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36 CHAPTER 3: Physical Examination
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Phase D. Examination of the anterior neck and chest, breasts, axillae, abdomen, legs, and feet.
Patient and examiner positions.
iner standing on the patient’s right, even if left-handed. Starting at the neck,
work toward the feet exposing one area at a time: the neck, anterior chest,
each breast separately, abdomen, groin, and legs.
Neck
Inspection. Observe the neck veins for fullness and pulsations.
Chest and precordium
Inspection. Inspect for deformities of the sternum and ribs then identify the
apical impulse.
Palpation. Palpate the apical impulse then search for lifts, heaves, and other
palpable cardiac signs.
Percussion. Percuss the lung elds anteriorly identifying the border of cardiac
dullness.
Auscultation. Starting at the apical impulse, identify the rst heart sound. Listen at the apex, the lower and upper left sternal borders, in the second right
intercostal space, and at the carotid bifurcation. Next auscultate lung sounds
on the anterior chest and in supraclavicular fossae.
Breasts. Expose each breast separately.
Inspection.
traction.
Inspect the breasts for symmetry, skin dimpling, or nipple re-
Patient is draped lying supine with exam-
Palpation. Palpate the breasts and nipples.
Axillae
Inspection. Lift the arms exposing the axilla to inspection.
Palpation. With patient’s arms at their sides, palpate for axillary and infracla-
vicular lymph nodes.
Abdomen. Reposition the drape over the chest and expose the abdomen from
below the breasts to the symphysis pubis. Relax the abdominal wall muscles
by having the patient ex the hips and knees.
Inspection. Observe the symmetry and shape of the abdomen while noting
scars and skin lesions. Tensing the abdominal muscles will reveal an abdominal wall hernia (Fig. 3-3).
Auscultation. Listen over the epigastrium, both anks, and both femoral triangles.
The Screening Physical Examination 37
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FIG. 3-3Abdominal Wall Hernia. This hernia is not evident when the patient is at rest on the exam table. Straining
forces the abdominal contents into the hernia as the abdominal wall muscles contract.
Percussion. Percuss the abdomen noting areas of tympany or tenderness.
Identify the liver by denitive percussion. Percuss above the left costal margin for splenomegaly.
Palpation. Perform supercial and deep palpation of the abdomen. Palpate
deeply to identify the aorta then palpate both femoral pulses and the inguinal
lymph nodes.
Legs and feet.
Inspection.
tucked sheet when examining the inner thighs. Flex each hip to 90° and perform internal and external rotation.
Palpation. Palpate dorsalis pedis and posterior tibial pulses. Palpate for edema and any areas of asymmetry, deformity, or joint enlargement.
Return the patient to the sitting position. This is the time to do further
neurologic examination as indicated by the history and exam to this point.
Phase E. Supplementary neurological exam, sitting.
Patient and examiner positions. Patient is draped and seated facing the examiner.
Screening neurologic exam.
the arms, reexes, and sensation (position, vibration, touch, and 10-g monolament), followed by stance, gait, and leg strength in Phase F.
Phase F. Supplemental neurologic and spine exams, standing. Done only if
the history or exam suggests neurologic disease or back problems.
Patient and examiner positions. Patient is standing facing the examiner.
Inspection. Observe the stance, then perform the Romberg maneuver. Check
the range of spinal motion. The patient walks away from the examiner, then
Cover the abdomen then expose the legs and feet.
Inspect skin, muscles, and joints. Keep genitalia covered with a
Test cranial nerves, muscle tone and strength in
38 CHAPTER 3: Physical Examination
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turns and walks back; repeat on tip toes and heels. Have the patient hop on
the balls of both feet, and then, if possible, on one foot at a time.
Phase G. The urogenital exams
Patient and examiner positions. Female patients should be in the lithotomy
position, male patients standing; examiner at the foot of the table.
Females.
sition. Perform the pelvic and rectal exams, see page 34.
Males.
Inspection.
Palpation.
table in the left lateral decubitus position.
Inspection. Examine the perineum and anus.
Palpation.
hygiene in view of the patient. Excuse yourself and exit the room.
Phase H. Concluding the visit. The patient dresses while alone in the exam
room. When you return, make sure the patient is comfortable. Review the
exam ndings, problem list, and recommendations for diagnostic tests, treatment, and follow-up. Conclude by asking if there are any questions. Arrange
a follow-up appointment appropriate for the patient and the problems.
years. Remember, the screening examination’s purpose is to detect signicant abnormalities in any body region or system, establish a baseline against
which future ndings are compared, and continually hone the clinician’s
exam skills. Truncating the exam in the interest of false efciency leads to
overlooking important ndings and loss of valuable clinical experience.
With the help of an assistant, the patient assumes the lithotomy po-
The patient stands facing the examiner.
Inspect the penis, scrotum, and inguinal areas.
Palpate the testes and evaluate for inguinal hernias.
Next, have the patient turn and bend over the exam table, or lie on the
Perform the rectal and prostate exams.
Provide tissues for the patient to clean themselves and repeat hand
The preceding routine has served the senior author well for many
ULTRASOUND IN BEDSIDE DIAGNOSIS
Ultrasound is a versatile diagnostic modality permitting real-time bedside
visualization of dynamic anatomy synergizing naturally with the physical exam. If ultrasound is being considered to conrm or exclude a disease
process, then an initial bedside ultrasound could prove useful increasing
efciency.
Technical Considerations: A basic understanding of the physics of ultraso-
nography is essential for proper use of this tool. Ultrasound imaging detects
ultrasound waves reecting from the body’s tissues. The intensity of the
reected wave is directly proportional to the tissue density. The exceptions
are gas-lled structures which do not transmit the ultrasound wave and
therefore block penetration to deeper structures, and, at the other extreme,
Ultrasound in Bedside Diagnosis 39
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bone so dense that ultrasound cannot penetrate. The boundaries between tissues of different density are seen most clearly. This is an important consideration in deciding which probe to use and how to obtain the best image.
B-mode. Basic gray scale two-dimensional images refer to the standard black
and white image on the ultrasound monitor.
Machine presets.
based on the anatomy being scanned.
The depth controls how much distance into the body the image dis-
Depth.
plays in the far eld.
Gain.
This adjusts the signal amplication, essentially how hard the machine
“listens” for returning echoes. As the gain is increased, all returning echoes
are amplied producing a brighter image. The correct gain is that which balances the desired signal against the background noise.
Zoom. This function allows magnication of one area on the screen.
M-mode.
ring in a one-dimensional scan line is displayed on the vertical axis over time
on the horizontal axis. It is used in conjunction with B-mode scanning. The
M-mode cursor is placed over the moving object on the B-mode image, and
the M-mode button is pressed. This is very helpful in measuring the respiratory variability of the inferior vena cava (to assess volume status) and in
evaluating the chest for pneumothorax.
Probe selection. Ultrasound probes are described by the size and shape of
their face (footprint). High-frequency probes provide better resolution at
the expense of decreased penetration compared with low-frequency probes
which provide better penetration with less resolution. Three basic probes are
used for a goal-directed ultrasound.
Linear (frequency 5–13 MHz). High frequency and better for imaging supercial structures and vessels.
Most machines have settings that will adjust an image
This is the mode to visualize moving structures. The motion occur-
Curvilinear (frequency 1–8 MHz). Wider footprint and lower frequency for
transabdominal imaging.
Phased array probe (frequency 2–8 MHz).
maneuvering between ribs which is ideal for echocardiography.
Ultrasound orientation. Orientation is a key to understanding what is seen
on the display screen. The two main aspects of orientation are: (1) how the
indicator is oriented relative to the screen, and (2) how the probe and the
indicator are oriented relative to the patient. Ultrasound orientation can be
challenging because it involves understanding how a two-dimensional plane
cuts through a three-dimensional object not just in the three standard planes
(sagittal, transverse, or coronal), but at any orientation.
Smaller footprint which allows
40 CHAPTER 3: Physical Examination
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Indicator–screen orientation. The “indicator” on the probe may differ between manufacturers but is typically a bump or a groove. There are two rules
for this orientation: (1) the left side of the screen corresponds to the side of
the probe marked with the indicator, and (2) the top of the screen displays
structures closer to the probe and the bottom of the screen those farthest away
from the probe.
Indicator–patient orientation.
the probe is placed on the patient, and images are viewed on the screen. Most
diagnostic ultrasounds are performed using the standard orientation where
the indicator (screen left) is toward the patient’s right, patients head, or in the
arc between these directions.
Anatomic planes. There are three standard anatomic planes scanned in diagnostic ultrasonography.
Transverse plane.
the anterior surface of the patient with indicator directed toward the patient’s right. In this orientation, anterior structures will be toward the top of
the screen, and right-sided structures will be on the left side of the screen as
viewed.
Sagittal plane. The sagittal plane is obtained by placing the probe on the
anterior of the patient with the indicator toward the patient’s head. In this
orientation, anterior structures will be toward the top of the screen, and the
patient’s head (cephalad structures) is to the left of the screen and feet (caudal
structures) to the right.
Coronal plane. The coronal plane is obtained by placing the probe on the
right or left ank with the indicator to the patient’s head. If the probe is on
the right ank, the top of the screen will be right and the bottom left. If the
probe is on the left, the top of the screen will be left and the bottom right. In
both the cases, the indicator should be directed to the patient’s head, and thus
the cephalad structures will be on the left of the screen and caudal structures
will be on right.
Scope of Ultrasound in Diagnostic Examination
Symptom- or sign-based ultrasound. This uses specic algorithms that
delineate which organ system should be examined based on patient’s
primary complaints, e.g., shortness of breath, chest pain, undifferentiated
hypotension, or undifferentiated abdominal pain. Bedside ultrasound should be
limited and goal-directed, which means that the purpose of the examination
must be clearly specied and goal-directed to impact the clinical decisionmaking of the physician performing the exam. If there is suspicion of a
particular disease, the study should be limited to a specic organ system that
can be expeditiously evaluated. After formulating a diagnostic hypothesis
and differential diagnosis based on the patient’s presenting symptoms and
signs, a quick focused ultrasound may identify the correct diagnosis and hasten treatment. These are some examples where ultrasound can be a useful
adjunct to physical examination:
The transverse plane is obtained by placing the probe on
Once indicator–screen orientation is veried,
Ultrasound in Bedside Diagnosis 41
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Abdominal pain. A quick bedside ultrasound can be used to identify free uid,
abdominal aortic aneurysm, acute cholecystitis, or hydronephrosis.
Chest pain and shortness of breath. The chest can be evaluated for pleural
effusion and the lung for interstitial pulmonary edema. The heart can
be assessed for systolic function, pericardial effusion, and signs of right
ventricular strain.
Hypotension. Bedside ultrasound can quickly evaluate for free uid and
abdominal aortic aneurysm. Volume status is ascertained from inferior
vena cava dimensions. Focused echocardiography identies cardiac dysfunction and pericardial effusion.
Diagnostic ultrasound for an emergent condition.
diagnose an emergent condition at the bedside, e.g., to assess for pneumothorax in a patient presenting shortness of breath or a ruptured aneurysm in a
patient presenting with abdominal pain. Ultrasound can assist in the evaluation of an unstable patient who cannot give a good history and/or cannot be
safely transported for denitive imaging.
Ultrasound is used to
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PART 2
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The Diagnostic Examination
In order to observe one must learn to compare. In order to
compare one must have observed. By means of observation
knowledge is generated; on the other hand knowledge is
needed for observation. And he observes badly who does
not know how to use what he has observed. The fruit grower
inspects the apple tree with a keener eye than the walker but
no one can see man exactly unless he knows it is man who is
the measure of man.
The art of observation applied to men is but a branch of
the art of dealing with men.
–B B
“Speech to Danish Working Class Actors on the Art of
Improvisation”
Early learn to appreciate the differences between the
descriptions of disease and the manifestations of that disease in
an individual—the difference between the composite portrait
and one of the component pictures.
–S W O
Not only to perceive the thing sharply, but to perceive the
relationships between many things sharply perceived.
–T R
“Poetry and Craft”
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44 PART 2: The Diagnostic Examination
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The Diagnostic Examination: Chapters 4 to 15
This section, organized by body region, explains the diagnostic utility of the
symptoms and signs commonly associated with each region, often with a
brief summary of the relevant physiology.
Each chapter is organized in the following sequence:
A brief review of the Major Systems examined, including relevant physiology, and anatomic landmarks.
The Physical Exam of the region.
The Symptoms commonly associated with region.
The Signs commonly encountered during examination of this region.
The Diseases and Syndromes associated with symptoms and signs in the
region.
The symptoms and signs are set in boldface type as paragraph heads.
These are clues to the pathophysiology of each disease which is important
for accurate diagnostic hypotheses. The key symptoms are commonly chief
complaints. The clinician should be familiar with the diseases and syndromes
summarized in the last subsection.
Symptoms, signs, and syndromes marked with the icon
need for urgent evaluation to avoid delaying diagnosis of a life-threatening
condition.
The signs are placed in approximate order as they are encountered during the head-to-foot physical exam.
When particular symptoms and signs are useful in differentiating
between the various etiologies, they are discussed after the
Some ndings are both a symptom and a sign. For instance, severe jaundice can be both the patient’s symptom and a clinical sign. In these instances,
the nding is discussed where it most commonly occurs: vomiting is most
often a symptom, though it can be witnessed; tenderness, although noted by
the patient, is a sign elicited by the examiner.
Diseases and syndromes associated with each symptom and sign are
listed under
CLINICAL OCCURRENCE.
signal the
DDX: notation.
CHAPTER 4
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Vital Signs, Anthropometric
Data, and Pain
This chapter discusses the vital signs (temperature, pulse, respirations, and
blood pressure [BP]), followed by measures of body size (height, weight, and
body-mass-index [BMI]), and nishes with pain assessment.
VITAL SIGNS
Why are temperature, pulse, respirations, and BP called vital signs? These
are the signs of life (L. vitalis, from vita: life); their presence conrms life and
their absence conrms death. The more abnormal these parameters become,
singly, but especially in combination, the greater the life is threatened. Since
ancient times, practitioners have used skin temperature, pulse, and respirations as prognostic signs. More recently, the BP was found to have similar predictive value. Entire texts were written on the interpretation of pulse, fever,
and respiratory patterns. It is now apparent that these signs are insufcient
for establishing a specic diagnosis. On the other hand, they are sensitive
indicators of disordered physiology and are useful in forming pathophysiologic hypotheses and differential diagnoses. They are strongly correlated
with severity of illness and outcome.
Body Temperature: Internal body temperature is tightly regulated to main-
tain vital organ function, particularly the brain. Temperature deviation of
more than 4°C above or below normal can produce life-threatening cellular
dysfunction. Internal temperature is regulated by the hypothalamus, which
maintains a temperature set point. The autonomic nervous system maintains
body temperature by regulating blood ow, conducting heat from the internal organs to the skin, and innervating sweat glands. Increasing ow and
dilating cutaneous capillaries radiate heat away by conductive loss whereas
sweat increases evaporative heat loss. Behavioral adaptations are also important. In hot conditions, people become less active seeking shade or a cooler
environment. Decreased body temperature is countered by shivering, which
generates heat, and by behavioral adaptations such as putting on clothes and
seeking a warmer environment. Sustained temperature deviation indicates
a change in the set point, increased heat production, decreased heat dissipation, failure of the regulatory systems, or any combination of those.
Record the patient’s temperature at each visit to establish a baseline
for future reference. Deviations from this baseline are either fever or hypothermia. Scales on clinical thermometers are either Fahrenheit or Celsius.
Conveniently remembered clinical equivalents are 35°C = 95°F, 37°C =
98.6°F, and 40°C = 104°F.
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