Physical examination – inspection,
palpation – general symptoms –
alterations of the skin – different
types of fever – case records – body
weight and heat measurement
Szántó Antónia
3rd Dept. Of Medicine 2009
Optimal circumstances for physical
examination
Quiet environment (ward, examination
room)
Optimal lighting
Highest discretion according to the
circumstances
Keeping the patient informed
Eye-contact
Physical examination
4 parts
inspection
palpation
percussion
auscultation
Practically, smelling is also used (foetor hepaticus, foetor
ex ore, aceton-like breath odor, uremic smell)
Basic equipment needed for physical examination
Stethoscope
Blood pressure gauge
Thermometer
Pupil-lamp, tape-measure, reflex-hammer
Physical examination
Different parts cannot be separated
Obligatory to perform
General inspection of the body
Percussion and auscultation of the chest-organs
Palpate arterial pulses
Palpation of the abdomen
Breast-examination
Palpation of peripheral lymph nodes
Orienteering examination of locomotory and nervous system
Measure blood pressure and pulse
Measuring heat, height and body weight
Rectal digital examination (up to 40/50 years)
Inspection
Preferred posture
Patient in good general state of health: vigilant, changes
position easily
Unconcious patient: „passive” lay (floppy muscles, sinking
into bed)
Decerebration, decortication:
Patient with meningitis: hunter-dog position
Tetanus, hysteric attack, meningitis: opisthotonus
Emphysema: „pink puffer”
Chronic bronchitis: „blue bloater”
Orthopnoe
Pleuritis, ptx: lays on involved side so as
to decrease chest movements
Pink puffer
Blue bloater
Patients with abdominal inflammatory
diseases: lying on their back, legs pulled up
from knees
One-side inflammation: often one-side leg
pulled up (e.g. appendicitis)
Peritonitis: moveless, laying on their back
Bilious, renal attack: unable to lay
immobile, restless
Types of walk
Mo. Parkinson: shambling steps, head
turned down, no swaying of arms
Mo. Bechterew (SPA): inclining back,
declined head
Multiple sclerosis: „spastic” walk (stiff,
uncertain, infirm)
Hemiparetic walking (circulating leg)
Ataxic walk: damage of the cerebellum,
posterior part of spine cord
Mood
Vivid or depressed
Talkative or laconic
Calm or troubled
Objective or overacted performance
Simulation: non-existing complaints
Aggravation: real symptoms overacted
Dissimulation: hiding real complaints and
symptoms
Nutrition
Cachexia (extreme leanness, no fat-tissue,
worsened somatic condition)
BMI (body mass index):
body weight (kg)/ hight (m)2
Well-nourished (normal BMI: 20-25)
Slight obesity: BMI 25-30
Moderate obesity: BMI 30-40
Severe obesity: BMI > 40
Hair
Abdominal hair:
Females ∇
Males ◊
Feminin-type hair at men, masculine-type
hair at women suggests endocrinologic
disorder
Hirsutism: bushy, rough hair, moustache,
beard
Rare hairs in males: e.g. liver cirrhosis
Constitution
Composition of inherited and aquired
somatic and psychic attitudes that
determine constitution
Asthenic
Picnic
Athletic
Chest deformities
Asthenic: plan, narrow chest
Picnic: wide, domed chest – just like emphysema
Pectus excavatum (shoemaker-chest)
Pectus carinatum
Scoliosis, kiphosis, kiphoscoliosis
Inspection of mucous membranes
Conjunctiva, mouth, pharynges
Pale conjunctiva (+hand and nailfold):
anaemia
yellow sclera: jaundice
Light-blue sclera: osteogenesis imperfecta
Cyanotic skin and mucous membranes:
cyanosis (peripheral = acral, central=
perioral)
Skin
(natural light is preferred)
Paleness: anaemia
Yellow color: jaundice
Pale face, eyelid-edema: kidney failure
„Mitral rose”: mitral stenosis
spots
Butterfly-rash, spider-angioma, purpura,
xanthelasma
Spider angioma
purpura
xanthelasma
First-sight-diagnoses
Scleroderma
Mo. Cushing
Graves-Basedow disease
Goals of palpation
Examining the skin
Palpation of deep-laying resistences
Examination of pain
Registrating some movements
happening inside
Palpation of the skin
Dry skin, with decreased turgor:
exsiccosis
Edema: holds fingerprints
Myxoedema: does not hold fingerprints, because of the lack of
interstitial fluid-retention
Search for deep resistances
Peripheral lymph nodes at skin, m. scm, inguinal
and axillar) (4-4 fingers)
Besides m. sternocleidomastoideus, there is a
supraclavicular pit (Virchow-nodule)
Palpation of the thyroid gland (moving behind
the sitting patient)
Physical examination of the breasts
Judging pain
• Carefully
•Started from the asymptomatic into the direction
of painful regions
•At abdomen: first is always auscultation.
Intracorporal movementphenomenons
Pulse
Pulsing of the heart-top
Friction rub at pleuritis
Chest deflexions during respiration
Pulse qualities
Frequence
frequent
Rare
Rhythm
rhythmic
arrhythmic
Altitude
Altus
parvus
Celerity
Quick
Slow
Aequality
Aequal
inaequal
suppressability
Durus
mollis
Measuring temperature
Indirect information about internal
temperature
Mostly in axillar pit (8-10 minutes)
Oral cavity 0,3-0,5° higher,
Rectal 0.5-1° higher than in axillar
pit (good to perform after collapse,
unconcious patient, under suspicion
of febris factitia – pretended fever)
Normal temperature: 36-37 °Celsius
Deepest at dawn, highest in the afternoon
Daily fluctuation around 1 ° Celsius
Temperature is elevated in healthy people:
Physical activity
Excitement
nutrition
Warm bath
First third of pregnancy, ovulation
Agents causing fever
Direct excitation of the thermal-centre
(enhanced intracranial pressure, e.g.
stroke) – may cause hyperpirexia
Infections
Absorption of necrotic tissues (burning,
tumor-lysis)
Parenterally given xeno-proteins
Increased metabolism (e.g.
hyperthyreosis)
Subfebrility: until 37,5 ° (constant
subfebrile condition is characteristic to tb,
focal infections, vegetative dystonia)
Moderate fever: 37,5-39 °C
High fever: 39,1-40 °C
Hyperpirexia: above 40 °C
Elevated temperature not caused by the
excitation of the heat-centre:
hyperthermia
Low temperature: starvation, myxedema
Types of fever- febris continua continens
42
41
40
39
38
37
36
6
10
14
18
Daily fluctuation is below 1°C
(e.g. untreated abdominal typhus)
22
Febris remittens
42
41
40
39
38
37
36
6
10
14
18
22
Daily fluctuations are higher than 1,5ºC, but normal
temperature is not achieved (tb)
Febris intermittens
42
41
40
39
38
37
36
6
10
14
18
22
Changes in temperature are very high, sometimes
reaching even normal (sepsis, malaria).
Febris recurrens
Changing of more-days time with fever and moredays time without
E.g.: Bang disease
Hodgkin.lymphoma (Pel-Ebstein-like fever)
-Sudden increase of temperature: cold shivers
-Temperature-decrease can be sudden (critic – e.g.
pneumonia) and lytic
-Pseudocrisis: decreasing fever, increasing pulse (bad
sign – crux mortis)
Weight measurement
Objective definition of constitution
Judge fluctuation of body weight
Good appetite and weight loss: hyperthyreosis,
diabetes
Bad appetite and significant weight loss: tumor,
atherosclerosis, adsorption disorders, anorexia
nervosa
Sudden weight increase: hypothyreosis,
hypothalamus diseases, hypertension, fluid retention
(latent edema, cardial decompensation)
Technique:
- In the same time, possibly in the morning, after going
to the toilet, before eating, within the same dress
- Every week, sometimes even every day