Physical Exam

Rapid Review

• Background
  • Eye examination should be performed with any complaint of vision loss, red eye, upper respiratory infection, neurological deficit, suspected toxicity, or head trauma
• Common Findings
  • Acute Angle-closure glaucoma
    • Fixed, mid-dilated pupil
    • Cloudy cornea
  • Anterior Uveitis
    • Ciliary flush
    • Photophobia
  • Blepharitis
    • Erythematous eyelid w/ crusting/scaling
  • Conjunctivitis
    • Red/pink eye w/ purulent yellow discharge and crusting
  • Central Retinal Artery Occlusion
    • “Cherry red spot” on fundoscopy
  • Central Retinal Vein Occlusion
    • “Blood and thunder” on fundoscopy
  • Optic Neuritis
    • Afferent pupillary defect
    • “Uhthoff phenomenon” (worsening of vision w/ elevated body temperature)
  • Retinal Detachment
    • Hazy gray w/ white folds

Pearls

• Remember the 5 vital signs of the eye: (1) visual acuity, (2) intraocular pressure, (3) visual fields, (4) pupils, (5) extraocular motility. Your ophthalmology consultant will be expecting them.
• Eyelid inversions are must for any patient complaining of eye irritation or foreign body sensation. You’ll be surprised what you find!

Deep Dive

• The 8-Point Eye Exam (American Academy of Ophthalmology)

Rapid Review

• Background
  • Ear examination typically includes inspection, palpation, otoscopy, +/- tuning forks. Typically and is warranted for patients who complain of ear pain, hearing loss, tinnitus, discharge, or vertigo.
• Common Findings
  • Mastoiditis
    • Erythematous, tender mastoid
    • Loss of postauricular sulcus
    • Anteroinferior displacement of pinna
  • Otitis Media
    • Bulging, erythematous TM
    • Immobility of TM
  • Otitis Externa
    • Pain w/ palpation of tragus or traction to pinna
    • Erythematous external auditory, +/- purulent discharge
  • Tympanic Membrane Perforation
    • Bloody otorrhea
    • Hearing loss, tinnitus

Pearls

• Parent cooperation and positioning is key for successfu otoscopy in pediatric patients.
• The presence of “blisters” on the tympanic membrane is likely bullous myringitis, a common, but painful condition typically caused by Strep pneumoniae

Deep Dive

• Trick of the Trade: Pediatric Ear Exam (ALiEM)

Rapid Review

• Background
  • Examination involves inspection and palpation of the nasal structures, as well as anterior rhinoscopy for observance of bleeding, discharge, or deformities. Perform with any history of facial trauma or symptoms of HEENT infection.
• Common Findings
  • Epistaxis
    • Bleeding is usually anterior, originating from Kiesselbach plexus
  • Rhinosinusitis
    • Clear mucus (classically viral/ allergic)
    • Green/yellow ,mucopurulent discharge (classically bacterial-usually unilateral)
    • Thick, white mucous (chronic rhinosinusitis)
  • Septal haematoma
    • “Cherry red” growth along nasal septum
    • Usually follows trauma
  • Nasal fracture
    • Break in the bone or deformity in the cartilage along the bridge

Pearls

• Missing a nasal septal hematoma can cause devastating consequences, including the development of an abscess which may lead to septal perforation or a saddle nose deformity. 
  
• “Watery” rhinorrhea may actually be cerebrospinal fluid, indicating a possible basilar skull fracture. The “halo test” and the glucose test can help differentiate CSF vs mucous, though these tests are not completely reliable.

Deep Dive

• Nose Examination (Oxford Medical Education)

Rapid Review

• Background
  • Throat examination is generally indicated for evaluation of cough, sore throat, or other upper respiratory symptoms. 
• Common Findings
  • Strep Pharyngitis
    • Erythematous pharynx
    • Tonsillar exudates (grayish-white)
    • Palatal petechiae
  • Peritonsillar Abscess
    • Unilateral swelling of peritonsillar area
    • Uvula deviation

Pearls

• Always examine under the tongue as well to look for a submandibular abscess (Ludwig Angina)
• Use a tongue depressor during all throat examinations to ensure you are getting a full view of the pharynx. Don’t cut corners!

Deep Dive

• Evidence-Based Evaluation and Management of Patients With Pharyngitis In The Emergency Department (EB Medicine)

Rapid Review

• Background
  • Neck examination involves inspection and palpation of neck structures (trachea, thyroid gland, lymph nodes) as well as measurement of jugular venous distension. This exam should be performed with any suspicious of infection or cardiac/respiratory pathology.
• Common findings
  • Tracheal Deviation
    • Late sign of tension pneumothorax
  • Jugular Venous distension
    •  Consider right-side heart failure, pericardial tamponade, pneumothorax
  • Goiter
    • Sign of hyperthyroid, hypothyroid, or iodine deficiency
  • Nuchal rigidity
    • Suspicious for meningitis 
  • Anterior cervical chain lymphadenopathy
    • Consider upper respiratory infection
  • Posterior cervical chain lymphadenopathy
    • Consider mononucleosis infection

Pearls

• To reduce fear and anxiety, inform the patient that you’ll be examining their neck before you do it. 
• For critical patients at risk for airway compromise, take the time to palpate and mark the thyroid cartilage.

Deep Dive

• Neck Examination (Oxford Medical Education)

Rapid Review

• Background
  • Cardiovascular examination typically involves inspection/palpation of the chest wall, auscultation of heart sounds, evaluation of pulses, and +/- orthostatic vitals. Generally indicated for evaluation of chest pain, palpitations, and shortness of breath.
• Common Findings
  • Aortic Dissection
    • Asymmetric pulses/BP
  • Atrial Fibrillation
    • Irregularly irregular HR
  • Aortic Stenosis
    • Systolic Murmur; crescendo-decrescendo 
  • Cardiac Tamponade
    • Muffled heart tones
  • Aortic Stenosis
    • Systolic murmur at upper right sternal border; crescendo-decrescendo
  • Pulmonic Stenosis
    • Midsystolic murmur at upper left sternal border; high-pitched crescendo-decrescendo
  • Tricuspid Stenosis
    • Mid diastolic murmur at lower left sternal border; continuous
  • Mitral Stenosis
    • Diastolic murmur at the apex
    • Loud first heart sound, opening snap, and diastolic rumble
  • Aortic Regurgitation
    • Early diastolic murmur; best heard at right upper sternal border
    • Soft, high-pitched, decrescendo
  • Pulmonic Regurgitation
    • Early diastolic murmur; best heard at the left upper sternal border
    • Soft, high-pitched, decrescendo
  • Tricuspid Regurgitation
    • Holosystolic murmur; best heard at left lower sternal border
    • High-pitched
  • Mitral Regurgitation
    • Holosystolic murmur; best heard at the apex in left lateral decubitus position. 

Pearls

• In some patients with pericarditis, you will be able to auscultate a “pericardial friction rub”, which is best heard over the left sternal border with the patient leaning forward and breath held in expiration.
• Systolic murmurs are often benign, but diastolic murmurs are always pathological and indicate the presence of a valvular abnormality.

Deep Dive

• Cardiovascular Examination (Merck Manual)

Rapid Review

• Background
  • Pulmonary examination includes inspection of breathing pattern, palpation/percussion of chest wall, and auscultation of lung fields. Commonly performed for evaluation of chest pain, shortness of breath, and fever/chills
• Common Findings
  • Bronchitis
    • Early-inspiratory crackles. Possibly rhonchi/wheezing
    • Resonant-hyperresonant percussion sounds
  • Asthma
    • Inspiratory and expiratory wheezing
    • Hyperresonant percussion sounds
    • Decreased fremitus
  • Pneumonia
    • Late inspiratory crackles
    • Dull percussion sounds
  • Pneumothorax
    • Absent/diminished breath sounds unilaterally
    • Tympanic percussion sounds
    • Absent tactile fremitus
  • Pulmonary Edema
    • Basilar rales
    • Flat-dull percussion sounds

Pearls

• Absent breath sounds are always an ominous sign. This can indicate severe asthma/COPD or pneumothorax.
• Pleural friction rubs (grating/creaking sounds with inspiration) can indicate pleuritis or other sources of pleural inflammation (thoracotomy, empyema, etc.)

Deep Dive

• Evaluation of the Pulmonary Patient (Merck Manual)

Rapid Review

• Background
  • Abdominal examination involves inspection/palpation/percussion of the abdomen, auscultation of bowel sounds, and +/- special tests (psoas, rovsings, murphy’s, etc.)
• Common Findings
  • Appendicitis
    • RLQ pain; rebound tenderness
    • (+) Psoas, (+) Rovsings
  • Cholecystitis
    • RUQ tenderness, guarding
    • (+) Murphy’s sign
  • Pancreatitis
    • Epigastric tenderness, guarding, distention
    • (+) Gray-turner sign/cullen sign if hemorrhagic pancreatitis
  • Diverticulitis
    • LLQ tenderness, guarding
    • May have rebound tenderness or palpable mass
  • AAA
    • Pulsating mass in middle of abdomen
    • (+/-) tenderness, (+/-) Cullen Sign, (+/-) Grey-Turner Sign

Pearls

• A thorough, reliable abdominal exam can help decrease the amount of radiographs and CT scans. 
• Intraabdominal organs are smaller in pediatric patients and tend to require deeper palpation for an accurate assessment.

Deep Dive

• Evaluation of the Gastrointestinal Patient (Merck Manual)

Rapid Review

• Background
  • Speculum examination of the vaginal walls and cervix, as well as a bimanual examination to evaluate the cervical os and evaluate for adnexal masses. Pelvic examination in the emergency department is controversial, but is universally recommended for the hemodynamically unstable vaginal bleeding patient.
• Common Findings
  • Pelvic Inflammatory Disease
    • Cervical motion tenderness (“chandelier sign”)
    • Mucopurulent discharge
  • Atrophic vaginitis
    • Pale, dry, shiny vaginal epithelium
  • Vulvovaginal candidiasis
    • White, cottage cheese-like discharge
  • Trichomoniasis
    • “Strawberry cervix”
    • Frothy green/yellow cervical discharge
  • Bacterial Vaginosis
    • Thin, white and gray discharge
  • Spontaneous Abortion
    • Threatened abortion: bleeding + closed os
    • Inevitable abortion: bleeding + open os
    • Incomplete: Partial passage of conception products (open os
    • Complete: Complete passage of conception products (closed os)

Pearls

Deep Dive

• Speculations on the Speculum: Is a pelvic exam ever needed in the ED? (emDocs)

Rapid Review

• Background
  • Shoulder examination involves inspection, palpation, and range of motion tests to identify musculoskeletal pathology. Examination is warranted for any non-cardiac shoulder complaints.
• Common Findings
  • Rotator Cuff Tear
    • (+) Drop test, (+) Lift off test, (+) Hornblower sign
  • Shoulder Impingement
    • (+) Neer test, (+) Hawkins test, (+) Empty can test
  • Biceps Tendinopathy
    • (+) Speed’s test, (+) Yergason’s test. (+) O’Brien’s sign
  • Adhesive Capsulitis
    • Diffuse stiffness, global ROM limitations
  • Labral tear
    • (+) O’Brien’s test
  • Anterior Shoulder Dislocation
    • Abducted, external rotation
    • (+) Apprehension test
  • Posterior Shoulder Dislocation
    • Abducted, internal rotation

Pearls

Deep Dive

• Exam Series: Guide to the Shoulder Exam (CanadiEM)

Rapid Review

• Background
  • Elbow examination involves inspection, palpation, and range of motion tests to assess for musculoskeletal pathology. Examination is warranted for any elbow complaints, forearm/shoulder complaints, or FOOSH injuries
• Common Findings
  • Radial Head Fracture
    • Point tenderness over lateral elbow
    • Difficulty with pronation and supination
  • Posterior Elbow Dislocation
    • Protuberance of olecranon sitting posterior to humerus (best seen from behind patient)
  • Nursemaid Elbow
    • Flexed, pronated arm held towards body
  • Lateral Epicondylitis
    • Tenderness over proximal extensor muscle group
    • Pain with extension, pronation, and wrist extension
  • Medial Epicondylitis
    • Tenderness 5-10 mm distal and anterior to medial epicondyle
  • Distal biceps tendon injury
    • (+) Hook test

Pearls

Deep Dive

• Elbow Examination (Geeky Medics)

Rapid Review

• Background
  • Examination of the hand and wrist involves inspection, palpation, and range of motion tests to assess for musculoskeletal pathology. Examination is warrant for any hand/wrist complaints, forearm injuries, or FOOSH injuries
• Common Findings
  • Distal Radius Fracture
    • Dorsal or volar displacement of wrist (Colles vs Smith fractures)
  • Scaphoid Fracture
    • Tenderness over anatomical snuffbox
  • Boxer Fracture
    • Tenderness over 5th metacarpal neck
    • May have “fight bite” injury
  • Skier (gamekeeper) thumb
    • Swelling/tenderness on ulnar side of first MCP joint
  • Carpal Tunnel Syndrome
    • (+) Phalen sign, (+) Tinel Sign

Pearls

Deep Dive

• The Hand: An Expedited Examination and Key Points Regarding ED Diagnoses (emDocs)

Rapid Review

• Background
  • Examination of the back involves inspection, palpation, and special tests to identify musculoskeletal, renal, or neurological pathologies.  Examination is warranted for complaints of back pain, peripheral neurological deficits, high-mechanism traumatic injuries, or urinary symptoms. 
• Common Findings
  • Disc herniation
    • (+) Straight leg raise, (+) Cross Straight Leg Raise
  • Back Strain/Sprain
    • Diffuse tenderness, reduced ROM (particularly flexion)
  • Spinal fracture
    • Midline, bony tenderness
  • Anterior Cord Syndrome
    • Loss of pain, motor, sensation below the injury
    • Proprioception and vibratory sensation intact
  • Brown Sequard Syndrome
    • Ipsilateral loss of motor, proprioceptor, and vibratory sensation
    • Contralateral loss of pain and temperature sensation
  • Central Cord Syndrome
    • Bilateral motor and sensory deficits
    • Affects upper extremities more than lower
  • Cauda Equina Syndrome
    • Progressive bilateral neurologic deficits
    • Saddle anesthesia
  • Pyelonephritis
    • (+) CVA tenderness

Pearls

• Always visualize the overlying skin around the point of tenderness. Don’t miss a herpes zoster rash!
• A digital rectal examination may be necessary to test rectal sphincter tone in cases of suspected cauda equina syndrome.

Deep Dive

• Exam Series: Guide to the Back Exam (CanadiEM)

Rapid Review

• Background
  • Hip examination involves inspection, palpation, and special tests to identify musculoskeletal pathology. Examination is warranted for hip pain, inability to walk, high mechanism injuries, penetrating trauma, or neurological deficits in lower extremities
• Common Findings
  • Trochanteric Bursitis
    • Point tenderness along greater trochanter
  • Piriformis Syndrome
    • (+) Piriformis Test
  • Meralgia Paresthetica
    • Decreased sensation along anterior/lateral thigh
  • Anterior Hip Dislocation
    • Shortened, externally rotated
  • Posterior Hip Dislocation
    • Shortened, internally rotated
  • Hip Fracture
    • Shorted, externally rotated
    • (+) Compression test, (+) Log rolling test
  • Slipped Capital Femoral Epiphysis
    • Decreased internal rotation
    • May have external rotation deformity

Pearls

• The FAbER (Flexion, Abduction, and External Rotation) test can help identify sacroiliac joint pain
• In cases of suspected pelvic fractures, avoid excessive physical examination to look for crepitus, as this can exacerbate injuries.

Deep Dive

• Approach to the Hip Region Exam (Stanford Medicine 25)

Rapid Review

• Background
  • Knee examination involves inspection, palpation, and range of motion tests to identify musculoskeletal pathology. Examination is warranted for knee pain, lower extremity complaints, or high mechanism injuries.
• Common Findings
  • Anterior cruciate ligament (ACL) injury
    • (+) Lachman test, (+) Anterior Drawer test
  • Posterior cruciate ligament (PCL) injury
    • (+) Posterior Drawer test
  • Medial collateral ligament (MCL) injury
    • Swelling/tenderness to medial knee
    • Pain exacerbated with valgus stress
  • Lateral collateral ligament (LCL) injury
    • Swelling/tenderness to lateral knee
    • Pain exacerbated with varus stress
  • Meniscus Injury
    • (+) McMurray or Apley test
  • Prepatellar Bursitis
    • “Dome-shaped” swelling over anterior aspect of the knee
  • Patellar Dislocation
    • Patella displaced over femoral condyle
  • Knee Dislocation
    • “Dimple” or “Puker” sign with posterolateral dislocation
  • Osgood-Schlatter Disease
    • Tenderness over tibial tubercle

Pearls

• The “Lever Test” may be a more sensitive and specific test for ACL injuries than the Lachman or Anterior Drawer.
• A “locked knee” (unable to passively extend the knee) may be an indicator of meniscus injury or ACL tear.

Deep Dive

• SplintER Series: 2-Minute Knee Exam (ALiEM)

Rapid Review

• Background
  • Ankle/foot examination involves inspection, palpation, and special tests to identify musculoskeletal pathologies. Examination is warranted for fall from heights, inversion/eversion injuries, or any lower extremity complaint.
• Common Findings
  • Ankle Sprain
    • Diffuse ankle swelling.
    • (-) Bony tenderness
  • Achilles Tendon Rupture
    • Tenderness along calf and heel
    • (+) Thompson test
  • Lisfranc Injury
    • Pain w/ torsion of midfoot
    • Ecchymosis between 2nd-3rd metatarsal
  • Maisonneuve Fracture
    • Tenderness along fibula
  • Talus Fracture
    • Point tenderness along talofibular ligament
  • Calcaneal Fracture
    • Tenderness over calcaneus (while squeezing heel from both sides)
  • Navicular Fracture
    • Tenderness/swelling/ecchymosis around navicular bone
  • Jones/Pseudojones fracture
    • Tenderness at the base of 5th metatarsal

Pearls

• The squeeze test can help identify syndesmotic injuries. These patients will require orthopedic follow up in 7-10 days. 
• Point tenderness along the middle shaft of the 2nd and 3rd metatarsals in the setting of no acute trauma is highly suggestive of a stress fracture. These will often not be visible on initial X-rays. 

Deep Dive

• SplintER Series: The 2 minute ankle exam (ALiEM)

Rapid Review

• Background
  • Skin examination involves inspection, palpation, and special tests to identify dermatological pathologies. Examination is warranted for any skin complaint or exposure to allergen, chemical, or environmental agent. 
• Common Findings
  • Atopic Dermatitis (Eczema)
    • Erythematous, scaly, hyperpigmented rash on flexor surfaces
  • Contact Dermatitis
    • Well-demarcated erythema, (+/-) erosions/vesicles
  • Cellulitis
    • Tender, erythematous rash w/ poorly demarcated borders
  • Erysipelas
    • Slightly raised, intensely erythematous rash w/ sharply demarcated borders
  • Herpes Zoster
    • Papulovesicular rash on an erythematous base
    • Unilateral dermatomal distribution
  • Impetigo
    • Crusted, honey-colored lesions. Typically on the face.
  • Erythema Multiforme
    • Erythematous, target-like lesions
  • Scabies
    • Papules, vesicles, and linear burrows in webbed spaces of digits
  • Steven-Johnson Syndrome (SJS)/Toxic Epidermal Necrolysis
    • Vesicles and bullae w/ mucous membrane involvement
    • (+) Nikolsky sign
  • Urticaria
    • Blanchable, edematous, papules, wheals, or plaques

Pearls

• Be thorough in your skin examination and explore the full extent of any rash present. You may find that it’s dermatomal!
• Be wary of the “false Nikolsky sign”, which is elicited by pulling the peripheral remnants of a blister that has already ruptured. This commonly occurs in bullous pemphigoid and is not representative of a true positive Nikolsky sign.

Deep Dive

• Skin Examination (Oxford Medical Education)

Rapid Review

• Background
  • Neurological examination involves cranial nerve assessment, sensorimotor/peripheral exam, and cerebellar testing. Examination is warranted for altered mental status, head injury, motor weakness, or sensory deficits. 
• Common Findings
  • Bell Palsy
    • CN VII nerve palsy w/ forehead involvement (lip droop, no forehead wrinkling, ipsilateral tongue numbness, loss of taste sensation)
  • Encephalitis
    • (+) asterixis, (+) scleral icterus
  • Wernicke Encephalopathy
    • (+) ataxia, (+) nystagmus, (+) gaze palsy
  • Guillain-Barre Syndrome
    • Decreased or absent deep tendon reflexes
  • Intracerebral Hemorrhage
    • Pinpoint pupils, CN VI palsy, decerebrate posturing
  • Meningitis
    • (+) Brudzinski sign, (+) Kernig sign
    • May have petechial rash
  • Multiple Sclerosis
    • Bilateral internuclear ophthalmoplegia (eyes can’t look at nose)
    • “Lhermitte phenomenon” (electric shock sensation with neck flexion)
  • Ischemic Stroke
    • Anterior = frontal/parietal hemiparesis (leg affected more arm)
    • Middle = frontal/parietal hemiparesis (arm more affected than leg)
    • Posterior = homonymous hemianopsia (deficit in same halves of visual fields in both eyes)
    • Carotid Circulation = neglect, aphasia, emiplegia, visual field defects
    • Vertebrobasilar = diplopia, vertigo, ataxia, Horner syndrome
    • Cerebellar = headache, vomiting, ataxia

Pearls

• Sensory testing is highly subjective; be careful not to over-interpret. To avoid false positives, do not allow the patient to view you touching the affected area.
• Facial drop/strength is best tested and interpreted during casual speech.

Deep Dive

• The 5-Minute Neruological Exam (URMC)