Physical examination

The physical examination, in clinical medicine, is the art of acquiring a small amount of information while looking fancy. It doesn't usually make the diagnosis... but can help you along that path.

The history is far more important. The radiology is more informative and the labs and pathology often more definitive.

The bit below is far from comprehensive and doesn't even think of pretending to be that. It was written from the perspective of someone that sorta knows the stuff. It is useful perhaps only as a review.

This was written to review the physical exam and serve as a template for the examination at autopsy... where one sees a lot more 'cause the subject doesn't have to be in one piece after one is done.

Respiratory

Inspection

Face & neck:

• Respiratory distress:
  • Purse-lip breathing.
  • Nasal flaring.
  • Cyanosis - lips, lingual frenulum.
• Trachea midline?
• Accessory neck muscle use.

Peripheral:

• Clubbing (lung causes DDx: abscess, bronchiectasis, cancer, decr. O2, empyema, fibrosis alveolitis).
  • Clubbing should be viewed with suspicion in patient with COPD, as it should not be seen in the context of pure emphysema. Clubbing in COPD is relatively rare; thus, in the context of COPD and smoking it should prompt a search for an occult lung cancer.
• Cyanosis - fingernails.

Chest:

• Respiratory distress:
  • Intercostal indrawing.
  • Diaphragmatic paradox.

Chest wall deformities:

• Kyphosis.
• Scoliosis.
• Barrel chest (seen in emphysema).
• Pectus excavatum.
• Pectus carinatum.

In trauma:

• Fail chest.
• Sucking chest wound.

Palpation

• Trachea midline (may be deviated in tension pneumothorax).

• Tactile fremitus (boy-o-boy or 99).

In trauma:

• Fail chest/broken ribs.
• Subcutaneous emphysema (popcorn popping sound).

Percussion

• Don't forget the apices.

Auscultation

• Bronchial at trachea.
• Vesicular at base.
• No wheeze. No stridor (upper airway). No crackles.

Vocal fremitus

• Egophony
• Whisper pectoriloquy

Extras

• Calf tenderness - think about DVT/PE.
• Homans' sign - calf pain on dorsiflexion (suggestive of DVT).
• Vitals - may help figure-out tumour vs. infection.

Precordial

Inspection

• Masses, scars, lesions, signs of trauma/previous surgery.

Palpation

Point of maximal impulse (mnemonic SALID):

• Size - should be less than 2-3 cm.
• Amplitude - should be tapping.
• Location - 5 ICS MCL.
• Impulse - monophasic (biphasic abnormal).
• Duration - <2/3 of systole.

Chest wall:

• Trills (at valve locations).
• Heaves with heel of hand.

Auscultation

• S1, S2 normal.
• No S3. No S4. No murmurs. No rub.

Head & neck

Neck nodes

• Submental.
• Submandibular.
• (Jugulodigastric).
• Pre-auricular.
• Post-auricular.
• Occipital.
• Posterior cervical.
• Superficial cervical.
• Deep cervical.
• Supraclavicular.
• Intraclavicular.

Thyroid

Inspection

• Masses, scars, lesions, signs of previous surgery or trauma.
• Swell/enlargement.
• Get patient to swallow.

Eyes:

• Exophthalmos.
• Lid retraction.
• Lid lag.

Skin:

• Sweaty (hyper)/dry (hypo).

Hair:

• Loss (hyper).

Periph.

• Tremor (hyper).
• Tibial myxedema.

Behavioural:

• Restlessness (hyper).

Palpation

• Use cricoid cartilage as a landmark.
• Palpate both lobes & isthmus - get patient to swallow whilst doing this.

Percussion

• None.

Auscultation

• Listen for bruit - get patient to hold their breath.

Extras

• Reflexes (hyperactive in hyper, hypoactive in hypo).
• Vitals
  • Tachycardia in hyper.
  • Rhythm disturbance (e.g. atrial fibrillation) in hyper.

General abdominal exam

Note that the order is different; it is not IPPA'. Auscultation is moved-up so one doesn't have a disturbed abdomen.

One should palpate the painful area last (for practical and psychological reasons).

Inspec.

• Masses, scars, lesions, signs of trauma & previous surgery.
• Distension.
• Bulging flanks.
• Ecchymoses:
  • Grey-Turner sign (flank).
  • Cullen's sign (periumbilical).
• +/-Stigmata of liver disease.

Auscultation

• Listen for bowel sounds - should listen for 1 minute to r/o movement.
  • Hyperactive in mechanical obstruction.
  • Tinkling in ileus.

Percussion

• Hyperresonance - upstream in mechanical obstruction.
• Dull - mass?

Palpation

• Soft/light... then deep.
• All four quadrants + periumbilical region.

Routine special

• Rectal examination with digital rectal exam and FOBT.
• Testicular exam/exam for hernias - particularly important in the context of small bowel obstruction (SBO).
• Murphy's sign (for cholecystitis) - stops inspiration when hand in RUQ (below gallbladder) - contacts the inflammed gallbladder.

Appendix

• Obturator sign - pain with internal rotation.
• Psoas sign - patient doesn't straighten leg (Px with extension when hip flexed).
• Rovsing sign - Px when poking at LLQ.
• Rebound tenderness - Px with quick letting go after deep palpation (hurts like hell... should warn the patient).

Liver

Inspection

Rule of fives.

Head - mnemonic FEATS:

• Fetor hepaticus (awful smell from mouth).
• Encephalopathy.
• Asterixis (mad flapper).
• Temporal wasting.
• Scleral icterus.

Hands:

• Leuconychia.
• Terry's nails.
• Clubbing.
• Palmer erythema.
• Dupuytren's contracture.

Body:

• Ecchymoses (Grey-Turner sign, Cullen's sign).
• Spider nevi.
• Bulging flanks.
• Testicular atropy.
• Jaundice.

Percussion

Liver span:

• 10-12 cm in males.
• 8-10 cm in females.

Palpation

• RLQ MCL to RUQ - look for liver edge.

Extras

• Should do spleen too... and rest of abdomen.

Spleen

Inspec.

• Masses etc.
• Stigmata of liver disease, lymphadenopathy.

Percussion

• Castell's sign - most sensitive.
  • 10 ICS ACL
  • Positive if dullness on inspiration.

Palpation

• RLQ to LUQ -- the spleen 'grows' (hypertrophies) down and to right side.

Pelvic examination

External

• Mass, scars, lesions, signs of trauma & previous surgery.
• Ulceration.
• Vaginal discharge/bleeding.
• Lymphadenopathy.

Internal

Speculum:

• Vaginal lesions.
• Cervical lesions - discharge, ulcerations.
• Do swabs.
• Do Pap test if none recent.

Bimanual:

• Uterine masses.
• Adnexal masses.
• Tenderness - adnexal.
• Cervical motion tenderness (think PID, appendicitis...).

Cranial nerves

Mnemonics:

• Oh Once One Takes The Anatomy Final Very Good Vacations Are Heavenly.
• Oh Oh Oh To Touch And Feel A Girl's Vagina And Hymen.

List:

• Olfactory (I).
• Optic (II).
• Oculomotor (III).
• Trochlear (IV).
• Trigeminal (V).
• Abducens (VI).
• Facial (VII).
• Vestibulocochlear (VIII).
• Glossopharyngeal (IX).
• Vagus (X).
• Accessory (XI).
• Hypoglossal (XII).

Integrated quick exam

• CN II: visual acuity, visual fields.
• CN II/III: pupils (round, regular and equal), no ptosis, papillary reflex (direct and consentual).
• CN III, IV, VI: smooth pursuit (H pattern), check for gaze nystagmus, check saccadic eye movement.
• CN II: fundoscopy.

• CN V (sensation): light touch V1, V2, V3.
• CN V (motor) - V3: open/close, lateral excursion, tense.

• CN VII (motor): frontalis, orbicularis occuli, puff cheeks, orbicularis oris, show teeth, whistle.
• mention corneal reflex (V1-VII).

• CN IX, X: "Ah" - palate symmetry.
• CN XI: sternomastoid - strength.
• CN XII: stick-out tongue.

Skipped:

• Optokinetic nystagmus - CN III, IV, VI.
• CN VII: skip taste ant. 2/3, parotid gl., lacrimal gl., stapedius m.
• Skip CN VIII entirely.

Screening neurologic exam

Adapted from: [1].

Mental status:

• Obtained during history.

CN:

• Visual acuity, visual fields, fundoscopy.
• Pupils (round, regular, equal), ptosis, pupillary reflex, accomodation (converge & constrict).
• Smooth pursuit, gaze nystagmus, saccadic eye movements.
• Face sensation (V1-V3).
• Face motor VII (eyebrows, eyes, puff cheeks, close mouth, show teeth, whistle).
• CN IX, X: "Ah" - observe palatal mvt.
• CN XI: sternocleidomastoid - strength.
• CN XII: stick-out tongue.

Motor:

• Muscle bulk & symmetry.
• Tone.
• Strength.
• Reflexes.

Sensory:

• Each limb one area:
  • Spinothalamic pathway test - light touch (could also use temp., pain).
  • Dorsal column pathway test - vibration (could also use proprioception).

Coordination:

• upper extremity - rapid alternating movements, finger-to-nose.
• lower extremity - heel walking, toe walking, heel-to-knee-to-shin.

Focused upper extremity exam

Light touch: T1 (pinky), C8 (ring finger), C7 (index finger), C6 (thumb). Vibration: T1 (pinky), C8 (ring finger), C7 (index finger), C6 (thumb).

Reflexes:

• Biceps C5 (C5, C6).
• Brachioradialis C6 (C5, C6) - brachioradialis is the beer drinker muscle... ergo 6... cause there are 6 beers in a pack.
• Triceps C7 (C6, C7).
• Finger extensors C7.
• Finger flexors C8 (C7-T1).

Motor:

• Biceps C5.
• Brachioradialis C6.
• Triceps C7.
• Finger extensors C7.
• Finger flexors C8.
• Thumb abduction and adduction T1.

See also

• Clinical history.