Mosby's Guide to Physical Examination, 7th Edition

CHAPTER 19. Head-to-Toe Examination

Adult

COMPONENTS OF THE EXAMINATION

There is no one correct way to order the parts of the physical examination. You are encouraged to consider and then to adapt and edit the following suggested approach for the unique needs of the particular patient and the relevant demands of the moment.

GENERAL INSPECTION

Start examination the moment the patient is within your view. As you first observe the patient, for example, in the waiting room, take note of:

Signs of distress or disease

Habitus

Manner of sitting

Degree of facial relaxation

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Relationship with others in room

Degree of interest in what is happening in room

Alacrity with which you are met

Moistness of palm when you shake hands

Eyes—luster and expression of emotion

Skin color

Facial expression

Mobility:

Use of assistive devices

Gait

Sitting, rising from chair

Taking off coat

Dress and posture

Speech pattern, disorders, foreign language

Difficulty hearing, assistive devices

Stature and build

Musculoskeletal deformities

Vision problems, assistive devices

Eye contact with you

Orientation, mental alertness

Nutritional state

Respiratory problems

Significant others accompanying patient

PATIENT INSTRUCTIONS (PLAN EACH STEP SO AS TO MINIMIZE THE PATIENT’S EFFORT AND TO CONSERVE ENERGY)

Empty bladder.

Remove as much clothing as is necessary (always respecting modesty).

Put on a gown.

MEASUREMENTS

Measure weight and calculate the body mass index (BMI).

Measure height.

Assess distance vision—Snellen chart.

Document vital signs—temperature, pulse, respiration, blood pressure in both arms.

PATIENT SEATED, WEARING GOWN

Stand in front of patient seated on examining table.

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Head and face

Inspect skin characteristics.

Inspect symmetry and external characteristics of eyes and ears.

Inspect configuration of skull.

Inspect and palpate scalp and hair for texture, distribution, quantity of hair.

Palpate facial bones.

Palpate temporomandibular joint while patient opens and closes mouth.

Palpate sinus regions; if tender, transilluminate (although often helpful, the sensitivity and specificity of transillumination are uncertain when considered separate from other findings.).

Inspect ability to clench teeth, squeeze eyes tightly shut, wrinkle forehead, smile, stick out tongue, puff out cheeks (CN V, VII).

Test light touch sensation of forehead, cheeks, chin (CN V).

Eyes

External examination:

Inspect eyelids, eyelashes, palpebral folds.

Determine alignment of eyebrows.

Inspect sclerae, conjunctivae, irides.

Palpate lacrimal apparatus.

Near-vision screening—Rosenbaum chart (CN II).

Eye function:

Test pupillary response to light and accommodation.

Perform cover-uncover test and corneal light reflex.

Test extraocular eye movements (CN III, IV, VI).

Assess visual fields (CN II).

Test corneal reflexes (CN V).

Ophthalmoscopic examination:

Test red reflex.

Inspect lens.

Inspect disc, cup margins, vessels, retinal surface.

Ears

Inspect alignment and placement.

Inspect surface characteristics.

Palpate auricle.

Assess hearing with whisper test or ticking watch (CN VIII).

Perform otoscopic examination:

Inspect canals

Inspect tympanic membranes for landmarks, deformities, inflammation.

Perform Rinne and Weber tests.

Nose

Note structure, position of septum.

Determine patency of each nostril.

Inspect mucosa, septum, turbinates with nasal speculum.

Assess olfactory function when indicated: test sense of smell (CN I).

Mouth and pharynx

Inspect lips, buccal mucosa, gums, hard and soft palates, floor of mouth for color and surface characteristics.

Inspect oropharynx: note anteroposterior pillars, uvula, tonsils, posterior pharynx, mouth odor.

Inspect teeth for color, number, surface characteristics.

Inspect tongue for color, characteristics, symmetry, movement (CN XII).

Test gag reflex and “ah” reflex (CN IX, X).

Perform sense of taste test (CN VII, IX) when indicated.

Neck

Inspect for symmetry and smoothness of neck and thyroid.

Inspect for jugular venous distention (also when patient is supine).

Perform active and passive range of motion; test resistance against examiner’s hand.

Test strength of shoulder shrug (CN IX).

Palpate carotid pulses. Be sure to palpate one side at a time (also when patient is supine).

Palpate tracheal position.

Palpate thyroid.

Palpate lymph nodes—preauricular and postauricular, occipital, tonsillar, submental, submandibular, superficial cervical chain, posterior cervical, deep cervical, supraclavicular.

Auscultate carotid arteries and thyroid.

Upper extremities

Observe and palpate hands, arms, shoulders.

Skin and nail characteristics

Muscle mass

Muscular strength

Musculoskeletal deformities

Joint range of motion and muscle strength—fingers, wrists, elbows, shoulders

Assess pulses—radial, brachial

Palpate epitrochlear nodes

PATIENT SEATED, BACK EXPOSED

Stand behind patient seated on examining table.

Have males pull gown down to the waist so entire chest and back are exposed.

Have females expose back; keep breasts covered.

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Back and posterior chest

Inspect skin and thoracic configuration.

Inspect symmetry of shoulders, musculoskeletal development.

Inspect and palpate scapulae and spine and percuss spine.

Palpate and percuss costovertebral angle.

Lungs

Inspect respiration—excursion, depth, rhythm, pattern.

Palpate for expansion and tactile fremitus.

Percuss posterior chest and lateral walls systematically for resonance.

Percuss for diaphragmatic excursion.

Auscultate systematically for breath sounds (egophony, bronchophony, whispered pectoriloquy): Note characteristics and adventitious sounds.

PATIENT SEATED, CHEST EXPOSED

Move around to front of patient.

Have females lower gown to expose anterior chest.

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Anterior chest, lungs, heart

Inspect skin, musculoskeletal development, symmetry.

Inspect respirations—patient posture, respiratory effort.

Inspect for pulsations or heaving.

Palpate chest wall for stability, crepitation, tenderness.

Palpate precordium for thrills, heaves, pulsations.

Palpate left chest to locate apical impulse.

Palpate for tactile fremitus.

Palpate nodes—axillary.

Percuss systematically for resonance.

Auscultate systematically for breath sounds.

Auscultate systematically for heart sounds—aortic area, pulmonic area, second pulmonic area, tricuspid area, mitral area.

Female breasts

Inspect in these positions—patient’s arms hanging loosely at the sides, extended over head or flexed behind the neck, pushing hands on hips, hands pushed together in front of chest, patient leaning forward.

Palpate (firmly but gently) breasts in all four quadrants, tail of Spence, over areolae; if breasts are large, perform bimanual palpation.

Palpate nipple: compress to observe for discharge.

Palpate axillary, supraclaricular lymph nodes.

Male breasts

Inspect breasts and nipples for symmetry, enlargement, surface characteristics.

Palpate breast tissue.

Palpate axillary, supraclavicular lymph nodes.

PATIENT RECLINING 45 DEGREES

Assist patient to a reclining position at a 45-degree angle.

Stand to side of patient that allows greatest comfort.

Inspect chest in recumbent position.

Inspect jugular venous pulsations; measure jugular venous pressure.

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PATIENT SUPINE, CHEST EXPOSED

Assist patient into supine position.

If patient cannot tolerate lying flat, maintain head elevation at 30-degree angle.

Uncover chest while keeping abdomen and lower extremities draped.

Female breasts

Inspect and palpate with patient in recumbent position. Use light, medium, and deep palpation with patient’s arm over her head.

Depress nipple into well behind the areola.

Heart

Palpate chest wall for thrills, heaves, pulsations.

Auscultate systematically; turn patient slightly to left side and repeat auscultation.

PATIENT SUPINE, ABDOMEN EXPOSED

Have patient remain supine.

Cover chest with patient’s gown.

Arrange draping to expose abdomen from pubis to epigastrium.

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Abdomen

Inspect skin characteristics, contour, pulsations, movement.

Auscultate all quadrants for bowel sounds.

Auscultate aorta and renal, iliac, and femoral arteries for bruits or venous hums.

Percuss all quadrants for tone.

Percuss liver borders and estimate span.

Percuss left midaxillary line for splenic dullness.

Lightly palpate all quadrants.

Deeply palpate all quadrants.

Palpate right costal margin for liver border.

Palpate left costal margin for spleen.

Palpate at the flanks for right and left kidneys.

Palpate midline for aortic pulsation.

Test abdominal reflexes.

Have patient raise head as you inspect abdominal muscles.

Inguinal area

Palpate for lymph nodes, pulses, hernias.

External genitalia, males

Inspect penis, urethral meatus, scrotum, pubic hair.

Palpate scrotal contents.

Test cremasteric reflex.

PATIENT SUPINE, LEGS EXPOSED

Have patient remain supine.

Arrange drapes to cover abdomen and pubis and to expose lower extremities.

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Feet and legs

Inspect for skin characteristics, hair distribution, muscle mass, musculoskeletal configuration.

Palpate for temperature, texture, edema, pulses (dorsalis pedis, posterior tibial, popliteal).

Test range of motion and strength of toes, feet, ankles, knees.

Hips

Palpate hips for stability.

Test range of motion and strength of hips.

PATIENT SITTING, LAP DRAPED

Assist patient to a sitting position.

Have patient wear gown with a drape across lap.

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Musculoskeletal

Observe patient moving from lying to sitting position.

Note coordination, use of muscles, ease of movement.

Neurologic

Test sensory function—dull and sharp sensation of forehead, cheeks, chin, lower arms, hands, lower legs, feet.

Test vibratory sensation of wrists, ankles.

Test two-point discrimination of palms, thighs, back.

Test stereognosis, graphesthesia.

Test fine motor function, coordination, and position sense of upper extremities, asking patient to do following:

Touch nose with alternating index fingers.

Rapidly alternate touching fingers to thumb.

Rapidly move index finger between own nose and examiner’s finger.

Test fine motor function, coordination, and position sense of lower extremities, asking patient to do following:

Run heel down tibia of opposite leg.

Alternately and rapidly cross leg over opposite knee.

Test deep tendon reflexes and compare bilaterally—biceps, triceps, brachioradial, patellar, Achilles.

Test plantar reflex bilaterally.

Test position sense of upper and lower extremities.

PATIENT STANDING

Assist patient to standing position.

Stand next to patient.

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Spine

Inspect and palpate spine as patient bends over at waist.

Test range of motion—hyperextension, lateral bending, rotation of upper trunk.

Neurologic

Observe gait.

Test proprioception and cerebellar function:

Perform Romberg test.

Ask patient to walk heel to toe.

Ask patient to stand on one foot, then the other, with eyes closed.

Ask patient to hop in place on one foot, then other.

Abdominal/genital

Test for inguinal and femoral hernias.

FEMALE PATIENT, LITHOTOMY POSITION

Assist female patient into lithotomy position, and drape appropriately.

Examiner is seated

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External genitalia

Inspect pubic hair, labia, clitoris, urethral opening, vaginal opening, perineal and perianal area, anus.

Palpate labia and Bartholin glands; milk Skene glands.

Internal genitalia

Perform speculum examination:

Inspect vagina and cervix.

Collect Pap smear/HPV and other necessary specimens.

Perform bimanual palpation to assess for characteristics of vagina, cervix, uterus, adnexa (examiner standing).

Perform rectovaginal examination to assess rectovaginal septum, broad ligaments.

Perform rectal examination:

Assess anal sphincter tone and surface characteristics; palpate circumferentially for rectal mass.

Obtain rectal culture if needed.

Note characteristics of stool when gloved finger is removed. Test for occult blood.

MALE PATIENT, BENDING FORWARD

Assist male patient in leaning over examining table (or into knee-chest or lateral decubitus position). Stand behind patient.

Inspect sacrococcygeal and perianal areas.

Perform rectal examination:

Palpate sphincter tone and surface characteristics.

Obtain rectal culture if needed.

Palpate prostate gland and seminal vesicles.

Note characteristics of stool when gloved finger is removed. Test for occult blood.

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EXAMINATION CONCLUSION

Allow patient to dress in private.

Share findings and interpretations with patient.

Answer any of patient’s additional questions.

Confirm that patient has a clear understanding of all aspects of the situation.

If patient is examined in a hospital bed:

Put everything back in order when finished.

Make sure patient is comfortably settled in an appropriate manner.

Put bed side rails up if clinical condition warrants it.

Make sure buttons and buzzers are within easy reach.

SPECIAL CONSIDERATIONS FOR THE HANDICAPPED PATIENT

Each disability affects each patient differently. The familiar process of physical examination must be adapted to constraints imposed by the patient’s handicap.

The patient has most often learned the best way to be transferred from a wheelchair or bed to another site or to a different position. Consult patient about it.

Let a hearing-, speech-, or vision-impaired patient guide you to the best communication system for your mutual purposes.

Bowel and bladder concerns are common to many disabled people and should be given the necessary attention during the examination process.