Physical Examination

Prof. Ezekiel M. Wafula

 Physical Examination: Outline
 Value of history and physical examination
 The Appropriate Environment
 General Examination
 Systemic Examination
 Examination of the ears and the throat
 Measurements: blood pressure, weight,
height, head circumference, mid-arm
circumference
 Important Things to Remember
 Physical Examination: Value of History
and Physical Examination
 Taking care of a sick person (child or
adult) involves three important components,
namely history taking, physical examination
and carrying out a diagnostic test
 The three components assist the health
worker to identify the illness or diagnosis and
therefore facilitate appropriate management
 History and physical examination are the
largest contributors to diagnosis
 Physical Examination: Value of History
and Physical Examination
Reference Diagnosis based Diagnosis based
on clinical on history and
history only examination
Crombie, J.
Coll. Gen. 88%
Pract. 6: 579;
1963
Sandler, Am. H.
J. 100: 928, 1980 56% 73%
Physical Examination: Value of History
and Physical Examination
 Inadequate history and/or inadequate
physical examination makes it difficult to
arrive at a proper diagnosis
 They are accurately given in Hutchison’s
Clinical Methods
 History taking has been given by Prof.
Onyango
 Physical Examination given here is a
skeleton to built on
Physical Examination: The Appropriate
Environment
 Facilitate the development of trust by the
child and the parent
 Explain to the parent what is to be done
 Be gentle both in voice, approach and
handling
 Encouraging comments helpful (not flattery)
 Use observation, to begin with, to note
any special features before physically
handling the child
Physical Examination: The Appropriate
Environment
 A child who is distressed may be examined on
the mother’s lap
 Request the mother to soothe the child if the
child cries or you give the child a toy
 Begin with respiratory and cardiovascular,
since they are most affected by the child’s crying
 Carry out the uncomfortable procedures like
examining the throat at the very end
 The child must be adequately undressed for an
adequate physical examination
 General Examination
 Observation is a critical component
 The posture of the child:
 Head and neck, the limbs, the rest of the body,
the face, the eyes
 The shape and size for the child’s body:
 The head (too big or too small), the chest and
back (abnormal shapes – kyphosis, scoliosis, pigeon
chest, withered or crooked limbs, abnormal eyes
(microphthalmia or bulthalmia, proptosis), large
abdomen (masses or fluid),
 General Examination
 The activity of the child:
 Movements of the head, the limbs, and the eyes
(abnormal movements or unable to move –
paralysed)
 The level of interaction of the child:
 Level of consciousness, ability to see and follow
objects, nature of social interaction, irritability,
recognition of those around, capacity to play
 Swellings or masses:
 Appearance, location, size
 General Examination
 Colour of the skin and other tissues:
 Skin pigmentation, jaundice, cyanosis, anaemia,
haemorrhages, hypopigmentation
 Skin rashes:
 Distribution, appearance, lignification, excoriation, colour
 Palpation is another critical component:
 Texture, size, warmth, and relationship with
underlying tissues
 For subcutaneous fat
 For shock and severe dehydration
 Skin pinch, capillary refill
Systemic Examination: The Respiratory
System
 By observation:
 Deformity
 Presence of respiratory distress:
 Respiratory rate, chest indrawing, flaring of the
alae nasae, suprasternal recession, intercostal
recession
 Wheezing, stridor, nasal blockage
 Chest movement
Systemic Examination: The Respiratory
System
 Percussion note:
 Dull, stony dull, hyperesonant, normal
 Auscultation:
 Adventitious breath sounds: rhonchi,
crepitations, rubs (pleural), vesicular, lack of breath
sounds
 Vocal fremitus
Systemic Examination: Nervous System

 Reflexes
 Biceps, triceps, knee, ankle, corneal, abdominal
 Muscle tone: increased, normal, reduced
 Muscle wasting, fasciculations
 Cranial and other nerves:
 2nd, 3rd, 4th 5th, 6th, 7th, 8th, 9th, 10th, 11th, 12th
 Fundoscopy
 Hearing test: tuning forks
 Systemic Examination: Cardiovascular
System
 Shape of the chest and presence of active
pulsations over the chest
 Presence of distress:
 Cyanosis, orthopnoea, severe tarchycardia
 Pulse:
 Volume, rate, character
 Apex beat
 Location, character
 Systemic Examination: Cardiovascular
System
 Other features:
 Thrill, heave
 Palpation:
 For palpable murmurs and thrills
 Auscultation
 Heart sounds
 Regularity, rhythm, loudness
 Murmurs (location, character, evolution, timing),
bruits
Systemic Examination: Abdomen
 Observation:
 Distension, size, movement
 Palpation:
 Masses: shape, size, texture (including liver,
spleen, kidneys)
 Tenderness
 Percussion: fluid thrill, shifting dullness
 Auscultation:
 Bowel sounds; other sounds
Physical Examination: Ears and Throat

 Ears
 Functional autoscope
 Adequate lighting
 Appropriate ear piece
 Examination of the ear drum
 Gentleness
 Throat
 Adequate light
 Spatula
 Gentleness
 Tonsils, pharynxy, mouth, tongue, palate
Physical Examination: Measurements
 Blood pressure
 Appropriate cuff
 Repeat measurement
 When child is calm
 Other measurements
 Weight
 Height or length
 Mid-arm circumference
 Head circumference
 Physical Examination: Important Things
to Remember
 More history taken if indicated in course of
physical examination or after
 Systematic approach recommended to avoid
missing out on some areas
 Differential diagnoses reflected on and specific
evaluations carried out to rule out or rule in as
may be necessary
 No part of examination omitted on account of
discomfort or lack of resources: apply gentleness
or source needed equipment