Physical Assessment Exam Study Guide Pt 2

PHYSICAL ASSESSMENT EXAMINATION STUDY GUIDE C. Temporomandibular Joint 1. Place the tips of your index fingers directly in front of the tragus of each ear. 2. Ask the patient to open and close their mouth. 3. Note any decreased range of motion, tenderness, or swelling. ************************************************************************************************* C. Examination of the Eye - see also Cranial Nerve II, III, IV, V Equipment Needed • • Snellen Eye Chart or Rosenbaum Pocket Vision Card Ophthalmoscope Visual Acuity In cases of eye pain, injury, or visual loss, always check visual acuity before proceeding with the rest of the exam or putting medications in your patients eyes. 1. Allow the patient to use their glasses or contact lens if available. You are interested in the patient's best corrected vision. 2. Position the patient 20 feet in front of the Snellen eye chart (or hold a Rosenbaum pocket card at a 14 inch "reading" distance). 3. Have the patient cover one eye at a time with an opaque card. 4. Ask the patient to read progressively smaller letters until they can go no further. 5. Record the smallest line the patient read successfully (20/20, 20/30, etc.) 6. Repeat with the other eye. Unexpected/unexplained loss of acuity is a sign of serious ocular pathology. Inspection 1. Observe the patient for ptosis, exophthalmos, lesions, deformities, or asymmetry. 2. Ask the patient to look up and pull down both lower eyelids to inspect the conjunctiva and sclera. 3. Next spread each eye open with your thumb and index finger. Ask the patient to look to each side and downward to expose the entire bulbar surface. 4. Note any discoloration, redness, discharge, or lesions. Note any deformity of the iris or lesion cornea. 5. If you suspect the patient has conjunctivitis, be sure to wash your hands immediately. Viral conjunctivitis is very contagious, so protect your self! Visual Fields - Screen Visual Fields by Confrontation 1. 2. 3. 4. 5. 6. Stand two feet in front of the patient and have them look into your eyes. Hold your hands to the side half way between you and the patient. Wiggle the fingers on one hand. Ask the patient to indicate which side they see your fingers move. Repeat two or three times to test both temporal fields. If an abnormality is suspected, test the four quadrants of each eye while asking the patient to cover the opposite eye with a card. Extraocular Muscles A. Corneal Reflections 1. Shine a light from directly in front of the patient. 2. The corneal reflections should be centered over the pupils. 3. Asymmetry suggests extraocular muscle pathology. PHYSICAL ASSESSMENT EXAMINATION STUDY GUIDE B. Extraocular Movement (EOM) 1. 2. 3. 4. 5. Stand or sit 3 to 6 feet in front of the patient. Ask the patient to follow your finger with their eyes without moving their head. Check gaze in the six cardinal directions using a cross or "H" pattern. Check convergence by moving your finger toward the bridge of the patient's nose. Pause during upward and lateral gaze to check for nystagmus (involuntary eye movement which differs in each eye). 6. Tests CN 3, 4, and 6 C. Pupillary Reactions 1. PERRLA is a common abbreviation that stands for "Pupils Equal Round Reactive to Light and Accommodation." The use of this term is so routine that it is often used incorrectly. If you did not specifically check the accommodation reaction use the term PERRL. 2. Look for direct and consensual responses. In a normal response, the eye which the light is shined has pupillary constriction (direct reflex) AND the other pupil also constricts (indirect or consensual reflex). An abnormal response (no pupillary constriction) can help to localize the lesion, particularly when interpreted with the result of vision testing. While observing the pupillary light response one should also check that the pupils are the same size. 3. Light a) Dim the room lights as necessary. b) Ask the patient to look into the distance. c) Shine a bright light obliquely into each pupil in turn. d) Look for both the direct (same eye) and consensual (other eye) reactions. e) Record pupil size in mm and any asymmetry or irregularity. 4. Accommodation If the pupillary reactions to light are diminished or absent, check the reaction to accommodation (near reaction): a) Hold your finger about 10cm from the patient's nose. b) Ask them to alternate looking into the distance and at your finger. c) Observe the pupillary response in each eye. Ophthalmoscopic Exam 1. Darken the room as much as possible. 2. Adjust the ophthalmoscope so that the light is no brighter than necessary. Adjust the aperture to a plain white circle. Set the diopter dial to zero unless you have determined a better setting for your eyes. 3. Use your left hand and left eye to examine the patient's left eye. Use your right hand and right eye to examine the patient's right eye. Place your free hand on the patient's shoulder for better control. 4. Ask the patient to stare at a point on the wall or corner of the room. 5. Look through the ophthalmoscope and shine the light into the patient's eye from about two feet away. You should see the retina as a "red reflex." Follow the red color to move within a few inches of the patient's eye. 6. Adjust the diopter dial to bring the retina into focus. Find a blood vessel and follow it to the optic disk. Use this as a point of reference. 7. Inspect outward from the optic disk in at least four quadrants and note any abnormalities. 8. Move nasally from the disk to observe the macula. 9. Repeat for the other eye. 10. Normal color should be creamy yellow-orange to pink. PHYSICAL ASSESSMENT EXAMINATION STUDY GUIDE Notes 1. Visual acuity is reported as a pair of numbers (20/20) where the first number is how far the patient is from the chart and the second number is the distance from which the "normal" eye can read a line of letters. For example, 20/40 means that at 20 feet the patient can only read letters a "normal" person can read from twice that distance. 2. You may, instead of wiggling a finger, raise one or two fingers (unilaterally or bilaterally) and have the patient state how many fingers (total, both sides) they see. To test for neglect, on some trials wiggle your right and left fingers simultaneously. The patient should see movement in both hands. 3. Diopters are used to measure the power of a lens. The ophthalmoscope actually has a series of small lens of different strengths on a wheel (positive diopters are labeled in green, negative in red). When you focus on the retina you "dial-in" the correct number of diopters to compensate for both the patient's and your own vision. ******************************************************************************************* D. Examination of the Chest and Lungs Equipment Needed • • Stethoscope Peak Flow Meter General Considerations 1. 2. 3. 4. The patient must be properly undressed and gowned for this examination. Ideally the patient should be sitting on the end of an exam table. The examination room must be quiet to perform adequate percussion and auscultation. Observe the patient for general signs of respiratory disease (finger clubbing, cyanosis, air hunger, etc.). 5. Try to visualize the underlying anatomy as you examine the patient. Inspection 1. Observe the rate, rhythm, depth, and effort of breathing. Note whether the expiratory phase is prolonged. 2. Listen for obvious abnormal sounds with breathing such as wheezes. 3. Observe for retractions and use of accessory muscles (sternomastoids, abdominals). 4. Observe the chest for asymmetry, deformity, or increased anterior-posterior (AP) diameter. 5. Confirm that the trachea is near the midline 6. A-P (anterior-posterior) diameter vs. transverse diameter a) A-P should be less than Transverse in adults; 1:2 – 5:7 b) Elevated A-P size = barrel chest, may be COPD in adult; normal in children Palpation 1. Identify any areas of tenderness or deformity by palpating the ribs and sternum. 2. Assess expansion and symmetry of the chest by placing your hands on the patient's back, thumbs together at the midline, and ask them to breathe deeply. 3. Check for tactile fremitus. (process page 16) PHYSICAL ASSESSMENT EXAMINATION STUDY GUIDE Percussion Proper Technique 1. Hyperextend the middle finger of one hand and place the distal interphalangeal joint firmly against the patient's chest. 2. With the end (not the pad) of the opposite middle finger, use a quick flick of the wrist to strike first finger. 3. Categorize what you hear as normal, dull, or hyperresonant. 4. Practice your technique until you can consistently produce a "normal" percussion note on your (presumably normal) partner before you work with patients. Diaphragmatic Excursion 1. Find the level of the diaphragmatic dullness on both sides. 2. Ask the patient to inspire deeply. 3. The level of dullness (diaphragmatic excursion) should go down 3-5 m symmetrically. Posterior Chest Anterior Chest Anterior Chest 1. Percuss from side to side and top to bottom using the pattern shown in the illustration. 2. Compare one side to the other looking for asymmetry. 3. Note the location and quality of the percussion sounds you hear. Posterior Chest 1. Percuss from side to side and top to bottom using the pattern shown in the illustration. Omit the areas covered by the scapulae. 2. Compare one side to the other looking for asymmetry. 3. Note the location and quality of the percussion sounds you hear. 4. Find the level of the diaphragmatic dullness on both sides. Interpretation Percussion Notes and Their Meaning Flat or Dull Pleural Effusion or Lobar Pneumonia Normal Healthy Lung or Bronchitis Hyperresonant Emphysema or Pneumothorax PHYSICAL ASSESSMENT EXAMINATION STUDY GUIDE Auscultation Use the diaphragm of the stethoscope to auscultate breath sounds. Posterior Chest 1. Auscultate from side to side and top to bottom using the pattern shown in the illustration. Omit the areas covered by the scapulae. 2. Compare one side to the other looking for asymmetry. 3. Note the location and quality of the sounds you hear. Anterior Chest 1. Auscultate from side to side and top to bottom using the pattern shown in the illustration. 2. Compare one side to the other looking for asymmetry. 3. Note the location and quality of the sounds you hear. Interpretation Breath sounds are produced by turbulent air flow. They are categorized by the size of the airways that transmit them to the chest wall (and your stethoscope). The general rule is, the larger the airway, the louder and higher pitched the sound. c) Vesicular breath sounds are low pitched and normally heard over most lung fields. d) Tracheal breath sounds are heard over the trachea. e) Bronchovesicular and bronchial sounds are heard in between. Inspiration is normally longer than expiration (I > E). 1. Breath sounds are decreased when normal lung is displaced by air (emphysema or pneumothorax) or fluid (pleural effusion). 2. Breath sounds shift from vesicular to bronchial when there is fluid in the lung itself (pneumonia). 3. Extra sounds that originate in the lungs and airways are referred to as "adventitious" and are always abnormal (but not always significant). Crackles Wheezes Rhonchi Adventitious (Extra) Breath Sounds These are high pitched, discontinuous sounds similar to the sound produced by rubbing your hair between your fingers. (Also known as Rales) These are generally high pitched and "musical" in quality. Stridor is an inspiratory wheeze associated with upper airway obstruction (croup). These often have a "snoring" or "gurgling" quality. Any extra sound that is not a crackle or a wheeze is probably a rhonchi. Low pitched. Special Tests A. Peak Flow Monitoring Peak flow meters are inexpensive, hand-held devices used to monitor pulmonary function in patients with asthma. The peak flow roughly correlates with the FEV1 1. Ask the patient to take a deep breath. 2. Then ask them to exhale as fast as they can through the peak flow meter. 3. Repeat the measurement 3 times and report the average. PHYSICAL ASSESSMENT EXAMINATION STUDY GUIDE B. Voice Transmission Tests These tests are only used in special situations. This part of the physical exam has largely been replaced by the chest x-ray. All these tests become abnormal when the lungs become filled with fluid (referred to as consolidation). C. Tactile Fremitus 1. 2. 3. 4. Ask the patient to say "ninety-nine" several times in a normal voice Palpate using the ball of your hand. You should feel the vibrations transmitted through the airways to the lung. Increased tactile fremitus suggests consolidation of the underlying lung tissues. D. Bronchophony 1. Ask the patient to say "ninety-nine" several times in a normal voice. 2. Auscultate several symmetrical areas over each lung. 3. The sounds you hear should be muffled and indistinct. Louder, clearer sounds are called bronchophony. E. Whispered Pectoriloquy 1. Ask the patient to whisper "ninety-nine" several times. 2. Auscultate several symmetrical areas over each lung. 3. You should hear only faint sounds or nothing at all. If you hear the sounds clearly this is referred to as whispered pectoriloquy. F. Egophony 1. Ask the patient to say "ee" continuously. 2. Auscultate several symmetrical areas over each lung. 3. You should hear a muffled "ee" sound. If you hear an "ay" sound this is referred to as "E -> A" or egophony. ************************************************************************************* E. Cardiovascular Examination and Peripheral Vascular System General Considerations 1. The patient must be properly undressed and in a gown for this examination. 2. The examination room must be quiet to perform adequate auscultation. 3. Observe the patient for general signs of cardiovascular disease (finger clubbing, cyanosis, edema, etc.). Pulses – see vital signs for radial pulse standards; Apical and others described below 1. Check the radial pulses on both sides. If the radial pulse is absent or weak, check the brachial pulses. 2. Check the posterior tibia and dorsalis pedis pulses on both sides. If these pulses are absent or weak, check the popliteal and femoral pulses. 3. Location of pulses a) Carotid – neck b) Brachial – upper arm c) Radial – wrist d) Femoral – groin e) Popliteal – behind knee f) Posterior tibial – back of leg near Achilles tendon g) Dorsalis pedis (pedal) – top of foot. Requires light touch PHYSICAL ASSESSMENT EXAMINATION STUDY GUIDE 4. Grading force of pulse 0 1+ 2+ 3+ absent weak, thready normal increased, full, bounding Blood Pressure – see vital signs (Blood pressure for process and interpretation) Pulse pressure: difference between the systolic and diastolic blood pressure reading. Amplitude and Contour (Carotid) 1. Observe for carotid pulsations. 2. Place your fingers behind the patient's neck and compress the carotid artery on one side with your thumb at or below the level of the cricoid cartilage. Press firmly but not to the point of discomfort. 3. Assess the following: a. The amplitude of the pulse. b. The contour of the pulse wave. c. Variations in amplitude from beat to beat or with respiration. 4. Repeat on the opposite side. Auscultation for Bruits (Carotids) If the patient is late middle aged or older, you should auscultate for bruits. A bruit is often, but not always, a sign of arterial narrowing and risk of a stroke. 1. Place the bell of the stethoscope over each carotid artery in turn. You may use the diaphragm if the patient's neck is highly contoured. 2. Ask the patient to inhale deep breath then exhale and hold momentarily. 3. Listen for a blowing or rushing sound--a bruit. Do not be confused by heart sounds or murmurs transmitted from the chest. Jugular Venous Pressure 1. Position the patient supine with the head of the table elevated 30 degrees. 2. Use tangential, side lighting to observe for venous pulsations in the neck. 3. Look for a rapid, double (sometimes triple) wave with each heart beat. Use light pressure just above the sternal end of the clavicle to eliminate the pulsations and rule out a carotid origin. 4. Adjust the angle of table elevation to bring out the venous pulsation. 5. Identify the highest point of pulsation. Using a horizontal line from this point, measure vertically from the sternal angle. 6. This measurement should be less than 4 cm in a normal healthy adult. Precordial Movement 1. 2. 3. 4. Position the patient supine with the head of the table slightly elevated. Always examine from the patient's right side. Inspect for precordial movement. Tangential lighting will make movements more visible. Palpate for precordial activity in general. You may feel "extras" such as thrills or exaggerated ventricular impulses. 5. Palpate for the point of maximal impulse (PMI or apical pulse). It is normally located in the 4th or 5th intercostal space just medial to the midclavicular line and is less than the size of a quarter. 6. Note the location, size, and quality of the impulse. PHYSICAL ASSESSMENT EXAMINATION STUDY GUIDE Capillary Refill 1. Press down firmly on the patient's finger or toe nail so it blanches. 2. Release the pressure and observe how long it takes the nail bed to "pink" up. 3. Capillary refill times greater than 2 to 3 seconds suggest peripheral vascular disease, arterial blockage, heart failure, or shock. Auscultation 1. 2. 3. 4. 5. Position the patient supine with the head of the table slightly elevated. Always examine from the patient's right side. A quiet room is essential. Listen with the diaphragm at the right 2nd interspace near the sternum (aortic area). Listen with the diaphragm at the left 2nd interspace near the sternum (pulmonic area). Listen with the diaphragm at the left 3rd, 4th, and 5th interspaces near the sternum (tricuspid area). 6. Listen with the diaphragm at the apex (PMI) (mitral area). 7. Listen with the bell at the apex. 8. Listen with the bell at the left 4th and 5th interspace near the sternum 9. Have the patient roll on their left side. Listen with the bell at the apex. This position brings out S3, S4 and mitral murmurs. 10. Have the patient sit up, lean forward, and hold their breath in exhalation. Listen with the diaphragm at the left 3rd and 4th interspace near the sternum. This position brings out aortic murmurs. 11. Record S1, S2, (S3), (S4), as well as the grade and configuration of any murmurs ("two over six" or "2/6", "pansystolic" or "crescendo"). Heart sounds S1: normal: closure AV, start systole, heard all over, loudest apex S2: normal: closure of semilunar valves, end systole, all over but loudest base, “dub” S3: extra heart sounds: vibrations that come from filling ventricles, start diastolic usually; audible in children, young adults, pregnant women – otherwise may be indicative of disease S4: extra heart sounds: end of diastolic, vibrations; usually abnormal to hear – may be indicative of disease PHYSICAL ASSESSMENT EXAMINATION STUDY GUIDE Murmurs 1. 2. 3. 4. Grade i-ii functional systolic murmurs are common in young children and resolve with age Auscultate for blowing, swishing sound. Some are ‘innocent” murmurs, but most are indicative of disease. Murmurs are graded. A grade “2” murmur would be rated ii/vi. Grade i ii iii iv v vi Description Barely audible. Heard only if room silent and then still hard to hear Clearly audible, but faint Moderately loud, easy to hear Loud, associated with thrill on chest wall Very loud, can hear with edge of stethoscope off chest Loudest, can hear with entire stethoscope off chest wall Edema, Cyanosis, and Clubbing 1. Check for the presence of edema (swelling) of the feet and lower legs. 2. Check for the presence of cyanosis (blue color) of the feet or hands. 3. Check for the presence of clubbing of the fingers. a) Normal = 160 degrees b) Curved = 160 degrees or less c) Early clubbing = 180 degrees Pitting edema: Scale 1+ 2+ 3+ 4+ Level of pitting Mild moderate Deep Very deep Indentation Slight Subsides rapidly Remains for short time Remains for long time Swelling of leg Not noticeable Leg looks swollen Grossly swollen and misshapen Lymphatics 1. 2. 3. 4. Check for the presence of epitrochlear lymph nodes. (antecubital) Check for the presence of axillary lymph nodes. (breast and arm) Check for the presence of inguinal lymph nodes. (groin) PEDIATRICS: to assess lymph nodes in younger children, tilt head slightly to check neck nodes. ******************************************************************************************** PHYSICAL ASSESSMENT EXAMINATION STUDY GUIDE F. Examination of the Abdomen Equipment Needed  Stethoscope General Considerations 1. When assessing start in RLQ over ileocecal valve 2. The patient should have an empty bladder. 3. The patient should be lying supine on the exam table and appropriately draped. 4. The examination room must be quiet to perform adequate auscultation and percussion. 5. Watch the patient's face for signs of discomfort during the examination. 6. Use the appropriate terminology to locate your findings: a) Right Upper Quadrant (RUQ) b) Right Lower Quadrant (RLQ) c) Left Upper Quadrant (LUQ) d) Left Lower Quadrant (LLQ) e) Midline: Epigastric f) Periumbilical g) Suprapubic Notes 1. Disorders in the chest will often manifest with abdominal symptoms. It is always wise to examine the chest when evaluating an abdominal complaint. 2. Consider the inguinal/rectal examination in males. 3. Consider the pelvic/rectal examination in females. Inspection 1. 2. 3. 4. 5. Look for scars, striae, hernias, vascular changes, lesions, or rashes. Look for movement associated with peristalsis or pulsations. Note the abdominal contour. Is it flat, scaphoid, or protuberant? Contour in newborn is normally protuberant and soft Contour in child is normally symmetric and slightly rounded Auscultation 1. Place the diaphragm of your stethoscope lightly on the abdomen. 2. Listen for bowel sounds. Are they normal, increased, decreased, or absent? Borborygmus = “growling” 3. Listen for bruits over the renal arteries, iliac arteries, and aorta. Percussion 1. Percuss in all four quadrants (clockwise) using proper technique: Inspect – Auscultation – Percuss – Palpate. 2. Categorize what you hear as tympanic or dull. Tympany is normally present over most of the abdomen in the supine position. Unusual dullness may be a clue to an underlying abdominal mass or full bladder.