Physical exam red flags every doc should know

Poor physical exam skills are a threat to patient safety. Specifically, a lapse in these skills can lead to missed/incorrect diagnoses and, consequently, poor patient outcomes. These slips can not only delay life-saving treatments, but also lead physicians down diagnostic rabbit holes—which carry their own risks for patients.

Some researchers have noted a decline in strong physical examination skills among modern physicians. Possible reasons attributed to the deterioration of this important skill-set include greater reliance on diagnostic technology, time constraints during patient consultations, and less time spent on bedside instruction 

In an article published in Cureus, researchers explored the implications of poor physical exams: “In an era where there is growing concern of over-utilization of health care resources and expense, poor physical examination skills lead to more injudicious referrals and patient mismanagement, leading to added costs.” They observed,“Poor physical examination skills are a threat to patient safety as the probability of diagnostic errors and oversights is increased...The unnecessary reliance on investigations has made it harder for modern-day physicians to meet the day-to-day needs of patients seeking medical care, especially in resource-limited settings.”

Here is a look at five important physical examination findings that all physicians should watch for in their patients. Results from these exams reflect systemic and often life-threatening health concerns.

Facial weakness

Classically, Bell palsy, or idiopathic facial paralysis, causes unilateral drooping of the facial muscles—including the forehead. In case the ability to wrinkle the forehead is spared, due to bilateral innervations of these muscles, stroke should be considered. Bell palsy is a tempting diagnosis in a person who may seem at low risk for stroke. But, missing the signs and symptoms of stroke—a condition in which early diagnosis is critical—can be life-threatening..

Ascites

The abnormal accumulation of fluid within the abdominal cavity, or ascites, is an ominous sign in any patient. Ascites can be indicative of several severe health conditions, such as cirrhosis, liver cancer, heart failure, or tuberculosis. The CDC points out that every physician should be aware of the signs of this condition, as well as physical exam findings to test for. Full details on the signs of ascites as well as detection methods and procedures can be found on the CDC website. 

Of note, sensitivity of these and other maneuvers used to detect ascites is limited by the amount of peritoneal fluid. Ultrasound is useful when looking for small amounts of fluid. Furthermore, in a small number of patients with ascites, a (usually) right-sided pleural effusion can be detected due to diaphragmatic defect that permits ascites fluid to pass into the pleural cavity.

Cerebellar deficits

The cerebellum governs balance, muscle tone, and coordination of voluntary movements. Cerebellar disease can take the form of stroke, cerebritis, and metabolic insults, with signs affecting the whole body.

Here are some tests of interest when examining cerebellar function:

Nystagmus. The fast phase points toward the lesion.

Scanning speech. The patient enunciates each individual syllable in a phrase.

Rapid-alternating movements. Check for dysdiadochokinesia by having the patient place one hand over the other and having them flip it back and forth as quickly as possible.

Rebound phenomenon. Have the patient pull on your hand and then wiggle out of their grasp. Under normal conditions, the patient’s hand will stop moving, but with cerebellar disease, the patient’s hand will continue moving in the desired direction. (Make sure the patient doesn’t strike themselves.)

Dysmetria. For the finger-to-nose test, have the patient extend the arm and then touch their nose or ask them to touch their nose and then fully extend their arm to meet your finger. You can increase difficulty by moving your finger to different locations or adding resistance. Another test of dysmetria involves having the patient run their heel down the contralateral shin.

Gait. Check for wide-based and staggering gait which indicates acute cerebellar ataxia. Patients may also fall toward the side of the lesion.

Pendular knee jerk. The patient’s knee keeps swinging more than four times following knee jerk with a positive test.

Liver size 

Hepatomegaly is a worrisome sign of liver pathology and can indicate a broad gamut of disease, including heart failure, autoimmune liver disease, hepatitis, and non-alcoholic fatty liver disease. Although there may be specific signs of liver pathology—such as jaundice, ascites, or spider nevi—this isn’t always the case, with some symptoms being nonspecific, such as anorexia, weight loss, and lethargy.

If you suspect something is abnormal with your patient’s liver, then palpation may be a good idea. With palpation, start all the way down at the level of the left iliac fossa (near the large intestine) and lateral to the rectus abdominis muscle (so as not to miss a really large liver). When palpating, ask the patient to lie supine and take a deep breath. Then, feel for the liver edge, and let the liver margin pass under the fingertips of your right hand while feeling for nodules and firmness, which could indicate pathology. Be sure to note any tenderness elicited, which could be indicative of hepatitis (ie, inflammation) or congestive heart failure. 

Pupil size

They say the eyes are the window to the soul. Although there’s no way to validate this claim, the eyes certainly are a window to health. By simply observing the size of your patient’s pupils—even without using light to test for pupillary response—you can assess concerning warning signs. 

For instance, if one pupil is dilated and the other is normal, this could be evidence of cancer of the oculomotor nerve, stroke of the oculomotor nerve, infection, trauma, or prior eye surgery. If both pupils are dilated, however, the patient could be under the influence of cocaine or some other sympathomimetic.  If both pupils are constricted, the patient could be under the influence of other narcotics. 

Even if you don’t routinely perform physical examinations during your practice of medicine, the focused application of a specific test upon suspicion, as well as prompt referral, could save a patient’s life.