Special Clinical Examination Techniques for Common Symptoms and Signs
The routine history and physical examination demonstrated above is all well and good when the patient is asymptomatic; however, it is grossly inadequate when a patient presents with certain common symptoms and signs. Additional clinical techniques for evaluation of patients with many common symptoms and signs will be discussed here. They are the result of the author’s many years of experience in clinical practice as well as reviewing a host of textbooks on physical diagnosis. Although some of these techniques will be familiar to the reader, many will not be.
Note that these symptoms and signs are organized into the five categories used in the review of systems: pain, lumps and bumps, bloody discharge, nonbloody discharge, and functional changes. The author hopes that the reader enjoys this fresh approach to the physical examination.
The purpose here is not to enter into a thorough discussion of inspection, palpation, percussion, and auscultation of the abdomen but to emphasize portions of a good examination that are often overlooked.
No matter what portion of the abdomen is involved in the complaint, the physician must look for rebound tenderness. If present, it is a clear indication of peritonitis or a ruptured viscus. One applies pressure to the abdomen where the pain is located and then suddenly releases it. If the patient winces, there is rebound tenderness and a serious abdominal condition. Guarding and rigidity usually indicate the same thing.
It is necessary to listen for bowel sounds for at least 3 minutes. If they are absent, there may be peritonitis or paralytic ileus. If they are hyperactive and high-pitched, there may be a bowel obstruction. In male patients, look for retraction of the testicles. If the right testicle is retracted, there is a possibility of a ruptured appendix. When both testicles are retracted, peritonitis from a perforated peptic ulcer or pancreatitis is likely.
One should look for Murphy sign. Place your thumb under the right subcostal margin and have the patient take a deep breath. If the patient winces, the sign is present. Do not forget to check for inguinal and femoral hernias as well as umbilical and incisional hernias. A rectal and pelvic examination must be done in any case of abdominal pain. They are essential in diagnosing a pelvic appendix, ruptured ectopic pregnancy, pelvic inflammatory disease (PID), and endometriosis. The finding of occult blood in the stool may point to intussusception or mesenteric infarct, as well as peptic ulcer disease and neoplasm.
If appendicitis is suspected, it is essential to look for a Rovsing sign. Applying pressure in the left lower quadrant causes pain in the right lower quadrant. Do not forget to look for psoas sign.
Arm and Hand Pain
The patient presenting with acute arm and hand pain should usually be no problem. A fracture dislocation, cellulitis, or even “tennis elbow” is obvious. Perhaps the clinician will miss referred pain from acute coronary insufficiency, but this is not likely. It is chronic recurrent pain in the arm and hand that often confounds the clinician. First, palpate the joints for the various forms of arthritis. Next, look for tenderness of the radial–humeral joint (tennis elbow) and lateral epicondyle (golfer elbow). If these techniques fail to reveal the diagnosis, it is time to look for the neurologic causes of the pain in four places:
Begin by palpating the cervical roots and performing a cervical compression test and Spurling test.
Next, perform Adson tests for the various types of thoracic outlet syndrome.
Now, tap the ulnar groove in the elbow for ulnar entrapment. Sensation to touch and pain should be reduced in the little finger and the lateral one-half of the ring finger if this is present. In some cases, the hypothenar eminence and interossei muscles are atrophied.
Finally, tap the medial surface of the wrist (Tinel sign), and flex the wrist for 3 minutes (Phalen test) to pin down the diagnosis of carpal tunnel syndrome. Sensation to touch and pain will be diminished in the first three fingers and the medial one-half of the ring finger if this is present. In advanced cases, there may be atrophy of the thenar eminence.
Obviously, a neurologist will perform a more detailed examination, but a primary care physician should be able to pick up most causes of chronic arm or hand pain using these techniques.
The author has no doubt that the reader will do an adequate job of auscultation and percussion of the heart and lungs in cases of chest pain. But what about remembering to check for tracheal deviation? The author recently had a case of carcinoma of the lung where the only clinical sign was tracheal deviation to the side of the lesion. In addition, remember to
Palpate the costochondral junctions to rule out Tietze syndrome.
Look for a dermatomal rash in case the patient has herpes zoster.
Check the axillary and cervical lymph nodes for metastasis.
Above all, it is essential to remember to check the lower extremities for signs of thrombophlebitis such as a positive Homan sign.
Many cases of dysuria are associated with a urethral or vaginal discharge, so the techniques used to evaluate these complaints apply here (see pages 9 and 10). In male patients presenting with dysuria alone, the physician will want to massage the prostate to determine if there is chronic prostatitis. If a discharge is produced by this procedure, even a small amount, the patient probably has prostatitis. One can confirm the diagnosis by putting a drop on a slide and examining for white blood cells under the microscope. Examine for flank tenderness in both male and female patients because there may be pyelonephritis.
In females presenting with dysuria, a thorough pelvic examination is clearly indicated. A uterine mass, PID, or ectopic pregnancy may be the cause of the dysuria.
In both males and females, the physician should be alert for congenital anomalies of the genitourinary tract (e.g., hypospadias) on examination. Catheterization for residual urine may be the only way of picking up a neurogenic bladder or bladder neck obstruction.
The patient who presents with headache is a special challenge. There are several things the physician can do while examining the patient when the headache is occurring:
Occlude the superficial temporal arteries for 1 to 2 minutes. If there is relief of the headache, the patient has a vascular headache, most likely migraine. If the blood pressure is elevated during an attack, think of pheochromocytoma. If there is nuchal rigidity, quite naturally one thinks of meningitis or subarachnoid hemorrhage.
It is absolutely imperative to do a funduscopic examination to look for papilledema and hypertensive retinopathy. If pressure on the jugular veins relieves the headache, the patient may have a postspinal tap headache.
Marked tenderness of the superficial temporal artery on one side should suggest temporal arteritis. Transilluminate the sinuses to look for sinusitis. If a pseudoephedrine spray (Neo-Synephrine) relieves the headache, the patient may have allergic or vasomotor rhinitis. Finally, sumatriptan relieves both migraine and cluster headaches and is therefore useful in the diagnosis.
If the physician sees the patient when the headaches are not occurring, a nitroglycerin tablet under the tongue assists in the diagnosis. If this precipitates the headache, the patient may have migraine. Histamine sulfate subcutaneously may precipitate a headache in both patients with migraine and in those with cluster headaches.
An injection of lidocaine 1% into the occipital nerve roots may relieve tension headaches. Note that many patients with so-called tension headache actually have common migraine.
When examining a patient with a history of trauma, the physician will undoubtedly obtain an x-ray of the hips before proceeding with an extensive clinical examination. If there is no evidence of fracture, he or she may proceed with an examination of the range of motion (extension and flexion, internal and external rotation) and palpation for point tenderness. Greater trochanter bursitis is a common cause of hip pain and is easily diagnosed by palpation over the greater trochanter bursa and subsequent relief of the pain by injecting the bursa with 1% to 2% lidocaine. Range of motion is restricted, and Patrick test (pain on external rotation of the hip) is positive in both osteoarthritis (and other forms of arthritis) and greater trochanter bursitis.
It is wise to do a femoral stretch test and straight leg raising test to be sure one is not missing a herniated lumbar disc in these patients.
The clinician must palpate the sacroiliac joints. The patient with sacroiliitis may present with “hip” pain.
Once again, the physician should obtain an x-ray to rule out fracture in most cases of acute knee pain before proceeding with an extensive clinical evaluation. This evaluation includes range of motion (extension and flexion) and palpation. Test for loose collateral ligaments by fully extending the joint at the knee and attempting to move the tibia, medially and laterally. Next, perform a McMurray test. Flex the knee on the thigh and with the foot rotated first internally and then externally slowly extend the knee. If a “pop” or locking of the joint is heard, the test is positive for a torn meniscus, and a referral to an orthopedic surgeon is necessary. Finally, use the drawer test to check for anterior or posterior cruciate ligament tears or rupture. With the foot dangling over the examination table, attempt to pull the tibia forward and backward on the femur. If there is significant movement one way or the other, the test is positive. Examine the knee for fluid by pressing the patella distally and feeling for ballottement (the patella bobs up and down on pressure).
There are several bursa around the knee. It is worthwhile to inject them with 1% to 2% lidocaine to see if significant relief of knee pain is achieved.
Here again, one must examine the patient for a possible herniated lumbar disc. Look for hip pathology as well.
Leg, Foot, and Toe Pain
No doubt the reader does not need instruction in performing inspection and palpation of the lower extremities for cellulitis, hematoma, or other mass lesions. The author also does not think it is necessary to discuss the examination of the bones and joints for inflammation or fracture dislocations.
However, the physician should not forget to perform a test for Homan sign to rule out thrombophlebitis and palpate for diminished pulses, not just the dorsalis pedis and tibial pulses, but also the popliteal and femoral pulses. Also, listen for bruits over the femoral arteries to detect significant occlusion of the femoral arteries or terminal aorta (Leriche syndrome).
One thing that many clinicians neglect to do is measure the calves. Often, this is the only way to detect unilateral swelling (in thrombophlebitis) or atrophy (in a herniated lumbar disc syndrome). A clinician should keep a tape measure on his or her person or in his or her bag at all times.
One should perform a straight leg raising test to rule out radiculopathy and external rotation of the hip joint (Patrick test) to rule out hip pathology. Finally, a good sensory examination does not just help diagnose radiculopathy or polyneuropathy but also rules out tarsal tunnel syndrome or Morton neuroma.
Low Back Pain
In cases of both acute and chronic low back pain, the physician’s main consideration is to rule out a herniated disc once he or she has ruled out a fracture with plain films. Perform a straight leg raising test, look for Lasègue sign (flexing the leg at both the hip and the knee and gradually straightening the leg), and check for a reduced ankle jerk (on the side of the pain) in L4–L5 and L5–S1 disc herniations. Also check for loss of pain and touch in the big toe (in L4–L5 disc herniations) and the lateral surface of the foot and little toe (in L5–S1 disc herniations). A foot drop or weakness of dorsiflexion of the big toe is a sign of L5 radiculopathy (or an L4–L5 disc herniation). In cases of chronic low back pain, measure the circumference of the calves and thighs because there is usually wasting on the side of the lesion.
A clinician will miss a disc herniation at L3–L4 or L2–L3 if he or she stops the examination at this point. Continue by performing a femoral stretch test. With the patient stretched out in the prone position, raise the lower leg and flex it onto the thigh. At 100 degrees or less, the patient resists further movement if an L3–L4 herniation is present. The knee jerk is diminished on the side of the lesion in most cases. In addition, there is often loss of sensation in the L3 or L4 dermatome.
No back examination is complete without examining for sacrospinalis (paraspinous) muscle spasm. With the patient standing in the “at ease” position (relaxed with feet 12 inches apart), one should palpate the paraspinous muscles and compare one side with the other. Normally, they should both feel doughy. When one is more tense than the other, a lumbosacral sprain or disc herniation is likely, although many other pathologic conditions of the lumbosacral spine may also be the cause. Anyway, significant spasm is a clear indication for a computed tomography (CT) or magnetic resonance imaging (MRI) scan of the lumbosacral spine.
The physician should not forget to check for tenderness of the sacrosciatic notches. A rectal examination is important to check for sphincter tone and control, which may be lost in a cauda equina syndrome. As mentioned on page 291, many cases of low back pain are due to a short leg syndrome, so measure the leg length.
When there are no objective findings, it is necessary to look for malingering. Certain signs are a clear indication of this condition. First of all, there is secondary gain (e.g., workman compensation). Next, if there is sensory loss, it is nondermatomal. Weakness and muscle wasting are also diffused. Ask the patient to bend over as far as he or she can. If there is malingering, he or she will not bend very far. Now hold onto the patient’s hips and ask him or her to rotate the shoulders right and left. If rotation is limited, the patient with low back pain is probably malingering because rotation of the spine is a function primarily of the thoracic spine. Now rotate the whole spine at the hip. If the patient says this duplicates the pain, he or she does not have back pathology. Many patients who are malingering are schooled in resisting the straight leg raising test and thus have a false-positive result; however, if the physician has them sit on the examination table with their legs dangling and creates a distraction, it is possible to straighten their legs without resistance if they are malingering.
When reviewing hospital charts, the author finds that the results of the neck examination are rarely listed, so he wonders if this part of the physical examination is often skipped. In a patient presenting with neck pain, the first thing to do is palpate for point tenderness. That way, the physician will not miss a subacute thyroiditis, occipital neuralgia, tender lymph nodes, or brachial plexus neuralgia.
Next, one must check the range of motion in all planes—anterior, posterior, adduction right and left, and rotation to the right and left. The patient should be able to extend 45 degrees, flex 65 degrees (so that the chin touches the chest), adduct 45 degrees right and left, and rotate 60 degrees right and left. Any major deviation from these norms suggests cervical spondylosis, herniated disc, fracture, or other pathology. If there is a herniated disc or significant osteoarthritic spurs, cervical compression or Spurling test precipitates radicular pain down the upper extremity. Tender cervical lymph nodes suggest inflammation in the throat, salivary glands, teeth, or sinuses.
It is necessary to look for Horner syndrome in patients with cervical pain because this may indicate a thoracic outlet syndrome, brachial plexus neuralgia, or mediastinal lesion. Cervical pain is associated with a mass in Ludwig angina, Zenker diverticulum, thyroiditis, and metastatic neoplasms. The pain may occasionally be referred from coronary insufficiency, cholecystitis, or intrathoracic pathology.