BY -DR NITESH KUMAR MD MEDICINE

1. B Y - D R N I T E S H K U M A R M D M E D I C I N E
GPE

2. GPE
 Complete assessment of a patient’s physical and
mental status.
 Systematic collection of objective information that is
directly observed or is elicited through examination
techniques.

3. OBJECTIVES
 To understand the physical and mental well being of
the patients.
 To detect diseases in its early stage.
 To determine the cause and extent of the diseases.
 To determine the nature of the treatment or nursing
care needed .
 To contribute to the medical research.

4. GENERAL PRINCIPLES OF PHYSICAL
EXAMINATION
 Introduce yourself
 Explain the purpose and nature of the examination
 Obtain the patient’s consent
 Quite, warm and well light room.
 Privacy
 Reassure and relax the patient
 Gentleness
 Always plan the examination relevant to the patient
 Further questioning if abnormal finding
 Always examined from right side of the bed

5. General appearance
 Consciousness,
cooperation &
orientation
 Attitute and posture
 Build and nutrition-
Height,Weight, BMI,
Anthropometric features,
Congenital anomalies.
Others--hair, face, oral
cavity, nail, extremites

6. FACIES
 Specific diagnosis can be
made by just looking at a
patient’s face.
 Some facial
characteristics are so
typical of certain diseases
that they immediately
suggest the
diagnosis….so called
diagnostic facies……

8. Oral Cavity
 The teeth and breath
 Check the oral cavity looking for
 MOUTH ULCERS
-Aphtous,drugs and trauma
-gastrointestinal disease;inflammatory bowel
disease,coeliac disease
-rheumatological;Behcets syndrome,reiter
-erythema multiforme
-infections;herpes zoster,simplex,syphilis,tuberculosis

10. Gum hypertrophy
 Phenytoin
 Pregnancy
 Scurvy(vitamin C
deficiency; gums become
swollen, spongy, red and
bleeds easily)
 Gingivitis; smoking
 leukemia

11. hair
 ALOPECIA
 Non-scarring
-alopecia areta
-scalp ring worm
-traction alopecia
• Scarring
-burns,radiation,lupoid
erythema,sarcoidosis

12. nails

13. VITAL SIGNS
 PULSE
 BLOOD PRESSURE
 TEMPERATURE
 RESPIRATORY RATE

14. PULSE
 The pulse is a wave form that is felt by fingers and
produced by cardiac systole which travels through
the peripheral arterial tree in peripheral direction at
a rate more faster than that of blood columm.
 Time lag from cardiac systole:
Carotid: 30ms
Radial: 80ms
Femoral: 75ms
Brachial: 60ms

15. IMPORTANCE:
 Also called the mirror of heart
 Information about arterial wall condition
 Rough estimation of SBP n DBP
 State of heart n circulation
 Detect and diagnosis of arrhythmia
 Diagnosis in case of AR and acute LVF

16.  The arterial pulse should be examined in all 4 limbs and
both sides of the neck
 1. Radials
 2. Brachials
 3. Carotids
 4. Femorals
 5. Popliteals
 6. Temporal
 7. Facial
 8. Peripheral arteries of the legs :Dorsalis Pedis Posterior
tibial

17. How to feel the Pulse
 The Radial pulse:
 The 3 middle fingers are used
 The palmar surface of the fingers overlies the radial
A. and encircles the wrist
 At first the artery is completely occluded, then
gradually release the pressure until maximum feeling
of the pulse wave is perceived.

18. Examination of pulses
 Rate ---- radial pulse used generally
 Rhythm --- radial pulse used generally
 Character --The carotid artery
 Volume -- The carotid artery
 Symmetry -- Compare arteries both side
 Radio femoral delay -- Compare radial and femoral
pulse
 Condition of vessels

19. Pulse: Rate
 Beats per minute
Adult 60-100 bpm
Neonate 120-160 bpm
Upto 3 yrs 100-120 bpm
At 6 yrs 80-100 bpm
Physiological variation:
 childhood
 Emotion
 Sleep
 Athlete

20. Pulse: Rhythm
 Regular-- Count for at least half a minute
 Irregular
Regularly irregular
Irregularly irregular

21. Carotid pulse
 Be careful
 Always one at a time
 Stimulating its
baroreceptors with low
palpitation
Severe Bradycardia
Even stop the heart
Pulse;character/volume

22. Pulse Volume
• Volume is the movement imparted to your fingers
and reflects the pulse pressure - the difference
between systolic and diastolic blood pressure
 best assessed by palpating the carotid artery
 Pulse pressure ;
30 to 60 mm Hg--normal
< 30 mm Hg, ----small
>60 mm Hg, ---large
 Pulse volume depends on stroke volume and arterial
compliance

23. Character
• Character is the impression of the pulse waveform
obtained
 best assessed in the carotid arteries except.
bisferiens pulse , pulsus alternans, are more
evident in peripheral arteries

24. CATACROTIC PULSE : NORMAL PULSE

25. Hypokinetic Pulse --Small
weak pulse
(small volume and narrow
PP).
Hyperkinetic Pulse---A high
amplitude pulse with a rapid
rise
(large volume and wide PP)

26. Anacrotic Pulse-A low
amplitude pulse (parvus)
with a slow rising and late
peak (tardus).
Pulsus bisferiens --is a single
pulse wave with two peaks in
systolebest felt in brachial and
femoral artery

27. Collapsing Pulse (Water-Hammer
Pulse, Corrigans Pulse)
 It is a large volume pulse
with a rapid upstroke
(systolic pressure is high)
and a rapid downstroke
(diastolic pressure is low).
 The rapid upstroke is
because of an increased
stroke volume.
The rapid downstroke is
because of diastolic run-off
into the left ventricle, and
decreased peripheral
resistance and rapid run-
off to the periphery.

28. Condition of Arterial Wall
 • Young adult : Not Palpable
 Old Individuals , Hypertensive patients Palpable
 First place the index and middle fingers of both
hands over the radial artery side by side and
exsanguinate the artery by moving the two fingers in
opposite direction. The radial artery is now rolled
over the radius by two index fingers

29. Brachial pulse
Flex the patient’s elbow
Feel the pulse just
medial to biceps tendon
Carotid Arteries
•At the level of thyroid
cartilage
Peripheral pulsations

30. The Carotids
 The patient lies down with the head of the bed
elevated 30 degrees
 Carotid pulsations may be visible just medial to
sternomastoid
 Place the left thumb on the right carotid A. in the
lower third of the neck at the level of the cricoid
cartilage, just inside the medial border of the
sternomastoid and press posteriorly
 Never press both carotids at same time

31. The dorsalis pedis artery
Lateral to the extensor hallucis
tendon
Absent in 10%
The posterior tibial pulse.

32. femoral artery- beneath the
inguinal ligament ,about mid
way between ASIS and SP
Popliteal artery- Patient knee
should be flexed –leg relaxed
Place the finger tips of both
hands so that they meet in the
middle line behind the knee
and press them deeply in the
popliteal fossa

33. RADIO-RADIAL & RADIO-FEMORAL
DELAY
 Delay of the left radial
compared with the right
radial is found in
THORACIC INLET
SYNDROME :
CERVICAL RIB
,TAKAYASU’S DISEASE
 Delay of the femoral
compared with the right
radial pulse is found in
coarctation of the aorta

34.  72 beats per min, regular rhythm, normal volume
and normal character, all peripheral pulses are well
felt, no radioradial or radiofemoral delay, no vessel
wall thickening

35. 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.

36.  Cuff size guidelines a
device used for
measuring arterial
pressure. Mercury,
aneroid, electric
 Cuff Arm cirum
Range at mid point
 Adult 27-34 cm
 Large Adult 35-44 cm
 Adult thigh 45-52 cm
Cuff
Sphygmomanometer

37. • Auscultatory method
• 1st sound systolic
• Dissapearance diastolic • Palpatory method
 Can measure only
systolic pressure
Measurement

39. TEMPERATURE
 Whether or not a patient is febrile is often obvious by
palpation of the forehead with the dorsum of the
hand
 But the exact temperature has to be recorded in
doubtful cases to document fever and to assess the
height of temp using a clinical thermometer

40. Temperature
.=Core
oral
rectal
=Surface
axillary
groin
 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 through out 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)

41. Respiratory rate
 It is expansion and relaxation of of chest wall
 Normal value is : 16 – 22 bpm (Adult)
 Rate
 Depth
 Type

42.  Respiratory rate– counted by placing the examiners
palm over the patient’s abdomen ,noting the rise and
fall of the abdomen
 Note-simultaneously divert the patient’s attention
 Types –abdominothoracic-(male)
thoracoabdominal(female)
Method- keep two hands flat , one on the chest and
other on the abdomen and watch for movements of
hands

43. CARDINAL SIGNS :
 1. Pallor
 2. Icterus
 3. Cyanosis
 4. Clubbing
 5. Lymphadenopathy
 6. Edema
 7. JVP

44. 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.

45. (must be compared with both side
and must be observed in day light)
 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
Sites where pallor is seen

46. ICTERUS
 Yellowish discolouration of skin,mucous
membrane and sclera.
 Due to increased bilirubin.
 Yellowish discolouration of sclera is due to the
high elastin content in the sclera
 Normal level- o.3-1 mg/dl
 Latent jaundice- below 3 mg/dl
 Clinical jaundice- more than 3 mg/dl

47. Sites
 Upper sclera
 Ventral surface of
tongue (between lingual
vein and frenulum)
 Nail bed
 Palm of the hand
 Sole of feet

48. Differential diagnosis of yellowish
discolouration of skin
 Carotenoderma (Increased intake of carrots,
oranges and leafy vegetables): here there is no
yellowish discolouration of sclera
 Quinacrine
 Chronic exposure to phenols
 Long standing anemia

49. CYANOSIS
 Cyanosis is the bluish discolouration of skin and
mucous membrane.
 It results from the increased amount of reduced
hemoglobin the the blood.
 Manifests when the reduced hemoglobin is >5g/dL
 Cyanosis may be masked in severe anemia

50. Types of cyanosis
 Central
 Imperfect
oxygenation of the
blood e.g Heart
failure , COAD
 Admixture of
venous with arterial
blood e.g
Congenital heart
diseases
 Peripheral
 Excessive reduction
of oxyhaemoglobin in
the capillaries when
the blood flow is
slowed

Vasoconstrictionexpos
ure to cold
 Arterial obstruction
 Low cardiac output

51. Sites :
 Tip of tongue (central cyanosis)
 Lips
 Tips fingers and toes
 Tip and alae of nose Central+Peripheral
 Earlobules Cyanosis

52. Central cyanosis Peripheral cyanosis
1)mechanism = Low SpO2
2)sites = Tip of tongues
3)Extremities= Warm
4)Application of
heat= No effect
5)Administration
of O2 = Cyanosis disappears
Poor peripheral circulation
Other sites
Cold
Cyanosis disappears
No effect
Differences

53. 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
. Schamroth’s sign (Diamond shape)

55. 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

56. Oedema
Accumulation of fluid in interstitial space.
Types:
Pitting type: Apply firm pressure on the shin of
tibia or 2cm above the medial malleolus for 30 s and
see for pitting.
Causes: Congestive cardiac failure, nephrotic
syndrome, liver cirrhosis, hypoproteinemia
 Non pitting type:Lymphatic obstruction , Deep
vein thrombosis, Myxoedema, Scleroderma

57. How edema can be recognized?
 Inspection:
Pallid and glossy
appearance of the skin at
the swollen part
 Palpation:
Doughy feeling
Pitting on finger pressure
(the pressure of the
finger should be
maintained for 30
seconds)

58. Lymph Node
 Lymphadenopathy- Enlargement of lymphnode
 Distributed all over the body
 Important part in the body’s defense against
infection

59. Distribution of lymph nodes
 neck
 Submental
 Submandibullar
 Pre- Post-auricular
 Ant- Post cervical
chain
 Occipital
 Supraclavicular
 (Virchow’s gland)

60.  Axillary :
 Apical (Sub clavicular)
 Central
 Post (Scapular)
 Lateral
 Anterior (Pectoral)
 Epitrochlear (Cubital)
 Popliteal
 Para aortic (Lumbar)
 Inguinal
 Horizontal, vertical

61. 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)

62. JVP:
 Jugular Venous Pulse ;
defined as the oscillating top of vertical column of
blood in right IJV that reflects the phasic pressure
changes in Right Atrium in cardiac cycle.
• Jugular Venous Pressure:
Vertical height of oscillating column of blood .

63.  Right atrial pressure during
systole and right ventricular
filling pressure during diastole
are producing pulsation and
pressure waves in jugular veins.
 Evaluation of JVP offers a
window into the right heart,
providing critical information
regarding its hemodynamics.

64.  Causes of Elevated JVP
1. Unilateral non-pulsatile
 Innominate vein thrombosis
2. Bilateral non-pulsatile
 SVC obstruction
 Massive right sided pleural
effusion
3. Bilateral pulsatile
a. Cardiac
 Cardiac failure
 Tricuspid stenosis
 Tricuspid regurgitation
 Constrictive pericarditis
 Cardiac tamponade
b. Pulmonary : COPD/cor
pulmonale
c. Abdominal :
 Ascites
 Pregnancy
d. Iatrogenic Excess IV fluids
 Low jugular venous
pressure
 Hypovolaemia.

65. Types- ejv and ijv

66.  Lateral to carotid
artery & deep to
sternomastoid
muscle.
 External jugular is
superficial to
sternomastoid

68. Examination of JVP
 Right IJV is usually assessed both for waveform and
estimation of venous pressure
 Unlike EJV pulsation, it is not possible to see IJV
pulsation directly as it is deep.
 We actually see the transmitted pulsations to
overlying skin between two heads of
sternocleidomastoid.

69. Why Internal Jugular Vein?
 • IJV has a direct course to RA.
 • IJV is anatomically closer to RA.
 • IJV has no valves( Valves in EJV prevent
transmission of RA pressure)
 • external jugular vein is more superficial & prone to
kinking and partial obstruction as it traverses
the deep fascia of the neck.
 • Vasoconstriction Secondary to hypotension ( in
 CCF) can make EJV small and barely visible.

70. Right IJV Preferred :Why?
 Right IJV have straight line course through innominate
vein to the svc and right atrium
 Less likely extrinsic compression from other structures in
neck.
 Left innominate vein compressed by arch of Aorta and
Presence of Left SVC can falsely elevate the JVP on Left
side.
 Left IJV drains into Lt innominate vein, which is not in
straight line from RA.
 Why not EJV-
No or less numbers of valves in IJV than EJV

71. Differences between IJV and Carotid pulses
 Superficial and lateral in
the neck
 Better seen than felt
 Has two peaks and two
troughs
 Descents >obvious than
crests
 Digital compression
abolishes venous pulse
 Jugular venous pressure
falls during inspiration
 Abdominal compression
elevates jugular pressure
 Deeper and medial in the
neck
 Better felt than seen
 Has single upstroke only
 Upstroke brisker and
visible
 Digital compression has no
effect
 Do not change with
respiration
 Abdominal compression
has no effect on carotid
pulse

72. Method Of Examination
 • The patient should be comfortable during the examination.
 • Clothing should be removed from the neck and upper
thorax.
 There should not be any tight bands around abdomen
 • Patient reclining with head elevated 45 °
 Ensure that the neck muscles are relaxed by resting the back
of the head on a pillow. Neck should not be sharply flexed &
slightly rotated towards the opposite side
 • Examined effectively by shining a light tangentially across
the neck from the right side of the patient
 • → Identify the internal jugular pulsation in between two
 heads of SCM , (DIFFERENTIATE it from CAROTID
PULSATION)

73. WHY 45° ?? FOR BETTER
VISUALISATION
 • (A) Supine: jugular vein
distended, pulsation not
visible.
 (B) Reclining at 45°:
point of transition
between distended and
collapsed vein can
usually be seen to pulsate
just above the clavicle.
 (C) Upright: upper part
of vein collapsed and
transition point obscured

74. Jugular venous pressure
 Level of sternal angle is about 5 cm above the level of
mid right atrium IN ANY POSITION.
 JVP is measured in ANY position in which top of the
column is seen easily.
 Usually JVP is less than 8 cm water
 < 3 cm column above level of sternal angle.

75. Measurement of JVP
 Two scale method is commonly used ( one scale at
the upper level of the JVP ,parallel to the ground and
second scale at the level of sternal angle
,perpendicular to the first scale.
 Normally JV pressure does not exceed 3- 4 cm above
the sternal angle
 Since RA is approximately 5 cm below the sternal
angle ,
 the jugular venous pressure corresponds to 9 cm
=7mmhg
 Elevated JVP : JVP of >4 cm above sternal angle

78. Hepatojuglar reflux
 Useful diagnostic maneuver when –
 1. JVP is borderline elevated
 2. Latent RVF
 3. Silent TR is suspected
Maneuver:-
 Gently apply firm pressure to the periumblical region for
10 – 30 sec with pt lying comfortably and breathing
quietly, while JVP is observed.
 Pressure shouldn’t applied over the Liver in Rt
hypochondrium region ,as it may be painful in presence of
hepatic congestion.

79. What happened in Normal
Subjects:-
 JV pressure rises transiently
(<15 sec.) to <3cm while
abdominal pressure is
continued, because Normal
RV is able to receive the
augmented venous return to
Rt heart without a rise in
mean venous Pressure.

80.  Positive Response
 A Sustained rise of >3cm in venous pressure for at
least 15 sec after resumption of spontaneous
respiration is a positive response.
 A positive test result indicates the inability of the
right heart to handle an increased venous return.

81.  Most common cause of a positive test is RHF/
(incipient Heart Failure )
• Positive test in: Borderline elevation of JVP
Silent TR
Latent RHF
• False Negative: SVC/IVC obstruction
Budd Chiari syndrome
• Positive Test imply SVC and IVC are patent

82.  thanks