Physical Exam

Physical Exam

For First Aid and First Responders

ภาษาไทย မြန်မာဘာသာစကားအတွက် ဤနေရာကိုနှိပ်ပါ။

The young woman fights back the tears as we feel her chest and ribs. She breathes in gasping breaths gritting her teeth against the pain. We respectfully apologize as our fingers search for what injuries she might have. “Does this hurt?” Do we feel crepitus? Is there blood on our fingers? Have we found something that could save her life? The physical exam of a patient can reveal key lifesaving details that we would not have known without properly feeling and viewing the patient’s body.

Just as other components of the patient assessment search for what is not normal, a physical exam checks for abnormalities. We do not want to delay patient treatment and transport but we do not want to miss important details. Skilled emergency responders provide rapid yet thorough physical exams.

What to Look For

In the physical exam we primarily check the patient using our hands and fingers to feel for abnormalities. We also visually check for abnormal colors and shapes. Other senses of smell and sound can sometimes be included in a physical exam as well. While we may expose a patient to visually check for problems and injuries, do not forget to cover the patient backup after completing the exam.

What do we check for?

The acronym DCAP-BTLS often reminds medical providers about different types of abnormalities (certain organizations may teach the acronym DCAP-BTLS-IC).

Deformities, we look for unnatural shapes or bumps. If something seems to be the wrong shape we can confirm it is abnormal by comparing with the opposite side, such as feeling the left shoulder and the right shoulder.

Deformed right ankle

Contusions, a fancy word for bruise. Do we see black, blue, purple, or other colors indicating a bruise? (see below for Crepitus)

left arm with a bruise

Abrasions, does the patient have scrapes or road rash? Do not forget to clean these to prevent nasty infections.

right knee with abrasions

Punctures, what holes have been punched into the patient? What objects are sticking out of the patient? There are first aid techniques for removing splinters, fish hooks, and bee stingers. For larger objects we should splint the objects in place so that a surgeon can properly remove the object without accidently ripping open any arteries.

Trauma patient punctured with three pieces of rebar

Bleeding and Burns, as we feel with our hands we should look at our gloves to see if any blood comes off on our hands. With burns we smell for the scent of grilled flesh.

Bleeding from the head
3rd Degree Burn to a Right Foot

Tenderness, ‘does this hurt?’ gets repeated to the patient over and over as we gently press with our fingers looking for injury sites. We must get over our fear of touching the patient to help the patient.

Patient with a knee tender to touch

Lacerations, another fancy medical word that means cuts. Cuts can be simple capillary bleeds, veinous bleeds, or arterial bleeds.

laceration to the back of a right hand

Swelling, does the body part appear larger than it should be? If ‘yes’ there might be swelling compare the possible swelling with the opposite side, for example does a swollen right knee look larger than the left knee.

Swollen right arm

(some sources have added an additional I and C to the acronym)

Instability, does the limb or affected area have the strength, grip, bone support, joint strength, flexibility that it should? This also refers to the patient’s ability to stand on their own without support. For possible stroke patients we check strength in the arms and feet while the patient sits.

Patient Unstable on Their Feet

Crepitus, the grinding crunchy feeling that might come from broken bones grinding against each other.

We do not always need remember every word so long as we can spot when the patient has a problem. Properly caring for patients is more important than knowing terminology.

How to Look 👁 👁

We start with the critical areas first and work our way to the less critical more distal locations. Critical areas are the head, neck, and chest. The patient needs a brain, airway, heart, and lungs to live.

Returning to the injured young woman at the beginning of the article, while rubbing our hands all over the patient and peeling her clothes off to see all of her body seems inappropriate, there is a way to do this confidently and politely. Explain to the patient what you are going to do before you do it. Apologize for needing to check and state that we need to check for problems. As you touch ask the patient “does this hurt?”.

Be confident and respectful

  • Head – Apologize briefly explaining why we need to check their head, then feel with your fingers searching the face and scalp for injuries you can not see.
    • Do they have facial droop?
    • Are their pupils equal and reactive?
    • If the patient is conscious ask them to open their mouth and say “ah”. What airway obstructions are there?
    • Are there any fluids coming out of the patient’s ears?
  • Neck – If possible, walk/trace your fingers along the cervical spine.
    • Any bulging blood vessels?
    • Any tenderness or injury to the cervical spine?
  • Chest and Shoulders – Lifting the patient’s shirt we can quickly see what might be wrong and listen to lung sounds. We use both hands to feel how the chest moves with breathing.
    • Do both sides of the chest move the same?
    • Are the collar bones aligned the same?
  • Abdomen – We tell the patient we will feel their belly. We imagine the abdomen divided into 4 sections left and right, upper and lower. Upper between the ribs and the navel, while lower is between the navel and the base of the pelvis. We roll a flat firm hand on top of each of the 4 sections.
    • Where do we find hard belly, instead of soft belly?
    • Where are organs popping out?
  • Back – With possible spine injuries the back can be delayed until the patient is rolled for backboarding if the patient is laying on their back, otherwise the back should be checked either after the abdomen or the chest. Besides looking and feeling for tenderness and bleeding, carefully trace your fingers along their spine from the top to bottom (cervical spine to the coccyx).
  • Pelvis – 2 options for checking patient genitals; use the back of our hand to press against the inside of the thigh, or borrow the patient’s hand to feel their own genitals. To check the pelvis bones, we place our hands on both of the iliac crests (hip bones) and press in.
    • Any instability?
    • Any movement?
  • Arms and legs – Methods vary for checking, for trauma cases we can often use our left and right hands to press on both sides of the limb at the same time.
    • Start close to the body proximally then move further down distally
    • When the patient indicates a specific location for pain, start slightly outside the indicated location, slowly feeling toward the center of the location, and compare.
    • In specific cases, ask a patient to move the injured limb to see if movement causes pain.
  • Hands and Feet – besides checking for injuries we check for circulation, sensation, and strength.
    • Circulation appears either in the pulse, radial or pedal, or with capillary refill. Is blood properly flowing to the limb?
    • Sensation appears by causing sensation to the hand or foot, pinch, tickle, scratch. Often I will shield the patient view with one hand while causing the sensation with the other hand, then ask the patient to describe what I am doing, i.e. “squeezing my big toe”, “pinching my little finger”, “rubbing the back of my hand”.
    • Strength is demonstrated by having the patient squeeze your fingers with their hands, and push and pull with their feet against your hands, similar to if your hands were pedals.

In the primary assessment we attempt to correct life threatening issues first (airway, breathing, and circulation), with the physical exam we care for the injuries as we find them (sometimes a physical exam is called the secondary assessment).

In the case of the young woman we discussed before, as we touch and search for injuries in a normally private or respected area such as the chest, face, abdomen, buttocks, we respectfully ask her/tell her about touching or exposing her. We speak to her as we feel and check including her in the process;

  • “Sorry, I am going to quickly check _______”
  • “Does this hurt?”
  • “I am not finding any obvious injury.”
  • “Let’s get you covered up.”

As we find a cut, we would bandage it. As we find a broken bone, we splint it. After caring for her injuries, we make sure to cover her with a blanket or sheet, covering in such a way that we can still access the bandages, splints, and other interventions when needed. Warmth helps treat for shock, and caring comfort goes a long way when she is injured and afraid.

We want to provide the most professional care possible not missing a single injury, and we want to follow the golden rule providing care to the young woman, care that we would want for ourselves if we were in the same situation.

Full Body versus Focused Exam

We should point out the differences between medical patients and trauma patients. With medical patients we collect a patient history and then follow our findings from the patient history with our physical exam. Typically, the patient history for a medical patient will guide us to a particular area of the body to examine, a focused exam. The focused exam generally only needs to check the problem area, such as examining the abdomen of a patient with stomach pain.

With trauma patients we tend to start by looking for injuries, and then add to our understanding of the situation with a patient history after or during our physical exam. While minor trauma cases may only need a focused exam, like a child with a scraped knee on the playground, severe trauma cases should be examined from the head to the toes, a full body exam, as adrenaline or distracting pain can mask injuries. Regardless of whether we do a focused exam or a fully body exam, we should follow the golden rule with how we examine patients. Instead of ensuring our authority is asserted over a patient, we need to be their hero by providing compassionate care in their hour of need.


Thank you to the Shade Tree Foundation for making this article possible together with first aid training for community workers, to K. Mink for helping translate into Thai, to Dr. Honey for help translating the Burmese, and Dr. Kay (Dr Kyaw Soe Naing) for providing medical guidance. Emergency medical service is a team effort. Thank you to N. Jed, Zaw Rescue, K. Pui, Pitakkarn Rescue Mae Sot Branch, Dr. Kay, and K. Tang for help with photos.

For more on patient assessment click here.

References

Limmer, D. O. (2007). Emergency Care 10th Ed. Upper Saddle River, New Jersey: Pearson Education Inc.

McEvoy, D., and Harper, T. (2024). Wilderness Medicine, 15th ed. . Missoula, Montana: Aerie Backcountry Medicine.

McNamara, E. C. (2020). Outdoor Emergency Care: A Patroller’s Guide to Medical Care (6th Edition). Burlington, MA: Jones and Bartlett Learning.

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