• Emergency Medicine Physical Diagnosis

    Emergency Medicine Physical Diagnosis

ORBITAL COMPARTMENT SYNDROME: CHECK FOR AFFERENT PUPILLARY DEFECT

A patient presents in a coma after head and face injury. You note proptosis and the CT shows retroorbital hematoma. You wonder whether you should decompress this. Normally we based decompression on visual acuity but that is not available in the comatose patient. What can we do?   Afferent pupillary defect (swinging flashlight test) may … Continue reading

BEDSIDE DIAGNOSIS OF COAGULOPATHY

A patient presents found in the rural backcountry after a motor vehicle accident. She has a grade V liver laceration and is not stable for transfer. Your general surgeon is getting ready to take her to the operating room for damage control laparatomy and packing. You notice she is oozing from her central line site. … Continue reading

GAIT ASSESSMENT: WALK THE WALK  

A mother brings her 2 year old child in for a limp. The student believes the patient has ankle pain because she cried when she grabbed the ankle. After that she cried with everything. After calming the child down you watch her walk and it is abnormal but you wonder how to interpret this.   … Continue reading

SCAPHOID FRACTURE: CHECK BOTH SIDES, LOCALIZE IT

A patient presents with wrist pain after a fall. X-rays are negative. You palpate the snuffbox and there is mild tenderness.  One dominant current practice is to apply a thumb spica splint in all such cases but you suspect this causes too many patients to be immobilized. Can the physical examination help?   There actually … Continue reading

HIP REDUCTION: LATERAL APPROACH USES GRAVITY TO HELP

[Although technically not physical diagnosis, some bedside procedures rely on discerning anatomical and physiological clues at the bedside, and thus are bedside skills] A patient presents after a hip injury with a right lower extremity that is flexed, adducted, and internally rotated. You suspect hip dislocation and confirm it quickly with x-rays. You attempt reduction … Continue reading

HOW TO PALPATE FEVER

Most studies say that palpation of fever is inaccurate. I am not so sure. Many of the studies use oral temperature as a gold standard, which of course can be as low as 50% sensitive for true fever. These studies conclude that the mothers’ palpation over-called the diagnosis but I wonder whether rectal temperature assessment … Continue reading

VERTEBRAL COMPRESSION FRACTURES: PERCUSSION AND SUPINE CHALLENGE

An elderly patient with a history of COPD presents with back pain radiating to the chest. After an extensive workup, a CT scan shows a vertebral compression fracture. You percuss the area and find that this reproduces the pain. Is this the cause of her pain?   Sometimes in emergency medicine we face the dilemma … Continue reading

PHYSICAL DIAGNOSIS OF RIB FRACTURES

A patient presents with chest discomfort after a fall from height. You suspected fractured ribs but the chest radiograph was negative. Traditionally radiographs are considered to have poor sensitivity for rib fractures. But how helpful is physical examination?   First, localize the tenderness. One can gently palpate the individual ribs through their arc. Crepitus essentially … Continue reading

SUPINE POSITIONING CAUSES AUTO-PEEP

Why do some critically ill patients, when they are laid flat for intubation, either get worse or sometimes even go into cardiac arrest?   Patients with CHF, COPD, and morbid obesity have expiratory flow limitation when laid supine, meaning that they do not exhale all the way. This is attributed to air trapping, presumably because … Continue reading

THE ART OF MEDICAL HISTORY TAKING

Studies show that patients omit symptoms when explaining their history to the doctor. I see this in academics when I get a story that adds information compared to what the resident elicited. When I observe resident history taking directly, I sometimes can gain insight into optimal and suboptimal medical history taking. Interruptions can be well-intentioned, … Continue reading

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