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Approach to Physical Examination

Wale Olajubelo, MD

UME - KJMC

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The Successful Clinician

Approachable

Empathic Listener

SelfReflective

Respectful

Courteous Professional

Reminder

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Patient Encounter; Interview

Establish a trusting Interview

Gather Information

Offer Information

Acknowledge Reassuring

Encourage

Clarify

Validate

Turn patient words into coherent narrative

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-Screening for disease, assure good health,

develop relationship/ rappaport w/patient

Identify cause of symptoms

Part of mystique & magic of medicine

power of touch & observation

***Exam is closesly linked to the History***

Purpose Of The Physical Exam

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Non Verbal Communication

Help read patient

Help interpersonal distance

Enhances information gathering

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Reminder

Patient ID

CC

HPI ROS

PE

General Vitals

ROS

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Physical Examination

Patient feel vulnerable & physically exposed . - Reassure them

Be systematic in your approach

Be flexible

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Note

The key to a thorough and accurate PE is developinga systematic sequence of examination.

Goals:

- Maximize patient comfort

- Avoid unnecessary changes in position

- Enhance clinical efficiency

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A Few Thoughts For The Road

Have fun & be enthusiastic!

You will not master material after one courseExam

skills develop w/time, practice & clinical

experience/exposure

Begin building solid foundation

Repetition & challenging yourself are key. If extra

timepractice prior weeks skills Never stop questioning & thinking

This is a life long endeavormore you put inmore

you get out!

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Become A Data Gathering

Machine!

Exam begins as soon as you see patient:

General Survey,

Patients Dress (neat, disheveled, work clothing)?

Sad, happy, angry, pain?

Gait / While walking to office

Accompanied? By whom?

Carrying things (books, bags, possessions)?

While waiting/ reading, sleeping, snoring/apnea?

Vital Signs,

Upper Extremity & Skin Exams

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Vital Signs

Pulse, Blood Pressure, Respiratory Rate,

Temperature

Provide insight into:

Asymptomatic disease (e.g. hypertension)

Degree of perturbation caused by acute

disease (e.g. dehydration) Compensation for chronic diseases

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One size doesnt fit all! If too

small/ BP artifactually high.

Length of bladder must reach

80% around circumference of

upper arm

Width 40%.

BP Cuff

(Sphygmomanometer)

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Confounding Environmentalwhen taking BP

Factors

Patient should rest, seated x 5 minutes (i.e. dont

take after theyve run into your office), feet flat

on floor.

No stimulants prior, if possible (e.g. coffee,

cigarettes, sudafed, etc)

Remove shirts, sweaters except loose t- shirts- exam gown is ideal

Errors in technique can be additive/resulting in

inappropriately diagnosing pt w/HTN!

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Hair Loss

Tinea Capitis

Dandruff

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Skin

Skin = largest organ

Disease can be primary to skin or

manifestation of problem elsewhere

Common asymptomatic disease = cancer

California

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Mild Moderate Severe

Weight loss Up to 5% 6-10% More than 10%

Appearance Active, alert Irritable, alert, thirsty Lethargic, looks sick

Capillary filling (compared to

your own)

Normal Slightly delayed Delayed

Pulse Normal Fast, low volume Very fast, thready

Respiration Normal Fast Fast and deep

Blood pressure Normal Normal or low Orthostatic hypotension Very low

Mucous memb. Moist Dry Parched

Tears Present Less than expected Absent

Eyes Normal Normal Sunken

Pinched skin Springs back Tents briefly Prolonged tenting

Fontanel (infant sitting) Normal Sunken slightly Sunken significantly

Urine flow Normal Reduced Severely reduced

Clinical assessment of dehydrationClinical assessment of dehydration is always approximate and the child should be frequently re-evaluated forcontinuing improvement during correction of dehydration.

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Skin Screening Exam: Basic

Principles Full exposure/See all skin

Particular attention to areas with max

exposure (face, ears, scalp) Look for areas that are: Non-healing

Growing/changing shape

Irregular borders Colored/bleeding

Palpate for: Size, firmness, depth, pain

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Changes in pigmentation

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Common Skin Cancers

Squamous Cell Cancer Basal Cell Carcinoma

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Upper Extremity Exam

Observation: Nails, fingers, hands, arm

Capillary refill: push on finger tip or nail bed/

time for red color to return < 2-3 sec - markerof perfusion.

Clubbing

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Nicotine

Clubbing

Onychomycosis

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Note: Shape ,color & size

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Lower Extremity

Dermatitis HerpetiformisPsoriatic plaques