Physical Exam

Front 1

Main Segments

Back 1

1. Intro

2. Vitals

3. HEENT

4. Posterior Thorax and back

5. Anterior Thorax

6. Heart

7. Abdomen

8. Upper extremities

9. Lower Extremities

10. Closing

Front 2

HEENT Sections

Back 2

1. Eyes

2. Ears

3. Nose

4. Mouth

5. Lymph nodes

6. Thyroid

Front 3

Posterior Thorax Sections

Back 3

1. Introduction/setup

2. Inspect/Palpate

3. Percuss

4. Auscultate

Front 4

Anterior Thorax Sections

Back 4

1. Position

2. Inspect

3. Palpate

4. Percuss

5. Auscultate

Front 5

Heart Sections

Back 5

1. Position

2. Palpate for PMI

3. Auscultate

4. Auscultate with bell

Front 6

Abdomen Sections

Back 6

1. Position and setup

2. Inspect

3. Auscultate

4. Percuss

5. Palpate

Front 7

Ending

Back 7

1. Upper Extremities

2. Lower Extremities

3. Wash hands. End.

Front 8

Introduction Steps:

Back 8

Start of Exam:

1. Introduce self (use name, role etc)

2. Demonstrate concert for comfort and privacy

3. Explain exam to patient, but dont ask too much permission

4. Use lay language

5. Have exam available and in easy reach.

6. Minimize patient repositioning

7. Make sure hands are clean and proceed!

8. Observe general appearance (outloud)

9. inspect exposed skin of head and neck (out loud)

Front 9

Vital Signs Steps:

Back 9

First:

1. Check radial pulse for 15 seconds (if regular)

2. Check respiratory rate for 30 seconds.

BP:

1. Roll up sleeve and check cuff size.

2. place cuff snugly, support arm.

3. Palpate radial pulse, then inflate cuff till pulse disappears, note palpatory BP

4. Keep supporting arm at heart level, listen with diaphragm or bell over brachial artery.

5. inflate cuff to 30mm hg over palpatory pressure, let air out at 3mm hg/second. Note ausculatory BP.

Front 10

Eyes Steps

Back 10

Inspection:

1. Inspect eyebrows and eyelids, globe, pupil

2. Pull lower lids down to examine palpebral and bulbar cunjuntivae.

3. ask patient to look up, left and right.

Opthalmoscopic Exam:

1. Darken room and explain

2. 15" away and 15° lateral to patient line of vision

3. Turn on opthalmoscope and choose large round beam of white light

4. use right hand for right eye, left hand for left.

5. set to 0 diopter

6. tell patient to look at point of wall.

7. brace scope on eyebrow

8. shine light into patients pupil, looking for the red reflex.

9. move in with the ophthalmoscope and your eye as one unit, keeping beam focused on red reflex until you are almost touching the patients eyelashes, focus accordingly.

10. examine optic disc (say out loud)

11. Exam all four quadrands of the fundus by following major vessels from optic disc to periphery.

12. repeat on left eye.

Front 11

Ears Steps

Back 11

1. Inspect Pinna, tragus and mastoid area

2. apply otoscope tip and turn on

3. hold in right hand for right ear

4. pull back and up gently on the antihileix with other hand, brace oto with hand

5. gently insert oto tip into auditory canal, look through lens

6. advance tip slowly to visualize tympanit membrane, adjusting position of the antihelix if needed.

7. repeat with left hand and left ear.

Front 12

Nose Steps

Back 12

1. Apply new oto tip, turn on again.

2. tip head back slightly gently compress tip of nose.

3. examine the vestibule of each nostril with illumination.

4. gently insert otoscope tip into each nostril to examine mucosa and turbinates

Front 13

Mouth steps

Back 13

1. Moisten tongue depressor and use it to expose surfaces of the mouth while examinig them with illumination.

2. examine lips, mucusa, gingiva and sides of teeth

3. examine hard and soft palate

4. examine dorsum of tongue.

5. examine lateral borders, base and beneath tongue.

6. ask patient to phonate (ahhh) and examine posterior oropharynx and soft palate

Front 14

Lymph nodes steps

Back 14

1. Make slow circle with finger pads, apllying pressure lightly, moving the skin over the udnerlying structures.

2. palpate preauricular, posterior auricular and occipital areas.

3. palpate anterior triangle (tonsillar, submandibular, submental, and deep cervicle lymph node chains)

4. palpate superficial cervical lymph node chain (over the SCM muscle)

5. palpate the posterior triantle (posterior cervicla lymph node chain)

6. palpate the supraclavicular area, asking patient to put hand on hip and roll arm forward to open fossa.

Front 15

Thyroid steps

Back 15

1. Inspect neck for thyroid gland (use tangential light, ask patient to swallow, offer sip of water if needed).

2. flex neck slightly forward, place index finger just below cricoid cartilage and palpate isthmus of the thyroid during swallow.

3. palpate left lobe w/ 2 fingers of right hand in space between trachea and SCM

4. Same on left side with left hand.

Front 16

Posterior Thorax/Back Positioning/Intro Steps

Back 16

1. Sitting on bed, remove arms from gown

2. Inspect back for skin abnormalitiies, musculoskeletal symmetry and alignment (out loud)

3. palpate spinal processes with firm pressure, ask to report for tenderness, neck to sacrum

4. prescuss spinous processes with light blows for tenderness, from neck to sacrum.

5. precuss costovertebral angles with light blows on each side.

Front 17

Posterior Thorax/Back Percussion Steps

Back 17

1. Use proper technique.

2. Observe rules of twos.

3. percuss paravertebral line. 5 spots on each side.

4. percuss posterior axillary line, 2 locations on each side.

Front 18

Posterior Thorax/back Auscultation Steps

Back 18

1. Instruct patient to breateh deeply through an open mouth

2. Listen to diaphragm through at least one complete respiratory cycle in each space.

3. RULE OF 2s

4. auscultate paravertebral line, 5 locations on each side.

5. auscultate posterior axillary line, 2 locations on each side.

Front 19

Anterior Thorax Into/Palpation Steps

Back 19

1. Untie gown, position it to cover anterior chest.

2. Elevate head of table to approx 30°, and have patient lie supine.

3. Extend end of table for patients feet.

4. inspect antior chest (out loud)

5. Palpate costochondrial junctions

6. Palpate Sternum

Front 20

Anterior Thorax Percussion Steps

Back 20

1. Use proper technique. again.

2. RULE OF TWOS

3. Percuss mid clavicular lines from the apex to the base, 4 positions on each side

4. Percuss anterior axillary lines to teh base. 2 positions each side.

Front 21

Anterior thorax Auscultation Steps

Back 21

1. Ask patient to breathe deeply through an open mouth

2. listen with diaphragm through at least one compete respiratory cycle. (in- and expiration) in each area.

3. RULE OF TWOS

4. auscultate the mid clavicular line from the apex to the base. 4 positions each side.

5. Auscultate the anterior axillary line to the base. 2 positions each.

Front 22

Heart Positioning/intro steps.

Back 22

1. 30° again, chest uncovered.

2. Palpate from PMI by inching in the 5th intercostal space (ICS) from the left sternal border (LSB) to the anterior axillary line (AAL)

Note: PMI is only palpable on 20-40% of healthy adults, tangential light may help...

Front 23

Heart Auscultation steps

Back 23

1. Use Diaphragm.

Auscultate the:

R 2nd interspace (aortic area)

L 2nd interspace (pulmonic area)

L 3rd

L 4th

L 5th (tricuspid area)

Apex - L 5th interspace, mid clavicular line (MCL).

In from Apex to AAL

2. Use bell.

Auscultate the L 5th interspace (tricuspid area) and L 5th int. MCL (mitral area)

Front 24

Abdomen Position/intro Steps

Back 24

1. 30° or flat

2. drape patient so area from xiphoid to pubic symphysis is exposed. (allow patient to put arms in gown, re-tie, and lift it above xiphoid if desired)

3. position patients with arms at sides or across chest and ask patient to bend (flex knees)

4. Inspect abdomen (look at skin, contour, peristalsis, pulsations, dilated vessels, umbilicus) (out loud)

Front 25

Abdomen Auscultation Steps

Back 25

AFTER INTRO, BEFORE PERCUSSIONS AND PALPATIONS.

1. Auscultate in one area for bowel sounds (dia or bell)

2. Auscultate renal arteries (bell)

3. Auscultate aorta (midline) (bell)

4. Auscultate common iliac arteries, right and left (midway between the anterior superior iliac spine (ASIS) and the umbilicus) with bell.

Front 26

Abdomen percussion steps

Back 26

After Auscultation, before Palpation

1. Proper technique

2. percuss all 4 quadrants

3. Percuss the liver span at the right MCL, beginning at the level of the umbilicus first and moving superiorly, marking the skin where dullness begins.

4. Percuss from above, beginning at the nipple line in the MCL (gently displace a woman's breast or ask her to do so for you if necessary) and move inferiorly, marking the skin where dullness begins

5. Measure the span (usually 6-12 cm)

6. Percuss the spleen in the ICS, AAL and on the left both at rest and with deep inspiration.

Front 27

Abdomen palpation steps

Back 27

After Auscultation and Percussion

1. Place contact hand (either hand) on patient's abdomen with finger pads of the hand over the DIP joints of the contact hand.

2. Palpate lightly and then deeply until the surface of the abdominal viscera are palpated in each location.

3. Follow a sequence that covers all four quadrants of the abdomen.

Liver palpation

1. Place left hand behind patient's right lower ribs and lift posterior thorax upward.

2. Place right hand with fingertips at the level of the umbilicus in the MCL

3. Palpate during inspiration, move the hand closer to the costal margin during expiration. continue sequence until liver edge is palpated (in most patients, you will not be able to palpate the liver edge below the costal margin)

Palpate the spleen.

1. Have patient roll to the right, lateral decubitus position, with knees and hips flexed.

2. Place left hand behind patients left lower ribs and lift the posterior thorax and spleen towards you.

3. Place right hand with fingertips at the umbilicus

4. Palpate during inspiration, move the hand closer to the costal margin during expiration. continue sequence until spleen edge is palpated (the spleen is palpable in only 5% of normal adults)

Front 28

Upper Extremities Steps

Back 28

1. Evaluate bilateral Radial pulse simultaneously and compare

Front 29

Lower Extremities Steps

Back 29

1. Press firmly with a finger over medial anterior tibia for 5 seconds to check for pitting edema (bilaterally)

2. Press firmly with finger over dorsum of foot for 5 seconds to check to pitting edema (bilaterally)

3. Palpate bilateral posterior tibial pulses (behind medal malleoulus) simultaneously and compare.

4. Palpate bilateral dosalis pedis pulses simultaneously and compare.

Front 30

Closing steps

Back 30

1. Clean hands.

2. Celebrate being done.