Physical Diagnosis 2 · Exam 1 — Study Guide

1 · Clinical Reasoning, Documentation & the Encounter

1.1 · Objective a — Format and components of the comprehensive history and physical

A comprehensive history and physical is the full record of an encounter, taken in a fixed order so that nothing is lost and so that anyone reading it later finds each piece where they expect it. The components, in the order they are gathered and written:

1.2 · Objectives b & d — Small groups, simulation and the Objective Structured Clinical Examination

These three formats all exist to make you reason out loud, which is the one thing reading cannot teach.

1.3 · Objective c — The oral case presentation

A presentation is a well-organized vignette that describes the patient and the clinical problem — not the written note read aloud. The provider's goal is to help the listeners visualize the patient and understand the problem.

1.4 · Objective e — Comprehensive versus focused

The distinction that matters, and the one most often got wrong: a focused encounter narrows both the history and the examination. It is not a comprehensive encounter written up more briefly, and it is not a full history with a short examination.

A focused encounter still has to produce the whole reasoning chain: differentials, laboratory and imaging studies, a diagnosis, and a treatment plan including patient education. Narrowing the data gathered does not narrow what you are expected to conclude from it.

1.5 · Objective f — The complete history and physical versus the SOAP note

Both document an encounter. They differ in scope and in purpose.

1.6 · Objective g — Documenting the complete history and physical

The rules that get marked against you, taken from the clinical assignment guidance:

1.7 · Objective h — Involving the patient in healthcare communication

Communication is a skill that is graded, and it is expected to adapt in style and content for each patient rather than follow one fixed script.

A related expectation: accept constructive feedback and modify behavior, and expect different facilitators to give different feedback. The variation is anticipated rather than a contradiction to be resolved.

2 · Dermatological History & Examination

2.1 · Objective a — Structure and function of the skin

Five functions: protection of internal structures · prevention of entry of microorganisms · temperature regulation · excretion · production of vitamin D.

2.2 · Objective b — The descriptive vocabulary

Five features describe any lesion: distribution (location) · configuration (shape) · morphology (form and structure) · color · texture.

Distribution — unilateral, bilateral, symmetric, asymmetric, photodistribution, intertriginous, flexural, extensor, palmar-plantar, hair-bearing areas. Distribution is often the fastest route to a diagnosis:

Configuration — the shape the lesions make together:

2.3 · Objective b — Primary morphology

A primary lesion forms first and results directly from the disease. Identifying it is the key to interpretation and description — every later description depends on getting this right.

2.4 · Objective b — Secondary morphology

A secondary lesion is a change in a primary lesion over time — from disease progression, from treatment, or from manipulation such as picking or scratching. That third cause is worth holding on to: the patient's own hands change the examination.

2.5 · Objective c — The dermatological history

The five core questions: where did the problem first appear · what did it look like · how has it progressed or changed · any associated symptoms · what treatment has been tried.

2.6 · Objective d — Abnormal findings: the skin

Vascular lesions. The single maneuver that sorts them is diascopy: press a piece of clear glass or plastic against the skin and look at the lesion under pressure. If the color fades, there is vascular engorgement; if it does not fade, it is hemorrhage in the skin.

Dermatographism — “writing on skin”, an urticarial type allergic reaction. Firm stroking produces the triple response of Lewis:

Decubitus (pressure) ulcers. Staged by depth:

Tinea infections, named by site: corporis (body) · pedis (foot) · barbae (beard) · cruris (groin) · capitis (scalp) · unguium (nails).

Malignancies of the skin.

2.7 · Objective d — Abnormal findings: hair and nails

Nails. Inspect for shape, size, color, brittleness, hemorrhages, lines and grooves, clubbing, and pitting.

2.8 · Objective e — Performing the examination

The four principles are inspection, palpation, percussion and auscultation. That order holds for every body system except the abdominal examination, and some systems do not use all four.

Six characteristics are assessed by inspection, palpation, or both:

Hair and scalp. Inspect color, distribution and quantity; palpate for texture. Separate the hair into sections to observe the scalp, and inspect behind the ears and the occiput. The scalp should be clean, with no lesions, discolorations, flaking or parasites.

3 · Advanced Ocular Medical History and Examination

3.1 · The history

Assess any eye complaint on four axes: time course, precipitating factors, palliative or exacerbating variables, and vision loss or visual deficits.

Also ask: corrective lenses; acute or chronic eye problems such as glaucoma; eye medications such as antiglaucoma drops or topical antibiotics; and eye surgery history. Tetanus status matters in eye trauma, and after a chemical splash you must establish whether the fluid was acid or alkali. Beck singled out three systemic diseases: diabetes, hypertension and human immunodeficiency virus — the last because it will affect basically any etiology.

3.2 · The symptom patterns

Eye pain, qualified: with blinking → corneal abrasion or foreign body · gritty → conjunctivitis · with photophobia → iris inflammation · with headache → acute narrow angle glaucoma · on eye motion → optic neuritis · with temporal pain → temporal arteritis.

Discharge: watery or mucoid → allergic or viral; purulent → bacterial.

3.3 · Inspection

Order of the examination: inspection → external examination → cornea without light, lens, pupils → visual acuity, the vital sign of the eye → visual fields → ocular motility → pupillary reactions, checked BEFORE dilating → corneal reflection → special tests → slit lamp → ocular pressure → direct ophthalmoscopy.

Proptosis: stand behind the seated patient and look down from above, drawing the lid slightly upward to compare the corneas against the lower lids. Causes: retrobulbar hemorrhage, orbital cellulitis, orbital tumor, Graves disease.

Nasolacrimal duct obstruction test: patient looks up; press on the lower lid near the medial canthus, just inside the bony rim, to compress the sac; look for fluid regurgitating from the puncta. Mucopurulent fluid means obstruction. Avoid the test if the area is significantly inflamed or tender.

Everting the upper lid to find a foreign body: patient looks down and relaxes; raise the lid so the lashes protrude, grasp them and pull down and forward; place a stick at least 1 cm above the lid margin at the upper border of the tarsal plate and push down as you raise the lid edge. Do not press on the eyeball. Never evert if globe rupture is suspected.

3.4 · Acuity, fields and motility

OD is the right eye, OS the left, OU both — she called these “terms that you must remember”. 20/200 means that at 20 feet the patient reads print a normal eye reads at 200 feet; the larger the second number, the worse the vision. If the patient cannot read the chart, document counting fingers, hand motion, or light perception.

Pinhole test: the pinhole admits only light perpendicular to the lens, so the light need not be bent to focus — it therefore corrects any refractive error. If the deficit is not corrected, consider cataract, optic nerve disease, or retinal disease.

Confrontation fields are best done with both the static finger wiggle test (arms' length, hands two feet apart lateral to the ears, wiggling fingers brought slowly into view, testing each quadrant) and the kinetic red target test (a 5 mm red-topped pin moved inward from beyond each quadrant, asking when it first appears RED). A temporal defect in one eye should prompt testing for a nasal defect in the other. The normal blind spot sits 15 degrees temporal to the line of gaze and is enlarged in glaucoma, optic neuritis and papilledema.

Nystagmus: fine rhythmic oscillation. A few beats on lateral gaze is normal — bring the finger back into binocular vision, and if it persists there, consider a neurologic condition. Lid lag — sclera visible above the iris on downgaze — is most often hyperthyroidism. The cover-uncover test reveals slight muscle imbalance not otherwise seen.

3.5 · The pupils

A difference of half to one millimeter is common, and anisocoria is benign if the reactions are normal. Abnormal: a difference greater than 1 mm, or a poorly reactive pupil.

Swinging light test. Indication: anisocoria. Normal — direct and consensual constriction. Abnormal: paradoxical DILATION of both pupils when the light swings to the affected eye, with an intact consensual reflex. That is a relative afferent pupillary defect — a Marcus Gunn pupil — and the lesion is the OPTIC NERVE. The mechanism: the afferent stimulus on that side is reduced, so the efferent signal to both pupils falls and a net dilation results.

Once local eye disease is excluded, only three causes of a dilated pupil remain: compression or other lesion of cranial nerve III; parasympathetic denervation from a ciliary ganglion lesion (Adie's); and pharmacologic block of the pupillary sphincter.

Oblique lighting and the crescent shadow: shine from the temporal side and look for a shadow on the medial iris. No shadow is normal — the iris is flat, the angle open. A shadow means the iris is bowed forward, a narrow angle, and a raised risk of narrow-angle glaucoma. A corneal scar is a superficial grayish-white opacity; do not confuse it with a cataract, which lies deeper and is seen only through the pupil.

3.6 · Fundoscopy

Do NOT dilate if serial neurologic examinations are required, in elderly patients who have had cataract surgery, or if acute angle-closure glaucoma is suspected. If you do dilate, document the time and the agents used.

3.7 · Trauma and disposition

Mechanism matters, and so does the size of the object: larger objects transfer most of their energy to the orbital rim, while smaller ones may strike the globe directly.

Fluorescein: orange dye instilled, blue light — taken up by areas of cornea devoid of epithelium.

4 · Advanced ENT History and Examination

4.1 · The ear history

It opens with one question — “Have you had any trouble with your ears?” — and then splits four ways: pain, discharge, hearing, and the vertigo and tinnitus group.

Pain is the one that misleads, because the ear may be entirely normal. Ear pain is frequently referred, and the sources to ask about are the temporomandibular joint, the teeth and the cervical spine — carried by cranial nerves V, VII, IX and X. Four sensory nerves supplying one small structure is exactly why disease well away from the ear arrives as otalgia. He made the wider point on history technique here [5:32]: “the first answer is you don’t go with the first answer. You’ve got to keep asking” — and then the reason: “if you’ve got the wrong history, that means you’re going to do the wrong physical, wrong physical, wrong diagnosis, wrong diagnosis, wrong treatment.”

Also ask about associated symptoms — fever, sore throat, cough, upper respiratory infection — and keep otitis media, otitis externa and Eustachian tube dysfunction in mind as the local causes. The history structure is OPPQRST: onset, palliative, provoking, quality, radiation, site, timing.

Discharge is characterized by color, consistency and quantity, and the possibilities are cerumen, blood, water or purulent fluid. It points to otitis externa, otitis media with perforation, or trauma and foreign bodies.

4.2 · Hearing, tinnitus and “dizziness”

“How is your hearing?” then “Do you have difficulty understanding people when they speak?” The second question is the useful one, because it separates volume from clarity:

Why noise helps in conductive loss is worth understanding rather than memorizing: the block attenuates the background along with everything else, while everyone around the patient raises their voice over that background. The speech-to-noise ratio actually improves.

Ask about medications: aminoglycosides, aspirin, non-steroidal anti-inflammatories, quinine and furosemide. All five are common, and none of them will be volunteered.

Tinnitus is sound with no external source. Unexplained tinnitus stands alone; tinnitus with hearing loss and vertigo is Ménière disease. Vertigo is the perception of rotation, spinning or tilting, and points to inner ear problems — labyrinthitis, cranial nerve VIII, benign positional vertigo, Ménière.

4.3 · The vertigo comparison

Read this table down the duration column first, then check hearing and tinnitus. The two columns together separate all six.

Three things to take from the table. First, hearing is the great divider: of the six, only Ménière, drug toxicity and acoustic neuroma touch it. Second, positional vertigo is defined by how brief each episode is, and the episode length and the illness length are different numbers — seconds for the attack, weeks for the condition. Third, central vertigo has no ear symptoms and plenty of neurological ones, which is the pattern rather than any single feature.

4.4 · The ear examination

Inspect and palpate before the otoscope: the auricles, the mastoid, and the tragus. Tenderness localizes disease before anything enters the canal.

Otoscopy technique, and every element earns its place:

Insufflation, done properly. Check the otoscope for leaks after the speculum is attached: place a finger over the speculum tip and squeeze the bulb — you should feel the pressure build if there is no leak. Insert, confirm the seal, then apply quick, firm but gentle pressure and watch the membrane. Without a seal the test is not merely harder, it is inaccurate, and an immobile-looking drum may just be a leaking instrument.

“You have to see hundreds of normal before you see anything abnormal” [31:55]: “you’ve got to get used to seeing the normal. This is what a normal looks like … and then the abnormal will hit you in the face.” He repeated it at the eardrum slide — “know what normal looks like … normal, normal, normal.”

4.5 · What you find in the canal and on the drum

In the canal. Cerumen, and foreign bodies — the deck's list is Q-tips, beads, pencil lead, styrofoam, crayons, popcorn and tympanostomy tubes, under the heading “if it fits…”.

Acute against chronic otitis externa is pain against itch, and swelling against thickening. The distinction is easier from the history than from the picture.

Bulging is graded, not binary. The deck carries a four-panel series, and the useful thing about it is the middle two — a mildly bulging drum still has landmarks you can pick out, and the point at which they disappear is the point the effusion has become convincing.

4.6 · Hearing screening and the tuning fork tests

Whispered voice test. Stand two feet BEHIND the patient — which removes lip reading — occlude the ear not being tested, and whisper a three number or letter sequence twice. Normal is three or more of six correct; abnormal is four of six incorrect. The other bedside screens are finger rub and a watch.

Voice volume is a feedback loop, and it is the bedside sign people forget. A patient who cannot hear themselves speaks up; a patient whose cochlea is intact hears their own voice by bone conduction perfectly well and has no reason to.

The Rinne result in sensorineural loss is the counterintuitive one. Rinne compares two routes to the same cochlea. Damage the cochlea and both routes degrade together, so the ratio between them is unchanged — a “normal” Rinne in an ear that hears badly. That is not a failure of the test; it is the test working.

4.7 · The nose and sinuses

Anatomy first, because the drainage explains the disease [0:16]. Three turbinates — superior, middle and inferior — and the maxillary sinus drains at the middle turbinate. The Eustachian tube opens into the same space, which is why “everything comes together, ear, nose and throat … that’s why when you cry you get congestion.”

And the warning that goes with it [0:46]: “the roof of the mouth is the floor of your brain … anything that happened there can go up. So you have to be careful. Any infection in this area, you have to be a little more aggressive.”

History: onset and duration, sick contacts and recent travel, recent dental work — because dental work can affect the maxillary sinuses sitting directly above the upper tooth roots — and seasonal or environmental triggers pointing to allergic rhinitis. Facial pain or tenderness points to sinusitis. Ask about medications: duration, efficacy, and specifically rhinitis medicamentosa and cocaine. Ask whether the sense of smell is affected.

Epistaxis is caused by digital trauma or other trauma, inflammation, dry mucosa, foreign body, or tumor. Recurrent bleeding, or bleeding and bruising elsewhere, suggests a systemic problem — one nosebleed is local until a pattern says otherwise.

Do not pull what you have not identified. He told a story against the nose examination [6:05]: a lesion everyone had called a polyp, which imaging showed to be brain tissue coming through. “You need to know what you’re looking at before you start pulling things. If you’re not sure, you’ve got to be careful.”

Septal hematoma is the nose finding that cannot wait. Injury disrupts the vessels and pulls the lining away from the cartilage, so blood collects between the two. It requires urgent drainage to prevent necrosis of the septal cartilage — the cartilage has no blood supply of its own and depends entirely on the lining that has just been stripped off it. His rule was broader than the nose [11:36]: “any time you have a septal hematoma — anywhere, in an ear, in the nose, whatever — that blood has to come out.”

A deviated septum may be entirely asymptomatic; he demonstrated pressing on an obvious external deviation with no obstruction behind it. What matters is airflow, not appearance.

4.8 · The oral cavity

Anatomy, named in order [13:10]: medial incisor, lateral incisor, canine, premolars, molars; then the hard palate, the soft palate and uvula, the tonsils between the anterior and posterior pillars, the pharynx behind, and the buccal mucosa.

History: sore throat — and here the Centor rule enters. Also sore tongue (aphthous ulcers; nutritional deficiency if sore AND smooth), bleeding gums (gingivitis), hoarseness (viral laryngitis, overuse, laryngeal nerve damage, reflux, smoking), swollen glands or lumps in the neck, and tobacco and alcohol use.

Switching hands is not fussiness, it is the only way to reach both lateral borders properly — and the lateral border and undersurface are exactly where the cancers are.

Pharyngitis: streptococcal gives erythematous tonsils, often with exudate. Candidal pharyngitis is its own picture. Necrotising ulcerative gingivitis — Vincent's angina, trench mouth — he described from the door [23:43]: “those people open their mouth back there and you can smell them over here, that’s how bad it is … the bacteria keep growing and it’s actually destroying tissue as it goes.” From poor dental hygiene, and drug use. Aphthous ulcers and torus palatinus — a benign midline bony growth on the hard palate — round out the findings.

4.9 · The neck, the thyroid and the head

The node chains, in the order to palpate them: preauricular, postauricular, occipital, tonsillar, submandibular, submental, superficial (anterior) cervical, posterior cervical, deep cervical, supraclavicular. Use the pads of the index and middle fingers. Following a fixed route is what stops one being missed — and on the practical, each one has to be named as it is palpated.

The left supraclavicular node is the one worth knowing cold: it drains territory a long way from the neck, so finding one there redirects the entire search.

The trachea is checked for deviation — masses, atelectasis, or a large pneumothorax.

The thyroid, found from the cricoid cartilage as the landmark [26:43], and the three-way split on diffuse enlargement turns on texture alone:

The head. History is OPPQRST again, and the headache patterns matter: migraine and tension are EPISODIC; migraine and cluster are UNILATERAL — migraine is in both lists, so the two features have to be read together. Sudden and severe → subarachnoid hemorrhage. New, progressive and persistent → mass. Also consider meningitis.

On examination: facial swelling or characteristic facies; lumps, rashes, hair loss, lesions, scars; lice; fine hair → hyperthyroidism, coarse hair → hypothyroidism; seborrheic dermatitis, psoriasis, atypical naevi, actinic keratosis; symmetry, involuntary movements, edema; tenderness and integrity; and size — enlarged in hydrocephalus and Paget disease, small in microcephaly.