SCIENCE EDUCATION > Clinical Skills

Physical Examinations II

This collection is a specialized edition featuring methodologies and procedures associated with more sensitive and comprehensive physical exams such as HEENT exams, abdominal exams, and pelvic exams.

  • Physical Examinations II

    11:27
    Eye Exam

    Source: Richard Glickman-Simon, MD, Assistant Professor, Department of Public Health and Community Medicine, Tufts University School of Medicine, MA

    Proper evaluation of the eyes in a general practice setting involves vision testing, orbit inspection, and ophthalmoscopic examination. Before beginning the exam, it is crucial to be familiar with the anatomy and physiology of the eye. The upper eyelid should be slightly over the iris, but it shouldn't cover the pupil when open; the lower lid lies below the iris. The sclera normally appears white or slightly buff in color. The appearance of conjunctiva, a transparent membrane covering the anterior sclera and the inner eyelids, is a sensitive indicator of ocular disorders, such as infections and inflammation. The tear-producing lacrimal gland lies above and lateral to the eyeball. Tears spread down and across the eye to drain medially into two lacrimal puncta before passing into the lacrimal sac and nasolacrimal duct to the nose. The iris divides the anterior from the posterior chamber. Muscles of the iris control the size of the pupil, and muscles of the ciliary body behind it control the focal length of the lens. The ciliary body also produces aqueous humor, which largely determines intraocular pressure (Figure 1). Cranial nerves II and III control pupillary reaction and lens accommodation; cranial nerve III controls upper lid elevation; cranial nerves III, I

  • Physical Examinations II

    07:43
    Ophthalmoscopic Examination

    Source: Richard Glickman-Simon, MD, Assistant Professor, Department of Public Health and Community Medicine, Tufts University School of Medicine, MA

    The simplest ophthalmoscopes consist of an aperture to look through, a diopter indicator, and a disc for selecting lenses. The ophthalmoscope is primarily used to examine the fundus, or the inner wall of the posterior eye, which consists of the choroid, retina, fovea, macula, optic disc, and retinal vessels (Figure 1). The spherical eyeball collects and focuses light on the neurosensory cells of the retina. Light is refracted as it passes sequentially through the cornea, the lens, and the vitreous body. The first landmark observed during the funduscopic exam is the optic disc, which is where the optic nerve and retinal vessels enter the back of the eye (Figure 2). The disc usually contains a central whitish physiologic cup where the vessels enter; it normally occupies less than half the diameter of the entire disc. Just lateral and slightly inferior is the fovea, a darkened circular area that demarcates the point of central vision. Around this is the macula. A blind spot approximately 15° temporal to the line of gaze results from a lack of photoreceptor cells at the optic disc. Figure 1. Anatomy of the eye. A diagram showing a sagittal view of the human eye with the structures labeled. Figure 2: Normal retina. A photograph showing an ophtha

  • Physical Examinations II

    09:09
    Ear Exam

    Source: Richard Glickman-Simon, MD, Assistant Professor, Department of Public Health and Community Medicine, Tufts University School of Medicine, MA

    This video describes the examination of the ear, beginning with a review of its surface and interior anatomy (Figure 1). The cartilaginous auricle consists of the helix, antihelix, earlobe, and tragus. The mastoid process is positioned just behind the earlobe. The slightly curving auditory canal ends at the tympanic membrane, which transmits sound waves collected by the external ear to the air-filled middle ear. The Eustachian tube connects to the middle ear with the nasopharynx. Vibrations of the tympanic membrane transmit to the three connected ossicles of the middle ear (the malleus, incus, and stapes). The vibrations are transformed into electrical signals in the inner ear, and then carried to the brain by the cochlear nerve. Hearing, therefore, comprises a conductive phase that involves the external and middle ear, and a sensorineural phase that involves the inner ear and cochlear nerve. The auditory canal and the tympanic membrane are examined with the otoscope, a handheld instrument with a light source, a magnifier, and a disposable cone-shaped speculum. It is important to be familiar with the tympanic membrane landmarks (Figure 2). Only two of the three ossicles - the malleus and incus - can normally be seen; the malleus is near the center, and the uncus i

  • Physical Examinations II

    08:45
    Nose, Sinuses, Oral Cavity and Pharynx Exam

    Source: Richard Glickman-Simon, MD, Assistant Professor, Department of Public Health and Community Medicine, Tufts University School of Medicine, MA

    This video provides an overview of sinus, nose, and throat examinations. The demonstration begins with a brief overview of the anatomy of the region. The upper third of the nose is bony, and the bottom two-thirds are cartilaginous. Air entering the nares passes through the nasal vestibules and into the narrow passageway between the nasal septum medially and the bony turbinates laterally. Beneath each curving turbinate is a groove or meatus. The nasolacrimal duct and most of the air-filled paranasal sinuses drain into the inferior and middle meatuses, respectively. Of the three sets of paranasal sinuses, only the maxillary and frontal can be readily examined. A continuous, highly vascular mucosa lines the entire nasal cavity and sinuses. Figure 1. Anatomy of the Nose. Figure 2. Location of the Major Sinuses. Muscular folds of the lips mark the entrance to the oral cavity. The pinkish gingiva, or gums, attach firmly to the teeth and adjacent bone into which the teeth embed. The buccal mucosa lines the inner cheeks, where the Stensen duct drains the parotid glands into small papillae near the upper second molars. Small, red papillae cover the dorsal surface of the tongue along with a whitish coat of varying thickness. The midline lingual frenulum con

  • Physical Examinations II

    06:17
    Thyroid Exam

    Source: Richard Glickman-Simon, MD, Assistant Professor, Department of Public Health and Community Medicine, Tufts University School of Medicine, MA

    The thyroid gland is located in the neck anterior trachea between the cricoid cartilage (above) and the suprasternal notch (below) (Figure 1). It consists of a right and left lobe connected by an isthmus. The isthmus covers the second, third, and fourth tracheal rings, and the lobes curve posteriorly around the sides of the trachea and esophagus. The normal gland, weighing 10 - 25 g, is usually invisible on inspection and often difficult to palpate. A goiter is an enlarged thyroid from any cause. In addition to assessing its size, it is important to palpate the thyroid for its shape, mobility, consistency, and tenderness. A normal thyroid is soft, smooth, symmetrical, and non-tender, and it slides upward slightly when swallowing. Symmetrical enlargement of a soft, smooth thyroid suggests endemic hypothyroidism due to iodine deficiency or one of two prevalent autoimmune disorders: Graves' disease or Hashimoto's thyroiditis. Thyroid nodules are common and usually incidental; however, 10% of thyroid nodules turn out to be malignant. They may be single or multiple, and are most often firm and non-tender. A tender, symmetrical goiter typically indicates thyroiditis. Figure 1. Anatomy of the thyroid gland. Illustration of the location and anatomy of the thyro

  • Physical Examinations II

    08:05
    Lymph Node Exam

    Source: Richard Glickman-Simon, MD, Assistant Professor, Department of Public Health and Community Medicine, Tufts University School of Medicine, MA

    The lymphatic system has two main functions: to return extracellular fluid back to the venous circulation and to expose antigenic substances to the immune system. As the collected fluid passes through lymphatic channels on its way back to the systemic circulation, it encounters multiple nodes consisting of highly concentrated clusters of lymphocytes. Most lymph channels and nodes reside deep within the body and, therefore, are not accessible to physical exam (Figure 1). Only nodes near the surface can be inspected or palpated. Lymph nodes are normally invisible, and smaller nodes are also non-palpable. However, larger nodes (>1 cm) in the neck, axillae, and inguinal areas are often detectable as soft, smooth, movable, non-tender, bean-shaped masses imbedded in subcutaneous tissue. Lymphadenopathy usually indicates an infection or, less commonly, a cancer in the area of lymph drainage. Nodes may become enlarged, fixed, firm, and/or tender depending on the pathology present. For example, a soft, tender lymph node palpable near the angle of the mandible may indicate an infected tonsil, whereas a firm, enlarged, non-tender lymph node palpable in the axilla of a female patient may be a sign of breast cancer. Regional lymph nodes draining the area of a lo

  • Physical Examinations II

    07:55
    Abdominal Exam I: Inspection and Auscultation

    Source: Alexander Goldfarb, MD, Assistant Professor of Medicine, Beth Israel Deaconess Medical Center, MA

    Gastrointestinal disease accounts for millions of office visits and hospital admissions annually. Physical examination of the abdomen is a crucial tool in diagnosing diseases of the gastrointestinal tract; in addition, it can help identify pathological processes in cardiovascular, urinary, and other systems. As physical examination in general, the examination of the abdominal region is important for establishing physician-patient contact, for reaching the preliminary diagnosis and selecting subsequent laboratory and imaging tests, and determining the urgency of care. As with the other parts of a physical examination, visual inspection and auscultation of the abdomen are done in a systematic fashion so that no potential findings are missed. Special attention should be paid to potential problems already identified by the patient's history. Here we assume that the patient has already been identified, and has had history taken, symptoms discussed, and areas of potential concern identified. In this video we will not review the patient's history; instead, we will go directly to the physical examination. Before we get to the examination, let's briefly review surface landmarks of the abdominal region, abdominal anatomy, and topography. Here is a list of useful landmarks: costal margins, xiphoid

  • Physical Examinations II

    06:49
    Abdominal Exam II: Percussion

    Source: Alexander Goldfarb, MD, Assistant Professor of Medicine, Beth Israel Deaconess Medical Center, MA

    Medical percussion is based on the difference in pitch between the sounds elicited by tapping on the body wall. The auditory response to tapping depends on the ease with which the body wall vibrates, and is influenced by underlying organs, strength of the stroke, and the state of the body wall. There are three main medical percussion sounds: resonance (heard over lungs), tympany (heard over the air-filled bowel loops), and dullness (heard over fluid or solid organs). The contrast between dullness vs. tympany or resonance allows for determination of the size and margins of organs and masses, as well as identification of fluid accumulation and areas of consolidation. Percussion remains an intricate part of the physical diagnosis since it was first introduced more than 200 years ago, and is especially useful in examination of the lungs and abdomen. As a part of an abdominal examination, percussion follows visual inspection and auscultation. The examiner should first percuss over each of the nine abdominal regions (epigastric region, right hypochondriac region, left hypochondriac region, umbilical region, right lumbar region, left lumbar region, hypogastric region, right inguinal region, and left inguinal region). Tenderness elicited by percussion is abnormal, and peritoneal inflammation should be su

  • Physical Examinations II

    08:24
    Abdominal Exam III: Palpation

    Source: Alexander Goldfarb, MD, Assistant Professor of Medicine, Beth Israel Deaconess Medical Center, MA

    Abdominal palpation, if performed correctly, allows for examination of the large and relatively superficial organs; for a skilled examiner, it allows for assessment of the smaller and deeper structures as well. The amount of information that can be obtained by palpation of the abdominal area also depends on the anatomical characteristics of the patient. For example, obesity might make palpation of internal organs difficult and require that additional maneuvers be performed. Abdominal palpation provides valuable information regarding localization of the problem and its severity, as abdominal palpation identifies the areas of tenderness as well as presence of organomegaly and tumors. The specific focus of palpation is driven by the information collected during history taking and other elements of the abdominal exam. Palpation helps to integrate this information and develop the strategy for subsequent diagnostic steps.

  • Physical Examinations II

    13:31
    Abdominal Exam IV: Acute Abdominal Pain Assessment

    Source: Joseph Donroe, MD, Internal Medicine and Pediatrics, Yale School of Medicine, New Haven, CT

    Abdominal pain is a frequent presenting concern in both the emergency department and the office setting. Acute abdominal pain is defined as pain lasting less than seven days, while an acute abdomen refers to the abrupt onset of severe abdominal pain with features suggesting a surgically intervenable process. The differential diagnosis of acute abdominal pain is broad; thus, clinicians must have a systematic method of examination guided by a careful history, remembering that pathology outside of the abdomen can also cause abdominal pain, including pulmonary, cardiac, rectal, and genital disorders. Terminology for describing the location of abdominal tenderness includes the right and left upper and lower quadrants, and the epigastric, umbilical, and hypogastric regions (Figures 1, 2). Thorough examination requires an organized approach involving inspection, auscultation, percussion, and palpation, with each maneuver performed purposefully and with a clear mental representation of the anatomy. Rather than palpating randomly across the abdomen, begin palpating remotely from the site of tenderness, moving systematically toward the tender region, and thinking about what lies below the fingers at each position. A helpful technique is to imagine a clock face with the xiphoid process at 12:00 and the pubic symphysis at 6

  • Physical Examinations II

    09:38
    Male Rectal Exam

    Source: Joseph Donroe, MD, Internal Medicine and Pediatrics, Yale School of Medicine, New Haven, CT

    While its usefulness in cancer screening is debated, the male rectal examination remains an important part of the physical exam. The exam is indicated in selected patients with lower urinary tract symptoms, urinary and/or fecal incontinence or retention, back pain, anorectal symptoms, abdominal complaints, trauma patients, unexplained anemia, weight loss, or bone pain. There are no absolute contraindications to the rectal exam; however, relative contraindications include patient unwillingness to undergo the exam, severe rectal pain, recent anorectal surgery or trauma, and neutropenia. When performing the rectal exam, the examiner should conceptualize the relevant anatomy. The external anal sphincter is the most distal part of the anal canal, which extends three to four centimeters before transitioning into the rectum. The prostate gland lies anterior to the rectum, just beyond the anal canal. The posterior surface of the prostate, including its apex, base, lateral lobes, and median sulcus, can be palpated through the rectal wall (Figure 1). The normal consistency of the prostate is similar to the thenar eminence when the hand is in a tight fist. The thumb knuckle is representative of what a hard nodule may feel like. The normal size of the prostate increases with age and is approximately 4.0 cm by 3.5 cm, or

  • Physical Examinations II

    14:43
    Comprehensive Breast Exam

    Source: Alexandra Duncan, GTA, Praxis Clinical, New Haven, CT Tiffany Cook, GTA, Praxis Clinical, New Haven, CT Jaideep S. Talwalkar, MD, Internal Medicine and Pediatrics, Yale School of Medicine, New Haven, CT

    Breast exams are a key part of an annual gynecological exam and are important for all patients, no matter their sex or gender expression. One out of every 8 women will be diagnosed with breast cancer; male breast cancer, though less common, has a lifetime incidence of 1 in 1000. Breast exams can feel invasive to patients, so it is important to do everything possible to make the patients feel comfortable and empowered, rather than vulnerable. Examiners should be aware of what they are communicating, both verbally and non-verbally, and give their patients control wherever possible (for instance, always allowing them to remove their own gowns). Examiners may choose to utilize chaperones for the patients' (as well as their own) comfort. Some institutions require the use of chaperones. While it is always important to avoid overly clinical language, certain colloquial words can cross the line from caring to overly intimate in this exam. It is helpful to avoid the words "touch" and "feel" in this exam, as this language can feel sexualized. Instead, use words like "assess," "check," or "examine." Additionally, the best practice dictates avoiding assump

  • Physical Examinations II

    12:41
    Pelvic Exam I: Assessment of the External Genitalia

    Source: Alexandra Duncan, GTA, Praxis Clinical, New Haven, CT Tiffany Cook, GTA, Praxis Clinical, New Haven, CT Jaideep S. Talwalkar, MD, Internal Medicine and Pediatrics, Yale School of Medicine, New Haven, CT

    The pelvic exam can feel invasive to patients, so it is important to do everything possible to make patients feel comfortable and empowered, rather than vulnerable. Clinicians should be aware of how they are communicating, both verbally and nonverbally, and should give their patients control whenever possible. There are many ways to do this, from how the exam table is positioned to how the patient is engaged throughout the exam. As many as 1 in 5 patients may have experienced sexual trauma; therefore, it is important to avoid triggering those patients, but it's not always possible to know who they are. The exam in this video demonstrates neutral language and techniques that can be employed with all patients to create the best experience possible. It's important to keep the patient covered wherever possible and to minimize extraneous contact. A clinician should be careful to tuck fingers that aren't being used to examine the patient to avoid accidental contact with the clitoris or anus. Before performing the pelvic examination, examiners should find out how knowledgeable the patients are about the exam and their own bodies, and establish the expectation that the patients can communic

  • Physical Examinations II

    10:57
    Pelvic Exam II: Speculum Exam

    Source:

    Alexandra Duncan, GTA, Praxis Clinical, New Haven, CT

    Tiffany Cook, GTA, Praxis Clinical, New Haven, CT

    Jaideep S. Talwalkar, MD, Internal Medicine and Pediatrics, Yale School of Medicine, New Haven, CT

    Providing comfortable speculum placement is an important skill for providers to develop, since the speculum is a necessary tool in many gynecological procedures. Patients and providers are often anxious about the speculum exam, but it is entirely possible to place a speculum without patient discomfort. It's important for the clinician to be aware of the role language plays in creating a comfortable environment; for instance, a provider should refer to the speculum "bills" rather than "blades" to avoid upsetting the patient. There are two types of speculums: metal and plastic (Figure 1). This demonstration utilizes plastic, as plastic speculums are most commonly used in clinics for routine testing. When using a metal speculum, it's recommended to use a Graves speculum if the patient has given birth vaginally, and a Pederson speculum if the patient has not. Pederson and Graves speculums are different shapes, and both come in many different sizes (medium is used most often). Prior to placing a metal speculum, it is helpful to perform a digital cervical exam to assess for the appropriate speculum size. The depth and direction of the cervix is estimated by p

  • Physical Examinations II

    13:00
    Pelvic Exam III: Bimanual and Rectovaginal Exam

    Source:

    Alexandra Duncan, GTA, Praxis Clinical, New Haven, CT

    Tiffany Cook, GTA, Praxis Clinical, New Haven, CT

    Jaideep S. Talwalkar, MD, Internal Medicine and Pediatrics, Yale School of Medicine, New Haven, CT

    A bimanual exam is a thorough check of a patient's cervix, uterus, and ovaries. It can tell an experienced provider a great deal, as it may lead to the discovery of abnormalities, such as cysts, fibroids, or malignancies. However, it's useful even in the absence of such findings, as it allows the practitioner to establish an understanding of the patient's anatomy for future reference. Performing the bimanual exam before the speculum exam can help relax patients, mentally and physically, before what is often perceived as the "most invasive" part of the exam. A practitioner already familiar with the patient's anatomy can insert a speculum more smoothly and comfortably. However, lubrication used during the bimanual exam may interfere with processing certain samples obtained during the speculum exam. Providers must be familiar with local laboratory processing requirements before committing to a specific order of examination. This demonstration begins immediately after the end of the speculum exam; therefore, it assumes the patient has provided a history and is in the modified lithotomy position. A rectovaginal exam is not always necessary,

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