The basic methods of

physical examination
Si XI-jian

What is physical examination?

It is a fundamental examining
method, proceeded by the sense
organs such as eyes, ears, nose
and hands or simple tools
stethoscope and plexor.

The basic methods of physical

examination
1 inspection
2 palpation
3 percussion
4 auscultation
5 smelling

1 Inspection
includes a general view of the
patients
mental status
development
nutrition
posture
body movement gait
facial expression complexion

Inspection

For example

pallor---anemia
exophthalmus---hyperthyroidism
moon face---cushing syndrome
spider angioma---liver cirrhosis
barrel chest---pulmonary emphysema
lower extremity edema---right heart
failure
Gastric type---pylorus obstruction
Abdominal respiratory movement
Apical impulse

2 Palpation
definition: the act of feeling, using the feeling of
touch to judge.
range: exclusive, important for abdomen
external structures, structures accessible through
the body orifices,
bones, joints, muscles, superficial nerves,
ligaments, tendon sheaths.

 the most sensitive locus of the examiner:

(1)finger pulp
(2) palmar surface of the metacarpophalangeal
joint is sensitive to vibration
(3)skin of back hand is sensitive to temperature

specific qualities elicited by palpation

Texture
Moisture
Skin temperature
Characteristics of masses
Precordial cardiac thrust
Crepitus
tenderness

thrills

vocal fremitus

Light palpation
Deep Palpation
deep slipping palpation
bimanual palpation
deep press palpation
ballottement

palpation

2.1 light palpation

Always begin palpation with a light
touch to examine the lesions of
superficial tissue.
abdominal muscle tensity
abdominal tenderness

2.2 Deep Palpation

deep slipping palpation ---deep mass,
gastrointestinal change
bimanual palpation ---liver, spleen,
kidney, swellen lesions
deep press palpation ---deep location,
tenderness point
ballottement ---(ascites): liver, spleen,
mass

bimanual palpation--liver and

spleen

deep press palpation---tenderness

point

 Cholecystic point Murphys

sign ---acute cholecystitis
Appendix point McBurney
point ---acute appendicitis
rebound tenderness
---acute peritonitis

Ballottement with massive ascites

---liver enlargement splenomegaly

Notice:
patient in supine position
ask patient flex his thighs and knees, tell
patient relax his abdominal muscles.
Doctor stands at the right side of patient,
warm hand, use your palmar aspect of
finger, examining gently and lightly, from
superficial to deep.
Urinate if palpate inferior belly
Do and think

3 Percussion
lungs---margin, heart---size and shape,
hydrothorax, liver / spleen---margin,
ascites
There are two methods:
Direct (immediate) percussion
Indirect (mediate) percussion

3.1 Direct percussion

This method can be done by striking the
body surface directly with the palmar
aspect of right hand, the tips of all of
the fingers held firmly together, or
reflex hammer.
mainly used to examine massive fluid
in thoracic cavity or lesions with
extensive areas.

Direct Percussion

Indirect percussion

3.2 Indirect Percussion

This is the form of percussion most
commonly used.
The palmar surface of the middle
phalanx of the left middle finger is
firmly pressed onto the body surface,
as a pleximeter.

 As a plexer, the tip of the right long

finger strikes a sharp blow on the distal
interphalangeal joint of the pleximeter
finger vertically, by bending only the
wrist or metacarpophalangeal joint.
The plexor should rebound quickly from
the pleximeter, two or three staccato
blows are struck in one place one time.

correct

wrong

pose of indirect
percussion

3.3 Percussion Sounds

Resonance
Dullness
Tympany
Flatness
Hyperresonance

* Resonance
The sound heard over normal
airfilled lungs, moderately low in
pitch

* Dullness

and

*flatness

Dullness is a short high pitched and is

not loud. The sounds heard over heart
or liver which are covered with lung
tissues or during pneumonia.
Flatness will be present when there is
an extensive pleural effusion or over a
solid organ such as the liver and heart

*Tympany and *hyperresonance

Tympany is somewhat similar to the sound
of a drum in loud intensity, it results from air
in a chamber such as stomach and bowel or
in pneumothorax
Hyperresonance is lower pitch than normal
resonance, it is heard normally in children
and pulmonary emphysema in adult

Suitable for: thorax, abdomen

Notices: environment is quiet
proper position
compare symmetrical site
change of percussion sound
proper strength

4 Auscultation
There are two methods
of auscultation:
direct auscultation
with the ear;
indirect auscultation
with the stethoscope.

by these two methods we can listen

to the sounds produced from heart,
lungs and abdomen or the blood
vessel murmurs

* stethoscope
There are two principal
type of stethoscope :
the bell and
the diaphragm .

the diaphragm type of chestpiece is

more suitable to listen to the high pitched
tones: such as the murmur of aortic
regurgitation .
the bell type is more suitable to listen to
the low pitched rumble such as the
murmur of mitral stenosis

Notice:
The stethoscope should be placed
firmly against the chest wall or
other part of the body to exclude
extraneous sounds.

5 Smelling
To identify the unusual odor which
produced from patient such as the
odor of sweat, sputum, pus fluid,
vomitus, stool, urine, breath.

 Sour smell of fermenting food retained

overlong from the vomitus --- pylorus
obstruction
A pungent odor of garlic on the breath --organic phosphorous poisoning
A sweet odor of rotting apples ---diabetic
ketoacidosis
Foul sputum --- bronchiectasis, lung abscess

Review
1. What are the 5 basic methods of physical examination?
2. How to doinspection, palpation, percussion, auscultation
and smelling?
3. How many ways do palpation have What are they for
4. How many ways do deep palpation have What are they
for
5. What are the 5 percussion sounds Where can you get
them on patients' body?
6. What are stethoscope's 2 types of chestpiece, What are they
used for?
7. What do the smells suggest in physical examination