Physical Examination

Zhang BAO, MD and PhD

First Affiliated Hospital of Zhejiang University
Division of Respiratory Medicine

baozhang2002@hotmail.com
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 References
 Textbook of diagnostics

 Textbook of physical diagnosis, 7th edition

 Hutchison's Clinical Methods, 23th edition

Clinicalkey (Zhejiang U, Library)

 Clinical Methods, 3rd edition

http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=cm
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The Successful and Intelligent Management of
Disease Depends on Accuracy of Diagnosis

Diagnosis

Hypothesis assembling

Hypothesis analysis

Hypothesis evaluation

Hypothesis generation

Problem identification

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Problem Identification

Problem ???

History Physical Laboratory

examination examination

taking

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 Symptoms vs. Signs
 The patient has fever
and chill for one week.
 In the last 3 days, he
felt weakness, fatigue,
palpitations and
dyspnea on exertion.
Symptoms (subjective
feeling from interview)
 The patient is thin.
 His face shows great sadness
and fear.
 His speech is difficult, his
mouth is dry.
 He is pale, his sclera are
icteric.
 His head bobs with each
heartbeat.
 His nails have subungual
hemorrhages.
Signs (objective findings
from physical examination)
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 Physical Examination (PE)
 Physical Examination:
Examination the process of evaluating objective
anatomic and pathophysiological signs through the use of
sight, touch, hearing and smell of a clinician.
 Thoughtfully performed, PE yields >20% of the data
necessary for diagnosis.
 Both patients and physicians should understand that the
interaction of PE is intended to be diagnostic.
 physicians should communicate respect to the patients.

 patients should be prepared for unpleasant portions of the

examination.

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 Methods of PE
 Inspection (sight)

 Palpation (touch)

 Percussion (touch and hearing)

 Auscultation (hearing)

 Smell

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 Equipments
 Thermometer
 Stethoscope
 Sphygmomanometer
 Ophthalmoscope
 Otoscope
 Flashlight
 Tongue depressor
 Reflex hammer
 …

A sharp eye and a keen mind are more valuable than all
the instruments in the medical bag.

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 Sequence of Systemic PE
 Systemic PE should be performed in an orderly fashion.
 Proper sequence: e.g., head→ neck → chest →
abdomen → spine → extremities.
 Minimum position shifts of the patient, avoid examining
systems each in turn.
 e.g. if you check the neurological system in its entirety,
followed by a complete vascular examination and others,
will make the patient tedious.

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 No Replacement
 PE cannot be replaced in the era of high technology.
 PE provides important imformation.
 PE is rapid, not require complex equipments, perform in all
clinical situations.
 Some clinical conditions are diagnosed by PE (e.g., wheeze
in asthma, a high-pitched, musical, adventitious lung sound
produced by airflow through an abnormally narrowed or
compressed airways).
 Some clinical conditions may be apparent on PE before
assistant examination signs appear (e.g., early stages of
pneumonia without abnormal signs in X-ray).

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 Conclusion
 PE is a key part that extends from the history to the
diagnosis of the present illness.
 clues derived from the history signal a more precise and
detailed PE.
 if the history and PE are linked properly, laboratory tests
should be confirmatory.
 PE can be the weak link if it is performed in a perfunctory
and superficial manner.
 Understanding the pathophysiological mechanism of a
physical abnormality is essential for correct diagnosis.

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 Methods of PE

 Inspection
 Palpation  Basic science
 Percussion  Techniques
 Auscultation  Clinical implications
 Smell

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 Inspection
 Inspection: search for physical signs by observing and
distinguish normal from abnormal phenomenon.
 We tend to see things that have meaning for us,
inspection depends entirely upon the knowledge of
the observer.
 Difficult for a novice to grasp all the important clues at
a glance, can be skillful after training.
 Learn to accurately describe what you have seen.

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Inspection
 The layman concludes that there is
something ‘peculiar’ about him.
 The physician can dissect the
“peculiarity” and recognize the
diagnostic components. Such as
the enlarged supraorbital ridges,
nose and hand, the widely spaced
teeth.
 From the study of disease, the
physician diagnoses ‘acromegaly’.

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 Types of Inspection
 Close inspection: focus observation on a single anatomic
region.
 General inspection: the initial act of inspection of the body
as a whole to obtain the general appearance.
 the astute physician will begin to gather this information
immediately upon meeting the patient.
 note mental status, eye contact, posture, facial expression,
statue, body movement, gait, skin, pattern of speech,
handshake, and quality of voice, etc.
 provide diagnostic clues to the illness, severity of disease,
the patient's social status, personality, etc.

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 How to Inspect
 Make sure the room is comfortable.
 Use proper light such as a uniform white light to avoid
color distortion.
 Completely expose the body part for inspection while
draping the rest, personal areas are not subjected to
improper exposure, avoid embarrassing the patient.
 Compare symmetrical body parts.
 “The clinician is much like a detective, searching for clues
in the physical examination, reserving judgment during
the quest for conclusive data.”

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 Methods of PE
 Inspection （ sight ）
 Palpation （ touch ）
 Percussion （ touch and hearing ）
 Auscultation （ hearing ）
 Smell

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 Palpation
 Palpation: act of feeling using the sense of touch,
perceive physical signs by tactile sense, temperature
sense, and kinetic sense of position and vibration.
 Employed on every part of the body accessible to the
examiner’s fingers, particularly important in abdomen
examination.
 Types of palpation
 light palpation
 deep palpation
-- bimanual palpation

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 Light Palpation
 Always palpate lightly before attempting deep palpation.

 Light palpation will put the patient in ease, forceful

palpation will tense the muscle and the patient will resist
examination.

 Sense of touch is most acute when lightly applied, often

detect subtle or mobile masses beneath skin that are
undetected by forceful palpation.

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 Light Palpation
 Place the entire palm with fingers
extended on the abdomen.
 Press the fingertips gently into the
abdomen to a depth of about 1cm.
 Gently slide fingertips over the skin
surface.
 Locate areas of particular tenderness,
rigidity, rebound tenderness and subtle
or mobile masses.

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 Deep Palpation
 Deep palpation of the abdomen is
performed by placing the hand on the
abdominal wall and applying firm, steady
pressure.
 Place the right hand on the abdomen.
 Fingers of the left hand press on the distal
interphalangeal joints of the right hand,
exert pressure to a depth of 4 to 5 cm .
 The lower right hand is used to feel, the
fingers should move slowly, laterally and
longitudinally in order to displace the
superficial tissues allowing palpation for
deeper lesions.

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 Bimanual Palpation
 Deep palpation of the abdomen may be helpful to use two-handed
palpation, particularly in evaluating a mass or an enlarged organ.
 Fingers of the two hands cooperate to examine the tissue between
them.
 Useful for liver and spleen palpation, as well as softy tissues like
breasts, pelvic, and intraoral examinations.

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 Qualities Elicited by Palpation
 Texture, moisture and temperature of skin
 Tenderness (elicitation of discomfort or pain on
palpation on accessible tissue and organ)
 Rigidity and rebound tenderness of abdomen
 Precordial cardiac thrust and thrills of the heart
 Crepitus of the lungs
 Mass or enlarged organ

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 Abdominal Tenderness
 Abdominal tenderness is the subjective expression
(language or facial expression) of pain from palpation.
 When elicited, it should be described as to its location
(quadrant), how much pressure is required to induce
tenderness, depth of palpation required to elicit it
(superficial or deep), and the patient's response (mild or
severe).

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 Abdominal Rigidity
and Rebound Tenderness
 Rigidity(or spasm) is the involuntary tightening of the
abdominal musculature that occurs in response to
underlying inflammation.

 Rebound tenderness is the elicitation of tenderness by

rapidly removing the examining hand.

All that needs to be done is smoothly but quickly to lift the

palpating hand off the abdomen and observe for pain or
facial grimace.

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 Clinical Significance
 While inflammation or irritation of the visceral peritoneum
will cause abdominal discomfort, anorexia, and poorly
localized pain, while it will not cause tenderness and
rigidity of the abdominal wall.
 Irritation or inflammation of the parietal peritoneum will
stimulate the pain fibers of the parietal peritoneum and
abdominal wall, creating the symptoms of localized pain
and the signs of tenderness, rigidity, and rebound
tenderness.
 Thus, if there is diffuse irritation of the peritoneum, as in
diffuse peritonitis, there will be diffuse tenderness,
rebound tenderness and rigidity.
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 Mass or Enlarged Organ
 Site
 Size
 Shape
 Regularity
 Tenderness
 Consistency
 Mobility
 Surface

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 Methods of PE
 Inspection （ sight ）
 Palpation （ touch ）
 Percussion （ touch and hearing ）
 Auscultation （ hearing ）
 Smell

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 Percussion
 Modern physical diagnosis began with the discovery of
percussion by Leopold Auenbrugger in 1761.
 Leopold Auenbrugger (1722–1809), the son of an innkeeper,
was born in Graz, Austria.
 Legend has it that discovery of percussion was based upon the
evaluation of the amount of wine present in the casks.

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 Percussion
 Definition: strike the body surface and distinguish the
underlying tissue by the elicited sound and tactile sense.
 Mechanism:
 When the body surface is struck, the underlying tissues vibrate.
 Vibration is transmitted, reflected back and picked up by the
examiner’s auditory and tactile sense.
 The sound heard and tactile sensation felt are dependent on the
quality of the underlying tissue and air-tissue ratio.

C D
A B
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Percussion

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 Types of Percussion
 Direct percussion
 elicit sound by striking the body surface directly with
fingers, hand or reflex hammer
 not commonly used, but can be rewarding under some
circumstances
 be careful not to strike the patient too firmly
 Indirect percussion (bimanual or mediate percussion)

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 Indirect Percussion
 Pleximeter: left long finger
 Plexor: right long finger plexor
 Place pleximeter firmly against
the patient’s surface wall.
Palm and other fingers held off
the skin surface. pleximeter
 Hold the plexor partly flexed
and deliver the blow on the
distal interphalangeal joint of
the pleximeter.
 Bend only the wrist, neither
the elbow nor the shoulder
should move.

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 Indirect Percussion
 Usually, 2 or 3 staccato blows
are struck in one place. plexor

 After the stroke, the plexor

should rebound quickly from
pleximeter
the pleximeter to avoid
damping the vibrations.
 Pleximeter is moved
elsewhere for second series of
blows to compare the sounds.

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 Indirect Percussion
 Light percussion
 localized and superficial lesions or organs, like heart
and liver for relative dullness borderline.
 Moderate percussion
 deep and generalized lesions or organs like heart and
liver for absolute dullness borderline.
 Heavy percussion
 deeper lesions (7 cm beneath the body surface)

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 Sequence of Percussion
 From one side to the other side.
 From upside to downside.
 Compare symmetrical parts.

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 Clinical Significance
 The purpose of percussion is to determine if the area
under the percussed finger is air filled, fluid filled or solid.
 Used to detect diaphragmatic movement, the size of
heart, edge of liver and spleen, ascites, et al.
 Percussion conveys tactile sense and auditory sense.
 To make this interpretation it is important not only to
listen for the sound produced but also to feel the intensity
and frequency of vibrations produced by this maneuver.

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 Sound of Percussion
 Sound of percussion is used to detect alterations in
the density of an organ or tissue-air ratio.
 Different sounds are given special names generated
from tissues of high density to low density.
 flatness
 dullness
 resonance
 hyperresonance
 tympany

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 Sound of Percussion
 Amplitude (intensity), pitch and duration of sound
 amplitude: the breadth or abundance of the sound, loud or soft
 pitch: the degree of sound, high or low

 duration: the time sound lasts, long or short

 Sound of percussion may be regarded as the note of a

scale, which progresses from tissue of high density to
low density in the following sequence.

Flatness
Dullness
Resonance
Hyperresonance
Tympany

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 Sound of Percussion
 The more air that the tissue contains (i.e., the less dense
the tissue), the lower and louder the sound will be.

 The denser the tissue, the higher and fainter the sound
will be.

 The examiner records sound elicited in percussion in

relation to the density of the tissue being vibrated.

 The least dense tissues produce tympany, successively

denser tissue results in hyperresonance, resonance,
dullness, and flatness.

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 Tympany
 Tympanic (drumbeat like), higher-pitched, hollow-quality.
 Percussion over a hollow air-containing structure, such as
the gastric air bubble.
 Bon, Bon, Bon…

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tympany
 Resonance
 Resonant, higher-amplitude, lower-pitched.
 Percussion over a structure containing less air within a
tissue, such as the lung.
 Pa, pa, pa…

resonance
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 Hyperresonance
 The quality of percussion sound is between the resonance and
tympany.
 Absent in normal body, found in pulmonary emphysema (high
air-tissue ratio).

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 Dullness
 Dull, low-amplitude, short-duration.
 Elicited by percussion over a solid organ, occurs when the
air content of the underlying tissue decreased and its solidity
increased, e.g. over the part of heart or liver covered by
inflated lung.
 Ba, ba, ba...

dullness
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 Flatness
 Low-amplitude, high-pitched, short duration.
 Found over part of heart or liver not covered by inflated
lung, the muscle of the arm or thigh.
 Bo, bo, bo…

flatness dullness
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 Sound of Percussion

Amplitude Pitch Duration Regions

Tympany +++ ++++ +++ Gastric air bubble

Resonance +++ ++ ++++ Air filled lung

Hyperresonance ++++ + +++++ Emphysema

Dullness ++ +++ ++ Liver not covered

by the lung
Flatness + ++++ + Thigh muscle

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 Methods of PE
 Inspection （ sight ）
 Palpation （ touch ）
 Percussion （ touch and hearing ）
 Auscultation （ hearing ）
 Smell

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 Auscultation
 Auscultation: literally means a method using sense of
hearing to obtain physical signs, most time performed by
listening with a stethoscope.
 Laennec, a French physician, invented auscultation and
stethoscope in 1816.

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 Stethoscope
 An acoustic medical device containing a vibrating column
connecting the body to the ears.
 Most often used to listen to heart and lungs, also used to listen
to intestine (bowel sound) and blood flow in arteries and veins.

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 Stethoscope

earpieces

bell

chest piece

diaphragm

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 Technique of Auscultation
 Warm the chest pieces.
bell
 Expose the body part and put the
chest piece on it.
diaphragm
 Eliminate distracting noises, like
skin or hair rubbing, movements of
the muscles, joints, or tendon.
 Diaphragm: press firmly, for high
frequency sound (normal heart
sounds and bowel sounds).
 Bell: hold lightly but seal tightly, for
low frequency sound(abnormal
heart sounds, murmur or bruits).

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 The Stethoscope Conveys…
 Evaluate the frequency, intensity, duration of subtle
sounds from human body.
 Lungs: normal breath sounds, whispers, wheeze, voice sounds,
crackles, and friction rubs.
 Heart: normal heart sounds, gallops, murmurs, rhythm
disturbances, pericardial rubs.
 Vessels: murmurs in the thyroid, carotid and subclavian arteries,
venous hums.
 Abdomen: bowel sounds, murmurs from aneurysms and stenotic
arteries.

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 Methods of PE
 Inspection （ sight ）
 Palpation （ touch ）
 Percussion （ touch and hearing ）
 Auscultation （ hearing ）
 Smell

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 Smell
 Smell is a method used to evaluate the relationship
between abnormal odor and disease of a patient.
 The odor is elicited from breath, sputum, vomitus, feces,
pus and urine of patient.
 Abnormal odor may provide important clues for the
diagnosis of the disease.
 Experience with similar sensations will give you a context
for interpretation.
 smell of acetone on the breath: diabetes
 fetor smell: advanced liver disease
 putrid smell: anaerobic infections
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 Methods of PE
 Inspection (sight)
 Palpation (touch)
 Percussion (touch and hearing)
 tympany
 resonance
 hyperesonce
 dullness
 flatness
 Auscultation (hearing)
 Smell

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 Quiz
 c
The feature of physical signs is ________.
a. subjective disturbance
b. patient's feeling
c. objective finding

d. as same as symptom

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 Quiz
 c
Hyperresonance is found over _____.
a. pneumonia
b. pneumothorax
c. emphysema
d. pleural effusion

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 Quiz
 Tympany is the sound emitted by percussing
d
________.
a. spleen

b. liver

c. heart

d. air-filled stomach

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 Sir William Osler
Author of the first modern textbook of medicine
“The Principles and Practice of Medicine”

The art of the practice of medicine is

to be learned only by experience, not
an inheritance; it cannot be revealed.
 Learn to see, learn to hear, learn to
feel, learn to smell and know that by
practice can you become expert.

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