This tape was transcribed by Adrian Whicker and Heather Shannon. The editors gratefully acknowledge their invaluable assistance.
Larry Schacht: Okay, the things that you’re expected to know for the uh, examination of the patient are: general description of the patient, their age, sex, and any characteristics about them which make them stand out from other people, and anything that’s particularly characteristic about them. You should describe the way they present with their illness, if they’re alert, if they’re in distress, if they’re cooperative, if they’re pleasant, or hostile or whatever emotional or physical characteristics they have. For instance, if they have uh, presented on a stretcher or in a wheelchair, then that’s the important information. You may want to comment on the way they dress or groom themselves.
Then you hit the physical uh– the physical exam first with the vital signs, and those include the temperature, which is taken orally usually, but if you don’t take it orally, then you have to specify which you– what you’ve done. Then you take the pulse, and you should feel both p– radial pulses at the same time to see that they’re equal in that they’re– they both arrive at the wrist at the same time, that they’re both equal in intensity. You should characterize the pulse as regular or irregular and uh– and uh, all your pulses should be recorded on a scale of 1+ to 4+, with a normal pulse being 2+, that means as soon as you touch the– the area, you feel the pulse, you don’t have to tune into it, and uh, (Pause) yet uh, it’s not what you’d call a 3+ or a 4+, which is a very strong, forceful pulse. After you’ve uh, recorded the pulses then– or the pulse rate rather, every uh– how many pulses in 15 seconds and multiply times four, then you do the blood pressure, and when you do the blood pressure, you be sure and occlude the radial artery pulsation and then go 10 or 15 millimeters above that point in order to be sure that you gone above true systolic. Then you reduce the uh, blood pressure down to (pause) a point where you hear the sound with the stethoscope over the brachial artery and uh, the systolic is when the sounds appear and the diastolic is when the sound disappears. Again uh, record the respiratory rate per minute by palpating the radial pulse and observing the rising of the anterior chest, or rather the anterior thorax of the chest.
Then start the physical exam and check the head and neck first. Check the hair, note the quality of the hair, the distribution, the uh, color may be pertinent. The uh– (pause) Check the scalp, search the scalp particularly in cases of head injury, notice the size and shape of the head. If it’s normal cephalic, then make a note that is normal cephalic, or the normal size and shape. Then do a study of the lymph nodes, the uh, preauricular, posterior auricular– those are in front of and behind the ears, the submaxillary nodes, the submental node, the occipital node, the posterior cervical nodes and those in the uh, deep cervical node, they’re anterior to the sternum mastoid muscle. While you’re in the neck, also palpate the carotid arterial pulse. And uh, at this time you may wish to listen for noise over the carotid arteries. However, you can leave this– this uh, palpitating of carotid arteries until you do the thoracic exam.
Then check the eyes, ex– ex– uh, inspect their external features, the brows, the lids. And look at the irises, the sclera, the cornea. Check the pupillary responses, check to see that the pupils are equal, round, and respond to light and accommodation. Check the extraocular muscle function. Check the fundi. When you check the fundi, it’s acceptable just to see the red reflex, but if you see the optic nerve head and the vessels that come from the optic nerve head, check the ratio– or rather, the size comparison between the arteries and the veins. And it should be uh, four to five. If you do see the optic nerve head, comment on whether it’s sharp or blurred. And of course note any abnormalities like arcus or cataracts or uh, pingueculas or anything else that uh– that you know to be abnormal.
Then check the uh, ears and uh, if you can see a cone of light, if you can see the tympanic membrane, if you can comment on its color and if it has perforations, then that’s uh, good, but we haven’t really discussed in detail and we haven’t had much experience with that, so at this point, it’d be sufficient just to properly uh, insert the uh, otoscope and be able to see the tympanic membrane.
When you inspect the nose, be sure to check the septum, be sure it’s intact. If the nasal passages are open and they look equal on both sides, you can look at the turbinates, and uh, you should be able to recognize if there’s any abnormal uh, structure obstructing the nose, or if there’s any discharge or if there’s any– uh, anything unusual.
The mouth you inspec– you inspect next. You check the pharynx, the uh, tonsillar areas uh, the uvula, you also look at the tongue, you have the uh, person uh, touch the top of their mouth with their tongue so you– you– so you can inspect the interior surface, and uh, also check their teeth to see what condition their teeth are in. Check around the gums. Uh, use a uh, tongue blade in order to avoid missing a uh, carcinoma that could be within the mouth. (Pause)
If there’s any doubt uh, you should also recognize that if a person has any uh, complaint of hearing at that time, you want to do a simple hearing test. That’s where you rub your fingers in the air on either side– on both sides of their head, and ask them if their hearing is approximately the same, or if it sounds the same on both sides.
The same with vision. You want to be sure that if they complain of vision that uh– or visual loss, that you do check their visual acuity with the chart. That’s not expected at this point, but I do put it in because it’s uh– it’s a necessary step uh, in the physical exam, although you’re not responsible for it at this point. (tape edit)
When you check the neck– you’ve already checked the carotid artery, you check the thyroid glands. If you palpate the cricoid cartilage, the thyroid cartilage and uh, the trachea, it’s to your advantage. If you uh– you should check the thyroid gland and be aware that if the person swallows, the gland rises and falls. It’s critical in– in– in being certain of what you are palpating is the thyroid gland and uh, not something else. It’s also uh– on the lymph node examination you check the supraclavicular nodes and the supraclavicular process.
Then you move to the chest, the thorax. Now the thorax exam uh, includes a breast exam. Uh, to do the breast exam, you stand in front of the patient, have them put their arms straight forward towards you, inspect the contour of the breast to be sure they are symmetrical. You check the uh– you check the breast with the hands on the hips while they’re pushing uh– pushing against the hips, and then you also check with the hands placed behind the neck. You check the uh, infraclavicular nodes, you check the axillary nodes, the nodes in the armpit rather, and you check them in the anterior part, in the middle part, and in the posterior part of the axillary.
Then, before the patient lies down and gets into a supine position, then you look at their back and inspect. You look for kyphosis or scoliosis. You check for any abnormal skin lesions which could be cancerous. Then you auscultate the uh, lungs, then you percuss the lungs. Then you percuss over the kidney areas, the costovertebral angles. Then you percuss with your fist up the spine. Uh, be sure there are no painful areas or uh, other lesions that may be uh, invisible, just by inspection.
Then after you’ve auscultated and percussed the back, you have the patient lie down in a supine position, and you can continue with the breast exam. You uh, have already done the uh, check for the uh, infraclavicular, supraclavicular nodes, the axillary nodes, and now you want to palpate the breasts themselves for tumor masses. Palpate in a circular motion, going in smaller and smaller circles towards the nipple, and when you get to that point, then you uh, ex– uh, try to express any kind of fluid or uh, secretion.
Then you check the lungs, you auscultate the lungs, comparing one side with the other. You have the patient– Of course you did this when they were uh, sitting also, you have them breathe in through their mouth quietly, but deeply, and watch the patient, be sure that if they are ill or have a cardiopulmonary disease, that you don’t uh, cause them to become too dizzy or to uh, begin feeling a numbness around their mouth or their– or their arms because of uh, hyperventilation. You auscultate the car– the anterior chest, and uh, in that way you examine the lungs, the anterior lungs.
Then you uh, go to the cardiac examination. You inspect the chest for the point of maximum intensity where the apex of the heart beats against– beats against the chest wall. Then you uh, palpate. You may have to turn the person in the left lateral uh, position or have them sit up forward and uh, expire the full expiration, in other words, blow all the air out of their lungs and then see if you can feel the apex of the heart uh, as it comes against– closer to the chest wall. After you’ve inspected and palpated the apex, you can percuss the size of the heart, and you should uh, get a good indication of the uh, cardiac uh– area of cardiac dullness, so you can estimate how large their heart is. Then after you percuss the heart size, you uh, auscultate. You uh, listen over the apex along the left sternal border, inching your way up to the left second intercostal space, which you know by now is right below the second rib which attaches to the uh, sternal angle, and then you (unintelligible word) across the sternum on the other side to the right, second intercostal space. (Pause) You listen in all these uh, areas of auscultation for S1 and S2. You should listen carefully first to S1, focus on it, then listen after that to S2 and focus in on S2. Then after you’ve focused in on both those sounds, then listen to the space between S1 and S2, and then after you’ve listened to that space, focus in on the space between S2 and S1 which is distally. We’ll go into this more later, but at this point in this basic uh– just basically between the S1 and S2 is all that’s really required.
Then uh, auscultate in the epigastric area, and again if you do hear a murmur of some kind, then you want to auscultate in the left axillary area, also listen in the anterior right and left uh– anterior, superior uh, areas of the chest, the infraclavicular areas. Also then you want to listen over the carotid arteries again. And there– these are just other areas you listened, including the uh– the back. If you do hear a murmur or an abnormal sound, you want to know how widely the uh, sound radiates. And now that include– that pretty much sums up the cardiac evaluation.
Then you go to the abdomen. And the abdomen you inspect, you uh, auscultate, percuss, and palpate. While you’re inspecting, you look for any scars, you want to find out what the scars are from. You want to notice if they’re obese, or particularly emaciated and thin, you want to be aware of uh, hernias that are in the abdominal wall and uh, you want to look for any abnormal uh, skin lesions again. Also note the hair distribution below the navel and above the pubic area. Then after you’ve inspected, you uh, auscultate. You listen over the liver for hums, or bruits, or friction rubs, and uh, again I want to reflect back to the thorax, you do listen for friction rubs over the thorax too. They will be sounds that you don’t hear commonly, but, I mean not in every normal physical exam, but you will hear them, and they should be uh, thought of. Then as you’re auscultating over the abdomen, you uh, do the scratch test for the liver so that you can detect its uh, inferior margin. Then auscultate for bowel sounds, starting primarily in the left uh, periumbilical area or to the left side of the navel. If uh, you don’t hear them there, then you can uh, try other areas. If you don’t hear any bowel sounds at all in a quiet room under good listening conditions for a full two minutes uh, then you can say that the bowel sounds are decreased or absent. Auscultate over the femoral artery area so that you can uh, listen for bruits, and then move on to percussion, percuss out the upper and the lower border of the liver. You should be able to measure the liver in centimeters in the midclavicular line, also measure the liver in centimeters in the midsternal line. This’ll be sure and uh, rule out the possibility of an enlarged liver. You’ll know the breadth of the liver, and you should be able to mark it in centimeters in the midclavicular line and in the midsternal line. In the midclavicular line, it should be anywhere from six to 12 centimeters, and in the midsternal line from three to four centimeters. In the uh– (pause) percussion, you put your uh uh– you also percuss over the spleen. Have the person take a deep inspiration and check to see that if the area you’re percussing in the lower left uh, costal margin becomes dull, then you suspect the spleen’s enlarged and it’s come down to that area, then uh– If it doesn’t, then you consider that the spleen is not enlarged.
Further percussing, you can percuss over the abdomen, particularly trying to uh, find out how much gas there is in the bowel, or if there’s a mass in the abdomen uh, you can percuss that to find out uh, if it’s still or hollow. After uh, percussing the spleen, and uh, if you need to percuss the bladder, that’s uh, usually a specialized need if you think that a person who’s unconscious or an elderly person who’s confused, has got a grossly distended bladder, then you may want to percuss the bladder. Uh– You might mention that, it’s good to know and think about. But uh, if it’s not– it’s not part of– at that point, it’s just uh, for extra credit. After you percuss the abdomen, you’re ready to palpate, you palpate the– the liver, you uh, palpate for the spleen. If you can’t feel the spleen, come down by palpating under the left costal margin when the person takes deep inspiration, and you can have them lie on their right side and take a deep inspiration again, and the spleen will likely come down, if it’s enlarged. You don’t have to mash in or feel too hard for the spleen, because the spleen will come and touch your fingertips if it’s enlarged. Also be sure that if uh, the left upper quadrant is dull, that you start down low enough a– along the left side of the abdomen to be sure that it’s the spleen is enlarged that you’re not feeling too high to feel its lower tip. The same with the liver. If you can’t seem to find it, recall the example I gave in which uh, the liver was all the way down to the pelvis, so you may have to start low, around the area of the navel and work your way up when you’re doing the uh, scratch test or percussion of the liver. Remember though, when you’re percussing the liver you should normally have the stethoscope– or rather when you’re doing the scratch test, you should have the stethoscope over the right uh, lower rib cage, not down in the abdomen itself. After you’ve uh, done palpation for the liver and the spleen, then you uh, palpate around in general and in the abdomen, using one hand as a sense– uh, as a uh, sensitive hand, and the other hand as a pressure hand on top of the sensitive hand. Then, if you’ve found no masses and no areas of tenderness uh, palpate the femoral arteries, recalling that they’re slightly below a line that connects the anterior superior iliac spine to the uh, pubic bone, or the pubis. Be sure you palpate around the abdominal uh, surface, the lower abdominal surface over the pelvis to be sure there are no ovarian masses or enlarged uterine tumors or uh, anything like that, or even uh, again like I said, an enlarged bladder. So you palpate for masses throughout the entire abdomen. Also palpate the costovertebral angles again when the person is in the supine position as part of the abdominal exam, just in case uh, you’re only examining the abdomen at that time and you still want to check the kidney area. Palpate the navel also just to be sure that there is no uh, tumor metastasis in the navel.
Then the next part of the exam is basically palpating the popliteal pulses, the uh, posterior tibial pulses, and the dorsalpedal pulses. And these should be characterized along with all the other pulses you palpated, the radials and the carotids as a 2+, 3+, or whatever they happen to be, and you should also comment on the lower extremities, the skin. Look for pretibial edema, look for uh– When I mean the skin, I mean look for uh, color changes, loss of hair, scars, old injuries uh, look at the feet and the the nails to detect if there’s circulatory uh, insufficiency, and uh, then uh, you can work your way back up doing the deep tendon reflexes uh, the plantar responses which, if abnormal, are called Babinksi’s sign where the large toe goes up and the other toes fan– fan out, and then the uh, ankle jerks, the knee jerks, the uh, biceps reflexes, triceps reflexes, the brachial raidialis, and uh, primarily be concerned that they be symmetrical, they’re the same on both sides, although as I mentioned, if there’s no paralysis or loss of function in an extremity or loss of sensation there or anything like that, then the– then the reflexes alone are not that significant. (Tape edit)
Uh– Points of clarification. In the uh, femoral pulse, the first thing you can do is to auscultate, and then after you percuss the abdomen, go back and palpate the femoral pulses, so you’re doing all your palpating at the same time and all your auscultating at the same time. It’s a good idea to try to be uh, as systematic as you can be and do all your– and break down your methods, whether the inspection, palpation, auscultation and percussion, do all those at the same time, [pause] in a given body area, remembering that you can, for instance, in a– uh, you can use al– almost all four of the methods in almost every part of the body. You can auscultate over the thyroid glands, you can uh, for bruits in an enlarged thyroid, you can even auscultate over the eye if you suspect there’s an arterial uh, malformation behind the eye, or you can auscultate over the skull if you want to listen for a bruits in a person– person who has a seizure problem, as uh– as has been pointed out. (Tape edit)
When you get through with the physical exam, actually that’s the time when you can best uh, evaluate the patient’s cooperation, alertness uh, degree or uh, absence of stress, and uh, then you– when you do your written eval– your written work-up, that’s when you include all that information. So at the onset of the exam, if you’re doing an oral test, you’re not going to really be able to uh, describe much more than in a– in a general way how they look, if they’re calm, if they’re anxious, if they’re apprehensive, if they’re uh, hostile, or if they’re pleasant. (tape edit) And like I said, you’re not responsible for the neurologic exam.
In Bates, on page uh, 314, 315, 316 you should uh, read this– uh, these pages, and uh, understand uh, how you will record a physical examination. And (unintelligible word) node that should be checked are the epitrochlear nodes. Uh– Also remember you should note the uh, external jugular vein, especially if you’re examining any senior who has– uh, who may well have congestive heart failure, you do want to look at the external jugular vein. As far as determining pressure levels at this point, that’s not necessary. (tape edit) The abdominal exam on page 316 is a– is a fairly comprehensive or well worth following the contour scars. I’ll send– (tape edit) Do not listen to this tape any further, but rewind it from this point. Do not listen to this tape any further, rewind it from this point– (tape edit)
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