Video 5: Physical Examination in Emergency Care

Dr. Nelson (00:01):

I’m Dr. Nelson. We are working with Full Code. Now let’s turn to the physical exam. Typically, we would take our patient history like we just spoke in the last video and then proceed to a physical examination, but that’s not always possible. 

So let’s go back to our case. In our physical examination, we would first start with vital signs, which are provided for us usually by the nursing staff. That includes a temperature, blood pressure, pulse, respiratory rate, and oxygen saturation level. In critical care patients, we start with doing the ABCs, which stands for airway, breathing and circulation. 

Let’s perform an airway examination. It says the airway is patent, without obstruction or strider, which means we looked in the mouth to make sure there wasn’t something in the way of the airway that would prevent air from getting into the lungs. Next, we’ll perform a breathing exam, which is done with a stethoscope, listening for breath sounds in both lungs on the front of the chest and the back of the chest.

Dr. Nelson (01:07):

And here it says we have symmetric breath sounds and chest rise with normal respiratory rate. Next, we perform a circulation exam where we check heart tones via our stethoscope, listening for the “lub-dub” of the closure of the valves of the heart and feeling for peripheral pulses and capillary refill, which is where we depress the fingernails and see how long it takes for the pink color to return after pressing on the fingernail. Subsequent to that, we then perform a head-to-toe examination.

First, we would do an HEENT exam, which stands for head, eyes, ears, nose, and throat. In this case, it says NCAT: normal cephalic atraumatic. We don’t see any trauma or deformities to the head. PERRL stands for Pupils are Equal, Round, and Reactive to Light, and the pupils are four millimeters in diameter bilaterally, or both sides. We could also look into the ear canals into the nose.

Dr. Nelson (02:13):

Next, we perform a neck exam looking for any swelling or masses, like a tumor, that could potentially be causing breathing issues. Here [on Full Code] it says there are no masses and the trachea or main breathing tube is in the middle midline. There’s nothing pushing it to one side or the other. 

Next, we would perform a cardiovascular examination, which is a more detailed version of our circulation exam. We’ve already performed our pulmonary examination and then we could proceed to our abdominal examination, where we would listen for bowel sounds or , and also press on the abdomen to see if there’s any distension tenderness or enlargement of the intra-abdominal organs, such as the liver and spleen. It’s not always necessary, but you can sometimes perform a genitourinary urinary exam. 

If there has been trauma to the pelvis or there’s some sort of complaint of an issue in the  genitourinary region. If we were concerned that there was some trauma, we would perform a back exam to see if there’s any bruising or penetrating wounds.

Dr. Nelson (03:18):

We could perform a musculoskeletal exam to assess for any edema of the legs or asymmetry of the muscles. A skin exam would allow us to assess how well the skin is being perfused and oxygenated. Is there any bluish tint or hypoxia that we can see? Are there any rashes or any lacerations or cuts? 

Next, we perform a neurologic exam where we test how the brain, spinal cord and nerves are functioning. And finally, we would do a psychiatric exam to see how well the patient’s mood and affect is doing. 

Let’s discuss some of those AAMC Premed Competencies that are relevant to this part of the case. One would be cultural humility, where different cultures might have different ways of approaching the physical exam, such as whether a male performs a sensitive exam of the genital urinary area on a female patient. Another competency would be empathy. 

I want you to stop the video and discuss amongst yourselves what it would be like to do a physical examination on a patient in the emergency department. What is it that is vital for all emergency department physicians to know in the physical examination?

• What is vital (hey, Dr. Nelson, this is a decent pun for emergency department physicians) for all emergency department physician to know ?
  
  
• Go back to the video or look at the transcript. Find some of the unfamiliar terms that Dr. Nelson uses.
  
  • Your small group’s task will be to look up definitions for three words your group doesn’t know (borborygmi does not count).
  • Have one person in your small group share these new medical terms with your entire chapter!

⚕️Medical Term Fun Fact: As Dr. Nelson said in the video, borborygmi (plural) is defined as the “abdominal gurgles due to movement of fluid and gas in the intestine.”

Read this interview/ listen to this podcast about borborygmi here and see this SciShow video for more!