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31 Cards in this Set
- Front
- Back
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Fisrt walk in the room
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Washes hands
Introduces self to patient |
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General Info & Observations
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-Note location, position and circumstances under which patient is examined
-Describe patient's age; race; sex; general appearance -Assess level of consciousness (state how it has been noted) -Assess orientation to person, place, time, and situation -General behavior/cooperation -Spontaneous speech (state it has been noted); comprehension (can follow command) -Note if patient is in any apparent distress |
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Vital Signs
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-Initiate Temperature, height and weight
-Pulse rate & rhythm -Respiration rate and rhythm -Blood Pressure (cuff must be over skin, not clothing & use proper technique) |
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INTEGUMENT (skin, hair, nails)
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-Inspect skin for overall color (pallor, cyanosis, jaundiced, etc.) and lesions
-Palpate skin for temperature -Palpate skin for hydration/texture/mobility & turgor -Inspect hair (head and on legs) for color, quantity, and distribution -Inspect fingernails and toenails for clubbing, cyanosis -Inspect hands & feet for ulcerations or other lesions (intertrigonal spaces too) |
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HEAD, FACE, & SCALP
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-Inspect head for cephalic size and signs of trauma; face for symmetry and pathologic facies
-Test muscle of facial expression (smile, frown, puff cheeks, show teeth, resist examiner opening of eyes, etc.) -Palpate head (skull, scalp, face) |
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EYES
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initiate
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EARS
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-Perform external ear exam (inspection)
-Assess auditory acuity to spoken voice, whispered voice, or watch tick -Perform Weber test (must use 512 Hz. tuning fork) -Perform Rinne test (must use 512 Hz. tuning fork -Check for pinna, tragus, and mastoid tenderness Otoscopic exam -Examine external auditory canals -Inspect TM's for intactness, color, contour, landmark |
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NOSE and SINUSES
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-Inspect & palpate the external nose for deformity
-Assess nasal patency, bilateral nares -Palpate maxillary and frontal sinues Nasal speculum exam (bilateral): -Inspect nasal mucosa for color, moisture, discharge, masses, lesions -Inspect turbinates (and meati) for color, polyps and septum for deviation, Kiesselbach's plexus, perforations |
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MOUTH
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-Inspect lips for color, lesions, symmetry
-Inspect oral cavity with light source and tongue blade: -buccal mucosa -gingivae and teeth -hard and soft palpate, tongue (depress tongue with blade), etc -Check tongue for midline protrusion, range of motion, and motor strength |
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THROAT
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-Inspect uvula, oropharynx, tonsilar pillars, and palatine tonsils
-Assess midline rise of soft palate and uvula with "ahh" -Assess gag reflex |
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NECK
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-Inspect neck for shape, symmetry, landmarks, masses, surgical scars
-Inspect thyroid gland including as patient swallows -Palpate thyroid isthmus before and during swallowing -Palpate thyroid lobes bilaterally before and during swallowing -Palpate carotid arteries -Ausculate for carotid bruits |
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LYMPH
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-Palpate cranial lymph nodes: occipital, post-auricular, pre-auricular, parotid,tonsilar )retropharyngeal), submandibular, and submental nodes
-Palpate cervical lymph nodes (anterior superficial, posterior superficial, and deep cervical chains) -Palpate for supraclavicular lymph nodes (esp. in area of Virchow’s nodes) -Palpate axillary lymph nodes (apical, mid-axillary, anterior, posterior, and lateral) -Palpate epitrochlear lymph nodes -Mention that you would Palpate "inguinal” and "femoral” lymph nodes |
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BREAST
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Initiate breast exam (state you would do it)
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THORAX & LUNGS (inspection)
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-Exposes patient’s chest so landmarks are visible
-Inspect symmetry of chest expansion, taking normal & deep breaths -Look for abnormalities in the inspiration:expiration ratio -Inspect for signs of labored respirations or other signs of resp. distress -Inspect AP:transverse diameter -Inspect (anterior) costal angle -Inspect for chest wall bony abnormalities |
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THORAX & LUNGS (palpate/percuss/auscultation)
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-Palpate thorax for symmetry, tenderness, bony abnormalities, etc.
-Palpate for thoracic expansion (rib excursion upon inspiration), anter. & poster. -Palpate for tactile fremitus -Anterior, Posterior, lateral thoraces -Percuss thorax -Anterior, Posterior, Lateral thoraces -Measure right and left diaphragmatic excursions by percussion (proper technique) -Auscultation: (proper technique of bilateral comparison) -Auscultate anteriorally -Auscultate posteriorally -Auscultate lateral lung fields (between anterior and posterior axillary lines) |
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CARDIAC (inspect/palpate)
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-Inspect (right internal) jugular venous pulse waveforms
-Measure (right internal) jugular venous pressure starting with HOB at 450 -Inspect for the apical impulse (PMI) -Palpate PMI -Inspect the precordium for abnormal movements -Palpate the precordium (at R base, sternum, L base, LSB, apex, L axilla, and epigastrium) for LV heaves, RV lifts, thrills, palpable heart sounds, etc. |
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CARDIAC (Auscultate)
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-Auscultates for rate, rhythm, heart sounds in (and correctly names aloud) all 5 main ausculatory areas:
-Aortic area (2nd RICS at sternal border) -Pulmonic area (2nd LICS at sternal border) -Second pulmonic area (Erb's Point) (3d LICS at sternal border) -Tricuspid area (4th LICS at sternal border) -Mitral area (5th LICS just inside MCL) -Auscultate with diaphragm in all 5 cardiac areas with patient semirecumbent or recumbent -Auscultate with bell in all 5 cardiac areas with patient semirecumbent or recumbent -Auscultate with diaphragm in all 5 cardiac areas with patient sitting -Auscultate with bell in all 5 cardiac areas with patient sitting -Auscultate with diaphragm at the base of the heart with patient in seated flexion position in expiration -Auscultate with bell and diaphragm at the apex with the patient in left lateral decubitus position |
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PERIPHERAL VASCULAR (arterial pulses)
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-Carotid arteries (see NECK)
-Palpate radial arteries -Say you would Palpate femoral arteries -Palpate popliteal arteries -Palpate dorsalis pedis arteries -Palpate posterior tibial arteries -Auscultate for carotid bruits (see NECK) -Auscultate for aortic, renal, iliac, & femoral bruits (see ABDOMEN) |
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PERIPHERAL VASCULAR (extremities)
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-Assess for temperature gradient & and color of upper and lower extremities (see INTEGUMENT)
-Assess capillary refill of fingernails -Assess capillary refill of toenails -Inspect for varicose veins (with patient standing), and other signs of venous insufficiency -Inspect for generalized edema ("anasarca" or "dropsy") -Inspect/palpate for dependent pitting edema over the ankles, anterior tibia -Inspect/palpate for non-pitting ("brawny") edema of the extremities |
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ABDOMINAL EXAM
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-Inspect abdomen (from side & foot of bed) during quiet breathing & deep inspir.
-Auscultate for bowel sounds (must be done in all four quadrants and epigastrium) -Auscultate (with bell) for abdominal aorta bruits -Auscultate (with bell) for renal artery bruits, bilaterally -Auscultate (with bell) for iliac artery bruits, bilaterally -Say you would Auscultate (with bell) for femoral artery bruits, bilaterally -Percuss in all quadrants abdomen and eipgastrium -Lightly palpate abdomen in all 4 quadrants and epigastric area -Deeply palpate abdomen in all 4 quadrants and epigastric area -Palpate liver -Palpate spleen -Fist percussion over bilateral CVA’s (warn patient first!) |
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MUSCULOSKELETAL (all Active ROM)
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-Overall general inspection of the standing patient (ant, post & lateral views) for posture
-Inspection of gait -Palpate and test AROM of Temporomandibular Joints (TMJ) -Inspect Cervical Spine including for ROM -Palpate (spinous and paraspinous areas) Cervical Spine -Inspect Thoracic Spine including for ROM -Palpate Thoracic Spine -Inspect Lumbar Spine including for ROM -Palpate Lumbar Spine -Inspect Shoulders including for ROM (winging of scapulae, name some landmarks) -Palpate Shoulders -Inspect Elbows including for ROM -Palpate Elbows -Inspect Wrists including for ROM -Palpate Wrists, phlanges -Inspect Hands including for ROM (screening like grip, claw hand…) -Palpate Hands, phalanges -Examine Legs for quadriceps symmetry & bulk, alignment, length… -Inspect Hips including for ROM -Palpate Hips -Inspect Knees including for ROM -Palpate Knees -Inspect Ankles including for ROM -Palpate Ankles -Inspect Feet and Toes including for ROM -Palpate Feet and Toes |
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Cranial Nerves (remainder of CN’s not mentioned above)
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-Facial sensation to sharp/dull in 3 div. of trigeminal nerve bi
-Facial sensation to soft touch in 3 div. of trigeminal nerve bi -Temporalis &/or masseter muscle tone -Swallowing function (must swallow a sip of water, not a “dry” swallow) -Motor strength of sternomastoid muscle |
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Deep Tendon Reflexes (must be done bilaterally)
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-Biceps
-Brachioradialis -Triceps -Patellar -Achilles |
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Superficial Reflexes (must be done bilaterally)
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Plantar Reflex (Babinski)
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Motor Strength Testing (must be done bilaterally)
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-Test overall muscle tone by passive ROM of a few selected joints
-Head & neck (flex/ext; R&L rotation) -Shoulders (flex/ext; ab/adduction) -Triceps/biceps -Hands (hand grip) -Fingers (flex/ext) -Quadriceps/hamstrings (knee or hip flex/ext) -Foot dorsiflexors /plantar flexors -Toe flexion/extension -Palmar Drift (Pronator Drift) Test |
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Cerebellar Function Tests
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-Observe gait (see under Musculoskeletal section)
-Heel-toe walking (“tandem” gait) -Upper extremity: choose ONE -Point-to-point (nose-finger-nose) testing, done bilaterally -Heel-knee-shin test, done bilaterally (must move heel up and down several times) -Lower extremity: choose ONE -Rapid alternating movements in upper extremities, done bilaterally -Rapid alternating movements in lower extremities, done bilaterally |
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Tests of Sensory Function (Spinothalamic Tract)
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-Pain (sharp/dull) on all four extremities (start distally)
-Light touch (cotton wisp) on all four extremities -Test (and correctly identify) spinal nerve dermatomes (at least 6 of the following): -prox. neck (C3) -thumb & index (C6) -medial foot (L4) -nipples (T4) -middle (C7) -mid-dorsum foot (L5) -umbilicus (T10) -ring and pinkie (C8) -lateral foot (S1) -inguinal (T12) (*done on palmar aspect of digit) |
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Tests of Sensory Function (Posterior Column proprioception)
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-Vibratory sense in fingers OR CHOOSE toes bi, distal DIP (128 Hz. tuning fork)
-Joint Position Sense fingers bi (grasp digits by lateral aspect) OR CHOOSE toes -Romberg Test with eyes closed and arms at sides (the classic Romberg test). EXAMINER MUST BE IN POSITION TO CATCH PATIENT! |
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Tests of Sensory Function (Sensory Cortex)
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-Stereognosis, bi (identify key, coin, or paperclip)
-Graphesthesia, bi (draw number in palm, oriented to pt.) -Point localization or extinction |
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GENITAL EXAM
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Initiate genital exam
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RECTAL
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Initiate rectal exam
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