Physical Examination

The Hand Exam

EMKF

  • A rapid hand exam can be performed in the following manner:
    • Ask the patient make an “OKAY” sign with thumb and first finger (median nerve). Spread the fingers apart maximally (ulnar nerve). Dorsiflex the wrist fully (radial nerve). These can be combined into an OKAY sign with remaining fingers spread apart and the wrist dorsiflexed to get an all-in-one motor exam.
    • Check sensation of the median and ulnar nerve by testing two-point discrimination at the index and small finger pads respectively. Radial nerve sensation can be tested over the dorsum of the thumb.
  • For carpal tunnel syndrome, perform Tinel’s and Phalen’s tests. Remember, a positive test occurs when the patient reports paresthesias in median nerve distribution.
  • Acute compartment syndrome must go to the OR within 8 hours of onset.
  • Kanavel’s Signs are key physical exam findings for flexor tenosynovitis: finger held in flexion, pain with passive extension, pain with palpation of the flexor tendon sheath, and fusiform swelling.
  • Beware of high-pressure injection injuries. They look more benign than they truly are, and warrant a careful physical examination of the hand and consultation.

How useful are physical examination manoeuvres for an adult patient with suspected meningitis?

EMKF

meningitis

The Kernig, Brudzinski and Jolt Accentuation signs have limited utility in assessing patients with acute meningitis. The poor sensitivities mean that meningitis cannot be ruled out if the signs are not present (remember sn[out]). The relatively high specificities mean that your suspicion might increase if the signs are present (remember sp[in]) but unfortunately the associated low positive likelihood ratios show that no exam manoeuvre can reliably rule in the diagnosis. All three must be used with caution and in conjunction with other supporting laboratory and historical data.

 

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DID YOU KNOW: Peritonitis

EMKF

Determining the presence or absence of peritonitis is a primary objective of the abdominal examination. All the methods alone are inaccurate. Thoracic inflammatory process adjacent to the diaphragm, a voluntary contraction of the abdominal wall in apprensive patients, a rough painful examination, may be misleading. But what is more interesting is that NO TEST ALONE is useful in ruling out a diagnosis of peritonitis. Furthermore a gentle percussion is as inaccurate as the rebound test is, but it saves unnecessary pain.