General Physical Examination

~ When you go to see the patient you:

1. Introduce yourself.
2. Always Always wash your hands, because we don’t want to give them any infection they
don’t have.
~When we take the patient profile and history we will be observing them and learning by
observation.
**The history is subjective it comes from the patient’s perspective.
**What we observe (the physical and general examination) is objective, it’s the things we
actually see, and it comes from our perspective.
~We learned (in other classes) how to get information from the patient’s perspective
now we will learn how to get information from our perspective:
When you walk into a room you will often know if someone is very sick in that room, once
you see them you will quickly sense who, because that person is not normal (you don’t have
to be a doctor to know that) but as a doctor we need to start thinking why that is not normal?
and what specifically is abnormal about it? so that we can know what is going on with the
patient.
*The first thing we want to talk about:
Any time we examine a part of the body (the heart/the lungs/the brain/the nerves/the
muscles/the bones) there are 4 parts to that examination (4 things we always think about
when we do a physical examination):
1. Inspection: which means we will be using our eyesight, the smell…etc, basically anything
we can learn about the patient without actually touching or putting hands on the patient
(typically looking and smelling).
2. Palpation: which means touching and feeling, using your sense of touch to examine the
patient.
3. Percussion: which means tapping or striking,( Trying to know what’s underneath from the
sound that comes back to you)
Sometimes the sound is solid and sometimes it is hollow:
>Sometimes the sound should be hollow; like the chest because it has lots of air inside of
it because of the lungs so that’s normal, if the chest is not hollow that’s a problem.
>If your abdomen (your belly) is hollow that’s a problem, it should not be hollow, because
it is mostly solid, either fluid or solid tissue (even though there is air but very little)
4. Auscultation: which means listening, (we are using our ears to listen to the patient)
usually with your stethoscope, sometimes you may hear a very bad murmur or sound from
the heart without your stethoscope, but usually we will use our stethoscope to listen.
*We will not do all 4 parts of the physical exam on every part of the body (we will not use
our stethoscope to listen the foot) but we should always think about these 4 parts to make
sure we are not leaving anything out (not forgetting something), so it’s good to have a
system so we do everything the same way every time so we don’t forget anything.

**Most of what we will talk about today is inspection:

Now we are walking into a room, there is a patient, or the patient comes walking, we will
notice some things right away:
-We will notice how they move (walk)
-How they’re sitting on the chair or bed
-What their facial expressions are
-Their color
-Their smell

We will notice these kinds of things right away and they will begin to tell you about the
patient.

>Notice how the walk (how they move)<

**We call that their Gait (walk):
Abnormalities of gait (page 44 book)

1-Steppage gait: they lost their sense of position from their nerves so they really
exaggerate with the step very high because they don’t know exactly where their feet are, it
could be from vitamin deficiency or stroke or certain infections or inflammatory conditions.
2-Sensory or cerebellar ataxia: (ataxia: means abnormal movement). Loss the sense of
balance, they try to keep balance and not fall over, comes from a problem in the cerebellum
(the back of the brain below the rest of the brain is called the cerebellum).It could be a stroke
or certain nutritional problems.
3-Parkinsonian gait: related to Parkinson’s disease, they lost the ability in their brain to
produce neurohormone called dopamine, when they sit still they have a little bit of a trimmer.
They walk slowly and stiffly, it is difficult for them to initiate their per start movement.
4-Spastic hemiparesis

>Notice how they are sitting<

- If they are slumped over (bent over) in the bed unconscious (not awake) you will notice
that isn’t good.
- Look how they sit, do they look uncomfortable, do they appear to be in pain … etc.
>Notice their face (facial expressions)<
-They might have no expressions at all:
>They may have Parkinson’s disease and they will have no expression, they will be just
sitting there blank, the muscles aren’t active at all, because they have a problem with
movement, so they sit there with their jaw a little open like they are not truly awake (they
are), they just can’t move the muscles correctly.
>Another person might look the same way, is someone who is really depressed, or they may
look very sad and down or flat.
-They may look scared and anxious:
>Maybe because they are nervous or scared but there is also some medical problems that
make people look that way
>If you have thyroid disease, if your thyroid gland is producing too much hormone you will
look very anxious, because your swelling behind your eyes, which pushes your eyes out and
they look very wide, also your metabolism is running very high and your heart rate (pulse) is
very high, and you feel anxious and scared and it’s not because you really are scared and
nervous, but it is because of your disease, because the thyroid hormone makes you feel that
way

Pay attention to how people look, how they move, their facial expressions.

>Notice their color<

Some patients are truly a different color:
They may be yellow: *we call that Jaundice and along with the skin, the white part of the
eye also turns yellow (in Greek we call it icterus which means yellow), because the liver
processes a pigment (coloring) called Bilirubin, which helps absorb fat when you eat, it’s like
a detergent or a soup almost, but when your liver can’t process it because it has hepatitis
(inflammation and infection of the liver or Cirrhosis or scaring of the liver), then it deposits
into your skin and you turn yellow.
*Babies sometimes may be yellow, because they are breaking up a lot of their red blood
cells; it is actually not very serious and goes away when we take care of it.
They may be white: they are whiter than they should be, we call that pallor or they are pale,
it could be from someone who has lost a lot of blood, because blood gives us that pink or red
color.
They may be blue: because they don’t have enough oxygen, we call it cyanotic.
>It could happen in babies if they have a hole in their heart, and the blood with oxygen mixes
with the blood without oxygen, and then gets pumped to the body, they will look a little blue
not pink.
>If your lungs just can’t deliver (get) enough Oxygen into your blood, some people with lung
disease from smoking will look blue (not all smokers).
>If you’re blue all over that is bad, but if you’re blue around the lips or just in the fingertips we
call that Acrocyanosis and it is not as serious, it is just a little blue, maybe because you’re
cold or the blood vessels are really constricted (tight/small) because of the cold temperature.
The may be red or flushed: -when people exercise -are very nervous and anxious
-very hot -they could have a fever -are severely ill
>Notice their smell<
Different smells can teach you different things going on with the patient :
>Smell like fruit: If you walk into a room in the hospital for example and it smells a little bit
like fruit, and it is coming from the patient, it is because they have diabetes and specifically
have Diabetic Ketoacidosis (DKA), the sugar is very high. What happens is that their body
thinks it is starving because there is no insulin, so the sugar cannot go into the cells and is
staying in the blood, therefore the cells (like a factory) have to produce/manufacture energy,
so cells start to use/burn fat instead of sugar, like a fuel to get energy, a side product of that
is something called acetone; which is the same chemical that fruit gives off , these people
are breathing it out, that is why they smell like fruit, because the fat is not just producing
energy but also producing acetone.
>Smell like fish: Someone with kidney failure could smell like fish.
>Mousey smell or odor: When the liver is not working (a yellow jaundice patient) they will
have what is called a mousey odor (smell).

Now we are going to look at specific parts of the body that also tell us about the
person
From examining one part of the body we could learn a lot about the person:
>Like the hands for example from looking at the hands, and also if you shake the hand of
the patient when you introduce yourself, we might notice many things, such as:
-Their hand is very warm or sweaty
-very pale and cold
-maybe it has a trimmer like in Parkinson’s patients
- it might be also very week (they can’t quite grip)
-it may be too stiff
(We will talk about the hands later)
>We will also talk about lymph nodes and the lymphatic system: there are some lymph
nodes that help fight infection and filter infection, our tonsils are lymph type tissues, so when
you get an infection in the throat the tonsils become swollen.
>We will talk about if there are any masses or growths or swelling
>We are going to talk about the tongue: it can give you a lot of clues about problems
patients may be having:
**Trimmer in the tongue: we have mentioned the thyroid (the scared anxious looking
person) they will also have a trimmer at times and their tongues can trimmer as well.
**Inflammation in the tongue: the tongue could be too large and is pushing against the
teeth, such as in
-Down syndrome (they have an extra chromosome, they have three chromosome number
21), they usually have a very large tongue.
-And sometimes it could be from someone who has lots of inflammation all the time, they
may have rheumatoid arthritis, where their body attacks their joints and they always have
high levels of inflammation, proteins called amyloid get produced and they could get into the
tongue and make it swell (big).
**White spots on the tongue:
- This occurs because yeast is growing on the tongue, it could happen to babies because
their immune system is very immature, so they could get this from their mother’s skin,
therefore they may have yeast on their tongue or Candida as we call it.
-These white spots on the tongue can also signify that the person has the HIV/AIDS.
**Geographic tongue: Sometimes the tongue can look like a map, it is called geographic
tongue and it is completely normal.
**Hairy or furry tongue: At times the tongue can look furry or hairy, normally that’s just
from smoking a lot (if the smoker quits, it will go away)
**Smooth tongue: The tongue can also be very smooth and lose all of the taste buds
and texture; this is because of poor nutrition.

Now we will go into palpating and auscultation, and we will measure some things
We will measure some things called vital signs
Vital (this word refers to life) signs (these signs are important for life)
-pulse
- Breathing (respiration)
- Blood pressure
- Temperature: the normal temperature for a human is 98.6 F = 37 c
- Oxygen saturation
- In some countries the level of pain someone is having is considered a vital sign, it isn’t
really a vital sign because you can live with or without pain, but the point is, if a patient is in
pain we ask how bad it is.
We also measure the height and the weight, because it can tell us about people’s
health:
-One problem we have is if you’re very tall on average then you will weigh more than
someone who is very short, so we can’t pick one weight number and say that is a healthy
weight, so what we want to know is if someone’s weight is healthy or not compared to their
height. How???

What we will do is take the height (meters) and the weight (kg) and we will divide the
weight by the height square and get what we call BMI:
BMI = weight/height^2
(Body Mass Index) BMI: we use it to know if someone’s weight is healthy or not healthy

***The numbers in the BMI only apply to adults not to children, in children their normal BMI
differs by age (by how old they are), because the body type of a baby is different from the
body type of an adult.

>We want to pay attention to really fast weight gain or really fast weight loss:
specifically someone comes to you, and you saw them 6 months ago, and they weighted 100
kilos, and now they come to you and weight 90 kilos, and they don’t know why they lost the
weight (they haven’t been exercising or dieting ), then we need to worry, and they may be
fine, and there might be no problem, but you want to think they may have an illness,
for example: -cancer can cause this, so you want to make sure that they had all the testing
they should have had for cancer
-infection can also cause this , bad long lasting infections like tuberculosis or chronic
inflammatory conditions like rheumatoid arthritis or lupus arythematosus.
(Very important) ~ If they lose 10% or more of their body weight in 6 months or less think
about why, if they don’t know why and weren’t trying to lose weight, you need to make sure
that nothing else is going on.
 So rapid weight loss and weight gain are important

The hydration status of the patient

>If a patient is dehydrated I always have to fix that first!!!
>If they have a bad problem with their sugar, like a DKA patient, they are always very
dehydrated, because they urinate so frequently because of the sugar … so we need to fix
that first! We give them a lot of fluid first before we fix their blood sugar problem, or if their
sodium level is very high or very low, we always fix their water problem first.
Why? Because 60-65% of our body is made of water, so if we lose a lot of water that
is a problem, if there isn’t enough water there isn’t enough blood to circulate, our brain may
shrink and lose the water it needs to function, so you might have alter consciousness.
We can’t live without water for very long, so hydration status is important.
You could be dehydrated, which means to not have enough water, and there are different
ways to know if someone is volume depleted or fluid depleted.
You could be over hydrated, meaning having too much water in your body, and those
people tend to be very swollen, you will see the water collecting in their legs, because of
gravity.

Over hydration:
We will inspect the status in general, we will look at the patient they may look completely
normal, but as you look more carefully and move down the body, you may notice that:
They have extra fluids in their legs the ankles are swollen.
-It could be that the kidneys aren’t working well to get rid of the water
-It can occur from the heart not working well, so the blood can’t get from the heart to the
kidney so it could get rid of it, so it backs up to the legs
-Liver failure, those people usually get very swollen for several reasons, but they also have
fluids build up, and they also a hard time delivering these fluids to their kidneys.
**So swelling is the thing to look for with over hydration over volume overloaded
(fluids overloaded)
 How do we know there is over hydration?
So typically, we will press on the leg, and we will look and see, we will press over the
tibia bone, we press inward and if it leaves a hole when you take your fingers away, they
have edema (they have swelling), the deeper we can push and the deeper the pit you leave,
the worse the swelling is, the longer it stays without slowly coming back out, the worse the
edema is, also the higher up the body it gets the worse it is.
Some things you need to know:
**If you have a little bit of swelling it will stay in the ankles and feet, if you have a lot of
swelling it may be up to your waist and you’ll notice it.
>Another thing to think about is that:
**When standing or sitting the swelling would go down to the lower part of our body which is
our feet ( because of gravity ), but if someone has been sick in the hospital for a few days,
and they have been laying down the whole time, we will check for swelling on them in their
back so we have to press on their back especially the lower back, because usually they will
prop the head of the bed a little bit so the head will be a little bit up, the back will be down,
and the feet will be a little up.
The same thing happens when someone has swelling in their legs and they sleep, when
they wake up the swelling is usually gone, because they have been laying down all night, so
the fluids pooled somewhere else, not in their legs, and when they get up and walk around, it
will go back to their legs.

Dehydration:
Again, the patient may look totally normal, so we will have to ask some questions, or
maybe they will tell you something;
- like they will say my urine is very dark, very strong and concentrated ( because the kidneys
will keep water back and make the urine very concentrated if the patient is dehydrated)
**So that may be the only clue that the patient is dehydrated.
-If the mouth is very dry, and there is less saliva than normal where the saliva is thicker, then
they have a little more dehydration
-sometime if they are upset, they may try to cry but not many tears come out.
-Or the tongue may not be moist or wet, that is worse dehydration
- If it’s a little bit more worse than that even, you may pinch the skin and when you take your
fingers away it stays up, so it looks like a tent, and they call it tenting of the skin or a loss of
skin turgor (water pressure) (not enough water in the skin), this is a more severe
dehydration, and they will actually look ill, and their face looks a little shrunk; because water
has gone out of the tissues of the face.
-Maybe their eyes look sunken back a little bit so they will look more sick.
-Sometimes they will feel dizzy when the sit up, or stand up, because they have lost so much
fluid, that not enough blood is getting to their brain, so in this because it is pretty severe and
pretty bad dehydration, and we want to do something.
We have to do something about this, what?
**We want to check those vital signs, specifically blood pressure and pulse, with them
-laying down - sitting down - standing up.
Because when we are laying down everything is on the same level, it’s very easy for your
heart to maintain blood pressure.
But when you sit up your heart has to pump against gravity.
So what we do is…. We check the blood pressure and pulse, with them lying down, have
them sit up wait 3 minutes and then check again, and then stand up wait 3 minutes and
check again.

>In blood pressure the top number is the systolic number, it is the peek pressure (the
pressure when your heart is squeezing) the bottom number is called the diastolic number
(the pressure when the heart is relaxed).

****For example …
Say the blood pressure is 120 millimeters of mercury, and the bottom number is 70, when
they sit up that number goes to 105, so if it change by 15 millimeters of mercury they
have then severe dehydration even if from laying for sitting to standing.
When there is not enough blood, the heart has to pump blood faster to maintain blood
pressure and blood flow, also if the pulse goes up, let’s say it goes from 100 to 110 or 120 so
if the pulse goes up more than 10 this also signifies severe dehydration (even if blood
pressure stayed ok, but the pulse went up, they have this problem)
We call this orthostatic vital signs, we check to see if the pressure stays static (stays the
same) when changing positions.
 >If blood pressure drops by 15 we say they have orthostatic hydro tension and that
goes with dehydration.
We need to give these people fluid, if they’re not vomiting the can drink the fluid (a great
way to give fluid) if we have to we can always give intravenous fluids, but remember giving it
by mouth (drinking) is better.

Watch out
~One mistake a lot of doctors make is that these signs don’t get checked, or they are
checked at the beginning, and they give the fluid, and then they don’t recheck the number to
see if it is back to normal.
~Whenever we get an abnormal reading on blood pressure, pulse, breathing … etc,
always recheck it.
~You can know (figure out) how much fluid you need to give someone by the weight, we
said that 60-65% of our body is water, so when I lose about a kilo of my weight in a day
that’s probably water, (you can’t lose that much weight of fat in a day), so if you get rapid
change in weight you know it is mostly water you’ve lost or gained.
~A liter of water weight 1 kilogram of weight
~Another mistake is that most doctors make, is they don’t check how much fluid the
patient needs, if there is tenting in the skin then there is 10% of their body weight
dehydration.