2. GENERAL PRINCIPLES OF PHYSICAL
EXAMINATION
1. Quite, warm and well lit room.
2. Privacy
3. Reassure and relax the patient
4. Gentleness
5. Avoid exhausting the patient
6. Always plan the examination relevant to
the patient
7. Further questioning if abnormal finding
2nd year MBBS 2Family medicine
3. VITAL SIGNS
PULSE
BLOOD PRESSURE
TEMPERATURE
RESPIRATORY RATE
2nd year MBBS 3Family medicine
4. PULSE
The arterial palpation of a heartbeat
can be palpated in any place that allows for
an artery to be compressed against a bone
Main peripheral arterial pulses:
Radial
Brachial
Carotid
Femoral
Popliteal
Posterior tibial
Dorsalis pedis
2nd year MBBS 4Family medicine
5. Examination of pulses
• radial pulse used generallyRate
• radial pulse used generallyRhythm
• The carotid arteryCharacter
• The carotid arteryVolume
• Compare arteries both sideSymmetry
• Compare radial and femoral pulseRadio femoral delay
Condition of vessels2nd year MBBS 5Family medicine
6. Pulse: Rate
Beats per minute
Physiological variation:
childhood
Emotion
Sleep
Athlete
Adult 60-100 bpm
Neonate 120-160 bpm
Upto 3 yrs 100-120 bpm
At 6 yrs 80-100 bpm
2nd year MBS 6Family medicine
7. Pulse: Rhythm
• Count for at least
half a minuteRegular
• Regularly irregular
• Irregularly irregularIrregular
2nd year MBBS 7Family medicine
8. Carotid pulse
•Be careful
•Always one at a time
Stimulating its
baroreceptors
with low
palpitation
Severe
bradycardia
even
stop
the
heart
2nd year MBBS 8Family medicine
9. Blood pressure
The pressure exerted by circulating blood on the walls
of blood vessels
Affected by exertion, anxiety, excitement and changes
in body posture, cuff size
The first number is the systolic blood pressure
reading, and it represents the maximum pressure
exerted when the heart contracts
The second number is the diastolic blood pressure
reading, and it represents the pressure in the arteries
when the heart is at rest.
2nd year MBBS 9Family medicine
10. Cuff size guidelinesa device used for
measuring
arterial pressure.
Mercury,
aneroid, electric
Cuff Arm Circumference
Range at Midpoint
(cm)
Adult 27-34 cm
Large
Adult
35-44 cm
Adult
thigh
Cuff
45-52 cm
Sphygmomanometer
2nd year MBBS 10Family medicine
11. Measurement
• Palpatory
method
• Can measure
only systolic
pressure
• Auscultatory
method
• 1st sound-
systolic
• Dissapearance-
diastolic
2nd year MBBS 11Family medicine
12. Classification of Blood Pressure for
adults aged 18 and older
Category Systolic pressure
(mm Hg)
Diastolic pressure
(mm Hg)
Normal <120 <80
Prehypertension 120-139 80-89
Hypertention
Stage 1 140-159 90-99
Stage 2 >160 >100
Family medicine2nd year MBBS 12
14. Body temperature
Normal value
Oral 36.30C~37.20C
Rectal 36.50C~37.70C
Axillary 360C~370C
The normal body temperature varies from person to
person, by age, and throughout day
Being lowest in the early hours of the morning and
highest in the afternoon
The variation may range within 10C
Rectal T >Oral T> Axillary T (each in 0.50C)
2nd year MBBS 14Family medicine
15. Respiratory rate
It is expansion and relaxation of of chest wall
Normal value is : 16 – 22 bpm (Adult)
Rate
Depth
Type
2nd year MBBS 15Family medicine
16. CARDINAL SIGNS :
1. Pallor
2. Icterus
3. Cyanosis
4. Clubbing
5. Lymphadenopathy
6. Oedema
7. Dehydration
2nd year MBBS Family medicine 16
17. Pallor
Paleness may be the result of decreased blood supply to the
skin (cold, fainting, shock, hypoglycemia) or decreased
number of red blood cells (anemia)
Depends upon
Thickness of skin
Quality of skin
Amount and quality of blood in capillaries.
2nd year MBBS Family medicine 17
18. Sites where pallor is seen
1. Lower palpebral conjuntiva
2. Dorsum of tongue
3. Mucous membrane of mouth
4. Nail bed
5. Palm of the hand
6. Sole of the feet
(must be compared with both side and must
be observed in daylight)
2nd year MBBS Family medicine 18
19. E.g :
Hookworm infestation
Chronic bleeding Hemorrhoids
Chronic reanal failure
Massive Haemorrhage
Aplastic Anemia
Acute Leukemia
2nd year MBBS Family medicine 19
20. Icterus (jaundice)
It is a clinical condition characterised by yellowish
discoloration of skin , sclera , mucous membranes
due to excessive bilirubin concentration in the body
fluids.
Normal level- o.3-1 mg/dl
Latent jaundice- below 3 mg/dl
Clinical jaundice- more than 3 mg/dl
20
21. Carotenaemia :
Clinical condition with yellow pigmentation of skin
associated with increased blood carotene levels,
associated with large carotene consumption of
carotene in diet, confused with jaundice.
21
22. Sites
Upper sclera
Ventral surface of tongue (between lingual vein and
frenulum)
Nail bed
Palm of the hand
Sole of feet
22
23. Types
1. Pre –hepatic or haemolytic : E.g
Hemolytic anemia, Malaria
2. Hepatocellular : E.g Cirrhosis of liver,
Hepatitis
3. Post hepatic or obstructive : E.g
Carcinoma of head of Pancreas, Gallstone, Ca
Gallbladder
23
24. Cyanosis
It is a bluish discoloration of the skin and mucous
membranes due to the presence of reduced
haemoglobin level > 5 gmdl in the blood.
24
25. Types of cyanosis
Central Peripheral
Imperfect
oxygenation of the
blood e.g Heart
failure , COAD
Admixture of venous
with arterial blood
e.g Congenital heart
diseases
Excessive reduction
of oxyhaemoglobin in
the capillaries when
the blood flow is
slowed
Vasoconstriction-
exposure to cold
Arterial
obstruction
Low cardiac output
25
26. Sites :
Tip of tongue (central cyanosis)
Lips
Tips fingers and toes
Tip and alae of nose
Earlobules
26
Central
+Peripheral
cyanosis
29. Oedema
Abnormal and excessive accumulation of
free fluid within the interstitial space or
body cavities.
Types
Pitting or non pitting
Localised and generalised (anasarca)
29
30. Sites
Relatively mobile patient – over distal end
of tibia or shin of tibia
In bedridden patient- over sacrum
Periorbital, Malar prominence of face
30
31. How edema can be recognized?
Inspection:
Pallid and glossy
appearance of the
skin at the
swollen part
Palpation:
Doughy feeling
Pitting on
finger.(the
pressure of the
finger should be
maintained for 30
seconds.
31
32. Causes of Oedema
Pitting
• Heart failure
• Nephrotic syndrome
• Cirrhosis of liver
• Severe Malnutrition
• Severe Anaemia
• Hypo proteinemia
Non-pitting
• Lymphatic obstruction
• Deep vein thrombosis
• Myxoedema
• Scleroderma
32
33. Dehydration
Loss of excessive water from the body.
How to elicit?
a. Skin pinch test Skin turgor
b. Tongue dryness
c. Lips crackled
d. Dry Mucous membrane (tongue)
e. Tears
33
34. Symptoms Signs
a. Increased thirst
b. Dry mouth
c. Decreased urine
output
d. Headache
e. Dry skin
f. Dizziness
g. Few or no tears
h. Lethargy, confusion
34
a. Low blood pressure
b. Rapid heart rate
c. Fever
d. Seizure
e. Poor skin elasticity
f. Shock
g. Coma
40. Inguinal group of Lymphnode
E.g
Infection : Tuberculosis
Carcinoma :
i. Hodgkin’s lymphoma
ii. Non Hodgkin’s lymphoma
iii. Carcinoma of stomach
iv. Carcinoma of breast
40
44. Points to be noted
Site
Number of nodes
Size
Consistency- hard, firm, rubbery, soft
Tenderness
Discrete or confluent
Mobile or fixed
Condition of overlying skin (local temp, discharging
sinuses)
44
47. 2. Localized :
• Local or acute infection
• Metastasis from carcinoma or other
solid tumour
• Lymphoma especially Hodgkin’s disease
48. CLUBBING
It is bulous swelling of subungal
connective tissue at onychodermal
angle
It is loss of onychodermal angle
(Lovi’s Bond), Normally < 160
Increase in the soft tissue of the base
of the nail
Drumstick appearance of the tip of
the finger
HOW TO ELICIT?
i. Fluctuation test
ii. Schamroth’s sign (Diamond shape)