Physical Examination: Four Principles

• The four principles of physical examination are inspection, palpation, percussion, and auscultation
• Competence in performing physical examinations requires sensory input coordination with time and practice
• Examiners should think of the four basic skills before moving on to evaluating the next area

Inspection

• Inspection can yield a significant amount of information
• Examiners must train themselves to look at the body utilizing a systematic approach
• Novice examiners often rush to use instruments before using their naked eyes for inspection

Patient Observation

• When taking the history, examiners observe general appearance, state of nutrition, body habitus, symmetry, posture/gait and speech
• General appearance includes state of consciousness and personal grooming
• Poor nutrition, sunken eyes, temporal wasting, and loose skin are associated with chronic disease
• Inspection can evaluate the state of nutrition, and individuals with chronic disease are often cachectic rather than overweight
• Long-standing ailments like cancer, hyperthyroidism, or heart disease can result in a markedly wasted appearance
• The asthenic, or ectomorphic, body habitus is thin with poor muscle development and appears malnourished
• The mesomorphic body habitus is athletic with excellent muscle and bone structure development
• The hypersthenic, or endomorphic, body habitus is a short, round individual with good muscle development and often a weight problem
• Note any asymmetry in the outward appearance of the body, as systemic diseases can provide clues
• A left supraclavicular swelling in a 61-year-old man may indicate an enlarged lymph node, potentially the only sign of gastric carcinoma
• A miotic pupil in a 43-year-old woman may indicate an interruption of the cervical sympathetic chain caused by a tumor at the apex of the lung
• A recent onset of a left-sided varicocele in a 46-year-old man could be related to the development of a left hypernephroma
• Observe the patient's posture and gait to evaluate coordination of the nervous and musculoskeletal systems
• Assess speech patterns for slurring and appropriate word usage; speech issues can provide clues to cranial nerve problems
• Orientation to person, place, and time can be evaluated by asking simple questions, which provide insight into the patient's mental status
• Cardinal signs of inflammation include swelling, heat, redness, pain, and disturbance of function

Palpation

• Palpation involves using touch to determine characteristics of an area such as skin elevation/depression, warmth, tenderness, pulses, crepitus, and organ/mass sizes
• An abnormal impulse palpated on the right side of the chest could relate to an ascending aortic aneurysm
• A pulsatile mass palpated in the abdomen might be an abdominal aneurysm
• An acutely tender mass palpated in the right upper quadrant of the abdomen that descends with inspiration is probably an inflamed gallbladder

Percussion

• Percussion relates to tactile sensation and sound produced when striking an area being examined
• Percussion gives valuable information about the structure of underlying organs or tissues
• Differences from normal sensation may relate to fluid in an area that typically doesn't contain fluid
• Lung collapse changes the percussion note, as does a solid mass in the abdomen
• Dullness in the midline of the lower abdomen in a man likely indicates a distended urinary bladder

Auscultation

• Auscultation involves listening to sounds produced by internal organs, furnishing information about an organ's disease process
• The examiner should learn as much as possible from inspection, palpation and percussion before using a stethoscope
• This instrument should corroborate the signs suggested by the other techniques
• Auscultation should be used together with inspection, percussion, and palpation to examine the heart, chest, and abdomen
• Detecting carotid, ophthalmic, or renal bruits can provide lifesaving information
• The absence of normal bowel sounds could indicate a surgical emergency

Examination Preparation

• Have a portable case with the necessary equipment
• Essential equipment includes a stethoscope, otoscope and ophthalmoscope, penlight, reflex hammer, tuning forks (128 Hz and 512 Hz), safety pins, tape measure and pocket visual acuity card
• Optional items include a nasal illuminator and nasal speculum
• Available items in most patient care areas include a sphygmomanometer, tongue blades, applicator sticks, gauze pads, gloves, lubricant gel, guaiac card for occult blood, vaginal speculum and hand sanitizer
• Arrange equipment on the patient's night table or bed stand
• Adjust lighting and use daylight if possible to avoid masking skin color changes
• Close the patient's curtains for privacy
• Adjust the bed to a convenient height and lower it after the examination is complete
• Wash hands, preferably in view of the patient, with soap and water for at least 10 seconds or use hand sanitizer
• Patients should wear a gown that opens at the front or back, or pajamas in hospitalized settings, and be allowed pillows to maximize comfort

Examination Procedure

• Strive for proficiency in each organ system examination and incorporate individual evaluations into the complete exam
• Minimize patient movement and avoid unnecessary changes in position
• Perform as much of the examination as possible with the patient in one position
• The physical examination should be conducted by body regions, not by systems
• Examiners conventionally stand to the right of the patient and use their right hand for most maneuvers
• Even left-handed individuals learn to perform the examination from the right side, using the right hand
• Expose only the areas being examined at that time
• Check both breasts for asymmetry while assessing a woman's breast
• The abdomen may be examined discreetly by placing a towel or sheet over the genitalia
• Respect patient privacy to build a good doctor-patient alliance
• Talk to the patient during the physical examination
• Refrain from comments like "That's good" or "That's normal", which can cause worry if omitted later
• Individual organ system examinations are discussed in later chapters

Healthcare Infection Prevention Practices

• All healthcare team members with patient exposure have the potential for infection exposure
• Infection prevention practices identify those harboring or infected with transmissible agents
• Follow the guidelines established by the CDC and OSHA
• Standard precautions involve treating all human blood and body fluids as if they are known to be infected with HIV, HBV, and HCV
• Focus is on preventing exposure and delivering HBV vaccinations (CDC)
• Protective barriers, such as gloves, gowns, masks, and eye protection, should be used to reduce exposure to body fluids
• Universal precautions supplement recommendations for routine infection prevention, including hand-washing and glove use
• Proper judgement and referral to guidelines is crucial, especially for those contacting body fluids or performing procedures
• Recommended for all patients regardless of their disease status, standard precautions include hand washing and using appropriate protective equipment
• Airborne precautions are used for infectious agents spread through small particles, such as varicella and tuberculosis
• Implementing airborne precautions requires the use of an N-95 or equivalent respiratory mask and isolating the patient in a negative-pressure room
• Droplet precautions are used for agents spread in large droplets, such as respiratory viruses, and require a surgical mask and gloves
• Contact precautions are used for agents spread by skin-to-skin contact or contact with surfaces, such Clostridium difficile and multidrug-resistant organisms, and require a gown and gloves.
• Use the needed precautions for patient care; signage should be on the door of the patient’s room
• Flush needlestick injuries with water, then seek care from the hospital’s needlestick coordinator
• Each hospital has a protocol in place and postexposure prophylaxis for HIV available

Hepatitis

• Hepatitis B serologic testing should be considered
• Immunoglobulin can be considered in rare situations
• Hepatitis C can be spread via needlestick
• Serologic testing should be done in 48 hours to test for nucleic acid testing
• Healthcare providers should get hepatitis B and annual influenza vaccinations
• Preemployment and student health screens include TB testing and serologic testing for hepatitis B
• Workers are responsible for not giving patients' the disease
• Workers with lesions on their hands should wear gloves; if they are sick, they should defer patient contact

Physical Examination Goal

• The goal is to get valid information about the health of the patient and to identify, analyze, and synthesize this information for a comprehensive assessment
• The validity of a physical finding depends on clinical experience and reliability
• False results reduce the precision of the techniques
• Variance can occur when techniques are performed by different examiners with different equipment on different patients
• Unconscious bias is an important concept, and can influence the evaluation of a physical finding

Predictive Values

• Predictive values such as sensitivity and specificity should be reviewed
• Sensitivity refers to the frequency of a positive test result or technique in individuals with a disease
• Specificity refers to the frequency of a negative test result or technique in individuals without a disease
• Positive predictive value is the frequency of disease in patients with positive test results
• Negative predictive value is the frequency of lack of disease in patients with negative test results
• A technique or test with high sensitivity can be utilized confidently to rule out disease for a patient with a negative finding
• A technique or test with high specificity can be utilized confidently to confirm disease for a patient with a positive finding

Medical Terminology

• Determine the meaning of medical terms by understanding roots, etymology, prefixes, and suffixes

The four principles of physical examination: inspection, palpation, percussion, and auscultation. Competence requires sensory input coordination with time and practice. Examiners should think of the four basic skills before evaluating the next area.