Doctor’s Physical Examination Checklist

This article outlines common clinical methods used by clinician/doctor during patient physical examination through;

A step-by-step approach

Image result for pic of stethoscope used
stethoscope used in examination

General Examination

  1. Position of the patient – gives valuable information e.g. severely ill patients slip down the bed, patients with heart failure sit up in bed and patients with abdominal pain are restless or roll about in bed.
  2. Assess the general condition of the patient – can be described as good, fair, sick looking or very sick looking (toxic).
  3. Mental and Emotional state – an anxious person may be restless.
  4. Assess the nutritional status (what are the parameters).
  5. The hair – check for the distribution, colour and texture.
  6. Jaundice – check on the sclera, frenulum of the tongue and skin.
  7. Oral thrush – look on,soft palate,hard palate,sides of the tongue and buccal mucosa
  1. Cyanosis
    • Central cyanosis – on the tongue and lips
    • Peripheral cyanosis – extremities of the hands and feet
  1. Pallor
    • Mucous membranes – Conjunctiva and tongue
    • Palms
    • Capillary refill test
    • Soles
    • Anus/perineum
  1. Dehydration
    • Mucous membranes
    • Tongue
    • Skin turgor
  2. Lymph nodes – lymphadenopathy ;

Characteristics

  • Site
  • Size
  • Consistency
  • Matted or discrete
  • Tender or non-tender
  • Mobility – fixed to skin or underlying structures

Sites

  • Occipital
  • Pre auricular
  • Post auricular
  • Anterior cervical
  • Posterior cervical
  • Supraclavucular
  • Infraclavicular
  • Axillary (anterior, posterior, medial, lateral & apical group)
  • Epitrochlear
  • Para-aortic
  • Femoral
  • Inguinal
  1. Finger clubbing
Test
  • Fluctuation test
  • Schamroth’s Window test
  • The nail curvatures – the horizontal and vertical curvatures
  1. Janeway lesions
  2. Splinter haemorrhages
  3. Koilonychia
  4. Leuconychia
  5. Osler’s nodes
  6. Herberden’s nodes – at the distal interphalangeal joints of all fingers
  7. Rheumatoid nodes at the proximal interphalangeal joints of all fingers
  8. Oedema
    • Bilateral pedal
    • Facial
    • Sacral
  1. Skin
    • Colour
    • Texture
    • Pigmentation
    • Bleeding spots – echymosis and purpura
    • Scars
    • Lesions – macules, papules, vesicles, pustules, bullae and crusts
    • Pallor
    • Yellowness
  1. Vital signs
    • Respiration rate
      1. Rate
      2. Rhythm
      3. Characteristics
  • Blood pressure – check all the steps
  • Temperature – check all the steps
  • Pulse
    1. Characteristics of the pulse
      • Rate – use radial pulse
      • Volume – use carotid pulse
      • Character – use radial pulse
      • Rhythm – use radial pulse
      • Synchronicity – use all corresponding pulses and the femoral and radial pulses
    2. Sites
      • Temporal
      • Carotid
      • Brachial
      • Radial
      • Aortic
      • Femoral
      • Popliteal
      • Posterior tibial
      • Dorsalis pedis

The Cardiovascular System Examination

Consider the inverted “J” format.

General Examination

  1. Pallor
  2. Splinter haemorrhages
  3. Finger clubbing
  4. Janeway lesions
  5. Radial pulse
  6. Brachial pulse
  7. Blood pressure (check the steps)
  8. Carotid pulse (differentiate with the JVP)
  9. Jugular venous pressure (JVP)
    • Position of patient
    • Identify the JVP
    • Measure JVP
  10. Palpate for the liver (examine all the aspects)
  11. Abdominal aorta
  12. Femoral pulse
  13. Popliteal pulse (check positioning of the patient)
  14. Dorsalis pedis
  15. Posterior tibialis
  16. Pedal oedema

Examination of the Preacordium

The Preacordium

A.      Inspection

  • Activity of the praecordium
  • Chest deformity

B.      Palpation

  • The Apex beat
    • Using the palm of the hand
    • Locate with finger tip
    • State the location using the vertical (mid-clavicular line) and horizontal (intercostals spaces) measurements
  • Thrills
    • Location (mitral area, tricuspid area, aortic area and pulmonary area)
    • Timing with the cardiac cycle (systolic or diastolic)
  • Heaves
    • Apical heave
    • Parasternal heaves
    • Grade the heaves (Grade 1-3)

C.      Percussion

  • All the borders of the heart when indicated.
  • The heart region produces a dull percussion note

D.      Auscultation

Use a suitable stethoscope utilizing both the diaphragm and bell effectively at the auscultatory areas (mitral, tricuspid, aortic and pulmonary areas)

  • The heart rate
  • Heart sounds (at all the auscultatory areas using both sides of the stethoscope)
    • Listen and identify the 1st and 2nd heart sounds
      • Intensity (normal, increased or decreased)
      • Splitting
      • 3rd and 4th heart sounds (what is the significance)
    • Added sounds
      1. Ejection systolic clicks – form the opening of semilunar valves
      2. Murmurs (at all the auscultatory areas using both sides of the stethoscope) check for;

#Change position of patient for different murmurs

Timing

#Magnitude

#Area of maximum intensity

#Radiation

#Grading (Grade 1-6)

Respiratory System; physical examination

A.   General Examination

A simultaneous general examination for the respiratory system includes: –

  1. The physique
  2. Voice
  3. Breathlessness
  4. Finger clubbing
  5. Cyanosis
  6. Pallor
  7. Intercostal recession
  8. Use of accessory respiratory muscles
  9. Venous pulses
  10. Lymph nodes

B.   Inspection

  1. Position of the patient
  2. Sputum (if present)
  • Colour
  • Amount
  • Contents
  • Smell

3.Signs of respiratory distress

  • Cyanosis (central and peripheral)
  • Use of accessory muscles of respiration (alae nasi, sternocleidomastoid muscle and trapezius)

4.Chest symmetry

  • Anterior
  • Posterior
  • Lateral right
  • Lateral left

5.Chest deformities

  • Anterior
  • Posterior
  • Lateral right
  • Lateral left

6.Chest movement

  • Anterior
  • Posterior

7.Scars

  • Anterior
  • Posterior
  • Lateral right

C.   Palpation

  1. Position of the patient (change the position for each examination skill as required)
  2. Swelling
  3. Cardiac impulse
  4. Tenderness on; anterior, posterior and lateral

5.Position of the trachea

  • Position of the patient
  • Locate the landmarks
  • Palpate for the trachea
  • Demonstrate the position of the trachea – centrality or shifting

6.Chest expansion

  • Demonstrate chest expansion at three levels anteriorly and two levels posteriorly.
  • Measure chest expansion at the level of T4
  • Tactile fremitus
  • Anterior (compare the left and right sides at each level) from top to bottom.
  • Posterior (compare the left and right sides at each level) from top to bottom.
  • Lateral – in the axilla region (Compare the left and right sides at each level) from top to bottom.

7.Rhonchial fremitus (if present)

  • Anterior (compare the left and right sides at each level) from top to bottom.
  • Posterior (compare the left and right sides at each level) from top to bottom.
  • Lateral – in the axilla region (Compare the left and right sides at each level) from top to bottom

C. Percussion

1.Position of the patient

2.Anterior – percuss from the clavicle downwards comparing the left and right sides of the chest

3.Posterior

  • Percuss from the apex of the lungs
  • Percuss form below the scapula downwards comparing the left and right sides of the chest

4.Lateral – percuss from the axilla region downwards comparing the left and right sides of the chest comparing the left and right sides of the chest

5.Interpretation of the percussion notes (resonant, dull, stony dull and hyper-resonant)

D. Auscultation

1.Breath sounds – listen to the breath sounds using both sides of the stethoscope from the top to the bottom at the anterior, posterior and lateral aspects of the chest. Take note of the quality and intensity of the sounds. The quality of breath sounds is described as either vesicular or bronchial.

2.Interpretation of the breath sounds i.e. bronchial and vesicular breath sounds

3.Vocal resonance – note if normal, decreased or increased

4.Sounds associated with vocal resonance

  • Whispering pectoriloguy (whispered words are distinctly heard)
  • Aegophony (the voice sounds nasal or bleating)
  • Brochophony (sounds appear to be near the ear piece of the stethoscope)

5.Auscultate for the added sounds noting the precise site where it is found

  • Wheezes/Rhonchi (musical sounds associated with airway narrowing) – monophonic wheezes (from a single bronchus) and polyphonic wheezes (diffuse obstruction – asthma and bronchitis)
  • Crackles (Crepitations – fine crackles; rales – coarse crackles)
  • Pleural rub – rubbing or creaking character

Per Abdomen Physical Examination

A.   General signs

Some of the general features in gastro-intestinal diseases include: -finger clubbing,palmar,leuconychia, jaundice,pruritus and scratch mark.

B.   Inspection

  1. Position of the patient
  2. Expose the patient adequately
  3. Check for symmetry
  4. Shape of the abdomen – contour
    • Normal contour
    • Scaphoid
    • Distended
  5. Umbilicus – everted or inverted
  6. Scars –surgical scars
  7. Striae
  8. Visible veins
  9. Visible peristalsis
  10. The skin
  11. Visible pulsations at the hepatic region and epigastric region

C.   Palpation

1.Superficial palpation

  • Begin the superficial (light) palpation at the left iliac fossa and move anticlockwise ending the palpation at the umbilical region.
  • Note the skill and technique of palpation

2.Deep palpation

The left kidney
  • Position of the patient
  • Positioning of the examiner’s hands
  • Do bimanual palpation
The Spleen
  • Positioning of the examiner’s hands
  • Starting point (right iliac fossa) and direction of movement during palpation.
  • Lower boarder and measure the size (Grade 1-5 or measure in cm below the subcostal margin on the mid-clavicular line)
  • Check movement of the spleen with respiration
  • Margins
  • Spleenic notch
  • Surface of the spleen
  • Consistency
  • Upper boarder
  • Dipping in case of massive ascites – turn patient to lie on the right lateral and palpate for the spleen in case of minimal Spleenomegally
The right kidney
  • Position of the patient
  • Positioning of the examiner’s hands
  • Do bimanual palpation

The Liver

  • Positioning of the examiner’s hands
  • Starting point (right iliac fossa) and direction of movement during palpation.
  • Lower boarder and measure the size and measure in cm below the subcostal margin on the mid-clavicular line)
  • Check movement of the liver with respiration
  • Margins
  • Surface of the spleen
  • Consistency
  • Upper boarder
  • Dipping in case of massive ascites
  • Check for hepato-jugular reflux (in case of liver congestion)
  • Palpate for tenderness by gently pressing on the rib cage (when hepatomegally is not marked)
  • Look for the liver span
The Gall bladder
  • Murphy’s sign (observe the steps)
  • Couvorsier’s sign (observe the steps)

The Urinary Bladder

  • Fundal height
  • Surface
  • Lower boarder

D.      Percussion

  1. Position of the patient
  2. General percussion – note the notes

a)Fluid thrill

  • Position of patient
  • Get assistant to apply pressure at the midline of the abdomen
  • Positioning of the hands of the examiner
  • Strike on side of the flanks of the abdomen while palpating for the thrills at the other flank

b)Shifting dullness

  • Position patient
  • Positioning of examiner’s hands
  • Percuss from the midline towards the flanks noting the changes in the percussion note.
  • Hold the pleximeter fingers in place
  • Turn the patient to lie on the lateral side
  • Allow for the fluid to resettle
  • Percuss from the flanks to the midline and note the shift in the dull percussion note.

E.    Auscultation

Listen for the bowel sounds and note whether they are increased, normal, decreased or absent

Steps;

  • Place stethoscope on one site (just to the right of the umbilicus)
  • Keep there until sounds are heard
  • Vascular bruits – over the abdominal aorta, above and to the left of the umbilicus and the iliac artery.

E. The Groins

  • Inspect the groins
  • Ask patient to cough and look for expansive impulse
  • The femoral arteries

F. Examine the male genitalia ;

  • masses, hernia, swellings

G. examination of the Anus and rectum

1.Inspection
  • Separate the buttocks
  • Inspect the perianal area and anus
  • Note presence of abnormality of perianal skin e.g. inflammation, skin lesions, any “hole or dimple, sinuses, piles, haematoma, abscess, prolapse
2.Digital Examination
  • Generously lubricate the gloved index finger of right hand
  • Place the pulp of the finger flat on the anus
  • Press firmly and slowly in a slightly backwards direction
  • Gently pass the finger into the anal canal
  • Rotate the finger through 360 degrees and feel for any thickening or irregularity of the anal wall

H. Vaginal Examination

 

Inspect the perineum in the dorsal or left lateral position

  • Note any inflammation, swelling, soreness, ulceration or neoplasia of the vulva, perineum or anus.

Digital examination

  • Lightly lubricate the examining fingers with a water based jelly
  • Patient in supine position, with her knees drawn up and separated
  • Swab the perineal region
  • Gently separate the labia with the index finger and the thumb of the left hand
  • Insert the index finger of the right hand into the vagina avoiding the urethral meatus
  • Exert sustained pressure on the perineal body to relax perineal musculature
  • Push finger full length until cervix is located
  • Inert second finger to improve sensitivity of examination.

Speculum examination;

  • Cusco’s (bivalve) speculum
  • Sim’s (double ended duckbill) speculum
  • Ferguson’s speculum

Physical Examination Of Nervous System

A. Mental Functions

  1. Appearance and behaviour – shows the patients general bearing
  2. State of consciousness – any disturbance of the state of consciousness e.g. coma, stupor, confusion. States of clouded or altered consciousness are important in patients with head injury or raised intracranial pressure.
  3. Emotional state – describes the patients mood; emotionally stressed or disturbed people often have abnormal sleep e.g. depression
  4. Delusions, Illusions & Hallucinations – delusions – false beliefs; hallucinations – false impressions referred to special senses (hearing, seeing and smelling).
  5. Memory – this is the ability to grasp and retain new information. Comprises of short and long term memory.
  6. Intelligence – assessment made from the patient’s vocabulary, educational level and occupational history
  7. Orientation in person, time and space
  8. Speech and language – examine for defects in articulation and enunciation of speech (Dysarthria) and disturbances of structure and organization of language (Aphasia). There are four main types of dysathria: cerebellar, pseudobulbar, bulbar and cortical dysathria.

B.   Cranial Nerves

  1. Cranial Nerve I (Olfactory) – test for the sense of smell. (What are the causes of anosmia?)
  2. Cranial Nerve II (Optic) – test for the visual acuity using the Snellen’s charts; Visual fields using the confrontation test (confrontation test using a finger and red pin confrontation test): Perimetry; Colour vision.
  3. Cranial Nerve III (Oculomotor) – test for occulor movements of the eye such as abduction, adduction, elevation and depression. The eye can make diagonal movements (version).
  4. Cranial Nerve IV (Trochlear) – test for the diagonal eye movements
  5. Cranial Nerve V (Trigeminal) – test for the motor functions, sensory functions and the corneal reflex
  6. Cranial Nerve VI (Abducent) – test for abduction of the eyes
  7. Cranial Nerve VII (Facial) – test for the taste of the anterior 2/3 of the tongue and the motor effects of the facial nerve (mainly the muscles of facial expression).
  8. Cranial Nerve VIII (Auditory, Vestibulo-cochlear) – test for sense of hearing and balance
  9. Cranial Nerve IX (Glossopharyngeal) – test for the motor functions of pharynx and stylopharyngeus muscle and sensation to the posterior one third of the tongue. Do the palatal reflex.
  10. Cranial Nerve X (Vagus) – the vagus has both the motor and sensory functions. It has visceromotor and cardio-inhibitory parasympathetic function.
  11. Cranial Nerve XI (Accessory) – test for the motor functions of the accessory muscles of respiration i.e. trapizius and sternocleidomastoid.
  12. Cranial Nerve XII (Hypoglossal) – test for the motor functions of the tongue

C.   Motor system; physical examination

  1. Muscle bulk – this is tested by palpating individual muscles and muscle groups and described as normal, reduced (atrophy) or increased (hypertrophy)
  2. Muscle tone – tested by performing passive full range movements of all joints which are facilitated by the various muscles and described as normal, reduced (hypotonia) or increased (hypertonia)
  3. Movement and strength of muscles – Muscle power (grade from 0-5). A a quick assessment can be made by observing a patient walk, stand up from lying and sitting position, dressing or undressing and lightly jumping or hopping. Then take the patient through the full range of movement against resistance from gravity and examiner.

The Medical Research Council Scale for grading muscle function

Grade 0         No movement, Complete paralysis 

Grade 1           A flicker of contraction only

Grade 2           Power detectable only when gravity is excluded

by appropriate postural adjustment

Grade 3           The limb can be held against the force of gravity

but not against the examiner’s resistance

Grade 4           There is some degree of weakness, usually

described as poor, fair or moderate strength

Grade 5           Normal power is present

a.The Upper limbs

  • Abductor pollicis brevis
  • Opponens pollicis
  • 1st dorsal interosseous
  • Interossei and lumbricals
  • Flexors of fingers
  • Extensors of the wrist
  • Flexors of the wrist
  • Brachioradialis
  • Biceps
  • Triceps
  • Supraspinatus
  • Deltoid
  • Infrasupinatus
  • Pectorals

b.Muscles of the trunk

  • Serratus anterior
  • Latissimus dorsi
  • Babinski’s “rising up sign” – get the patient to lie supine with legs extended and then sit up without using the hands.
  • Beevor’s sign – the umbilicus is pulled upwards with paralysis of the lower segment

c.Muscles of the lower limb

  • Extensors of the knee
  • Flexors of the knee
  • Extensors of the hip
  • Flexors of the thigh
  • Adductors of the thigh
  • Abductors of the thigh
  • Rotators of the thigh
  • Flexors of the foot
  • Extensors of the foot

4.Reflexes

a)Tendon reflexes (grade 0-4)

  • Knee jerk
  • Ankle jerk
  • Triceps jerk
  • Biceps jerk
  • Supinator jerk
  • Jaw jerk
  • Test for ankle or knee clonus

b)Superficial reflexes

1.Plantar reflex

  • Babinski’s sign – this is tested by stimulating the outer edge of the sole of the foot by firmly scratching a key or a stick a long it from the heel towards the little toe.
  • Oppenheim’s sign – squeeze the calf or press heavily along the inner border of the tibia and elicit dorsiflexion of the foot
  • Gordon’s sign – pinch the calcaneous tendon to elicit dosriflexion of the foot
  1. Superficial abdominal reflexes
  2. Corneal reflex

    c) Sphincteric reflexes such as;

  • Swallowing
  • Defecation
  • Micturartion
  • Sexual function

5.Coordination – impaired coordination is referred to as ataxia.How to test.

  • Upper limbs – rapid alternating clapping and finger-to-nose test
  • Lower limbs – heel sheen-to-knee test and tandem walking along a straight line
  • Romberg’s sign – the features of this sign is the patient is more unsteady standing with the eyes closed than with them open

6.Gait – observe the patient’s gait very keenly to detect any abnormalities such as;

  • Spastic gait – patient walks on a narrow base, has difficulty in bending the knees, drugs the feet
  • Hemiplegic gait
  • Sensory ataxia (stamping gait)
  • Festinant gait – patient bends forwards and advances with rapid, short, shuffling steps – patient appears to be struggling to catch up with the centre of gravity
  • Waddling gait – like the gait of the duck
  • High stepping gait

7.Involuntary movements Includes;

  • Epilepsy – generalized or partial epilepsy
  • Myoclonus – rapid, irregular jerking movement of a group of muscles in a limb or the whole body occurring in response to an extraneous stimulation e.g. a loud noise/bang
  • Tremors – regular or irregular distal movements having an oscillatory character. This can be due to anxiety, essential tremor, physiological tremor, thyrotoxicosis, Parkinson’s disease and heavy metal poisoning with mercury, manganese and thallium
  • Athetosis
  • Chorea
  • Dyskinesia
  • Dystonia
  • Torticolis
  • Tics
  • Tetany – associated with Trousseau’s sign and Chvostek’s sign
  • Cramps
  • Asterixis

D.  Sensory system physical examination;

Perception of sensations depends on the physiological interaction of afferent (sensory) inputs at different levels in the nervous system. The important tests are light touch, vibration, position sense and pin-prick (surface pain). Begin with testing sensation of touch and position and test pain later when the patient has gained confidence.

1)Tactile sensibility;

  • Light touch
  • Pressure
  • Tactile localization and discrimination

2)Position sense/proprioception – this is appreciation of passive movements

3)Stereognosis –recognition of size, shape, weight and form of objects

4)Vibration

5)Temperature

6)Graphiaestesia

7)Romberg’s sign

8)Pain

E. Autonomic function

Bedside assessment of autonomic function includes check for papillary responses to light, skin (whether dry or sweating), resting tachycardia and slow pulse rate with deep inspiration. Some of the autonomic abnormalities include inability to maintain blood pressure in erect position, constipation and other gastrointestinal motility, incontinence of urine, impotence and papillary areflexia.

Other signs to look for during bedside assessment

  1. Heart rate – tachycardia at rest
  2. Orthostatic hypotension – allow patient to rest for 15 minutes and check the resting blood pressure. Then ask the patient to stand, note the pulse rate between the 15th and 30th beats after standing and measure the blood pressure 1 and 3 minutes after standing. The systolic pressure should not decrease by more than 10 mmHg in normal subjects. In patients with autonomic dysfunction, the systolic pressure falls by 30 mmHg.
  3. Deep breaths test – ask the patient to lie flat and allow for rest then record the pulse rate during six maximal deep breaths.Normally the pulse rate should fall by > 15 beats/min while in autonomic disorders the pulse rate slows by <10 beats/minute
  4. Valsalva test
  5. Handgrip test

F.      Signs of meningeal irritation

The main feature is neck stiffness. The common causes of meningeal irritation are meningitis and sub arachnoid haemorrhage.

  1. Kerning’s sign – put the patient in supine position and passively extend the patient’s knee on either side when the hip is fully flexed. This causes pain and spasm of the hamstrings in patients with meningeal irritation.
  2. Neck stiffness ask the patient to flex the neck as fully as possible to ascertain the degree of movement possible and then to relax the neck. There is increased resistance to passive flexion of the neck.
  3. Straight leg raising test – useful in patients with sciatica. The sciatic nerve and its roots are stretched by passively elevating the patient’s extended leg with the hand.
  4. Brudizinski’s sign-this is tested by stimulating the outer edge of the sole of the foot by firmly scratching a key or a stick a long it from the heel towards the little toe.

 

 

 

About Docbobhe 26 Articles
Am Robert Mathenge, a healthcare provider in Nakuru county. i love this profession as it gives me chance to serve my call, interacting with people from various social backgrounds makes me feel good.

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