Friday, 1 May 2009

Physical Examination - Revisited ---- again

Dear Bloggers

I have been exceedingly busy recently ! However, I am back :-)

I wanted to reiterate the importance of the physical examination. One method of teaching from the UK involves taking no history from the patient and hence, using only observational skills to make a diagnosis! Although history can give the diagnosis in a high percentage of cases, the physical exam aids the physician to confirm or refute various differential diagnoses in certain circumstances e.g. the patient complains of palpitations but on the physical examination the patient has a normal pulse despite the patient still being symptomatic. On the other hand, the patient might complain of unilateral pleuritic pain, cough and sputum and the physical exam reveals a pneumonia. Hence, physical examination can be positively or negatively correlated to the history.

The purpose of performing the bedside exam without the history is to hone the skills of the residents to get them to look but also to recognise what they see. Observational skills are exceedingly important and are often under-utilised. For example, when starting the physical examination, perhaps the most important thing is to look around the bedside. Many items surround the typical patient e.g. portable toilet (maybe the patient is too weak or too breathless to walk), the walking stick, intravenous infusion (rehydration, antibiotics, other drugs), oxygen via mask or nasal specs, the patient's regular drugs! These elements give the physician an idea of the patient's general status and functional capacity. They can also reveal the patient's previous medical history and tell you what is wrong with them! For example, a recent patient had a mitral valve murmur and had an infusion of gentamicin running into a peripheral vein. The immediate diagnosis to consider was infectious endocarditis!

Looking for the urine bag can provide information about the patient's vascular state and type of illness- is there urine? Check the colour -- e.g. blood, coke coloured (glomerulonephritis), orange (liver disease / Tb drugs), purple (UTI), green (propofol, UTI). Concentrated urine of small volume suggests hypovolaemia before even touching the patient.

Looking at the patient at the end of the bed generally can give clues -- general state e.g looks well / unwell, weight loss (backs of the hands, temporal regions, upper arms and legs), colour of the skin / sclerae at a distance e.g. jaundice.
Many clues about the patient can be picked up like this to make a preliminary opinion of the patient's condition before even laying a hand on the patient.

The UK way of examination, after general inspection, starts with the hands. The hands are an important part of the physical exam -- the type of handshake might indicate a neuropathy or myopathy. Unilateral wasting of the dorsal interossei might suggest a unilateral Pancoast tumour of the lung.
Checking the fingers for clubbing can very quickly narrow the problem down to specific cardiac, respiratory or abdominal causes. Many other signs are present in the nails which are beyond this talk today. However, having a combination of signs may overlap with just a single condition and give the diagnosis or there may be separate diagnoses! For example, a recent patient with clubbed fingers also had Terry's nails, which when both present suggests liver disease. The patient had mild scleral jaundice and was unkempt. The resident rightly considered alcoholic liver disease, and he was correct. The liver was markedly enlarged and firm.

Checking the nail folds is imperative because infarcts may be seen in addition to capillary loops (seen with an opthalmoscope) which might indicate several forms of vasculitis or other rheumatological conditions.
Of course, checking the digits may provide the diagnosis of rheumatoid arthritis or osteoarthritis. Asking the patient to extend the hands at the wrists with spreading the fingers can help identify those patients with encephalopathy e.g. liver failure, uraemia, CO2 retention.

Checking the pulse is not just counting the rate per minute. Feeling the volume is important. It may indicate the slow rise of aortic stenosis or the fast upstroke and immediate loss of the Waterhammer pulse of aortic regurgitation. A low volume 'thready' pulse may indicate poor cardiac output or hypovolaemia. The jerky pulse may even suggest HOCM at the wrist!

Checking the skin turgor can help indicate the fluid status of a patient although it is not so accurate in the elderly patient. However, a combination of signs e.g. thready pulse, tachycardia, cold digits, small volume concentrated urine in the catheter bag in addition to poor skin turgor indicate hypovolaemia. You don't need the BUN and Creatinine to tell you that. information as physical examination does just fine. The use of lab data in such a circumstance is to know the extent of the derangement :-)

Moving up to the head, the sclerae can be checked -- they might show anemia, jaundice, haemorrhages etc.. Again the mouth and throat can provide information. Checking the mucosal surfaces may reveal the Kaposi sarcoma or the lateral border of the tongue may have the Oral Hairy Leukoplakia of AIDS. The presence of white exudates on the mucosa and tongue suggest candida and then one must consider the DDx of why the patient has got it e.g. immune suppression from steroids, DM, AIDS. Has the patient been using recent antibiotics. Mucosal bleeding may be present indicating possible thrombocytopaenia!

Telangiectasia on the tongue, under the tongue and on the face with the presence of spoon nails 'koilonychia' should lead one to consider the rare diagnosis of Osler-Weber-Rendu (Hereditary Haemorrhagic Telangiectasia) with iron deficiency anaemia.

The facial skin can give a wealth of information. One might see the purply-red cheeks of SLE! However, remember that in an elderly patient with swollen legs, purple lips and purple fingers with the facial 'flush' is more likely to be due to low cardiac output e.g. CHF, rather than SLE!

Checking the neck can provide further information - the JVP being elevated and evaluating the wave form e.g. a wave or v wave, can tell use which problem may exist e.g. tricuspid regurgitation.
Observing the neck for the carotid pulsation may reveal Corrigan Sign (common) and DeMusset's sign (head nodding with each pulsation -- rare). If you do see this sign or suspect aortic regurgitation then go back and look at the hands again. Try and find Quinke's Sign. I have found Quinke's sign in many patients simply because of the suspicion of AR through these ancillary signs and a suggestive murmur. Unless you look you will not find.

Checking the earlobes can reveal Frank Sign -- the diagonal earlobe crease suggestive of coronary artery disease although this depends on the population in question. The highest association is in caucasian patients.

The chest surface examination can reveal spider naevae and gynaecomastia of chronic liver disease, excoriations due to pruritis or tattoos and old scars amongst others. Looking at the skin teaches us about the patient's present and past.

Abdominal inspection may show obvious distension, eversion of the umbilicus, and caput Medussa of chronic liver disease.

The lower limbs can reveal similar features from the hands e.g. Clubbing, Terry's nails. However, specific rashes may occur which can give a clue about the illness e.g. petechial haemorrhage may suggest low platelets or a vasculitis. The presence of palpable, painful, multifocal erythematous lesions may suggest erythema nodosum with its respective differential diagnosis.

Notice, no chest or abdominal organ has been palpated, percussed and no stethoscope has been placed on the patient in the above examples of examination. All of the above signs can be found on inspection and point towards various diseases. Of course, examination of the heart, lungs and abdomen should be performed on a normal basis as well. However, what I am trying to emphasize is that physical examination is not just focusing primarily on the major organs. It is also looking at all the other areas of the body, which are often under appreciated, to try and pick up relevant clues which may relate to the problem of the major organ and thereby provide the clinical diagnosis at the bedside based on pattern recognition of disease.

Observational physical examination skills training, with a senior doctor who can then point out the relevant signs if the resident misses them, leads to improvement in recognition skills by the residents. By explaining the history to the resident after their finishing the examination, reinforces the physical signs teaching. Not only that, it is really exciting to see as things unravel.

For those medical educators out there, you may wish to consider doing this training with your residents. It can be illuminating to hear the correct diagnosis come forth without a word of history being heard and not a lab test or scanner in sight :-)
Please consider....