Medical Body Examination

by Noor Sash, PhD

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    00:00 Okay. So, we’ll start off by washing my hands. Hello. My name is Sasha, one of the doctors. Can I just check your name, please? Tom.

    00:07 What’s your date of birth? 01/03/1980.

    00:09 Great! I’ve got the right person. I was just wondering if there’s any chance I could do an examination of you, Tommy? Would that be all right? This could involve you lying flat. I’m going to have a look and then I’m going to have a look at your hands and your face, then I would have a feel of your tummy if that’s all right? Can I get you to lie flat for me, please? So ideally, I don’t expose the patient. I’d say nipple to knees, but as long as you got adequate exposure.

    00:28 So I’m just going to start by having a look from the end of the bed. I’m kind of looking around the bed for any signs of sick bowls or any lines or tubes or anything else like that. I can’t see anything obvious. Also, just in the end of that examination of the abdomen, I can’t see any obvious scars or any hernias. Can I get you to have, if you lift your head up so that you’re looking towards your feet? That would make any hernias a little bit more obvious. That’s fine. You can relax for me.

    00:52 So I’m going to move on to inspection of the hands. Can I borrow both of your hands first? So I’m just feeling the temperature, a little bit cold. I’m checking capillary refill.

    01:03 That’s fine. I’m looking for any nail signs. So there’s no signs have clubbing or oncholysis. Can I feel your pulses there? Yeah.

    01:13 That’s fine. So pulse is irregular and symmetrical. I’m just going to have a look at your hands as well. There is no palmar erythema and I’m just going to feel across your palms, and there are no contractures or anything else like that. That’s fine. As I move up the arm, I’m just having a look for any signs, excoriation, if there are any skin lesions, if there’s any trap marks, all of those things could tie with liver disease.

    01:34 Now, I’m coming up to your face. Can I get you just to take your specs off for me? That’s great. Would you be able to look up? And I’m just going to draw your low eyelids down.

    01:42 That’s fine if you look down for me. That’s fine. You can put your specs back on again.

    01:47 Wonderful! Can you open your mouth for me? Stick your tongue out. That’s fine. So I couldn’t see any signs in the eyes such as anaemia, and I’m looking in the mouth as well for any signs of aphthous ulcers or a big tongue which might indicate a deficiency of some sort. Do you have any pain in your neck at all? No. That’s fine. So I’m just going to feel just specifically for a node called Virchow’s node which is associated with gastric malignancies.

    02:12 Ideally I’d want to do full lymph node exam. Okay. So I’m going to move on to have a look at your tummy if that’s all right next? Okay.

    02:19 So, on inspection, I’m looking for things like scars. Is there any distension? Is there any scratch marks? Is there any bruising? Bruising around the umbilicus is called Cullen’s sign, excellent. And any bruising around the flanks, so you’d have a look at both sides.

    02:35 Grey-Turner’s sign. Absolutely. So, Grey-Turner’s is associated with the retroperitoneal bleeding. So you may think of it as a triple A. It has something to do with the kidneys. Another thing to look at is potential scars that go into the flanks which might indicate -- Kidney surgery.

    02:48 Yeah. Absolutely, absolutely. I can’t see anything obvious when I’ve examined you, Tommy. So, would it be all right for me to have a very quick feel of your tummy? Yeah. Okay. It’s an important thing to get down to the patient’s level, and I’m keeping my eyes focused on the patient. Is there any sore at the moment? No.

    03:05 What would you do if there was? Start away from the area.

    03:09 Yeah, start away from them. So, I was trying to think of the light touch as you’re sort of feeling out for any areas that might be so -- okay. So I’m just going to start up here. Just tell me if anything is feeling sore. So I’m just systematically palpating all nine quadrants and having a look at the patient’s face for any signs the discomfort.

    03:28 That’s all okay, sir? Yeah, fine.

    03:31 Would it be alright for me to have a bit of a deeper feel, Tommy? This time, the deeper feel is more to feel for masses, pulsations. Is there anything else obvious that I can listen such as a deep pain when I’m palpating? Again, I’d palpate deeply at all nine quadrants.

    03:49 Things that you need to look for when you’re palpating is the pain when you’re pushing in, is it worst when you’re letting go? That gives you an idea of whether or not there’s any rebound tenderness. In terms of palpation, I’m going to move on to just have a quick feel of your kidneys if that’s okay? So you just lay back. I’m just going to slip my hand just behind your back. You relax for me. I’m just going to press back and forth.

    04:10 Is that feeling sore at all? No.

    04:11 Okay. So you’re feeling for the size of the kidney. That’s fine. And if it’s enlarged, you might feel a renal mass, but you’re also trying to feel if there’s any renal angle tenderness. Next thing I want to do is feel out for the liver. How do we do that? Ask them to breath in and as they breath in, you’d put your fingers through and it will tap against them. Perfect! So I’m just going to let the patient know. I’m just going to see if I can feel the side of your kidney, and I’m going to start here, just above your hip, okay. What I’d like you to do is take some deep breath in and out. Breathe in, good, and breathe out. Again, breathe in and out. Essentially, what you’re doing is pushing in as the patient breath in, and you’re trying to catch that liver edge as it goes past. Okay. You do the same for this spleen, where would you start? Same place, yeah. Remember, if you can feel any enlarged spleen, it’s an enlarged spleen. It has to be about three times the size which we’d be able to palpate it. So again, you start from here. You’re getting the patient to take breathe in and out and go all the way across. If it was a woman and she was potentially gravid, you may also feel for a uterus as well, and you can also palpate for the body. Okay.

    05:25 But I won’t do that because you might want to rush in the bathroom. What would you do after palpation? Percussion? Yeah, absolutely. I’m going to just have a quick tap on you, Tommy, if that’s alright? So again, I’m looking at his face and I’m going to systematically, across all nine quadrants. What is this useful for? Ascites.

    05:49 Yeah, ascites. So it’s checking to see if there’s any fluid. What would you hear if it was fluid? Shifting dullness.

    05:59 Absolutely. So it’s quite an important sign that you need to elicit as well. So, what would you do in that case if you just saw any abdominal distension that you wanted to see if there was any fluid there? You’d start from the centre and percuss out.

    06:12 And then if you got to the point where your resonant percussion note became a dull percussion note, keep your finger on there and you’d ask the patient to roll over to the side.

    06:20 So, can I get you to roll over to the side? Please don’t fall off the couch. Great! Keeping your finger in the same place and you’d say to them I’m going to keep you like this for about 30 seconds. If I can demonstrate that this dull percussion note has gone to a resonant percussion note, then I’ve demonstrated shifting dullness.

    06:36 That’s fine. Can I get you to lay back? We can also percuss out the borders of the liver and the spleen as well. I’m going to go onto auscultation. So just explain to the patient what you’re doing. I’m going to have a quick listen into your tummy as well just to check your bowels. So, I’d have to listen in. You can potentially have to listen for up to three minutes to hear bowel sounds and you just comment on whether or not they’re present on what they sound like. What’s the normal bowel sound? Gurgling. Absolutely. So it’s just normal gurgling bowel sound. If you’re hearing more than that, what might that indicate? Obstruction? Yeah, potentially. So they might have some sort of an ileus. And absent bowel sounds again, that’s another sign. Absolutely, fine.

    07:31 Okay. What I’d like to do now is I’ll cover the patient over. Thank you very much for letting me examine you. I’m going to the examiner and I’d present my findings so I’d say, on general inspection, there was nothing to find. On the examination of the abdomen, there were no signs of scarring or distention. There was no tenderness when I palpated both on light and deep palpations. There was a normal percussion with no fluid demonstrated and an auscultation bowel sounds are present and normal. To complete my examination, what sort of thing would you want to do? Urine dipstick? Yeah. So when you’re talking about what you do after the exam, try and talk about examinations first and then investigation. So yeah, urine dip is good. Say that again? But not first. Hernias? Hernia. So we said hernias, PR, external genitalia.

    08:28 Yeah. You could look at the calves for erythema nodosum and stuff like that. Potentially, yeah.

    08:36 That’s a rare sort of thing. The other thing I mention is doing an exam of the lymph nodes as well because the liver and spleen, big lymph nodes. Okay. Then you go and say what investigations you do. Urine dip? Yeah. FBC, U&E, abdominal X-ray, if it’s normal, potentially abdominal ultrasound, have a look at the values for the rest of the labs.

    09:11 Absolutely, yeah. Some bedside observations will be good.

    09:16 Again, take it all in the clinical picture of what they’ve given you to examine. So, that’s fine. You can sit out. Thank you very much. I remember when I have my finals, you tend to get patients that are stable or have fixed conditions that their signs can be replicated over and over. I remember revising a lot about colostomies and ileostomies and things. In our actual exam, we end up getting a peritoneal dialysis catheter. So it’s just being able to recognize and comment on the health of it. Does it look clean? Is there any odor? What does the skin look like around it? Is it cellulitic? Does the abdomen look distended? And it’s just picking upon those kinds of cues. He also had a scar as well in the flank. So it’s important to make sure you’re looking at the flanks as well. Okay.

    10:03 Did you do the full abdomen exam? Say that again? At that station, did you do a full abdomen exam? Yes. So, you can just stand into the bed and say, “I’m going to comment on the most obvious thing.” I can see it as a tube coming out of this part of the abdomen, but I’m going to go through systematic just to make sure I don’t miss anything and it’s just a tick in the box to show that yeah you picked from the obvious thing. But don’t let it throw you because that was the thing when you see a colostomy bag, it’s something like, “I know what it is and I know what’s going on” but just make sure you don’t miss anything else. Are you guys happy? What do you do in the full abdomen exam, does that stuff include JVP? You can do. What would you do when you examine the JVP? Position the patient to 45 degrees and turn the head to the left and get a good light source and feel the veins.

    10:57 Absolutely. What’s the other thing you can do to make -- Press on the liver. Exactly! So you just make sure in that as well that you’re asking them, are you tender at all and I’m going to push in your tummy. So the salient point for an abdomen exam is make sure you’re exposing the patient appropriately. Make sure that the patient is lying flat. I remember in one exam that a friend did at different university. They had the patient at 45 degrees inclining and you had to go in and put the patient flat. The other thing is when you palpate in the abdomen, make sure that you’re on the patient’s level and you’re looking at the patient’s face.

    11:30 Just be really systematic, okay? Just make it look like you’ve done it a million times before. So for shifting dullness, you start at the umbilicus? So you start at the umbilicus and you go down.

    11:41 You’re trying to demonstrate. So if you imagine you’ve got fluid, it’s going to sit in the flanks. So you’re going from resonant, resonant, resonant into the fluid level. That’s where it becomes dull. So you keep your finger on that and get the patient to roll over to the side. Far away from you.

    11:54 Well, yeah, they’d have to roll away from you. So if you want them to roll towards you, you percuss the other side over the patient. Roll towards you, wait for 30 seconds, and then re-percuss. So what additional information does hepatojugular reflex give you? In terms of the JVP, if you think about the blood supply going back to the heart, you have a lot of venous reserve in the liver.

    12:20 So when you’re pushing on that, you’re increasing the venous return. So the idea being that you might make a JVP that’s otherwise not visible to be more prominent.

    12:30 What would that be, normal or abnormal? It’s in the context of the patient. So say if you’re the patient that had a heart condition, that might not result in any rise in the JVP.

    12:42 But if you’ve got a patient that’s dehydrated and you’re able to increase the venous return to the heart, you might see that that’s raised, so in dehydrated patient that would cause a rise. It shouldn’t cause a rise in a normal patient? It will do. But if someone has got an incompetent valve no matter how much blood you’re pushing back into the heart, the amount, the cardiac output is not going to be affected by whatever you effort is.

    13:04 Does that make sense? I don't understand. It doesn’t make sense at all. Okay. So your cardiac output is your stroke volume. So the volume of blood that’s in your ventricle times by your heart rate.

    13:18 So when you’re looking at the JVP, you’re not necessarily getting the patient’s heart to work any faster but you are trying to increase the amount of blood that’s going back in. If you’ve got an incompetent valve, so every time the ventricle beats it opens up, but it is not closing and stopping the blood from flowing back. You might get a lot of blood coming up, but it would drop very quickly. Does that make sense to you? Do you necessarily see the JVP rising in the same way? It makes sense but now it doesn’t make sense why you do it and do the reflex in the abdo exam because if you can’t see it and then you push on the abdomen and you can see it, what’s the significance of that? Is it actually raised or you’re just showing that it can be raised by you pushing on this? It can give you an idea about the patient’s fluid status. And if you think that someone has got a lot of hepatomegaly because it’s now either you got a lot of venous storage of blood. That might give you an idea that the liver is enlarged as well. It’s not directly related to an abdo exam which is why I don’t always do when I do my abdo exam.

    14:19 So in a normal person, when you press on the abdomen, it wouldn’t raise as much? If you have someone that is otherwise normal, you push on the liver, the JVP will go up.

    14:34 Okay. If you’ve got a patient with dehydration, you might not see the JVP to begin with and you push on the liver, it might go up a little bit, because you’re increasing that cardiac return to the heart. So you’ve got an increased volume that’s coming out of the ventricles.

    14:49 If you’ve got a patient that is otherwise, what was the other question? Normal. Yeah. If a patient is otherwise normal and you do that, you will get a rise but it’s just demonstrating that perhaps if you couldn’t see it first, you are doing something to make it more prominent. I hope that makes sense.

    15:08 Yeah, I understand it to be a way of making it more easy to say rather than any pathological -- It’s all in the clinical context of whatever you’re examining the patient. So don’t get too hung up about it.

    15:22 Back to ascites, shifting dullness, is it alright to do that or do you have to do the fluid thrill thing as well? You can do the fluid thrill. Shall we? Do you want to demonstrate how? I can’t remember how to do that.

    15:37 Okay. So, what I’m going to ask you to do is I’m just going to have to tap on your tummy. But if I can borrow your hand, just get you to place that across your tummy, what I’m going to do is I’m going to flick on one side of your tummy and I’m going to put a hand on the other side. So, what am I doing? That’s fine.

    15:54 You can get the patients to do that. Exactly. Sit up for me. So, what you’re doing is essentially when you’re tapping one side, you are just stopping any skin conduction by putting that hand there and you’re checking to see whether or not that pulse is being transmitted through the underlying fluid. But again, take it in the context. If someone has obviously got ascites, that somebody has got a massive amount of tense ascites.

    16:17 So you might have a small ascites that you might necessarily be able to demonstrate a fluid thrill on, but you might be able to demonstrate shifting dullness on.

    16:25 I have a quick question about hepatomegaly. I’ve read different things in different books. Some people would say that it’s better to feel in for the liver when they’re breathe in. Yeah. And then some people say that when you breathe out, your lungs fill with air so they push the liver down. So, that means you should do it when they breathe out because then you’ll feel the liver hitting your hand. So I wasn’t too sure which one – When you breathe in your lungs fill with air.

    16:52 Oh yeah. But I’ve read two different things in the book.

    16:59 No. I can see why you’re confused. I thought you want to be in there when they take a breath. As they’re taking a breath in and you’re pushing in and you’re supposed to be putting your hand a third down so you can feel that long-edge passing as they’re taking a breath in. Does that make sense? So not when they’re breathing out? When they’re breathing out, that liver is just moving about. So you might potentially catch the edge of it but it’s much easy to feel something going in that direction. Yeah, breathing in pushes it down. Okay.

    17:27 That’s fine. I think you meant like in the book, like you push in and keep your hands still while they breathe out and then you might feel it hitting your hand. Yeah. Maybe that’s probably it. So, wait for them to breathe out and then leave your hand-- And then when they breathe in, yeah. But you’re trying to like meet it.

    17:48 In clinical practice, I don’t really do that because I don’t find it very accurate.

    17:51 So, what I tend to do is, have you heard of a scratch test, which I don’t know what are you doing in your exams. Can I get you to lie down again for me? I remember one of my consultants teaching me this. You probably don’t do this because you are really young.

    18:06 But if you’ll imagine the train track and someone is tapping on one side because that transmission is going through the train track. You can feel it further down. It’s the same principle. So because all of this is air and you’ve got a rib overlying a relatively dense structure like the liver, what you can do is if you take your stethoscope, feel for the bottom part of the rib and you put your stethoscope on. If you kind of scratch up when you notice that you can hear the scratching.

    18:33 That’s the liver edge.

    18:34 Yes, he did. He still teaches that.

    18:38 Does he? Yeah.

    18:40 I think that’s the most useful thing that I’ve done because I find it quite difficult to palpate out livers. And if you’re tapping for shifting dullness, do you have to be parallel to the bed of your finger going down? Because a lot are doing it like that but is it the correct way to do like that? Say that again. So, why not -- Your finger, the one that you have on the abdomen must be parallel to the counter base. Because if I’m doing it that way, I’ll give you an exam and I could say, “Well, how do you know that it’s not the tip of your phalanx rather than down here where you’re feeling the percussion note?” So yeah, it needs to be parallel. It’s fine. You can get up again.

    19:25 I think it was about the liver. See, you need to be tapping out the borders, and how big should the liver actually be? You tell me, how big should it be.

    19:34 Four fingerbreadths, about 10-12 cm. Above the costal margin. Where does your liver start in your chest? Yeah, it’s about your sixth anterior but it’s around T4. So it goes really -- Tell me why we have to tap it out from the top because if it’s a woman, it’s difficult isn’t it? Again, it’s different to what you do in clinical practice, but ideally yeah you’re supposed to tap it out and I always start on the chest, go down. It’s unlikely you’re going to get woman for an abdo exam if it’s something that you need to percuss out anyway. So if you percuss it down you’ll go from resonant resonant resonant because you’re going lung, lung, lung. Then when you get to liver, you’ll notice the percussion note changes.

    20:16 Spleen has to be three times its normal size to be palpable. The liver even in thin persons, can you feel it and know pathology? Someone told me that even in thin persons you'll never feel the liver unless there’s something wrong, but I seem to find that you can feel it -- I’ve felt it in people that are otherwise well. Okay. Thank you.

    About the Lecture

    The lecture Medical Body Examination by Noor Sash, PhD is from the course Medical Body Examination. It contains the following chapters:

    • Expose the patient
    • Examining the stomach
    • Examining the liver
    • Auscultation
    • Completing the examination
    • JVP
    • Shifting dullness
    • Scratch test

    Included Quiz Questions

    1. Lift his or head up while lying supine.
    2. Lift his or head up while lying prone.
    3. Lift his or head up while lying laterally.
    4. Lift his or head up while sitting.
    1. Percussing until a dull sound is heard.
    2. Percussing until a hollow sound is heard.
    3. Percussing until no sound is heard.
    4. Percussing with your stethoscope.
    1. Pushing into the liver with exhalation.
    2. Pushing into the liver on inhalation.
    3. Lightly tapping the liver.
    4. Pinching the base of the liver.
    1. Absent or Hyperactive bowel sounds
    2. Normoactive bowel sounds
    3. Intermittent bowel sounds
    4. Hypoactive bowel sounds
    1. Jugular Venous Pressure
    2. Jugular Arterial Pressure
    3. Carotid Venous Pressure
    4. Sternocleidomastoid pressure
    1. Shifting dullness
    2. Auscultation
    3. Vibrating the stomach
    4. McMurry’s test
    1. Identify the liver
    2. Identify the kidney
    3. Identify the gallbladder
    4. Identify the spleen

    Author of lecture Medical Body Examination

     Noor Sash, PhD

    Noor Sash, PhD

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