Transcript Physical Examination Demonstration (up through abdominal exam

Physical Examination
Demonstration
Systems Approach
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A. PRELIMINARY Washes hands before starting
examination (in front of patient)
B. VITAL SIGNS Blood pressure done - 1 arm
Systolic BP estimated by palpation of brachial or radial
arteries with BP cuff
BP done correctly (not over clothing, cuff tight, arm
correct relaxed position, etc.)
Patient seated with back supported and both feet flat
on ground
Blood pressure taken with the bell of the stethoscope
Heart rate - at least 15 seconds checking radial pulse
with fingers, not thumb
Respiratory rate - inconspicuously watching chest
movement (at least 20-30 seconds)
Temperature (done correctly – will beep when done if
electronic)
10. C. HEAD Palpates scalp:
11. Palpates thoroughly (temples, including
over temporal arteries), parietal – sides
above ears, crown, occipital – back,
palpate temporomandibular joint as
patient opens and closes jaw
Eyes
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Inspect
Visual acuity
Extraoccular movements, accommodation
Visual fields
Pupillary response, swinging flashlight
Fundoscopic exam
Inspect, Visual acuity
Inspect, Visual acuity
12. D. EYES Inspects external ocular (eye)
structures (lids, conjunctiva, iris cornea,
pupils)
13. Gently moves eyelids up and down to
obtain better view
14. Checks acuity with Snellen and from
proper distance (12-14 inches and any
printed material is acceptable)
15. Checks acuity both eyes separately
Extraoccular movements,
accommodation
16. Evaluates extraocular movement (big H)
17. Checks convergence and
accommodation (follows finger from far
to near)
Six Cardinal Positions of Gaze
Convergence and
Accommodation
Need our picture
Needs illustration
Visual Fields
Visual fields
18.Visual fields - both eyes independently
19. Visual fields - eight cardinal directions for each
eye (N,NE, E, SE, S, SW, W NW)
20. Visual fields - simultaneous stimulation (each
eye should only be able to see on hand – the
one on that side)
21. Visual Fields – Examiners hands or object to
view introduced in the plane half-way between
patient and examiner
Pupillary response, swinging
flashlight
Swinging Flashlight Test
Pupillary response, swinging
flashlight
22. Pupillary response to light – direct (same
eye the light is directed into)
23. Pupillary response – indirect (eye light is
not directed into)
24. Swinging flashlight test (start in one eye,
quickly move to other eye, wait then fast
back to original eye and wait)
Fundoscopic exam
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Ophthalmologic Examination: Lights are dimmed
Examiner uses R hand R eye to look in R eye
Inspects anterior structures ophthalmoscope - R eye (start at +
15-40 to see anterior structures and move toward 0)
Inspects optic nerve - R eye (comes in at 15 0 with lens at 0 or
moving from the positive towards 0)
Traces vessels to all four quadrants - R eye
Observes macula - R eye (credit to be given if #28 and look
laterally)
Examiner uses L hand L eye to look in L eye
Inspects anterior structure ophthalmoscope - L eye (start at + 1540 to see anterior structures and move toward 0)
Inspects optic nerve - L eye (comes in at 15 0 with lens at 0 or
moving from the positive towards 0)
Traces vessels to all four quadrants - L eye
Observes macula - L eye (credit to be given if #33 and look
laterally)
Fundoscopic exam
Fundoscopic exam
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Ophthalmologic Examination: Lights are dimmed
Examiner uses R hand R eye to look in R eye
Inspects anterior structures ophthalmoscope - R eye (start at +
15-40 to see anterior structures and move toward 0)
Inspects optic nerve - R eye (comes in at 15 0 with lens at 0 or
moving from the positive towards 0)
Traces vessels to all four quadrants - R eye
Observes macula - R eye (credit to be given if #28 and look
laterally)
Examiner uses L hand L eye to look in L eye
Inspects anterior structure ophthalmoscope - L eye (start at + 1540 to see anterior structures and move toward 0)
Inspects optic nerve - L eye (comes in at 15 0 with lens at 0 or
moving from the positive towards 0)
Traces vessels to all four quadrants - L eye
Observes macula - L eye (credit to be given if #33 and look
laterally)
Ears
Inspect
Palpate
Acuity
Otoscope
Ears
36. E. EARS: Inspects externally bilaterally
(including behind ears)
37. Palpates auricles bilaterally
38. Otoscopic examination bilaterally
39. Otoscopic examination performed without pain
40. Auricles pulled superiorly, posteriorly, and
away from patient
41. Auditory acuity tested (eyes closed if finger rub
and you can see movement of hands or arm)
42. Auditory acuity tested correctly (each ear
independently, etc.)
Nose and Sinuses
• Nasal Speculum
• Palpate sinuses
Nose and Sinuses
43. F. NOSE Otoscope used with nasal speculum
to inspect nasal vault or may use otoscope ear
speculum
44. Nasal speculum examination done without
causing pain
45. Palpate frontal sinus for tenderness (medial
brow left and right, be sure not too high)
46. Palpate maxillary sinus for tenderness (correct
position)
47. Palpate ethmoid sinus (bridge of nose) for
tenderness
Mouth
• Look everywhere
• Say “ah”
Mouth
48. G. MOUTH Should use light source for
inspection
49. Inspect lips, gums, buccal mucosa, teeth
50. Inspect tongue, posterior pharynx
51. Inspect floor of mouth (under tongue)
52. Elevation of palate ("ah")
52. Examination done with minimal
discomfort
Neck
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Inspect
Carotids: palpate, auscultate (2)
Thyroid: isthmus and both lobes
10 lymph node areas
Carotids
10 Lymph Node Areas
Thyroid
Neck
54.H. NECK Inspects anterior neck for symmetry
55.Carotid arteries palpated
56.Carotid arteries correctly palpated, singly, (lower third of neck), fingers or thumb
57.Auscultation of carotid arteries (lower carotids bilaterally)
58.Auscultation of carotid arteries (upper carotids bilaterally)
59.Thyroid gland palpated: Palpation from behind, chin is slightly extended
(can palpate from front)
60.Hands in proper position (below the cricoid cartilage)
61.Palpates the isthmus and has patient swallow
62.Palpates the lobes and has patient swallow
63. I. LYMPH NODES - HEAD AND NECK Periauricular (in front of the ear)64.
65.Posterior auricular (behind the ear)
66.Occipital (base of skull)
67.Tonsillar (angle of jaw)
68.Submaxillary (mid-jaw)
69.Submental (under chin)
70.Posterior cervical (back of neck)
71. Superficial cervical (on top of the sternomastoid muscle)
72. Deep cervical (deep in the sternomastoid muscle)
73. Supraclavicular
Chest
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Posterior, anterior, lateral
Inspection
Chest expansion
Proper position
Start at apices
Tactile fremitus
Percussion
– Diaphragmatic movement
– Costovertebral angle
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Auscultation
Chest Expansion
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B.
Tactile Fremitus
Diaphragmatic Movement
CVA Tenderness
Posterior Chest
84. K. CHEST - Posterior Chest: Inspection: For symmetry
85. Palpation: Bilateral movement chest wall (hands on sides, try to bring thumbs
together, moderate pressure)
86. Palpation: For tactile fremitus (attempted)
87. Palpation: Alternates from side to side or may use both hands simultaneously
88. Percussion: Check diaphragmatic movement bilaterally
89. Percussion: Posterior lung fields (attempted)
90. Percussion: Alternates from side to side
91. Percussion: Done correctly bilaterally, symmetrically, good tone
92. Auscultation: Bilaterally (attempted)
93. Auscultation: Done correctly (above scapula, 3 - 4 places, throughout inspiration and
expiration)
94. Auscultation: Patient instructed deep slow breaths, mouth open
95. Auscultation: Alternates from side to side
96.Auscultation: At least 3 - 4 areas auscultated posteriorly
97. Arms crossed for tactile eremites, percussion and auscultation
98.Lateral Chest. Percussion laterally can be done as part of anterior or posterior
99.Auscultation laterally can be done as part of anterior or posterior
100.Other: Stethoscope placed examiner's ears correctly
101.Other: Correct order of inspection (palpation or percussion), auscultation
102.Percussion over costovertebral angle
Anterior Chest
73.J. CHEST -- Anterior Chest (lying or sitting or at 30 0) Inspection:
For symmetry
74.Palpation: For tactile fremitus (attempted)
75.Palpation: Alternates from side to side or may use both hands
simultaneously
76.Percussion: Anterior chest (attempted)
77.Percussion: Alternates from side to side
78.Percussion: Done correctly (bilaterally, symmetrically, good tone)
79.Auscultation: Bilaterally (attempted)
80.Auscultation: Done correctly (above clavicle, 3-4 places, listens
throughout inspiration and expiration)
81.Auscultation: Patient instructed slow, deep breath, mouth open
82.Auscultation: Alternates from side to side
83.Auscultation: At least 3-4 areas auscultated on each side
Cardiac Exam
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Jugular venous pulsation
Inspection
Palpation
Auscultation
Special maneuvers
Cardiac Exam
• Jugular venous pulsation
• Inspection
• Palpation
– Valve areas
– PMI
• Left lateral decubitus
• Auscultation
– Diaphragm
– Bell
• Tricuspid, mitral
• Special maneuvers
– Left lateral decubitus, apex, bell
– Sit up, lean, LLSB, exhale, diaphragm
Jugular Venous Pulsations
Jugular Venous Pulsations
PMI
Auscultation Areas
Auscultation Areas
Special Maneuvers: MS
Special Maneuvers: AR (AI)
CV Exam
103.L. CARDIAC Inspection jugular vein (remember can be done at 0, 15, 30, will likely
move table position)
104. Inspection done correctly; right side, head tilted left, patient elevated
105. Inspection, palpation and auscultation for rest of cardiac examination performed at
30 degrees
106.Inspection of all 4 areas
107.Palpation of aortic area (right second intercostal space just lateral to sternum)
108. Palpation of pulmonic area (left second intercostal space just lateral to sternum)
109.Palpation of right ventricular area (left lower sternal border)
110.Palpation of apical area (about fifth intercostal space mid-clavicular line)
111.If apical impulse not palpable, patient in left lateral decubitus
112.Palpation done with fingerpads in all 4 areas
113.Auscultation with Diaphragm Aortic area
114.Auscultation with Diaphragm Pulmonic area
115.Auscultation with Diaphragm Tricuspid area (left lower sternal border)
116.Auscultation with Diaphragm Mitral area (apical area)
117.Auscultation with Diaphragm Sitting, left lower sternal border, patient fully exhaled
118.Auscultation with bell. Tricuspid area
119.Auscultation with bell. Mitral area
120.Auscultation with bell. Mitral area in the left lateral decubitus position
121.Done correctly - Bell applied light pressure, not heavy (remember newer
stethoscopes diaphragm lightly OK)
122Other. Stethoscope placed in examiner's ears correctly
Abd Exam
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Inspection
Auscultation
Percussion
Palpation
Abd Exam
• Inspection
• Auscultation
• Percussion
– All 4 quadrants
– Liver span
• Palpation
– All 4 quadrants
– Liver
– Spleen
• Right lateral ducubitus
– Kidneys
– Aorta
Palpation: Liver
Palpation: Spleen
Palpation: Kidneys
Palpate R Kidney
Palpate L Kidney
Palpation: Aorta
Abd
123. M. ABDOMEN. Inspection with adequate exposure (lower chest to pelvis)
124. Auscultation: Listens at least 10 secs. (one place or can move to several areas,
must listen for at least 10 secs)
125. Percussion: L abdomen above below umbilicus
126.Percussion: R abdomen above below umbilicus
127. Percussion: Liver span (measure liver span, may do scratch test)
128. Palpation: Lightly, all 4 quadrants
129.Palpation: Deeply, all 4 quadrants
130. Palpation: Liver (attempts to do)
131. Palpation: Liver (correctly – palpating deepest full inspiration, 1 hand under one
hand palpating or 2 palpating)
132. Palpation: Spleen (attempts to do)
133. Palpation: Spleen (correctly - position, breaths, palpating deepest full inspiration, 1
hand under L side, 1 feeling)
134. Palpation: Spleen (if not palpable, R lateral decubitus)
135. Palpation: R kidney (take a deep breath, capture kidney, exhale, slowly release
kidney
136. Palpation: L kidney (take a deep breath, capture kidney, exhale, slowly release
kidney)
137. Palpation: For abdominal aorta (to feel both the left and right walls of the aorta)
138. Palpation: Inspects patient’s face during palpation (at least 50% of the time)
139. In correct order: Inspection, auscultation, percussion and palpation
140. Abdominal Examination was done at 0.