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9/19/2011 Clinical Skills Resource Centre, University of Liverpool, UK 1
The basics of examination
9/19/2011 Clinical Skills Resource Centre, University of Liverpool, UK 2
First things first …
The majority of a diagnosis is formulated from what is
ascertained from the history and should be taken prior to
examinations and investigations.
In preparing for any examination or procedure - think about
UNIVERSAL PRECAUTIONS. Which precautions are most
appropriate ?
(Don’t forget HAND WASHING before and after
patient contact!)
What equipment (if any) is required ?
On approaching the patient introduce yourself explain who
you are and why your there and gain INFORMED consent
for the examination
9/19/2011 Clinical Skills Resource Centre, University of Liverpool, UK 3
General
Remember to use an appropriate environment-
Warm enough? Private? Light enough?
The distinction between history and examination is
arbitrary and artificial in relation to diagnosis
Examination starts as the doctor or patient enters a
room
A handshake can welcome the patient and can
point to a variety of clinical conditions
9/19/2011 Clinical Skills Resource Centre, University of Liverpool, UK 4
Basics of Examination
The basic elements of examinations are -
Inspection
Palpation
Percussion
Auscultation
Not every component is used in every
examination and may be used to a greater or
lesser degree
9/19/2011 Clinical Skills Resource Centre, University of Liverpool, UK 5
Inspection (to look)
General overall impression way a person walks (gait ,posture), talks, looks
(demeanour, expression, colour)
Specific inspection of the hands moving up to the face etc. swellings, defects, paralysis, rashes, tremor, scars
Specific abnormalities relating to system to be examined GIT (gastro intestinal tract ) - abdominal distension
CVS (cardio vascular system) / RS (respiratory system) – cyanosis
9/19/2011 Clinical Skills Resource Centre, University of Liverpool, UK 6
Palpation (to feel)
Using hands with appropriate pressure to assess both
normal and abnormal tissues
A range of palpation techniques could be used e.g.
superficial, deep, balloting
Can be used to describe the physical characteristics of
both normal and abnormal tissues
Always observe your patient for signs of discomfort
during palpation.
Palpating appropriate lymph node groups is required.
9/19/2011 Clinical Skills Resource Centre, University of Liverpool, UK 7
Percussion (tapping)
The technique of
tapping with a
fingertip over an
area of the body
to elicit a sound-
described as
“resonant” or
“dull”
Used to indicate
presence or
absence of:
Air = Resonant
Solid = Dull
Fluid = Stony dull
9/19/2011 Clinical Skills Resource Centre, University of Liverpool, UK 8
Percussion technique 1
Place the middle finger of
the examining hand on
the area you want to
percuss
If this area is the chest
wall the middle finger
should be placed
between the intercostal
spaces
Striking
handExamining hand
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Percussion technique 2
Use the tip of the
middle finger of
your striking hand
to elicit the sound
by……………
9/19/2011 Clinical Skills Resource Centre, University of Liverpool, UK 10
Percussion technique 3
Striking the middle phalanx firmly using a sharp tapping movement (preferably using sharp palmer flexion of the wrist joint)
9/19/2011 Clinical Skills Resource Centre, University of Liverpool, UK 11
Percussion technique 4
Remove the
striking finger
sharply
Two or three taps
in any one site is
sufficient
9/19/2011 Clinical Skills Resource Centre, University of Liverpool, UK 12
Poor percussion technique? THINK:
Finger nails must be short to ensure the
very tip of the striking finger is used
All the fingers of the examining hand must
be splayed apart to avoid dampening the
sound
The finger to be percussed (tapped) must
be in firm contact with the patient
(particularly the middle phalanx)
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Clinical practice
You may see other methods used in practice
This is the “text book” method and is the method you will be expected to demonstrate
Direct percussion of the chest wall is possible only over the clavicles. In all other sites you should percuss on to the fingers of the examining hand firmly applied to the surface to be percussed always comparing right to left when possible
Assess areas of altered resonance by percussing from areas of normal resonance around the abnormality to determine extent
9/19/2011 Clinical Skills Resource Centre, University of Liverpool, UK 14
Auscultation
LISTENING
Use a CLEAN stethoscope
Bell
Diaphragm
Used to listen to
heart sounds
lung sounds
bowel sounds
Arterial bruits
other sounds
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Revision of stethoscope
Bell - best for low pitched
sounds
Diaphragm - best for high
pitched sounds
Ear pieces should be
angled forwards
Spring should retain the
ear pieces in the ear
comfortably
Ensure the hole is
aligned with the part
being used to listen
Ears
Active
Off
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Special
Use of various techniques and procedures
to extend the examination beyond
superficial tissues e.g.
Ophthalmoscopy retinal examination
Otoscopy ear examination
Proctoscopy anal canal
Torches assess pupil reflexes
transillumination of swellings