear tug test. If the patient experiences pain then the text is positive and confirms the presence of otitis externa in that ear.

Mastoid tenderness is positive in middle ear infection or inflammation. this is referred to as otitis media. Examined by gently pressing the tip of the mastoid with your thumb. If the patient experiences pain then the text is positive and the patient has otitis media associated with that ear.

1.6. Eyes

  • Look for xanthelasma (swellings near the medial end of the eyes), which is suggestive of hypercholesterolemia. Look for pallor, redness, yellowing of the sclera by pulling down on the lower eyelid.
  • Check for extraocular movements. Extraocular movements are tested as follows. Have patient sit in front of you, facing you. Have the patient follow your finger with his/her gaze only (no head movement permitted). You test the patient's ability to look up, down, sideways (both right and left), and diagonally. All eye muscles tested are supplied by cranial nerve III except superior oblique (C.N. IV) and lateral rectus (C.N. VI).
  • Light reflex. To test for light reflex have patient positioned as with extraocular movement testing. Have patient look straight ahead. Bring a flashlight from the right side and shine it onto the right eye. Note pupillary constriction in that eye and look for simultaneous constriction in left eye. The constriction in the right eye is the direct light reflex and the simultaneous constriction in the left eye is the indirect light reflex. Follow similar steps listed, using the light from the left side. The afferent cranial nerve for this reflex is C.N. II and the efferent is cranial nerve III.
  • Visual fields
    • Exophthalmus - protrusion of the eyeballs. Lid lag test is positive if exophthalmus occurs due to Grave's disease. To test for Lid Lag text: Have patient sit in front of you. Hold the patient's head with your left hand and have the patient follow your moving right index finger with his/her gaze. As the gaze moves downwards, if expopthalmus is present, the upper eyelid will not roll over the eyeball and you will see the white sclera.
    • Enophthalmus is sinking in of the eyeballs. It occurs with acute starvation; loss of body mass due to a carcinoma, etc.

1.7. Nose and sinuses

Check for sinus tenderness by tapping lightly over the ethmoid, maxillary and frontal sinuses. Flexing of the neck and lowering the head towards the chest can bring out pain associated with sinusitis (patient experiences pain in the sinuses when he/she leans forward, bending the head towards the chest).

1.8. Mouth and throat

Examine teeth, gums, mucous membranes, tongue, oropharynx and roof of the mouth. Gingival hypertrophy can be related to puberty, pregnancy, leukemia, drugs like phenytoin sodium (epilepsy drug), niphedipine, (an anti-hypertensive agent), cyclosporine (anti-rejection agent given to patients who have received an organ transplant).

1.9. Neck and axilla

1.9.1. Lymph gland examination: by palpitation, examination

Stand behind or to the side of the patient and palpate the following nodes with the pulp of your fingers, one side at a time or both sides at the same time.

The only node that should be palpated one side at a time is the tonsillar node. Simultaneous palpation of the tonsillar nodes can massage the carotid sinus resulting in bradycardia( slowing of the pulse). This becomes particularly detrimental in the elderly patient.

Normally, you don’t feel any nodes.

If you do palpate some nodes then they should be soft, pea sized, non tender and freely mobile. These could be leftovers from a past infection.

If the nodes are tender then they indicate a current infection. Look for associated symptoms and signs.

If the nodes are non tender, non-mobile pea sized or enlarged, one has to suspect the cause as being a tumor, benign or cancerous.

1.9.1.1. Nodes that drain superficial tissues only:

  • Preauricular
  • Postauricular
  • Occipital

1.9.1.2. Nodes that drain superficial and deep tissues:

  • Submental
  • Submandibular
  • Tonsillar

Bimanual palpation of the floor of the mouth should additionally be done if the submental and submandibular nodes are enlarged. Using gloved hands, support the floor of the mouth firmly with your left palm under the chin. Place the fingers of your right hand inside the mouth and feel the floor and sides of the mouth for any enlargements or swellings. Note the shape, size, mobility and tenderness.

1.9.1.3. Nodes that collect drainage from above-mentioned nodes:

  • Anterior cervical
  • Posterior cervical
  • Deep cervical

Palpate the area along the anterior border of the sternocledomastoid muscle for the anterior cervical nodes, and along the posterior border for the posterior cervical nodes. The deep cervicals cannot be palpated.

1.9.1.4. Supraclavicular:

Palpated by standing in front of the patient. Have the patient flex the neck towards the chest. Feel behind the clavicle adjacent to the suprasternal notch, on both sides simultaneously with the pulp of your fingers. You will begin palpation as the patient takes a deep breath. Deep breathing brings to the surface any enlarged nodes, if present. Tumors involving the lungs, breast, upper abdomen or liquid tumors can enlarge the supra clavicular nodes.

1.9.1.5. Additional nodes:

  • Trapezius
  • Supraclavicular

1.9.2. Thyroid examination: inspection

Stand in front of the patient and ask the patient to hyperextend the neck and swallow. There should be free mobility of the thyroid gland.

  • Palpation of the thyroid gland is done by standing behind the patient. Does the gland feel warmer than the surrounding skin when you place your palm on the patient’s neck? Is the surface smooth? Check for size by palpation of each lobe individually.

1.9.3. Trachea position:

  • Normal position is midline. Deviation may suggest tumor, pneumothorax or lung collapse.

1.10. Hands

  • Check temperature, appearance, color, nails, joints, palms (palmar creases) and any deformity if present.
  • Compare the palm color with your own palms, if you are looking for anemia.
  • If the palmar creases are white, the hemoglobin is less than 50% normal. Palmar erythema is frequently seen in alcoholics.
  • If the knuckle joints and the proximal interphalangeal joints are affected bilaterally, it is indicative of rheumatoid arthritis.
  • If the distal interphalangeal joints are affected unilaterally, it is suggestive of osteoarthritis.
  • Look for changes in the nails:
    • Clubbing (as with chronic cardiopulmonary diseases); spooning, also referred to as koilonychia (seen with iron deficiency anemia); splinter hemorrhage in the nails (as seen in SBE-subacute bacterial endocarditis).

1.11. Back

Patients with limited movements should be assisted in and out of the dental chair. rheumatoid arthritis affects the cervical spine and the temporomandibular joint (TMJ). Osteoarthritis affects the lumbosacral joint mobility.

  • Inspection:
    • Look for any spinal deformity.
  • Palpation:
    • Done to elicit any area of tenderness along spinal column.
  • Movements:
    • Ask the patient to bend forward, backward and sideways to check for mobility of the spine.

1.12. Lower extremities

  • Inspection:
    • Inspect for any skeletal or muscular deformity: varicose veins; joint deformity ; loss of hair on the toes, shin, and feet (loss occurs due to poor circulation).
  • Palpation:
    • Palpate the joints for any tenderness, swelling or redness. Also, with the back of your hands check for the relative warmth of the feet and toes, to indirectly assess perfusion.

1.13. Chest examination (Pulmonary)

  • Inspection:
    • Note symmetry and shape of chest. Barrel chest is seen with obstructive lung disease and with emphysema (hyperinflated lungs). Note rate, rhythm and regularity of respiration if not yet done.
    • Normal rate for adults is 12-16 respirations/min.
    • Resting shallow tachypnea (rapid shallow breathing) is seen with restrictive lung disease.
  • Hyperpnea (rapid deep breathing):
    • This is commonly seen with anxiety, exertion, or metabolic acidosis.
    • The rapid deep breathing as seen in metabolic acidosis is called Kussmaul's respiration.
  • Palpation:
    • Confirm bilaterally equal chest movements by palpation, testing from the apex to the base of the lungs. Strapping the chest in your hands, note the equality of chest excursions on both sides as the patient takes deep breaths.
    • To palpate the apex of the lungs: Place your palms on the patient's shoulders, press down firmly as you ask the patient to breathe. Note if both the apex of both lungs rise up equally. A collapsed apex is usually due to TB in the adult patient.
  • Percussion:
    • Compare percussion notes on both lung fields at same intercostal levels. Normal percussion note is resonant. Dullness on percussion is caused by consolidation (as in pneumonia), fluid (as in pleural effusion). Hyperresonance heard in case of a pneumothorax.
  • Auscultation:
    • Auscultate the anterior chest wall (both right and left), especially the apex of both lungs. TB commonly affects this area.
    • Auscultate the posterior chest in right and left lung fields, especially at the base of the lungs, for breath sounds and adventitious sounds (rales, ronchi, wheezes).
    • The normal breathing pattern heard all over the lung is referred to as vesicular breathing. The inspiration limb is longer than the expiration limb.
    • Bronchial breath sounds (see figure below), where the expiratory sound is higher pitched and louder than in vesicular breath sounds, the expiratory component is equal to or greater than the inspiratory component. These bronchial sounds are normal over the trachea and the large bronchi. It is abnormal if heard in the peripheral parts of the lungs.
    • Auscultation of the right and left lung must be done at the same intercostal level for comparison of auscultatory findings.

    The vesicular and bronchial breath sounds in relationship to the inspiratory and expiratory component:

    Bronchial breath sounds

  • Wheezes:
    • Wheezes are whistling sounds caused by constriction of the bronchioles, e.g., asthma.
  • Rales and ronchi:
    • These are crackling sounds produced due to the presence of fluid in the lungs, e.g., bronchitis, congestive heart failure (CHF). The vesicular and bronchial breath sounds in relationship to the inspiratory and expiratory component.

1.14. Cardiovascular examination

  • Inspection:
    • Note the jugular venous pulsation (JVP) in the neck, with the patient lying at a 30-40° angle. Normally, the pulsations will be seen at or below the clavicle. If the JVP is increased it is suggestive of decreased forward cardiac output or increased backward flow. Also note the apex beat of the heart. It is usually located in the fifth intercostal space, medial to the midclavicular line. Confirm the apex beat location.
  • Palpation:
    • Palpate the carotid pulse in the middle of the neck (one carotid at a time); establish the rate/min. Never palpate the carotid at the angle of the mandible as you will compress the carotid sinus as with the palpation of the tonsillar lymph nodes.
    • Palpate the radial pulse at the wrist; count the beats per minute. Radial pulse is located on the side of the thumb.
    • Note any other pulses or thrills over the cardiac area (thrill is a purring sensation, felt on palpation. Thrills are caused by a loud heart murmur). Murmurs are sounds produced by turbulent blood flow or vibrating heart valves.
  • Percussion:
    • Done to outline the right and left border of the heart.
  • Auscultation:
    • Auscultate the carotid arteries if there is a disparity in the rate of pulsation between the right and left carotids. On auscultation, you will hear a bruit (a swooshing sound) over the carotid artery with the lesser pulsation if there is any obstruction to the flow. It occurs because of a turbulence of blood flow in the partially obstructed carotid artery. When auscultating the carotids, always ask the patient to hold his/her breath, because a bruit and breath sounds are similar sounding.
    • Auscultate for heart sounds. S1 is caused by closure of mitral and tricuspid valves. S2 is caused by closure of aortic and pulmonic valves. The phase between S1 and S2 is the systolic phase (when ventricles contract), and the phase between S2 and S1 is the diastolic phase (when the atria are contracting).

    S1 to S2 is the ventricular contraction/systolic phase; S2 to S1 is the atrial contraction/diastolic phase (see figure below):

    Systolic Diastolic phase

    • Aortic stenosis (AS), Pulmonary Stenosis (PS), Mitral Incompetence/Regurgitation (MI), or Tricuspid Incompetence (TI) can cause a systolic murmur.
    • Diastolic murmurs can be caused by Mitral Stenosis (MS), Tricuspid Stenosis( TS), Aortic Incompetence (AI) or Pulmonary Incompetence (PI).
    • Auscultation must be done in the four cardiac areas outlined on the chest: aortic (second right intercostal space); pulmonic (second left intercostal space); tricuspid (third and fourth intercostal spaces, along the left border of the sternum); and mitral (fifth intercostal space, medial to the midclavicular line). The apex beat is located in the mitral area.
    • It is important to realize the cardiac murmurs, especially those associated with the aortic valve, are usually not confined to such discrete areas as the traditional listening areas (aortic, pulmonic, tricuspid, mitral valves, and associated murmurs). An aortic murmur may radiate and be heard maximally in any portion of the "actual" aortic area.

    Examination of the heart

1.15. Musculoskeletal system

  • Warm tender elbow joints with subcutaneous nodules is seen commonly with rheumatoid arthritis.
  • Palpable enlargement of bones in hands (referred to as nodules) is suggestive of osteoarthritis.
  • If the wrists are swollen bilaterally, think of rheumatoid arthritis.
  • If the large toe is affected, think of gout.

1.16. Abdominal examination

1.17. Neurological examination

1.18. Cranial nerve examination

Cranial Nerves: I - XII
Number Name Actions
I Olfactory Smell
II Optic Vision
III Oculomotor All extraocular muscle movements except lateral rectus and superior oblique muscle action; pupillary constriction.
IV Trochlear Movement of the eye down and in (superior oblique muscle movement).
V Trigeminal Sensory to face, ophthalmic, maxillary and mandibular components; motor to temporal and masseter muscles—muscles of mastication. Trigeminal nerve examination: Have patient shut the eyes for examination of the sensory component. Take a cotton tip and touch the skin in the ophthalmic, maxillary and mandibular area. The patient feels all sensations if the sensory divisions are adequately functioning. To test for the motor component, put your hands on either side of the patient’s face and ask the patient to clench. Note equal tension of muscles on both sides (masseter muscles). Test the temporalis on either side of the forehead similarly.
VI Abducens Lateral movement of the eye (lateral rectus muscle movement).
VII Facial Motor to most facial muscles; anterior tongue taste. Ask the patient to blow, whistle and look up.
VIII Acoustic Hearing and balance.
IX Glossopharyngeal Sensory and motor to pharynx; posterior tongue taste .
X Vagus Motor to palate, larynx, pharynx; sensory to pharynx and larynx. The IX and X cranial nerves are tested together. Ask the patient to say a deep “aah” while you look into the patient’s mouth with a flashlight. You note if the palate rises equally on both sides.
XI Spinal accessory Motor nerve to sternocleidomastoid and trapezius muscles. The XI cranial nerve is tested as follows. Stand behind the patient and press down on both the patient’s shoulders with your hands. Ask patient to shrug against pressure. The tension should be equal on both sides. (Trapezius tested.) Next place your right palm on patient’s right cheek. Feel tension in left sternomastoid as you apply pressure while patient tries to turn his face to the right. Follow similar steps on left side of face. (Sternocleidomastoid tested.)
XII Hypoglossal Motor to tongue. Ask patient to protrude the tongue. Normally the tongue should be in the midline and have no tremors. If one of the cranial nerves is damaged, it causes the tongue to deviate toward the affected side.