Table 2: General Physical Examination
| Physical Sign / Manoeuvre | Rationale | Technique(s) | Interpretation | Evidence | Pre-Clerkship | Clerkship |
|---|---|---|---|---|---|---|
| General Appearance | ||||||
| Apparent state of health | Triage Management | Observe Reflect | Well Ill Acute Ill Chronic | None | 4 | 4 |
| Level of Consciousness | Communication Triage Management Neurological | Observe Arouse – verbal, touch, sternal Stimulation | Alert Lethargy Stuporous Comatose | None | 4 | 4 |
| Delirium | Communication Diagnosis Triage Management | Confusion assessment method – Look for 1. acute fluctuating mental status, 2. difficulty focusing, and 3. disorganized thinking or 4. altered LOC-lethargy, stupor or hyper-alert for positive test | Delirium (Positive test renders bedside dementia tests meaningless) | McGee, 2007, Chapter 4. +LR 10.3 - LR 0.2 | 3 | 4 |
| Signs of distress | Communication Triage Management | Observe Reflect | Comfortable Uncomfortable | None | 4 | 4 |
| Height/Weight BMI– Waist Circumference | Risk assessment– Obesity, DM, CAD Risk, metabolic syndrome. Weight changes - DX nutritional state, neoplasm, volume status, chronic illness, eating disorders Prognosis Management | BMI KG/m2 - correlates with total body fat BMI > 25 Overweight BMI > 30 Obese Waist circumference female>88 cm Male>102 cm Measured mid way between ribs and ileac crest correlates with intra-abdominal fat | Weight loss, Gain, Obesity Abdominal obesity | McGee, 2007, Chapter 11. Bray, 1976. Pouliot, 1994. Attia, 1999. | 4 | 4 |
| Pallor | Diagnosis Management | Observe conjuctiva, conjunctival rim, palmer creases, skin | Chronic anemia | McGee, 2007, Chapter 8. Sheth, 1997. +LR 16.7 for conjunctival rim pallor | 4 | 4 |
| Jaundice | Diagnosis | Observe conjunctiva, skin for abnormal yellow discoloration | Hepatocellular damage, Cholestasis, Hemolytic disorders | McGee, 2007, Chapter 6. | 4 | 4 |
| Central Cyanosis | Diagnosis Management | Observe lips,tongue, sublingual mucous members, hands and feet for blue discoloration | Hypoxia Severity of hypoxia, amount of deoxyhemoglobin | McGee, 2007, Chapter 7. | 4 | 4 |
| Peripheral Cyanosis | Diagnosis Management | Observe hands and feet Lips for blue discoloration (not seen in sublingual mucous membranes) | Poor limb perfusion, cold exposure | McGee, 2007, Chapter 7. | 4 | 4 |
| Scars Wounds | Diagnosis | Observe | Indicates previous surgery, trauma | None | 4 | 4 |
| Obvious deformity, Appliances, Prosthesis | Diagnosis Management | Observe | Mobility Disability | Yes – for how cane used McGee, 2007, Chapter 5. | 4 | 4 |
| General grooming and hygiene | Diagnosis | Observe | Mental status, socioeconomic status | None | 4 | 4 |
| Affect | Communication Diagnosis | Observe for Normal, Flat or Hyperactive | Mental Illness Delirium Dementia | none | 4 | 4 |
| Odour | Diagnosis Management | Observe smell -
Alcohol, Ketones, Fetor hepaticus, Fecal, Urine | Alcohol DKA Severe portal- systemic shunting Incontinence | Fetor McGee, 2007, Chapter 6. | 3 | 4 |
| Asterixis | Diagnosis | Arms outstretched, fingers spread Observe flapping | Encephalopathy hepatic, hypercapnia, uremia | McGee, 2007, Chapter 6. | 3 | 4 |
| Clubbing | Diagnosis | Interphalangeal depth ratio, nail fold angle | Respiratory disease, liver disease, endocarditis, cyanotic heart disease | McGee, 2007, Chapter 25. Myers, 2001. Simel, 2010, Chapter 14. | 3 | 4 |
| Hypovolemia (in adults) | Diagnosis Management | Postural Vitals Postural dizziness Axilla dryness. Mucous membranes | Hypovolemic | McGee, 2007, Chapter 9. McGee, 1999. Simel, 2009, Chapter 24. | 3 | 4 |
| Dehydration (in children) | Diagnosis Management | Skin turgor. Capillary refill Abnormal respirations | Dehydration | Steiner, 2004. Simel, 2009, Chapter 25. | 3 | 4 |
| Meningeal Signs | Diagnosis | Nuchal rigidity (neck stiffness) Kernig’s Brudzinski’s Jolt accentuation of headache (2-3/s rotations of head horizontally) | Acute meningitis in adult | McGee, 2007, Chapter 23. Attia, 1999. Simel, 2009, Chapter 30. | 3 | 4 |
| Edema | Diagnosis Management | Pressure of 1-2 seconds with finger over bony prominence produces pitting for pitting edema, recovers easily – non-pitting edema- does not pit easily | Pitting edema – hypo-proteinic states, CHF Non pitting edema – lymphedema (may pit in early stages), inflammatory edema | McGee, 2007, Chapter 52. Simel, 2009, Chapter 16. | 3 | 4 |
| Vital Signs | ||||||
| Temperature | Detect fever/hypothermia Diagnosis Prognosis | Rectal 0.4-05. C Higher than oral. Oral 0.4-0.7C higher than axillary Oral 0.4 C Higher than tympanic membrane. Tympanic rapid, convenient reflects core temperature (falsely low if cerumen present) | Defined as 99th percentile of maximum temperatures in healthy person -37.7° C oral Fever patterns – less useful in antibiotic/antipyretic era Extreme pyrexia > 41.1C or, (<36.1 indicates poor prognosis in certain clinical conditions) | McGee, 2007, Chapter 16. | 4 | 4 |
| Respiration Rate | Diagnosis Prognosis | Observation while patient unaware measurement being done for at least 30-60 seconds | Normal rate averages 20 breaths per minute (range 15-25) Tachypnea > 25 Bradypnea < 8 | Fetor McGee, 2007, Chapter 17. | 4 | 4 |
| Respiratory Pattern | Cheyne-Stokes Kussmaul’s | Alternating cycles of hyperpnea and apnea Rapid deep breaths | Congestive heart failure, neurologic disorders Metabolic | McGee, 2007, Chapter 17. | 4 | 4 |
| Blood Pressure | Diagnosis Prognosis | In stable clinical situations to avoid misdiagnosis of hypertension – patient sits 5 minutes, arm at heart level, arm supported, appropriate cuff size (cuff bladder to encircle at least 80% arm), inflated to 20-30 mm HG above systolic pressure, released 2 mm Hg per second using bell or diaphragm Average of 2 readings should be taken. Hospitalized | Essential hypertension- three or more reading over three visits separated by weeks exceeds 140/90 Blood pressure difference between two arms approx 10 mm Hg. More than 20 mm Hg difference indicates subclavian steal or aortic dissection Low leg BP in young hypertensive indicates coarctation of aorta Hypotension – systolic BP <90 – increased in mortality in ICU Systolic BP < 80-increased mortality in Myocardial infarction | McGee, 2007, Chapter 15. Reeves, 1995. | 4 | 4 |
| Pulse Oximetry | Superior to cyanosis as a sign in detecting hypoxemia | Measurement on earlobe or finger tip | Indicates the degree of oxygen saturation of haemoglobin, not affected by haemoglobin concentration | McGee, 2007, Chapter 18. | 4 | 4 |
References
- Attia J, et al. The rational clinical examination. Does this adult patient have acute meningitis? JAMA 1999 Jul 14;282(2):175-181.
- Bray GA, et al. Evaluation of the obese patient. 2. Clinical findings. JAMA 1976 May 3;235(18):2008-2010.
- Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults--The Evidence Report. National Institutes of Health. Obes.Res. 1998 Sep;6 Suppl 2:51S-209S.
- McGee S, et al. The rational clinical examination. Is this patient hypovolemic? JAMA 1999 Mar 17;281(11):1022-1029.
- McGee SR. Evidence-based physical diagnosis. 2nd ed. St. Louis, Mo.: Saunders Elsevier; 2007.
- Myers KA, et al. The rational clinical examination. Does this patient have clubbing? JAMA 2001 Jul 18;286(3):341-347.
- Pouliot MC, et al. Waist circumference and abdominal sagittal diameter: best simple anthropometric indexes of abdominal visceral adipose tissue accumulation and related cardiovascular risk in men and women. Am.J.Cardiol. 1994 Mar 1;73(7):460-468.
- Reeves RA. The rational clinical examination. Does this patient have hypertension? How to measure blood pressure. JAMA 1995 Apr 19;273(15):1211-1218.
- Sheth TN, et al. The relation of conjunctival pallor to the presence of anemia. J.Gen.Intern.Med. 1997 Feb;12(2):102-106.
- Simel DL, et al. The rational clinical examination : evidence-based clinical diagnosis. New York; Chicago, IL: McGraw-Hill Medical; JAMA & Archives Journals, American Medical Association; 2009.
- Steiner MJ, et al. Is this child dehydrated? JAMA 2004 Jun 9;291(22):2746-2754.