physical examination

physical examination

1. inspection

   • general
     • nutritional status
       • The wear and tear and hallmarks of poor nutrition can indicate chronic illness
     • symmetry
     • patient posture
     • first
   • specific
     • the doctor performs a more specific examination of the skin, looking for
       • redness or other signs of infection
       • hair loss
       • nail thickening
       • moles or other areas of pigmentation
       • inquires about any recent changes in skin lesions that could indicate early cancer
         • in particular, areas that the patient normally would not be able to see, such as the scalp, the back, and the buttocks.
     • after

2. palpation

   • Palpation is the act of feeling the surface of the body with the hands to determine the characteristics of the organs beneath the surface. It can be performed with one hand or two and can be light or deep
     • light
       • Light palpation is used to detect tenderness, muscle spasm, or rigidity of the abdomen
         • If abdominal pain is present, gentle palpation begins farthest away from the pain to localize the point of maximum tenderness
     • deep
       • Deep palpation of the abdomen is used to determine the size of the liver, spleen, or kidneys and to detect an abnormal mass.
         • An abdominal aortic aneurysm can be detected by palpating a pulsatile mass in the upper abdomen
         • An acutely tender mass in the right upper abdomen that is more painful on inspiration is probably an inflamed gallbladder
         • An unexplained nontender abdominal mass could be as nonthreatening as a hard stool or as serious as a tumour

3. percussion

   • Percussion is a diagnostic procedure used to determine the density of a part by tapping the surface with short, sharp blows and evaluating the resulting sounds.
     • In the abdomen it can be used to detect fluid (ascites), a gaseous distention of the intestine as occurs in bowel obstruction, or an enlargement of the liver
   • It is used most often to evaluate the chest
     • Percussion produces a resonant note when the area over a healthy lung is struck; a dull sound, however, will emanate if the lung contains fluid, as in pneumonia
     • when a region over a solid mass such as the heart is tapped
     • A lung that is diseased with emphysema contains more air than a healthy lung and produces hyperresonance
     • A stomach distended with air will produce a high-pitched, hollow tympanic sound

4. auscultation

   • Auscultation is performed with a stethoscope to evaluate sounds produced by:
     • the heart
       • Cardiac auscultation is the evaluation of the sounds made by the heart valves—namely, the aortic, the pulmonary, the tricuspid, and the mitral—for murmurs that may be due to turbulent blood flow or vibrations from a heart valve deformity
         • Murmurs may be physiological (unimportant clinically) or pathological, indicating a problem that needs attention, especially if they reflect obstruction of normal blood flow.
         • Heart murmurs vary according to their timing in the cardiac cycle (i.e., during systole, the period of contraction when blood is pumped from the heart ventricles, or diastole, the period of filling of the right and left ventricles between contraction), location, duration, intensity, pitch, and quality
     • the lungs
       • Listening to the sound of air passing in and out of the lungs can be useful in detecting an obstruction, as in asthma, or an inflammation, as in bronchitis or pneumonia
         • rubs
           • rubs sound like creaking leather and are caused by pleural surfaces roughened by inflammation moving against each other, which occurs in patients with pneumonia and pulmonary infarction
         • wheezes
           • sounds heard mostly during expiration, are caused by rapid airflow through a partially obstructed airway, as in asthma or bronchitis
         • crackles
           • They are caused by fluid in the small passageways that adheres to the walls during respiration. Crackles are heard in congestive heart failure and pneumonia
     • the blood vessels
       • Bruits are blowing vascular sounds resembling heart murmurs that are perceived over partially occluded blood vessels. When detected over the carotid arteries, a bruit may indicate an increased risk of stroke; when produced by the abdomen, it may indicate partial obstruction of the aorta or other major arteries such as the renal, iliac, or femoral arteries.
     • or the bowels
       • Lack of bowel sounds indicates a paralyzed or malfunctioning bowel, and high pitched "clinking" sounds suggest bowel obstruction. The "growling" of the stomach is an accentuation of these sounds during periods of intestinal hyperactivity