The document outlines the general principles and techniques of physical examination, including vital signs assessment (pulse, blood pressure, temperature, and respiratory rate). It provides detailed information on the significance of various abnormal findings, such as pallor, icterus, cyanosis, clubbing, lymphadenopathy, oedema, and dehydration, including their causes and examination techniques. Additionally, it covers the normal ranges for vital signs and the classifications of blood pressure, emphasizing the importance of thorough and relevant patient assessment.

1. DR. BIJAY KR. YADAV
MBBS (TU)

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
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3. VITAL SIGNS
 PULSE
 BLOOD PRESSURE
 TEMPERATURE
 RESPIRATORY RATE
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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
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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
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7. Pulse: Rhythm
• Count for at least
half a minuteRegular
• Regularly irregular
• Irregularly irregularIrregular
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8. Carotid pulse
•Be careful
•Always one at a time
Stimulating its
baroreceptors
with low
palpitation
Severe
bradycardia
even
stop
the
heart
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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.
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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
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11. Measurement
• Palpatory
method
• Can measure
only systolic
pressure
• Auscultatory
method
• 1st sound-
systolic
• Dissapearance-
diastolic
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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
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13. Temperature
Core
oral
rectal
Surface
axillary
groin
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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)
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15. Respiratory rate
It is expansion and relaxation of of chest wall
Normal value is : 16 – 22 bpm (Adult)
 Rate
 Depth
 Type
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16. CARDINAL SIGNS :
1. Pallor
2. Icterus
3. Cyanosis
4. Clubbing
5. Lymphadenopathy
6. Oedema
7. Dehydration
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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.
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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)
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19. E.g :
 Hookworm infestation
 Chronic bleeding Hemorrhoids
 Chronic reanal failure
 Massive Haemorrhage
 Aplastic Anemia
 Acute Leukemia
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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
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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.
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22. Sites
 Upper sclera
 Ventral surface of tongue (between lingual vein and
frenulum)
 Nail bed
 Palm of the hand
 Sole of feet
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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
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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.
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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
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26. Sites :
Tip of tongue (central cyanosis)
Lips
Tips fingers and toes
Tip and alae of nose
Earlobules
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Central
+Peripheral
cyanosis

27. Differences
Central
cyanosis
Peripheral
cyanosis
mechanism Low SpO2 Poor peripheral
circulation
sites Tip of tongues Other sites
extremities Warm cold
Application of
heat
No effect Cyanosis
disappears
Administration
of O2
Cyanosis
dissappears
No effect
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28. E.g :
 Acute pulmonary edema
 Chronic obstructive pulmonary disease
 Acute severe asthma
 Tetralogy of fallot
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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)
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30. Sites
 Relatively mobile patient – over distal end
of tibia or shin of tibia
 In bedridden patient- over sacrum
 Periorbital, Malar prominence of face
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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.
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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
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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
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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
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a. Low blood pressure
b. Rapid heart rate
c. Fever
d. Seizure
e. Poor skin elasticity
f. Shock
g. Coma

35. E.g :
1. Diarrhoea
2. Vomiting
3. Burn
4. Sun exposure
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36. Lymph Node
 Lymphadenopathy- Enlargement of lymphnode
 Distributed all over the body
 Important part in the body’s defense against infection
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37. Distribution of lymph nodes
Cervical
 Submental
 Submandibullar
 Pre- Post-auricular
 Ant- Post cervical chain
 Occipital
 Supraclavicular
(Virchow’s gland)
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38. Axillary :
 Apical (Sub clavicular)
 Central
 Post (Scapular)
 Lateral
 Anterior (Pectoral)
Epitrochlear (Cubital)
Popliteal
Para aortic (Lumbar)
Inguinal
 Horizontal, vertical
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39. Axillary LN
39

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
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41. 41

42. 2nd year MBBS Family medicine 42

43. 43

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)
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45. Cervical lymphadenopathy

46. Causes of Lymphadenopathy :
1. Generalized :
• Lymphoma
• Leukemia
• Infections
-Viral : Infectious Mononucleosis, CMV, HIV
-Bacterial : Tuberculosis, Syphilis
-Protozoal : Toxoplasmosis
• Connective tissue disease
• Infiltration : Sarcoidosis
• Drugs : Phenytoin

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)

49. 49

50. 50

51. Causes
1) Cardiovascular
-Cyanotic congenital heart disease ,Infective
Endocarditis
2) Respiratory
- Lung carcinoma
- Bronchiectasis, ,lung abscess, empyema, PTB
- Lung fibrosis
3) Gastrointestinal
- Cirrohis, IBS, Coeliac disease
4) Thyrotoxicosis
5) Familial
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