Before starting clinical examination:
- Analyze patient’s history.
- Probable diagnostic possibilities
- Think of the common diseases
- Determine physical findings consistent with these entities.
- Permission
- Privacy
- Presence of a nurse
- Precautions
Observe your patient while history taking for:
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General health- emaciated (? Malignancy)
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Intelligence
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Attitude
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Mental state (dehydration, encephalopathy)
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Posture:
- Peritonitis- flexed & still
- Intestinal, biliary or renal colic- rolling around in agony
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Mobility
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4 parts: Inspection, Palpation, Percussion, Auscultation
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Practice a standard routine every time
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Hand- Head to toe
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Weight- loss (malignancy), gain (DU)
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Pulse (Tachycardia- infection, fluid/ blood loss
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Blood pressure (low- fluid loss, bleeding)
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Temperature ( Fever- infection)
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Respiration rate- raised in infections
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Pulse- rate, rhythm, volume, nature
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Nails- koilonychia, clubbing, leukonychia
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Skin- dehydration, moist palm, anemia
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Anemia- conjunctiva, nail bed
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Jaundice- sclera, under surface of tongue
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Oral cavity- mucous membrane for hydration , tongue for coating
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Scalp
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Ear/ nose
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Neck- vein, goiter, lymph nodes, other swellings
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Chest- asymmetry, expansion, breath sound, added sound
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Cardiac- rhythm, heart sound, murmur
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Limbs- asymmetry, swelling, movement, pulses, power
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Abdomen (local examination)
Abdomen Exam
- Exposure: nipples to knees (ideal)
- Cover genitalia
- Patient lying flat on a pillow
- Arms by the side ( not under the head!)
- Sit or kneel beside the patient
- Adequate light includes 4 parts of examination process Inspection, Palpation, Percussion, Auscultation
Perineum Examination
Presenting history
Pain:
- perianal abscess, fissure in ano, anal fistula, thrombosed piles
Bloody discharge:
- Piles, fissure, fistulae, tumours (polyp, carcinoma anus/ rectum)
Purulent discharge:
- perianal abscess, fissure in ano, anal fistula
Mass or swelling:
- Abscess, piles, neoplasms
Left lateral decubitus position:
- hips flexed to 90º and knees flexed to
- less than 90°.
- Lift- uppermost buttock to expose
- the area
Jack-knife position
Inspection:
- scar of previous surgery,
- Sinus- one opening blind track
- Fistula- track connecting two epithelial surfaces
- Fecal soiling, blood/mucous discharge
- Mass protruding from anus
Palpation:
- tenderness, discharge, mass
Rectal examination:
Tone, tenderness, mass, prostate, blood, stool
