The General Paramedic Physical Exam

 
 


This is based on a check sheet I  use for testing students. When I test students I have them do one station where they show me every point in the head to toe exam and I ask them to explain how they would examine this item, and what different findings mean. What I’ve written below is the information that I’m expecting them to tell me. Then I ask them to do one of the specific exams at random (to make sure they’ve studied them). 


So basically, if you take the paramedic program with me, there are six separate physical exams that you need to learn:

  1. Complete (outlined below), as well as ...

  2. Cardiac

  3. Respiratory

  4. Neurological

  5. Gastrointestinal

  6. Trauma




Head and Neck Exam


The Head and Neck Exam is kind of long, but it can be remembered the following way: (1) check for new holes, (2) check the old holes (ears, eyes, nose, mouth/speech), (3) check the face, and (4) check the neck.



Assess for facial and cranial lesions (DCAP-BTLS)

  1. Check in all neurological and trauma patients.

  2. DCAP-BTLS = Deformities Contusions Abrasions Punctures/Penetrations Burns Tenderness Lacerations Swelling.  This is an American acronym and it’s useful for students because it proves they know what they are looking for, but once you graduate you can use the all encompassing term ‘lesions’, which is more concise.

  3. Check for Battles’ sign (mastoid ecchymosis) and Raccoon’s Eyes (bilateral, periorbital ecchymosis) in head injury.

  4. Be aware that Battles’ sign usually occurs DAYS after an injury.  If you’re pulling someone from a car or other traumatic injury and you discover Battle’s sign, you must consider previous trauma.  Were they in another accident a few days ago?

  5. Racoon’s eyes usually happens HOURS after an injury, so again, you have to wonder how they got that if you’re at a ‘fresh’ trauma.

  6. Technical point: it’s not “Battle’s” sign, it’s “Battles’ sign” (note the apostrophe).  This is because it’s not a ‘sign of battle’ (which is what most people think), instead it’s named after a physician named ‘Battle’ who first described it.

Assess if pupils are equal and reactive to light (PEARL)

  1. Check in all patients, but use caution in patients who have been having recent seizures (because you might elicit another seizure by flashing a light in their eyes).

  2. Report if unequal, or report as a pertinent negative in the traumatic and neurological patient.

  3. 25% of the population have naturally unequal pupils (“anisocoria”), otherwise the pupils should be equal and reactive.  The best way to tell if a patient has anisocoria is to ask them (or someone who knows them, if they can’t answer).  I don’t know of any way to tell just by physical exam.

  4. Be aware that if you shine light in one pupil, both will react.

  5. Please don’t use very bright lights to test this.  That’s pretty uncomfortable for the patient.  In this day and age of LED flashlights you can really blind someone.  Test your light - if it’s too bright for your eyes, it’s too bright for theirs.

  6. Generally, one blown and dilated pupil indicates head injury (stroke or trauma).

  7. Bilaterally dilated, non-reactive pupils indicates brain death. However, in the cardiac arrest patient who has received epinephrine and atropine the pupils will be dilated and non-reactive.  This does not necessarily mean they are brain dead! (although they might be)  It could be drug effect.  Keep that in mind.

  8. Pinpoint non-reactive pupils generally indicates narcotic overdose, but there are some synthetic narcotics that do NOT cause this, so don’t use normal pupils to rule out narcotic overdose.

  9. Bilaterally dilated pupils that DO react are often due to fear, dark ambient light or non-endogenous sympathomimetics.

Assess pupils for midline, conjugate gaze

  1. Check in all patients.

  2. Report as a pertinent negative in the traumatic and neurological patient.

  3. To assess this, hold up one finger and draw a capital ‘H’ about 60cm (2 feet) or so in front of the patients face.  Ask them to follow your finger.

  4. Be aware that some patients do not have conjugate pupils.  If the patient has a dysconjugate gaze, ask them if this is normal.

Assess pupils for nystagmus

  1. Check in all patients.

  2. To assess this, hold up one finger and draw a capital ‘H’ about 60cm (2 feet) or so in front of the patients face.  Ask them to follow your finger.

  3. Many drugs can cause nystagmus (barbiturates, benzodiazepines, alcohol, lithium, phenytoin) as well as thiamine deficiency (vitamin B1 deficiency - common in alcoholics, best not to give these patients dextrose until you’ve given thiamine).

  4. MS, strokes and decompression sickness can also cause nystagmus.

  5. As a general rule though, horizontal nystagmus (side to side) and orbital nystagmus (going in circles) is usually due to toxicological causes (think alcohol) and vertical nystagmus (up and down) is due to CNS pathology.  I remember this by thinking ‘look sideways to the bottle, and look up to the brain’.  Maybe I’m crazy, but it works for me.  :-)


Assess for Ottorrhea/Rhinorrhea & Ottorrhagia/Rhinorrhagia

  1. Check in all neurological and trauma patients.

  2. These mean: ear/nose fluid & ear/nose blood.  If you’re having trouble remembering the trouble between Otto meaning ‘ear’ and Rhino meaning ‘nose’, just remember that Rhinoceroses have big noses (rhino is greek for nose and keras is greek for horn). 

  3. Report if positive, or report as a pertinent negative in the traumatic patient.

  4. Whenever there is ottorhagia (ear blood), perform the ‘bulls-eye test’.  To do this, put some of the blood on a white or pale sheet.  If a pinkish centre with a clear fluid area surrounding it forms on the sheet you should assume that there is CSF in the fluid.  This is a very ominous sign.  I read an article not too long ago stating that this test might not actually be as effective as we are all taught, so take it with a grain of salt.  Certainly, don’t rule out the presence of cerebrospinal fluid based on a negative bulls-eye test.

  5. In the non-traumatic patient rhinorrhagia can be a ‘sentinel bleed’ in occult hypertension, so ‘nose bleed = check blood pressure’.


Asses for speech deficits or abnormalities

  1. Check in all speaking patients, but especially cardiac, neurological and trauma patients.

  2. If in doubt, ask the patient to repeat a simple phrase such as ‘the sky is blue today’.

  3. This is an important indicator of stroke, if it is present check for ptosis and other facial asymmetry as well as unilateral paralysis or weakness (check pronator drift).  These tests are the three elements of the Cincinnati Prehospital Stroke Exam.


Assess mucous membranes for moistness and colour

  1. Check in all patients, especially the medical and/or dehydrated patient.

  2. In the medical and/or dehydrated patient also check skin turgor.

  3. Mucous membrane colour is especially important to check in patients with dark skin, when pallor may not be noticeable in the skin, check the inner lining of the eye lids or the inside of the lips.


Assess for oral trauma (bitten lips, cheeks or tongue)

  1. Check in all neurological, cardiac and trauma patients.

  2. This is a common finding in patients who have seized (they tend to chew up the inside of their mouthes while seizing).


Assess for ptosis and other facial asymmetry

  1. Check in all neurological and trauma patients.

  2. This is an important indicator of stroke, if it is present check for speech deficits and unilateral paralysis or weakness (check pronator drift) again, this is the Cincinnati Prehospital Stroke exam.


Assess for JVD

  1. Check in all cardiac, neurological, respiratory and trauma patients.

  2. Be aware: most people who are lying down will have significant JVD (try it and see). This is important to know because if a patient is lying down and they do NOT have significant JVD then this is an abnormal finding.

  3. Ideally, JVD should be assessed when the patient is lying at a 45 degree fowlers position.


Assess for tracheal deviation

  1. Check in all cardiac, neurological, respiratory and trauma patients.

  2. Report as a pertinent negative in all respiratory/trauma combination patients.

  3. To assess this properly you must use palpation (not just visualization!).  Put a finger on either side of the suprasternal notch and feel to make sure that the trachea is evenly between both fingers.  Assessing for tracheal deviation visually (only) will result in a failing mark for this assessment if you’re doing it in front of me.


Assess for cervical vertebral body deviation & tenderness

  1. Check in all neurological and trauma patients.

  2. The cervical bodies should be midline and non-tender. 

  3. Practice assessing this on classmates and other healthy people to get the feel of it.


Assess for cervical muscle spasm & tenderness

  1. Check in all neurological and trauma patients.

  2. The cervical muscles (the bands on either side of the cervical bodies) should be soft and non-tender.

  3. Practice assessing this on classmates and other healthy people to get the feel of it.




Chest Exam


Assess for lesions (DCAP-BTLS)

  1. Check in neurological, respiratory and trauma patients.

  2. DCAP-BTLS = Deformities Contusions Abrasions Punctures/Penetrations Burns Tenderness Lacerations Swelling.

  3. Be alert for subcutaneous emphysema, this is a sign that somehow the pleura surrounding the lung have ruptured and air is escaping from the lung parenchyma into the musculature.


Assess chest wall respiratory movement

  1. Check in all patients.

  2. Check for symmetry, and paradoxical or diminished movement.  This is often an indicator of broken ribs (as in a flail segment)

Assess Anterior/Posterior ratio

  1. Check in cardiac and respiratory patients.

  2. ‘Barrel chested’ patients have a higher incidence of cardiac and respiratory problems.




Respiratory Exam

Note: perform this in all patients.  You should be very good at this!

See the ‘Secondary B page for a detailed explanation.


A   Assess for Accessory muscle use

  1. Report as a pertinent negative in the respiratory patient


B   Assess Breath sounds

  1. Report as a pertinent negative in the respiratory patient

  2. Pattern: (Eupnea, Hyperpnea, Tachypnea, Bradypnea, Cheyne-Stokes, Biots, Kussmauls, Apneustic)

  3. Adventitia: (coarse/fine crackles, ronchi, wheezes, stridor, rubs)

  4. Locations: (basilar, mid-scapulary, apices)

  5. Symmetry: (compare and contrast left and right sides)

  6. Phase: (inspiratory, expiratory or both)


C   Assess Colour and condition of skin

  1. If the patient appears pale, ask friends/family if this is normal (if possible)

  2. Assess mucous membranes for colour in the dark-skinned patient


D   Assess word Dyspnea

  1. How many words can they say per breath? 

  2. Less than ten words is worrisome, less than five is critical.

  3. This is probably the single best ‘field test’ of someone’s ability to breathe, so learn to pay close attention to it.


E   Assess for Extending position

  1. i.e. tripoding, orthopnea - both of which indicate real difficulty breathing.


F   Assess SpO2 using Finger probe

  1. CO poisoning will produce a falsely high SpO2 reading (100%), so do not use in patients with smoke inhalation (or, at least, be cautious with your findings.  If you pull a patient with obvious smoke inhalation injuries who is not responding to pain out of an enclosed, smoky environment and get a sat of 100%, don’t blithely assume that everything is fine in terms of PaO2!)


G   Assess end tidal CO2 Gas values and waveforms

  1. Check if trained, and if the patient is in respiratory distress.

  2. This is a GREAT tool and (IMHO) should be used not only on any intubated patients, but in any patient who has SOB.


H   Heart Rate

  1. Check in every patient (as a part of vitals), dyspnea usually results in tachycardia, unless they’ve really crashed - then they can be bradycardic (maybe sinus brad from hypoxia, or an agonal rhythm).


I   Assess the inspiratory/expiratory ratio (“i/e ratio”)

  1. Normally it takes twice as long to breath out as it takes to breath in (remember, exhalation is passive), so the normal i/e ratio is about 1:2.  This changes depending on the disease processes present.  In asthmatics (who have trouble breathing out) the i/e ratio becomes more like 1:3 or 1:4, with long, laboured, wheezy expirations (try it, if you’ve got field experience this will sound familiar).  In pulmonary edema it’s the opposite.  It takes work to get air into the fluid filled alveoli, so breathing in is difficult and the i/e ratio can change to 2 or 3:1.  So paying attention to the i/e ratio (which you can see from across the room) is a good clue to what is happening in your patient.





Abdominal Exam


Assess for lesions (DCAP-BTLS)

  1. Check in gastrointestinal and trauma patients.

  2. DCAP-BTLS = Deformities Contusions Abrasions Punctures/Penetrations Burns Tenderness Lacerations Swelling


Assess for shape

  1. Check in gastrointestinal and trauma patients

  2. Normally (non-obese) patients have an s-shape to their stomach, this is called a ‘normal scaphoid curve’.

  3. If the patient seems normally thin, but they have a large belly, it could be because of blood in the belly (especially in trauma patients).  If you suspect this, cut a piece of tape and place it on the belly, just above the umbilicus, with the short ends touching (it should look kind of like this: --).  If, over time the inner ends of the tape pull apart (so they look more like this: - -) then the belly is expanding and you should suspect an internal bleed.


Assess for abdominal cough tenderness

  1. Check in gastrointestinal and trauma patients

  2. DO NOT use rebound tenderness.  This is an antiquated and cruel assessment.  There isn’t anything additional to be learned using rebound tenderness, and it’s really painful.

  3. If present, cough tenderness suggests blood in the abdominal cavity.

  4. Often, just bumping the stretcher (or the bouncing of the ambulance) will be enough to elicit abdominal tenderness in the abdominally bleeding patient.


Assess for softness / guarding

  1. Check in gastrointestinal and trauma patients.

  2. Do this very gently.  Do not use ‘rebound’ tenderness (see above).

  3. If present it suggests blood in the abdominal cavity.


Assess for colour and temperature

  1. Check in gastrointestinal and trauma patients.

  2. Be wary of the cool, mottled abdomen - this is a sign of shock.


Assess for ascities/obesity

  1. Check in cardiac, respiratory, gastrointestinal and trauma patients.

  2. There’s a difference between obesity and ascities and it can be assessed by tapping the abdomen and seeing what type of wave is produced.  Have someone experienced demonstrate or explain this to you, or just play around a bit an experiment with this while you’re doing your exams.  You’ll get it.


Assess for abnormal pulsatile masses

  1. Check in cardiac and gastrointestinal patients.

  2. Be very gentle if you find one!  DO NOT push on it.

  3. Finding this is typically considered a diagnostic clue to a dissecting abdominal aortic aneurysm (AAA).


Assess for appliances

  1. Check in all patients

  2. Ask the patient why the appliance was placed (if they are able to respond)

  3. Be alert for signs of internal bleeding, or of infection.


Assess for scars

  1. Check in all patients.

  2. Ask the patient what the scar is from (if they are able to respond), often they are from previous surgeries.

Assess children for paradoxical respiratory motion

  1. Children normally have their belly go out during inspiration and in during expiration, if this is reversed it’s considered the same as accessory muscle use in the adult.

Assess for abdominojugular reflux

  1. Check in all cardiac patients (especially those with CHF).

  2. To do this, press on the abdomen (if safe and appropriate to do so) and watch if their JVD goes up (normally it won’t).  If it does, it suggests that the right ventricle is not working properly and can’t accommodate an increased venous return (think: constrictive pericarditis, right ventricular infarction, and/or restrictive cardiomyopathy).

Bowel sounds

  1. Report as present if you happen to hear them while auscultating the chest, but do not specifically assess for these in the field as a paramedic.  They aren’t that important to us because in order to properly assess for bowel sounds you must listen in each quadrant for a full minute, and that’s four minutes that we generally don’t have (unless, of course, you do,  In which case - knock yourself out).



Pelvic Exam


Assess for lesions (DCAP-BTLS)

  1. Check in trauma patients.

  2. DCAP-BTLS = Deformities Contusions Abrasions Punctures/Penetrations Burns Tenderness Lacerations Swelling.


Assess for stability in 3 planes (in up, and down)

  1. Check in trauma patients.

  2. Crepitus and/or instability suggests a pelvic fracture.


Assess for priaprism

  1. Check in neurological and trauma patients.

  2. DO NOT check in female patients or people will (rightfully) laugh at you

  3. If present it suggests spinal cord injury. Anal sphincter tone will also probably be loose, but this is not commonly assessed by paramedics.

  4. If you discover priaprism, take a look again for a sweat line on your patients torso.  Sweating is a sympathetic response, so there should be sweating on the upper part of the torso (it might be pale and mottled too - all indicating SNS innervation).  If there is a spinal cord transection, the part of the torso that is not receiving SNS innervation (the lower part) will be well coloured and won’t be sweaty.  Mark the sweat line with a pen or marker.


Assess for urinary and fecal incontinence

  1. Check in neurological and trauma patients.

  2. Urinary incontinence is not uncommon in patients who lose consciousness, fecal incontinence is less common and more ominous.




Extremity Exam


Assess for lesions (DCAP-BTLS)

  1. Check in all patients.

  2. DCAP-BTLS = Deformities Contusions Abrasions Punctures/Penetrations Burns Tenderness Lacerations Swelling.

  

Assess for PMS (pulse, motor, sensory) 

  1. Check in cardiac, neurological and trauma patients.

  2. You can just check for pulses only in isolated cardiac patients.

  3. If the USA the acronym is PMS, in Canada we used to just say “motor neurovascular” (as in ‘patient has good motor-neurovascular times 4) which I rather prefer, but take your pick.


Assess for clubbing of the fingers

  1. Check in cardiac and respiratory patients.

  2. Presence suggests chronic anemia.

  3. This is a common sign in long-term smokers.


Assess for ROM (range of motion)

  1. Check in neurological and trauma patients.

  2. Only check if there is no evidence of musculo-skeletal trauma (ie don’t move broken bones!)


Assess for ambulation if appropriate (ability, posture and gate)

  1. Check in neurological and trauma patients.

  2. Assess the ability to ambulate, resting posture, and their gate while walking

  3. Assess for tremors or ataxia.

  4. Be careful with this, don’t ask your patient to try walking when they are unsteady on their feet, only to let them take a nose-dive because you weren’t guarding to make sure they didn’t!  you and your partner should walk beside them if you’re testing this because you have doubts about their ability to walk.  Be prepared to catch them!


Assess for strength (grip strength and pronator drift)

  1. Check in neurological and trauma patients.

  2. Pronator drift is a more sensitive sign than grip strength and is preferred.

  3. This is an important indicator of stroke, if it is present check for ptosis and other facial asymmetry as well as for speech deficits.


Assess for bilaterally equal BPs in arms

  1. Check in ALL cardiac patients.

  2. Unequal pressures (more than a 10-20 mm/Hg difference) suggests the possibility of subclavian steal from a dissecting aortic aneurysm.


Assess for radio-femoral pulse transmission delay

  1. Check in cardiac patients, especially in those with suspected abdominal aortic aneurysm (AAA).

  2. This isn’t actually all that difficult to do, check in yourself, other students, or healthy patients

  3. Also visualize the thighs in the suspected AAA patient (pull down their pants) and check for colour and temperature.  Unilateral coolness and pallor suggests the dissecting AAA.  Check their big toe too for the classic ‘blue toe’ sign, indicating lack of perfusion.


Assess for orthostatic hypotension

  1. Check in cardiac, neurological and trauma patients.


Assess for tremors or ataxia

  1. Check in neurological patients.

  2. Presence suggests CNS lesion (especially to cerebellum), possibly due to CVA/TIA, traumatic head injury, CP, MS or tumor. 

  3. May also be due to drug effects, especially sedatives such as alcohol, barbiturates or benzodiazepines.  Solvent inhalation (i.e. ‘glue sniffing’ or other propellants such as those used in spray paint or hair spray) is a commonly encountered cause in EMS.


Assess for edema

  1. Check in cardiac and respiratory patients.

  2. Is there any present?

  3. Is it pitting?

  4. How high up the legs does it go?

  5. Ensure that sacrum/scrotum is examined for dependent edema too.

  6. Note: ‘Anasarca’ is often used in EMS to describe edema from foot to abdomen in the sitting patient (it actually means widespread/globalized edema) .

  7. Pitting edema suggests liver, kidney or (most commonly) right sided heart failure.  Be sure to assess breath sounds for pulmonary edema.


Assess for skin turgor

  1. Check in all patients, especially the medical/dehydrated patients.


Assess for Plantar- Babinski reflex

  1. Check in neurological and trauma patients

  2. The patients response is either plantar (toes go down) or babinski (toes go up).  Do not use silly terms like ‘positive (or negative) plantar response’.  These make no sense.

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Comments?  Suggestions? Anything to add?  E-mail me.