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Medical Information

When you want, or need, to know more than the superficial, such as when you are

where there is no access to a physician.

Prototypically: Medicine at Sea

Comments/Disclaimer

This medical information is provided for education purposes only. I am making no attempt to practice medicine over the internet. This is being written to give some basic knowledge for those that are physically isolated from access to professional medical care, such as sailors at sea. This is to help in deciding whether an emergent medical condition exists, how to initially deal with it, and whether evacuation is needed. It is by no means exhaustive or meant to replace personal medical attention. Please do not contact me regarding your personal condition. Over the years I have received many emails from people asking for help with their personal chest pain, or whatever. Sometimes they write during acute pain. This is ridiculous. You can't practice medicine over the internet. If I find their email, after it has been filtered by my spam filter, it may be days or weeks later. My response, if any, will be to contact their regular provider. Even a bad doctor in person is better than an email. Please use this information in the spirit in which it is intended.

Sincerely, Mark R. Anderson, M.D.

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The Story and the Exam

The MOST IMPORTANT part of making a

tentative diagnosis.

The HISTORY and PHYSICAL EXAMINATION

v. 1.2

(Neck, Back and Extremities added: 2/25/2010)

Mark R. Anderson, M.D.

 

General principles:

You who are stuck with the job of pretending to be a medical care provider, whether because you are at sea, in the wilderness, or just trying to care for your family and decide whether you need to go to a licensed clinician, are faced with many difficulties. Among the most important of these are 1) lack of knowledge, 2) lack of equipment to facilitate examination, 3) lack of testing equipment, and 4) lack of experience. The purpose of this article is to attempt to get past most of these obstacles to make a reasonably adequate assessment of the problem and form a plan for it’s care. That care could be carried out totally on your own, or it could require evacuation to a clinician, whether by foot, car, boat, ambulance or helicopter. Your decision making is based on two foundations, the history, (which is actually the most important) and the physical examination. In this chapter, I’ll try to relay a general examination from head to foot, within the limitations of what could be hoped for by a layman with the above four deficiencies.

Examining the human body to detect disease or injury requires the ability to detect deviations from the normal. This of course is pretty obvious, but you need to understand and accept that there is a considerable range of what can be considered normal. In the absence of sufficient experience to know this, you need to rely on your intuition backed up, as needed, by comparing the patient to yourself and others that are available to you. It is often useful to compare opposite sides of the body, because for the most part your body is symmetrical. Some of this exam will be covered in more detail under headings regarding the specific part of the body. Here we’ll be fairly general and try to pick up clues that might lead in various directions.

Even if you are already approaching a patient with a strong suspicion of where the problem lies, you should always do at least a cursory exam of the rest of the body so that you don’t miss another injury or a clue to a different problem.

Tentative diagnoses are a best guess based on the pattern of the illness and pain and the physical exam. The history of the illness is the most important. Age, sex, exposures, family history. Time pattern of symptoms. Symptom progression and changes, plus as detailed description as can be obtained. Some people simply can’t describe their symptoms very well. The clever diagnostician rephrases the questions in several ways and reads between the lines to look for clues. The physical exam generally is used to narrow down the diagnostic choices that seemed most likely after the history is taken. Occasionally important findings point in unexpected directions.

The basics of taking a history:

Ask Nosey Questions:

You never know what might be important. Be a detective. The history is moreimportant than the physical, usually.

Get the whole story, from the beginning. Understand the sequence. When the patient says, "I have this pain" or cough or whatever, take that in but then ask, "When did you first start to feel bad? What happened first? And then what?"

Who’s the patient?

Age, sex, physical conditioning, habits, immunizations, honesty, insightfullness

What are the symptoms?

Pain pattern, disability, associated symptoms, local or generalized symptoms

When do they, or did they, occur?

New, recent or old? Recurrent? What makes them better? What makes them worse? How long do they last? What has been tried to relieve it? Did it help?

Has this happened before?

Where do they occur?

Where are the symptoms, and does the pain or other symptoms radiate, i.e go to another part of the body?

Why did this happen?

Narrowing your thoughts about causes and later about prevention. A useful question is "What do you think this is?" This may head you in a direction you hadn't thought of.

The basics of The Physical:

Look (Inspection)

Symmetry, deformity, movement, color, texture, person’s posture, movement and response

Feel (Palpation)

Temperature, vibration (e.g. “crunching” in fractures). Hard, firm or soft? Separate pain from tenderness by whether pushing on something causes pain. Judge this a lot by the patient's body language. If you're not sure, then distract them by conversation or by pushing with a stethoscope in your hand. If there's no pain response, it's not really very tender.

Tap (Percussion)

Vibration and sound. Hollow sound means gas and dull means liquid/solid.

Listen (Auscultation)

Person’s voice/screams, stethoscope or ear to chest and abdomen. The creak and crack of bones and joints.

Smell:

Even this is sometimes useful.

The Physical Exam, Head to Toe

VITAL SIGNS:

Temperature: Use a thermometer, though a rough guestimate of fever can be obtained by touch of the forehead or chest. Don't rely on touching an extremity. Normal oral temp. 98.6 F or 37 C. It's not a fever unless it's over 100 or 100.5. To convert an armpit temp. to oral, add one degree F. To convert a rectal temp to oral, subtract 1 deg. F.

Pulse (how many heart beats per minute): Feel the pulse at the wrist, or in the neck, or listen to the heart. Count for a full minute or for 15 sec. and multiply by 4. Normal adult pulse: 60-100 at rest. Rapid pulse could just be pain or anxiety (100-140). 150 or high probably has some cardiac rhythm problem. Notice if it's regular or irregular. A slow pulse (45-60) with symptoms of dizziness or weakness may not mean much in a healthy physically fit person, but with symptoms can be from cardiac problems, or the common faint, or serious illness or toxicity.

Respirations: How many breaths per minute. Normal 12-20 Count while still feeling the pulse. This way the patient doesn't know you're checking their breathing and so do unconsciously speed it up or slow it down. Observe whether it seems abnormally deep or shallow, or labored.

Blood Pressure (BP): I'm going to guess that you're not going to be able to get that information, but perhaps you have the equipment. Normal adult 120/80 (range 100-140). Less than 90 and you're going into shock. Without being able to measure it, if you can feel the carotid pulse well, but not at the wrist, and the hand is getting cool, then the BP is too low.

HEENT (Head, Eyes, Ears, Nose and Throat)

HEAD, FACE AND SCALP:

The head, ignoring hair patterns, is quite symmetrical and it’s usually very useful comparing one side with the other. Study the scalp for wounds, if that’s appropriate. It may take considerable pawing through the hair to find a scalp laceration. Feel with both hands, e.g. one each on opposite sides, feeling all the bony contours for tender or swollen areas. You may find what you thought was the bump of a bruise is actually just a skull bump as the same exists on the other side. Look for bruising. In the case of a significant head injury, especially look for bruising behind the ears, (Battle’s Sign) or bruising in the eye sockets that ends sharply at the borders of the orbital socket, (Raccoon’s Eyes). These are both usually clues to a skull fracture, though most skull fractures don’t have them. If there’s a tender and or swollen injured area of the scalp, try to feel within it for any depression of the skull itself. Feel within large scalp lacerations also for these depressed skull fractures with a clean, preferably sterile gloved finger. Similarly follow the margins of the orbits and cheek bones noting whether the bones are asymmetrical and tender indicating a displaced facial fracture. For facial injuries, note whether the teeth come together evenly, (and ask the patient whether they feel like they fit normally). This, plus pain with opening the mouth, and pain or looseness when you shake the jaw by grabbing it between the lower teeth and the point of the chin strongly suggest a jaw, (mandible fracture). Grab and push/pull on the upper teeth. Is there looseness there and does a portion of the face move with it, indicating a mid-face fracture?

If there’s facial pain and possible infection, (e.g. sinusitis) note whether there’s tenderness with tapping with your finger on the cheek on either side of the nose, and on the forehead on either side. Look for the cardinal signs of inflammation, of whatever cause, tumor (swelling), rubor (redness), calor (increased heat) and dolor (pain).

CRANIAL NERVES: (part of the neurologic exam)

Does the face move symmetrically when the person smiles? Does the forehead wrinkle the same on both sides with raising the eyebrows? Is the mouth crooked? Are the skin folds symmetrical. These signs indicate facial paralysis or weakening. A subtle sign of facial weakness is the loss of the ability to whistle. If severe, the patient may drool from one side of the mouth and words may be garbled. Also to check the nerves of the face and head do this: Can the pt. see equally well with either eye alone? (Ask the pt. to make a general judgment of this and back it up by trying to read a book at 10, 20, 30 in. or signs in the distance. Are the pupils equal and round? Suddenly shine a flashlight into each eye. Do the pupils constrict briskly and symmetrically? Have the patient follow your finger up, down, left and right. Do both eyes move together and the same amount? Is there jerkiness to the eye movements, (nystagmus). Can the pt. feel equally the light touch of a stroke of the finger or the sharp touch of a point on both sides of the face, and in all three portions of the face, the forehead, the cheeks, and the chin? Stick out the tongue. Does it come out straight or go to one side? Feel the cheek muscle muscles as the pt. grits the teeth. Do both sides feel tight? Have the pt. resist pushing against either side of the head. Is there weakness on one side? See if you can gag the patient with a tongue blade or spoon in the back of the throat. Look at that dangly thing in the back of the throat, (the uvula), as the pt. says “ah”. Does it pull up straight or go to one side? Congratulations, you’ve tested the cranial nerves.

EYES:

Most important is to check the vision, as described above. If the pt. can’t read with one or both eyes at any distance or see anything sharply, can he/she count fingers at three feet? How about detect movement? Detect light? Anything?

Check the Extra Ocular Movements, (EOM’s) as above by following a finger in the four directions. Inability to move an eye in one or more directions, indicates either a central nervous system (CNS) problem such as a stroke, or an injury to one or more of the 6 eye muscles that are within the eye socket. Circumstances would indicate if there could be a direct laceration of a muscle, (e.g. a penetrating wound) or an indirect injury to the muscle from being caught in a facial fracture or just being bruised. Generally, the loss on an EOM means either a CNS problem, or muscle bruising from trauma. If the person was struck in the eye with something, (a Champagne cork is an excellent example, or just a fist), the pressure in the orbit from the blow can “blowout” the thin floor of the orbit and the lower muscles can get trapped in the fracture. Sometimes the injured eyeball looks like it is more deeply set into the skull, since it’s been pushed in. This is a serious injury, but surgery can usually be delayed a few days, and often the muscles don’t work just because they’re bruised.

If the eyes make rapid jerky movements (nystagmus), with anything other than looking far to one side, you’ve got one of three problems: 1) Intoxication, (most common), e.g. alcohol, downers, PCP, 2) an inner ear problem (fairly common), or 3) a problem in the base of the brain, (uncommon). All are associated with spinning around type dizziness, (vertigo), with the last being the most severe.

Look at the conjunctiva. That’s the pink lining of the eyelids, seen easily by pulling the cheek skin down. Is it very pale, indicating anemia or shock? Is it quite red, indicating inflamation from allergy, chemical or dust or foreign body irritation, or infection? Is there any goop, (discharge) coming from the conjunctivae. Is it colored, thick, ropey?

Look at the eyeball, (the globe). Are the whites of the eye reasonably white, or quite red. Certainly compare both eyes, since if only one eye is symptomatic, the other acts as a good comparison. People vary alot in the normal whiteness of their “sclera”. Is it red in general, or are there lots of tiny blood vessels over the sclera. This is called “injection”. Is there hemorrhage under the sclera? (This can be dramatic and sometimes quite swollen, but generally this is not dangerous.) Is the sclera yellow? True jaundice usually spares the sclera a bit right around the iris. Some eyes, particularly those of some blacks, tend to look yellow anyway.

Look at the cornea. That’s the clear bulge in the middle of the eye that does most of the lens work of seeing. It should be absolutely clear and shiny. If it looks hazy or cloudy, along with deep eye pain, decreased vision and often nausea think acute glaucoma, a very serious eye emergency that demands immediate attention. A caustic chemical in the eye can do the same thing. (Especially alkalie like lye, oven cleaner, engine degreaser) I hope you have Flourescein available to check for corneal injuries, such as abrasions. Sometimes you can see a scratched cornea by a very careful look at the surface of the cornea, looking for areas that don’t reflect light so shinily. Use a magnifier if you can. Minute foreign bodies, dust, grit, etc. may easily scratch the cornea, and possibly get stuck on it. Look CLOSELY. Looking for foreign bodies in the eye also requires flipping the upper eyelid over. Sometimes they hide up there. To do this, have the pt. continually look at his/her feet, relax, and you grab the upper eyelashes, press something narrow crosswise down on the middle of the upper lid, (e.g. a toothpick or match) and pulling on the eyelashes flip the lid back. As long as the pt. continues to look down, the lid will stay flipped, (unless swollen). To unflip, just have the pt. look up.

Look at the “anterior chamber”. This is the fluid filled space between the basically flat iris and the convex cornea. It should be clear. If it seems to be pink or have gross blood in it, (ranging from a layer at the bottom to completely blocking out the view of the iris, an “8-ball”) this is a hyphema. This is a pretty serious result of a blow to the eye. If it’s cloudy but more gray or white, along with pain and decreased vision, you may have serious inner eye inflamation. This is rare enough that I’ve only seen it a couple times.

Look at the iris, (the flat colored ring), with the black pupil, (the hole in the middle). The pupil should be in the center and round. Previous surgery or fresh or remote trauma may cause it not to be round. Are the 2 pupils the same size? They should be but aren’t in 10% of the public. In a dim room, shine a flashlight into each eye individually and note how the pupil shrinks. Each eye should react the same. In the context of head injury or coma, if they’re significantly unequal and the larger one doesn’t react well to light, this indicates probable life threatening build-up of pressure in the brain. (On the other hand, by the time the pupils are unequal, there are probably many other clues to a significant head injury, such as confusion and vomiting.) If the eye is very painful, the pupil in that eye is quite small, perhaps not quite round and light exposure is very painful, think iritis, a serious inflammation.

Without the equipment and training you can’t see into the back chamber of the eye, but you can check the “red reflex”. This is equivalent to a cat’s eyes shining in the headlights. From about 2-3 ft. away, shine a flashlight directly into an eye while looking directly at the pupil with your own eye right next to the flashlight. The pupil should glow red. If the patients vision is very poor in that eye and the pupil stays dark, think “vitreous hemorrhage” or “retinal detachment”.

EAR

There’s not much you can tell about the ear by physical exam without an otoscope to look inside, and the knowledge of what you’re looking at. If there’s been a head injury and a bruise develops over the bone right behind the ear, (Battle’s Sign), or if blood or watery clear and thin fluid is draining from the ear canal, there’s probably been a skull fracture, though few skull fractures actually show those signs. If there’s a complaint of ear pain and you see nothing, you’re probably either dealing with wax being packed in tight, (often because the ear’s owner uses cotton swabs in the ear or ear plugs), or there’s a middle ear infection. If there’s purulent (pus) drainage from the canal, and no pain, then the middle ear infection probably ruptured the eardrum. If there’s drainage, considerable pain and the pain increases with manually moving the external ear (pinna) and/or pushing on the bump in front of the ear canal, (tragus), you’ve found an external ear infection.

NOSE

After all that about the eye, you’ll be pleased that the nose is much simpler. Basically there’s the bony part of the nose, (the normally hard part) that is what gets broken and the cartilaginous part, (the soft part). Except for injuries, you’ll basically be interested in the inside part. Note whether the lining “mucosa” is the normal pink, or extra red or quiet pale. If it’s bleeding, you’re 90% likely that it’s from the front soft part, even if it’s bleeding too much to see the source. You should be able to stop the bleeding as long as you pinch the whole soft part with your fingers. Otherwise, note whether the septum, (that’s the wall in the middle that divides the 2 halves) is close to the middle or not. (Some people are born with a deviated septum.) The front septum is the usual source of nose bleeds, (epistaxis). You can get an idea of how swollen the inside is by pinching off one side and having the pt. try to breath through the nose. Is there drainage, (a discharge)? Is it clear, (typical of allergies, and the early part of a cold). Or is it colored, e.g. yellow or green. This means the presence of white blood cells, (purulent) and is often equated with bacterial infection, though this is often just the evolving changes of a typical 'cold'.

If you’re looking for something stuck up the nose, don’t be thrown off by the turbinates. Those are those big pink bulbous things that are like shelves inside the nose. You can usually only see one, but there are three.

MOUTH

Lips are among the most sensitive and vascular of body parts. (That ought to be no surprise to all you kissers out there.) Cuts, (lacerations), of the outside are cosmetically very important, especially if the involve the vermilion border. That’s the sharply outlined edge of the outer lip. Cuts of the inside of the lip, unless gaping and floppy can be left alone. The same applies to cuts of the tongue.

The tongue is just a big coordinated muscle. Of interest will be whether it appears somewhat dry if dehydration is a concern.

The throat, i.e. pharynx, is what often gets sore. It and all the mucosa lining the mouth is normally pink. If inflamed, you may just see tiny vessels appearing on it or it may get quite red. A beefy red throat is classically a strep throat but there are also viral and other causes. Exudate is white or yellowish pus like, purulent, material that may be in patches or cover significant areas of the throat. This should definitely be considered a sign of bacterial infection and treated as such, but virus can also do this.

The tonsils are balls of bumpy tissue that are on either side at the back of the oral cavity just before the pharynx widens out. Normally they’re less than 3/4 in. (2 cm). They’re actually lymph nodes, (“glands”) that enlarge with infection. If they’ve been removed you’ll just see a thin web or two on either side. These are the pillars, between which the tonsils were located.

The uvula is that dangly thing at the back of the throat. It doesn’t do much but can also get inflamed.

To get a good look at the throat, some people can just open wide and get their tongue down and out of the way. Usually you have to use something as a tongue depressor. In lieu of a std. wooden one, use a spoon or spoon handle. Push down on the middle of the tongue, perhaps even pulling it forward a bit. Don’t push back or the person is sure to gag. A severe gagger can be controlled by having them pant rapidly. It’s impossible to gag and breath at the same time.

You all know what a hoarse voice is, (dysphonia) but another breathing noise is more serious. Stridor is a rather harsh whistling sound from a partial blockage of the airway in the neck. This can be from severe swelling or foreign body. Fortunately it’s rare but can progress to total airway obstruction and death. If due to foreign body, e.g. choking on food, a Heimlich maneuver may be called for, but only if the patient can’t clear it himself and is about to pass out. If due to swelling, (rare), and the pt. is passing out, it’s time for a surgical airway.

NECK

The Adam’s Apple is the larynx. At the bottom of it, right in the front of the neck is a little notch. This is the cricothyroid membrane, and is the site for a surgical airway, most rapidly done by poking a large diameter needle through it, or by a vertical stab wound with a sharp knife to make a wound about 3/8 in. long followed by a twist of the blade 90° to open up the hole, then insert a small tube such as a Bic pen housing or equivalent. Do this only if the alternative is death.

You can feel the trachea, (windpipe) down the middle of the front of the neck. Make sure it's in the middle. You can feel the Carotid pulse by pressing in the hollow on either side of it a couple inches below the jaw. Don’t press on both sides at once or you may shut off circulation to the brain, (not good).

That muscle band on either side of the front of the neck is the Sterno Cleido Mastoideus, (SCM) and is the muscle that spasms in wry neck, (torticollis). Just in front of it is where the commonly swollen neck “glands”, (actually lymph nodes) occur. These lumps usually can’t be felt. They can get quite large at times, especially in Strep throat and Mono. Much less commonly you’ll feel nodes, (perhaps only 1/4” or so in diam. behind the SCM. These posterior nodes are more selectively enlarged with Mono and some other viruses. Enlarged nodes lasting longer than 2 wks. occur in Mono and a few other viruses, but also in lymph cancers (lymphomas) and in the spread (metastasis) of other cancers.

At the base of the neck in front, just above the breast bone, occurs the thyroid gland, covering the trachea and spreading a bit to the sides. Usually you can’t feel it, but when it’s enlarged it’s a goiter. Goiters are common in 3rd world countries due to Iodine deficiency, especially away from the coast, (there’s lots of iodine in most seafood). Goiters also occur with either over or under active thyroid glands, and a large tender thyroid rarely presents as a sore throat due to thyroiditis.

The muscles of the neck, especially in the back, may become tender and tight with neck strains. This will reduce comfortable movement but is usually self-limited. If the pt. suffered a significant fall, and complains of neck pain, carefully feel the spine in the neck. If this is tender, or the bumps of the spine don’t line up, or if there is definite numbness or weakness, or boggy swelling over the spine, suspect a neck fracture and don’t move the pt.. More specifically, the pt. must be moved only in a manner that doesn’t move the head with respect to the body. This is usually done by strapping the pt. to a board. If you’re alone with the patient, and can get help, don’t move the pt. until help has arrived. Help could be an ambulance w/ EMT’s or the Coast Guard by helicopter. Fortunately, there must be a thousand neck strains for every neck fracture, so you might have to be flexible. If the pt. is alert and sober, and there’s no definite numbness and weakness, statistically you may be safe if the pt. is willing to move their neck themselves. You makes your judgment and you takes your chances.

A truly stiff neck in the context of severe headache and (usually) vomiting may mean ruptured brain aneurysm. Add a fever and you should be worried that it's meningitis. By stiff, I mean stiff. The patient in unable to bend the chin toward the chest. I don't mean just some pain with movement. This is 'meningismus'. The patient will still be able to tilt the neck to one side.

CHEST EXAM:

Chest Wall:

Compress the chest front to back and side to side between your two hands. If this causes pain, there's a problem in the chest wall, such as rib fracture, rib joint injury or inflammation. You can then press on individual ribs. I specific ribs are tender, and the pain is felt some distance away from the pressure, then be pretty sure there's a fracture or a rib joint injury. If the tenderness is only directly at the painful spot, then it's probably just a bruise. If there's painful breathing but no tenderness, then the problem is muscular between the ribs or internal. Also feel for cracking (crepitance) that may occur w/ fractures. A feeling in the skin like crinkling cellophane is air in the soft tissues and likely means a severely punctured lung. If that's combined w/ overt inflammation (hot red swelling), then it's a serious gas forming infection that may lead to gangrene. Also look for bruises and local inflammation. Look far sucking in of the skin between ribs of labored breathing (retractions). If a local painful injured area moves in while the res moves out with breathing in, you've got a flail chest which is a serious chest injury.

Lungs:

Respiratory rate (normal, fast or slow?) (normal deep or shallow?) Symmetrical chest movement? Labored?

Tap on all areas of the chest like trying to find the level of beer in a barrel. It should sound hollow, except over the heart. If it's dull where it should be hollow, then it's filling with fluid within or around the lungs.

Listen w/ the ear or stethoscope. Compare to others to get an idea of normal. A musical whistling sound breathing out is wheezing. A coarse moist sound is rhonchi suggesting bronchial disease, i.e. the tubes of your lungs. A fine dry or moist crackling sound is rales. It's like rubbing hair between your fingers by your ear. Rales indicate disease of the tiny air sacks in the lungs and suggests pneumonia or congestive heart failure.

Heart:

I don't expect you to get much from listening to the heart except the rate and rhythm. If you count the heart beat (lub-dub) and it's a lot faster than what you feel at the wrist, then it's not pumping effectively because it's not generating enough of a pulse pressure to feel. It should be steady and regular, whatever the rate. If irregular, note whether there's a pattern to the irregularity (regular irregularity) or whethe it's totally irregular (irregularly irregular) The latter is probably atrial fibrillation that can be fast or slow, and acute or chronic.

ABDOMINAL Exam:

The examiner should have warm hands and start feeling the abdomen away from the area of pain. Feel the painful area last. First feel gently for soft or tense abdomen. Then progressively deeper. Having the patient bend hips and knees with the feet on the bed helps to relax the abdomen. Sometimes you only get relaxation when the patient takes a breath. If ticklishness is a problem, the patient should put their hand sandwiched between the examiner’s hands. You can't tickle yourself and this will eliminate the problem.

Tenderness:

This must be distinguished from the pain itself. I.e. tenderness is pain caused by pushing at that area. You can have severe pain without tenderness and tenderness without otherwise having pain. Watching the facial expression and bodily reaction of the patient during the exam is a more convincing indication of tenderness than what the patient says. A reaction that disappears if the patient is distracted or deceived shows the absence of true tenderness. (E.g. feeling the abdomen with the stethoscope.)

SLR (Straight leg raise). If the tenderness is the same or increases (inc'd) when the patient tenses the abdominal wall, such as by doing a SLR, then the problem is in the abdominal wall (superficial injury, or strain, though it could be a hernia). If it decreases (dec'd) then the problem is internal.

Guarding

Guarding is a tightening of the abdomen when the examiner touches or pushes on a sore area. Voluntary guarding can be stopped by the patient and may be nothing more than anxiety that the exam will hurt. Otherwise, guarding, like facial wincing, indicates tenderness. Involuntary guarding can’t be stopped by the patient. It is a convincing indication of true tenderness. Involuntary guarding is more serious. Rigidity of the abdomen, either locally or generally is the ultimate in involuntary guarding and usually means peritonitis. Rigidity means the abdominal is tight even if not touched, but you determine it by lightly touching the abdomen.

Rebound tenderness

Rebound pain is pain that momentarily increases when pressure on the abdomen is suddenly released. (Differentiate this from a simple startle reaction.) Consistent rebound tenderness is a sign of peritonitis. The same information can be gained several ways. Light tapping of the abdomen. Gentle shaking of the abdomen by shaking the hips, or a thump on the sole, or jostling the bed. When any movement, e.g. walking, or standing on tip toes and dropping down onto the heels, is clearly more painful than not moving, think peritonitis.

B.S. Bowel Sounds.

Your stomach always rumbles. True absence of bowel sounds is a severe problem. Listen w/ ear or stethoscope to abdomen. Usually you'll hear some in a few seconds. Don’t consider them absent unless there are no sounds for three minutes.

Neck and Back

How is the patient moving? Obvious pain with movement suggests a muscular or skeletal problem or underlying inflammation that is aggravated by the movement. If the person was just injured and has not moved before you examine them, then feel for tenderness, swelling or deformity. Ask where they hurt and start some distance away from that, working towards the painful area. This is both to minimize the patient's anxiety, but also to help avoid missing other injuries. If there is a deformity, then it should be stablelized before the patient is moved. Before you move them, ask them to try to move themselves. They're much less likely to harm themselves if there is a serious injury, then you are by moving them. If you think there's a step off or other sudden misalignment, they should certainly be immobilized and evacuated. Log roll them onto a rigid board with someone stabilizing the head so that it moves with the body like a unit. Secured to the board they can be moved to a safer place.

Feel along the spine for direct tenderness. Bony tenderness often means a fracture but could mean injury to attached ligaments. Gentle tapping or thumping along the spine with your finger tips or your palm is a good clue for a fracture, such as the compression fracture that commonly occurs by landing on your butt. Feel the muscles for tenderness or spasm.

Before asking them to move, check the extremities for injuries and for vascular or nerve injuries. (See below.) Ask them to bend the neck or back forward (flexion), backward (extension), to either side (side bend) and twisting to either side. Look for assymetry in motion due to pain or spasm.

Extremities:

Appearance and Palpation: Look for any assymetry compared to the opposite extremity. Swelling, bruising, deformity, color changes, wounds. Gently feel all parts, starting away from the suspicious (e.g. injured) area. Try to find if the soft tissues feel right. Is there soft tissue (skin, fat, muscle) tenderness, abnormal firmness or softness, or gaps? Is any area of bone tender. Point tenderness of part of a bone is highly suspicious for a fracture. Soft tissue tenderness adjacent to a bone or where ligaments attach may mean a sprain. Don't move or stress anything yet.

Circulation: Is the extremity warm to the tips? Are both left and right extremities equally warm? Check capillary filling: Pinch or press the finger tip or toe and then quickly remove your fingers. The nailbed or skin should be pale but pink up again within about 2 seconds. Longer than 3 seconds is a problem with circulation, due to cold, damage to blood vessels, or low blood pressure (shock). Use the circumstances and symmetry or lack of it to narrow the problem down. Check the pulses in the extremities. Know several places to feel the pulse. At the wrist (radial pulse on the thumb and palm sides just above the wrist crease and by the radius bone). In the groin, (femoral pulse roughly half way between the genitals and the hip, just below the crease at the top of the thigh. At the ankle (just behind the inner ankle bump).

Peripheral nerve function: Check that the basic functions of the extremity work and if not, try to determine whether a problem is a real nerve problem (unable to do something) vs. due to pain or fear (unwilling or painful to do something).

Sensation: Check whether the patient can feel a light touch (e.g. light scratching with your fingernail) and sharp touch ( can they identify a pointy touch vs. a dull touch such as the point or blunt end of a safety pin) with their eyes closed. Can they do this at the pads of each finger or toe and on the tops and both sides of the hand or foot?

Motor function: Check that all the basic limb motions can be done: Straighten out (extend) and bend (flex) fingers and toes. Spread the fingers. Touch the thumb to the pinky finger. Extend the wrist. Flex the wrist. Straighten and bend the elbow. Roll the forearm palm up and palm down. Move the upper are in front, in back, and to the side. Flex the hip. Straighten (extend) the knee and flex it. Bend the ankle up (extend or dorsiflex)) and point the toes down (plantarflex) the ankle.

Motion and Function:

Active vs. Passive Range of Motion (ROM): You've learned a lot by asking the patient to put the joint or extremity through its motions. Perhaps he/she was unable or unwilling to do some of this checking of active ROM. Particularly if it couldn't be done due to pain, now comes the really useful part of the exam to determine if there is a fracture or sprain. If you support the extremity (in whole or part) and you can move it through a normal ROM, even though the patient may be unable to, then you've a good clue that nothing is broken or dislocated.

If the extremity has passed all this, then stress test each portion of it. Have the patient push against you for each of the normal motions (up, down, flex, extend, side to side, twist, roll, etc.) without allowing any actual motion. If this is painful, then there's likely a sprain or fracture. Now grasp the area in such a way as to be able to try to bend or compress a bone without moving it. If this is painful, there's likely a fracture. The other classic signs of fracture are more obvious but far less common. They are: bony deformity, crepitance (i.e. a heard or palpated crunching with passive or active movement), and false motion (i.e. the bone moves or bends in an unnatural way. If these things exist it's a no brainer, but it's far more sensitive to examine for bone stress pain.

Neurological

Skin

To Be Continued

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