Lecture 1 by Dr. Mohammed Hussien for clinical pharmacy ( Kafrelsheikh University)

1. Introduction to Physical
Assessment Skills
Dr/ Mohammed Hussien
Assistant Lecturer of Gastroenterology & Hepatology
Kafrelsheik University
Membership at American Collage of Gastroenterology (ACG)
Membership at Egyptian association for Research and training in
Hepatogastroentrology
2018

2. Information obtained from the obtained during a patient medication
history & examination & laboratory data are used to assess patient
response to drug and nondrug therapy.
At least must know common physical assessment and understand the meaning
of specific physical assessment findings documented by other health care
professionals.
Although the need for hands-on in specific physical assessment
skills varies according to the type of patient care setting, all
pharmacists need a basic understanding of these skills.
Data
physical
laboratory

3. Pharmacists in some clinical settings (e.g., ambulatory care clinics)
 Routinely assess patient response to medication regimens themselves using a variety of physical assessment skills.
 Confirm more direct patient care responsibilities.
This course introduces the pharmacist to the techniques, assessments, and terminology associated with the
physical examination.
(e.g., vital sign measurement, cardiovascular assessment, pulmonary assessment).

4. The Process
It is important to respect the patient’s privacy and
minimize patient discomfort and embarrassment
throughout the examination.
The physical examination, usually conducted from the patient’s right side.
A thorough and detailed examination of all organ systems is required for a severely ill patient with
multiple complaints; subsequent examinations may target specific organ systems.
Usual Physical Assessment Sequence
10. Breast
11. Chest and lungs
12. Heart
13. Abdomen
14. Extremities
15. Back and spine
16. Nervous system
17. Mental status
18. Genitalia and rectum
1. Vital sign
2. Appearance and behavior
3. Skin
4. Head
5. Eyes
6. Ears
7. Nose
8. Mouth
9. Neck

5. Inspection, Palpation, Percussion, and Auscultation Techniques
The physical examination consists of a detailed patient evaluation using the four fundamental techniques of
(although not every organ system is evaluated using all four techniques).
Inspection denotes visual surveillance. Observe the patient’s breathing, clothing, body position (e.g., sitting
comfortably, shifting uncomfortably in pain, leaning forward with chin propped up on hands), affect (mood), and
appropriateness of the patient’s affect to the situation. Inspect the skin for color and the presence of lesions, visible
trauma, or other abnormalities.

6. Palpation consists of using the hands to feel areas that cannot be seen; palpation can be performed with the fingertips, palm,
or back of the hand. Palpation may be superficial (light touch) or deep. Use the back of the hand to assess skin temperature,
superficial palpation with the fingertips to assess the point of maximal impulse, and deep palpation with the fingertips to feel
the lower edge of the liver and the spleen tip.
Palpation:
A, Light palpation; press in 1 cm or less. B, Deep palpation; press in deeply. C, Palpation for temperature; lightly touch the
patient with the back of the hands

7. Percussion is a technique to assess the density of underlying structures. A percussion note is created by either tapping
the patient’s body directly with the distal end of a finger (direct percussion) or by tapping the examiner’s finger (indirect
percussion). For indirect percussion, place the hand flat on the surface of the patient’s body. Raise up the hand and
fingers so that only the finger that is going to be tapped touches the patient. Then tap the middle phalanx between the
distal interphalangeal joint and the proximal interphalangeal joint with the ends (not pads) of the fingers. With indirect
percussion, it is important to touch the patient only with the finger that is being tapped; this creates the most clear
percussion note and avoids dampening the vibrations with the palm or rest of the fingers on the hand. The resultant sound
is described as one of four percussion “notes”: resonant, dull, tympanic, and flat. In health, each of these four percussion notes
is elicited over specific areas of the body.
1-A resonant percussion note, described as a hollow sound, is normally elicited over healthy
lung.
2-Percussion over a healthy liver produces a dull percussion note.
3-A tympanic percussion note, described as a drumlike sound, is elicited over the stomach.
4-Percussion over large muscles such as a thigh muscle produces flat percussion notes.

8. Auscultation of listening either directly with the ear or indirectly with the aid of a device (typically a
stethoscope) to sounds that arise spontaneously from the body (e.g., breath sounds, heart sounds, bowel
sounds). The diaphragm of the stethoscope is placed directly on the skin, never over clothing. The diaphragm is
placed so that the entire surface of the diaphragm is held firmly in contact with the skin.

9. Equipment
Several pieces of equipment are required for the physical examination.
Table 2. Physical Assessment Equipment
Equipment Purpose
Flashlight Assess pupillary reflexes; aid in inspection of the oropharynx
and skin
Ophthalmoscope Perform funduscopic examination
Otoscope Assess external ear canal and tympanic membrane
Tongue depressor Inspect oropharynx
Watch Assess heart and respiratory rate
Thermometer Measure body temperature
Stethoscope Assess cardiovascular, pulmonary, and abdominal systems
Sphygmomanometer Measure blood pressure
Reflex hammer Assess neurologic function
Tuning fork Assess neurologic function

10. S tethoscope
The stethoscope, an important auscultatory tool, consists of two earpieces angled at the same angle as the ear
canal, rubber tubing, and a head with either a diaphragm (plastic disc). The diaphragm accentuates high-frequency
sounds. Stethoscopes are available in a variety of styles and price ranges, including electronically amplified
stethoscopes. Quality is important. Higher-quality stethoscopes transmit sounds more efficiently and are more
durable than cheaper models. The earpieces should fit the ear canals comfortably; the goal is for the sound to be
transmitted from the patient to the eardrum through an unbroken system.

11. The sphygmomanometer
includes a cuff (a cloth-covered inflatable rubber bladder), a valved rubber bulb for inflating the cuff,
and a manometer that measures the cuff pressure.
Use an appropriately sized cuff; cuffs that are too short or too narrow falsely elevate the blood pressure,
whereas cuffs that are too big falsely decrease the blood pressure.
There are two types of manometers: the classic wall-mounted mercury-filled glass tube and the aneroid dial.
Mercury-based manometers are durable, are easy to read, and provide consistent, accurate measurements
but are bulky and must be in an upright position and at eye level for accurate measurements.
Mercury is a hazardous substance; many health care professionals prefer to use aneroid manometers, which
do not contain mercury. Aneroid manometers are relatively inexpensive and work in all positions but are
delicate and must be recalibrated if bumped or dropped. There are also a variety of automatic digital
manometers.

12. The ophthalmoscope consists of a head and a handle. The head contains viewing lenses and
beam selection controls. The viewing lens control (lens wheel) is used to focus the instrument.
Positive diopter values (black or green numbers depending on the manufacturer) are used to
correct the focal length for nearsighted eyes; negative diopter values (red numbers) are used to
correct the focal length for farsighted eyes. The beam control wheel is used to select the aperture
(beam); aperture selection depends on the structure being assessed. The light intensity is
adjustable on some ophthalmoscopes.

13. Components of the Ophthalmoscope.
Otoscope
The otoscope consists of a head and a handle. The otoscope is used
to assess the ear canal and tympanic membrane. The head consists
of a speculum and magnifying glass and can be rotated up and down
into several positions. Disposable speculum covers are available in a
variety of sizes to fit most ear canals. Some otoscopes and
ophthalmoscopes are available as interchangeable heads that fit the
same handle.

14. Reflex Hammer
The reflex hammer, also known as a percussion hammer, consists of a rubberlike head attached to a
handle. The reflex hammer primarily is used to elicit superficial and deep tendon reflexes. The Taylor,
or tomahawk-style, reflex hammer has a triangular head. Several other styles are
available. Generally the pointed end of the head of the reflex hammer is used to strike the tendon and
elicit the reflex
Tuning Fork
Tuning forks, typically aluminum, consist of a stem (handle) and two prongs that form a U- shaped
fork. The tuning fork vibrates at a set frequency after being struck on the heel of the hand and is used
to assess vibratory sensation and hearing (air conduction and bone conduction). Hold the tuning fork
by the stem, not the prongs. Tuning forks are available in a wide range of frequencies (64 Hz to 4096
Hz); 128 Hz is a commonly used frequency for screening.

16. Vital Signs
The vital signs include the heart rate, respiratory rate, blood pressure, and temperature. Along with height and weight, the vital
signs provide important screening and diagnostic information as well as monitoring data for assessment of short-term and long-
term response to medication therapy.
Techniques
Arterial Pulse
To assess the arterial pulse, determine the heart rate, the strength of the pulse, and the regularity of the pulse. The radial artery is
commonly used to assess pulse, although any accessible large artery (e.g., femoral, carotid) may be used. The radial artery is
located in the wrist below the thumb and between the flexor carpi radialis and abductor pollicis longus tendons. Gently compress
the artery with the fingertips; do not palpate with the thumb (the pulse in the examiner’s thumb may confuse the assessment of
the patient’s pulse). Determine the number of heartbeats per minute (beats/min, BPM) by counting the number of pulses in 15
seconds and multiplying by 4 (or use any combination that gives the per-minute rate). The strength of the pulse is described as
“normal,” “weak,” or “bounding” (stronger than normal). Determine if the pulse is regular (evenly spaced beats) or irregular
(unequally spaced beats). If irregular, determine if the sequence has a repeating pattern (regularly irregular) or not (irregularly
irregular).

17. Arterial Pulse Checklist
□ Locate the radial pulse.
□ Palpate with the fingers (not thumb).
□ Report/record the per-minute rate. (Example: The heart rate is 80 beats per minute.)
□ Report/record the strength. (Example: The pulse is normal strength.)
□ Report/record the regularity. (Example: The pulse is regular.)
The normal heart rate is approximately 60 to 100 beats/min with normal strength and regular beats. Bradycardia, a
slow heart rate (<60 beats/min), is caused by medications such as beta- adrenergic blocking drugs and digoxin and
by sinus node or atrioventricular (AV) node dysfunction. Tachycardia, a fast heart rate (>100 beats/min), is caused
by anxiety, volume depletion, fever, exercise, and inotropic drugs such as epinephrine and dobutamine. A weak pulse
is caused by conditions associated with decreased cardiac output (e.g., heart disease, hypovolemia). A strong
(bounding) pulse is caused by conditions associated with increased cardiac output (e.g., anxiety, pain,
hyperthyroidism). The heart rate is normally regular, with evenly spaced beats. An irregular heart rate, characterized
by irregularly spaced beats, may be completely irregular (no identifiable pattern) or regularly irregular (repetitive
abnormal pattern). Cardiac dysrhythmias are commonly associated with irregular heartbeats.

18. Respiration
Unobtrusively observe the patient breathe (a patient aware of being watched will control his or her breathing). Determine the
per-minute respiratory rate, the pattern of breathing, and whether the patient is using accessory muscles to breathe. One
technique for observing the patient’s respiration unobtrusively is to position the patient so that the patient’s chest can be
observed while the pulse is assessed. Continue to hold the patient’s wrist and watch the clock after completing the
assessment of the pulse but count the respiratory rate. Note that one breath equals one respiratory cycle (inspiration plus
expiration). Determine the number of breaths per minute (breaths/min, BPM) by counting the number of breaths in 15
seconds and multiplying by 4. Observe whether the pattern of breathing is normal (normal depth of breathing and regular
rate) or abnormal (shallow, deep, shallow then deep, periodic apnea, etc.).

19. Respiration Checklist
□ Unobtrusively observe the patient’s breathing.
□ Report/record the rate. (Example: The respiratory rate is 12 breaths per minute.)
□ Report/record the pattern. (Example: The respiratory pattern is normal.)
The normal respiratory rate is 12 to 20 breaths/min. Tachypnea, a fast respiratory rate (>20
breaths/min), is caused by pain, anxiety, exercise, and respiratory failure. Bradypnea, a slow
respiratory rate (<12 breaths/min), is caused by medications such as narcotics and medical
conditions associated with elevated carbon dioxide levels. The respiratory rate is normally regular,
with evenly spaced inspirations and expirations, and of normal tidal volume (volume per breath).
Abnormal breathing patterns include abnormally fast and deep breathing (associated with
metabolic acidosis), fast and shallow breathing (associated with obstructive airway disease), slow
and shallow breathing (associated with narcotics), apnea (no breathing; associated with sleep
apnea).

20. Blood Pressure
Patients should be at rest for at least 15 minutes before the blood pressure is measured, and if the patient is
sitting, the patient’s feet should be flat on the floor (the blood pressure will be falsely high if the legs
dangle). Select an appropriately sized cuff and palpate for the brachial artery before positioning the cuff on
the arm. Place the arterial portion of the cuff directly over the brachial artery with the bottom of the edge
approximately 2.5 cm above the antecubital
crease. Support the patient’s arm at the level of the heart; tensed muscles falsely elevate the blood pressure
(the blood pressure will be falsely high if the arm is below the level of the heart and falsely low if the arm
is above the level of the heart).

21. Blood Pressure
Patients should be at rest for at least 15 minutes before the blood pressure is
measured, and if the patient is sitting, the patient’s feet should be flat on the floor
(the blood pressure will be falsely high if the legs dangle). Select an
appropriately sized cuff and palpate for the brachial artery before positioning the
cuff on the arm. Place the arterial portion of the cuff directly over the brachial
artery with the bottom of the edge approximately 2.5 cm above the antecubital
crease. Support the patient’s arm at the level of the heart; tensed muscles falsely
elevate the blood pressure (the blood pressure will be falsely high if the arm is
below the level of the heart and falsely low if the arm is above the level of the
heart).

22. Korotkoff sounds (tapping sounds) are created by turbulent flow through the partially occluded artery.
Each heartbeat creates a sound as the bolus of blood encounters the partially occluded artery; the tapping
sound varies with the degree of arterial occlusion. As the pressure falls, the sounds become louder and
then slowly diminish before disappearing altogether. The DBP is the pressure at which the beats are not
longer audible. The tapping sounds may disappear during phase II or III and then reappear as the arterial
pressure falls. This is called an auscultatory gap and is sometimes observed in elderly patients and
hypertensive patients.

23. Normal blood pressure is defined as an SBP of less than 120 mm Hg and a DBP of less than 80 mm Hg.
Patients may have isolated systolic hypertension (SBP ≥140 mm Hg with DBP <90 mm Hg) or isolated diastolic
hypertension (SBP <140 mm Hg with DBP ≥90 mm Hg).
Blood Pressure Classification
Classification∗ Systolic Blood Pressure (mm Hg) Diastolic Blood Pressure (mm Hg)
Normal <120 <80
Prehypertension 120-139 80-89
Stage 1 hypertension 140-159 90-99
Stage 2 hypertension ≥160 ≥100

24. Temperature
Body temperature is used to screen for illness and to monitor patient response to drug
therapy. The measured temperature varies depending on where the body temperature
is measured (oral cavity, rectum tympanic membrane, axilla, ear, bladder) and the
device used to measure the temperature (oral thermometer, temperature-sensitive
crystal, thermal scanner.). Other variables include the time of day. Oral temperature
measurements are influenced by drinking hot and cold beverages and chewing gum.
Digital thermal scanning thermometers are quick and easy to use but rely on
proprietary predictive algorithms and are therefore less accurate than other
technologies. Record the temperature, date and time of day, and route and instrument
used to obtain the temperature.
Normal oral body temperature is 37° C (98.6° F). Fever is generally accepted to be an
oral body temperature of 38° C (100.4° F) or higher. Oral body temperature is 1° lower
than rectal body temperature and axillary temperature is 2° lower than rectal body
temperature.

25. Height and Body Weight
The patient’s height and body weight are not considered vital signs but are useful
screening and monitoring parameters and are components of the body mass index (BMI)
equation:
BMI(metric)=weight in kilograms÷ (height in meters) 2
The waist circumference and waist/hip ratio (WHR) are additional screening and
monitoring parameters (WHR = waist circumference ÷ hip circumference). The waist
circumference is measured at the narrowest part of the waist. The hip circumference is
measured at the widest part of the hips.

26. Classification BMI
Underweight <18.5
Normal weight 18.5-24.9
Overweight 25-29.9
Class I obesity 30-34.9
Class II obesity 35-39.9
Class III obesity ≥40