Physical Examination

Xiao Li
Department of Physical Diagnosis
Department of Nephrology
Rui-jin Clinical College
Shanghai Jiao-tong University School of Medicine
Physical Examination
z It is the process of examining a patient’s body
to obtain valid information concerning the
health of the patient
z The examiner must be able to identify, analyze,
and synthesize the accumulated information
into a comprehensive assessment
HOW TO LEARN

Teach the eye to see, the finger to feel,

and the ear to hear

-William Osler

Learned with time and practice

Equipment for physical examination
stethoscope、sphygmomanometer、
tongue blades、 penlight、
reflex hammer、 safety pins、
tape measure、ophthalmoscope
Important aspects of physical examination

z comfortable environment
z prepare the equipment for physical examination
z kind attitude & decent manner
z sequential

z proper expose
 Important aspects of physical examination

Where does the examiner stand?

z Stand right side of the bed

z Exam with right hand

Sequential

z Conducted in head to toe order:

head---neck---chest---abdomen---spine---
extremities---anus---genital---nervous system

z Patients tire quickly when asked to “sit up”,

“lie down”, “turn on your left side”, “sit up”,
“lie down” and so on
 Proper expose
z Exposing only the area that are being examined at that
time without undue exposure of the other areas

z This caring for the patient’s privacy goes a long way in

establishing a good doctor-patient relationship
The methods of physical examination

z Inspection

z Palpation

z Percussion

z Auscultation

z Smelling
 Inspection

z Method of observation used

during physical examination
z First step in examining a patient
or body part
Inspection
za general survey of the patient’s
mental status posture gait
body movement speech breath
state of nutrition stature skin
 How to inspect

z Make sure the room is a comfortable temperature

z Use good lighting, preferably sunlight
z Look and observe before touching
z Completely expose the body part you are inspecting while
draping the rest
z Compare symmetrical body parts
Palpation
z The examiner touches and feels the patient’s body part
with his hands to examine the size, consistency, texture,
location, and tenderness of an organ or body part
z The palpation of abdomen is particularly important
How to perform palpation
zThe palpating hand should be warm, because cold hands
may produce voluntary muscular spasm called “guarding”

zEngaging the patient in conversation often aids in

relaxing the patient’s abdominal musculature

zAsk patient to be in a supine position and to flex the

thighs and knees
 How to perform palpation
z The degree of muscle rigidity or resistance may be made
by light palpation
z One should determine whether the abdominal wall
exhibits voluntary muscle tightening or actual rigidity
z Always begin palpation in an area of the abdomen that is
farthest from the location of pain
Types of palpation
z Light palpation
z Deep palpation
deep slipping palpation
bimanual palpation
deep press palpation
ballottement
 Light palpation
z Using the flat part of the right hand or the pads of the
fingers, not the fingertips
z The hand should be lifted from one area to area instead of
sliding over the abdominal wall
z Used to feel for pulses, tenderness, muscle spasm, rigidity,
surface skin texture, temperature, moisture or mass, its size,
location, hardness and outline
 Light palpation
z Rigidity is involuntary spasm of the abdominal muscles
and is indicative of peritoneal irritation
z Rigidity may be:
diffuse (diffuse peritonitis)
localized (over an inflamed appendix or gallbladder)
z In patients with generalized peritonitis, the abdomen is
described as “board-like”
Light palpation
 Deep palpation
z Used to determine organ size as well as the presence
of abdominal masses
z Pressure should be applied to the abdomen gently
but steadily
z The patient should be instructed to breathe quietly
through the mouth and to keep arms at the sides
Deep slipping palpation
z The examiner uses his forefinger, middle finger and
ring finger that are tightly together, slowly and
gradually palpate the abdominal organs or masses,
slipping up-, down, right side and left side

z It is frequently used for examining the deep mass

of abdomen or GI lesions
 Bimanual palpation
z Uses two hands, one on each side of the body part being
palpated
z Placing the left hand over the pack of organs to be
examined, in order to fix or elevate the organs. It may be
helpful for the right hand palpation
z It is employed during the processes of liver, spleen, kidney
or abdominal masses examination
Bimanual palpation
liver and spleen
 Deep press palpation
z The examiner uses his thumb or 2~3 fingers together to
palpate with gradually increasing pressure, in order to
identify deep organ lesions or localize the area of
abdominal pain
z Such as the pain produced by inflamed gallbladder or
appendicitis
z In a patient with abdominal pain, the rebound tenderness
should be determined
Deep press palpation
tenderness point
 Rebound tenderness
z It is a sign of peritoneal irritation and can be elicited by
palpating deeply and slowly in an area from the suspected
area of local inflammation

z The palpating hand is then quickly removed

z The sensation of pain on the side of inflammation that

occurs on release of pressure is rebound tenderness
 Ballottement
z The examiner places 3~4 fingers together on the surface of
suspected abdominal area and push quickly and shortly for
several times with the motion from the wrist
z The fingertips might feel the abdominal organs are floating,
because it produce ascitic waves
z Employed in palpating the enlarged liver, spleen or masses
ballottement
 Percussion
z A methods of “tapping” of body parts during physical
examination with fingers, hands, or small instruments to
evaluate the size, consistency, borders and presence of
fluid in body organs
z Percussion of a body part produces a sound that indicates
the type of tissue within the organ
 Percussion
z It is used to detect diaphragmatic movement, the size of heart,
edge of liver and spleen and ascitis etc
z Tapping on the chest/abdominal wall is transmitted to the
underlying tissue, reflected back, and picked up by the
examiner’s tactile and auditory sense
z The sound heard and tactile sensation felt are dependent on
the air-tissue ratio
Methods of Percussion

z Indirect percussion

z Direct percussion
 Indirect Percussion
z The examiner places the middle finger of one hand (left hand)
firmly against the patient’s surface wall (chest or abdomen),
with palm and other fingers held off the skin surface
z The tip of the right middle finger of the hand strikes a quick,
sharp blow to the terminal phalanx of the left finger on the
skin surface
z The motion of the striking finger should come from the wrist
and not from the elbow
z Deliver 2~3 quick taps and listen carefully
Indirect percussion
Direct Percussion
 Quality of Percussion

z Resonance percussion over a structure containing air

within a tissue, such as the lung, produces a resonant,
higher-amplitude, lower-pitched note

z Tympany percussion over a hollow air-containing

structure, such as the stomach, produces a tympanic,
higher-pitched, hollow quality note
 Quality of Percussion
z Hyperresonance the quality of percussion sound is between
the resonance and tympany. Such as in children, pulmonary
emphysema
z Dullness percussion over a solid organ, such as the liver,
produces a dull, low-amplitude, short-duration note without
resonance
z Flatness very short, and high pitched (absolute dullness).
Flatness occurs when there is no air present in the
underlying tissue
 Auscultation

z A method used to “listen” to the sounds of the body during

a physical examination

z Performed by listening through a stethoscope, and to

evaluate the frequency, intensity, during, number and
quality of sounds
Auscultation

z Direct auscultation

z Indirect auscultation
 How to auscultation

z Eliminate distracting noises

z Expose the body part you are going to ausculate
z Use the diaphragm to listen for normal heart sounds, and
bowel sounds
z Press the diaphragm firmly
z Use the bell to listen for abnormal heart sounds or bruits
z Hold the bell lightly
Ausculation
How to use the stethoscope
z Do’s
warm the diaphragm or bell
explain what you’re listening for and answer
patient’s question promptly
z Don’ts
do not apply too much pressure when using the bell
do not try to listen through clothing
 Smelling

z A method used to evaluate the relationship between

abnormal ordor from the patient and disease
z The ordor is elicited from the exudates of skin, mucosa,
respiratory tract, GI, blood etc
z Abnormal ordor may also provide important clues for the
diagnosis of the disease
Thanks !