By Mille Vissing, MD, Mie Pilegaard Bjarnesen, BCs. med. and Mia Wangsmo Steffenssen, MD
The physical examination during the medical documentation has two objectives. First, to uncover the physical state of the patient to uncover any issues that might affect the treatment/surgery planned. Second, to prepare for the planned treatment by taking the correct measurements and noting details concerning the operating field. Not all parts of the following examination will be relevant for every patient, thus some elements can be left out if irrelevant. In the subsection concerning the various body parts, an examination of the condition and characteristics of the skin in the area should be noted in accordance with the steps listed in the “skin” subsection. The “skin” subsection itself is limited to notation of general skin conditions concerning multiple parts of the body i.e. rashes, eczema, or psoriasis.
General condition: Brief evaluation of consciousness and the patient’s general appearance.
Nutritional status: A rough assessment of the patient’s nutritional status (below average, average, or above average).
Vitals: Body temperature, respiratory rate, pulse, blood pressure, pulse oximetry as well as height, weight, and BMI.
Cranium/facies: Lesions or tumors found on the head, face, or ears. Skin conditions.
Eyes: Ectropion (condition where the lower eyelid turns outwards exposing the inner eyelid surface) and eyelid ptosis, symmetry of the pupils, pupillary light reflex, and conjunctiva.
Oral cavity/oropharynx: Lesions and palpatory findings in the oral cavity. It should be noted whether the patient has difficulty fully opening their mouth (significant in case of intubation) as well as the condition of the teeth and the mucosa of the oral cavity.
Neck: Skin condition, lymphadenitis, and goiter (abnormal enlargement of the thyroid gland).
Lymph nodes: Occipital region, neck, infra and supra clavicular, axillary, inguinal, and popliteal lymph node stations are thoroughly palpated, and pathological findings are noted with their accurate location, size (length, width, thickness) and mobility.
Heart auscultation: Heart rhythm and notation of the absence/presence of abnormal findings during stethoscope auscultation. In case of abnormalities these should be described in detail (systolic/diastolic, strong/weak) and whether they are previously known.
Lung auscultation: A description of the breathing; normal with little effort or difficult, absence/presence of wheezing, rhonchi, and crackles bilaterally in all lung fields during stethoscope auscultation.
Breasts: Do a systemic examination of both breasts in both standing and supine position including the following:
- Inspection: Note the skin conditions as well as any malignant signs such as skin dimpling, nipple retraction and nipple discharge. Secretion from the nipple should be specified in color, amount, and consistency. Describe symmetry of the breasts (fig. 2), the appearance of the nipples, and ptosis of the breasts using the terms in fig. 1.
Gland size, Tanner scale (Fig. 4), and pain in the breasts during the physical examination should be specified in cases with patients with gynecomastia.
- Palpation: Thoroughly palpate the breasts and describe any palpable tumors with estimated size, approximate distance from the dermis, location as on a dial (1-12 o’clock), and with distance in cm from the nipple. Note whether the tumor is clearly defined or situated in lumpy tissue.
- Measurements: Note breast size in CC/ml using sizing cups, jugulum-nipple distance, diameter of the nipple and measure the breast ptosis in cm. over the inframammary line (IMF) (Fig. 3).
Breast ptosis grades (Fig 1):
Breast shapes (Figure 2):
The standard breast measures (Fig 3):
Tanner scale (Fig 4):
Abdomen: Palpatory findings including but not limited to hepatomegaly and splenomegaly and description of scars and skin condition. In cases of MWL patients, measure ptosis over the mons pubis and any ptosis of the skin covering the umbilicus. Describe the skin quality with laxity, striae, and thickness of the subcutaneous layer.
Genitals: Note skin and palpatory findings.
Extremities: Note edema, skin condition, loss of sensation, capillary response, loss of function, and mobility. Describe peripheral pulses such as the dorsal artery of the foot or the posterior tibial artery. Foot pulses should be described when planning skin grafts on lower extremities, and if compression socks will be prescribed during admission. Other relevant findings such as varicose veins, AV-shunts, perfusion, and blood supply can be noted, especially the latter when planning flap reconstruction.
In cases of MWL patients, skin excess is described by measuring skin mobility in cm, ampleness in degrees or percentage of skin excess of the total width of the extremity. The circumference of the extremity should be noted, and when examining excess skin on the arms note the length of the excess skin from the edge of the muscle, when the arm is in a 90-degree angle from the body.
- Description of the general skin quality with skin-type I-IV, scars, sun damage, rashes, infection, field damage and skin turgor – the elasticity of the skin due to the fluids in the tissue (pinching the skin on the back of the hand and noting, if it returns slowly indicates a decrease in skin turgor and can be a quick and rough estimate of dehydration).
- The subcutaneous layer´s thickness is estimated along with laxity and hair-bearing areas when relevant.
- Both acute-, chronic- and clinically malignant wounds are described with location, size, boundaries, shape (elevated, round, papillomatous), color and signs of infection.
- Burns are described by the “hand rule”: The patient’s palm including fingers is equal to 1% of the patient’s total body skin surface. The degree of the burn is noted (1st, 2nd, 3rd depending on epidermal-, dermal-, or subdermal involvement).
- Relevant pigmented, macular, or nodular moles are also described by size and accurate anatomical localization. Signs of melanocytic malignancy should be noted including size (considered large if >6mm), asymmetry, uneven border, ulceration, several colors, and variation in pigmentation. If the patient is examined continuously, growth should be noted under patient history. Dermoscopy can be a useful if carcinoma is suspected. Note adherence, and whether the lesion is nodular, pearly, with telangiectasias or ulceration.
Illustrators: Christian Kaare Paaskesen, BSc. Med and Marie Helles, BSc. med.