OLFU College of Medicine Class 2015

Medicine

Lecture 2: Physical Examination

Dr. Cortez

June 25, 2012

General Survey

description of patients appearance

Observation of the patient begins with the first moments

of your interaction
I. Apparent State of Health

Acute or chronically ill, frail, fit or robust

II. Loss of Consciousness

Reflect patients capacity for arousal or wakefulness

Determined by the level of activity that the patient can be

aroused to perform in response to escalating stimuli from
the examiner
A.

Alertness
o Awake, opens eyes, looks at you
o Responds fully and appropriately to stimuli and
command
o Arousal intact
o Speak to the patient in a normal tone of voice

B.

Lethargy
o Appears drowsy but opens eyes and looks at you
o Responds to questions, follows command
o Falls asleep
o Speak to the patient in a loud voice

C.

Obtundation
o Opens eyes, looks at you
o Responds slowly
o Somewhat confused
o Decreased alertness and interest in the
environment
o Shake the patient as if awakening a sleeper

D.

Stuporous
o Arouses from sleep only after a painful stimuli
o Verbal responses are slow or even absent
o Patient lapses into an unresponsive state when
the stimulus ceases
o Minimal awareness of self or environment
o Apply a painful stimulus: rub your knuckles
over sternum, pinch a tendon, push the nail
cuticle
o Patients response: moan, grimace, remove the
examiners hand away

E.

Comatose/Unconscious
o Asleep
o Remains unarousable with eyes closed
o No evident response to any stimuli
o Apply repeated painful stimuli

III. Dress, Grooming and Personal Hygiene

How is the patient dressed?

Is clothing appropriate to the temperature and weather?

Is the clothing clean, properly buttoned or zipped?

Glance at the patients shoes or footwear?

Is the patient wearing unusual jewelries/tribal customs?

Note for the patients hair, fingernails, use of cosmetics.

IV. Facial Expression

Observe facial expression at rest, during interview and

physical exam

Natural, sustained, unblinking, averted quickly, absent

Ut In Omnibus Glorificetur Deus

V. Posture, Gait, Motor Activity

What is the patients preferred posture?

Is patient restless or quiet?

Is there apparent involuntary motor act?

Are body parts immobile?

Does the patient walk smoothly?

Is patient ambulatory?

Is there any problem with ambulation?

Ex.
fast frequent movements hyperthyroidism
Slowed movements hypothyroidism
Leaning forward with arms braced COPD
Sitting up heart failure, pericardial effusion
A. Gait Abnormalities
1. Scissors Gait
o Spinal cord disease with lower extremity spasticity
o Gait is stiff
o Patient advances his legs slowly and thigh tend
o Hypertonia in the legs, hips and pelvis areas
become flexed appearance of crouching
o tight adductors extreme adduction, presented
by knees and thighs hitting, or sometimes even
crossing, in a scissors-like movement
o opposing muscles, the abductors, become
comparatively weak from lack of use
2. Parkinsonian Gait
o Basal ganglia disease
o Posture is stooped with flexion of head, arms, hips
and knees
o Slow in getting started
o Steps are short in shuffling with involuntary
hastening (festination)
o Arm swings
3. Steppage Gait
o Seen in foot drop
o Usually secondary to peripheral motor disease
o Drag the foot or lift them high with knees flexed
and bring down with a slap onto the floor,
appearing as if walking up the stairs
o Tibialis anterior and toe extensors are weak
4. Cerebellar Ataxia
o Staggering, unsteady and wide-based gait
o Exaggerated difficulty at turns
o Cannot stand steadily with feet together
o Positive Romberg test
B. Abnormal Postures
1. Decorticate Rigidity
o Abnormal flexor response
o Upper arms are flexed right to the sides with
elbows, wrists and fingers flexed
o Legs are extended and internally rotated
o Feet are plantar flexed
2. Decerebrate Rigidity
o Abnormal extensor response
o Jaws are clenched and neck extended
o Arms are adducted and stiffly extended at the
elbows, with forearms pronated, wrist and fingers
flexed
o Legs are stiffly extended at the knees, with the feet
plantar flexed
C. Tremors and Involuntary Movement
involuntary, rhythmic, alternating, or oscillatory
movements of interrelated muscle groups
typically involve the hands, head, facial structures, vocal
cords, trunk, or legs
can be characterized by:
o Frequency of oscillation (rapid or slow)
o Amplitude of movement (fine or coarse)
o Movements or postures that evoke them (eg, rest,
action, certain positions)

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1. Resting Tremors (Static)
o maximal at rest and decrease with activity; they
occur at a frequency of 3 to 6 cycles/sec (Hz).
2. Postural Tremor (Action Tremor)
o maximal when a limb is maintained in a fixed
position against gravity (eg, holding the arms
out); they occur at a frequency of 5 to 18 Hz
Appears when the affected part is actively
maintaining a posture
o May worsen somewhat with posturehas three
subtypes: essential, familial, senile
o tremors of posture or activity
o disappears with rest
o usually asymmetrical
o head is commonly involved
o legs are rarely affected
o lower amplitude than parkinsonism
o no rigidity or bradykinesia
o may be relieved temporarily by alcohol intake
3. Intention Tremor
o Absent at rest
o Appear with activity
o maximal during movement toward a target, as in
finger-to-nose testing; they occur at a frequency
of 3 to 10 Hz.
4. Oral-Facial Dyskinesia
o Rhythmic repetitive bizaare movements that
involve the face, mouth, jaw, tongue
o can manifest as oral-buccal-lingual dyskinesia
o Grimacing, pursing lips, protrusion of tongue,
opening and closing of mouth, deviations of jaw
o Trunks and limbs are less often affeccted
o usually due to prolonged intake of neuroleptics
(phenothiazines)
5. Tics
o Brief repetitive, stereotyped coordinated muscle
contractions that are often suppressible
o Can be simple and involve a single muscle or
complex and affect a range of motor activities
6. Athetosis
o Slower and writhing movements, resembling the
action like a snake
o Distal parts of the limb are more active than
proximal
o Grimaces are more deliberate than in chorea
o Grotesque athetoid is produced by flexion of
some digits with others extended
o Disappear with sleep
o Frequently associated with diseases of the basal
ganglia and levodopa therapy for Parkinson
disease
7. Dystonia
o Abnormally prolonged tonic contractions of a
muscle or muscle group
o Often associated with certain activities and can
become disabling
8. Chorea
o Rapid, purposeless, jerky, asynchronous
movements involve various parts of the body
o Although some are spontaneous, many are
initiated and all are accentuated by voluntary
acts, as in extending the arms or walking
o Commonly occur in both Sydenham and
Huntingtons chorea
o Coarser and more bizarre movements in
Huntingtons chorea
o Disappear with sleep
VI. Speech

Evaluates patients communication skills, both receptive

and expressive

Voice quality volume, quality, pitch

Articulation evaluate spontaneous speech for

pronounciation and ease of expression

Quantity talkative/silent

Rate fast/slow

Loudness - loud/soft

Ut In Omnibus Glorificetur Deus

Fluency fluent/nonfluent

A. Abnormalities of Speech
1. Aphonia
o Loss of voice
o Due to disease affecting the larynx and nerve supply
2. Dysphonia
o Less severe impairment in volume, quality or pitch of
voice
o May be hoarse or only speak in whisper
o Due to laryngitis, laryngeal tumors, vocal cord
paralysis (CN X)
3. Dysarthria
o Defect in muscular control of speech apparatus (lips,
tongue, palate, pharynx)
o Words may be nasal, slurred, indistinct
o Central, symbolic aspect
4. Aphasia
o Disorder in producing or understanding language
o Due to lesions
a. Brocas aphasia (Expressive Aphasia)
Word comprehension fair to good
Impaired speech flow, nonfluent
Telegraphic speech, omission of keywords,
laborious effort
Inflection and articulation are impaired, but
words are meaningful
Reading comprehension is intact
Writing is impaired
Lesion in inferior frontal lobe
b. Wernickes aphasia (Receptive Aphasia)
Can hear words but cannot relate them to
previous experiences
Fluent speech, often rapid and effortless
Comprehension is impaired for spoken and
written language, for single words as well as
sentences
Language output is fluent but is highly
paraphasic and circumlocutious
c. Global aphasia
Speech output is nonfluent
Comprehension of spoken language is severely
impaired
Naming, repetition, reading and writing also are
impaired
Combined dysfunction of Brocas and Wernickes
area
VII. Moods

Assess during interview

Sadness, deep melancholy, contentment, joy, euphoria,

elation, anger, rage, anxiety
VIII. Development

Body build

Short or tall

Slender or lanky

Muscular or stocky

Is body symmetrical?

Note general body proportions and look for any

deformities
IX. Nutritional Status

Thin, overweight, obese

BMI
o Underweight <18.5
o Normal 18.5-24.9
o Overweight 25-29.9
o Obese I 30-34.9
o Obese II 35-39.9
o Obese III >40
X. Febrile/Afebrile

Determine if patient has fever or not

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XI. General Appearance

Generalized jaundice

Pallor

Edema

Skin lesions
XII. Signs of Distress

Cardiac Distress
o High/low BP
o Tachycardia/bradycardia
o Arrhythmia
o pallor

Respiratory Distress
o bradypnea/tachypnea
o apnea
o hyperpnea
o cyanosis
o signs of use of accessory muscle or respiration
o retraction of intercostal muscles, suprasternal,
supraclavicular, subcostal
A. Abnormalities in Breathing
1. Bradypnea
slow breathing <16/minute
causes: diabetic coma, respiratory muscle
fatigue, drug-induced, increased ICP
2. Tachypnea
rapid breathing >20/minute
causes: anxiety, often exertion, metabolic
acidosis, cardiovascular disease, hypoxia,
hyperventilation
3. Kussmauls breathing
air hunger
hyperpnea and tachypnea
rapid, deep breathing
cause: metabolic acidosis
4. Sighing Respiration
breathing punctuated by frequent sighs
due to a hyperventilation syndrome
5. Obstructive
prolonged expiration
narrow airways increase resistance to
airflow
causes: asthma, COPD
6. Cheyne-Stokes breathing
periods of deep and fast breathing
then became shallow and slow
repetitive pattern of breathing
crescendo/decrescendo sequence of respiration
with interval of apnea
7. Biots Breathing
unpredictable irregularities
breathing maybe shallow or deep then stop
periods of apnea
The patient is obtunded, well-kept, sad, uncooperative, ambulatory
with minimal slow soft speech, asthenic, afebrile, not in cardiorespiratory distress.

Ut In Omnibus Glorificetur Deus

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