Once you have done your initial introductions and examination from the end of the bed described in the examinations page you can then move onto more specific examination. Now we can approach the patient and start to take a good close look at them. As with both respiratory and cardiovascular examination we always start with the patients hands. As well as just looking one can also tell a lot from the feel of those hands:
- Are they warm or cold? A cold septic patient is often a sicker one than a warm septic patient.
- If they are cold do they appear peripherally shut down? Are their hands mottled looking? What is their capillary refill time?
- Do they feel sweaty or clammy?
- Do their hands appear pale or anaemic looking?
- Are there any signs of a chronic smoking habit i.e. nicotine staining around the fingers.
- Are their finger nails clubbed? Always hold the hands up to eye level if possible or get down to their level to look at the nails side on which is the best angle from which to judge nail clubbing.
- Is there any sign of a tremor? This could be caused by the bronchial dilator drugs we are giving them or it could be that they are starting to develop a metabolic retention flap which can occur once a patient begins to become encephalopathic.
We then move our examination up the arm. I always make a point of looking at the arm as I move up so that I do not forget anything. At this stage we need to check the radial pulse and we are checking it for presence, rate, rhythm and volume. A very tachycardic patient may be septic, or it could just be the drugs which we give them which are making their heart beat faster. A patient with a bounding pulse may be showing early signs of carbon dioxide retention. As with all systems when you have two of something you should always compare and contrast. So you should check the other hand to see if there are any differences and you should compare the radial pulses on both sides.
Moving further up the arm as you go higher this is a visual reminder to check the blood pressure. The patient with an abdominal problem may often present with a lowered blood pressure. Also remember that the human body tries to maintain a good blood pressure through various compensatory mechanisms. A low blood pressure may indicate that these mechanisms are starting to fail and the patient is potentially a very ill one.
We then move up to examine the patients face. First look at the eyes to see if there are any indications of such things as anaemia or jaundice. Does the patient actually have their eyes open and if not why not. Is it because they are neurologically compromised because of a dysfunctional gastro-intestinal system? Look at the pallor of the patients face. Do they look pale or sweaty? Their mouth may provide you with some clues as to their problem. Firstly do they look dehydrated? Is their tongue dry in appearance? Does their oral mucosa appear dry? What is their dentition like? Do they look like they visit a dentist regularly or indeed do they have their false teeth in if they use them?
The lymph glands should be palpated now to ascertain if there are any enlarged, painful or hard glands. This process may be made easier if one tries to visualise the anterior and posterior triangles on the neck. The anterior triangle starts at the chin, moves along the jaw to in front of the ear and then down anterior aspect of the sterno-cleidomastoid to the sterna head of this muscle. The posterior triangle then runs along the clavicle, up the posterior aspect of the sterno-cleidomastoid and then into the occiput. So when examining the glands one should follow the lines of these triangles to ensure that you cover all the relevant areas:
- Systematically palpate with the pads of your index and middle fingers for the various lymph node groups.
- Submental – Under the jaw in the midline.
- Submandibular – Under the jaw on the side.
- Tonsillar – At the angle of the jaw.
- Preauricular – In front of the ear.
- Postauricular – Behind the ear.
- Superficial (Anterior) Cervical – Over and in front of the sternomastoid muscle.
- Supraclavicular – In the angle of the sternomastoid and the clavicle.
- The deep cervical chain of lymph nodes lies below the sternomastoid and cannot be palpated without getting underneath the muscle:
- Inform the patient that this procedure will cause some discomfort.
- Hook your fingers under the anterior edge of the sternomastoid muscle.
- Ask the patient to bend their neck toward the side you are examining.
- Move the muscle backward and palpate for the deep nodes underneath.
- Occipital – At the base of the skull.
- Note the size and location of any palpable nodes and whether they were soft or hard, non-tender or tender, and mobile or fixed.
We can now move to examining the abdomen for any problems. The visual examination will initially start by getting down to the level of the abdomen and examining it from the side. We are looking for a number of things including:
- Visible peristalsis
Auscultation for bowel sounds is best carried out over the ileo-ceocal junction, and be sure that you listen for a couple of minutes before stating that there were no bowel sounds.
One of the common symptoms that a patient will present with will be abdominal pain and it is this pain that will dictate the way in which you examine your patient’s abdomen. The first thing you must do before laying your hands on them is establish exactly where the pain is so that you may avoid that area until you need to. Once you have done so you can then start to lightly palpate the 9 areas of the abdomen, watching the patients face whilst you do so, trying to establish where the pain is and also noting any swollen areas or lumps.
You would then move on to deep palpation of the abdomen, trying to establish the edges of any areas of which you may be suspicious. This deeper palpation is more of a two handed technique, and again it is important to bear in mind the patients level of pain.
Palpation of the liver edge is another important part of the abdominal examination. This starts with the ulna aspect of the hand on the patient’s abdomen in the right iliac fossa. By a gentle rocking of the hand one tries to feel the edge of the liver. Gradually move the hand up the abdomen asking the patient to breathe in to help in the process as you press downwards. If you do feel a liver edge, try to estimate the size of the liver and remark upon any tenderness, and whether the liver feels hard or irregular. A similar process is then carried out for the spleen. This time the fingers point towards the area of the spleen as the palpation process takes place.
Percussion of the abdomen aims to identify the edges of the liver and any abnormal fluid levels in the abdomen. When trying to percuss out the liver edges first start above the right nipple and percuss downwards until dullness is obtained. This will likely be the top of the liver. Continue percussing downwards until the sound becomes more resonant, marking the lower edge of the liver. With ascetic fluid in the abnormal one can attempt to percuss for shifting dullness. First percuss out from the midline of the abdomen trying to elicit dullness. When this is obtained then get the patient to roll on their side and if there is a lot of fluid in the abdomen then the level of dullness will shift as the fluid level moves relative to the abdominal wall.
One other part of the abdominal examination is the rectal examination. This examination, whilst uncomfortable for the patient, can potentially provide a lot of useful information. If intending to do this examination it is obviously important to explain the process to the patient, so that they can understand what you are about to do and why you need to do it. Firstly get the patient to lie on their left side and ask them to pull their knees up as far as possible. Ensure that your gloved finger is well lubricated. Before you insert your finger ensure that you examine the anal area for any abnormalities such as tears, anal fissures, excoriation or discolouration. When you introduce your finger do it slowly with the pulp of your finger at six o’clock. You may encounter some anal spasm when first trying this. If you do it may be necessary to withdraw and perhaps you some topical anaesthetic before trying again. Once your finger is in you then need to rotate your finger slowly round trying to feel for any abnormalities as you do so. You may for example feel an enlarged prostate or cervix. You also need to ask the patient to try to grip your finger thereby checking for anal tone. When you withdraw your finger you need to check the colour and consistency of any faeces which are on it.
Do you need some help to remember all this information? Are you about to take an OSCE to examine your skills in Clinical Examination? Maybe you will find the Audio files I have created to help you revise the OSCE process helpful?