Physical
examination
Dr. Laszlo Jakab
Approach to evalution of the
patient
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History taking
Physical examination
Laboratory studies
Medical/dental consultation/referral
Dental office
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Identification of undetected systemic disease
To identify patients who are taking drugs or medication
To protect any malpractice
Medical consultant
Establish a good patient/doctor relationship
Abbreviated outpatient evaluation
Relatively safe treatment
History taking
 Personal dialogue, interview
 Display a professional attitude
 Evaluate the patient’s mental status
History taking
 Patient identification: full name, age, date
of birth, sex, race, marital status,
occupation
 Source of information: patient, relative,
previous medical charts, referral letter
 Chief complaint 1. Abdominal pain for 1
month 2. Vomiting blood for 1 day
History taking
 Present illness: complaints, chronological
order, precise description of all the
symptoms, presence or absence of
symptoms
Past history
 Previous illnesses, response to therapy,
previous hospitalization and surgery
 Medication allergies: drugs, contrast
media
 Immunization: tetanus, pneumonia,
flu,hepatitis, mumps
 Trauma: significant injuries, blood
transfusions
Previous diseases,
present complaints
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Describe them in chronological order
Ask a special group of questions
When did the complaint start?
Cardiology question group
Respiratory question group
Gastroenterology question group
Urinary tract
Cerebral function
Previous medication and drug allergy
General inspection 1.
1. Nourishment: well nourished, well developed
2. Skin (body hair): moderetly pigmented, no
abnormalities, body hair normal
3. Subcutaneous tissue: no edema, the turgor of
the skin normal
4. Mucus membranes: moderately blood filled
and intact
5. Conjunctiva: moderately blood filled
Sclera: bluish and white
General inspection 2.
6. Throat: moderately blood filled, intact
7. Teeth: replaced, well aligned
8. Lymphoid nodules: no enlarged palpable
lymph nodes
9. Genitals: morphologically intact
10. Breast: no palpable nodules
11. Thyroid gland: not enlarged, no
palpable
nodules
Chest organs, blood
circulation 1.
1. Shape of the chest: symmetric
2. The movement of the chest during the
respiration: both sides are equal
3. Borders of the lung, lung percussion according
to figure
4. The diaphragm movement during the
respiration: both sides are equal 2-3 cm
5. The results of lung auscultation: vesicular
sounds
6. Pectoral fremitus: both sides are equal
Chest organs, blood
circulation 2.
7. Apex beat: palpable
Location:5th intercostal space in the
midclavicular line
8. The relative upper border of the heart is in the:
3rd intercostal space
on the right: does not exceed the right border
of the sternum
on the left: in the 5th intercostal space 1 finger
with medial from the midclavicular line
Chest organs, blood
circulation 3.
9. Heart sounds:rhythmic, tone is normal, clear,
RRR (regular, rate and rhythm)
10. Heart murmurs: no murmurs heard over the
heart
11. Radial pulse: regular, rhythmic, equal,
frequency=70/min
12. Blood pressure: 120/80 mmHg
13. Arteries: femoral arteries, popliteal arteries,
dorsalis pedis arteries, posterior tibial arteries
are palpable
Abdomen 1.
 Abdomen is at the level of thorax,
symmetric, respiratory movement on both
sides are equal.
 Umbilicus is inverted. Scars are not
present.
 No pain, defense musculaire (guarding),
or any pathologic resistance during
superficial and deep palpation.
 Bowel sounds +
Abdomen 2.
 Liver, dullness, palpation: not enlarged, normal
dullness, normal consistency, not sensitive
upon touching, no nodes are palpable
 Spleen, dullness, palpation: The spleen is not
palpable, normal size, percussed between 9th11th intercostal space and between anterior
and midaxillary line.
 Kidney: not sensitive, no enlargement during
balloting palpation. No costovertebral angle
tenderness.
Muscolosceletal system
 Joints, bones, muscles: morphologycally
and functionally normal.
Nervous system
1. Pupils: are equal, round, centrally
located, and diameter is normal.
Response to direct and indirest light
reaction, convergence and
accomodation are normal.
PERLA=pupils are equally reactive to
light and accomododation.
2. Muscle stretch reflexes (tendom
reflexes): no pathologic reflexes, no
pyramidal signs.
Palpation 1
The Posterior Chest
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Undress, sitting position
Inspect, palpate, percuss, auscultate
Compare sides: apex and base
Identification of tender areas
Assessment of the shape of the chest
Assesment of the respiratory expansion:
unilateral diminution: pleural effusion,
lobar pneumonia
Palpation 2
The Posterior Chest
 Tactile fremitus: 99, 1-1-1, palpable
vibrations from the lung to the chest wall
 Compare symmetrical areas
 Increased: lobar pneumonia, the alveoli
filled with fluid, WBC, RBC
 Decreased: fluid in the pleural cavity=
pleural effusion or air = pneumothorax
Palpation 3
The Anterior Chest
 Supine position
 Assesment of respiratory expansion
 Assessment of tactile fremitus both sides
of the chest
 Identification of a fractured rib: local pain,
tenderness. Compression of the sternum
increase in local pain
Palpation 4
The Arterial Pulse
 Radial pulse: heart rate
 Rhythm: regular, irregular: premature
contraction, atrial fibrillation
 Amplitude:small-weak or large-bounding,
carotid artery, bigeminal pulse
 Thrills on carotid artery: vibrations,
stenosis
Palpation 5
The Heart
 Supine position, stop breathing
 Use the fingerpads
 Apical impulse: cardiac apex. Location 5th
interspace, medial to the midclav. line,
diameter ˃ 2 cm in adults, amplitude:
small, gentle, duration ˂ 2/3 of systole
 Apical impulse: undetectable in obesity,
muscular chest wall
Palpation 6
The Heart
 Apical impulse: displaced in left
ventricular enlargement, mediastinal shift
 Apical impulse increased in amplitude:
aortic stenosis, young persons,
hyperthyroidism, severe anaemia
 Apical impulse prolonged duration:
hypertrophy of the left ventricle
 Thrills = loud heart murmurs:AS, MS,
VSD
Palpation 7
The Abdomen
 Quadrants: RUQ, LUQ, RLQ, LLQ
 Sections
 Relaxed patient, legs flexed at knees, supine
position
 Stand/sit on the patient’s right side
 Examine painful areas last with warm hands
and short fingernails
 Watch patient’s face for signs of discomfort
Palpation 8
The abdomen
 Normal structures palpable: normal liver, tip of
the normal spleen, lower pole of the right
kidney, distended bladder, sigmoid colon,
pulsation of the abdominal aorta
 Light palpation: abdominal tenderness,
muscular resistance (voluntary or involuntary),
superficial organs
 Deep palpation - masses = malignancy:
location, size, shape, consistency, tenderness,
pulsations, mobility
Palpation 9
The Abdomen
 Assesment of peritoneal irritation:
musculas spasm, abdominal pain on
coughing, on light percussion,
tenderness
 Peritonitis = inflammation of the parietal
peritoneum
Palpation 10
The Liver
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Below the right costal margin
Use the fingertips of the right hand
Patient takes a deep breath
Edge of the liver palpable: normally soft, sharp,
regular
 Surface of the liver: normally smooth
 Abnormalities: enlargement, hardness,
rounded liver edge, irregularity of its surface,
tenderness (hepatitis)
Palpation 11
The Spleen
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Below the left costal margin
Tip of the spleen
Tenderness
Enlargement = splenomegaly
Palpation 12
The Kidneys
 Right kidney
 Left hand on contovertebral angle + right
hand on RUQ
 Patient takes a deep breath
 The lower pole may be palpable
 Enlargement: hydronephrosis, tumor
 Tenderness et costovertebral angle:
pyelonephritis
Palpation 13
The Aorta
 Deep palpation, pulsation
 Abdominal mass with pulsation: aortic
aneurysm
Palpation 14
The Neck
 Lymph nodes: occipital, cervical,
submandibular, supraclavicular,
preauricular
 Assesment of size, shape, discrete,
grouped together, mobility, consistency,
tenderness
 Normal person: lymph nodes present
(small, mobile, discrete, nontender)
 Enlargement: regional, generalized
Palpation 15
The Thyroid gland
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Palpate behind the patient
Patient swallows
Feel both lobes and the isthmus
Goiter = diffusely enlarged thyroid
Assess: size, shape, consistency,
nodules, tenderness
Palpation 16
The Breasts
 Quadrants: upper inner, lower inner,
upper outer, lower outer
 Tenderness
 Nodules = lumps = masses: location, size
in cm, shape, consistency (hard,soft),
mobility to the skin/underlying chest wall
 Cancer: hard, irregular, fixed
 Discharge of the nipple: milk, blood,
quantity
Palpation 17
The Axillae
 Sitting position
 Normal person: small, nontender nodes
 Enlarged lymph nodes: hard, tender,
intection, breast cancer
Palpation 18
The Anus, Rectum, and
Prostate
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Rectal examination
Side-lying position, glove, lubricant
Perianal area: hemorrhoids, perianal abscess
Anus and rectum: carcinoma
Prostate gland: both lobes normally rubbery,
nontender, rounded, 2.5 cm in length, no
nodules
 BPH:5th decade, symmetric enlargement,
smooth, obstraction of urinary flow
 Cancer: hard
Palpation 19
The Peripheral Vascular
System
 Both legs: swelling, symmetry, venous enlargement,
ulcers
 Inguinal lymph nodes:normal patient nontender,
discrete, 1-2 cm in diameter
 Femoral pulse: decrease/absence - occlusion
 Popliteal pulse: absent . occlusion in the thigh
 Dorsal pedis pulse: dorsum of the foot
 Posterior tibial pulse: ankle (below the medial
malleolus)
 Ankle edema: bilateral, unilateral, pitting = depression
by pressure
Percussion 1
The Posterior Chest
 Percussion: audible sounds, motion of the chest wall
and underlying tissues
 Technique: the pleximeter finger: hyperextension of the
middle finger of left hand, its DIP joints press firmly,
avoid contact by other part of the hand (decrease of
vibrations)
 The plexor: right middle finger partially flexed
 Tip of the plexor strike the pleximeter finger
 Transmission of vibrations: through the bones of DIP
joint, through the underlying chest wall
 Strike 2x in 1 location
Percussion 2
The Posterior Chest
 Penetration: 5-7 cm into the chest, deepseated lesions undetected
 Thick chest wall: heavier strike required
 Appropriate wrist movement
 Compare one side with the other, apex to
base, sitting position
 Percussion notes: intensity, pitch, duration,
tympany
 Normal case: percussion note resonant
Percussion 3
The Posterior Chest
 Abnormal dullness: fluid in the pleural space = pleural
effusion (hemothorax: blood, empyema:pus)
 Abnormal dullness: solid infection and iflammation in
the lung = lobar pneumonia (alveoli filled with fluid,
RBC, WBC)
 Unilateral hyperresonance: large ptx
 Identification of the level of diaphragmatic excursion:
dullnes – diaphragm, 5-6 cm distance between levels
of dullness on full exspiration and full inspiration
 Omit the scapular areas: thick musculosceletal
structures
Percussion 3
Summary
 Normal case: percussion note resonant, tactile
fremitus normal
 Lobar pneumonia: bacterial pneumonia, alveoli
filled, percussion note dull over the airless
area, tactile fremitus increased
 Pleural effusion: fluid accumulates and
separates the air-filled lung from the chest wall,
blocks the trransmission of sounds, percussion
note dull over the fluid, tactile fremitus
decreased
Percussion 4
 Ptx: air in the pleural space, blocks the
transmission of sounds, percussion note
hyperresonant or tympanic over the
pleural air, tactile fremitus decreased or
absent over the pleural air
 Emphysema: lungs hyperinflated,
percussion note diffusely
hyperresonant
Percussion 5.
The Anterior Chest
 Supine position, compare both sides
 Identification of the upper border of liver
dullness
Percussion 6.
The Heart
 Supine position
 Estimation of cardiac size
 Percuss from lung resonance to cardiac
dullnes
 Relative heart borders: left, right and
upper border
Percussion 7.
The Abdomen
 Relaxed patient, supine position
 Patient’s right side
 Orientation: tympany predominate –
gastric air bubble
 Dullness: liver, spleen, suprapubic area –
distended bladder, enlarged uterus
Percussion 8.
The Liver
 Liver dullness
 Vertical span in cm, in the right midclav.
Line
 Increased span: enlarged liver
 Decreased span: small liver
 Liver dullness disappear: free air present
below the diaphragm, sign of
perforation
Percussion 9.
The Spleen
 Left midaxillary line
 Oval area of splenic dullness
 Surrounding: lunf resonance, abdominal
tympany
 Splenomegaly = enlarged spleen (large
dull area)
Percussion 10.
Ascites
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Protuberant abdomen
Ascites fluid sinks with gravity
Dullness outward to central area tympany
Shifting dullness: pazient turns to one
side – dullness shifts
 Fluid wawe: impulse transmitted through
the fluid