Advanced Physical Exam Maneuvers

When becoming a nurse, we are taught how to assess our patients and perform a physical exam. We talk with them and make sure they are alert and oriented, we listen to their lungs and heart, check for leg swelling or redness, and are making sure there are no significant changes every shift. However, there are many advanced physical exam maneuvers that are not taught to us in nursing school.

This may be because these advanced physical exam maneuvers tend to guide diagnosis and “nurses don’t diagnose”. However, performing advanced physical exam techniques can help you recognize serious conditions in your patient, which you can notify the Provider about and improve patient outcomes.

1. Extraocular Muscles

Extraocular Muscles (EOMs) are responsible for eye movement and are largely innervated by the third cranial nerve – the oculomotor cranial nerve, as well as the 4^th and 6^th cranial nerves. Intact EOMs suggests that those three cranial nerves are intact, but also is important in ruling out a central lesion such as a stroke or a mass – although a more thorough cranial nerve assessment is required.

When looking at the extremes of vision, sometimes nystagmus can occur. Nystagmus is defined as a fine rhythmic oscillation of the eyes. A few beats at the lateral gaze extremes can be normal,  but any excessive nystagmus, especially when the eyes or more centered, can suggest vertigo, seizure activity, Chiari malformation, stroke, or a mass.

Additionally, testing EOMs in your physical exam can be useful to test when evaluating for orbital cellulitis. Orbital cellulitis is an infection of the orbital structures and muscles. As you might expect, when the extraocular muscles are infected, they are inflamed and painful. This means testing of the EOMs often is painful, especially when looking in a certain direction. Painful EOMs in association with swelling or redness of the eye or surrounding area should prompt a CT of the orbits with contrast to rule out any orbital cellulitis. Orbital cellulitis often requires IV antibiotics, whereas periorbital cellulitis can usually be discharged home with PO antibiotics and close ophthalmology follow-up.

EOMs should be tested whenever there is any neurologic complaint (possible strokes, vertigo, seizures), or when you suspect periorbital or orbital cellulitis.

To test EOMs – hold out a finger or a pen approximately 2 feet away from the patient’s eyes. Ask them to follow your finger or object with their eyes only. Now move your finger/object in the six cardinal directions, making a large “H” in the air. To the right, upper right, lower right, then to the left, upper left, and lower left (see illustration).

An abnormal exam is when these movements are painful, when they cause dizziness, or when one or both eyes are unable to gaze in a specific direction. The latter can indicate a brain lesion such as a stroke, so this is a major physical exam finding that you don’t want to miss and is part of your NIH scale!

Be sure to check out my advanced cranial nerve assessment for more information on proper neurological assessments! Keep reading for more advanced physical assessments!

2. Jugular Vein Distention

Jugular vein distention, or JVD, is just that – when the jugular veins are bulging or distended. Pressure in the jugular veins indicates right atrial pressure, which can be helpful when evaluating patients with known or suspected heart failure, volume overload, or even pulmonary embolisms.

Testing the Jugular venous pressure isn’t exactly easy, and sometimes a “gestalt” JVD is noted by healthcare providers. This can usually be noticed when the patients are in clear volume overload.

JVD can be tested whenever you suspect a patient to have volume overload or increased right atrial pressures. This means whenever you suspect heart failure, volume overload in renal failure patients, or a pulmonary embolism.

JVD can be “noticed” with a bulging external jugular vein when the patient is between 30 and 45 degrees semi-fowlers, with their head turned toward their left. You should be evaluating their right side as this is the most accurate indication of right atrial pressures. The higher they are sitting up while maintaining jugular venous distention, the higher the pressure is.

If you want to get technical, you can also measure – but most of us don’t carry around a measuring device. I have never seen a non-specialty clinician actually perform this in real life. However, to officially test the jugular venous pressure, you want to elevate the head of the bed to approximately 30-45 degrees. Have the patient turn their head to the left. Identify the top of the venous pulsations of the external jugular vein, or preferably the internal jugular vein. You can not directly visualize the internal jugular vein, but should be able to see the pulsations. Use a pen to “draw” or visualize a horizontal line from the top of the pulsations to above the sternal angle. This is the notch where the sternum begins. Now measure how high this horizontal line is above the skin. Then add 5cm because the right atrium is approximately 5cm deep. The total is the patient’s estimated central venous pressure (CVP).

Remember that normal CVP are 0-8 cm H2O. Anything higher is considered abnormal and could indicate the increased right atrial pressures.

Hepatojugular Reflux

The hepatojugular reflux (HJR) is an additional physical exam maneuver to help determine possible heart failure exacerbation or other conditions which could increase venous pressures. This is often performed if JVD is not obvious but clinical suspicion remains.

To test the HJR, position the patient the same as JVD. Apply gentle pressure over the RUQ or mid-abdomen for 10-60 seconds, and watch for increased JVD. Normal patients should have a decrease in JVP (less distention) with this physical exam maneuver since it should decrease venous return. Those with fluid overload and heart failure will have an increase >3cm in measured JVP.

Related article: “Interpreting Cardiac Labs”

3. Murphy’s Sign

Murphy’s sign is a physical maneuver to determine the possibility of cholecystitis or inflammation of the gallbladder. This can be a great physical exam test to aid in the clinical suspicion of acute cholecystitis (inflammation of the gallbladder).

Murphy’s sign is tested when a patient presents with abdominal symptoms such as abdominal pain, nausea, or vomiting. You can also perform this physical exam maneuver if the patient has a fever of unknown etiology – especially in the elderly or those who may not be able to verbally express pain.

To check for Murphy’s sign, place your fingers firmly in the patient’s right upper quadrant underneath the patient’s ribs, and ask the patient to take a deep breath. This is considered deep subcostal palpation, and on inspiration, the diaphragm pushes the gallbladder towards your palpating fingers, which should be painful if the gallbladder is inflamed.

A positive’s Murphy sign is indicated when during inspiration, the patient has an acute increase in pain that will often cause them to stop inspiring mid-way through their breath. In true acute cholecystitis – this is often positive as Murphy’s sign as high sensitivity (97%) for acute cholecystitis, however, it is much less specific (48%) – this means that it could indicate other pathology within the liver or surrounding area.

4. Costovertebral Angle Tenderness (CVA Tenderness)

Costovertebral angle tenderness (CVA tenderness) is a physical exam maneuver that is often used when evaluating potential kidney stones or other inflammatory renal pathology. The costovertebral angle is “formed by the lower border of the 12^th rib and the transverse process of the upper lumbar vertebrae.” Basically – On the back when the ribs end on each side – approximately where the kidneys lie. If there is a condition that has your kidneys or surrounding structures inflamed and irritable, percussion over this area often causes acute worsening of pain.

CVA tenderness should be checked whenever the clinician suspects a kidney stone or pyelonephritis. Often, this means the patient presents with flank pain, back pain, or some form of dysuria – whether painful urination, difficulty going, or even hematuria.

To check for CVA tenderness – place one hand over the costovertebral angle on the back, and percuss with your other fist. You don’t want to be too forceful because if they do have a kidney stone – this can be very painful. However, you also want to ensure you are not percussing too lightly. Percuss a few times on each side.

Positive CVA tenderness is when the patient reports pain with percussion. From my own experience – this is often very painful for those with acute kidney stones. However, I have also had plenty of patients with negative CVA tenderness who had acute renal pathology including kidney stones. 

5. McBurney’s Sign

Not to be confused with Murphy’s sign above, McBurney’s sign is an advanced physical exam maneuver to help raise suspicion for acute appendicitis.

Mcburney’s point tenderness is when the patient’s most tender area is 1.5-2 inches from the anterior superior iliac spine in the direction of the umbilicus. Draw an imaginary line from the anterior superior iliac spine to the naval, and approximately 1/3 down the line closest to the the iliac spine is the “sweet spot”.

If a patient has abdominal pain with this being their most tender spot, they should undergo further testing to rule out acute appendicitis. Mcburney’s sign is 50-94% sensitive, and 75-86% specific.

As always, these advanced physical exam maneuvers should always be used with clinical judgment as part of a full history and physical exam. Hopefully these advanced physical maneuvers can help aid in your diagnosis. Nurses are constantly at the bedside, and knowing these physical exam maneuvers can help strengthen your physical assessment skills.

Let me know if you found these helpful below in the comments!

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