Physical Examination for Internal Medicine

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The Patient as a Historian:

When taking a past history, we need to assess whether or not the patient is a reliable historian. Even when the patient is speaking, we need to be able to point out whether the patient is having illusions, hallucinations, delusions, deliriums, and dementia. In fact, your HPI must include whether the patient is a reliable historian or an unreliable historian.

Appearance of the Patient:

You should assess the visual appearance of the patient - including orientation and mental function. For example, a patient with Parkinson's disease may have a blank and glazed stare.

Head:

Make sure there are no lacerations or any major issues.

Eyes:

There are two things you need to look in the eyes - icterus and pallor. Make sure you examine the patient in natural light and not in colored light. Pallor is in the bulbar conjunctiva. Another way of looking at pallor is in the palm creases. Normally, the crease is darker than the palm; however, if the crease is lighter than the palm, the patient has pallor. Pallor is more obvious when the hemoglobin levels are low.

Ears:

You have to use an otoscope and ensure that the tympanic membrane is intact. You have to especially observe the tympanic membrane in patients with fever because otitis media can cause fever in unsuspecting patients.

Neck:

Lumps in the Neck:

Note pulsations and any unusual lumps. If you think there is a lump in the patient's neck, there are two things that can cause that lump - a thyroid or a thyroglossal cyst. How can you differentiate between the two? Both the lumps move with swallowing - thyroglossal and thyroid. However, when the lump moves with the movement of the tongue (eg., asking the patient to stick out their tongue) it's a thyroglossal cyst. When you do find a thyroid mass, you need to be able to figure out whether it is a single or multi-nodule, and whether the mass elicits any pain. For example, if it is an enlarged soft thyroid, it is probably Grave's disease. If it is an enlarged painful thyroid, it is De Quervain thyroiditis. If there is a *single* nodule in you thyroid examination, you always do a fine needle aspiration cytology (FNAC) or a fine needle aspiration biopsy. We do this because we have to rule out malignancy in a single nodule.

The second thing to look in the neck region is pulsation. You need to be able to differentiate between an arterial and venous pulse. An arterial pulse in the neck most commonly originates from the carotid artery. However, if you can also detect a venous pulse, we're talking JVD.

Differentiating between Venous and Arterial Pulses in the Neck:

1. If there is a definite and sudden cut-off in pulsation, it is a venous pulse. A diffuse pulse is an arterial pulse.

2. You need to place your finger on the pulse and if you can feel the pulse coming back and hitting your finger, it is an arterial pulsation. You can see a venous pulse but you can't feel it.

3. You can make the patient lie down at an angle of 45 degrees and ask them to take a deep breath. Now if it is an arterial pulsation, the intensity of the pulse is constant; if it is a venous pulsation, the intensity of the pulse decreases.

Examining cervical lymph nodes:

You always stand behind the patient. When you're palpating the thyroid mass or a thyroid lump, you have to palpate against a solid surface. You can do this in the neck by holding onto one side of the neck and palpating the other side (and then vice-versa); the non-palpating side becomes your solid surface or platform. You can't palpate on both sides simultaneously.

Any patient who comes in with fever, you need to do two things - look into the throat and feel for their cervical lymph nodes. If the patient has enlarged cervical lymph nodes and exudate in the throat, clinical diagnosis 99% of the time is strep throat. Suppose the patient does have strep throat, the next step is to treat the patient and do a rapid strep test immediately. You should remember that a throat culture result comes back in 4 weeks so a rapid strep test is a quicker screening tool. A throat culture should only be done if the rapid strep test is negative.

Skin:

Make sure you look for unusual rashes or any edema. The most important rash that we miss is a shingles rash. In shingles, pain is always preceded by rash. For example, a patient may complain of chest pain and the rash would appear a few days later. A shingles rash never crosses the midline (ie., the spine). By the way, we treat shingles with acyclovir.

Clubbing of Nails:

Another thing you look for in the periphery is the clubbing of nails. If clubbing exists only in one digit, it is mostly due to a congenital abnormality; a systemic insult can result in clubbing of multiple digits. Hypertrophic obstructive pulmonary arthropathy (HOPA) is one cause of nail clubbing.

Peripheral Edema:

If edema exists only in one extremity, the cause is mostly of local nature. If edema exists bilaterally, there may be a systemic cause. When evaluating pitting edema, you have to press and hold your finger on the patient's skin for at least 5 seconds to allow enough time for subcutaneous fluid to get displaced. Always look for pitting edema against a bony prominence and not against soft tissue.

Peripheral vs Central Cyanosis:

• Cyanosis is the bluish discoloration of the skin. There are two kinds of cyanosis - central and peripheral, and one general cause of cyanosis is a decrease in hemoglobin. One cause of central cyanosis is decreased oxygen saturation (eg., CHF). One cause of peripheral cyanosis is decreased circulation (eg., Raynaud's disease). Central cyanosis mostly affects the skin and the mucous membranes while peripheral cyanosis mostly affects the periphery (mucous membranes are generally not involved.)

• Peripheral cyanosis: pink tongue, cold extremities, pale white extremity, and nails may be cyanotic.

• Central cyanosis: blue tongue, pale skin, nice and warm extremities.

Peripheral Pulses:

A description of pulses must be accompanied by five variables - rate, rhythm (ie., regular or irregular), character (pulsus parvus et tardus, pulsus paradoxus, water hammer pulse, pulsus alternans, etc.), volume, and radio-femoral delay. Pulses can be felt in the radius, brachial, carotid, femoral, popliteal, dorsalis pedis, and posterior tibial. You should feel for the pulses in at least 2-3 peripheral sites. When palpating the carotid pulse, make sure you don't palpate both the carotids simultaneously because the patient may experience syncope. Furthermore, the patient may have carotid hypersensitivity, so be gentle with palpating carotid pulses.

Character of Pulses:

Pulsus parvus et tardus (anacrotic pulse):

• This is a slow rising, low volume pulse seen in aortic stenosis. It takes a long time for blood to leave the left ventricle.

Pulsus paradoxus:

• This is a measurement of blood-pressure. If systolic blood pressure drops 5-10 mm mercury on inspiration, it is pulsus paradoxus and is indicative of cardiac temponade.

Water hammer pulse (Corrigan's pulse):

• High-rising, high volume, rapid down-stroke pulse seen in hypodynamic conditions - pregnancy, aortic regurgitation, tachycardia, fever.

Pulsus or electrical alternans:

• Intensity of the pulse keeps alternating between weak and strong; seen in end stage left ventricular heart failure.

Radio-femoral Delay:

In normal physiology, radial and femoral pulses are simultaneously palpable. However, a delay in the femoral pulse signifies coarctation of aorta.

Miscellaneous Tips:

• The ideal way to calculate the respiratory rate or pulse is when the patient is unaware of it.

• Make sure the ankle-to-brachial (ABI) index is always more than 1.0 (ankle is always greater than brachial by 20 mm of mercury systolic). If the ABI index is less than 1.0, the patient has peripheral arterial disease, which is most common in diabetic patients.

Additional Reading:

Random USMLE Facts

1. Random USMLE Facts volume 1-1
2. Random USMLE Facts volume 2-1
3. Random USMLE Facts volume 3-1
4. Random USMLE Facts volume 4-1
5. Random USMLE Facts volume 5-1
6. Random USMLE Facts volume 6-1
7. Random USMLE Facts volume 7-1
8. Random USMLE Facts volume 8-1
9. Random USMLE Facts volume 9-1
10. Random USMLE Facts volume 10-1
11. Random USMLE Facts volume 11-1
12. Random USMLE Facts volume 12-1

General and Systemic Examinations

1. General Examination for Internal Medicine
2. Jugular Venous Distention Workup
3. ER Chest Pain Workup
4. Format for Patient Presentation
5. Pulmonary Examination for Internal Medicine
6. Cardiac Examination for Internal Medicine
7. Abdominal Examination for Internal Medicine
8. Cranial Nerve Reflexes
9. Motor System Examination
10. Random Sensory System Facts
11. Random Stroke Facts

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USMLE Step 2 CS Videos

1. Video of Cardiology Examination in a Clinical Setting
2. Video of Neurology Examination in a Clinical Setting
3. Video of Pulmonology Examination in a Clinical Setting
4. Video of Musculoskeletal Examination in a Clinical Setting
5. Video of Abdominal Examination in a Clinical Setting
6. Video of HEENT Examination in a Clinical Setting
7. Video and Description of Rinne Hearing Test
8. Video and Description of Weber Hearing Test

USMLE Laboratory (lab) Values

1. USMLE Blood Lab Values
2. USMLE Cerebrospinal Lab Values
3. USMLE Hematologic Lab Values
4. USMLE Sweat and Urine Lab Values

Medical Images

Useful Medical Images & Diagrams (link opens in a new window)

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