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Physical Exam: Armed and Dangerous (part 1)

Yes, it's time for another installment of my series on the physical exam.  The goals of this series are:

  1. To educate my readers on the intricacies of the physical exam.
  2. To teach the anatomy and physiology as it relates to different parts of the human body.
  3. To delight my readers with my wit and fine prose.
  4. World peace.

untitled-1112So you see, through my hard work and persistence (writing almost 30,000 words about the physical exam so far), I have come nowhere near any of these goals.  In fact, I have made absolutely no progress toward world peace.  I think I've been banned in Iran for using the word "Shuttlecraft" too many times.

Maybe I just need some new goals.  How about these:

  1. To irritate my high school English teachers.
  2. To cause at least 200 people to waste time that they could have spent watching Oprah.
  3. To make sure Canada stays north of us and does not sneak to Florida.
  4. To put those pesky French people in their place.

stereotype

Yes, I think those are much better goals.

Extremely Upper

Our journey over the human body has now led us to the long things that stick out of the top of your torso that have those grabby things on the ends.  We doctors call these things arms. There are some hoity-toity doctors who call them the upper extremities. These are the doctors you don't want to invite to dinner, as they will probably tell you disgusting scientific facts about the food you are eating.  Consider yourself warned.

The exam of the arms is usually only referred to vaguely during routine exams.  Most docs don't deal with the arms unless they pick up subtle clues that are discovered only by trained professionals, like when the patient says "I'm having problem with my arms".  We doctors are proud of our mad skills.

happy_cow_large

What I am driving at is that the arm exam is a problem-oriented exam.  If you have a boo-boo, the doctor looks at it and sees if a kiss will make it better.  If a kiss doesn't work, usually an anti-inflammatory will (but we'll get to that later).  And boo-boos problems with the arm are usually specific to the longitude and latitude on the body.  So today we will discuss the shoulder.

The Shoulder

deodorant-testersThe shoulder is a joint - meaning, it is a place where your body bends.  Without joints, your arms would be unwieldy and you'd whack everyone who came near to you.  Not only that; it would also make it impossible to put on deodorant.  So between whacking people and offending them with your odor, a jointless existence would truly be a hard one.  We all should thank our joints more often.

There is not a more complex joint in your body than your shoulder.  Here are some amazing facts about the shoulder:

  • There are three bones that are involved in different types of movement: the collarbone (clavicle), shoulder blade (scapula), and humerus (not humorous).
  • There are at least 18 muscles that are involved in shoulder movement.  Two of them have the word "rhomboid" in them.  I like the word "rhomboid."
  • When people say the word "shoulder," they may be referring to the joint, and they could be referring to the top part of their torso - between their neck and shoulder joints.  This is a sad testimony to the English language and just serves to make the jobs of medical professional all the harder.
  • The word "shoulder" rhymes with a lot of of words and so is very useful in poetry.  For instance:

You shouldn't have told her that she's looking older She wants you to hold her with arm on her shoulder And go get the folder that llamas once sold her But there on the boulder the weather is colder. A fine Jell-O mould or perhaps something bolder Has rocked her and rolled her but never controlled her So anger may smolder at cellular slime mold or Other thingies, sort of.

See?  Pretty amazing, isn't it?  Try doing that with "elbow!"  Perhaps Dino could write a haiku about it.

So it should not be seen as a coincidence that the shoulder has by far the largest range of motion of any of the joints in the body.  This makes things very confusing for medical students when they have to describe the motion, as the joint doesn't follow any of the rules the other joints have agreed upon.  Most joints can be bent (flexed) and straightened (extended).  Some joints (like the wrist) can be hyperextended and rotated as well.  All the other joints are content with these motions.  Is this good enough for the shoulder?  Not even close.

Here are the basic movements of the shoulder:

1.  Flexion - moving the arm forward toward the chest.

2.  Extension - moving the arm toward your back.

3.  Abduction - Being picked up by aliens and brought to their mother ship.  (This also refers to lifting your arms up from your sides).

lens2392503_1232733258alien_abduction

4.  Adduction - Bringing your arms down back to your sides

5.  Rotation - Turning the arm around the axis of the humerus bone.

I have suggested a few more motions that may be added to the roster:

6.  Subflaxion - What you have to do to your shoulder to get your elbow in your ear.

7.  Soufflétion - When your shoulder is mixed with eggs and baked at 400 degrees.

8.  Mallardduction - When your shoulder gets down.

So far the shoulder committee hasn't answered my mail.  I'm not sure why.

But really, the shoulder is very confusing to many medical professionals.  The range of motion is so great that it blurs the lines between the typical movements.  For instance, adduction is supposed to be when the limb is moved toward the body's midline.  The shoulder makes this difficult.  When you put your arm by your side and when you raise it over your head, you move it toward midline.  Both could be considered adduction.  The same is true with flexion and extension - when is the shoulder joint opened up and when is it closed?

Really, in this modern time we should give up this archaic nomenclature and instead use a GPS device to determine shoulder position.

Wow.  1000 words already and I haven't gotten to the actual exam.  I'll give it a rest now and let you ruminate on words that rhyme with "elbow."

I probably should sober up as well.

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Physical Exam: Call to arms/legs

To those of you who were hoping my most recent post in the physical exam series was the end of the series, sorry, there's plenty more ground to cover. To those who were looking forward to my posts on the uh...naughty bits (I know Frank is among them), I must also disappoint.  There was no way I could write on those subjects without making it NSFW.  I also suspect that my Google hits would skyrocket, but not with the kind you'd want your mom to meet.

So, to save my mom, I will shift the focus on the exam of the extremities.

Physicians have many ways of writing out the exam of the extremities, depending on their specialty.  As a PCP, I have seen the extremity exam written in several ways:

  • Ext - MAEW - translation: Extremity exam: Moves all Extremities Well
  • Ext - No edema - translation: No swelling in the legs
  • Ext - No c/c/e - translation: Extremity exam: No clubbing, Cyanosis, or Edema.

Others, depending on the moon-phase, emotional state, and time-schedule of the examining physician.

The first was the exam as written by pediatricians where I trained.  It mainly was used for newborns, indicating that nothing got messed up in the process of being born.  This is an important thing to note.

The second is the more common way I've seen (and written) the exam of the extremities.  It is short, to the point, and uses slashes (which doctors seem to like writing).  Of course, this begs the question, "what the heck is clubbing, cyanosis, and edema?"

Thanks for asking, although you didn't need to beg.

Clubbing - What it's not

Greenpeace activists can relax, as this has nothing to do with baby seals.  We don't examine baby seals very often, and I doubt their extremities get clubbed.  At least I hope they don't.

Clubbing also doesn't refer to something one might find on an episode of the Flintstones.  The animators for that show had trouble with the torso, much less the hands and feet.  The clubs you did see on that show are not the kind we see our patients carry.  If they did carry that kind of club, we wouldn't simply notate it as "clubbing present," but instead something like: "Patient showed significant aggression towards the examiner, expressing his displeasure over the rectal exam."  This has never happend to me.

Clubbing does not refer to the practice of going out to several bars in an evening.  I am sure some of my patients do go clubbing in this way.  The only reason I would mention this kind of clubbing it would be if they were holding an alcoholic beverage in the exam room.  In this case, it probably wouldn't represent the carousing habits of the patient, it would more likely be a way to talk me out of doing a rectal exam.

Finally, clubbing doesn't refer to the style of golf I employ between shouts of frustration.

Clubbing - What it is

Credit

Clubbing has the following features:

  1. Softening of the nail bed - The red part on the above picture is soft to touch
  2. Loss of the normal <165° angle between the nailbed and the cuticle
  3. Increased convexity of the nail fold - The nail bends downward at the tip
  4. Thickening of the whole distal (end part of the) finger (resembling a drumstick)
  5. Shiny aspect and striation (grooves/lines) of the nail and skin

Clubbing often happens for no known reason.  Perhaps the fingers didn't have anything better to do and thought clubbing could be fun, we just don't know.  I have repeatedly asked clubbed fingers for an explanation, but they have been anything but forthcoming.

The reason we look for clubbing is the association of this physical finding with certain diseases, including:

  • Lung cancer
  • Chronic lung disease
  • Heart disease (especially congenital heart disease)
  • Liver disease (including cirrhosis and hepatitis)

The thing about clubbing is that it really isn't that common.  Yes, some studies say that up to 1% of internal medicine patients can have clubbing, but my experience is that it is far less common than that.  I think the real reason doctors document this so often is more tradition than the importance of noting this on everyone who comes in with a runny nose.  It also gives an extra chance to use a slash.

Cyanosis - Feeling Blue

Cyanosis is a description of the phenomenon when a person's skin turns blue.  This can happen for several reasons:

  • Saying something over and over (until they got blue in the face)
  • A smurf ancestry is finally showing itself.
  • Careless use of highlighter pens.
  • The oxygen level in a person's blood is low.

The reason saying something repeatedly causes facial blueness is one of controversy.  Some have speculated that if the person did not take a breath between saying it, the oxygen level would drop and the percent of carboxyhemoglobin would rise.  Others have suggested shunting of blood away from the head (brain) would be the only good explanation of why someone would repeatedly say something.  Proponents of this theory point out that this would cause selective blueness in the head, while other causes blueness in the extremities as well, and nobody says "blue in the hands and face".  Still others point point to the fact that saying something over and over is frequently associated with people attacking with highlighter pens.

The controversy rages.  We'll let the scientists fight this one out.

Since this is a post on the extremities, we don't really care about it.  What we care about is acrocyanosis. Acrocyanosis is when a person's hands and/or feet turn blue when the rest of the body do not.  When a person's blood oxygen level is low, the hands and feet are the first place to show it.  Acrocyanosis also happens when a person's core body temperature drops, causing their blood vessels to shunt blood away from their arms and legs.  As a kid I had a skinny friend who would always get acrocyanotic when he went swimming.  We didn't know what was the explanation, so we called him "smurf boy."

Truthfully, acrocyanosis is uncommon enough that it probably doesn't merit inclusion in routine exams.  Doctors' love of slashes explains this again.  An exception of this is the newborn baby, where cyanotic heart disease is always a concern.  Certain congenital heart abnormalities result in the inability for the child to properly oxygenate their blood.  This may show up at birth, but can also be delayed in its presentation.  This is one of the main reasons pediatricians are reluctant to send babies home before 48 hours of age.

smurf

Medical professionals should be on the look-out for smurf heritage, as this can lead to misdiagnosis.  One of the major clues to this is the substitution of the word "smurf" for other words in common speech.  Wikipedia gives a cogent explanation of this:

A characteristic of the Smurf language is the frequent use of the word "smurf" and its derivatives in a variety of meanings. The Smurfs replace enough nouns and verbs in everyday speech with "smurf" as to make their conversations barely understandable: "We're going smurfing on the River Smurf today."

When used as a verb, the word "Smurf" typically means "to make", "to be", "to laugh", or "to do". The word appears to serve the same function as the Spanish verb "hacer" or the French verb "faire". It was implied a number of times that Smurfs still understand each other due to subtle variations in intonation.

Humans trying to communicate in Smurf language find that simply using the term "smurf" is not enough. In one adventure, Peewit explains to a group of bold fighters that the statement "I'm smurfing to the smurf" means "I'm going to the wood", but a Smurf corrects him by saying that the proper statement would be "I'm smurfing to the smurf", whereas what Peewit said was "I'm warbling to the dawn". In other words, "I'm smurfing to the smurf" and "I'm smurfing to the smurf" are not the same.

He goes on to explain that: "If you smurf: I'm smurfing to the smurf then what you're smurfing is: I'm smurfing to the smurf, and they'll smurf that you want to smurf to the smurf whereas you're smurfing to the smurf!" The bold fighers hasten away in total confusion.[7]

It's subtle, but nobody said medicine was easy.

Edema

Edema is another word for swelling.  Doctors say things like edema, acrocyanosis, and sphigmomanometer for several reasons:

  • To impress potential mates
  • To intimidate enemies
  • To make their moms proud

There are problems with this, however, because the response of the recipients of these words can have unpredictable responses.  Enemies can become impressed and proud, and mates and moms can be intimidated.  The good news is that most people have none of these reactions, but instead simply say: "huh?"

brad_pitt_troyThe swelling to which the word edema is attached is usually in the legs.  This happens when fluid seeps from the blood vessels into the the tissue outside of them.  The exam is done by pushing a finger into the front of the lower leg and holding it for several seconds.  Edema is present when the pressure from the pressure leaves a dent.  This is called pitting.  The degree of pitting is equivalent to the severity of the edema.

  • Trace pitting describes a small amount
  • 1+ edema a little more
  • 2+ more than that
  • 3+ a whole lot less.  Just kidding.  It's a bunch.

This is a very subjective assessment, and the difference between 1+ and 3+  doesn't mean much - especially between different providers.

What edema means

Between c, c, and e, the e is the most common and hence the most clinically significant.  Really, docs should just write:

Ext - No e

or, for those who love slashes:

Ext - /////no/////////e///

Nobody does this, however.

Edema has a wide range of causes, from benign to life threatening.  The benign causes are the most common, and they include:

  • Eating too much salt (also caled "pringle's syndrome").
  • Allergies - usually mild edema, and one of the few common causes of swelling in the hands.
  • Hormones - female hormones are related to other hormones called mineralcorticoids which can cause fluid retention.
  • Veins in the legs become less good at pumping blood back to the heart, causing what is known as dependent edema. This happens as people age, being worse in some people than others.  This can be severe enough to compromise blood flow to the soft tissue, resulting in a skin lesion called a stasis ulcer.

Edema can be a sign of more serious disease as well, including:

  • Deep Venous Thrombosis (blood clot in the leg) - This generally presents with one leg swelling more than the other, although I have seen cases where it was in both legs at once.  A more abrupt onset or the onset after prolonged sitting (as in travel) are things that should raise suspicion of this.
  • Heart failure - Blood is not able to be pumped back to the heart well because of a weakened heart.
  • Lung disease - Any lung problem that causes the carbon dioxide level to stay up for longer periods of time can do this.  In my experience sleep apnea is a common cause of this and should be suspected as the cause if the patient has facial bruising (caused by being hit by a spouse).
  • Kidney disease.
  • Low protein levels in the blood due to liver disease, kidney problems, or malnutrition.  This causes swelling in the hands and even the face.

Treatment of edema depends on the cause.  In general, the best thing to do is to raise the legs and eat less salt.  Diuretics (water pills) are probably over-prescribed, as they can cause significant problems with a person's electolytes (sodium, chloride, potassium).  For those with dependent edema, wearing compression stockings may be the best (and most fashionable) option.

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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

pm25-24a-nw

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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Physical Exam: Hey Baby (Part 1)

Today was an excellent day; excellent because I got to examine a bunch of babies.  If you are a baby-lover like me, one of the best ways to lift your mood  is to walk into a room and have a 6-month old give you a toothless grin.

angry_baby_head I know, all of you adult doctors out there think of pediatrics as just screaming kids and smelly diapers.  The fact is, my adult patients have an average smell worse than my pediatric ones (if you can average FW9685 smells...I think my son's fancy calculator can do that).  There is a deeper reason for these physicians' aversion to the micro-human: fear.  It is not widely known, but the majority of doctors are actually terrified of babies.  No, they don't fear baby commando squads or babies with poison darts; they are afraid to take care of babies.  They just aren't like those bigger humans: you know, those things that babies turn in to.

So before exploring the abdomen and more southern reaches, I want to do a quick overview of the examination of an infant.  While adult exams are usually done focusing on a problem or complaint, the exam of an infant is looking for normality.  I want to find nothing but a normal baby when I do an infant exam.  Yet my exam is also focused on what I don't want to find.

I will focus on the exam of the newborn, taking some diversions to more mature babies if the exam warrants.  The newborn exam is important because it is the child's first exam ever.  Nobody has examined the child before, so if there are problems you will be the one to diagnose them.  I always keep this in mind when I do my first exam on an infant.

So here is my exam of the bun when it is fresh out of the oven...

buns2

General:  First you have to assess the overall status of the child.  Is it breathing well?  Is it pink or blue (not boy or girl, oxygenated or sick)?  How does it react when you examine it (normal babies cry)?  Does it have tentacles, antlers, or skin made out of composite fiber able to deflect bullets?  All of these are important things to decide before examining the child; both for the child's sake (so you can treat problems) and yours (so you don't get stuck with antlers).

coneheads Head:  Heads of newborns are not normal.  The bones are not fused, so they can get bent out of shape easily through the process of being born.  This results in a condition called molding, where the infant's head gets squashed as it passes through mom's pelvis and so comes out elongated (looking somewhat like Jane Curtin).  It is worse in firstborn children, as mom's pelvis has not been stretched.  Pediatric nurses hide molding by putting a hat on the child (the hat also warms the head).  This keeps parents from thinking they have brought a mutant into the world.  Molding resolves in the first few days.

The heads can also have large squishy areas at the back of the top of the head.  This is from trying to fit a big head through a little exit.  It is called a cephalohematoma.  While these feel funny, they don't cause any problems (except maybe for extra jaundice if the squishy area is big enough).

Finally, the head is examined for a normal fontanel.  This is the "soft" spot (there are actually two) where more than two bones in the head come together.  When examining the fontanels and the sutures where two skull bones come together, the bones should move freely of each other.  If they are prematurely fused, it results in a condition called crainosynostosis.  This makes the head grow into a funny shape and needs to be fixed surgically (although it is usually not picked up until 4-6 months of age).

Eyes:  People often ask of their newborn: "Can they see?  What is their vision like?"  Unfortunately, in the fourteen years I have practiced, not one infant has answered this question for me.  It must be classified information.

The main goal of the eye exam is to rule out a cancer that happens in infants called retinoblastoma.  This happens in the first six months of life, and not only can cause the eye to go blind, but it actually can spread all over the body - so it is important to find it quickly.  Retinoblastoma is ruled out by looking for the red reflex, which is the redness to the eyes that is photoshopped out of digital photos.

The other thing that can happen with the eye is a blocked tear duct.  This causes the eye to be really goopy.  It is no big deal, but parents don't like the goop.

baby_reindeer Ears:  On a newborn exam, the ear exam isn't very important.  You just make sure the ears are present and accounted for.  You also try and avoid any antlers.

Nose:  The main problem that can happen with the nose is for it to get blocked up.  Since babies are obligate nose breathers, blocked nasal passages can cause significant distress (and can make the baby snort loudly).  A membrane sometimes covers the nose as it enters the mouth cavity; this is called choanal atresia.  This has to be fixed right away.

Mouth:  The main problem in the mouth of the newborn is a problem with the palate.  Cleft palate happens when the two sides of the palate (top of the mouth) don't join together properly.  Sometimes this causes a significant deformity, but sometimes it is only the soft palate that is cleft.  (which can interfere with feeding).

Neck:  Babies don't have much in the way of necks, although they do have more than an offensive lineman has.

Image00069485

This picture illustrates the neck-less nature of the offensive lineman, which is similar to that of some babies.  Babies, however, don't usually wear a tux or hold a helmet.

Chest:  The chest exam of a newborn is also generally boring.  More important is the assessment of the child's breathing.  You generally know there is a problem before you listen to the chest.

This is a good stopping point for this post.  Stay tuned for more infantile hijinx.

Hmm....I suppose "infantile hijinx" sums up this blog, doesn't it?

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Physical Exam: To the Cor (Part 2)

Yes, this is part 2.  If you read this before reading part 1 you will totally spoil it for yourself.  Please read it in the proper order.  I really don't want to be responsible for traumatizing you. The exam is written as follows:

Cor - RRR s M/G/R

Meaning

The heart is going at a normal speed without irregular beats.  There are no abnormal noises with the heart beat.

Since all of you (ahem) have read the previous post, I will dive right back into the aspects of a heart exam.

Whooshes

"Murmur" is probably one of the best words in the English language.  It is fun to say and it sounds very much like a murmur - except a heart murmur.  Heart murmurs don't sound like people murmuring at all, unless it is a bunch of people with laryngitis.  "Whoosh" more accurately describes what it sounds like and is fun to say, but it is not nearly as dignified as "Murmur."

A murmur is caused by turbulent blood flow.  Normal blood flow makes very little sound, much like a calm river does not make sound.  When a river goes over rapids (turbulence), it gets noisier.  The faster the blood flow, the louder the "whoosh."

rapids

The main thing that causes turbulence is the narrowing of the path for the blood.  Here's the story of how this came to be known in the medical community:

There were two guys named Hagen and Poiseuille* who were really smart mathematicians.  One day, as they were hanging out doing the "cool" things mathematicians do, they happened on the following formula:

They showed it to a bunch of doctors, whose reaction was: "Huh?"

The mathematical community delights in having three equal signs and multiple Greek numbers, but this is just not acceptable to the medical community (which strongly adheres to a "one equal sign per equation" policy).  So the scientists simplified it, making the Hagen-Poiseuille Equation:

Unfortunately, the doctors still responded: "Huh?"

But then the scientists explained that the "DP" represents the change in pressure in a tube, like a blood vessel or airway in a patient.  They also said that the doctors could ignore the stuff on the top on the fraction (which they were doing anyway).  The important part is the bottom of the fraction:

"pr4"

which represents the number pi times the radius to the fourth power.

To which the doctors responded: "Huh?"

math15

This really annoyed the scientists, but they explained how it relates to blood vessels and airways.  The pressure in these tubes increases by the 4th power as the radius of that tube gets smaller.  This makes the blood or air in those tubes move much faster, and hence more turbulent.

To which the doctors responded: "Ohhh....Now we get it!"

Hagen and Poiseuille headed immediately to the nearest bar and ordered stiff drinks.

________________________________________

*These scientists are no relation to Haagen and Dazs, who single-handedly doubled the income of cardiologists

So what is the significance of this story?  When blood is forced through a smaller space, it speeds up and makes noise.  If it is in a blood vessel, it is called a bruit (pronounced "broo-ee", and to be covered in another post); if it is in the heart, it is called a murmur.

When, Where, What

When listening for murmurs, the examiner must address three things:

When The two main heart sounds (S1 and S2, remember?) mark the boundaries of the two phases of a heart beat.  Between S1 and S2, the heart is squeezing blood out of the main chambers in the phase called systole.  Between S2 and the next S1, the main chambers are relaxing and filling with blood in the phase called diasystole.  So murmurs are classified as being either 20953_smsystolic or diastolic.  Systolic murmurs happen because of turbulent flow coming out of the heart, while diastolic murmurs happen as blood enters the main chamber of the heart.

Think of the heart as a Whoopie Cushion.  A diastolic murmur happens when you blow up the cushion.  The noise is there, but not very loud.  A systolic murmur happens when someone sits on that cushion, making a much louder sound.  Systolic murmurs, however, don't cause as much madcap hilarity as a Whoopie Cushion (except among cardiologists). 

Where The location of murmurs tells much about their cause.  In adults, the vast majority of murmurs happen because of abnormal flow across a heart valve.

There are four valves in the heart, three of which cause significant murmurs.  The poor tricuspid valve gets the shaft here, as the pressure is just too low on both sides to cause much noise.  Does it bring attention to itself?  No, the tricuspid just does its job in silence.  Before moving on to the noisy boys, let us tip our hats and hairpieces to the tricuspid valve.

Systolic Murmurs

Aortic Stenosis - When the left side of the heart squeezes, blood flows through the aortic valve and goes to the body.  If there is narrowing of this valve, it makes this systolic murmur heard near the right collarbone.

Pulmonic Stenosis - In the same way, the right heart pushing blood through a narrow pulmonic valve causes this  systolic murmur near the left collarbone. 

Mitral Regurgitation - No, the Mitral (bicuspid) valve isn't nauseated, it is having fluid going in the wrong direction.  When the Mitral valve is leaky, the squeezing of the left heart causes blood to flow the wrong direction across that valve.  It makes a systolic murmur heard around the left nipple.

Diastolic Murmurs

Aortic Regurgitation - This is caused by a leaky Aortic valve. This allows backward flow over that valve when the left heart relaxes.  This causes a diastolic murmur over the left mid-breastbone.

Mitral Stenosis - Blood entering the main chamber of the heart through a narrow Mitral valve makes a low diastolic rumble.

There are other murmurs caused by holes in the heart that happen in pediatric patients, but I am not going into that on this post.

What

The last clue as to what is causing a murmur is to what it sounds like. 

  • Is it high-pitched, or low pitched? 
  • Is it steady, or does it get loud then soft? 
  • Does it last the whole systole or diastole, or does it just last for part of it? 
  • How loud is it? 

All of these give good ideas of the type and seriousness of the murmur.

So What?

The goal of the heart is to take blood from the body and pump it to the lungs, then pump blood from the lungs and send it back to the body.  Each of these murmurs decreases the efficacy of these tasks.  If valves get narrow or leaky enough, they need to be replaced.

What's the Rub?

rub_mah_tummy (1) The last sound listened for is a rub.  Rubs are caused by irritation of the pericardium (the sack that surrounds the heart).  When the heart beats, it normally moves smoothly in the pericardium.  If that sack is irritated, the inside is rough and causes a crunching sound when the heart beats.

Truthfully, heart rubs are among the sounds used to embarrass medical students.  They are very hard to hear.  I hear maybe one every couple of years.  The biggest problem is that the movement of the stethoscope on the skin of the patient also sounds like crunching.

The Heart of the Exam

The heart exam is both literally and figuratively a central part of the exam.  So far we have gotten halfway through the physical exam.  Stick with me on this trip (taking lots of Dramamine).  You have to wonder how I am going to handle some of the more "seedy" parts of the exam.

Heck, I wonder how I am going to handle them.

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Physical Exam: To the Cor (Part 1)

Ka-thump ka-thump ka-thump.

Listening to the heart.  I do it every day on countless patients.  While this isn't the most important thing I do (usually), there is still something special about hearing a person's heart beating.  It is the measure of life.

In a patient record, this mystical experience is reduced to:

Cor - RRR s M/G/R

Which means:

Heart exam - Regular rate and rhythm without murmurs, gallops, or rubs

Which is translated:

The heartbeat is of normal speed and consistent rhythm, without any extra sounds indicating abnormalities of the heart.

Of course, this part of the exam requires a tool: The Stethoscope

Listening Device

doctor_with_stethoscope For medical students, one of the milestones made is when they get their first stethoscope.  Doctors share other devices for medical exam, but they generally own their own stethoscope.  I have a picture of Scooby Doo on mine.

I doubt the guy on the left has Scooby Doo on his.

It takes a bit of time to get used to stethoscopes.  They hurt your ears when you first start using them.  I usually use soft ear pieces that make the scope more comfortable to wear.  Some clinicians use hard ear pieces.  I suspect that they are punishing themselves for something; either that or their ears have developed calluses.

There are two sides of the other end of the stethoscope (the end you put on people's chests): the bell and the diaphragm.  The diaphragm is used the most, and is used for higher-pitched sounds.  The diaphragm is also the part that is chilled - to enhance the patient experience.   The bell is used for listening for lower-pitched sounds.

Most stethoscopes are just a series of tubes - very low tech.  Some newer scopes have electronics in them to enhance the sound quality.  My partner had one of these for a while.  It worked too good.  It made normal heart and blood vessels sound abnormal.  He sent it back.

Lub Dub

The heart beats with two cycles: Systole (sis-toe-lee) and Diastole (die-ass-toe-lee).  Sorry if I embarrassed anyone with that last one.  In systole, the heart's main chambers are squeezing, causing the mitral and tricuspid valves to shut, making the first heart sound, or S1.  Diastole is when the heart relaxes and the main chamber refills with blood, causing the aortic and pulmonic valves to snap shut, making the second heart sound, or S2.

350px-Diagram_of_the_human_heart_(cropped).svg

The heart is usually not colored in such a pretty way.

When listening to the heart, the clinician is listening for the two heart sounds.  Consistent-sounding and regularly spaced sounds are a sign of a healthy heart.  Normal adults have heart rates of 60-100, although athletes (whose hearts pump more blood with each beat) can operate with much lower heart rates.

Problems with the heart valves will sometimes result in turbulent flow over the valve, causing the heart sound to be a "whoosh" rather than a "thump."  I will go into heart murmurs in more detail in the second post about the heart.

Mythological Hoof Beats

torchlt1 There are two more heart sounds that physicians are taught about in medical school: S3 and S4.  A person with an S3 gallop, we were taught, will have heart sounds making the rhythm of the word "Kentucky" - three fairly evenly spaced sounds.  The S4, on the other hand, will have sounds making the rhythm of the word "Tennessee" - where the three syllables come quick, and then are followed by a pause.

From this one might conclude that the 3rd and 4th heart sounds happen when the heart uses chewing tobacco, but that would be incorrect.  The real cause of the S3 gallop is described as follows:

S3 is thought to be caused by the oscillation of blood back and forth between the walls of the ventricles initiated by inrushing blood from the atria. The reason the third heart sound does not occur until the middle third of diastole is probably because during the early part of diastole, the ventricles are not filled sufficiently to create enough tension for reverberation. It may also be a result of tensing of the chordae tendineae during rapid filling and expansion of the ventricle.

So it is basically the vibration of the heart wall like a rubber band.  I prefer the following description:

340x The S3 is caused by the intense desire of cardiologists to feel superior to other doctors.  They have invented this sound for the sole purpose of making other doctors embarrassed that they can't hear it, while the cardiologist says "it's obvious."  This is often heard on cardiology rounds, where the cardiologist listens to the heart of a patient carefully and proclaims, "listen to this patient for a very clear S3 gallop."  The medical students and residents each spend five minutes listening to the heart trying to hear the mythical sound, nodding their heads to avoid embarrassment.

Those who fake it the best are those who are chosen for cardiology fellowships.

I have never heard an S3, but I have faked it several times.  It is said to be a sign of heart failure (the gallop, not the faking).

The cause of the S4 is described:

S4 is caused by the atria contracting forcefully in an effort to overcome an abnormally stiff or hypertrophic ventricle. This causes abnormal turbulence in the flow of blood that can be detected by a stethoscope.

Which is to say that the S4 is like the atrium (or smaller heart chamber) grunting as it tries to push blood into a stiff ventricle (or larger chamber).  I think I have heard an S4 gallop, but I am not certain.  It could have just been that stampede of caribou in the room next to me.

373513163_420bc6fe69

Got Rhythm?

discofire Do you feel awkward on the dance floor?  Do you feel like you move when you shouldn't?  Do you look like a person with a rare neurological condition when you are trying to two-step?  If so, you know how the heart sometimes feels.

The heart normally has a good sense of rhythm.  It beats with the regularity of the pounding sound coming from the 2 trillion watt speakers in the back of a teenager's car.  It does so without complaint, day and night, rain or shine.  The heart really likes to "shake it's groove thing."

The regular rhythm is produced by an electrical impulse traveling down electrically conductive cells (or purkinje fibers) that cause the heart to contract.  This electric pulse normally starts from the pacemaker of the heart, or SA Node.

But sometimes, the groove thing just won't shake, and the heart goes into an irregular rhythm.  There are many ways for this to happen, including:

Extra beats thrown in the middle of the regular ones.  This are called premature contractions, and are usually no big deal.  They can happen at regular intervals or just randomly.  It is quite easy to experience premature contractions; just drink three cans of Red Bull and let the fun begin.

Fast regular beats.  Whether this is good or terrible depends on where the beats start from. 

  • If they start from the SA node, then it is called Sinus Tachycardia, and is a generally benign condition.  This condition can also be caused by drinking Red Bull, as well as by watching Victoria's Secret commercials
  • If the fast beats come from other parts of the atrium (or small chamber), it is an atrial tachycardia, which is possibly a more serious, but not life-threatening problem.
  • If the fast beats come from the ventricle (or large chamber), it is called ventricular tachycardia.  This means you are in deep yogurt.  It is really bad.
  • If the beats come from the car next to you at the intersection, then it is only dangerous if you open your window and give them the finger.  Don't do that.

band-middle-84 Irregular beats.  These beats come randomly - kind of like the percussion section of a middle-school band (and possibly just as dangerous).  The common cause of this condition is called atrial fibrillation.  A Fib happens when the pacemaker goes haywire, and signals the heart to beat at a very high rate.  Fortunately, the heart can ignore the rapid random beats of the SA Node, so that the whole heart doesn't go at a dangerously fast rate. 

I am going to stop here, as I am running out of bizarre analogies.  When I think of more, I will finish with the rest of the heart exam.

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Physical Exam: Treasure Chest

It has been a long time since I did a post on the physical exam.  For those who have not read them, I have done a series on the nuances of a physical exam from the perspective of one who has done them for 20+ Years.

For those of you who were relieved by the fact that I wasn't doing these any more, I offer you my sincerest apologies.

The usual exam of the chest is written as follows:

Chest: CTA

This translates: clear to auscultation, which means:

"I didn't hear anything abnormal in the lungs with my stethoscope"

The chest exam is generally, in fact, the lung exam.  Since breathing is something I recommend all of my patients do, I am always interested in listening to the lungs.  I want to make sure there are no signs my patients will stop performing this activity.  But before we go to the lung exam, let me touch on the other part of this exam.

Wall to Wall

The outside of the thorax is referred to as the chest wall.  It is always important to have good walls.  Walls keep bad stuff out, and walls keep good stuff in.  Like the walls of ancient cities, walls protect those within from nasty invaders.  The more precious the thing inside, the higher the walls.  There isn't much in your body more precious than your heart and lungs. 

Your chest wall is made to withstand the onslaught of pokes, punches, nunchucks, and other foreign invaders that try to get in and cause havoc.  The ribs give strength and support, while the space between the ribs, the intercostal space, gives the chest the ability to expand and contract.   

floridaretirementThe intercostal space is often mistaken for the intercoastal waterway, which is a waterway along the Atlantic coast of the US, allowing people to safely go by boat from New Jersey to Florida (a very common migration pattern during the winter).  While the intercoastal waterway plays a vital role in the economy of the Sunshine State, it does not expand and contract with breathing, nor is it flanked by ribs on either side.

The main bad thing that can happen to the ribs is a fracture.  Broken ribs, while very painful, are not treated with anything other than pain medications.  It is not feasible to put a cast on a rib fracture, and the intercostal space serves to splint the broken rib quite well.  The one exception to this is a flail chest, where several ribs are broken in more than one place.  This causes the segment between the fractures to pull in when a person inhales, and can cause significant breathing problems.

Image Credit

The main bad thing that can happen to the intercostal space is for people from New Jersey to try using it to get to Florida.

A rib fracture is diagnosed on physical exam by the clinician pushing on various parts of the chest wall and saying, "does this hurt?"  When the patient either curses or tries to physically harm the examiner, the rib fracture is confirmed.

Inspire, don't Expire

The examination of the lungs is done as follows:

  1. Take the stethoscope out of the freezer
  2. Place it on the patient's back, telling them to breathe deeply
  3. Chuckle to yourself when they find they cannot breathe out

The clinician usually listens to the various parts of the chest: the lower and upper parts of the lung on the back, and the lungs on the front of the thorax.  There are several sounds that are listened for:

  •  Rhonchi - a rattling or rumbling sound, kind of like a garden hose when the water has just been turned on.
  • Rales - a crackling sound, like when paper is crinkled.
  • screamingWheezes - a high-pitched whistling sound made on exhaling.
  • Transmitted breath sounds - sound a lot like rhonchi, but they come from above the vocal cords (i.e. a head full of snot).
  • Rub - a soft brushing sound, like when sandpaper goes on wood.
  • Decreased (or absent sounds)
  • Loud screaming - the sound most pediatricians hear on the chest exam.

Rhonchi are present when there is excessive phlegm in the larger airway tubes leading to the lungs.  They tend to happen with bronchitis, which defined as: a condition that causes lots of phlegm in the large tubes leading to the lungs.  Bronchitis is not usually caused by bacteria, and requires antibiotics only a small percent of the time.

Rales are present when there is fluid in the lungs themselves.  This is either caused by infection (such as pneumonia) or the backing up of fluid in heart failure.  Rales are generally not good.

Wheezes are the cardinal physical exam sign for asthma.  They occur when the medium-sized airway tubes are inflamed and constrict, making it easier to breathe in than out.  Wheezes also occur in the pediatric condition known as bronchiolitis, usually caused by the respiratory syncytial virus (RSV).  Louder wheezes are actually often better than softer wheezing, as the latter may be a sign that not much air is able to get out.  In general, the longer it takes for a person to exhale, the worse their problem is.

freeA Rub happens when the sack that surrounds the lungs, called the pleura, becomes inflamed.  The job of the pleura is to allow the lungs to expand and contract smoothly without sticking to the inside of the chest wall.  When it becomes inflamed, it is called pleurisy.  Pleurisy is usually caused by a virus, and feels like someone is stabbing you in the chest with a pencil every time you take a deep breath.  If you think you may have pleurisy, first check to see if someone actually is stabbing you with a pencil.  That condition is known as annoying little brother syndrome.

Rubs are difficult to hear, and are a handy way to make medical students feel stupid.  This is done when the resident or attending physician listens to the chest and says: "if you listen carefully, you can hear a rub."  The students listen and only hear normal breath sounds and the distant chuckling of the teaching physician.  The student then pretends to hear it clearly, saying something like: "wow, that's the best rub I have ever heard."  This causes the humiliation to be passed on to the other medical students in the room.

Decreased breath sounds happen due to a decreased movement of air.  This can be due to a problem with the lung itself (such as emphysema), or the pleural space (such as as a fluid collection, or an effusion, and a collapsed lung, or pneumothorax)A pneumothroax happens when air gets in the pleural space surrounding the lung.  This can happen from trauma, illness, or can just happen spontaneously.  Collapsed lungs are quite painful, and often require a tube being placed in the intercoastal waterway intercostal space, called a chest tube.  You don't ever want to get a chest tube if you can help it.  They hurt like heck.

Other Stuff

There are other things doctors sometimes do on the chest exam:

  • Percussion - this is where the examiner places one finger on the chest and taps it with the other.  The resonance of the "thump" can sometimes give clues to diagnosis.  Some physicians just like the rhythm.
  • Tactile Fremitus - this is where the hands are placed on both sides of the chest (on the back!) and the patient is told to say "Ninety-Nine."  If the vibration of the chest is decreased, there may be an effusion present.  This also serves well in confusing the patient.
  • Egophony - Egophony is elicited when the examiner places the stethoscope on the chest and tells the patient to say the long "E" sound.  In normal lungs, the E sounds like "E."  If there is fluid on that part of the lung, the E sounds like "A."  This also confuses patients.
  • Whispered Pectoriloquy - This technique is performed by the examiner having the patient whisper "Ninety-Nine" while listening to the lungs with the stethoscope.  If there are problems with the underlying lung tissue, the whispering will be much louder.  By the time you are doing whispered pectoriloquy, the patients ask to see your medical license.

The origin of the use of the word "Ninety-Nine" in these techniques is not well understood.  Many have suggested other words.  Toward the end of the millenium, some progressive medical schools were instead teaching the students to have patients say the lyrics to Prince's popular song, "Tonight I'm going to party like it's 1999."

prince

Most of these techniques are seldom used in our country.  It has been replaced with a more effective procedure: filling out a chest x-ray requisition.

Conclusion

That's about all I have to say about the lung exam.  It really is a quite important part, with many visits of patients to the office centering on problems related to breathing. 

Now, before you go to another web site, I want you to put your hands on your computer monitor and say "Ninety-Nine."

Thanks.  That helped a lot.

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Physical Exam: Sticking out your neck (part 1)

After a long break, I am rejoining the tour of the human body as examined by a physician.  To view the previous posts on physical exam, please follow this link.

We now move down the body to the neck.  The neck seems to simply be a connection of the head to the torso.  It seems to be just a transportation system between the command center and the main workers.  Steve Martin seemed to have this in mind when he said.

I want a woman with a good head on her shoulders.  I Hate Necks!!

 

zimmer_g While it seems that there are some professional athletes and cartoon characters who have no necks, the neck is actually quite a hapnin' place when it comes to the physical exam and when it comes to the function of the body.  I actually examine the neck on nearly every visit, and generally note it as follows:

Neck:  Supple, without LAD or TMG

Dang.  That football player really has no neck.

The exam translates to mean: The neck bends easily.  There are no lymph nodes present and the thyroid does not feel abnormally large.

Smooth and Supple

The use of the word "supple" to describe the neck is referring to the fact that it can be easily bent.  Stiff necks are the most common physical signs in meningitis, and so I have always felt that the inclusion of the word "supple" was more for defensive purposes than anything. 

fred-and-barneyMeningitis, or an infection of the fluid that surrounds the brain and the spinal cord, will classically present with a fever and a stiff neck.  For younger infants, the stiff neck is much less reliable, and so many infants with unexplained fevers will get a spinal tap to rule out meningitis as a cause.  Also, meningitis is not the most common cause of neck pain and fever.  Many common problems (such as mononucleosis or strep throat) can also cause this.  A careful exam will usually rule out meningitis, as the pain is usually on the back of the neck and is worse with full flexion forward.

The good news is that we see relatively little meningitis these days.  In the past, meningitis was much more common, but two vaccines: the one against the bacteria hemophylus influenza, and the one against streptococcus pneumoniae, have greatly reduced its incidence.  Score one for the value of immunizations.  I have to say that I have never seen a child with h. influenza meningitis since I started practice but just recently diagnosed a child with streptococcal meningitis.  It is of interest that she had not gotten the vaccine against that bacteria.  My guess is that they are being paid off by the big drug companies to convince us to throw lots of money at their vaccines that cause autism.

There is also a vaccine against the most scary form of meningitis, Meningococcal meningitis.  This disease is rare, but is probably one of the most frightening disease around in that it happens in young and healthy people and it can kill in hours.  Meningococcal infection has up to a 50% death rate.  My kids are being immunized for this one.

 

John Supple2

This is one of the pictures that came up when I Goggled the word "Supple."  I would like to introduce you to Mr. John Supple.  He has a neck.

A Pain in the Neck

More often, a cause of neck stiffness is a strain of the trapezius muscles at the back of the neck.  This causes pain when the neck is flexed forward or is turned toward the side of the trapezius muscle affected.  This can be caused by sleeping on a bad pillow or by flexing the neck for too long of a time (getting a "crick"). 

The trapezius has also been a veritable gold mine for personal injury attorneys in the form of Whiplash.  Whiplash is a common consequence of being in an auto accident, especially from being rear-ended.  While it is clear that the insurance companies want to close auto claims far too quickly (I usually recommend that people don't sign off on the claim until they feel better), there are also many abuses. 

rotator

I don't see many primary care physicians advertising on the back cover of the phone book.

collarIn general, neck strains take a while to heal, and are best treated with physical therapy and anti-inflamatories.  If a person has a lot of pain, immobilization of the neck through the use of a soft neck collar is appropriate, although they should not be over-used as they can actually increase stiffness if used excessively (especially by dogs).

So this raises the interesting question: what would that football player or Fred Flintstone do if they were in an accident?  How would you put a cervical collar on them?  It seems that they have a built-in collar by their own anatomy.

Sometimes the complaint of stiff neck comes from tonsillitis or pharyngitis.  Young children with sore throats will often say that their neck hurts, and the swelling of the lymph nodes (that will be covered in part 2) can make a neck stiff.

Torticollis

Torticollis is a condition where the neck is stuck in a position bent to one side and back.  The most common form happens in infants from birth and generally resolves with physical therapy.  Torticollis happening later in life may simply be due to muscle spasm, or may be a sign of more serious problems.

Torticollis has nothing to do with these guys:

no-tortoise-behind

Nor is it a gate for a Medieval Castle

Portcullis_Bucharest

Finally, there is the whole issue of someone being a "pain in the neck."  I suppose it is a more polite part of the anatomy to use than the more southern area of pain; whatever the case, it bears some thought as to why this should be used in this expression.  There is a reason.  People won't say "He was a pain in the Uvula."  I guess they could in very rare circumstances, but my imagination is getting the best of me.

While I could not find a definitive reason for the inclusion of the neck, it must be pointed out that stress will often cause the neck muscles to tighten and hurt - often resulting in a tension-type headache.  This means that something that is a pain in the neck figuratively could be a pain in the neck literally.  The same does not hold true for the more southern site of pain.

OL-Donkey-Cart

This ass does not appear to be in pain, despite the stress.

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