This chapter provides an overview of the techniques of inspection, palpation, percussion, and auscultation that are used throughout the physical examination. In addition, general use of the equipment for performing physical examination is discussed ( Box 3.1 ). Specific details regarding techniques and equipment as they relate to specific parts of the examination can be found in the relevant chapters. This chapter also addresses special issues related to the physical examination process.
Students are confronted by a large number and variety of pieces of equipment for physical examination. A commonly asked question is “What do I really need to buy?” The answer depends somewhat on the expectations from your educational program and where you will be practicing. If you are in a clinic setting, for example, wall-mounted ophthalmoscopes and otoscopes are provided. This is not necessarily true in a hospital setting.
The following list is intended only as a guideline to the equipment that you will use most often and should personally own. The price of stethoscopes, otoscopes, ophthalmoscopes, and blood pressure equipment can vary markedly. Different models, many with optional features, can affect the price. Because these pieces of equipment represent a significant monetary investment, evaluate the quality of the instrument, consider the manufacturer’s warranty and support, and decide on the features that you will need.
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Stethoscope
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Ophthalmoscope or PanOptic ophthalmoscope
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Otoscope
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Blood pressure cuff and manometer
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Centimeter ruler
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Tape measure
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Reflex hammer
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Tuning forks: 500 to 1000 Hz for auditory screening; 100 to 400 Hz for vibratory sensation
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Penlight
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Near vision screening chart
Precautions to Prevent Infection
Because persons of all ages and backgrounds may be sources of infection, it is important to take proper precautions when examining patients. Standard Precautions are to be used for the care of all patients in any setting in which health care is delivered. These precautions are designed to prevent the transmission of HIV, hepatitis B, and other blood-borne pathogens based on the principle that all blood, body fluids, secretions, excretions except sweat, nonintact skin, and mucous membranes may contain transmissible infectious agents. Standard Precautions include the following:
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Hand hygiene
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Personal protective equipment (PPE): use of gloves, gown, mask, eye protection, or face shield, depending on the anticipated exposure
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Respiratory hygiene/cough etiquette
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Safe injection practices
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Safe handling of potentially contaminated equipment or surfaces in the patient environment. Guidelines for Standard Precautions are summarized in Table 3.1 . Use precautions to protect yourself and patients.
TABLE 3.1
Recommendations for Application of Standard Precautions for the Care of All Patients in All Healthcare Settings
From Siegel et al, 2007 .
COMPONENT
RECOMMENDATIONS
Hand hygiene
After touching blood, body fluids, secretions, excretions, contaminated items; immediately after removing gloves; between patient contacts
Personal protective equipment
Gloves
For touching blood, body fluids, secretions, excretions, contaminated items; for touching mucous membranes and nonintact skin
Gown
During procedures and patient-care activities when contact of clothing/exposed skin with blood/body fluids, secretions, and excretions is anticipated
Mask, eye protection (goggles), face shield *
During procedures and patient-care activities likely to generate splashes or sprays of blood, body fluids, secretions, especially suctioning, endotracheal intubation
Soiled patient-care equipment
Handle in a manner that prevents transfer of microorganisms to others and to the environment; wear gloves if visibly contaminated; perform hand hygiene
Environmental control
Develop procedures for routine care, cleaning, and disinfection of environmental surfaces, especially frequently touched surfaces in patient-care areas
Textiles and laundry
Handle in a manner that prevents transfer of microorganisms to others and to the environment
Needles and other sharps
Do not recap, bend, break, or hand-manipulate used needles; if recapping is required, use a one-handed scoop technique only; use safety features when available; place used sharps in puncture-resistant container
Patient resuscitation
Use mouthpiece, resuscitation bag, other ventilation devices to prevent contact with mouth and oral secretions
Patient placement
Prioritize for single-patient room if patient is at increased risk of transmission, is likely to contaminate the environment, does not maintain appropriate hygiene, or is at increased risk of acquiring infection or developing adverse outcome after infection
Respiratory hygiene/cough etiquette (source containment of infectious respiratory secretions in symptomatic patients, beginning at initial point of encounter, e.g., triage and reception areas in emergency departments and physician offices)
Instruct symptomatic persons to cover mouth/nose when sneezing/coughing; use tissues and dispose in no-touch receptacle; observe hand hygiene after soiling of hands with respiratory secretions; wear surgical mask if tolerated or maintain spatial separation, >3 feet if possible.
* During aerosol-generating procedures on patients with suspected or proven infections transmitted by respiratory aerosols, wear a fit-tested N95 or higher respirator in addition to gloves, gown, and face/eye protection.
A second tier of precautions, Transmission-Based Precautions, are designed to supplement Standard Precautions in the care of patients who are known or suspected to be infected by epidemiologically important pathogens that are spread by airborne or droplet transmission or by contact with dry skin or contaminated surfaces.
Guidelines and recommendations for the prevention of healthcare-associated infections are available from the Centers for Disease Control and Prevention ( https://www.cdc.gov/infectioncontrol/guidelines/index.html ).
Latex Allergy
Allergic reactions to latex can be potentially serious, although rarely fatal from anaphylaxis. Latex allergy occurs when the body’s immune system reacts to proteins found in natural rubber latex. Latex products also contain added chemicals, such as antioxidants, that can cause irritant or delayed hypersensitivity reactions. Box 3.2 describes the various types of latex reactions.
Irritant contact dermatitis —Chemical irritation that does not involve the immune system. Symptoms are usually dry, itching, irritated areas on the skin, typically the hands.
Type IV dermatitis (delayed hypersensitivity) —Allergic contact dermatitis that involves the immune system and is caused by the chemicals used in latex products. The skin reaction usually begins 24 to 48 hours after contact and resembles that caused by poison ivy. The reaction may progress to oozing skin blisters.
Type I systemic reactions —True allergic reaction caused by protein antibodies (immunoglobulin E antibodies) that form as a result of interaction between a foreign protein and the body’s immune system. The antigen-antibody reaction causes release of histamine, leukotrienes, prostaglandins, and kinins. These chemicals cause the symptoms of allergic reactions. Type I reactions include the following symptoms: local urticaria (skin wheals), generalized urticaria with angioedema (tissue swelling), asthma, eye/nose itching, gastrointestinal symptoms, anaphylaxis (cardiovascular collapse), chronic asthma, and permanent lung damage.
Healthcare providers are at risk for developing latex allergy because of exposure to latex in the form of gloves and other equipment and supplies. Sensitization to the latex proteins occurs by direct skin or mucous membrane contact or through airborne exposure. Box 3.3 contains a summary of recommendations to protect you from latex exposure in the workplace. Be aware that some patients who have had multiple procedures or surgeries performed are at higher risk for the development of latex allergy. Those patients with latex allergies are at risk when exposed to the latex gloves worn by the clinician. Direct contact is not necessary; inhalation of latex airborne molecules from powder-filled latex gloves can trigger an allergic reaction.
Healthcare providers do not have better immune systems than other people, although we sometimes behave as though we do. Nor are we invincible against the everyday work-related injuries. We stand a much better chance of staying well if we are scrupulous in protecting ourselves:
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Follow Standard Precautions.
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Use personal protective equipment (PPE) when appropriate.
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Minimize latex exposure.
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Use good body mechanics or lift devices in transferring or assisting patients into various positions. NO EXCEPTIONS!
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Use NONLATEX gloves for activities not likely to involve infectious materials. Hypoallergenic gloves are not necessarily latex free, but they may reduce reactions to chemical additives in the latex.
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For barrier protection when handling infectious materials, use powder-free latex gloves with reduced protein content.
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Use vinyl, nitrile, or polymer gloves appropriate for infectious materials.
When wearing latex gloves, do not use oil-based hand creams or lotions because they may cause glove deterioration
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After removing gloves, wash hands with mild soap and dry thoroughly.
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Use good housekeeping practices to remove latex-containing dust from the workplace.
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Take advantage of latex allergy education and training provided.
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If you develop symptoms of latex allergy, avoid direct contact with latex gloves and products
Examination Technique
Patient Positions and Draping
Most of the physical examination is conducted with the patient in seated and supine positions. Other positions are used for specific aspects of the examination. Special positioning requirements are discussed in the relevant chapters.
Seated.
When seated, position the drape to cover the patient’s lap and legs. You can move it to uncover parts of the body as they are examined.
Supine.
In the supine position, the patient lies on his or her back, with arms at the sides and legs extended. The drape should cover the patient from chest to knees or toes. Again, you can move or reposition the drape to give appropriate exposure.
Prone.
The patient lies on the stomach. This position may be used for special maneuvers as part of the musculoskeletal examination. Drape the patient to cover the torso.
Dorsal Recumbent.
This position may be used for examination of the genital or rectal areas. The patient lies supine with knees bent and feet flat on the table. Place the drape in a diamond position from chest to toes. Wrap each leg with the corresponding lateral corner of the “diamond.” Turn back the distal corner of the drape to perform the examination.
Lateral Recumbent.
This is a side-lying position, with legs extended or flexed. The left lateral recumbent position (patient’s left side is down) may be used in listening to heart sounds or palpating the spleen.
Lithotomy.
The lithotomy position is generally used for the pelvic examination. Variations of positioning are discussed in Chapter 19 . Begin with the patient in the dorsal recumbent position, with feet at the corners of the table. Help the patient to stabilize the feet in the stirrups and slide the buttocks down to the edge of the table. Drape in the diamond position as with the dorsal recumbent position.
Sims.
The Sims position can be used for examination of the rectum or obtaining rectal temperature. The patient starts in a lateral recumbent position. The torso is rolled toward a prone position; the top leg is flexed sharply at the hips and knee, and the bottom leg is flexed slightly. Drape the patient from shoulders to toes.
Inspection
Inspection is the process of observation. Your eyes and nose are sensitive tools for gathering data throughout the examination ( Box 3.4 ). Take time to practice and develop this skill. Challenge yourself to see how much information you can collect through inspection alone. As the patient enters the room, observe the gait and stance and the ease or difficulty with which getting onto the examining table are accomplished. These observations alone will reveal a great deal about the patient’s neurologic and musculoskeletal integrity. Is eye contact made? Is the demeanor appropriate for the situation? Is the clothing appropriate for the weather? The answers to these questions provide clues to the patient’s emotional and mental status. Color and moisture of the skin or an unusual odor can alert you to the possibility of underlying disease. These preliminary observations require only a few seconds, yet provide basic information that can influence the rest of the examination.
The first observation when entering an examining room may be an odor, obvious and pervasive. A foreign body that has been present in a child’s nose may cause this. Distinctive odors provide clues leading to the diagnosis of certain conditions, some of which need early detection if life-threatening sequelae are to be avoided. However, do not rush to premature diagnosis. Appreciate these odors for what they are—clues that must be followed up with additional investigation. Examples of odor clues follow:
| CONDITION | SOURCE OF ODOR | TYPE OF ODOR |
|---|---|---|
| Inborn errors of metabolism | Phenylketonuria | Mousy |
| Tyrosinemia | Fishy | |
| Infectious diseases | Tuberculosis | Stale beer |
| Diphtheria | Sweetish | |
| Ingestions of poison or intoxication | Cyanide | Bitter almond |
| Chloroform and salicylates | Fruity | |
| Physiologic nondisease states | Sweaty feet | Cheesy |
| Foreign bodies (e.g., in the nose or vagina) | Organic material (e.g., bead in a child’s nose) | Foul-smelling discharge |
The odors may range from objectionable to bland to rather pleasant. The examiner often is the one to determine the characterization of the odor.
Inspection—unlike palpation, percussion, and auscultation—can continue throughout the history-taking process and during the physical examination. With this kind of continuity, observations about the patient can constantly be modified until a complete picture is created. Be aware of both the patient’s verbal statements and body language right up to the end of the encounter. The stance, stride, firmness of handshake, and eye contact can tell you a great deal about the patient’s perception of the encounter (see Clinical Pearl, “The Handshake” ).
Although a nice gesture (coupled with appropriate hand washing), be careful not to harm your patients by squeezing too tightly, especially those patients with conditions that may involve their hands—rheumatoid arthritis or osteoarthritis, for example.
Some general guidelines will be helpful as you proceed through the examination and inspect each area of the body. Adequate lighting is essential. The primary lighting can be either daylight or artificial light, as long as the light is direct enough to reveal color, texture, and mobility without distortion from shadowing. Secondary, tangential lighting from a lamp that casts shadows is also important for observing contour and variations in the body surface. Inspection should be unhurried. Give yourself time to carefully observe what you are inspecting. Pay attention to detail and note your findings. An important rule to remember is that you have to expose what you want to inspect. All too often, necessary exposure is compromised for modesty, convenience, or haste at the cost of important information. Part of your job is to look and observe critically.
Knowing what to look for is, of course, essential to the process of focused attention. Be willing to validate inspection findings with your patient. The ability to narrow or widen your perceptual field selectively will come with time, experience, and practice.
Palpation
Palpation involves the use of the hands and fingers to gather information through the sense of touch. Certain parts of your hands and fingers are better than others for specific types of palpation ( Table 3.2 ). The palmar surface of the fingers and finger pads is more sensitive than the fingertips. Use this surface whenever discriminatory touch is needed for determining position, texture, size, consistency, masses, fluid, and crepitus. The ulnar surface of the hand and fingers is the most sensitive area for distinguishing vibration. The dorsal surface of the hands is best for estimating temperature. Of course, this estimate provides only a crude measure—use it to compare temperature differences among parts of the body.
| TO DETERMINE | USE |
|---|---|
| Position, texture, size, consistency, fluid, crepitus, form of a mass, or structure | Palmar surface of the fingers and finger pads |
| Vibration | Ulnar surfaces of hand and fingers |
| Temperature | Dorsal surface of hand |
Specific techniques of palpation are discussed in more detail as they occur in each part of the examination (see Clinical Pearl, “Right-Sided Examination?” ). Palpation may be either light or deep and is controlled by the amount of pressure applied with the fingers or hand. Short fingernails are essential to avoid discomfort or injury to the patient.
It is the convention, at least in the United States, to examine patients from the right side and to palpate and percuss with the right hand. We continue with this convention, if only to simplify description of a procedure or technique. We feel no obligation to adhere strictly to the right-sided approach. Our suggestion is that students learn to use both hands for examination and that they be allowed to stand on either side of the patient, depending on both the patient’s and examiner’s convenience and comfort. The important issue is to develop an approach that is useful and practical and yields the desired results.
Touch is in many ways therapeutic, and palpation is the actuality of the “laying on of hands.” Our advice that your approach be gentle and your hands warm is not only practical but also symbolic of your respect for the patient and for the privilege the patient gives you.
Percussion
Percussion involves striking one object against another to produce vibration and subsequent sound waves. In the physical examination, your finger functions as a hammer, and the impact of the finger against underlying tissue produces the vibration. Sound waves are heard as percussion tones (called resonance) that arise from vibrations 4 to 6 cm deep in the body tissue. The density of the medium through which the sound waves travel determines the degree of percussion tone. The more dense the medium, the quieter the percussion tone. The percussion tone over air is loud, over fluid less loud, and over solid areas soft. The degree of percussion tone is classified and ordered as listed in Table 3.3 and as follows:
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Tympany
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Hyperresonance
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Resonance
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Dullness
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Flatness
| TONE | INTENSITY | PITCH | DURATION | QUALITY | EXAMPLE WHERE HEARD |
|---|---|---|---|---|---|
| Tympanic | Loud | High | Moderate | Drumlike | Gastric bubble |
| Hyperresonant | Very loud | Low | Long | Boomlike | Emphysematous lungs |
| Resonant | Loud | Low | Long | Hollow | Healthy lung tissue |
| Dull | Soft to moderate | Moderate to high | Moderate | Thudlike | Over liver |
| Flat | Soft | High | Short | Very dull | Over muscle |
Tympany is the loudest, and flatness is the quietest. Quantification of the percussion tone is difficult, especially for the beginner. For points of reference, as noted in Table 3.3 , the gastric bubble is considered to be tympanic; air-filled lungs (as in emphysema) to be hyperresonant; healthy lungs to be resonant; the liver to be dull; and muscle to be flat. Degree of resonance is more easily distinguished by listening to the sound change as you move from one area to another. Because it is easier to hear the change from resonance to dullness (rather than from dullness to resonance), proceed with percussion from areas of resonance to areas of dullness. A partially full milk carton is a good tool for practicing percussion skills. Begin with percussion over the air-filled space of the carton, appreciating its resonant quality. Work your way downward and listen for the change in sound as you encounter the milk. This principle applies in percussion of body tissues and cavities.
The techniques of percussion are the same regardless of the structure you are percussing. Immediate (direct) percussion involves striking the finger or hand directly against the body. Indirect or mediate percussion is a technique in which the finger of one hand acts as the hammer (plexor) and a finger of the other hand acts as the striking surface. To perform indirect percussion, place your nondominant hand on the surface of the body with the fingers slightly spread. Place the distal phalanx of the middle finger firmly on the body surface with the other fingers slightly elevated off the surface. Snap the wrist of your other hand downward, and with the tip of the middle finger, sharply tap the interphalangeal joint of the finger that is on the body surface ( Fig. 3.1 ). You may tap just distal to the interphalangeal joint if you choose, but decide on one and be consistent because the sound varies from one to the other. Percussion must be performed against bare skin. If you are not able to hear the percussion tone, try pressing harder against the patient’s skin with your finger that lies on the body surface. Failing to press firmly enough is a common error. On the other hand, pressing too hard on an infant or very young chest can obscure the sound.
Several points are essential in developing the technique of percussion. The downward snap of the striking finger originates from the wrist and not the forearm or shoulder. Tap sharply and rapidly; once the finger has struck, snap the wrist back, quickly lifting the finger to prevent dampening the sound. Use the tip and not the pad of the plexor finger (short fingernails are a necessity). Percuss one location several times to facilitate interpretation of the tone. Like other techniques, percussion requires practice to obtain the skill needed to produce the desired result. Box 3.5 describes common percussion errors. In learning to distinguish between the tones, it may be helpful to close your eyes to block out other sensory stimuli, concentrating exclusively on the tone you are hearing.
Percussion requires practice. In learning percussion, beginning healthcare providers often make the following errors:
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Failing to exert firm pressure with the finger placed on the skin surface
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Failing to separate the hammer finger from other fingers
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Snapping downward from the elbow or shoulder rather than from the wrist
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Tapping by moving just the hammer finger rather than the whole hand
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Striking with the finger pad rather than the fingertip of the hammer finger
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Failing to trim the fingernail of the hammer finger
You can also use your fist for percussion. Fist percussion is most commonly used to elicit tenderness arising from the liver, gallbladder, or kidneys. In this technique, use the ulnar aspect of the fist to deliver a firm blow to the flank and back areas. Too gentle a blow will not produce enough force to stimulate the tenderness, but too much force can cause unnecessary discomfort, even in a well patient. The force of a direct blow can be mediated by use of a second hand placed over the area. Practice on yourself or a colleague until you achieve the desired middle ground.
Auscultation
Auscultation involves listening for sounds produced by the body. Some sounds, such as speech, are audible to the unassisted ear. Most others require a stethoscope to augment the sound. Specific types of stethoscopes, their use, and desired characteristics are discussed later in the section on stethoscopes .
There are some general principles that apply to all auscultatory procedures. The environment should be quiet and free from distracting noises. Place the stethoscope on the naked skin because clothing obscures the sound. Listen not only for the presence of sound but also its characteristics: intensity, pitch, duration, and quality. The sounds are often subtle or transitory, and you must listen intently to hear the nuances. Closing your eyes may prevent distraction by visual stimuli and narrow your perceptual field to help you focus on the sound. Try to target and isolate each sound, concentrating on one sound at a time. Take enough time to identify all the characteristics of each sound. Auscultation should be carried out last, except with the abdominal examination, after other techniques have provided information that will assist in interpreting what you hear (see Clinical Pearl, “Unexpected Findings” ).
