The General Physical Examination

A chiropractor is a portal of entry provider, which means you may be the first clinician to see a patient whose back pain is really an aneurysm, whose neck pain is a thyroid mass, or whose headache is a blood pressure of 210 over 125. Part III cases routinely slip a single abnormal vital sign or physical finding into a musculoskeletal story and ask what it means and what you should do next. This chapter teaches the general physical examination as a set of decisions: what to look for, what is abnormal, and how each finding changes management.

Section 1General survey and vital signs in the case

The general survey

The general survey begins as the patient walks in. Note apparent age versus stated age, level of distress (calm, guarding, writhing, unable to sit), body habitus (cachexia, obesity, central adiposity), posture and movement, skin color (pallor, cyanosis, jaundice, flushing), hygiene and dress, speech, affect and alertness. A patient lying perfectly still because any movement hurts suggests peritonitis; a patient who cannot find a comfortable position suggests renal or biliary colic. A patient leaning forward to ease epigastric pain suggests pancreatitis, while leaning forward to ease leg symptoms on walking suggests stenosis. Cachexia with temporal wasting suggests cancer or chronic disease. Jaundice points to liver or biliary disease; pallor to anemia; a malar rash to lupus; a moon face, central obesity and purple striae to Cushing syndrome; a tall slender build with long limbs to Marfan syndrome (aortic root dilation and dissection risk).

Body mass index and anthropometrics

BMI is weight in kilograms divided by height in meters squared. Waist circumference adds information about visceral fat and cardiometabolic risk. Unexplained weight loss of more than about 5 percent of body weight over 6 to 12 months is a red flag for cancer, infection, endocrine disease or depression.

Blood pressure: technique

Measurement errors routinely move blood pressure by 10 mmHg or more, so technique is tested. The patient avoids caffeine, exercise and smoking for 30 minutes, empties the bladder, and sits quietly for 5 minutes with the back supported, feet flat and legs uncrossed. The arm is bare, supported at heart level. The cuff bladder should encircle about 80 percent of the arm circumference and its width should be about 40 percent; a cuff that is too small reads falsely high, one that is too large reads falsely low. Estimate the systolic pressure by palpating the radial pulse as the cuff inflates, then inflate 20 to 30 mmHg above that point to avoid missing an auscultatory gap, and deflate at 2 to 3 mmHg per second. Systolic pressure is the first Korotkoff sound (phase I); diastolic is disappearance (phase V). Take two or more readings and average them, and at the first visit measure both arms, using the higher arm thereafter.

Special blood pressure findings

• Interarm difference above about 15 to 20 mmHg systolic suggests subclavian artery stenosis (subclavian steal), aortic dissection (with tearing pain) or coarctation. A consistent difference over 10 mmHg is also a marker of cardiovascular risk.
• Orthostatic hypotension is a fall of at least 20 mmHg systolic or 10 mmHg diastolic within 3 minutes of standing. Causes include dehydration, blood loss, antihypertensives and diuretics, autonomic neuropathy (diabetes, Parkinson disease) and prolonged bed rest. It explains dizziness on rising from the treatment table and is a fall risk.
• Leg pressures are normally equal to or slightly higher than arm pressures. Lower leg than arm pressure in a young hypertensive patient suggests coarctation of the aorta (with radiofemoral delay and rib notching on chest radiographs).
• Wide pulse pressure (systolic minus diastolic, normally about 40) occurs in aortic regurgitation, hyperthyroidism, anemia and stiff arteries of aging. Narrow pulse pressure occurs in aortic stenosis, heart failure, tamponade and shock.
• Pulsus paradoxus, a fall of more than 10 mmHg in systolic pressure on inspiration, suggests cardiac tamponade, severe asthma or COPD exacerbation.

Pulse, respiration, temperature and oxygen saturation

Count the radial pulse for 30 seconds and double it if regular, or for a full 60 seconds if irregular, noting rate, rhythm, amplitude and symmetry. Count respirations without telling the patient (for example, while appearing to continue taking the pulse), because awareness changes breathing. Note the breathing pattern: Kussmaul (deep, rapid; metabolic acidosis such as diabetic ketoacidosis), Cheyne Stokes (cycles of crescendo breathing and apnea; heart failure, brain injury) and pursed lip breathing in COPD. Oral temperature is reduced by recent cold drinks and mouth breathing; older adults and immunosuppressed patients may mount little fever despite serious infection.

The sepsis and instability screen

A patient with suspected infection who has two or more of the quick SOFA criteria (respiratory rate 22 or more, altered mentation, systolic blood pressure 100 or less) has a high risk of a poor outcome and needs emergency care. More generally, any combination of hypotension, tachycardia, tachypnea, hypoxemia, fever and confusion signals a physiologically unstable patient who is not a candidate for office treatment that day.

Section 2Head and neck, thorax and lungs

Eyes

Inspect the lids, conjunctivae and sclerae, then test pupils, extraocular movements, visual fields and, when indicated, the fundus. The findings that matter in a chiropractic case are those that indicate neurological, vascular or systemic disease.

Ears, nose and throat

Otoscopy shows a pearly gray tympanic membrane with a cone of light in the anteroinferior quadrant; a red, bulging membrane indicates acute otitis media, and a retracted membrane suggests eustachian tube dysfunction. Hearing is screened with the whispered voice test, then characterized with a 512 Hz tuning fork. In the Weber test, the vibrating fork is placed on the vertex; normally sound is heard equally in both ears. In the Rinne test, the fork is placed on the mastoid until the sound fades, then held beside the ear; normally air conduction is heard longer than bone conduction (a "positive" Rinne).

Unilateral sensorineural hearing loss with tinnitus and imbalance suggests an acoustic neuroma (vestibular schwannoma) and needs MRI. Sudden sensorineural hearing loss is an emergency for steroid treatment within days. In the nose, note septal deviation, polyps and bleeding; in the mouth and throat, look for tonsillar exudate, dental abscess (a cause of jaw and neck pain), leukoplakia and nonhealing ulcers (oral cancer in smokers and drinkers).

Lymph nodes

Palpate the cervical chains systematically: preauricular, postauricular, occipital, submental, submandibular, tonsillar, anterior and posterior cervical, and supraclavicular. Describe each node by size, consistency, tenderness, mobility and whether it is matted. Small (under 1 cm), soft, mobile, tender nodes are usually reactive to infection. Hard, rubbery or fixed, nontender nodes over about 1.5 to 2 cm, nodes that persist beyond 2 to 4 weeks, and any supraclavicular node are suspicious for malignancy. A left supraclavicular node (Virchow node) suggests abdominal malignancy, especially gastric cancer; a right supraclavicular node suggests lung, mediastinal or esophageal cancer. Rubbery, painless nodes with fever, night sweats and weight loss suggest lymphoma.

Thyroid and carotids

Examine the thyroid from behind with the neck slightly flexed, asking the patient to swallow; the gland moves upward with swallowing. A diffusely enlarged gland (goiter) may be hyper or hypothyroid; a single hard nodule, fixation, hoarseness or associated nodes raise suspicion of cancer. Look for systemic signs: hyperthyroidism (tachycardia, atrial fibrillation, fine tremor, warm moist skin, weight loss, proximal weakness, exophthalmos) and hypothyroidism (bradycardia, dry skin, weight gain, delayed relaxation phase of reflexes, carpal tunnel syndrome, myalgia and fatigue). Hypothyroidism is a treatable cause of diffuse muscle pain and carpal tunnel syndrome.

Palpate each carotid separately (never both at once, and gently in older patients because of the carotid sinus reflex) and auscultate with the bell for a bruit, a whooshing sound from turbulent flow that suggests stenosis. An asymptomatic carotid bruit is a marker of atherosclerosis; a bruit with transient ischemic attack symptoms (transient monocular blindness, called amaurosis fugax, hemiparesis, aphasia) requires urgent referral. A murmur from aortic stenosis can radiate to the carotids and must be distinguished.

Thorax and lungs

Examine the chest in the order inspection, palpation, percussion, auscultation. Inspect for shape (barrel chest in emphysema with an increased anteroposterior diameter; pectus excavatum and carinatum; kyphoscoliosis restricting ventilation), use of accessory muscles, intercostal retraction, and symmetry of expansion. Palpate for tenderness, crepitus and tactile fremitus (vibration felt as the patient says "ninety nine"), which is increased over consolidation and decreased over fluid or air. Measure chest expansion at the fourth intercostal space; less than about 2.5 cm suggests restriction (ankylosing spondylitis, chronic lung disease). Percuss comparing side to side: resonance is normal over lung, dullness indicates consolidation or effusion (stony dull), and hyperresonance indicates air (pneumothorax, emphysema). Auscultate with the diaphragm comparing side to side.

Adventitious sounds: crackles (discontinuous; fluid or reopening airways in pneumonia, heart failure, fibrosis), wheezes (continuous, musical; narrowed airways in asthma and COPD), rhonchi (low pitched, clear with coughing; secretions), stridor (inspiratory, high pitched, over the neck; upper airway obstruction, an emergency) and pleural friction rub (creaking with breathing, localized; pleurisy, pulmonary infarction). Pleuritic chest pain that changes with breathing can mimic a rib or costovertebral lesion, so ask whether it also changes with trunk movement and whether there is fever, cough or dyspnea.

Section 3Cardiovascular and peripheral vascular examination

Inspection and palpation of the precordium

With the patient supine and the trunk raised about 30 to 45 degrees, inspect for visible pulsations and palpate the point of maximal impulse (PMI), normally a dime sized tap in the left fifth intercostal space at the midclavicular line. A PMI displaced laterally and downward, or larger than about 2.5 cm, suggests left ventricular enlargement (dilated cardiomyopathy, chronic regurgitation); a sustained, forceful PMI suggests left ventricular hypertrophy (hypertension, aortic stenosis). A thrill (palpable vibration) accompanies loud murmurs of grade 4 or higher.

Auscultation areas and normal heart sounds

Listen with the diaphragm (high pitched sounds: S1, S2, regurgitant murmurs, rubs) and the bell (low pitched sounds: S3, S4, the rumble of mitral stenosis) in each area. S1 is closure of the mitral and tricuspid valves at the start of systole, loudest at the apex. S2 is closure of the aortic and pulmonic valves at the end of systole, loudest at the base. On inspiration, increased venous return to the right heart delays pulmonic closure and S2 splits physiologically; a fixed split that does not vary with respiration suggests an atrial septal defect, and a paradoxical split (widening on expiration) suggests left bundle branch block or severe aortic stenosis.

Extra heart sounds

An S3 (ventricular gallop, "Ken-tuc-ky") occurs in early diastole as blood fills a volume overloaded ventricle. It is normal in children, young athletes and pregnancy but in an adult over about 40 suggests heart failure or severe regurgitation. An S4 (atrial gallop, "Ten-nes-see") occurs in late diastole as the atrium contracts against a stiff ventricle (hypertension, left ventricular hypertrophy, ischemia, aortic stenosis); it is absent in atrial fibrillation. A pericardial friction rub is a scratchy, three component sound heard best with the patient leaning forward; with sharp chest pain eased by sitting up and leaning forward, it indicates pericarditis. An opening snap in early diastole indicates mitral stenosis, and a midsystolic click indicates mitral valve prolapse.

Murmurs

Describe a murmur by timing (systolic or diastolic), location, radiation, intensity, pitch, shape and response to maneuvers. Intensity is graded 1 to 6: grade 1 is barely audible; grade 3 is moderately loud without a thrill; grade 4 has a thrill; grade 6 is audible with the stethoscope just off the chest. Diastolic murmurs are always pathological and require referral. Soft, short midsystolic murmurs (grade 1 to 2) without other findings are often innocent flow murmurs, particularly in children, pregnancy, fever and anemia.

Most murmurs from the right side of the heart get louder with inspiration and most from the left side get louder with expiration. The two murmurs that get louder with Valsalva and standing (which reduce preload) are hypertrophic cardiomyopathy and mitral valve prolapse; nearly all others get softer.

Jugular venous pressure

With the patient reclined at about 45 degrees and the head turned slightly left, identify the highest point of pulsation of the right internal jugular vein. Its vertical height above the sternal angle is normally 3 cm or less (the right atrium lies about 5 cm below the sternal angle, so this corresponds to about 8 cm of water). An elevated JVP indicates raised right atrial pressure: right heart failure, fluid overload, tricuspid disease, pericardial tamponade or constriction, or superior vena cava obstruction. The hepatojugular (abdominojugular) reflux test applies firm pressure over the abdomen for 10 seconds; a sustained rise in the JVP of more than 3 cm supports heart failure. Unlike the carotid pulse, the jugular pulse is not palpable, has a double waveform, is obliterated by light pressure above the clavicle, and changes with position and respiration.

Peripheral pulses and the vascular examination of the limbs

Palpate the carotid, brachial, radial, ulnar, femoral, popliteal, dorsalis pedis (lateral to the extensor hallucis longus tendon on the dorsum) and posterior tibial (behind the medial malleolus) pulses, comparing sides. Grade amplitude on a 0 to 4 scale: 0 absent, 1+ diminished, 2+ normal, 3+ increased, 4+ bounding. An isolated absent dorsalis pedis with a normal posterior tibial pulse may be a congenital variant. Auscultate for bruits over the abdominal aorta, renal, iliac and femoral arteries. Examine the skin for signs of chronic arterial insufficiency (cool, shiny, hairless skin, thickened nails, pallor on elevation, dependent rubor, delayed capillary refill over about 2 seconds, painful punched out ulcers on the toes and heels) and venous insufficiency (edema, brown hemosiderin staining, stasis dermatitis, varicose veins, shallow painless ulcers near the medial malleolus).

The ankle brachial index

The ankle brachial index (ABI) is measured with a handheld Doppler and a blood pressure cuff. With the patient supine for 5 to 10 minutes, measure systolic pressure in both brachial arteries and in the dorsalis pedis and posterior tibial arteries of each ankle. For each leg, divide the higher ankle pressure by the higher of the two brachial pressures.

Vascular versus neurogenic claudication

Both conditions are common in the same age group and they often coexist, so an older patient with leg symptoms on walking needs both a pulse examination and a neurological examination. Acute limb ischemia (an embolus or thrombosis) presents with the 6 Ps: pain, pallor, pulselessness, paresthesia, paralysis and poikilothermia (a cold limb). It is a vascular emergency, with irreversible damage within about 6 hours.

Section 4Breast and axilla, abdomen

Breast and axillary examination

Breast examination is performed with consent, a chaperone where appropriate and clear explanation, and within the scope of practice of the jurisdiction. Inspect with the arms at the sides, raised overhead and pressed on the hips, looking for asymmetry, skin dimpling or retraction, peau d'orange (orange peel skin from lymphatic obstruction), nipple inversion of recent onset, nipple discharge (particularly bloody or unilateral), eczematous change of the nipple (Paget disease of the nipple) and redness. Palpate in a systematic vertical strip pattern from the clavicle to the inframammary fold and from the midaxillary line to the sternum, including the axillary tail, with the patient supine and the ipsilateral arm raised. Then palpate the axillary (central, anterior, posterior, lateral), infraclavicular and supraclavicular nodes.

Breast cancer is the most common source of skeletal metastasis in women and favors the thoracic spine, ribs, pelvis and proximal femur. A woman with a history of breast cancer, even many years earlier, who develops new constant thoracic pain needs imaging.

The abdominal examination

Position the patient supine with the knees slightly flexed and arms at the sides, and examine in the order inspection, auscultation, percussion, palpation; auscultation comes before palpation so that palpation does not alter bowel sounds. Examine the painful area last.

• Inspection: contour (flat, scaphoid, distended), scars, striae, visible peristalsis, pulsation, hernias (ask the patient to raise the head), dilated veins (caput medusae in portal hypertension), and periumbilical (Cullen) or flank (Grey Turner) ecchymosis.
• Auscultation: bowel sounds are normally present every 5 to 15 seconds. High pitched, tinkling or rushing sounds suggest early obstruction; absent sounds after listening for 2 or more minutes suggest ileus or peritonitis. Listen for bruits over the aorta (midline above the umbilicus), renal arteries (just lateral to the midline above the umbilicus; a renal bruit with resistant hypertension suggests renal artery stenosis), iliac and femoral arteries.
• Percussion: tympany over gas, dullness over solid organs and fluid. The liver span at the right midclavicular line is normally about 6 to 12 cm. Dullness at the lowest left intercostal space in the anterior axillary line (Traube space) on inspiration suggests splenomegaly. Shifting dullness and a fluid wave indicate ascites.
• Palpation: light palpation for tenderness, guarding and superficial masses; deep palpation for organs and deep masses. Note voluntary guarding (reduced with distraction) versus involuntary rigidity (board like abdomen in peritonitis).

Organomegaly and aortic palpation

Palpate the liver edge at the right costal margin during deep inspiration; a smooth, tender edge suggests hepatitis or congestion (heart failure), and a hard, nodular edge suggests cirrhosis or metastases. The normal spleen is not palpable; a palpable spleen is enlarged at least two to three times (infectious mononucleosis, leukemia, lymphoma, portal hypertension). In infectious mononucleosis, splenic rupture can follow minor trauma, so contact sport and forceful abdominal or lower thoracic pressure are avoided for at least 3 to 4 weeks. The kidneys are palpated bimanually; an enlarged kidney suggests polycystic kidney disease, hydronephrosis or tumor.

Palpate the abdominal aorta deeply in the epigastrium, slightly left of the midline, placing a hand on each side of the pulsation. A normal aorta is about 2 cm wide; an expansile (pushing the hands apart, not just upward) pulsatile mass suggests an abdominal aortic aneurysm, defined as a diameter of 3 cm or more. Sensitivity of palpation rises with aneurysm size and falls with obesity, so a normal palpation does not exclude AAA in a high risk patient; ultrasound is the screening test (recommended once for men 65 to 75 who have ever smoked). Risk factors are age over 60, male sex, smoking, hypertension, atherosclerosis and family history. Aneurysms over about 5.5 cm, rapidly enlarging aneurysms and any symptomatic aneurysm need surgical evaluation; a tender aneurysm, or back pain with hypotension, suggests leak or rupture and is an emergency. Avoid deep abdominal pressure, and avoid prone lumbar thrust techniques in a patient with a known or suspected aneurysm until it has been assessed.

Special abdominal signs

What abdominal findings mean for the back pain patient

Every patient with thoracolumbar or low back pain that does not behave mechanically deserves an abdominal examination. A pulsatile mass suggests AAA; costovertebral angle tenderness with fever suggests pyelonephritis; epigastric tenderness radiating to the back suggests pancreatitis or a posterior duodenal ulcer; a positive psoas sign with fever and a flexed hip suggests a psoas abscess (often from vertebral osteomyelitis or Crohn disease) that can mimic a hip flexor strain; and a hard, fixed mass or hepatomegaly suggests malignancy. Abdominal wall pain (positive Carnett sign) and costochondral pain are reproduced by palpation and movement, unlike visceral pain.

Section 5Urogenital and rectal findings and putting the exam together

Scope, consent and chaperones

Genital, rectal and breast examinations are sensitive. Whether a chiropractor performs them depends on the law of the jurisdiction, and many practitioners refer them to a medical colleague. Part III expects you to know what the findings mean and when they are needed, particularly for the patient with groin pain, testicular pain or suspected cauda equina syndrome. Whenever such an examination is performed, obtain and document specific informed consent, offer a chaperone, explain each step, provide privacy and draping, and stop if the patient asks.

Hernias

Groin pain in an athlete or laborer may be a hernia rather than an adductor strain or hip lesion. Examine the standing patient, inspecting for a bulge at rest and with coughing or straining. In men, the examining finger invaginates the scrotal skin up to the superficial inguinal ring while the patient coughs.

An incarcerated hernia cannot be reduced; a strangulated hernia has a compromised blood supply and presents with a tense, tender, red bulge, vomiting and signs of bowel obstruction. Strangulation is a surgical emergency.

Testicular and scrotal findings

Scrotal and testicular disease can present as groin, lower abdominal or even low back pain, because the testis is innervated from about T10 to T12 and the scrotum from L1 and the sacral segments. The cremasteric reflex (stroking the upper medial thigh elevates the ipsilateral testis) tests L1 to L2.

Prostate and rectal examination

The digital rectal examination (DRE) is performed with the patient in the left lateral (Sims) position or bending over the table. It assesses anal sphincter tone at rest and on voluntary squeeze, perianal sensation, rectal masses, and in men the prostate. The normal prostate is about the size of a walnut, rubbery, smooth and nontender with a palpable median sulcus.

Rectal tone, saddle sensation and sacral reflexes

When the history raises cauda equina syndrome, the examination must include the sacral segments. Saddle sensation is tested with light touch and pinprick over the perineum, perianal skin, buttocks and posterior upper thighs (S2 to S5 dermatomes); patchy or bilateral loss is significant. The anal wink (superficial anal reflex) is a contraction of the external sphincter when the perianal skin is stroked; it tests S2 to S4. The bulbocavernosus reflex (contraction of the anal sphincter on squeezing the glans or tugging an indwelling catheter) also tests S2 to S4. Reduced resting tone and weak voluntary squeeze on DRE indicate sacral root or conus dysfunction. A post void residual bladder volume over about 100 to 200 mL (by bladder scan or catheter) objectively confirms retention. In a patient with suspected cauda equina syndrome, these findings are obtained in the emergency department as part of the urgent workup; if you cannot perform them, do not delay referral to do so.

Putting the physical examination together

A complete general examination is not performed on every patient. Instead, choose components by hypothesis: the history determines which systems need examination. Every new patient should have vital signs and a general survey. A patient with thoracic pain needs the chest, heart and abdomen examined if the pain does not behave mechanically. A patient with low back pain and red flags needs the abdomen (aorta, kidneys), pulses, a lymph node survey and a neurological examination including the sacral segments if the history suggests it. A patient with neck pain and headache needs blood pressure, a cranial nerve screen and, in older patients, palpation of the temporal arteries.

After the examination, write a problem list that includes every abnormal finding, not only the chief complaint. For each problem, decide one of three paths: treat (within scope, no contraindication), co-manage (treat the musculoskeletal component while another provider manages the other problem, for example a patient with stage 2 hypertension and mechanical neck pain), or refer, with an urgency that matches the risk.

Words worth knowing