Guerilla Clinic Basics – Physical Exam, Part One, by Teddy Beard (D.O.)
David Caldwell Log Cabin School – Virtual
Teddy Bear holds a Doctor of Osteopathy (D.O.) degree, and practices medicine as a general practitioner. As a hobby, Teddy collects various state’s medical licenses. Having entered medical school specifically with a coming collapse in mind, Teddy appreciates the opportunity to educate, viewing it as a form of caching. Teddy Bear trains to protect the innocent from monsters when the lights go out, and hopes you do, too.
Previous Installments:
TAKING A PATIENT HISTORY IN A CLINIC OR SICK VISIT SETTING
Physical Exam Part 1: Head, Neck, Chest, and Belly
Having reviewed how to take a history and review of systems, it’s time to discuss the physical exam. While it is true that a proper history can give us the majority of the information that we need to start diagnosing the problem, sometimes patients can’t communicate, due to their level of consciousness, age (small children), or a language barrier. This is when laying hands on our patient is absolutely essential. Done correctly, it also builds rapport with the patient. You may be able to diagnose shingles from a description over the phone, but the patient may not feel that you gave them proper care unless you visually inspect the lesion(s). Additionally as a provider, experience doesn’t mean omniscience, and patients can have more than one problem at the same time. To use the shingles example, maybe they’ve been scratching it to the point of breaking the skin, and now there’s a wound to deal with.
As a topic, physical exam techniques can be quite extensive, depending on what you are looking for. For the purposes of this article, which is designed to prepare you to evaluate a patient in a clinic setting, we will be discussing a general physical exam that is applicable and appropriate to most if not every patient you will see. In future articles, pertinent history and physical findings will accompany specific disease and injury discussions.
Head to toe examination is how I do my exam so that I don’t forget things, so that is how this article will lay it out. Also, the Inspect (look), Auscultate (listen), Percuss (thump), and Palpate (feel) (IAPP) will be included for each section as they apply.
Head and Neck
Inspect (look): on the scalp, look for bald spots, damaged skin, cuts (lacerations), sores, ticks, lice. On scalp, face and neck, lumps, bumps, bruises, and irregularly shaped moles. From the back and from the front, look for asymmetry in the head and neck. For example, eyes should look the same as each other, mouth corners level, trachea (adam’s apple) midline, and no veins standing out on the neck. If available, use an otoscope to inspect the ear canal and ear drum, as well use an ophthalmoscope to evaluate the back of the eye. A detailed discussion of eye examination will accompany a future case discussion on increased intracranial pressure.
Placing your thumbs gently just below the lower lids, ask your patient to look up. If you have applied just enough friction to their lower lids, the inside of the lid (conjunctiva) will be exposed. If it’s remarkably pale, the patient may have an iron deficiency. Also note at this time the color of the patient’s sclera aka the “whites of their eyes.” Yellow sclera can indicate jaundice, which suggests liver problems. Here is an example. ( https://physicaldiagnosispdx.com/gastroentereology-m/cirrhosis/ ) With your otoscope or even a penlight, you can examine the patient’s nostrils, looking for polyps or scabs.
Also with your pen light, you can examine the inside of the patient’s mouth, paying special attention to the condition of their teeth, gums, tongue, and roof of the mouth (hard palate). With or without a tongue depressor, you can ask your patient to stick their tongue out and say “Ah.” This moves the tongue out of the way. The act of making the “ah” sound lifts up the back of the roof of the mouth (soft palate) allowing you to visualize their tonsils, uvula, and pharynx. Notice the little red bumps on the hard palate of this patient with strep throat. https://physicaldiagnosispdx.com/infectious-disease-m/palatal-petechiae/
Auscultate: you can use your stethoscope on both side of the front of the neck to listen to bruits (whooshing noises in the carotid artery due to a disturbance in flow), or wheezing in the upper airway. Ask your patient to not talk whenever you auscultate, but especially on the neck as you are right over their vocal chords and it’s painfully loud when they speak.
Percuss: since the head and neck mostly contain solid structures, there is not much to percuss. With suspected sinusitis, you can tap or press gentle but firmly over the eyebrows and on both cheekbones below the eyes. Inflammation of the sinuses deep to these points will make these areas tender and percussing them will cause pain.
Palpate: this involves using our sense of touch, but carries a sense of probing, not simply light touch. In an adult, we can palpate firmly on the skull because we are looking for any signs of trauma such as bones moving when they shouldn’t. This is very different when we palpate the head of a newborn because their skulls haven’t finished developing and are relatively soft. One primary concern with palpating the head of newborn is to check that there is no swelling in the anterior fontanelle (the soft spot above the forehead) as that could be a sign of infection. On the other hand, a markedly depressed fontanelle is associated with dehydration in infants. I will keep my discussion of this topic limited, but my in-house pediatric specialist has agreed to write up an article on conducting a newborn exam.
Lymph nodes are primarily what we palpate regularly in the head and neck, other than a carotid pulse. (If you cannot find a carotid pulse, please rectify that immediately. :) ) Swollen lymph nodes, which are associated with the body fighting off an infection, feel like soft squishy jelly beans just under the skin. They run in chains, so we palpate for them using certain body landmarks, sweeping our fingers in a line across the skin. The preauricular chains are located just in front of the ears, and the retroauricular chains are located just behind the ears. In the neck, the anterior cervical chains run just in front the sternocleidomastoid (SCM) muscles and the superficial cervical chains run across and just behind the SCM. The SCM muscles are the big rope-like muscles that form a V in the front of your neck and contract when you touch your chin to your chest. The carotid arteries are palpable just to the inside (medial) of the SCMs. Do not put pressure over both of these arteries at once unless you want your patient to pass out.
The last thing to palpate in neck is the thyroid, which usually sits down low enough behind the sternum (breast bone) that it is not palpable. We can momentarily feel the thyroid when the patient swallows, so we stand behind the patient and place our fingers gently at the base of the neck where the SCMs come together and ask them to swallow. We should feel the same amount of tissue move under the skin on both sides, and we shouldn’t feel any hard spots within the softer thyroid gland.
Chest (Thorax)
This is the area of your body between the base of your neck and the end of your ribcage, not including your arms or shoulders. It contains the heart and lungs, as well as several large blood vessels.
Inspect: All physical exam techniques are higher quality when done with exposed parts of the body. For example, we are looking for accessory muscle use in breathing. This is common in labored breathing, and often involves pronounced use of neck muscles during the breathing cycle. We can also observe if the patient’s chest expands equally side to side. Obviously in trauma it is even more important that we expose the patient down to the skin to look for signs like bruising or breaks in the skin. To best evaluate for asymmetric chest wall motion, we place our hands in a C shape around the base of the patient’s posterior ribcage, with our thumbs toward each other, centered on the spine. We ask the patient to take a deep breath in, and see if one of our hands moved more than the other. You may have to ask the patient to breath in and out deeply a few times if the difference is subtle or you’re still getting used to the technique. Just keep in mind that multiple deep breathing cycles makes most people dizzy, so remember to give your patient a break. I usually don’t do more than six at one go.
Auscultate: This will be your primary modality with the thorax. Being pumps, the heart and lungs make certain noises as part of their normal function. To listen to the lungs, you will listen on the front and back of the chest, while listening to the heart only involves listening on the front, but often involves using both heads of your stethoscope (diaphragm and bell).
For the front lung auscultation, start by placing the diaphragm of your stethoscope (the big flat side) on the patients skin just below the middle of the collarbone and ask them to slowly take a deep breath in and out. You should hear air movement, but no crackles, wheezing, popping, or velcro-like noises. Now do the same on the other side. Next, move your steethoscope down and toward the middle of the chest, about where the breast pocket on a shirt would be and repeat the process. Then do the same on the other side. For your last two spots on the front, imagine the patient wearing a pistol in a horizontal-style shoulder holster. Your last front listening point will be where the end of the grip would touch the chest. Now do the corresponding point on the other side. Moving to the back, listen over the spot where the muzzle of the imaginary shoulder holstered pistol would sit, as well as the contralateral (opposite) side of the back. Moving up (cephalad) and in (medial) listen just below and inside the shoulder blades (scapulas) on each side. Having the patient cross their arms or hug themselves, will move the scapulas up and around the rear chest, giving you better listening spots. Have the patient maintain this posture as you listen just inside (medial) to the top of the scapula. Keep this listening landmarks in your mind’s eye, because you will also percuss over these same points.
Egophony is when the patient says E it sounds like A or “ah.” The mechanism is thought to be that the consolidated lung better transmits low frequency sounds and filters out some of the high frequency sounds, leading to this change in the sound. For examples of this go to https://physicaldiagnosispdx.com/pulmonology-m/egophony/ .
For cardiac auscultation, start with the larger side of your stethoscope and place it below the (patient’s) right collarbone near where the collarbone meets the breastbone (sternum). This is the aortic valve listening post, and if you hear a whooshing noise (murmur) between the “lub-dub” (S1 & S2) sounds that is loudest here, then the murmur is most likely due to an abnormality in the aortic valve. The aortic valve is the last valve that oxygenated blood goes through as it leaves the heart to go to the rest of the body via the aorta. The pulmonic valve listening post’s location mirrors the aortic valve listening post. The pulmonic valve allows deoxygenated blood to go from the heart to the lungs via the pulmonary arteries to be oxygenated. (Note that while we usually think of arteries as carrying more blood than their corresponding veins, the pulmonary arteries and veins are the reverse. This is because these arteries and veins are distinguished by whether they taking blood away from or toward the heart, respectively.)
The pulmonic and aortic valves close at the same time, forming the second sound “dub” (S2) in “lub-dub.” From the pulmonic listening post, move down the patient’s chest to the (patient’s) left side of the sternum and level with the nipples for a male. This location is the tricuspid valve listening post. This valve allows deoxygenated blood to move from the top chamber (atrium) to the bottom (ventricle) on the right side of the heart, so that the ventricle can push the blood through the pulmonic valve to the lungs. Since the tricuspid valve is not associated with a structure outside the heart like the lungs or aorta, it is named based on its structure, which is three parts (leaflets) coming together. A closed tricuspid valve looks like the mercedes-benz symbol. The fourth and final cardiac listening point is for the mitral valve, and is located just below and to the left of the left nipple for a male. (For a female, you should ask her to lift her breast in order listen at this location. The correct anatomical description for this is 5th intercostal space along the mid-clavicular line. This is an imaginary line drawn down from the middle of the collarbone. (Not only is this the best location to listen to the mitral valve, but it is also the location to palpate for the point of maximal impulse (PMI), discussed below.) The mitral valve allows oxygenated blood returning from the pulmonary circulation to move from the left atrium down into the left ventricle. Like the tricuspid valve, the mitral valve takes its name from its shape rather than location. Unlike the tricuspid’s three leaflets, the mitral valve has two leaflets, a resemble a mitre, the headgear of clergymen of certain church denominations. For a thorough cardiac auscultation, turn your stethoscope’s head 180 degrees so that the smaller side is the larger one was, and retrace your steps back through the listening posts: mitral, tricuspid, pulmonic, and aortic.
To listen various recorded heart sounds, check out this excellent website. https://physicaldiagnosispdx.com/cardiology-multimedia-new/
Percuss: This is a useful technique for determining changes in density of the organs in the thorax (chest) and abdomen/pelvis (belly). If you have ever looked for a stud in your wall by tapping on the paneling or sheetrock, you have percussed. Unlike that example, simply tapping directly on the body surface will not get us our best result. When you tapped on the wall, that surface formed a diaphragm like a drum that transformed your tapping into a sound. Humans are to soft and squishy for this to work, so we create a “drumhead” by pressing our non-dominate hand (fingers together) against the surface we are going to percuss. Our hand will serve the role that the wall did in the stud-finding example. Using one fingertip (usually the middle as it is longest) vigorously tap the fingers of your other hand as it remains pressed firmly against the chest. Done correctly, this will result in a hollow thumping sound. If you had heard any wheezing, crackles, popping, or a simply no air movement at all, you will want to pay special attention to that listening spot when you percuss. Percuss on and around the listening spot of interest, paying attention to changes in resonance as you tap over different points. If there is a higher tone like when you find a stud, you have found an area in the chest that has a higher density from the surrounding tissue. This could suggest fluids like blood (hemothorax), pus (empyema), plasma (pleural effusion), or solids such cancers, granulomas from tuberculosis, or lung scarring from past pneumonias. A lower tone on percussion, while more difficult to appreciate, would indicate lower density, such as pneumothorax.
Palpate: Since the rib cage is a rigid structure, there is not a lot of soft areas for us to palpate. We would feel for supraclavicular lymph nodes just above the collarbones, and we might feel for lymph nodes in the armpit (axilla) on both sides (bilaterally). Palpating for axillary lymph nodes is most commonly done when screening for breast cancer spread (metastasis).
PMI is the Point of Maximal Impulse, and is part of our heart exam. As noted above in the auscultation portion, you will find the PMI in the same area as where you listened to the mitral valve, mid-clavicular line, 5th intercostal space. Feeling the PMI takes practice, as it should be small and its location varies slightly from person to person. A PMI that is large and not near where we expect it suggests an enlarged and/or displaced heart, and so is a pathologic finding.
Another palpatory technique that complements the percussion technique to evaluate the lungs is called tactile fremitus and involves comparing felt vibrations through the chest wall as the patient says a standardized phrase, such as “toy boat.” You will want to use the most sensitive part of your hand for this, so check with your other hand where you are most ticklish. Have the patient repeat the phrase as you feel over their back. You are assessing for asymmetry, which may be abnormally decreased on one side or increased on the other. Decreased fremitus may be due to fluid (effusions) or air (pneumothorax) between the lung and chest wall (the extra interface causes some sounds to be reflected rather than transmitted), or increased air (lower density) in the lungs (COPD). Increased fremitus is felt in pneumonia, as the sound waves travel better through consolidated lung than air filled lung. However, if the bronchial tubes are blocked, you may not feel increased fremitus (or hear bronchial breath sounds or vocal resonance).
Belly (Abdomen)
For our consideration of the abdomen, we first define its boundaries, then how we subdivide it for examination. The abdomen is the region of trunk below the ribcage and above the beltline. (Below the beltline we consider the pelvis.) We subdivide the abdomen into quadrants. Think of a crosshair or plus sign, centered on the bellybutton (umbilicus). The patient’s right upper quadrant (RUQ) lies over the liver, gallbladder, and the corner of the ascending colon leading into the transverse colon. The LUQ lies over the stomach, pancreas, abdominal aorta, spleen, and corner of transverse colon into descending colon. The left lower quadrant (LLQ) lies over the descending colon. The RLQ lies over the appendix and junction of small bowel with the ascending colon, called the iliocecal junction.
Inspect: note if the abdomen is flat, distended, or obese. Look for unusual color, such as yellow from jaundice, purple or blue on the flanks or umbilicus from internal bleeding. Also look for spider angiomas in patients you suspect for cirrhosis.
Here is an example of spider angiomas. https://physicaldiagnosispdx.com/gastroentereology-m/spider-angioma/
If the abdomen is distended, we are very concerned for infection. A rigid, distended abdomen is commonly referred to as a “surgical abdomen” because that patient will need a surgical solution to their problem.
Auscultate: place your stethoscope over the center of each quadrant. You are listening for bowel sounds. Everyone is a little different with how much noise their bowel makes, so you just need to listen to different people to get an idea of normal variation. Here is an example of concerning sounds from a bowel obstruction. https://physicaldiagnosispdx.com/cardiology-multimedia-new/high-pitched-bowel/
Percuss: the technique for percussion is as outlined above in the thoracic exam section. In the RUQ, start your percussion at the bottom of the ribcage. A healthy liver should not extend below the ribs, but a cirrhotic liver can extend below the ribs. In that case, when you percuss you get the same sounds as over the ribs. If the patient has inflammation of the gallbladder, tenderness to percussion may be your first sign. In the LUQ, we can use percussion to evaluate for an enlarged spleen the same way we evaluated the liver. In the LLQ, percussing can tell you if someone has a lot of gas in the bowel, or the reverse in the case of constipation. You may or may not elicit pain in on the LLQ in a patient with appendicitis. In the RLQ, we will often elicit pain when percussing in a patient with appendicitis.
Similar to percussion, we can tap with a closed fist on the back over the angle where the ribs meet the spine. This spot is called the costovertrebal angle (CVA). This is a exam technique for a person with a suspected kidney stone (nephthrolithiasis).
Palpate: Roll your flattened hand across each quadrant. If you have a particular area that you expect will be tender, start away from that area and work your way toward it. For a given spot, first palpate lightly, then probe deeper. Here is an example of palpating the RLQ in a case of appendicitis. https://physicaldiagnosispdx.com/gastroentereology-m/acute-appendicitis/
Regarding appendicitis, other than pushing down directly over the appendix in the RLQ, there is another physical exam technique called Rovsing’s sign. This is performed by pushing down slowly into the LLQ, then releasing pressure quickly. Pain from this technique is indicative of appendicitis.
In the interest of getting this article out without further delay, I am going to break the physical exam discussion here. We will be continuing with this topic, covering musculoskeletal, neurologic, and genitourinary exams in the next installment.
Special equipment: An otoscope is that handheld light that the doctor stuck in your ear. An ophthalmoscope was the handheld light (other than a penlight) that he shown in your eye and really close to your face. Small, battery powered versions of these are available on amazon, and are the least expensive option of their type.
AA-powered Otoscope
AAA-powered Otoscope
A less expensive otoscope
https://store.doomandbloom.net/otoscope-ear-scope-with-light-pocket-size-red-color/
A least expensive option that also includes an ophthalmoscope head
Stethoscope:
Non-electronic, updated version of what I use:
Somewhat less expensive, but also good one that a friend uses:
Note: both of the above have two heads, which allow for listening to sounds at different depths as well on having a smaller head for pediatric patients. Also, I recommend avoiding electronic extras on this basic piece of gear, as it’s one more thing to eat batteries unnecessarily, and one more piece of electronics to break.
If you would like to practice these skills and use these tools in person, consider coming out to a class with Stuck Pig Medical. I have been more than pleased with my experience as a student in virtual classes with MechMedic, and am looking forward to assisting with the upcoming field sanitation and clinical skills class in June. Hope to see you there. (I have no financial relationship to disclose.)
Registration is available at this link:
https://stuckpigmedical.com/product/guerilla-clinic-foundation/
For further reading, consider purchasing the Survival Medicine Handbook. Physical exam is just one of many topics it covers. https://a.co/d/0Jb9iPD
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