Physical Exam

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

Deep Dive

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

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

Deep Dive

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

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

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

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

Deep Dive

• Evaluation of the Gastrointestinal Patient (Merck Manual)