general surgery clinical and physical examination

Clinical examination

1. PATIENT’S CLINICAL
( PHYSICALEXAMINATION
PE

2. 4

1- Inspection
2- Palpation
3- Percussion
4- Auscultation
“Teach The Eye to See, The Finger to Feel,
”
5- What is the fifth ?
Smelling

3. Equipment For Physical Examination
Required Optional
Stethoscope Gloves
Tongue blades Gauze pads
Penlight Lubricant gel
Tape measure Nasal speculum
Sphygmomanometer Tuning fork
Reflex hammer
Safety pins Pocket visual acuity card

4. Important Aspects of Physical
Examination /Physician
1- Elegant Appearance ﻖ﮵
﮲ا ﺮﻬﻈ ﻣ
2- Decent Mannerﺔ﮵ﻟﺎﻋ قﻼ
﮲ ﺣ ا
3- Kind Attitudeﻒ﮵ﻄﻟ ك ﻮ ﻠ ﺳ
4- High Responsibilityﺔ﮵ﻟﺎﻋ ﺔ﮵ﻟ و ﺆ ﺴ ﻣ
5- Good Medical Moralsةﺪ﮵﮳ﺣ ﺔ﮵﮳ ﻃ ق ﻼ
﮲ ﺣ ا

5. Important Aspects of Physical Examination
Physician
A - Wash Your Hands, preferably

B - Washing with soap and water is

6. Sequential Examination
A


system
B- Patients tire quickly when asked to “sit up”
, “lie down”, “turn on your left side”, “sit up”
, “lie down”

7. /Patient
A- The patient should be made as
comfortable as possible during
the examination
B- The patient should be properly
drapedءﺎﻄ
﮲ﻋ

8. IMPORTANT ASPECTS OF PHYSICAL EXAMINATION
WHERE IS THE BED PLACED ?
A-


B-ideal
in the centerof the examining room

9. Important Aspects Of Physical Exam
Where Does The Examiner Stand ?
A- Stand right side of the bed
B- Exam with one’ right hand

11. Only
without undue exposure of the other areas


This Caring for The Patient’s Privacy Goes

12. Precautions /
A- The use of gloves should provide
adequate protection when performing
the physical examination or when
handling blood-soiled or body
fluid-soiled sheets or clothing
B- Gloves should be worn when examining
any individual with exudative lesions
or weeping dermatitis

13. Precautions2
C-Hands or other contaminated skin surfaces
should be washed thoroughly & immediately
if accidentally soiled with blood
other body fluids
D- All sharp items, such as needle, must
be handled with extraordinary care to
prevent injuries
- A patient may be in isolation
precautions if he / she is suffering from a
contagious

14. FIRSTInspection
A- Method of observation used during Physical Exam
B- First step in examining a patient or body part
C- It includes a general survey of the patient’s

1-Mental status 6- Posture

15. 1 -

2 -
3 -
4 -
are inspecting while draping the rest
5 -

16. 16
Inspection
Use vision, hearing &
smell
Always first
Look for symmetry
Use good lighting
Use good exposure

17. 17
Principles of Accurate Inspection
Good lightening either day light or artificial light is suitable.
Expose body parts being observed only.
look before touching.
warm room for examination of the client “not cold not hot".
Observe for color, size, location, texture, symmetry, odors, and
sounds.
Compare each area inspected with the opposite side of body if
possible.
Use pen light to inspect body cavities.

18. ABDOMEN: Inspection
There should be
adequate
exposure of the
abdomen for
proper inspection.
The patient
should be
exposed from the
inferior chest to
the anterior iliac
spines bilaterally.

19. POSTURE
1 - It may reveal significant information
2 - Congestive heart failure: Sit in a chair the

3 - Patients with body / tail of the pancreatic cancer:

4 - Thus the positions of the pt. at the time of the


5 - A history of assuming Certain Positions to

20. SECONDPALPATION
A- Methods of “Feeling via Hands”

B- The Examiner touches and feels the


1- Size 4- Consistency
2- Texture 5- Location
3- Tenderness
C- The Palpation of Abdomen is particularly

21. Palpation
Touch & feel with hands to determine:
Texture – use fingertips (roughness,
smoothness).
Temperature – use back of hand (warm,
hot, cold).
Moisture (dry, wet, or moist).
Organ location and size
Consistency of structure (solid, fluid, filled)
Slow and systematic
Light to deep
Light palpation (tenderness)
Deep palpation (abdominal organs/masses)

22. 22
Principles for Accurate Palpation
Examiner finger nails should be short.
Use sensitive part of the hand.
Light Palpation precedes deep palpation.
Start with light then deep palpation
Tender area are palpated last
Tell client to take slow deep breath to enhance muscle relaxation.
Examine condition of the abdominal organs


23. palpation may be facilitated by distracting
conversation or questions regarding the
history

the preliminary stages, muscle
relaxation is the goal
Ask The Patient to Flex The Thighs

24. A - Light Palpation
B - Deep Palpation
1- Deep Slipping Palpation
2-
3-
4-

25. LIGHT PALPATION / 1
1- Using The Flat part of the Right hand
or The Pads of the fingers,
not the fingertips
2- The Fingers Should be together
3- Sudden Jabs are to be avoided
4- The Hand’d be lifted from one area
to an area instead of sliding over
the abdominal wall

26. 26
Light palpation

27. LIGHT PALPATION

28. Abdominal Palpation
128, 129. Palpate lightly in all 4
quadrants. Press down around 1 cm.
Remember to look at the patient’s face
during palpation to see if any
tenderness is elicited

29. 1-

2-

3-

4-

30. Palpation: Deeply, all 4 quadrants
One should use two hands. Press
down around 4 cm

31. 31
Deep palpation

32. DEEP PALPATION

33. DEEP SLIPPING PALPATION
A-The Examiner uses his Forefinger, Middle
Finger & Ring tightly
together, slowly & gradually palpate the
abdominal organs or masses, slipping
Up / Down - Right side / Left side
B-
Deep Mass of abdomen or
GI

34. Palpation: Liver
Stand on the pt’s right side. Place your left hand behind the
patient’s R side under the 11th and 12th rib area. Press upward
with the L hand.
Place your R hand on the pt’s
abdomen well below where you
percussed the liver edge

35. 130-131: Palpation of Liver: Alternative Method
It is acceptable during palpation of the liver to
use both hands to palpate abdomen. You use
the fingers of one hand to palpate and the other
hand is used to apply pressure to the dorsum of
the other hand. Thus the hand you are using to
palpate does not need to be used to apply
pressure.

36. 132-133: Palpation: Spleen
Palpation: Spleen (correctly -
position, breaths, palpating
deepest full inspiration, 1
hand under L side, 1 feeling)
Palpation: Spleen (if not
palpable, R lateral decubitus)

37. Right
lateral
decubitus

38. 135-136: Palpation of Kidneys
Right kidney (take a deep
breath, capture kidney, exhale,
slowly release kidney
Left kidney (take a deep breath,
capture kidney, exhale, slowly release
kidney)

39. A- 2

B-Placing the Left hand over the

FixElevate
Right

C- It is Used to Assess Liver

40. BIMANUAL PALPATION

43. A- Thumb2~3
together to Palpate with Gradually increasing
pressure, in order to identify Deep
Lesions or Localize the area of
Abdominal Pain
B- Pain
Gallbladder or Appendicitis
C-
the Rebound Tenderness‘d be

44. A-
be elicited by palpating deeply and slowly
in an area from the suspected area of
local inflammation
B- The palpating hand is then quickly
removed
C- The Sensation of Pain at the site of
inflammation that occurs on release of
pressure is Rebound Tenderness

45. THIRD
A-
during PE with fingers, hands, or small
instruments to EvaluateSize,
Consistency, Borders
Fluid
B-
a Sound

C-

46. Percussion 125-126
Percussion: the left and right abdomen should be percussed
above and below the umbilicus. Most examiners will percuss 8
or more areas.

47. 47
Percussion

48. Percussion of the chest
Percussion of the chest for cardiac border

49. ForDeep Lesions
(7cm )

50. 1- It should be performed from

2- From One side to the other side
3- Comparison

51. QUALITY OF PERCUSSION
According to The Identity of the tissue, amount of


:
1- Resonance
2- Tympany
3- Hyperresonance
4- Dullness
5- Flatness

52. SOUND RECORD QUALITY HEARD SITE

Resonance Hollow Normal Lung
HyperresonanceBooming Air-filled lungs
Tympany Drum like Abdomen
Dullness Thud like Liver
Flatness Flat Muscle, Bone

53. A- Listen ” to the Sounds
PE
B- Performed By Listening through

Frequency
Intensity
Duration
Number
Quality Of Sounds

55. Stethoscope (Diaphragm and
Bell)
© Martin Kubát/ShutterStock, Inc.

56. 56
Auscultation
Listening to body sounds
Movement of air (lungs)
Blood flow (heart)
Fluid & gas movement
(bowels)
Remember the sound
changes in the abdomen…

57. 124: Auscultation
Auscultation can be done
with the diaphragm or the
bell; most examiners use the
diaphragm. You should
listen for at least 10-15
seconds and note the pitch
and frequency of bowel
sounds. If you do not hear
any bowel sounds, you
should listen for a full two
minutes before you can state
that the patient does not
have any bowel sounds.
Bowel sounds should occur
from every other second to
every 12 seconds.
Note: During the abdominal exam
auscultation is done before palpation

58. Auscultation of the chest
Auscultation of the chest using the
diaphragm and bell in various positions to
include the following locations
–Aortic area at the right second intercostal
space–S2 is louder than S1
–Pulmonic area at the left second intercostal
space–S2 is louder than S1
–Erb’s point at the left third intercostal space–S1
and S2 are heard equally

59. Figure 17.24 Positions for auscultation of the heart. A. Supine.

60. Figure 17.24 (continued) Positions for auscultation of the heart. B. Lateral.

61. Figure 17.24 (continued) Positions for auscultation of the heart. C. Sitting.

62. How to Use The Stethoscope
DO’S
1- Warm The Diaphragm or Bell
2-
3-
DON’TS
1-Do Not Apply too much pressure when
The Bell
2-

63. FIFTHSMELLING
1-
Abnormal Odor from the patient

2- The Odor is Elicited from the exudates of
Respiratory Tract, GIT,
Blood
3-
Clues

64. THANKS