5 steps to an accurate physical exam
You are on scene with a patient who is complaining of isolated abdominal pain; what tips can improve your physical exam of this patient?
After introducing yourself to your patient and obtaining a history of both the present medical condition and the patient’s previous medical history, you must decide what type of physical exam to perform. The physical exam can help to augment the history you have already obtained and can aid in developing a differential diagnosis and treatment plan. There are two basic versions of the physical exam to choose from: the head-to-toe exam and the focused physical exam.
As a general rule, the head-to-toe exam is reserved for trauma patients when you aren’t sure what body system may be involved based on the mechanism. In contrast, the focused physical exam is limited to one or two body systems or regions, and is based largely on the nature of the patient’s complaint. Choose the focused physical exam when you already have a good idea of what system may be involved in the patient’s present illness.
Here are five assessment tips when performing a focused exam:
1. Know when to use the focused exam
Broadly, while the head-to-toe exam is generally reserved for trauma patients, the focused exam is generally utilized for medical patients. Consider the mechanism for a trauma patient when determining whether to use the head-to-toe exam. Generally, a blunt traumatic mechanism can affect multiple body systems. As such, it is wise to assess each of the body systems or regions methodically because of the unknown extent of injuries associated with blunt trauma.
In contrast, a medical patient’s complaint generally involves a single body system. As a result, the EMS provider may usually limit her assessment to just the body system involved in the complaint. Take our abdominal pain patient as an example: her pain came on suddenly and was not the result of any traumatic mechanism she can recall.
Given that information, it seems unlikely that she also sustained a closed head injury around the time that her abdominal pain began. As head trauma is unlikely, the providers treating her can safely avoid additional assessment involving her head and neurological status unless some particular finding raises their index of suspicion. Their exam can safely be limited to her abdomen.
2. Have a differential diagnosis in mind
When performing a focused exam, remember what led you to use that exam to begin with. During your history, you ruled out traumatic mechanism (and, by extension, a head-to-toe exam) but you also ruled out a variety of other medical issues. In our patient with abdominal pain, you hopefully included several options on your differential diagnosis list. Among those options should have been ectopic pregnancy (even though she denies a possibility of pregnancy) along with ovarian cyst, diverticulitis and colitis.
By considering your differential diagnosis, you can select a particular region of the body to assess in greater detail. In this case, a physical exam of the patient’s abdomen will allow you to assess for most of the likely causes of her complaints.
3. Consider adjacent regions
While it makes sense to focus on a particular region or system of the body when performing an exam, it may be useful to consider adjacent regions or systems as well. Using our abdominal pain example, consider the implications of a patient complaining of upper abdominal or epigastric pain. While this could certainly be a symptom of an illness involving the abdominal organs, it is also possible that the patient is experiencing a cardiac event.
Consider the patient’s symptoms broadly when determining whether or not to also assess a region adjacent to the area of primary interest. For instance, if a patient has epigastric pain and also has nausea, diaphoresis or weakness, it is recommended to also assess the chest, including an ECG if available.
4. Document positives and negatives
Often when performing a physical exam, EMS providers are interested in abnormal findings. While it is important to understand what findings are unusual during a patient exam, it is also important to know what findings are not. A normal finding doesn’t necessarily mean the absence of disease, but it can help to exclude certain conditions from the list of differential diagnoses.
For instance, a patient with intact distal neurological function isn't precluded from having a spinal fracture, but it is likely that they do not have an injury to their spinal cord. Beyond just recognizing that positive and negative findings are important, it is equally vital to document both of these findings on the patient care report. Given that a patient’s condition can be fluid, the receiving facility and treating providers need to know if a patient’s presentation was initially normal but has now changed. If those normal findings don’t make it on to the care report, then they cannot be referenced later.
5. Explain yourself
Most patients that EMS providers interact with did not plan to experience a medical assessment when they started their day. Additionally, most patients are not previously familiar with their EMS provider in the way they would be with their personal physician. As a result, the medical exam performed by EMS can be the somewhat anxiety-inducing. When assessing your patient, remember that this can be a stressful experience for her.
Explain the steps of your assessment and what you’re looking for. Most patients want to know that what they are experiencing is normal and has a purpose in their overall episode of care. Also, explaining your assessment process makes it easier to explain the findings and what impact they have on the list of differential diagnoses. Also, it’s always good practice to make your patient a partner in their assessment and care.
Given Gina’s relatively stable presentation and her public location, you wait for the transporting unit to arrive before performing a physical exam. When they do, Gina is loaded onto the stretcher and taken out to the ambulance. You assist the transporting paramedic in performing Gina’s focused exam and find that her pain increases with palpation and movement.
Ultimately, Gina is transported to the emergency department and is simply monitored by the transporting crew on the way. Once there, she undergoes ultrasound and CT which reveals that she is experiencing an ovarian cyst. She is medicated for pain and discharged home the same day.