Body Examination

Generally, the examination is called the physical. This involves a look at the patient, his skin, his eyes, his level of alertness, and any defects visible in any part of the body. It is important to touch and feel certain areas where there is pain, to see if it is due to afflictions in the skin, the muscles, or deeper structures.

At times percussion is used to elicit areas of deeper tenderness. Tapping skillfully over an organ, such as the heart or liver, serves to outline its size, as well as compare that area with others for tenderness or distention, as when the bowel is obstructed and there is accumulation of gas.

Finally, the use of a stethoscope has achieved a degree of prominence in medical diagnosis and many uses of this may be learned by the layman, with a little practice. This instrument, invented by Laennec about 1816, has gone through many refinements in recent years.

The stethoscope is commonly used to take the blood pressure. This measurement is extremely important in a physical examination, and can be done by anyone who understands the physiology involved and has practiced to attain proficiency.

The blood pressure is measured by wrapping the inflatable cuff, connected to a measuring device, around the arm, or sometimes the leg. Usually this is done with the patient in a sitting position, but it can also be done lying down or standing up, if the position of the patient is noted and the blood pressure compared with other postures.

The standard of measurement is that of mercury barometer. Usually the pressure is measured in millimeters of mercury. The pictured instrument measures the blood pressure on a round dial. It is called an aneroid—type device, or sphygmomanometer.

The blood pressure cuff, after being calibrated, is inflated by closing the screw knob on the blood pressure cuff. Careful listening over the artery detects the beginning of a sound. This is intermittent and corresponds to the beat of the heart, pumping blood through the now opened vessel.

The pressure continues to drop; where it just begins to fade, a second muffled sound occurs, termed the diastolic pressure. The two figures are conventionally recorded as a fraction, i.e., 120/80. This is called the blood pressure.

It is felt that although the pressure increases with advancing age in most people, a pressure higher than 140/90 is abnormal. Usually the lower values correlate with a lessened risk of cardiac disease or stroke

The pulse is also an important measurement. It can be obtained by counting the pulsations in any artery of the body. The radial artery on the thumb side of the wrist, the carotid arteries in the neck, the femoral arteries in the groin, or small vessels in the forehead can also be used to measure the number of beats per minute the heart makes. More skill is required to assess the character of the pulse.

The thermometer should be held between two fingers only, shaking it down with a quick thrusting motion before taking the temperature. To read the thermometer, hold it at eye level and rotate it slightly until the mercury column becomes visible behind the scored degree markers.

Recording the temperature of the body is a useful marker of physical health, After the patient holds the thermometer under his tongue for three or more minutes, a careful reading of the thermometer usually gives the accurate temperature.

If water or cold liquids have been taken just before the measurement, it will not be accurate until the mouth has returned to its previous temperature. Rectal temperatures can be taken and should always be used in children under four years of age.

A patient who is comatose or unable to hold a thermometer in his mouth, and conditions where extreme shortness of breath prevents the taking of the temperature orally likewise require a rectal or axillary approach. Newer electronic thermometers are useful and safe in children, though more expensive.

Most thermometers are available with directions that explain how they can be read. Disinfecting the thermometer in alcohol between patients is important for household hygiene.

Examination of the head can detect many health problems. The nose should be inspected to see if one side or the other is blocked, and if the blockage is due to mucous, blood, or some foreign material. Symmetry of the organs of the face, including eyes, ears, nose, and mouth, as well as the facial muscles, smiles and grimaces, can also be a helpful sign.

Inspection of the ear canals can be done with a flashlight or even better with an otoscope. This instrument has a small light, operated by batteries, attached to a speculum—a tiny plastic cone—that is inserted carefully into the ear to visualize the drum.

Shine a light into the eyes to reveal if both pupils are of equal size. Both should constrict when the light is beamed on them. The eyes should both track back and forth, and up and down in a normal direction.

The teeth should be in good condition with no inflammation, redness, or swelling of the gums. The tongue should be a healthy pink color. Redness of the tongue may indicate an inflammation, such as scarlet fever or a B vitamin deficiency.

If the throat contains pus or a material resembling cottage cheese, infection with Streptococcus or yeast is quite likely. In children the tonsils protrude and could actually block the oral cavity, hindering swallowing or respiration. Unusual coating of the tongue is seen in certain disease states, particularly in tobacco users and in those who are dehydrated.

Careful palpation of the neck to estimate the size of the thyroid gland, to assess the quality of the pulses in the carotid arteries, and to detect any enlargement of the lymph nodes is advisable. At times stiffness in the neck, in association with high fever may be the first sign of meningitis, a serious infection in the lining of the brain and spinal cord.

Respiration should be free and unhindered. Both sides of the chest should expand equally and there should not be unusual retractions of soft tissues between the ribs during the phase of inhalation. Listening with the stethoscope over the lungs may disclose the presence of wheezes.

These musical sounds are caused by bands of mucus in the bronchial tubes and may be associated with asthma, emphysema, or pneumonia. Rales, or crackling sounds, resemble the rubbing of hair between the fingers. They may indicate fluid in the small air sacs of the lungs. This is often found in pneumonia, and sometimes can also indicate congestion from heart disease.

The heart sounds are of particular interest and the “lub dup” sounds are familiar to anyone who has listened to the heart. The chest usually does not rise markedly, although a thrust may be felt with the hand on the left side of the breast bone, during heart contraction.

Listening with the stethoscope should disclose a regular rhythm. Murmurs are sounds produced by damaged valves, where blood is flowing either in the wrong way or under difficulty, and may sound like the rushing of water through a pipe that is narrowed. These murmurs should be brought to the attention of a physician.

The abdomen should be soft. The liver edge is sometimes felt below the right rib margin. Tenderness in the right lower corner of the abdomen should be observed for possible appendicitis. Unusual bulges in the lower abdomen or groin may indicate a hernia. This rupture sometimes requires surgical repair.

Listening with a stethoscope over the abdomen should disclose the presence of bowel sounds. These occur intermittently and are a gurgling or rushing in nature.

The abdomen should not be unusually drum—sounding (tympanitic), as when distended by air, or completely dull—sounding to percussion, as when there is an excess of fluid accumulation. The examination of the external genitalia may give some clue to disease.

The extremities should move freely with a normal range of motion. Varicose veins are dilated blood vessels in the legs. These may be troublesome. Occasionally thrombosis or clotting occurs.

The calves of the legs should not be tender and the ankles should move freely. Stiffness in the ankles or pain in the calves when the foot is raised may be an early indicator of a clot in the veins, called thrombophlebitis.

Reflexes may be assessed by stroking the abdomen to elicit a muscle contraction. Tapping just below the knee cap, with the leg hanging in a relaxed position, should elicit a kicking motion. The Achilles’ tendon behind the heel can be tapped briskly with a small blunt object to provoke a foot contraction in a downward direction.

The Babinski sign is an abnormal reflex, except in infants, and involves a spreading of the toes with raising of the great toe when the bottom of the foot is stroked with a sharp object. This indicates central nervous system disease, and is often seen after a stroke or in multiple sclerosis.

The gait is evaluated by having the patient walk, noticing if there is tremor, unsteadiness, limping, or lack of coordination. Balance can be tested at the same time. Coordination of all the extremities is important in evaluating a person for neurological disease.