Physical Examination 231

Primary Survey

In emergency urology, many decision trees branch on the vital signs of blood pressure, pulse rate, respiratory rate, temperature, and general assessment of the patient (i.e., toxic or well appearing). These should be available from nursing personnel before any history taking by the doctor; if not, they must be obtained quickly (and updated frequently). After the vital signs, the initial assessment follows. Although urologists will be tempted to emphasize the genitourinary physical examination, elements of airway, breathing, circulation, disability (neurologic) and exposure (environmental), making up the ABCs, must be assessed (even briefly) in emergency cases before getting down to the U for urology! The authors have witnessed patients with impres sive gunshot wounds to the genitalia that completely diverted primary caregiver attention from chest gunshot wounds that ultimatelyrequired emergencythoracoto-my.

The urologist will be better able to make use of modern diagnostic tools and management algorithms in a purposeful manner once the urologic history and physical examination are complete. They should not be bypassed. A prospective controlled study addressing the predictive value of abdominal examination in the diagnosis of abdominal aortic aneurysm, for instance, reported a negative predictive value higher than 90 % for aneurysms of 4 cm and a positive predictive value over 80 % for those larger than 5 cm (Vendatasubramaniam et al. 2004). Another group (van den Berg et al. 1999) compared the detection of groin hernia by different diagnostic tools and physical examination. Interestingly, physical examination achieved a sensitivity of 75 % and a specificity of 96%. In patients with acute abdominal pain (Bohner et al. 1998), the variables with the highest sensitivity for bowel obstruction were distended abdomen, decreased bowel sounds, history of constipation, previous abdominal surgery, vomiting, and age over 50 years. The authors of this study calculated that, if only those patients presenting two of these variables had undergone imaging, radiography could have been avoided in 46% without loss of diagnostic accuracy.

Secondary Survey

After vital signs and the initial assessment, the secondary assessment is conducted. If possible, the physical examination should be conducted in a systematic way in a fully exposed patient. In trauma patients, the risk of hypothermia must be considered even in the warmer months; nevertheless, it should not hinder complete exposure for examination and it will be reduced bywarm infusions and by covering with external warming devices after assessment (ATLS Manual 2004a). With the exception of life-threatening emergencies requiring immediate evaluation and therapy, the secondary assessment should include organ systems other than those assumed to be affected. This will allow the discovery of physical signs not necessarily linked to the working hypothesis, as well as those arising from any additional disease (e.g., discovering a melanoma in a patient presenting with renal colic).

The reduced interrater reliability (Close et al. 2001) or accuracy (Weatherall and Harwood 2002) of some physical tests should not lead to a dismissal of the physical examination as a whole. For example, blood at the urethral meatus is only 50 % predictive of posterior urethral distraction injury, and a high-riding prostate is only 33 % predictive, but they are nonetheless useful features of the assessment. It remains the task of uni versities and training programs to support the teaching of these basic physical examination skills and their successful incorporation into diagnostic and therapeutic algorithms.

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