Physical examination of the patient

Propaedeutics or propedeutics is a historical term for an introductory course into a discipline: art, science, etc. Etymology: pro- + Greek: paideutiks, "pertaining to teaching". Propaedeutics may be defined as knowledge necessary for learning, but not for proficiency.
[1]

In medicine, the terms "propedeutics"/"propedeutic" specifically refers to preliminary collection of data about patient by observation, palpation, temperature measurement, etc., without specialized diagnostic procedures. The 1851 Encyclopaedia Americana writes that it is:
[2]

"...a term used by the Germans to indicate the knowledge which is necessary or useful for understanding or practising an art or science, or which unfolds its nature and extent, and the method of learning it. It is applied, therefore, not only to special introductions to particular branches of study, but also to auxiliary sciences, logic, philology, etc., and the encyclopaedic views of particular branches of science which facilitate an insight into the relations of the parts. Such a survey can he presented only by one who has studied a science in all its ramifications. The term propaedeutics is often, of course, merely relative : thus philology belongs to the propaedeutics of history, while it is itself the main study of a certain class of scholars. The term, however, in its common use, is generally restricted to the body of knowledge, and of rules necessary for the study of some particular science rules which originate in the application of the general laws of science or art to a particular department. Thus we find in the catalogues of lectures to be delivered in German universities medical propaedeutics, &c., enumerated." [edit]See

also

Physical Exam
After obtaining a history, the physician proceeds to perform a physical examination. Depending upon the patient's condition and suspected medical problem, a physician may include one or more of the following four phases of the physical examination: Inspection Palpation or "hands-on" examination Percussion or "tapping" examination Auscultation or use of stethoscope

Inspection: During this portion of the examination, the physician inspects or looks at different parts of the patient's body. For example, while inspecting the eyes, the physician could obtain a clue about an overactive thyroid that could be responsible for the patient's rapid heart beat. A characteristic growth on the eyelids could point to a high cholesterol level that is a risk factor for coronary artery disease. Inspection of the neck veins and its prominence could be indicative of heart failure and an excessive load on the right side of the heart. A bluish discoloration of the tongue and nail beds could point to a low oxygen level in the blood, while pallor or a pale appearance could indicate a low level of hemoglobin. Additionally, inspection of the chest may provide information about enlargement of the heart. Thus, a physician obtains an enormous amount of information even before touching the patient.

Palpation or "hands-on examination": During palpation, the physician uses his or hands to examine the patient. During this phase, the physician can feel the heart beat and diagnose enlargement. Loud heart murmurs may also be felt without the use of a stethoscope. This is known as a "thrill." Palpation of the belly could help diagnose liver enlargement, find the tenderness of an active ulcer, or help uncover an aneurysm. The patient's pulses are also felt to help determine if there is disease of the blood vessel accounting for calf pain when the patient walks. Pressing the legs and feet with the fingertip can diagnose the presence of edema or excess fluid.

Percussion or Tapping: During percussion, the examiner places one hand on the patient and then taps a finger on that hand, with the index finger of the other hand. Since hollow and solid areas generate different vibrations, the physician

or other examiner uses this technique to determine if various organs (heart, liver, etc.) are enlarged or not. Percussion is also used to diagnose fluid in the abdominal and chest cavities or make one suspect the presence of pneumonia.

Auscultation or listening with a stethoscope: During auscultation, the physician listens to the patient's heart beat, lungs and blood vessels of the neck and groin. Abnormal heart sounds, known as gallops, are a clue to heart disease. Also, the location, character and timing of a heart murmur (this is a prolonged sound that is created by turbulent blood flow across heart valves) are used to diagnose various valve diseases. However, it should be recognized that murmurs may also be heard in many normal individuals. Certain characteristics of the murmur and other portions of the examination help the physician diagnose specific forms of heart diseases. Similarly, blockages in the arteries of the neck and those that supply the legs may also produce a turbulent flow. This can be heard with a stethoscope and is known as a "bruit" (pronounced broo-ee). Listening to the lungs, when integrated with the history and other portions of the physical examination, can diagnose such conditions as heart failure, accumulation of fluid, asthma, bronchitis, pneumonia, collapsed lungs, etc.

Physical examination or clinical examination is the process by which a doctor investigates the body of a patient for signs of disease. It generally follows the taking of themedical history an account of the symptoms as experienced by the patient. Together with the medical history, the physical examination aids in determining the correct diagnosis and devising the treatment plan. This data then becomes part of the medical record.
Contents
[hide]

1 Uses of physical examinations 2 Format and interpretation

3 Evidence-based medicine 4 Vital signs 5 Basic biometrics

o o o

5.1 Height 5.2 Weight 5.3 Pain

6 Structure of the written examination record

6.1 Organ systems

7 See also 8 References 9 External links

[edit]Uses

of physical examinations

A physical examination may be provided under health insurance cover, required of new insurance customers, or stipulated as a condition of employment. In the United States, physicals are also marketed to patients as a one-stop health review, avoiding the inconvenience of attending multiple appointments with different healthcare providers.
[1][2]

Comprehensive physical exams of this type are

also known as executive physicals, and typically include laboratory tests, chest x-rays, pulmonary function testing, audiograms, full body CAT scanning,EKGs, heart stress tests, vascular age tests, urinalysis, and mammograms or prostate exams depending on gender.
[3] [4]

The executive physical

format was developed from the 1970s by the Mayo Clinic and is now offered by other health providers, including Johns Hopkins University, EliteHealth and Mount Sinai in New York City. While elective physical exams have become more elaborate, in routine use physical exams have become less complete. This has led to editorials in medical journals about the importance of an adequate physical examination. [edit]Format
[5][6]

and interpretation

Auscultation of a man in Vietnam

Although providers have varying approaches as to the sequence of body parts, a systematic examination generally starts at the head and finishes at the extremities. After the main organ systems have been investigated by inspection, palpation, percussion and auscultation, specific tests may follow (such as a neurological investigation, orthopedic examination) or specific tests when a particular disease is suspected (e.g. eliciting Trousseau's sign in hypocalcemia). With the clues obtained during the history and physical examination the healthcare provider can now formulate a differential diagnosis, a list of potential causes of the symptoms. Specific diagnostic tests (or occasionally empirical therapy) generally confirm the cause, or shed light on other, previously overlooked, causes. While the format of examination as listed below is largely as taught and expected of students, a specialist will focus on their particular field and the nature of the problem described by the patient. Hence a cardiologist will not in routine practice undertake neurological parts of the examination other than noting that the patient is able to use all four limbs on entering the consultation room and during the consultation become aware of their hearing, eyesight and speech. Likewise an Orthopaedic surgeon will examine the affected joint, but may only briefly check the heart sounds and chest to ensure that there is not likely to be any contraindication to surgery raised by the anaesthetist. Nonspecialists generally examine the genitals only upon request of the patient. A complete physical examination includes evaluation of general patient appearance and specific organ systems. It is recorded in the medical record in a standard layout which facilitates others later reading the notes. In practice the vital signs of temperature examination, pulse andblood pressure are usually measured first. [edit]Evidence-based

medicine

Most elements of the physical examination have not been subjected to clinical trials to test their usefulness in identifying signs of disease. A 2003 study of 100 patients in hospital found that 26% had signs identifiable on physical examination that led to important changes in clinical management. Of these 26, only 14 (54%) had conditions that could have been detected by laboratory testing or imaging.
[7]

[edit]Vital

signs

Main article: Vital signs The primary vital signs are: Temperature recording Blood pressure Pulse Respiratory rate

Pain level assessment

[edit]Basic

biometrics

[edit]Height Height is the anthropometric longitudinal growth of an individual. A statiometer is the device used to measure height although often a height stick is more frequently used for vertical measurement of adults or children older than 2. The patient is asked to stand barefoot. Height declines during the day because of compression of the intervertebral discs. Children under age 2 are measured lying horizontally. [edit]Weight Weight is the anthropometric mass of an individual. A scale is used to measure weight. Medical professionals generally prefer to use the SI unit of kilograms, and many medical facilities have ready-reckoner conversion charts available for professionals to use, when patients describe their weight in non-SI units. (In the US, pounds and ounces are common, while in the UK stones and pounds are frequently used; in most other countries the metric system predominates.) Body mass index (BMI) or height-weight tables, may be used to compare the relationship between height and weight, and may suggest conditions such as obesity or being overweight or underweight. [edit]Pain Because of the importance of pain to the overall wellness of the patient, subjective measurement is considered by some to be a vital sign. However, some doctors have noted that pain is actually a subjective symptom, not an objective sign, and therefore object to this classification.
[8]

Clinically pain is measured using a FACES scale which is a series of faces from '0' (no pain at all showing a normal happy face) to '5' (the worst pain ever experienced by the patient). There is also an analog scale from '0' to maximum '10'. It is important to allow patients to make their own choices on a pain scale. [edit]Structure [edit]Organ

of the written examination record

systems

Cardiovascular system Blood pressure, pulse rate and rhythm. Jugular venous pressure (JVP), peripheral oedema and evidence for ** **Precordial exam (cardiac exam)

Respiratory system Lungs 4 parts: observation, auscultation, palpation, percussion

Observation involves observing the respiratory rate which should be in a ratio of 1:2 inspiration:expiration. It is best to count the respiratory rate under pretext of some other exam, so that patient does not sub consciously increase his baseline respiratory rate. An acidotic patient will have more rapid breathing to compensate known as Kussmaul breathing. Another type of breathing isCheyne-Stokes respiration, which is alternating breathing in high frequency and low frequency from brain stem injury. It can be seen in newborn babies which is sometimes physiological (normal). Also observe for retractions seen in asthmatics. Retractions can be supra-sternal, where the accessory muscles of respirations of the neck are contracting to aid inspiration. Retractions can also be intercostal, there is visible contraction of the inter costal muscles(between the ribs) to aid in respiration. This is a sign of repiratory distress. Observe for barrel-chest (increased AP diameter) seen in COPD. Observe for shifted trachea or one sided chest expansion, which can hint pneumothorax.

Lung auscultation is listening to the lungs bilaterally at the anterior chest and posterior chest. Wheezing is described as a musical sound on expiration or inspiration. It is the result of narrowed airways. Rhonchi are bubbly sounds similar to blowing bubbles through a straw into a sundae. They are heard on expiration and inspiration. It is the result of viscous fluid in the airways. Crackles or rales are similar to rhonchi except they are only heard during inspiration. It is the result of alveoli popping open from increased air pressure.

For palpation, place both palms or medial aspects of hands on the posterior lung field. Ask the patient to count 1-10. The point of this part is to feel for vibrations and compare between the right/left lung field. If the pt has a consolidation (maybe caused by pneumonia), the vibration will be louder at that part of the lung. This is because sound travels faster through denser material than air.

On percussion, you are testing mainly for pleural effusion or pneumothorax. The sound will be more tympanic if there is a pneumothorax because air will stretch the pleural membranes like a drum. If there is fluid between the pleural membranes, the percussion will be dampened and sound muffled.

If there is pneumonia, palpation may reveal increased vibration and dullness on percussion. If there is pleural effusion, palpation should reveal decreased vibration and there will be 'stony dullness' on percussion.

Metelko , Harambai H. i sur. Internistika propedeutika i osnove fizikalne dijagnostike, Medicinska naklada, Zagreb, 1999.

Internal Propaedeutic Workbook

esk verze

Case History - Admitting Examination Symptoms of Internal Diseases Physical Examination Collection of Sound and ECG Records Literature ABC Index

Doc. MUDr. Jitka Zelenkov, CSc. MUDr. ing. Jan Vejvalka as. MUDr. Dagmar Hol MUDr. Jitka Segethov Zuzana Pavelkov MUDr. Helena Meleznkov (English translation) Charles University, 2nd Faculty of Medicine Internal Medicine Clinic of the 2nd Faculty of Medicine and Teaching Hospital Motol Department of Applied Informatics

The sections and chapters present the framework of the multimedia teaching aid for internal propaedeutic. The chapters are organised in several relevant sections providing: Practical instructions for processing of anamnestic data of the internal patient. List of symptoms of important common internal diseases. Instruction how to evaluate basic physical examination findings grouped by body system, and supplemented with selected picture or sound documentation.

The intension of the teaching aid presented here is not to replace the classical internal propaedeutic textbook. The objective was to make the orientation in this area of medicine easier for students. It is based on the knowledge of classical examination procedures applied to individual body systems. It provides systematically organized overview of pathological findings with the data on their most common causes. The text skeleton of the workbook, divided into 18 thematic sections, is supplemented with our own or borrowed pictorial and sound documentation. An independent part of the presentation is sound record collection of heart murmurs and respiratory sounds, available from the existing presentations on the Internet.

This form of processing (WWW presentation on the Internet) allows for ongoing supplementation, extension, and updating of both propaedeutic data and particularly the picture and sound documentation. One of the objectives of the whole project is, of course, further extension of the illustration material. Its value consists of a clearly organised presentation of picture and sound material, which is usually rather scarce in classical textbooks. We would like to ask you for your comments, observations and proposed supplementations either using the WWW forms, which are refered at the end of each chapter, or via e-mail address intprop@lfmotol.cuni.cz. The Authors The basis for the presentation was formed in 1999 with the support of the Grant No.1299/99 and No.1756/2001 of the Higher Education Development Fund.