Physical examination

Habari! Welcome to the Wards: Your Hands as Diagnostic Tools

Congratulations on making it to Year 3! You've spent years with your head buried in Guyton, Hall, and Robbins. You've memorised the Krebs cycle and the brachial plexus. Now, the real work begins. Forget the lecture hall for a moment; your new classroom is the bedside, and your most important teachers are the patients. This lesson is about the art and science of the Physical Examination – the bridge between your patient's story and their diagnosis.

In a setting like ours, where a CT scanner or an MRI might not be immediately available, your ability to conduct a thorough physical exam is not just a skill; it's a superpower. It’s how you become a clinical detective, using your senses to uncover clues that lie hidden just beneath the skin.

The Four Cardinal Techniques: Your Clinical Toolkit (IPPA)

Every great detective has a toolkit. Yours consists of four fundamental techniques, always performed in this order (with one famous exception we'll discuss later!). Remember the acronym IPPA:

• I - Inspection
• P - Palpation
• P - Percussion
• A - Auscultation

Think of it like building a house here in Kenya:

1. Inspection: You first look at the *shamba* (land). You observe the slope, the soil, the general layout. Is it flat or hilly? Are there any obvious problems?
2. Palpation: You feel the ground. Is it firm and stable, or is it soft and marshy? You're assessing the foundation.
3. Percussion: The *fundi* (craftsman) taps on the walls. Does it sound solid or hollow? He's finding the strong points and the weak spots.
4. Auscultation: You listen. Is there the sound of water running in pipes you can't see? You're listening for hidden processes.

  The Clinical Workflow:
  +------------------+
  |    INSPECTION    |  (Look)
  |   (General &    |
  |     Specific)    |
  +--------+---------+
           |
           v
  +--------+---------+
  |    PALPATION     |  (Feel)
  | (Light & Deep)   |
  +--------+---------+
           |
           v
  +--------+---------+
  |    PERCUSSION    |  (Tap)
  |  (Direct &      |
  |    Indirect)     |
  +--------+---------+
           |
           v
  +--------+---------+
  |   AUSCULTATION   |  (Listen)
  |  (Stethoscope)   |
  +------------------+

The General Examination: The First Five Minutes Tell a Story

Before you zoom in on the heart or the lungs, you must perform a general survey. This is your first impression and it provides a wealth of information. What do you see when the patient walks in or as they lie in bed?

Key Components:

• General Appearance: Are they conscious, alert, and oriented? Do they look their stated age? Are they well-nourished, thin, or cachectic? Are they in any obvious distress?
• The Hands: A treasure trove of signs! Check for:
  • Clubbing: A sign of chronic hypoxia (e.g., bronchiectasis, cyanotic heart disease).
  • Koilonychia (spoon-shaped nails): Iron deficiency anaemia.
  • Pallor of the palmar creases: Suggests significant anaemia (Hb < 7 g/dL).
  • Splinter Haemorrhages: Tiny blood clots under the nails, a classic sign of infective endocarditis.
• Head & Neck:
  • Eyes: Check the sclera for jaundice (yellowness) and the conjunctiva for pallor.
  • Mouth: Look at the tongue for central cyanosis (bluish discolouration) and check for oral hydration.
  • The Jugular Venous Pressure (JVP): This is an estimate of the patient's central venous pressure and a crucial sign in assessing fluid status, especially in heart failure.

Image Suggestion: A close-up, high-quality clinical photograph of a patient's hand showing classic finger clubbing. The image should clearly display the loss of the nail bed angle (Schamroth's window sign). The patient should have dark skin to be representative of the local population.

Calculating the JVP: A Step-by-Step Guide

Measuring the JVP might seem intimidating, but it's a logical process. It's the vertical height of the blood column in the internal jugular vein above the sternal angle.

Step 1: Position the patient correctly.
   - Recline them at a 45-degree angle.
   - Ask them to turn their head slightly to the left.

Step 2: Identify the landmarks.
   - Locate the Sternal Angle (Angle of Louis), the bony ridge where the manubrium joins the sternal body.
   - Identify the pulsation of the Internal Jugular Vein (IJV) between the two heads of the sternocleidomastoid muscle. It's a soft, biphasic pulse that is non-palpable.

Step 3: Measure the height.
   - Place a ruler vertically on the Sternal Angle.
   - Place another ruler horizontally from the top of the IJV pulsation to the vertical ruler.
   - Read the vertical height in centimetres (cm).

Step 4: Calculate the final JVP.
   - The right atrium is considered to be 5 cm below the sternal angle.
   - Formula: JVP = [Measured Height (cm)] + 5 cm
   - A normal JVP is less than 8 cm H2O.

The Systems-Based Approach: The Deep Dive

After your general survey, you focus on the system relevant to the patient's complaint. We will cover each system in detail during your rotations, but here's a quick overview.

Respiratory Examination

You'll check for chest expansion, feel for tactile vocal fremitus, and percuss the lung fields. A normal lung is resonant. A lung filled with fluid (pleural effusion) or consolidated tissue (pneumonia) will be "stony dull" to percussion.

      ANTERIOR CHEST PERCUSSION AREAS

              \       /
 Supraclavicular   Supraclavicular
    +-----------+-----------+
    |   Right   |   Left    |  (2nd Intercostal Space)
    |   Upper   |   Upper   |
    +-----------+-----------+
    |   Right   |   Left    |  (4th Intercostal Space)
    |   Middle  |   Lingula |
    +-----------+-----------+
    |   Right   |   Left    |  (6th Intercostal Space)
    |   Lower   |   Lower   |
    +-----------+-----------+

Abdominal Examination - The Exception to the Rule!

Remember IPPA? For the abdomen, we change the order to Inspection, Auscultation, Percussion, Palpation (IAPP). Why?

Because palpating or percussing the abdomen can change the frequency of bowel sounds. So, we must listen before we touch. You'll listen for bowel sounds, then percuss for organ size and palpate for masses, tenderness, or organomegaly (e.g., hepatosplenomegaly from chronic malaria or schistosomiasis).

Image Suggestion: An instructional medical illustration showing the nine regions of the abdomen (epigastric, umbilical, hypogastric, etc.). Overlaying the diagram are arrows showing the correct direction for palpation, starting in the right iliac fossa and moving anti-clockwise, ending at the site of pain.

Putting It All Together: More Than Just Technique

A physical exam is not a robotic checklist. It's a conversation between you and the patient's body, and it requires respect, empathy, and professionalism.

• W.I.P.E.R: A great acronym to remember before you start!
  • W - Wash your hands. Always.
  • I - Introduce yourself. "Habari ya mchana, mimi ni daktari mwanafunzi [Your Name]." (Good afternoon, I am a student doctor...).
  • P - Permission. Ask for consent. "Ningependa kukupima. Je, ni sawa?" (I would like to examine you. Is that okay?).
  • E - Expose the patient appropriately, ensuring dignity and privacy with sheets or curtains.
  • R - Reposition the patient as needed.
• Examine from the Right Side: By convention, the physical exam is performed from the patient's right side. This standardises the approach, makes palpating the liver and spleen easier, and allows for better assessment of the JVP.

A Quick Story from the Wards:

I once had a student just like you examining an elderly *shosho* (grandmother) who came in with shortness of breath. The student was systematic. After noting her difficulty in breathing, he carefully examined her legs. He found pitting oedema up to her knees. He then correctly positioned her and found a significantly raised JVP. He auscultated her lungs and heard fine basal crackles. Before the consultant even arrived, he had confidently put together a diagnosis of congestive heart failure. He didn't use any fancy machine; he used his hands, his eyes, his ears, and his brain. That is the power of a good physical examination.

Your Journey Begins Now

My friends, your stethoscope is not a fashion accessory. It's your connection to the patient. The skills you learn now will serve you for your entire career, whether you end up in a top private hospital in Nairobi or a rural health clinic in Turkana. Be curious. Be gentle. Be thorough. The patients will teach you everything you need to know. Now, let's go to the wards and practice.