The Physical Exam continued

I must apologize for not posting in the past few weeks, residency is starting to catch up with me. Anyway, I'll continue on with the physical exam.

I usually examine patients in a systematic way so that I don't forget anything. My way of doing it is from top to bottom. So after I examine the eyes, I'll move down to the nose. There isn't a whole lot to do in the nose except, well look inside of it. Here I'll use the little instrument that is usually hanging on the wall that has a light with a magnifying lens. It's the same instrument used to look in the ear. Looking into the nose gives you a look at the mucus membranes. These are the thin membranes that can bleed when you're having a nose bleed. Many people are prone to nose bleeds because the membrane is so thin here, and all it takes is a small break in the mucosa. This is also the area that can become inflamed when you're having a cold. In this case, the membrane will look red and have lots of, well, snot dripping from it (exudate would be a more medical term). Allergies have a different appearance. When somebody has bad nasal allergy symptoms, the nasal mucosa will look blue and have a boggy appearance. So if a patient comes in to see you with a lot of nasal discharge and you want to distinguish a viral infection and an allergic reaction, you can just have a look in the nose. Another thing that you may notice in the nose is the septum. This is the wall of tissue that separates the right and left nostrils. It is usually continuous until you get to the back part of your nasal cavity (you shouldn't be able to feel with your finger where the septum ends). But people who snort cocaine or other things chronically may have eroded this septum and have a hole in it. So looking in the nose can give you even more information about a patient than what his nose is like.

Next I'll examine the mouth. Looking at the lips is important because there are certain symdromes and other diseases which will give you focal lesions of the lips. One syndrome called Peutz-Jeger syndrome is associated with multiple polyps of the GI tract which will eventually become cancerous. This syndrome is also associated with purple-ish lesions of the lips and oral mucosa. So if you see something like this when you examine the lips, you may be able to diagnose this syndrome and save somebody's life from colon cancer.

After looking at the lips, a thorough exam would include taking a brief glance at the teeth and gums. Obviously, dentists do the majority of the dental work, but teeth and gums are a part of the body and can have major impacts on otherall health. Usually I just have a quick glance at them just to make sure there are no rotting teeth or large abscesses. Then I move on to the back of the mouth. This is the part where the doc takes the tongue depressor and sticks it to the back of your mouth. What we are trying to do is smoosh the tongue down so that we can see the throat. If the throat is red, the patient may have a cold (sore throat) from a viral infection. You can also see puss combined with redness, which would probably indicate strep throat. The difference between strep throat and a viral infection is that one is caused by a bacteria (strep) and can be treated with antibiotics, whereas the viral infection does not really have a treatment. The presence of puss is usually a tip off that there may be a bacterial infection, but patients with strep throat are also usually much sicker than patients with a viral infection. While looking at the back of the mouth, you should also be able to see the tonsils.

The tonsils are basically lymph nodes that sit in the back floor of your mouth. Lymph nodes become enlarge in infection (as they would in strep throat). You can also get abscesses forming on the tonsils. Abscesses are focal collections of puss. Puss (or exudate) is thick proteinacious material that is basically the products of your immune system trying to fight a bacterial infection. If you look at it under a microscope, you'll see dead white blood cells (your immune cells) and dead bacteria as well as some live cells too. An abscess occurs when your body notices the production of puss and tries to wall off the focus of infection in an attempt to stop it from spreading. You can think of it like a blister filled with infection. The bad thing about abscesses is that the walls surrounding them are thick and prevent antibiotics from penetrating into the abscess. So treating the infection is not as simple as prescribing a pill. To treat abscesses, you have to pop them. You need to drain that puss. Many would argue that you don't even need to treat an abscess with antibiotics if you can drain it (I think most doctors would give antibiotics in addition, though). So an abscess on the tonsil can be a serious thing because it requires draining.

The next thing that I examine is the neck. Here, I will check for lymph nodes. There are a collection of lymph nodes running along the underside of the jaw, chin, and along the neck muscles. These can also become enlarge in infections like colds or strep throat. In fact strep throat will cause specific lymph nodes to become enlarged more frequently than others. Cancers (lymphoma) can also cause lymph nodes to become enlarged. It is important to characterize the enlarged lymph node. Does the lymph node hurt when you push on it? Are the lymph nodes mobile or do they seem fixed to the underlying muscle (this would imply tumor invasion into surrounding tissues). A careful exam for lymph nodes would also include feeling at the back of the neck since there are lymph nodes that live back there too. Many clinicians have different techniques for feeling for lymph nodes. Some will use the tips of their fingers and use a rolling motion up and down the neck. Others will just slap their entire palms down on the neck and massage the neck to feel for any irregularities.

The thyroid gland also lives in the neck. It can become enlarged in certain diseases. It can have nodules, or focal bumps in it. It can also have nodules if there is a cancer growing in it. Unfortunately examining the thyroid can be tricky. I can't say that I am entirely confident with my ability to feel it and that's because it is a very spongy tissue and doesn't have very defined borders to it. Obviously an endocrinologist who feels thyroids all day long is probably quite adept at it. The thyroid gland lies in the midline right at or a little under the Adam's apple. There are a couple of techniques for examining the thyroid, one of which is to stand behind the patient and use one set of fingers for each side of the neck with the palms by the patient's ears. The other way is to just stand next to the patient and use one hand to feel that area. Usually we will ask the patient to swallow and try to feel the thyroid moving up and down.

Another important thing to examine in the neck is the carotid arteries. These arteries are sort of important because they feed blood to the brain. On TV, when they are checking to see if somebody is dead, they are putting their fingers on the neck and trying to feel the pulse of the carotid artery. You should be able to feel your own if you put 2 fingers on your Adam's apple (women have Adam's apples too, they're just less prominent) and move maybe 3 centimeters to either side and push gently. If you can't feel it, start moving around until you feel a bounding pulse. If you still can't feel it, you're either not feeling in the right place, or you're about to die. Anyway, examining the carotid artery includes feeling for it, but also trying to characterize it. Does it feel strong? If it's a wimpy little pulse, there may be some atherosclerosis in the vessel. This can be a serious thing because if the blood vessel becomes narrowed enough, there may be decreased blood flow to the brain which could cause stroke. Parts of the cholesterol plaque may also break off from the carotid artery and plug up the arteries in the brain. Listening to the carotid artery with a stethoscope can give some clues about the heart. As blood leaves the heart on its way to the carotid artery, it goes through a set of valves which are designed to prevent back flow in the vessel. These valves can become diseased or "stenotic". This means that the valve area becomes narrowed and the blood has a smaller diameter to get through. You can see how this would be a bad thing. When you listen to the carotid artery, you may be able to hear what is called a bruit (pronounced broo-ie) which is a blowing sound that the blood makes as it shoots through the stenotic valve and into the carotid artery. You will also be able to hear the bruit in the heart (in which case it would be called a murmur), but the fact that you can hear the bruit in the carotid artery and the heart tells you that there is stenosis of a specific valve.

Next thing I examine in the head is the ears. Again, it's important just to look first. Many clinicians just take the light, have a quick look in the ears and that's it. But looking at the outside is important too. Many skin cancers can start in the ear since it is constantly exposed to sunlight. The ear is divided into 3 portions: the inner, middle, and outer ear. I wont go into the anatomic structures within each compartment, but the inner ear basically can't be examined directly. The outer ear is the part of the ear that you can stick your finger into. Patients (especially diabetics or swimmers) can get infections of the outer ear. You may see puss running out of the ear. Or if you tug on the outside of the ear, there may be pain from an "outer ear infection". Deep to the outer ear, past the ear drum is the middle ear. When physicians stick the light into your ear, they are trying to look at the ear drum, which can be a window into the middle ear. If there is an inner ear infection, the ear drum may be red. If there is a bacterial infection in the middle ear, there may be puss behind the ear drum. Some patients may also have a perforated ear drum which can also be seen. The middle ear is prone to infection because it has a tube which connects it to the nasal cavity (the Eustacian tube). This gives bacteria a road to follow up to the middle ear, which is nice and dark, enclosed, and moist--perfect conditions for an infection. That's why many ear infections start off as an infection in the nose or throat and then travels up to the ear.

Testing the actual hearing function is also important and may be obvious in gross hearing loss, but it can also be subtle. I like to have the patient close their eyes and tell them to raise their hand when they hear something. Then I take my fingers and rub them together about a foot away from each ear. If they can hear it, I take that as being fairly normal. If somebody comes in with a complaint of hearing loss or if I know there are underlying deficiencies, there are more sophisticated tests using tuning forks that can be done, but the underlying physiology is a little beyond this blog, I think.

That about covers the exam of the head. I will usually return to examining parts of the head later on when I do the neurological exam. The neurological exam is much more complicated and can be subtle, so I usually chose to do it separately and all at once.

My hands are getting typed-out, so I think I'll continue on with the chest and abdomen next time. Again, feel free to leave comments if you think this topic is getting boring.