physlcal exam from Lop Lo bouom

vlLal slgns
pa|pate rad|a| pu|se for aL leasL 30 seconds
measure Lhe resp|ratory rate for aL leasL 60 seconds
measure 8 [arLery" marker over brachlal arLery, nd brachlal arL.]
each arm, arm aL heart |eve|.
head
palpaLe and observe sca|p [musL Louch Lo examlne]

nose and slnuses
hx. allergles, pasL slnus lnfxns, exposures, fever, sore LhroaL, dlscharge
|nspect. nosLrlls, ears, LhroaL, mouLh
LesL patency of nasal passages- close one and breaLhe Lhrough oLher
pa|pate fronta| s|nus for Lenderness above each eye
max|||ary s|nuses below each eye
eyes
|nspect each eye [lld/cornea/con[ucuva- hold bouom lld- look up
hold Lop lld ask pauenL Lo look down]
v|sua| acu|ty- [Cn ll] each eye- screenlng charL
pup|||ary responses- dlrecL and lndlrecL [consensual]
CN III, IV, VI- ask pauenL Lo look rlghL, up, down, shape of P"
convergence
CN VII- moLor ask pauenL Lo force eyellds closed agalnsL reslsLance
v|sua| he|ds- posluon face 1-3 feeL from pauenL's face aL Lhelr eye
level. ask for number of ngers held up ln each of four quadranLs
for each eye.
ophtha|mascope- vlsuallze posLerlor sLrucLures of eye
rL. hand = rL. eye and le Lo le eye
nodes and Lhyrold - 2/3 clrcular palpauons w/ 3 ngers over each
palpaLe- preaur|cu|ar
poster|or aur|cu|ar
occ|p|ta|
tons|||ar
submax|||ary
submenta|
poster|or cerv|ca|
suprac|av|cu|ar
anter|or cerv|ca| [Lhree spoLs ln fronL of SCM]
ask pauenL Lo swallow- observe Lhe thyro|d g|and
palpaLe thyro|d [from behlnd]- w/ and w/ouL swallowlng
ears
quesnons. lnfx? boLh? work exposures? fam hx?
|nspect exLernal ear [bend plnna Lo observe backslde of ear]
otoscope- pull plnna up and back, use oLoscope upslde
down/anchored
perform tests:
+ aud|tory acu|ty- CN VIII- rub forenger and Lhumb 10 cm away-boLh
+ weber- 312 Pz Lunlng fork on mlddle of forehead- whlch ear ls lL
heard besL?
+ k|nne- vlbraung fork on masLold unul no longer heard-
sound should be audlble Lo pauenL aer conducuon ls noL.
*Weber- really can only glve lnfo abouL unllaLeral hearlng loss.
unllaLeral conducnve hear|ng |oss = sound loudesL ln aecLed ear
[ amblenL nolse wlll be masked by defecL- sound seems louder]
unllaLeral sensor|neura| hear|ng |oss =louder ln un aecLed ear
[aecLed ear sucks aL plcklng up sound even conducuon]
* 8lnne- compares percepuon of sound as Lransmlued by alr or
bone conducuon Lhrough masLold. conducnve hear|ng |oss.
|nterpretanon- normal = alr conducuon > bone conducuon
conducuve hearlng loss = 8C>AC
mouLh and LhroaL
|nspect. ||ps, gums, tongue and teeth [use Longue blade and llghL]
+ poster|er pharynx- lnsLrucL pauenL Lo breaLhe Lhrough mouLh
[use llghL]
+ e|evanon of pa|ate [CN Ik and k] ahhhh"
+ CN kII- suck Longue ouL and move from slde Lo slde
+ CN V- moLor fxn.- pL. Lo blLe down whlle you palpaLe masseLers
+ CN VII-moLor fxn.- show lower LeeLh
+ CN kI- roLaLe head agalnsL reslsLance boLh dlrecuons
+ CN kI- shrug shoulders agalnsL reslsLance.
lungs and Lhorax. all percusslon/ausculLauon musL be done on skln
poster|or-
|nspect post. thorax- scars/asymmeLry/conLour Lell pauenL as you look
pa|pate. Lacule fremlLus [!consolldauon/" uld] [egoph-"a" ln consolld]
percuss
+ poster|or |ung he|ds- bllaL, symmeLrlcally, alLernaLely over
upper, mlddle, lower lung elds- compare le and rlghL aL each
level
+ hst percuss costoverterbra| ang|e- ask pL. lf Lender [kldney]
auscu|tate poster|or |ung he|ds- ask pL Lo cross arms and breaLhe w/
open mouLh before beglnnlng. asculLaLe bllaL, symm, alLernaLely
anter|or-
|nspect. resp eorL, dlsLress?, symmeLry.
pa|pate. mldllne Lracheal posluon, chesL expanslon
percuss- aplcal lung area- bllaL, symmeLrlcally and alLernaLely
auscu|tate- bllaL sup. lobes, rlghL mld lobe, le llngular dlvlslon.
hearL. all palpauon/asculLauon musL be done on skln
|nspect]pa|pate
IV- elevaLe Lrunk/head/neck Lo 30 degrees. have pL. Lurn head
Lo le. shlne llghL obllquely across rlghL neck Lo vlsuallze
[ugular venous pulsauons. lf none vlslble- pL. suplne and check
agaln. Lry hepaLo[ugular reux lf noL vlslble.
[elevaLed !v = rL. slded hearL fallure/venous P1n.
measure verL. helghL from sLernal noLch Lo hlghesL polnL of
!v pulsauons. lf more Lhan 3 cm. above sLernal angle
=paLhologlcal. normal= shouldn'L see aL 30 degrees, buL
should when suplne]
A1M for Lhrlll/pulsauon
MI. mld-clavlcular llne ln 4Lh-3Lh lnLercosLal space- rsL suplne, Lhen
le laLeral decublLus posluon lf can'L feel when suplne.
precord|um. for Ml and for abnormal, susLalned ouLward movemenL
Lhrlll" or heave". use: u|nar surface of pa|m on tr|cusp|d area
auscu|tate
A1M w/ dlaphragm [hlgh plLched sounds] Lhen bell [low plLch]
rsL llsLen Lo S1 and S2- ampllLude, spllmng?
Lhen Lo sysLole- murmurs, exLra sounds?
dlasLole
add pu|ses] edema |f necessary
abdomen. auscul/percuss/palpauon on skln. pL on back. dr on rL slde
|nspect for conLour, marklngs, venous, changes w/ resplrauon
auscu|tate four quadrants
pa|pate four quadrants [LuC #LLC#8LC#8uC]
sp|een
||ver
percuss ||ver
breasL exam
|nspect- |nstruct pt:
Lo |ower gown -- boLh breasLs vlslble
Lo ra|se both arms- examlne for dlmpllng, conLour changes,
dlscolorauon
Lo hands to h|ps- press lnward. lnspecL as above
Lo |ean forward]ho|d arms extended- lnspecL as above
pa|pate ax|||ary nodes- anLerlor axlllary fold/posL. ax. fold/along
prox. humerus/ axlllary vaulL uslng pads of Lhree ngerups
pa|pate breast nssue- one arm ouL of gown and on forehead.
use pads of Lhree ngers. use clrcle-sllde" Lo apply Lhree levels of
pressure on each reglon. descend from clavlcle Lo below
lnframammary rldge and back up agaln ln verucal llnes unul all reglons
have been palpaLed. boLh breasLs
pulses and Lesung for perlpheral edema. on skln. pL suplne
ascu|tate carond artery- have pL. hold breaLhe. do CnL aL a ume
pa|pate- carond pulses one aL a ume
femora|
pop||tea|
dorsa||s ped|s [bllaL]
poster|or nb|a| [aL ankle behlnd medlal malleolus]
p|mng edema- press each shln 3-3 seconds.
k 07 [+]
1. ask pauenL how Lhey are generally
2. ask pauenL whaL Lhey Lhlnk ls Lhe cause for problem
3. ask pauenL whaL quesuons Lhey have
4. whaL Lhey prefer Lo be called
3. Lell your educauon level/ask lf lL's ok Lo examlne
6. Lalk before Louch
7. glve brlef resulLs as you proceed.
physlcal exam
musculoskeleLal
+ every [olnL perform: |nspecnon- swelllng/deformlLy/eryLhema. compare sldes for symmeLry
pa|pate [olnL llne, perlarucular [llgamenLs/Lendons] for Lenderness
assess AkCM
assess kCM lf 8CM ls llmlLed.
musc|e strength
spec|a| maneuvers [varles by [olnL]
+ legs/hlps
h|p ex|on- grasp heel and move Lhlgh Loward Lrunk
h|p externa| rotanon] |nterna| rotanon- reLurn Lhlgh Lo a posluon perpendlcular Lo exam Lable whlle
holdlng shln parallel Lo exam Lable. move ankle med|a||y = externa|, |atera||y =|nterna|.
ex and extend knee- repeaL on oLher slde
+ knee
|nspect
ba||otment [olnL euslon and pa|panon for Lenderness
AkCM
kCM lf A8CM abnormal
men|scus |n[ury-McMurray/appleygrlnd
||gamentous |n[ury- ACL = anLerlor drawer or Lachmann's LesL, MCL = valgus sLress, LCL= varus sLress
+ feeL
|nspect mldfooL, Loes, planLar surfaces of boLh feeL
p|antarex and dors|ex ank|es
+ hands/arms
|nspect pa|ms]back of hands
hnger extens|on- have pL spread ngers
hnger ex|on- have pL. make sL
|nspect hsts]wr|sts- whlle suplnaung and pronaung forearms
whlle exLendlng and exlng wrlsLs
|nspect, ex, extend e|bow
+ shoulder
|nspect swelllng/deformlLy of acromlon, clavlcle, acromlo-clavlcular [olnL, scapula, delLold, suprasplnaLus,
lnfrasplnaLus, Leres mlnor
pa|pate same sLrucLures and subacromlal space
AkCM-
shou|der ex|on- ask pL. Lo brlng arms forward and ralse overhead
externa| rotanon- pL Lo clasp boLh hands behlnd neck and pull elbows back hollywood"
|nterna| rotanon- pL Lo place boLh hands behlnd back as hlgh as posslble yoga". observe from behlnd.
ab and adducnon, forward ex|on and extens|on
kCM lf A8CM abnormal
spec|a|
|mp|ngment]rotator cu tendon|ns]subacrom|a| burs|ns- already palpaLed subacromlal bursa space,
reslsL abducuon, reslsL exLernal roLauon, Pawkln's LesL/neer's LsL
b|ceps tend|n|ns- palpauon of long head of blceps, reslsL suplnauon of forearm
+ splne/neck
neck ex|on- have pL. place chln on chesL
neck extens|on- have pL. look Lo celllng
rotanon- chln Lo each shoulder
|atera| bend|ng- pL. Lo lncllne head Lo each shoulder
thoraco|umbar |atera| ex|on- pL. Lo sLand and bend Lorso Lo rlghL and le. observe from behlnd.
|umbar ex|on- pL Lo bend forward aL walsL and Lry Lo Louch Loes. observe from behlnd.
|umbar extens|on- pL Lo bend backwards. observe from behlnd.
from beh|nd observe- Lhoracolumbar mouon, lumbar exlon/exL., allgnmenL of splne/knees/heels/feeL
neurologlcal. compleLe would lnclude Cn exam and menLal sLaLus exam
+ moLor [slmng on exam Lable or chalr]
pronator dr|h test- pL close eyes ,hold arms ln fronL of chesL, palms Lo celllng. observe for pronauon 13 sec
gr|p strength bllaLerally
de|to|d strength bllaL
b|ceps strength bllaL
tr|ceps strength bllaL
h|p exor- each slde separaLely
knee extensor- LesL sLrengLh by pL push agalnsL dr's hand on ankle/ knee exor- pL. pull Loward self
+ sensauon [show Lhem whaL Lhe sensauons feel llke, Lhen ask Lhem Lo close Lhelr eyes]
d|erence between sharp and du||- on proxlmal area llke asympLomauc forearm- pL. close eyes, use couon
ball and broken couon-upped appllcaLor. also on trunk, arms, |egs
CN V- Lell pL. rsL Lhen sLroke V1- forehead, V2- cheek, V3-[aw ||ne
v|branon- show pL. whaL vlbraung Lunlng fork feels llke before havlng pL. close eyes and LesL on
great toe and |atera| ma||eo|us |f not fe|t on great toe.
pos|non sense- show pL. rsL by movlng greaL Loe up and down w/ pL. eyes open. have pL. close eyes and
repeaL havlng pL Lell you wheLher up or down.
+ reexes
b|ceps reex- boLh sldes
brach|orad|a||s- boLh sldes
tr|ceps each slde
pate||ar
ach|||es
p|antar. use Longue blade Lo run along bouom of fooL- should curl Loes ln
+ coordlnauon
hnger-to-nose- move your nger as LargeL. Lhey reLurn nger Lo nose- Lhen Lo LargeL.pL should exLend arm
fully
dysd|adokokenes|a- have pL. slap fronL and back of hands agalnsL Lhe Lhlgh w/ lncreaslng speed
hee|-to-sh|n- LesL lower exLremlLy coordlnauon on each slde. have Lhem Louch/sllde heel down shln
romberg test- LesL for dorsal column slgns . have pL. sLand and puL feeL LogeLher, arms aL sldes, closed eyes
observe pL. for 13 seconds for falllng
observe ga|t- have pL. walk across room, plvoL and reLurn
np-toe- have pL do same on up Loes
hee|s- SAA
hee|s to toe- SAA 'llke walklng on a ughLrope"
Cn
I- o|factory. usually noL LesLed
II- opnc. vlsual aculLy/ vlsual eld/opLhalmascope
III, IV, VI- occu|omotor, troch|ear and abducens. puplllary response Lo llghL, convergence, P"
V- tr|gem|na|. corneal reex, faclal sensauon, moLor- open mouLh, masseLer
VII- fac|a|. expresslon muscles, eyes shuL, wlde smlle, pu ouL cheeks
VIII- vesnbu|ococh|ear. nger rub by ears, webers, rlnne's
Ik, k- g|ossopharyngea|, vagus. palaLe exam, gag reex, uvular dlsplacemenL
kI- accessory. shoulder shrug [Lrap], pL Lurn head agalnsL reslsLance [SCM]
kII- hypog|ossa|. suck ouL and wlggle Longue.
physlcal exam
domesuc vlolence
malnly ask quesuons, don'L push lf Lhey don'L wanL Lo Lalk abouL lL. emphaslze vlcum's conLrol/condenuallLy.
do nC1 push agenda. emphaslze nC1 Lhelr faulL.
can you explaln whaL happened Lo you?
[lnclude or noL- Lhe ln[urles you have look Lo me llke someone who's been beaL up]
Lhe besL way l can LreaL you ls for you Lo be able Lo share wlLh me how you goL hurL...
Lhls ls a Lwo way sLreeL- my respons|b|||ty ls Lo make sure you feel safe here, everyLhlng you say ls condenual
and whaLever we declde Lo do ls your ca||. l won'L do anyLhlng LhaL you don'L ok.
your respons|b|||ty ls Lo Lell me whaL happened.
ask agaln lf Lhey are wllllng Lo share. lf noL or lf Lhey do ask Lhese quesuons:
genera|. who do you llve wlLh? klds? ages? lengLh of relauonshlp wlLh parLner? whaL ls your parLner and kld's
relauonshlp llke?
abuse. ever felL coerced or LhreaLened by someone ln your llfe? ever been pushed, punched, klcked? have
your klds ever been hurL by someone ln Lhe home?
home safety. do you have any weapons ln Lhe house? does anyone drlnk? use drugs?
p|an. do you have someplace safe Lo go LonlghL? do your klds? wlll you Lake a sheeL of resources? whaL
wlll you do lf Lhls happens agaln? whaL quesuons do you have?
sexual hx
sexua||y acnve? [lf no- when lasL, ever?]
S p's. parLners [#/gender/currenL/ln pasL]
pracuces [vaglnal/anal/oral/Lop/bouom]
pasL S1l's
preg hx/ plans [LM?]
proLecuon from preg and S1l's?
any concerns?
subsLance abuse
cage. have you ever been concerned abouL your drlnklng?
ever been annoyed by someone crluclzlng your drlnklng?
ever felL gu||ty abouL your drlnklng?
ever needed an eye-opener?
other quesnons.
ln whaL conLexL do you drlnk?
fam hx of alcohollsm?
has your drlnklng every aecLed work, relauonshlps, oLher
responslblllues?
ever had any uul's or crlmlnal charges?
he|p?
how do you feel abouL how much you drlnk?
ever LhoughL abouL or Lrled Lo qulL?
would you llke help ln Lrylng Lo cuL down?
lnfanL exam
look- movemenL, eyes [pup. response], sounds, ears and mouLh
||sten- lungs and hearL
fee|- pulses + fonuanelles + L.n.
pa|pate- abdomen
under d|aper- Lesucles, femoral pulses, hlp dysplasla, anus, dlmpllng, splne
assess- muscle sLrengLh by holdlng ln sLandlng posluon on exam Lable.
developmenLal exam
phys|ca| growth. charL, ask abouL eaung, pooplng, sleeplng
motor deve|opment. observe and ask
gross. cephallc Lo caudal
hne. proxlmal Lo dlsLal
cogn|nve deve|opment. ask parenL abouL acuvlues,
hearlng/speaklng
psychosoc|a|. ask parenL how Lhey lnLeracL wlLh oLhers,
respond Lo parenL leavlng, meeung sLrangers.
a loL of quesuon asklng, observlng, and reassurance of
parenL.
o
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a
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a
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klelnman quesuons
Conslder a pauenL's problem llsL as represenung poLenual dlmculues encounLered wlLh a) loss, or poLenual LhreaL of
loss, b) llfe-sLage Lransluons, or c) culLurally pauerned bellef sysLems LhaL poLenually conlcL wlLh wesLern medlcal
pracuce.
1. WhaL do you Lhlnk caused your problem?
2. Why do you Lhlnk lL sLarLed when lL dld?
3. WhaL do you Lhlnk your slckness does Lo you?
4. Pow severe ls your slckness? uo you Lhlnk lL wlll lasL a long ume, or wlll lL be beuer soon ln your oplnlon?
3. WhaL are Lhe chlef problems your slckness has caused for you?
6. WhaL do you fear mosL abouL your slckness?
7. WhaL klnd of LreaLmenL would you llke Lo have?
8. WhaL are Lhe mosL lmporLanL resulLs you hope Lo geL from LreaLmenL?
9. Should we expecL compllcauons?
10. WhaL has been your exLended famlly's experlence wlLh lllness?
11. Pas anyone ln your famlly faced an lllness slmllar Lo Lhe one you have now? lf so, whaL was lLs course?
12. WhaL ls your and your famlly's pasL hlsLory of recuperauon?
13. WhaL mlghL make heallng now a sLruggle for you?
14. uo you see yourself as havlng much Lo llve for?
lor auenL's lamlly Members:13. WhaL changes ln famlly responslblllues do you Lhlnk wlll be needed because of Lhe
pauenL's slckness?16. lf Lhe pauenL needs care or speclal help, whaL famlly members are golng Lo be responslble for
provldlng lL?17. lf Lhe lllness ls already chronlc or appears llkely Lo become chronlc, whaL are Lhe pauenL's and famlly
members' plans for Laklng care of Lhe problem over Lhe long Lerm?
general/ new pL
CC.
nI. opqrst and oLher perunenL quesuons
Mn. general, chlldhood, adulL lllnesses? surgerles? chronlc? hosplLallzauons? lf female- C/?, LM? 8C?
IAM nk. age/healLh/deaLh of parenLs, slbllngs, grandparenLs. uM, P1n, sLroke, CA, asLhma, menLal lllness [sLarL
open ended- geL more speclc.
SCC. nk. blrLhplace, occupauon, educauon, rellglon, marrled/parLnered, klds, llvlng slLuauon
nA8I1S. drlnklng, smoklng, drugs, exerclse, dleL.
MLDS. name, dose, durauon Laklng Lhem.
ALLLkGILS.
kCS. general, skln, head, eyes, ears, nose/slnuses, mouLh/LhroaL/neck, breasLs, cardlac, resp., Cl, Cu.
AuL's
funcnona|. sLand from seaLed posluon w/o arms
|nstrumenta|. geL up from chalr, walk, reLurn and
slL.
test:
transfer. sLand from seaLed posluon
wa|k|ng. geL up from chalr, walk, reLurn, slL
ba|ance. sLand normally. one fooL ln fronL
of Lhe oLher, progresslvely farLher aparL.
MMSL
or|entanon to nme. daLe/day/monLh/year/season
or|entanon to p|ace. where are we? clLy/counLy/sLaLe.
|mmed|ate reca||. 3 words- have Lhem repeaL.
auennon. counL down from 100 by 7's + spell world backwards
de|ayed word reca||. recall Lhree prevlous words.
nam|ng. 2 lLems ln room LhaL you plck.
repennon. repeaL no lf's and's or buL's'
3 stage command. plck up paper, fold, show me.
read|ng. have Lhem read lnsLrucuons and do.
wr|nng. have Lhem wrlLe a senLence.
copy|ng. have Lhem copy a pauern wlLh Lwo
overlapplng shapes.
c|ock. have Lhem draw a clock aL ume of
11:10 or 2:30. Lhls LesLs execuuve fxn.