Patient Assessment Practical Exam 1

Front 1

Technique for accurate measurement of blood pressure

Back 1

 No caffeine or nicotine for 30 minutes prior to measurement

 Rest for at least 5 minutes prior to measurement (may need to repeat)

 Quiet, comfortable room

 Ideally, the arm should be free of clothing

 Position the arm so the brachial artery (antecubital crease) is at heart level and relaxed

 Center the inflatable bladder over the brachial artery with the lower edge of the cuff 2-3 cm above the antecubital crease and secure snugly

 Using the bell mode (light pressure for low-pitch sounds) of the stethoscope, place the chestpiece over the brachial artery

 Inflate the cuff rapidly to the predetermined level and deflate at a rate of 2-3 mmHg per second

 The pressure at which you hear the first sounds is the systolic pressure

 As you continue to lower the pressure, the sounds will become muffled and disappear

 The pressure at which the sounds disappear is the diastolic pressure

Front 2

Heart rate (pulse) and rhythm

Back 2

Radial pulse - highly variable between patients

Rhythm (regular vs. irregular) - If irregular, is it regularly irregular or irregularly irregular (i.e. is there a pattern?)

Front 3

Respiratory rate and rhythm

Back 3

Usually performed by visual inspection for 1 minute

Normal adults breathe 14-20 times in 1 minute

Front 4

Temperature

Back 4

Oral - Normal 37 C/98.6 F (Range 35.8-37.3 C/96.4-99.1 F)

Front 5

Pain

Back 5

For the purpose of including pain in the vital signs, most adult patients are simply asked to describe their pain on a scale of 0 to 10

0 = pain free, 10 = the worst pain they can imagine

Location of pain is also documented if pain is present

Front 6

Head/Face plapation

Back 6

Gentle rotary movement progressing from front to back

Masses, nodules, tenderness

Hair texture and adherence

Temporal arteries

Lymph nodes (LAD = lymphadnopathy) (swelling of the lymph nodes)

Record - Normocephalic, atraumatic (NCAT). Normal hair distribution. Scalp without erythema, flaking, nits. Hair of normal texture and adherence. No lymphadenopathy (LAD)

Front 7

Lymph Node locations

Back 7

Preauricular - located just across from the ear (temple)

Tonsilar - directly below the ear and the jaw line

Submandibular - below the jaw line to the left and right of the chin

Submental - directly below the chin

Anterior/Posterior Cervical - located on the crevical muscle

Supraclavicular - located above the clavicle bone

Front 8

Neck Exam

Back 8

Inspection:
Bilateral symmetry of sternocleidomastoid and trapezius muscles

Alignment of trachea

Masses, nodules, erythema

Jugular Venous Distention (JVD) - CHF

Carotid artery prominence

Range of motion

Palpation:
Tenderness, deformity, masses
Tracheal position
Lymph nodes

Pertinent findings:
Rigidity (Meningeal signs)
Masses

Record - Neck supple. No JVD. Trachea is midline. No masses or nodes. Thyroid is of normal size and consistency, without nodule. Carotids are 2+, and no bruit.

Front 9

External Ear Exam

Back 9

Inspection:
Gently move auricles around - ask patient if painful

Size, Shape, Symmetry, Color
lesions, wax, edema, erythema, discharge

Palpation:
tenderness or deformity

Record - Pinnae are symmetric, with normal contours and no masses or tenderness

Front 10

Hearing Test: Whispered numbers

Back 10

The examiner stands arm's length (0.6 m) behind the seated patient and whispers a combination of numbers and letters (for example, 4-K-2) and then asks the patient to repeat the sequence

The examiner should quietly exhale before whispering to ensure as quiet a voice as possible

If the patient responds correctly, hearing is considered normal; if the patient responds incorrectly, the test is repeated using a different number/letter combination

The patient is considered to have passed the screening test if they repeat at least three out of a possible six numbers or letters correctly

Each ear is tested individually, starting with the ear with better hearing, and during testing the non-test ear is masked by gently occluding the auditory canal with a finger and rubbing the tragus in a circular motion

Record - Auditory acuity intact to whispered numbers A.D. and A.S. (right and left ears)

Front 11

Hearing Test: Weber Test

Back 11

Place pitchfork on patient’s head (midline to the body)

Ask patient where he/she hears vibrations

Interpretation: “good” ear with sensorineural hearing loss; “bad” ear with conductive hearing loss

Record - Weber equal. AC > BC A.D. and A.S.

Front 12

Hearing Test: Rinne Test

Back 12

Place base of pitchfork on mastoid bone behind ear and level with ear canal

When patient states he/she can no longer hear the vibration, place the fork close to the ear canal and see if he/she can still hear vibrations

Interpretation: Air conduction > bone conduction in normal and sensorineural hearing loss (Bone conduction > air conduction in conductive hearing loss)

Front 13

Otoscopic examination

Back 13

Put plastic otoscope cover on!

Straighten auditory canal
Hold otoscope like pen (between thumb and index finger)

Rest pinky against head to stabilize hand

Slowly insert speculum to ~ ½ inch

Avoid touching auditory canal walls

Record - External auditory canals are without erythema or lesion. Tympanic membranes are pearly gray with intact landmarks

Front 14

Cardiovascular Exam: Inspection

Back 14

Observation:
Physical and mental state, and respiratory efforts

Color: face, lips, fingers, toes

Front 15

Cardiovascular Exam: Palpation

Back 15

Apical Impulse:
Lay patient supine

Stand on patient’s right side

Place palm of right hand across patient

Heel rest along sternal border below nipple

Tip of middle finger in the 5th interspace

A small pulsation at the 4th or 5th interspace should be felt:
√ size, location, amplitude

Record - Apical impulse is barely palpable in 5th ICS just medial to L MCL, singular, 1 interspace in width

Front 16

Cardiovascular Exam: Auscultation

Back 16

Ideal patient position:
Supine, Head of table raised 30 degrees

Auscultate in pattern!

1) Aortic Area: 2nd right interspace

2) Pulmonic Area: 2nd left interspace

3) Tricuspid Area: Lower left Sternal border over 4th interspace

4) Mitral Area: Left 4th Interspace

Listen for S1 and S2:
S1 loudest over left 4th interspace (Mitral valve closure, begins systole)

S2 loudest along 2nd right and left interspaces (Aortic valve closure, begins diastole)

Record - S1, S2, of normal intensity. No murmurs or extra sounds

Front 17

Cardiovascular Exam: Carotid Artery

Back 17

Palpation:
Check carotid pulse
√ rate, amplitude

Auscultation:
Listen over both arteries with stethoscope (diaphragm)
Tests for thrills and bruits

Record - Carotid upstrokes are brisk, without bruits

Front 18

Eye Exam: Inspection

Back 18

All structures: Position & Alignment

Surrounding structures:
Eyebrows - √ size, extension, hair texture

Orbital areas – periorbital edema

Eyelids:
√ width of palpebral fissures
√ adequacy of closing, redness, swelling, flakiness

Conjunctivae & Sclera (normally white):
Ask patient to look up, draw lower lid down w/thumb

√ color, presence of erythema or exudate

Cornea, Lens, Iris:
√ if opacities – cataracts - cloudiness in the lens of the eye

Pupil:
√ size, shape, symmetry, reactivity

Normal pupil size (normally 3-5mm)

Lacrimal apparatus:
√ for swelling, excessive tearing or dryness

Record - Eyebrows and eyelids full and symmetric. Conjunctivae pink, corneas clear

Front 19

Eye Exam: Visual Acuity

Back 19

Far Vision – Snellen Chart:

Have patient stand 20 feet away from chart and cover one eye with card

Test each eye individually

If the patient wears glasses, test with and without them

Determine smallest line which patient can identify more than half the letters

Visual Acuity recorded as a fraction (eg. 20/40)

Numerator: distance of patient from chart

Denominator: distance which normal eye (population) can read the line

Near Vision – Rosenbaum Card:
Hold card at comfortable distance (~14 inches) from eyes

Front 20

Eye Exam: Visual Fields - Direct Confrontation Test

Back 20

Stand and face patient at a distance of ~ 20 inches

Have patient cover right eye while you cover your left eye (open eyes are directly opposite each other)

Extend your arm between patient and yourself

Move your arm in centrally while wiggling fingers

Have patient inform you when he/she sees fingers

Test 4 peripheral fields of vision

Documentation:
Normal peripheral vision by confrontation
Abnormal peripheral vision by confrontation

Front 21

Eye Exam: Pupillary Reaction to Light

Back 21

Face patient and have patient look at distant object behind you

Shine penlight into eye and observe constriction (DIRECT reaction)

Shine penlight again into same eye and watch opposite pupil constrict (CONSENSUAL reaction)

Repeat with opposite eye

Note any asymmetry or abnormality (PERRL)

Front 22

Eye Exam: Pupillary Reaction to Accommodation

Back 22

Face patient and have patient look at distant object behind you

Have patient change focus to test object (a pencil or your finger) held near the bridge of the nose

Note any pupillary constriction (PERRLA)

Front 23

Eye Exam: Extraocular Muscles - Movement

Back 23

Eye movement controlled by cranial nerves and 6 extraocular muscles

Have patient hold head still

Have patient watch your finger move through the 6 cardinal fields of gaze

Record: EOMI – Extra-ocular movements intact

Front 24

Eye Exam: Extraocular Muscles - Convergence

Back 24

Have patient hold head still

Have patient watch your finger or pencil as you move it towards the bridge of the nose

Converging eyes normally follow the object

Front 25

Fundoscopic Exam

Back 25

Dim lights in the room (when possible)

Switch on light to round beam of white light

Set diopter dial to zero

Ask patient to stare at object on the wall

Hold the scope to your right eye

Gradually approach the patient’s right eye with the scope

Look for the red reflex (orange glow in the pupil)

Follow the red reflex, continue to approach the eye, while focusing the scope with the diopter dial

Locate a blood vessel and follow it inward to the optic disc

Repeat procedure for left eye

Front 26

Respiratory Exam: Inspection

Back 26

Observation of breathing:
√ rate (14 – 20 bpm), rhythm, effort, depth

√ use of accessory muscles (pneumothorax, pleural effusion) (eg. sternocleidomastoids)

Listen for audible wheezing

Patient color (eg. cyanosis)

Observe shape of chest and movement:
√ for obvious chest or spine deformities

Front 27

Respiratory Exam: Palpation

Back 27

Expansion & Symmetry of Chest:

Place hands on patient’s back with thumbs pointed toward spine

Ask patient to inhale deeply

Feel for range and symmetry of rib cage

Fremitus:
Palpable vibrations

Place ulnar surface of hand on appropriate places on patient’s back (start at the shoulders and work your way around the shoulder blades)

Ask patient to say/repeat “ninety nine” or “one-on-one”

Feel for symmetric vibration

Record - Thorax symmetric with good expansion.

Front 28

Respiratory Exam: Percussion

Back 28

Method of evaluating consistency of tissue below the skin by the quality of the reflected sound

Pleximeter – finger on chest – middle finger (only the finger should be touching the patient, nothing else)

Plexor – tapping finger

Have patient cross arms

Percuss in symmetric locations

Use a ladder-like pattern (tap parallel from the spine and around the bottom of the shoulder blades)

Will hear dullness at diaphragm

Record - Lungs resonant

Front 29

Respiratory Exam: Auscultation

Back 29

Have patient sit upright and breathe deeply through an open mouth

Listen to sounds with diaphragm of stethoscope

Compare symmetric areas

Listen to at least 1 full breath in each location

For sounds, note:
Regions / Locations (start at the shoulders and work your way around the shoulder blades, then listen in the front around pectoral muscle)

Intensity

Pitch: Resonance (normal lung), hyperresonance (hyperinflated lung COPD), dullness (fluid), flatness (large plural effusion)
Duration of expiratory/inspiratory sounds (inspiration should last longer than expiration)

Presence of adventitious sounds – abnormal sounds like wheezes, rattles, crackles, rails, etc.

Record - Breath sounds vesicular; no rales, wheezes, rhonchi

Front 30

Respiratory Exam: Peak Flow Meter

Back 30

Make sure yellow indicator within “reset” diamond

Have patient take as deep a breath as possible

Place mouthpiece into mouth and seal lips

Blow out as hard and as fast as possible (“fast hard blast" )

Record number on scale

Repeat 3 times

Record the highest of 3 ratings

“Normal” PEF – based on gender, age, height – for asthma patients you use their personal best

Front 31

Respiratory Exam: Volumetric Exerciser

Back 31

Slide the yellow pointer to 2500-3000

Have patient exhale normally

Then place the mouth-piece around the in mouth and inhale slowly to raise the white piston.

While inhailing maintain "best" flow rate

Continue inhailing and try to reach the prescribe limit