Case History, Vital Signs and the Physical Examination
Most diagnoses are made, or at least strongly suspected, before a single lab test or film is ordered: a careful history points to the answer in the large majority of cases, and the physical examination confirms or refutes it. In a chiropractic office these skills separate a mechanical back pain from an aneurysm, a pyelonephritis or a metastasis.
By the end of this chapter you can
- Organize a complete case history from the chief complaint through the review of systems, using OPQRST to characterize a symptom.
- Ask the red flag questions that screen for fracture, cancer, infection, cauda equina syndrome and vascular emergencies, and document the encounter in SOAP format.
- Measure blood pressure correctly, name the Korotkoff phases, classify the reading, and recognize the common sources of error.
- Interpret pulse, respiration, temperature, oxygen saturation, BMI and orthostatic vital signs.
- Perform and interpret visual acuity, visual fields, ophthalmoscopy, otoscopy, and the Weber and Rinne tests.
- Examine the lymph nodes, thyroid, carotids and jugular venous pressure, and know which findings demand referral.
- Predict percussion, tactile fremitus, breath sounds and voice sounds in consolidation, effusion, pneumothorax and emphysema.
- Locate the auscultation areas, explain S1 to S4 and splitting, identify the classic murmurs and grade them I to VI.
- Perform the abdominal exam in the correct sequence, interpret the special signs (Murphy, McBurney, Rovsing, psoas, obturator), and distinguish hernias, prostate findings and the acute scrotum.
Section 1The case history
The history builds a differential diagnosis, a ranked list of plausible explanations, and gathers the facts that move each candidate up or down the list. It also establishes rapport and identifies patients who should not be treated in the office at all.
Components of the comprehensive history
A new patient deserves the full structure; a follow up may need only a focused history.
- Identifying data and source: age, sex, occupation, who is giving the history (patient, relative, interpreter, records) and how reliable that source appears.
- Chief complaint (CC): the main reason for the visit, recorded in the patient's own words and kept short, for example "my low back has been killing me for three days." It is not a diagnosis.
- History of present illness (HPI): a chronological, detailed account of the chief complaint, organized with a mnemonic such as OPQRST or OLDCARTS, including associated symptoms, pertinent positives and pertinent negatives, prior episodes, prior care and its results.
- Past medical history (PMH): childhood and adult illnesses, surgeries, hospitalizations, prior injuries and accidents, obstetric history, current medications (prescription, over the counter, supplements), allergies with the type of reaction, and immunizations.
- Family history (FH): age and health or cause and age at death of parents, siblings and children; heritable conditions such as early coronary disease, diabetes, hypertension, cancer, rheumatoid arthritis, ankylosing spondylitis, osteoporosis and bleeding disorders.
- Personal and social history (SH): tobacco (in pack years, packs per day multiplied by years smoked), alcohol (quantity and a screen such as CAGE), recreational and injection drug use, occupation and ergonomics, exercise, diet, sleep, stress, living situation, sexual history when relevant, and travel.
- Review of systems (ROS): a head to toe checklist of symptoms in each body system that the patient may not have connected to the complaint.
Characterizing a symptom: OPQRST and OLDCARTS
Every symptom, and pain in particular, has a set of attributes that together form a recognizable pattern. Two mnemonics are widely taught and cover the same ground.
| Letter | Attribute | What it helps distinguish |
|---|---|---|
| O | Onset | Sudden (vascular, rupture, fracture, disc herniation) versus gradual (degenerative, inflammatory, neoplastic) |
| P | Provocation and palliation | Mechanical pain changes with posture and movement; pain unchanged by rest or position suggests visceral, inflammatory or neoplastic disease |
| Q | Quality | Burning, electric or shooting suggests nerve; deep, dull, poorly localized suggests sclerotomal or visceral; throbbing suggests vascular; colicky suggests a hollow viscus |
| R | Region and radiation | Dermatomal radiation suggests radiculopathy; referral patterns suggest viscera (gallbladder to right scapula, kidney to flank and groin) |
| S | Severity | Baseline for outcome tracking; severity out of proportion to findings is a warning sign |
| T | Timing | Morning stiffness over 30 to 60 minutes suggests inflammatory arthritis; unrelenting night pain suggests tumor or infection |
OLDCARTS expands the same idea: Onset, Location, Duration, Character, Aggravating and Alleviating factors, Radiation, Timing and Severity. Whatever mnemonic you use, always add associated symptoms (fever, weight loss, numbness, weakness, bowel or bladder change, nausea, dyspnea), previous episodes, and treatment so far with its effect. A pertinent negative is a symptom the patient denies that matters to the differential: "no saddle numbness, no urinary retention" is as important in a back pain note as anything the patient does report.
Pain intensity is recorded on a numeric rating scale (0 to 10) or a 100 mm visual analog scale; disability questionnaires are covered in Chapter 4.
The review of systems
The ROS is a head to toe symptom inventory, asked after the HPI, that catches what the patient did not volunteer: constitutional symptoms (fever, chills, night sweats, fatigue, weight change), then each organ system. Positive answers relevant to the complaint move into the HPI. The constitutional, gastrointestinal, genitourinary, vascular and neurologic sections are the ones most likely to reveal that a "back pain" is not musculoskeletal.
Red flag questions
A red flag is a history or examination feature associated with serious pathology that needs further investigation or referral. Red flags do not prove serious disease (many are individually weak predictors), but their presence changes the plan. Every new spinal patient should be screened for them, and the screening should be documented.
| Serious condition | History red flags | Action |
|---|---|---|
| Cancer (primary or metastatic) | Prior cancer (strongest predictor), unexplained weight loss, age over 50, failure to improve in about a month, unremitting night pain | Imaging and labs (ESR or CRP, CBC) or referral |
| Spinal infection | Fever, injection drug use, recent bacterial infection, immunosuppression, recent spinal procedure | Same day referral if febrile with spinal pain |
| Fracture | Significant trauma, minor trauma in the elderly or osteoporotic, prolonged corticosteroid use, age over 70 | Radiographs before manipulation |
| Cauda equina syndrome | Urinary retention or overflow incontinence, fecal incontinence, saddle anesthesia, progressive bilateral leg weakness | Emergency referral (surgical decompression is time critical) |
| Abdominal aortic aneurysm or dissection | Older male smoker, tearing or pulsatile back or abdominal pain, pain unaffected by movement, known vascular disease | Emergency referral if acute |
| Cervical artery dissection or vertebrobasilar insufficiency | Sudden severe neck pain or headache unlike any before, the "5 Ds and 3 Ns": dizziness, diplopia, dysarthria, dysphagia, drop attacks; nausea, numbness, nystagmus; also ataxia and Horner syndrome | Do not manipulate; emergency referral |
| Subarachnoid hemorrhage | Thunderclap headache reaching maximum within a minute, "worst headache of my life", neck stiffness, altered consciousness | Call emergency services |
| Acute coronary syndrome | Exertional chest, jaw, arm or upper back pressure, dyspnea, diaphoresis; atypical in women, diabetics and the elderly | Call emergency services |
Interviewing and communication
The interview starts with open ended questions ("Tell me about your back") that let the patient tell the story, then narrows to closed questions ("Does the pain go below the knee?") to test specific hypotheses. Avoid leading questions ("The pain is worse when you cough, isn't it?") and compound questions that ask two things at once. Useful techniques include facilitation ("go on"), reflection (repeating the patient's words), clarification ("what do you mean by dizzy?"), empathic responses and a closing summarization. With a language barrier, use a trained medical interpreter rather than a relative and speak directly to the patient.
Documentation
The record is a legal document and a communication tool. Most visits are recorded in SOAP format.
| Part | Contents |
|---|---|
| S, Subjective | What the patient reports: CC, HPI, pain scores, function, pertinent history |
| O, Objective | What you measure: vitals, inspection, palpation, range of motion, orthopedic and neurologic tests, imaging and lab results |
| A, Assessment | Diagnosis or differential and progress |
| P, Plan | Treatment, frequency, home care, tests, referrals, goals and reevaluation date |
Records are legible, dated, signed and timely. Errors are corrected with a single line through the entry, leaving it readable, with date and initials; entries are never erased or backdated. Informed consent (nature of the procedure, material risks, alternatives, chance to ask questions) is documented before treatment.
Take the history in a fixed order (CC, HPI, PMH, FH, SH, ROS), characterize symptoms with OPQRST, and screen every new patient for red flags of cancer, infection, fracture, cauda equina syndrome and vascular emergency. Document in SOAP format.
Section 2Vital signs and general survey
An abnormal vital sign is often the first clue that a patient is sicker than they appear.
The general survey
The general survey starts as the patient walks in: apparent versus stated age, consciousness, distress, habitus, posture and gait, hygiene, skin color (pallor, cyanosis, jaundice), odors (alcohol, ketones, uremia) and affect. A patient with peritonitis lies still; one with renal colic writhes and cannot get comfortable.
Blood pressure technique
The difference between systolic and diastolic is the pulse pressure; mean arterial pressure is about diastolic plus one third of the pulse pressure.
- Prepare the patient: no caffeine, exercise or smoking for 30 minutes, empty bladder, seated quietly for at least 5 minutes with back supported, feet flat on the floor and legs uncrossed, and no talking during the measurement.
- Support the bare arm with the cuff at heart level (the midsternum).
- Choose the correct cuff: the bladder length should encircle about 80 percent of the arm circumference and its width about 40 percent. Center the bladder over the brachial artery with the lower edge 2 to 3 cm above the antecubital crease.
- Estimate systolic pressure by palpation: inflate while feeling the radial pulse, note where it disappears, deflate, and then inflate 20 to 30 mm Hg above that point for the auscultatory reading. This avoids being misled by an auscultatory gap.
- Place the stethoscope bell or diaphragm lightly over the brachial artery and deflate at 2 to 3 mm Hg per second.
- Record systolic at the first of two consecutive tapping sounds (Korotkoff phase I) and diastolic at the disappearance of sounds (phase V). Take at least two readings a minute or more apart and average them; at the first visit measure both arms and use the higher arm thereafter.
| Phase | Sound | Significance |
|---|---|---|
| I | First faint, clear, repetitive tapping | Systolic pressure |
| II | Softer, swishing | A silent auscultatory gap may occur here in hypertension |
| III | Crisper, louder tapping | No specific value |
| IV | Abrupt muffling | Used as diastolic when sounds persist to zero (children, pregnancy) |
| V | Disappearance | Diastolic pressure in adults |
Common errors: a cuff that is too small reads falsely high (the usual error in obese or muscular arms) and one too large reads low; an arm below heart level reads high and above reads low; an unsupported back or arm, crossed legs, talking or a full bladder raise the reading; deflating too fast or missing an auscultatory gap underestimates systolic.
Blood pressure classification
The current adult classification used in the United States is based on the average of two or more properly measured readings on two or more occasions.
| Category | Systolic (mm Hg) | Diastolic (mm Hg) | |
|---|---|---|---|
| Normal | Under 120 | and | Under 80 |
| Elevated | 120 to 129 | and | Under 80 |
| Stage 1 hypertension | 130 to 139 | or | 80 to 89 |
| Stage 2 hypertension | 140 or higher | or | 90 or higher |
| Hypertensive crisis | Over 180 | and/or | Over 120 |
A reading above 180/120 with signs of acute target organ damage (chest pain, dyspnea, neurologic deficit, confusion, visual loss, papilledema, acute kidney injury) is a hypertensive emergency requiring immediate transfer. Without organ damage it is an urgency needing prompt medical care. Older references define hypertension as 140/90 or above.
A difference of more than about 10 to 15 mm Hg between arms suggests subclavian artery stenosis, aortic dissection or coarctation. Leg pressures are normally equal to or slightly higher than arm pressures; leg pressures lower than arm pressures suggest coarctation of the aorta (with radiofemoral delay) or aortoiliac disease.
Orthostatic vital signs
Measure supine after 5 minutes, then 1 and 3 minutes after standing. Orthostatic hypotension is a fall of 20 mm Hg or more systolic or 10 mm Hg or more diastolic within 3 minutes of standing. A drop with a brisk heart rate rise suggests volume depletion; a drop without a rate rise suggests autonomic failure (diabetic neuropathy, Parkinson disease) or beta blockers. A symptomatic rise of 30 or more beats per minute without hypotension defines postural orthostatic tachycardia syndrome.
Pulse
Count a full minute if irregular; an apical rate exceeding the radial rate (pulse deficit) is typical of atrial fibrillation.
| Finding | Description | Classic cause |
|---|---|---|
| Normal rate | 60 to 100 per minute | Athletes may rest in the 40s or 50s |
| Irregularly irregular | No pattern to the beats | Atrial fibrillation |
| Water hammer (Corrigan) pulse | Rapid forceful upstroke and sudden collapse | Aortic regurgitation |
| Pulsus parvus et tardus | Small and late rising | Aortic stenosis |
| Pulsus bisferiens | Two systolic peaks | Aortic regurgitation (with or without stenosis), hypertrophic cardiomyopathy |
| Pulsus alternans | Regular rhythm, alternating strong and weak beats | Severe left ventricular failure |
Respiration
Count respirations without telling the patient, since awareness changes the rate. The normal adult rate is about 12 to 20 per minute.
| Pattern | Description | Associated with |
|---|---|---|
| Tachypnea | Rapid, shallow | Fever, pain, pneumonia, pulmonary embolism, restrictive disease, anxiety |
| Bradypnea | Slow | Opioids, sedatives, raised intracranial pressure, hypothyroidism |
| Hyperpnea or Kussmaul respiration | Deep, rapid, labored | Metabolic acidosis, especially diabetic ketoacidosis |
| Cheyne Stokes | Crescendo decrescendo breathing alternating with apnea | Heart failure, bilateral cerebral damage, uremia, sleep at altitude |
| Biot (ataxic) | Irregular depth and rhythm with unpredictable pauses | Medullary or pontine damage, meningitis |
Temperature
Normal oral temperature averages about 37°C (98.6°F), lowest in early morning. Rectal readings run about 0.5°C higher and axillary about 0.5°C lower. Fever is 38.0°C (100.4°F) or higher; the elderly and immunosuppressed may mount little fever even with serious infection.
Oxygen saturation
Normal SpO2 is about 95 to 100 percent; under 90 percent corresponds roughly to an arterial PO2 under 60 mm Hg. Readings are falsely normal in carbon monoxide poisoning and unreliable with poor perfusion, motion, nail polish and darker skin pigmentation.
Height, weight and BMI
Body mass index equals weight in kilograms divided by height in meters squared. Height loss over about 4 cm (1.5 inches) suggests osteoporotic compression fractures; unintentional loss of more than 5 percent of body weight in 6 to 12 months is a red flag.
| BMI (kg/m2) | Classification |
|---|---|
| Under 18.5 | Underweight |
| 18.5 to 24.9 | Normal weight |
| 25.0 to 29.9 | Overweight |
| 30.0 to 39.9 | Obesity class I (30 to 34.9) and II (35 to 39.9) |
| 40 or higher | Obesity class III (severe) |
Waist circumference over 40 inches (102 cm) in men or 35 inches (88 cm) in women marks increased cardiometabolic risk.
Measure blood pressure rested, arm at heart level, correct cuff, slow deflation; systolic is phase I, diastolic phase V. Stage 1 begins at 130/80, stage 2 at 140/90, crisis over 180/120. Know normal pulse (60 to 100), respiration (12 to 20), fever (38.0°C), SpO2 (95 to 100 percent), BMI (18.5 to 24.9) and orthostatic hypotension (a fall of 20 systolic or 10 diastolic).
Section 3Head, eyes, ears, nose, throat and neck
Many head and neck findings are windows onto systemic disease: papilledema signals raised intracranial pressure, a Virchow node abdominal cancer, an elevated JVP right heart failure.
Head and face
Classic facies include the moon face of Cushing syndrome, the coarse features of acromegaly, the puffy face with thinned lateral eyebrows of hypothyroidism, the masked face of Parkinson disease and the malar rash of lupus sparing the nasolabial folds. Palpate the temporal arteries in older patients with new headache: tenderness, nodularity or a reduced pulse suggests giant cell arteritis, which threatens vision and calls for same day referral.
Visual acuity and visual fields
Distance acuity is tested one eye at a time with a Snellen chart at 20 feet (6 meters), with the patient's glasses on. The result is a fraction: the numerator is the testing distance and the denominator is the distance at which a normal eye can read that line. 20/40 means the patient reads at 20 feet what a normal eye reads at 40. Legal blindness in the United States is best corrected acuity of 20/200 or worse in the better eye or a visual field of 20 degrees or less. Near vision is tested with a card at about 14 inches; age related loss of near vision is presbyopia.
Visual fields are screened by confrontation, comparing the patient's field in each quadrant with the examiner's. A lesion of the optic chiasm (classically a pituitary adenoma) gives bitemporal hemianopia; lesions behind the chiasm give a contralateral homonymous defect, with macular sparing in occipital strokes (detailed in Chapter 6).
Pupils and external eye
Pupils should be equal, round and reactive to light and accommodation (PERRLA); a difference under about 1 mm is often physiologic. In the swinging flashlight test: if both pupils dilate when the light swings onto one eye, that eye has an afferent defect, the Marcus Gunn pupil or relative afferent pupillary defect (optic nerve disease). Also know the Argyll Robertson pupil (small, irregular, accommodates but does not react to light) of neurosyphilis; Horner syndrome (ipsilateral ptosis, miosis, anhidrosis; Pancoast tumor, carotid dissection) and the fixed dilated pupil of third nerve compression (uncal herniation, posterior communicating artery aneurysm).
On the external eye, look for xanthelasma and early arcus (hyperlipidemia), Kayser Fleischer rings (Wilson disease), scleral icterus (bilirubin over about 2.5 mg/dL) and exophthalmos (Graves disease). A painful red eye with reduced vision, a fixed mid dilated pupil and a hazy cornea is acute angle closure glaucoma, an emergency.
Ophthalmoscopy
Use your right eye for the patient's right eye, in a dark room. Find the red reflex from about 15 inches, move in to the optic disc, follow the vessels to each quadrant, and finish at the macula. The normal disc is round, yellow orange, with sharp margins and a central physiologic cup less than half the disc diameter (cup to disc ratio under about 0.5). Arteries are lighter and narrower than veins (artery to vein ratio about 2 to 3), and spontaneous venous pulsations at the disc indicate normal intracranial pressure.
| Finding | Appearance | Meaning |
|---|---|---|
| Absent red reflex | Dark or white pupil | Cataract; in a child, retinoblastoma |
| Papilledema | Swollen disc, blurred margins, loss of venous pulsations | Raised intracranial pressure; usually bilateral |
| Glaucomatous cupping | Enlarged cup (ratio over 0.5 or asymmetric between eyes) | Open angle glaucoma |
| Hypertensive retinopathy | Arteriolar narrowing, AV nicking, copper and silver wiring, flame hemorrhages, cotton wool spots | Chronic or severe hypertension |
| Diabetic retinopathy | Microaneurysms, dot and blot hemorrhages, hard exudates (nonproliferative); neovascularization (proliferative) | Diabetes; annual eye examination needed |
| Cherry red spot | Pale retina with red macula | Central retinal artery occlusion; Tay Sachs disease in infants |
| Roth spots | Hemorrhages with pale centers | Infective endocarditis, leukemia |
Ears and hearing
Before inserting the otoscope, pull the auricle up and back in adults (down and back in infants and young children) to straighten the canal, and use the largest speculum that fits comfortably. Pain on moving the auricle or pressing the tragus suggests otitis externa; pain without that tenderness suggests middle ear disease. The normal tympanic membrane is translucent and pearly gray, with the handle and short process of the malleus visible and a cone of light reflecting anteroinferiorly (at about 5 o'clock in the right ear and 7 o'clock in the left).
| Finding | Suggests |
|---|---|
| Red, bulging, immobile drum with loss of landmarks and light reflex | Acute otitis media |
| Swollen red canal with debris, pain on tragal pressure | Otitis externa |
| Blood behind the drum (hemotympanum), mastoid bruising (Battle sign), periorbital bruising (raccoon eyes) | Basilar skull fracture |
Tuning fork tests, ideally with a 512 Hz fork, separate conductive loss (outer or middle ear: wax, otitis media, otosclerosis, perforation) from sensorineural loss (cochlea or cochlear nerve: presbycusis, noise, ototoxic drugs, Meniere disease, acoustic neuroma).
- Weber test: the vibrating fork is placed on the vertex or midforehead and the patient says where the sound is heard. Normally it is heard in the midline. In a conductive loss the sound lateralizes to the affected ear (the ear is shielded from room noise and bone conduction is relatively enhanced); in a sensorineural loss it lateralizes to the good ear.
- Rinne test: the fork is placed on the mastoid process until the patient no longer hears it, then held near the ear canal. Normally air conduction is greater than bone conduction (about twice as long), a "positive" Rinne. In a conductive loss bone conduction equals or exceeds air conduction in the affected ear (a "negative" Rinne). In a sensorineural loss air conduction remains greater than bone, but both are reduced.
Nose and sinuses
Look for septal perforation (cocaine, granulomatosis with polyangiitis), the pale boggy mucosa of allergic rhinitis and nasal polyps (asthma, aspirin sensitivity, cystic fibrosis in a child). Most nosebleeds arise from Kiesselbach plexus on the anterior septum. Frontal and maxillary sinuses are palpated or percussed for tenderness and transilluminated; reduced glow suggests fluid. Sinus tenderness with purulent discharge, maxillary toothache, and symptoms lasting more than 10 days or worsening after initial improvement ("double sickening") suggests bacterial sinusitis.
Mouth and throat
Inspect every surface including the underside of the tongue and floor of mouth, and palpate any lesion. Tonsils are graded 1+ (within the pillars) to 4+ (touching).
| Finding | Association |
|---|---|
| Leukoplakia (white plaque that does not scrape off) | Premalignant; tobacco and alcohol; biopsy if persistent |
| Thrush (white patches that scrape off, leaving a red base) | Candida; antibiotics, inhaled steroids, diabetes, HIV |
| Smooth red tongue (atrophic glossitis) | Deficiency of B12, folate, iron or niacin |
| Painless indurated ulcer, especially on the lateral tongue or floor of mouth | Squamous cell carcinoma; refer any oral ulcer lasting more than 2 to 3 weeks |
| Tonsillar exudate, fever, tender anterior nodes, no cough | Streptococcal pharyngitis (Centor criteria) |
| Uvula deviated away from a swollen, fluctuant tonsillar area, trismus, "hot potato" voice | Peritonsillar abscess (refer urgently) |
The mouth exam also tests cranial nerves. When the patient says "ah," the uvula and soft palate pull away from the side of a vagus (CN X) lesion, toward the strong side. On protrusion, the tongue deviates toward the side of a hypoglossal (CN XII) lower motor neuron lesion, pushed by the intact genioglossus.
Lymph nodes of the head and neck
Palpate with the finger pads, comparing sides, in a consistent sequence: preauricular, posterior auricular, occipital, tonsillar (jugulodigastric), submandibular, submental, superficial cervical, posterior cervical, deep cervical chain and supraclavicular. For each node note size, shape, consistency, tenderness, mobility and whether nodes are matted together.
| Feature | Reactive or infectious node | Malignant node |
|---|---|---|
| Size | Usually under 1 cm, shrinks over weeks | Over 1 to 2 cm, persistent or growing |
| Consistency | Soft to rubbery | Hard (carcinoma) or rubbery (lymphoma) |
| Tenderness | Tender (rapid capsular stretch) | Usually nontender |
| Mobility | Mobile, discrete | Fixed to deep tissue, matted |
| Location | Anterior cervical with pharyngitis, posterior cervical with mononucleosis | Any supraclavicular node is suspicious |
A hard left supraclavicular node, the Virchow node (Troisier sign), suggests metastasis from an abdominal or pelvic cancer, classically gastric, via the thoracic duct. Generalized lymphadenopathy raises mononucleosis, HIV, lymphoma and leukemia.
Thyroid
Palpate the thyroid as the patient swallows; a normal gland is barely palpable. A diffusely enlarged gland with a bruit suggests Graves disease; a firm, rubbery, nontender goiter suggests Hashimoto thyroiditis; a tender gland after a viral illness suggests subacute (de Quervain) thyroiditis; and a single hard, fixed nodule with cervical lymphadenopathy or hoarseness suggests carcinoma.
Carotid arteries and jugular venous pressure
Palpate the carotids one at a time, low in the neck, away from the carotid sinus. Auscultate with the bell during a held breath; a bruit suggests atherosclerotic stenosis, though an aortic murmur can radiate to the neck.
The jugular venous pressure (JVP) estimates right atrial pressure. With the head of the table raised 30 to 45 degrees, identify the right internal jugular pulsation and measure the vertical distance from the sternal angle to the top of the pulsation. A height over 3 to 4 cm above the sternal angle (equivalent to a right atrial pressure over about 8 to 9 cm H2O, since the right atrium lies about 5 cm below the angle) is elevated: right heart failure, fluid overload, tricuspid disease, constrictive pericarditis, tamponade or superior vena cava obstruction. A sustained JVP rise with abdominal pressure is a positive hepatojugular reflux (right sided failure). A paradoxical rise in JVP on inspiration is Kussmaul sign (constrictive pericarditis, restrictive cardiomyopathy).
In the jugular waveform, the a wave is atrial contraction and the v wave atrial filling against a closed tricuspid. Absent a waves mean atrial fibrillation; large cannon a waves mean the atrium is contracting against a closed tricuspid valve (complete heart block, ventricular tachycardia); giant v waves mean tricuspid regurgitation.
Snellen at 20 feet, confrontation fields, pupils and fundus for papilledema and hypertensive or diabetic change; Weber and Rinne separate conductive from sensorineural loss; hard, fixed or supraclavicular nodes are suspicious; JVP over 3 to 4 cm above the sternal angle is elevated.
Section 4Thorax, heart and lungs
The chest exam follows inspection, palpation, percussion and auscultation, posterior chest first.
Landmarks
The sternal angle marks the second rib and the tracheal bifurcation (T4 to T5). Posteriorly, the inferior scapular angle lies at about the seventh rib, and the lung bases at about T10 on expiration and T12 on deep inspiration.
Inspection and palpation
The normal anteroposterior diameter is about half the lateral; a barrel chest (ratio near 1 to 1) suggests emphysema. Note pectus deformities, kyphoscoliosis, accessory muscle use, unilateral lag (pneumonia, effusion, rib fracture) and paradoxical movement (flail chest). Clubbing suggests lung cancer, bronchiectasis, fibrosis, cyanotic heart disease or endocarditis, not uncomplicated COPD.
Chest expansion measured by tape at the fourth intercostal space normally exceeds about 5 cm; expansion under about 2.5 cm is a classic finding in ankylosing spondylitis. Tactile fremitus is the palpable vibration transmitted to the chest wall when the patient says "ninety nine": sound travels better through solid tissue than through air or fluid, so fremitus is increased over consolidation and decreased or absent over effusion, pneumothorax, emphysema, a thick chest wall or an obstructed bronchus.
Percussion
Percuss symmetrically, side to side, avoiding the scapulae.
| Note | Pitch and quality | Normal location | Abnormal example |
|---|---|---|---|
| Flat | Soft, high, short | Thigh, large muscle | Large pleural effusion |
| Dull | Medium intensity, thud like | Liver, heart | Lobar pneumonia, effusion ("stony dull"), atelectasis |
| Resonant | Loud, low, hollow | Healthy lung | Chronic bronchitis |
| Hyperresonant | Louder, lower, longer, boomy | Not normal in adults | Emphysema, pneumothorax |
| Tympanic | Loud, high, drumlike | Gastric air bubble, bowel | Large pneumothorax |
Normal diaphragmatic excursion is about 3 to 6 cm.
Breath sounds and voice sounds
Normal vesicular sounds (soft, low, inspiration longer than expiration) are heard over most lung; bronchovesicular sounds near the main bronchi; bronchial sounds (loud, high, expiration longer) over the manubrium.
When bronchial breath sounds are heard over the peripheral lung, air filled alveoli have been replaced by fluid or tissue that conducts sound well: consolidation. Three voice sounds confirm it: bronchophony (spoken "ninety nine" becomes louder and clearer), egophony (a spoken "ee" sounds like "ay", the E to A change) and whispered pectoriloquy (whispered words heard distinctly).
| Sound | Description | Mechanism and causes |
|---|---|---|
| Fine crackles (rales) | Brief, high, discontinuous, like hair rubbed between fingers, late inspiratory | Small airways popping open: heart failure, pulmonary fibrosis, early pneumonia; not cleared by cough |
| Wheezes | Continuous, high pitched, musical, usually expiratory | Narrowed airways: asthma, COPD, foreign body (if localized) |
| Rhonchi | Continuous, low pitched, snoring | Secretions in large airways; often clear with coughing |
| Stridor | Loud, high pitched, inspiratory, heard best over the neck | Upper airway obstruction: epiglottitis, croup, foreign body, anaphylaxis (an emergency) |
| Pleural friction rub | Creaking, grating, in both phases | Inflamed pleura: pleurisy, pneumonia, pulmonary infarction; disappears when the breath is held, unlike a pericardial rub |
| Condition | Trachea | Percussion | Fremitus | Breath sounds | Added sounds and voice |
|---|---|---|---|---|---|
| Lobar consolidation (pneumonia) | Midline | Dull | Increased | Bronchial | Late crackles; bronchophony, egophony, whispered pectoriloquy |
| Pleural effusion | Midline or away if large | Stony dull | Decreased | Decreased or absent | Possible rub; egophony at the upper border |
| Pneumothorax | Midline, or away (tension) | Hyperresonant | Decreased or absent | Decreased or absent | None |
| Emphysema (COPD) | Midline | Hyperresonant | Decreased | Decreased, prolonged expiration | Possible wheezes |
| Atelectasis (lobar, bronchus blocked) | Toward the affected side | Dull | Decreased or absent | Decreased or absent | None |
| Left heart failure | Midline | Resonant (dull if effusions) | Normal | Vesicular | Bibasilar late inspiratory crackles |
The heart: inspection and palpation
The apical impulse or point of maximal impulse (PMI) is normally in the fifth intercostal space at or just medial to the left midclavicular line, no more than about 2.5 cm in diameter, brief and tapping. A laterally displaced, diffuse impulse suggests left ventricular dilation (heart failure, regurgitant lesions); a sustained, forceful but not displaced impulse suggests left ventricular hypertrophy (hypertension, aortic stenosis). A lift or heave along the left sternal border indicates right ventricular enlargement. A thrill is a palpable vibration from a loud murmur (grade 4 or higher) and is best felt with the palm or the ball of the hand.
Auscultation areas
Use the diaphragm for high pitched sounds (S1, S2, regurgitant murmurs, rubs) and the bell, held lightly, for low pitched ones (S3, S4, mitral stenosis rumble).
Heart sounds
| Sound | Timing and cause | Heard best | Significance |
|---|---|---|---|
| S1 | Closure of the mitral and tricuspid valves at the start of systole | Apex, diaphragm | Loud in mitral stenosis; soft in mitral regurgitation |
| S2 | Closure of the aortic (A2) then pulmonic (P2) valves at the end of systole | Base, diaphragm | Loud A2 in systemic hypertension; loud P2 in pulmonary hypertension |
| S3 (ventricular gallop) | Early diastole, rapid filling of a volume loaded ventricle | Apex, bell, left lateral decubitus | Normal in children, young adults, athletes and pregnancy; over about 40 it suggests heart failure or volume overload (mitral regurgitation) |
| S4 (atrial gallop) | Late diastole, atrial kick into a stiff ventricle | Apex, bell | LV hypertrophy from hypertension or aortic stenosis, ischemia, hypertrophic cardiomyopathy; absent in atrial fibrillation |
| Opening snap | Early diastole, high pitched | Apex to left sternal border | Mitral stenosis |
| Midsystolic click | Mid systole | Apex | Mitral valve prolapse |
Splitting of S2: during inspiration, increased venous return to the right heart delays P2, so A2 and P2 separate (physiologic splitting), heard best in the pulmonic area. Wide splitting (present in both phases, wider on inspiration) occurs when P2 is delayed by right bundle branch block or pulmonic stenosis. Fixed splitting that does not vary with respiration is the hallmark of an atrial septal defect. Paradoxical (reversed) splitting, heard on expiration and narrowing on inspiration, means A2 is delayed: left bundle branch block, severe aortic stenosis.
Murmurs
Describe a murmur by timing, location, radiation, intensity, pitch, quality and shape. Soft midsystolic flow murmurs can be innocent; diastolic murmurs are always pathologic.
| Grade | Description |
|---|---|
| I/VI | Very faint, heard only after the listener has tuned in, not in every position |
| II/VI | Quiet but heard immediately on placing the stethoscope |
| III/VI | Moderately loud, no thrill |
| IV/VI | Loud, with a palpable thrill |
| V/VI | Very loud, with thrill, heard with the stethoscope partly off the chest (edge only) |
| VI/VI | Heard with the stethoscope entirely off the chest, with thrill |
| Lesion | Timing and shape | Location and radiation | Associated findings and maneuvers |
|---|---|---|---|
| Aortic stenosis | Midsystolic ejection, crescendo decrescendo, harsh | Right second interspace, radiates to the carotids | Soft A2, pulsus parvus et tardus; angina, syncope, heart failure |
| Mitral regurgitation | Holosystolic, plateau, blowing | Apex, radiates to the left axilla | S3; louder with handgrip |
| Mitral valve prolapse | Midsystolic click then late systolic murmur | Apex | Standing or Valsalva moves the click earlier; squatting moves it later |
| Tricuspid regurgitation | Holosystolic | Left lower sternal border | Louder on inspiration (Carvallo sign), giant v waves |
| Hypertrophic cardiomyopathy | Midsystolic crescendo decrescendo | Left sternal border, little carotid radiation | Louder with Valsalva and standing, softer with squatting and handgrip; cause of sudden death in young athletes |
| Aortic regurgitation | Early diastolic, decrescendo, high pitched, blowing | Left sternal border (third interspace), heard best sitting, leaning forward, in held expiration | Wide pulse pressure, water hammer pulse |
| Mitral stenosis | Opening snap then low pitched mid diastolic rumble, presystolic accentuation | Apex, bell, left lateral decubitus | Loud S1; usually rheumatic; atrial fibrillation, hemoptysis |
Peripheral vascular signs
Pulses are graded 0 absent, 1+ diminished, 2+ normal, 3+ increased, 4+ bounding; capillary refill is normally under about 2 seconds.
Pitting edema is graded 1+ to 4+. Bilateral edema suggests heart failure, nephrotic syndrome, cirrhosis or venous insufficiency; unilateral calf swelling, warmth and tenderness suggests deep vein thrombosis. The Homans sign (calf pain on passive dorsiflexion) is neither sensitive nor specific and should not be relied upon; a pretest probability score (Wells) plus D dimer or duplex ultrasound is the accepted approach.
The ankle brachial index (ABI) divides the higher ankle systolic pressure (dorsalis pedis or posterior tibial, measured by Doppler) by the higher brachial systolic pressure. Values of 1.0 to 1.4 are normal, 0.91 to 0.99 borderline, 0.90 or less diagnostic of peripheral arterial disease, under about 0.4 critical ischemia, and over 1.4 indicates noncompressible, calcified vessels (diabetes, chronic kidney disease). Acute limb ischemia presents with the six Ps: pain, pallor, pulselessness, paresthesia, paralysis and poikilothermia (coldness), and is an emergency.
Consolidation is dull with increased fremitus and bronchial sounds; effusion is stony dull with decreased fremitus; pneumothorax is hyperresonant. S3 means a volume loaded ventricle, S4 a stiff one, fixed S2 splitting an ASD. Aortic stenosis radiates to the carotids, mitral regurgitation to the axilla; diastolic murmurs are abnormal and a thrill means grade IV or more. ABI 0.9 or less defines peripheral arterial disease.
Section 5Abdominal, rectal and male urogenital examination
Abdominal and pelvic organs refer pain to the back, flank, groin and shoulder, so the abdominal exam belongs in the workup of many spinal complaints.
Regions and sequence
The abdomen is divided into four quadrants by a vertical midline and a horizontal line through the umbilicus, or into nine regions (hypochondriac, epigastric, lumbar, umbilical, inguinal and hypogastric).
The patient lies supine with knees slightly flexed; examine the painful area last. The sequence is inspection, auscultation, percussion, palpation: auscultation comes before percussion and palpation because manipulating the bowel can alter bowel sounds.
Inspection and auscultation
Note purple striae (Cushing syndrome), caput medusae (portal hypertension) and visible pulsation (normal when thin, or an aneurysm). Bruising around the umbilicus (Cullen sign) or in the flanks (Grey Turner sign) indicates retroperitoneal hemorrhage, classically from hemorrhagic pancreatitis, also from ruptured ectopic pregnancy or aneurysm.
Normal bowel sounds occur roughly 5 to 35 per minute; listen at least 2 minutes before calling them absent (ileus, peritonitis). High pitched, tinkling, rushing sounds suggest early mechanical obstruction. Listen for bruits over the aorta, renal arteries (renal artery stenosis with hypertension), iliac and femoral arteries.
Percussion
Tympany predominates; dullness lies over solid organs, masses, fluid and a full bladder. Liver span in the right midclavicular line is normally about 6 to 12 cm (larger in tall people and men). The spleen is percussed in Traube space (the left lower anterior chest, normally tympanic) and at the lowest left interspace in the anterior axillary line (Castell sign: dullness there on deep inspiration suggests splenomegaly). Ascites is suggested by shifting dullness and a fluid wave. Costovertebral angle tenderness is tested by a firm fist percussion over the angle between the twelfth rib and the spine (Murphy punch); marked pain suggests pyelonephritis or other renal disease, though muscle soreness can produce mild tenderness.
Palpation
Light palpation precedes deep palpation. Voluntary guarding lessens when the patient relaxes or exhales; involuntary rigidity (a boardlike abdomen) persists and indicates peritoneal inflammation.
- Liver: the edge descends to the examining hand on deep inspiration; a normal edge is soft and smooth at or just below the costal margin, while a hard, nodular edge suggests cirrhosis or metastases.
- Spleen: a spleen must be roughly two to three times its normal size before it can be felt, so a palpable spleen is abnormal (mononucleosis, portal hypertension, hematologic malignancy). A large spleen is vulnerable to rupture, so avoid deep pressure and contact sports, and avoid vigorous thoracolumbar thrusts during acute mononucleosis.
- Aorta: width over about 3 cm, or a pulsation that pushes the hands apart (expansile rather than merely transmitted), suggests an abdominal aortic aneurysm. Ultrasound is the screening test (once for men 65 to 75 who have ever smoked).
Special abdominal signs
| Sign or test | How it is done | Positive finding | Suggests |
|---|---|---|---|
| Murphy sign | Fingers hooked under the right costal margin at the midclavicular line; patient inhales deeply | Sharp pain causes abrupt inspiratory arrest | Acute cholecystitis |
| McBurney point tenderness | Pressure one third of the way from the right ASIS to the umbilicus | Localized tenderness | Appendicitis |
| Rovsing sign | Deep pressure in the left lower quadrant | Pain felt in the right lower quadrant | Appendicitis (peritoneal irritation) |
| Psoas sign | Patient raises the straight right leg against resistance, or lies on the left side while the right hip is passively extended | Increased abdominal pain | Retrocecal appendix or psoas abscess irritating the iliopsoas |
| Obturator sign | Flex the right hip and knee to 90 degrees and internally rotate the hip | Hypogastric pain | Pelvic appendix or abscess irritating obturator internus |
| Rebound tenderness (Blumberg sign) | Press slowly and deeply, then release quickly | Pain on release greater than on pressure | Peritonitis; gentler alternatives are cough tenderness and percussion tenderness |
| Kehr sign | History or pressure on the left upper quadrant with the patient supine | Pain referred to the left shoulder tip | Diaphragmatic irritation by blood: ruptured spleen, ectopic pregnancy |
| Courvoisier sign | Palpation in a jaundiced patient | Palpable, nontender gallbladder | Obstruction by carcinoma of the pancreatic head, not stones |
| Carnett sign | Patient tenses the abdominal wall (head and shoulders lifted) while the tender spot is pressed | Tenderness unchanged or worse | Abdominal wall source (muscle, nerve entrapment); visceral tenderness lessens |
Hernias
Examine the groin standing: invaginate scrotal skin up to the external inguinal ring and ask the patient to cough.
| Hernia | Path | Who | Exam clue |
|---|---|---|---|
| Indirect inguinal | Through the deep ring, lateral to the inferior epigastric vessels, along the canal, may descend into the scrotum (patent processus vaginalis) | Most common hernia in both sexes and in children; young men | Impulse strikes the fingertip at the external ring |
| Direct inguinal | Through the floor of Hesselbach triangle (bordered by the inferior epigastric vessels, the lateral rectus border and the inguinal ligament), medial to the vessels; rarely enters the scrotum | Older men, acquired weakness of the transversalis fascia | Bulges forward against the pad of the finger |
| Femoral | Below the inguinal ligament through the femoral canal, medial to the femoral vein | More common in women than in men (though indirect inguinal is still the most common hernia in women) | Bulge below the ligament, lateral to the pubic tubercle; highest risk of strangulation |
A hernia that cannot be reduced is incarcerated; if its blood supply is compromised it is strangulated, presenting as a tender, tense, discolored bulge with fever and signs of bowel obstruction. Strangulation is a surgical emergency.
Rectal and prostate examination
Assess the anal wink (S2 to S4) and resting sphincter tone and voluntary squeeze; reduced tone with saddle anesthesia is a sign of cauda equina syndrome.
The prostate is felt on the anterior wall. A normal gland is about the size of a walnut (roughly 2.5 cm long and 4 cm wide), rubbery, nontender and smooth, with two lateral lobes separated by a palpable median sulcus.
| Condition | Prostate on DRE | Other features |
|---|---|---|
| Benign prostatic hyperplasia | Symmetrically enlarged, smooth, rubbery, nontender; sulcus may be obliterated | Arises in the transition zone around the urethra; weak stream, hesitancy, frequency, nocturia, incomplete emptying |
| Carcinoma | Hard, irregular nodule or asymmetry, may be fixed | Arises mostly in the peripheral zone, posterior, within reach of the finger; often silent; osteoblastic metastases to the lumbar spine and pelvis cause back pain |
| Acute bacterial prostatitis | Exquisitely tender, warm, boggy, swollen | Fever, chills, dysuria, perineal and low back pain; do not massage (risk of bacteremia) |
Male genital examination and the acute scrotum
Palpate each testis (normally 4 to 5 cm, smooth, rubbery), the posterolateral epididymis and the cord. Note paraphimosis (retracted foreskin cannot be returned, an emergency), discharge and genital ulcers (the painless, indurated chancre of primary syphilis versus the painful ulcers of chancroid and herpes). The cremasteric reflex (stroking the inner thigh raises the ipsilateral testis) tests L1 to L2. Any scrotal mass should be transilluminated with a light pressed against the scrotum in a dark room: fluid glows, solid tissue and blood do not.
| Condition | Presentation | Key findings | Urgency |
|---|---|---|---|
| Testicular torsion | Sudden severe scrotal pain, nausea, vomiting; mostly adolescents | High riding testis with a horizontal lie, absent cremasteric reflex, no relief on elevation (negative Prehn sign) | Emergency: testicular salvage falls sharply after about 6 hours |
| Epididymitis | Gradual pain and swelling, fever, dysuria | Tender, swollen epididymis posterior to the testis, cremasteric reflex present, pain eased by elevation (positive Prehn sign) | Prompt medical treatment |
| Testicular cancer | Painless firm mass, ages about 15 to 35 | Hard nodule within the testis, does not transilluminate; para aortic spread can cause back pain | Urgent referral |
| Hydrocele | Painless scrotal swelling | Smooth, cystic, transilluminates | Elective |
| Varicocele | Dull ache or heaviness, infertility | "Bag of worms" above the testis, larger standing, mostly left (left testicular vein enters the left renal vein at a right angle) | Elective; a new right sided varicocele suggests a retroperitoneal or renal mass |
Inspect, auscultate, percuss, palpate. A palpable spleen is abnormal and an aorta over 3 cm is aneurysmal. Murphy sign means cholecystitis; McBurney, Rovsing, psoas and obturator signs mean appendicitis. Indirect hernias lie lateral to the inferior epigastrics, direct medial. On DRE, cancer is hard and nodular, BPH smooth and rubbery; reduced tone suggests cauda equina syndrome. Torsion is an emergency.
The chapter in one breath
- The history (CC, HPI, PMH, FH, SH, ROS) provides most diagnoses; characterize every symptom with OPQRST and record pertinent negatives.
- Screen every new patient for red flags of cancer, infection, fracture, cauda equina syndrome and vascular emergency; prior cancer is the strongest predictor of spinal malignancy.
- Measure blood pressure seated and rested, arm at heart level, correct cuff, palpatory estimate first, deflation at 2 to 3 mm Hg per second; systolic is Korotkoff phase I, diastolic phase V. A small cuff reads high.
- Normal is under 120/80; stage 1 starts at 130/80, stage 2 at 140/90, crisis over 180/120; orthostatic hypotension is a fall of 20 systolic or 10 diastolic.
- Chiasm lesions give bitemporal hemianopia; papilledema signals raised intracranial pressure; AV nicking and flame hemorrhages signal hypertension.
- Weber lateralizes to the bad ear in conductive loss and the good ear in sensorineural loss; the Rinne reverses (BC greater than AC) only in conductive loss.
- Hard, fixed, nontender or supraclavicular nodes are suspicious; the left supraclavicular Virchow node signals abdominal cancer.
- Consolidation: dull, increased fremitus, bronchial breath sounds, egophony. Effusion: stony dull, decreased fremitus and breath sounds. Pneumothorax: hyperresonant, absent sounds.
- S3 means volume overload, S4 a stiff ventricle, fixed split S2 an ASD; aortic stenosis radiates to the carotids, mitral regurgitation to the axilla; diastolic murmurs are always pathologic and a thrill means grade IV or higher.
- Abdomen: inspect, auscultate, percuss, palpate; Murphy for cholecystitis, McBurney, Rovsing, psoas and obturator for appendicitis; indirect hernias lateral and direct hernias medial to the inferior epigastrics; torsion with absent cremasteric reflex is an emergency.
Words worth knowing
| Term | What it means |
|---|---|
| Chief complaint | The main reason for the visit, recorded briefly in the patient's own words. |
| Pertinent negative | A symptom or sign that is absent and whose absence helps narrow the differential diagnosis. |
| Red flag | A history or exam feature associated with serious underlying disease that warrants further testing or referral. |
| SOAP note | A documentation format with Subjective, Objective, Assessment and Plan sections. |
| Korotkoff sounds | Sounds heard over the brachial artery during cuff deflation; phase I marks systolic and phase V diastolic pressure. |
| Pulsus paradoxus | An inspiratory fall in systolic pressure greater than 10 mm Hg, classic for cardiac tamponade. |
| Orthostatic hypotension | A fall of at least 20 mm Hg systolic or 10 mm Hg diastolic within 3 minutes of standing. |
| Bitemporal hemianopia | Loss of both temporal visual fields from a lesion of the optic chiasm, classically a pituitary adenoma. |
| Papilledema | Swelling of the optic discs from raised intracranial pressure, with blurred margins and loss of venous pulsations. |
| Weber test | A tuning fork on the vertex; sound lateralizes to the affected ear in conductive loss and the unaffected ear in sensorineural loss. |
| Rinne test | Compares air and bone conduction in one ear; bone conduction greater than air conduction indicates conductive loss. |
| Virchow node | An enlarged left supraclavicular lymph node, a sign of metastatic abdominal or pelvic cancer. |
| Jugular venous pressure | The height of the internal jugular venous column above the sternal angle, an estimate of right atrial pressure. |
| Tactile fremitus | Palpable chest wall vibration during speech; increased in consolidation and decreased in effusion or pneumothorax. |
| Egophony | A spoken "ee" heard as "ay" through the stethoscope over consolidated lung. |
| Point of maximal impulse | The apical beat, normally in the fifth intercostal space at the left midclavicular line and under 2.5 cm across. |
| Third heart sound | An early diastolic sound of rapid filling into a volume loaded ventricle, a sign of heart failure after about age 40. |
| Thrill | A palpable vibration over the precordium produced by a murmur of grade IV or louder. |
| Ankle brachial index | Ankle systolic pressure divided by brachial systolic pressure; 0.90 or less indicates peripheral arterial disease. |
| Rebound tenderness | Pain greater on sudden release of abdominal pressure than on pressing, a sign of peritonitis. |
| Hesselbach triangle | The area bounded by the inferior epigastric vessels, rectus border and inguinal ligament, through which direct hernias pass. |
| Cremasteric reflex | Elevation of the testis when the inner thigh is stroked, mediated by L1 and L2; absent in testicular torsion. |