Contenido:

PHYSICAL EXAMINATION

EXAMINATION OF BODY PARTS

After this, a general examination should be performed and, as with the clinical history, it should be done in an orderly fashion, starting with the head and finishing with the lower limbs. Since the body is symmetrical, we should compare one side to the other.

HEAD

We should check the pupils (central black part of the eye) assessing if they are the same size and if they react to light, using a torch. Normally, the pupils contract with light.

If there is a complaint of an uncomfortable sensation or pain in the eye, two further examinations may be required:

• Invert the eyelid. Turn the upper eyelid over to check the inside and make sure that there are no foreign bodies hidden there (see pictures 3-11 and 3-12).

 

The examination of the head continues by checking if one side of the face is symmetric to the other, if there is any kind of deviation (for example, one eyelid lower than the other, twisted mouth…) and checking if the patient is able to make facial gestures (close eyelids, whistle or blow the cheeks, laugh…).

In case of an accident, it is important to check if there is any blood or other liquid leaking from the ears, nose or mouth, and if haematoma appear around the eyes or behind the ears.

The inside of the mouth should be examined with a depressor (DRAWER 11, First aid kits A and B) or spoon to help lower the tongue (avoid pushing the spoon inwards, as it may trigger nausea in the patient). Ask the patient to say "Ah" continuously for the uvula to move upwards (see picture 3-14).

Check for deviations of the tongue, uvula, mucosa colour, teeth appearance, white or red dots in the back of the throat, size of the tonsils… (see picture 3-15).

In the ears , sudden pain or pain induced by applying pressure to the auditory duct or behind the ears, suppuration and haemorrhage should be examined.

Ask about hearing loss or hearing of noises or buzzing sounds… and explore any swelling or lumps behind the ears.

Inquire about mucus in the nose, bleeding or loss of smell.

NECK

Check if there is stiffness: ask the patient to touch his chest with his chin (with the mouth closed) (see picture 3-16) and to move the head sideways (touching the shoulder with the ear).

THORAX OR CHEST

Check if the patient breathes without difficulty or if it is "hard to breathe"; if there is pain, cough, or productive cough (mucus, blood).

ABDOMEN

To examine the abdomen the patient should be lying down, without a pillow, breathing normally, and the legs slightly bent.

Ask the patient if he feels any pain, the area or spot where it is worse, to where it spreads (radiates) and what position improves it. It is also important to know if the pain varies with meals, defecation or vomiting.

Place yourself on the right side of the patient and start to palpate with stretched hands and fingers together. The whole abdomen should be palpated softly, slightly increasing the pressure on a second palpation.

When the patient complains of pain, start palpating from the point furthest away from the pain and check the patient's face, since sometimes pain gestures may appear, which are often more indicative than any other information.

The abdomen may be soft or hard, may show painful spots, or lumps or masses be felt. If these lumps are located in the groin, examine the patient standing up and lying down, checking if the lump varies in size. Ask the patient to cough, and check if the lump "grows".

When there is abdominal pain a manoeuvre is performed by pushing with the fingertips in the right and lower abdomen, a few centimetres above the groin (in the mid point between the hip bone and the navel), and release suddenly asking the patient whether it is more painful when pushing or releasing.

If there is pain, we will also perform another manoeuvre that consists of placing the fingers of both hands below the lower ribs on the right side of the patient and pressing down while the patient breathes in deeply. Ask the patient if the pain appears or not when breathing in.

BACK

In case of lumbar pain, perform these two manoeuvres:

LIMBS

If in the rest of the body it is important to assess symmetry, in the limbs it is crucial. Every time there is something abnormal, it should be compared with the opposite.

Examine:

• Inflammatory, swollen or varicose areas.
• Temperature: if they are cold or warm or if there is any temperature difference between them.
• Colour: redness, bruises…
• Deformity.
• Strength: to assess it, ask the patient to give you this hand and squeeze yours, to push his foot against your resistance, holding his ankle…
• Sensibility: is examined with a pen, touching, symmetrically and alternately, both limbs.

SKIN

The inspection of the skin may show signs of disseminated disease or specific skin conditions. It should be performed, when possible, with natural light.

We should assess:

• Skin colour changes: may appear yellowish, redness, pallor or bluish.
• Localised lesions: may be spots, warts or lumps, desquamation, blisters, pus…in this case we should describe the number, size and location, their limits (well or ill defined), confluence or proximity of other lesions, their appearance and colour, if they are painful or not. Identify the lesion with one of the following pictures:

Tumours or lumps:

Lumps should be examined palpating with the hand stretched and not only with the fingertips. We should determine their size as well as their consistency, comparing with known objects (pea, walnut, stone).

Check if they are stuck to the skin or if the skin moves over, and if they are painful or not.