Guerilla Clinic Basics – Physical Exam, Part Two, 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 2: Musculoskeletal/Neurological
Inspect: Symmetry is key to examining these body systems. Atrophy, or the loss of muscle mass due to nerve damage or disuse, is most easily appreciated when there is a normal side to compare to. Bilateral atrophy due to disuse is most common in the recovering hospitalized patient or a wheelchair-bound patient. We can expect patients to lose muscle mass in their legs if they are not up and walking around.
Facial asymmetry (droop) is due to a neurologic problem, but not necessarily a stroke. If one whole half of the patient’s face droops or does not move, they have Bell’s palsy, a peripheral nerve disorder and not as serious as a stroke. If only the lower half of one side of the face (usually most noticeable as the corner of the mouth) droops, but the patient can still raise his eyebrows and wrinkle his forehead symmetrically, you are looking at a patient with a stroke, more formally known as a cerebral vascular accident (CVA).
Another part of inspection is to have the patient walk for you if they are able. Observe their normal gait, then have them across the room heel-to-toe, up on their toes, and on their heels. Have them stand still with their feet together, holding both arms straight out in front of them, palms up and close their eyes. Be prepared to steady them if start to fall. If they lose their balance when they close their eyes, or one outstretched arm drifts out of alignment with the other own, they likely have some sort of brain stem, cerebellar, or spinal cord damage.
Auscultate: this is not applicable to these systems.
Percuss: When testing deep tendon reflexes (DTRs), the idea is create a nerve impulse by abruptly stretching a tendon. A common example of this is the patellar reflex. The ligament attached to the kneecap (patella) is struck smartly with a reflex hammer, and the knee momentarily extends, briefly causing a kicking motion (shield your patient from kicking you when this happens). Another method is to place your thumb onto the relaxed tendon, stretching is slightly, then briskly tapping your own thumb and feeling for the tendon to “jump.” While an exhaustive neuro exam involves 5 DTRs on each side, you can easily check biceps (big tendon at the elbow that pops out when you do a curl) and patellar DTRs bilaterally as part of your general exam.
Don’t tell any neurologists I told you this, but common practice outside of neurology is to use the side of your stethoscope instead of a reflex hammer. If you would like have a dedicated reflex hammer, I will put the link below in the equipment section.
Palpate: We want to know active (patient moves their body) range of motion (ROM), for the neck, trunk, arms, and legs. For the neck and trunk, we want them to show flexion (bending forward), extension (bending backward), side-to-side, and rotational. For the limbs, we want to see full rotational ROM for ball-and-socket joints of the shoulders and hips, as well as the compound joints of the wrists and ankles. For the joints of the elbows and knees, we simple need flexion and extension (bend and straighten). It may be useful to also test passive ROM by having the patient relax and moving the limb for them. This is especially helpful if the patient’s active ROM is limited by pain. If the patient is reporting pain in an area, it is appropriate to gently squeeze the limb above and below the problematic area to determine the extent of the painful area. Some pain is relieved by pressure, but most painful areas will also be tender to palpation. With regard to the hinge joints, don’t forget to test for laxity forward/backward and side-to-side. This is done by fixing the distal limb (put the hand/wrist in your armpit; pin the foot under your thigh) and applying sideways pressure to the hinge joint in question.
Conclusion
As the purpose of this article is to describe a general exam you can perform on every patient, we will save the genitourinary exams for a separate discussion, as well as other more specialized exams including infants and small children.
Special equipment:
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 as having a smaller head that can be ideal 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.
A much less expensive option that will work adequately under ideal circumstances:
Babinski reflex hammer:
https://www.amazon.com/MDF-Neurological-superficial-responses-Free-Parts/dp/
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
If you are already a medical provider or healthcare professional and would like even further reading, I recommend Improvised Medicine by Kenneth V. Iserson. https://www.amazon.com/Improvised-Medicine-Providing-Extreme-Environments/dp/
Share This Story, Choose Your Platform!
About the Author: Patriotman
One Comment
Comments are closed.
Related Posts
GUNS N GEAR
Great info! I tell people, in a SHTF scenario, there isn’t going to be trained healthcare professionals around & most if not all hospitals will be closed. Medical supplies could possibly be all gone or nowhere to be found. Train & prepare now. By the way, nobody is coming to save you!