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Physical Exam

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The Physical Exam: Thighs Matters

One of my favorite series of posts I did on my old blog was a run-down of the physical exam.  Some might say I ran down the physical exam as one might run down a pedestrian, I suppose, but it was a fun series to write.  If you didn't get the chance to read it (or don't remember the trauma of first reading them) go here.  If you do, please make sure to do the following:

  • Have bucket handy
  • Buy a bottle of strong liquor
  • Stay away from sharp objects.

Trust me on this.

So, I have decided, I will once again inflict share this series with the readers of this blog.  Feel free to flee in terror.

My last writing on this subject was on the exam of the hip joint, which is, as I pointed out, a very confusing topic.  What most people call "hips" are not actually hips, but the outside portion of the thigh.  To clear this up, I now turn to the subject of the thigh.  The thigh, which is just south of the hip (but is not the hip), is that portion of the leg the spreads out when you sit down, causing many to go on diets and compulsively buy strange products when watching late night TV shows.

 

Underneath the spreading tissue is the largest bone in the body, known as the femur.  The femur connects the knee to the groin. Now, my use of the phrase, knee to the groin has probably brought out one of two responses in my readers:

  1. A dull moan accompanied by cold sweats from male readers who had PTSD flashbacks to middle school
  2. A desire to watch the popular TV show, America's Funniest Videos, which has built an empire on traumatic groin injuries.
It is interesting that two totally-opposite reactions would happen from the use of one phrase: "knee to the groin."  I would speculate that it was a male traumatized in middle school who chose the name "femur" was chosen instead of "humerus" or "funny bone."  Clearly the people who make the show America's Funniest Videos are the ones in middle school who were associated with kneeing, not groining.  Either that, or they have exceptionally good therapists.
Double-entendres aside, there is one thing about the femur none can deny: it's big.  Orthopedists, who definitely were the doctors doing the kneeing and not the groining during medical school, go one step further, calling the femur a big honking bone.  Paleontologists (who were more likely on the receiving end of the knee/groin transaction) also are prone to use the word "honking" (or it's language equivalent) in reference to the femurs found as dinosaur fossils.
This is a paleontologist next to the femur of a dinosaur. I think the sign he's holding says "this is a huge honking bone."
There is some controversy, however, as to the nature of one specimen discovered that dates back to the yabba-dabba-dithic period:

Some scientists believe that the bone in the hair of this child (nicknamed "Pebbles" for unknown reasons) is a femur, noting the similarity to the big honking bone the paleontologist with the sign is standing next to.  Others eschew this theory, pointing the lack of the ball-shaped portion of the bone (acetabulum) that inserts into the hip. The first scientists call the second group a bunch of smart-acetabulums, leading to some more knee/groin interactions.  Despite the acrimony of this debate, all scientists agree on one thing: that's one darling little girl.

(Note, astute reader Ngsurgery corrected me on this one, as the ball portion is actually the head of the femur, while the acetabulum is the socket the head goes into.  I won't change it, as it would make the smart-acetabulum pun drop in its funniness quotient.  I appreciate sharp readers pointing out my brain farts).

The femur isn't the only part of the thigh with size as it's claim to fame.  The sartorius muscle, in its circuitous course from outer pelvis to inner knee, is the longest muscle in the body.

The sartorius muscle gets its name from the Latin word sartor, which means "tailor," and hence it gets the nickname, "the tailor's muscle."  Just why someone chose to name this muscle after a profession not quite known for its physicality is cause for discussion.
There are four hypotheses as to the genesis of the name: One is that this name was chosen in reference to the cross-legged position in which tailors once sat. Another is that it refers to the location of the inferior portion of the muscle being the "inseam" or area of the inner thigh tailors commonly measure when fitting a pant. A third is that the muscle closely resembles a tailor's ribbon. Additionally, antique sewing machines required continuous cross body pedalling. This combination of lateral rotation and flexion of the hip and flexion of the knee gave tailors particularly enlarged sartorius muscles. (from Wikipedia)
I personally think these people have too much time on their hands.
So what's the use of the sartorius muscle?  Again, from Wikipedia:
Assists in flexing, abduction and lateral rotation of hip, and flexion of knee.  Looking at the bottom of one's foot, as if checking to see if one had stepped in gum, demonstrates all four actions of sartorius.
Stepping on gum, a fact of modern life, is not something others have experienced through history. I've uncovered a new possibility for the word origin of sartorius, coming from an Indo-European expression shouted out when people stepped in dog feces.  This sculpture, found in the Metropolitan Museum of Art, depicts such a misadventure.So what about the exam of the thigh?  How did this post devolve to a discussion of people stepping in dog poop?  What about the quadriceps muscles?  What about the hamstrings?  What about Suzanne Summers?I gave you the chance to flee in terror.  Now look what you've stepped in: a bunch of yabba-dabba-doo.

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Physical Exam: The Rest of the Belly

arrheniusOn my previous post on the abdomen, I covered the very important subjects of innies vs. outies and navel lint.  This discussion sparked much debate in the scientific community.  Well, actually it was read by one person who once took a science class, but that certainly could lead to debate in the scientific community.  I try to do my part to advance the cause of science. Now we move on to the rest of the abdominal exam.

As you recall, the physical exam of the abdomen is notated as follows:

Abd: Soft, NT, Normal BS, no HSM or masses.

So lets go through this in order it is written:

1.    Soft

yoeman-guardSoft is good.  At least it is good when you examine the abdomen, although not too soft.  When doctors push down on the belly of the patient, the first thing they note is the consistency.  If bad stuff is going on in the abdominal cavity, the person involuntarily tenses his/her abdominal muscles.  This is known as guarding.

Sometimes guarding is involuntary - the pain is bad enough that people can’t help tensing up.  In its extreme - a rigid abdomen - it is tense even when the doctor isn’t pushing down on it.  Then there is voluntary guarding, where the patient tenses up on purpose.  Why someone would do this is mysterious to me.

Here are some possibilities:

  1. The doctor’s hands have just come out of a bucket of ice (which I do on a regular basis).
  2. The patient is trying to get the doctor to order a barium enema.
  3. The patient wants to get the deductible met faster by having the doctor order a whole lot of tests.
  4. The patient thinks “voluntary guarding” is a way of serving their country.

To uncover voluntary guarding, the doctor can put the stethoscope on the abdomen and push down.  This tricks the patient, and they don’t tense up their abdomen - unless the doctor keeps the stethoscope in a bucket of ice like I do.

2.    Nontender

The word tender can mean a lot of things:

  1. To be kind and sympathetic
  2. To be soft and easy to chew
  3. To be inclined to roll when blown by the wind
  4. To offer money as a payment
  5. A railcar coupled to a steam locomotive to carry fuel and water
  6. To be sensitive to pain.

stthomastrain1034

Doctors use the last definition (although I sometimes use #3 when examining a boat).  In short, if the patient says “Ow, that hurts” when I push on their abdomen, it is tender.  Sometimes they just do involuntary guarding instead of saying “Ow, that hurts,” which makes it harder.  And that, my friends, is what separates the good doctors from the ones with forged diplomas.

If a patient has a tender abdomen, it can mean they need surgery (appendix, gallbladder), need antibiotics (diverticulitis), or just need to poop.  One of my attendings in residency referred to the last one as PID: “Poo in dere.”  He told that joke all the time.

When pushing on the abdomen, I often tell a joke of my own.  I tell patients that a trick doctors use is to push real hard on the abdomen so that it hurts.  Then we can charge more.  Pretty clever.

A sign of significant abdominal problems (possibly requiring surgery) is a condition called rebound.  Rebound is pain that occurs when the examiner pushes in slowly and then lets go.  If the patient has pain when the examiner stops pushing, they have rebound tenderness, which usually means there is serious inflammation in the abdominal cavity which could be life-threatening.  If the patient asks the examiner for a date, they are probably just on the rebound.

3.    Bowel Sounds

hmong-fraternity-hafBowel sounds are not what you think.  They are not a noise commonly emanating from a fraternity.  Bowel sounds are the gurgling sound a doctor wants to hear when the stethoscope is placed on the abdomen (following the shock from the frigid temperature).  It is the sound that similar to the “stomach rumbling” - the trickling of fluid through the intestine.  This carries the fun word borborygmi (not to be confused with blogborygmi).

Bowel sounds are evidence of a normally functioning intestinal tract.  Sometimes they can become hyperactive - which is when they make a whole bunch of noise (commonly happens at job interviews or blind dates).  It generally signifies irritation of the intestines.  The intestines are irritated when teased by the spleen.  They are also irritated when you get a case of “the trots.”

Diminished or absent bowel sounds are a bigger problem.  This happens when the intestines functionally shut down, which can occur with serious conditions like appendicitis and perforated ulcer.

4.  Oranomegaly

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Oregonomegaly is when the state of Oregon invades and annexes Idaho.  Organomegaly is when an abdominal organ is enlarged.  The two main organs to enlarge are the liver and the spleen.  The liver is felt in the right upper part of the abdomen (under the bottom of the ribcage).  It is enlarged most commonly from fluid backed up from a poorly-pumping heart.  It can also be enlarged from problems from the liver itself.  The spleen is on the left side under the ribcage.  The significance of the spleen is twofold:

  1. Trauma can result in a “ruptured spleen,” which is life-threatening.
  2. Whenever doctors mention the spleen, patients invariably ask: “what does the spleen do?” in response to which the doctor changes the subject.

The spleen is most commonly enlarged with mononucleosis.

Idaho is massing a militia at the border.

5.   Masses

mass01-largeWhen I push on the abdomen, patients often ask me what I am feeling for.  “Nothing” is usually my response.  I don’t want to feel anything.  The “something” I am feeling for (and hoping not to feel) is an abdominal mass.  The presence of a mass can signify a tumor (colon or kidney cancer), infection (from prolonged diverticulitis), or an enlargement of the aorta (called an abdominal aortic aneurism - AAA).  AAA’s are pulsatile masses that are in the middle of the abdomen.  They used to be fixed only with major surgery, but now they can be done in a much less dangerous way (stenting).

I will finish your tour of the abdomen with a story.  I was doing a routine exam of a gentleman in his 30’s.  As I pushed on his belly, I felt a large smooth mass on his left size.  It was really large - about the size of a cantaloupe.  “How long have you had this mass?” I asked him.

“What mass?” he responded.

One week later, the surgeon called me with the news.  He removed a 7-pound lipoma (benign fatty tumor) from the gentleman’s abdomen.  The patient named it Susan.

Have a cigar.

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