Exam1 / Lecture 2: Physical Exam Flashcards
What are the 2 Hearing Tests and when are they used?
- Weber’s Test - using a tuning fork on R/L ears to evaluate conductive and sensorineural hearing losses
- Rinnes Test - evaluates hearing loss by comparing air conduction to bone conduction
These tests will be used for Craniotomies so *think about your devices and how to position the patient. *
slide 98
What are the concerns for Nose and Sinuses surgeries?
Concerns include:
* barotrauma
* air trapping
* bleeding
* risk for Meningitis
especially with ETT placement through the nose.
REMEMBER: pretreat if possible
slide 99
What to inspect on the lips?
- lesion
- pallor - indicates anemia
- cyanosis - indicates hypoxia or hypoperfusion (respiratory, cardiovascular problems)
- cherry colored - indicates Carbon Monoxide poisoning
- swelling
- dryness - common complaint, use lacrilube
- smoothness
remove lipstick before examination of lips
slide 100, slide 105, slide 106
What to inspect on the buccal mucosa?
- jaundice
- pallor
- leukoplakia (thick white patches that is precancerous)
slide 100
What to inspect on the neck?
- anatomical position
- function of the* sternocleidomastoid muscle* (flex the next with the chin to the chest)
- function of the trapezius muscle (move head sideway so the ear moves toward the shoulder)
slide 100, Slide 111
What are abnormal findings of the tongue?
- Color - pallor, cyanosis, redness
- lesions
- white coating
- fissure (dry and crusty) - due to dehydration
- bright red - seen in Iron, B12, or Niacin deficiency
- black - necrosis and poor perfusion
can also see assess Tonsils and see if it is red
slide 101
What to assess with the Nose?
- shape
- size
- lesions
- inflammation
- deformity - check for cartilage damage
- edema
- mucus color
- patency of nares
- epistaxis (bleeding)
- discharge
- Polyps - important because it can get in the way with nasal intubation
*Pen light and nasal speculum *can be used to view inside of nares.
Slide 102, Slide 103
How to assess the Sinus?
Transillumination - take a light source and shine it through the Frontal sinus and Maxillary sinus and ask patient to open their mough and see if light shines through and assess some degree of fluid.
Slide 104
What to assess with Teeth?
- Dental hygiene
- loose teeth
- color of teeth - check for dental carries
- halitosis
- dentures
- arrangement - Upper molar should rest directly on the lower molar with upper incisors slightly overriding the lower incisors. ANY DEVIATION IS NOT A GOOD THING
Slide 107, Slide 108
What to assess with the Gums?
- color
- edema
- gingivitis
- ulcer
- sponginess - can bleed easily and indicates vit-C deficiency
- Leukoplakia (thick white patches) due to smoking and alcohol
healthy gums are pink, smooth, and moist
Slide 101, Slide 109
How and what to assess with the Pharynx?
- Inspect for: edema, ulcer, inflammation, lesions
- Gag reflex
- Dysphagia
How to assess: Extend his neck slightly, open the mouth widely and say “ah‟.
Place tongue depressor on the middle third of tongue. Use penlight for inspection
Slide 110
Where is the Thyroid gland located and what to assess?
Location: anterior lower neck, both sides of trachea
Inspect for visible mass of thyroid gland, symmetry and fullness at the base of neck.
Palpation: Flex the neck forward and laterally toward the side being examined. Give water then see for bulging of the gland
Slide 112
What to assess with Female breasts?
- symmetry
- pain
- lump - indicates abnormal tissue
- discharge
- swelling
- trauma - can cause loss sensation of nipple due to positioning of electrodes
- history of breast disease
- past surgey - mastectomy, thoracic
Slide 113
What to assess with Male breasts?
- lump
- swelling
- gynecomastia
Men can also have breast cancer
Slide 114
What to assess with Thorax and Lung?
- size
- shape - barrel chest (COPD) / concave chest (Pectus excavatum)
- chest movement
- respiratory rate
- rhythm
- breathing pattern
- breath sounds
- chest pain with breathing - flail chest = shunting
- cough - productive vs nonproductive
- hemoptysis - what is the cause
Slide 115, Slide 116
What to assess with Cardiovascular System?
- Apical pulse - located at the 5th ICS
- Radical pulse
- Heart rate
- Rhythm
- Perfusion
- Edema – site of edema
- Cyanosis or Pallor
- Fatigue/Syncope
Slide 117, Slide 118
What to assess with Gastrointestinal system?
- Abdomen
1. size
2. shape
3. abdomen distention
4. surgical mark
5. ostomy present
6. bowel sounds - stool frequency/character
- last bowel movement
Slide 119
What to assess with Genitourinary system?
- urinary complaints
- discharge
- anuria
- hematuria
- dysuria
- urinary incontinence
- urinary retention
- urine
- last voided
- Catheter present
- Male - opening of penis & location, penile discharge
- Female - LMP, Vaginal discharge
slide 120, slide 121
What to assess with Musculoskeletal?
- Weakness
- Paralysis
- Contracture
- Joint swelling
- pain
- Extremity strength
- ROM
Slide 122
What are the types of Range of Motions (ROM)?
- Wrist Extension vs. Flexion
- Elbow Flexion vs. Extension
- Shoulder Abduction (away from body) vs. Adduction (towards the body)
-
Knee Flexion vs. Extension - check for Deep Tendon Reflexes due to Magnesium
*** Plantar flexion vs. Dorsiflexion **
Slide 124 - Slide 127
What do we assess on the Spine?
Curvature of the spine
Types:
* Lordosis - increased lumbar curvature
* Scoliosis - lateral spinal curvature
* Kyphosis - exaggeration of posterior curvature of thoracic spine
Slide 128
What do you check during Neurological Examination?
- Orientation - place/ person/ time
- Level of Consciousness - confused/ alert/ restless/ lethargic/ comatose
- Coordination to walk
- Equilibrium test
- Sensation test
Slide 129
What is a Romberg test?
Test that determines a patient’s balance related to proprioception.
Ask the patient to keep their feet together and their hands outstretched in front of them. Then ask them to shut their eyes for a few seconds. Reassure them that you will be near them in case they become unstable and fall
Slide 130
What is a Pronator Drift Test?
a pathological neurological sign to detect upper limb weakness.
- Stroke evaluation
Slide 131
How to assess Biceps Reflex
- Identify biceps tendon
- have patient flex elbow against resistance while you palpate antecubital fossa
- Place arm so it’s bent ~ 90 degrees
- Place one of your fingers on tendon and strike it.
Reflex: Flexion of arm at elbow.
Slide 133
- Flex patient’s arm at elbow, holding arm across chest or hold upper arm horizontally.
- Strike triceps tendon just above elbow.
Reflex : Extension at elbow.
Slide 135
How to assess Patellar reflex?
- Have client sit with leg hanging freely over side of table.
- Tap patellar tendon just below patella.
Reflex : Extension of lower leg.
Slide 137
How to
How to assess Achilles reflex?
- Have patient assume same position as for patellar reflex.
- Slightly dorsiflex patient’s ankle by grasping toes in palm of your hand.
- Strike Achilles tendon just above heel at ankle malleolus.
Reflex : Planter flexion of foot.
How to assess Plantar reflex?
- Have patient lie supine with legs straight and feet relaxed.
- Take handle end of reflex hammer and stroke lateral aspect of sole from heel to ball of foot, curving across ball of foot toward big toe.
Reflex : Planter flexion of all toes.
1/18/23
How do you assess the eyes?
Inspect external eye structure, position and alignment (like exophthalmos or strabismus)
- think about endocrine disorders or trauma!
(Slide 86)
1/18/23
What do we need to consider for patients with glasses or contact lenses?
Remove them!
- Glasses so they don’t break b/c expensive
- Contacts can cause corneal ulcers & abrasions!
(Slide 88)
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When assessing eye/eyelids:
What is ectropion?
What is entropion?
What is ptosis?
Ectropion: eversion, lid margin turn out
Entropion: inversion, lid margin turns inwards
Ptosis: abnormal drooping of lid over pupil
(Slide 87)
1/18/23
How does anesthesia cause ptosis (droopy eyelid)? Is it normal?
Think Horner’s syndrome:
- persistent miosis (small pupil)
- difference in pupil size between the two eyes (anisocoria)
- Little/delayed dilation of the affected pupil in dim light
- Drooping of the upper eyelid (ptosis)
- Slight elevation of the lower lid, sometimes called upside-down ptosis
- Sunken appearance to the eye
- Little or no sweating (anhidrosis) either on the entire side of the face or an isolated patch of skin on the affected side
YES! these are normal signs when doing an interscalene block, tells you you got a good block
(Slide 87)
1/18/23
Whats the treatment for a stye?
Warm moist towel, helps increase perfusion and unclog the duct.
(Slide 88)
1/18/23
What can cause corneal abrasions? What can we do to prevent these?
Contacts or eyelashes!
Take out contacts and tape eyelids before allowing anything to scratch cornea!
(Slide 88)
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How do we cause and fix constricted pupils?
Opioids -> Narcan
(Slide 89)
1/18/23
When assessing the eye, what is PERRLA?
“Pupils equal, round, and reactive to light and accommodation”
(Slide 89)
1/18/23
What is arcus senilis? is it common?
- a depositing of phospholipid and cholesterol in the peripheral cornea in patients over the age of 60
- appears as a hazy white, grey, or blue opaque ring.
- Arcusis common and benign when it is in elderly patients.
(Slide 89)
1/18/23
In what stage of anesthesia do the pupils partially dilate?
Stage 2
(Slide 89)
1/18/23
What is accommodation?
eyes’ ability to see things that are both close up and far away.
- If your pupils are nonreactive to accommodation, it means they don’t adjust when you try to shift your focus to an object in the distance or near your face.
(Slide 90)
1/18/23
What do you do if you see something worrisome with patient’s pupils?
Call ophthalmology for consult!
(Slide 91)
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What’s the Snellen test?
big E chart (eye exam) but assessment of visual acuity “Can also be as simple as focusing on and counting fingers”
(Slide 92)
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Why does assessing extra ocular movement matter?
- consider nerves that may be impacted by regional anesthesia or injury
- An orbital fracture with nerve or muscle entrapment is an emergency vs a delayed procedure.
- consider possible stroke
(Slide 93)
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What can cause peripheral vision loss?
- optic nerve damage from glaucoma
- neuro damage from stroke, disease or head injury
- papilledema
(slide 94)
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What’s important when assessing ears?
positioning and alignment!
- don’t allow pressure on ear itself, might need a donut
- especially during lateral position!
(Slide 95)
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What is cauliflower ear?
repeated trauma to someone’s ear with scarring and ears are massive and cauliflower-like.
- will need extra padding!!
- void putting pressure on the ear itself = a donut is placed around the ear
(Slide 95)
1/18/23
What is important about someone with hearing aids?
Make sure you secure them b/c very expensive, also make sure they have them and can hear you for postop assessment
(Slide 96)
What is battle sign?
Ecchymosis/ bruising around the eyes and behind ears. Caused by basiliar skill fracture, orbital injury or spontaneous bleeding
Slide 69
What causes petechiae?
Thrombocytopenia, medications, infections, leukemia, sepsis, DIC, prolonged straining.
They lost capillary integrity and cells popped open
Slide 70
What are the possible causes of skin lesions?
Abuse, infection, Kaposis sarcoma (caused by AIDS), cigarette burns, diabetes skin breakdown
slide 71
What can cause edema
Edema can occur as a result of systemic issue such as cardiac failure or a localized issue such as inflammatory response to a sting. Should be symmetrical- if not, think DVT, infection
Slide 73
What are the grades of pitting edema?
Grade 0: none
Grade 1: trace; 2mm (disappears fast)
Grade +2; 4mm (10-15s)
Grade +3; 6mm (>1 min. deep!)
Grade +4; 8mm (lasts up to 5 minutes. very deep)
slide 75
What are nails abnormalities
Koilonychias (spoon nail)
Clubbing (smokers)
Paranychia
Indentations called (beau’s line)
Normal nails should be convex shped, smooth texture, pink and normal cap refill
Slide 77
What to assess when assessing head and neck and hair
Assess size, symmetry, for nodules or masses.
Hair: Look for brittle hair, hirsutism (hair in face, caused by PCOS, Cushings, tumors, meds, or congenital adrenal hyperplasia.)Alopecia can be caused by chemo and their skin is very fragile
Slide 80
Lecture 1/18/24
What are 2 main compents of a health assessment
Health History
Interact with the family
Physical Assessment
Most are done at the door way
May have lay hands a look at the patient
Slide 5
Lecture 1/28/24
What are the 5 reason why it is important to do a health assessment?
- Establish a client relationship.
- Gather data about the patient’s general health status, integrating physiologic, psychological, cognitive, socio cultural, development and spiritual dimensions.
- Identify patient’s strengths.
- Identify actual and potential health problem.
- To evaluate the physiological outcome of care.
Slide 6
Lecture 1/18/24
Skin cancer is 20% higher in Caucasian Americans than African Americans and prostate cancer is higher in African Americans than Caucasian Americans is an example of what type of general examination assessment?
Gender and race
Slide 8-13
Lecture 1/18/24
Older aged people and children are more prone to infection is an example of what type of general examination assessment?
Extremes of age
Lecture 1/18/24
Showing signs of pain and difficulty in breathing is an example of what type of general examination assesment?
Signs of distress
Slide 8-13
Lecture 1/18/24
A thin or obese person is an example of what type of general examination assessment?
body type
Slide 8 -13
Lecture 1/18/24
A person that is standing, upright position, or knee flexed is an example of what type of general examination assessment?
Posture
Sldie 8-13
Lecture 1/18/24
Assesing the patient’s coordination and normal walk with the arms is an example of what type of general examination?
Gait
Slide 8-13
Lecture 1/8/24
Assessing a if a patient’s movement are purposeful or immobile is an example of what type of general examination?
Body movement
Slide 8-13
Lecture 1/18/24
Assessing if a patient’s personal hygiene is maintain or cosmetics are used is an example of what type of general examination?
hygiene and grooming
Slide 8-13
Lecture 1/18/24
What general examination is an expression of the patient’s culture, life style, or socio economic status. It should be appropriate according to weather condition.
Dress
Slide 8-13
Lecture 1/18/24
Unpleasant odor, poor hygiene, bad breath, and poor oral hygieneis an example of what type of general examination assessment?
Body odors
Slide 8-13
Lecture 1/18/24
A patient’s pressure, tone, and speed is describing what of the patient’s?
speech
Slide 8-13
Lecture 1/18/24
Feeling’s to others, emotionally expression, and mood appropriate per situation is an example of what type of general examination assessment?
affect and mood
Slide 8-13
Lecture 1/18/24
Any problem during growing and serious health problem during childhood is an example of what type of general examination?
This can also seen in the elder popultion
Client abuse
Slide 8-13
Lecture 1/18/24
A patietnt consuming drugs, alcohol,or ganjais an example of what type of general examination assessment?
substance abuse
Slide 8-13
What is the definition of health history?
is a collection of subjective and objective data that provide a detailed profile of the client’s health status.
Slide 14
What are examples of patient identification?
Patient’s name:-
Age: -
Sex-
Hospital Name:-
File No./MRN No.:-
Source providing history:-
Date/ Time of admission-
Slide 15-16
When asking about current medications, what 4 things do you want to know?
- Medication
- Dose/frequency
- Route
- Last dose taken
what is the example of special assistive devices?
Wheel chair, braces, crutches, walkers.
Contact lenses/Hearing aid/Prosthesis/Glasses
Dentures: Total/Partial
What type of question would you ask to gather psychosocial hx?
Any recent stress?
Who is with the patient in the hospital?
Does the patient have anybody who will give financial support if needed?
Who will care for the patient at home? Calm/Anxious
What are 5 steps of physical assessment?
Inspection
Palpation
Percussion
Auscultation
Olfaction
What is inspection? what findings may be significant?
Visual assessment of the patient and surroundings
Findings that may be significant:
Patient hygiene
Clothing
Eye gaze
Body language
Body position
Skin color
Odor
Observe the body part
What is important to make visual inspection for?
Cleanliness
Prescription medicines
Illegal drug
Weapons
Signs of alcohol use
What are the principles of visual inspection?
Make sure adequate lighting is available.
Position and expose body parts so that all surface can be viewed.
Inspect each area of size, shape, color, symmetry, position and abnormalities.
If possible, compare each area inspected with the same area on the opposite side of the body.
Use additional light to inspect body cavities.
Do not hurry inspection.
Pay attention to detail.
What is palpation? how would you perform palpation?
A technique in which the hands and fingers are used to gather information by touch.
Palmar surface of fingers and finger pads are used to palpate for
Texture
Masses
Fluid
Assess skin temperature
Patient should be relaxed and positioned comfortably because muscle tension during palpation impair its effectiveness.
You should warm your hands, ask pt to continue breath normally, inform the pt when and where the touch will occur.
What are the types of palpation?
Light palpation
Deep palpation Bimanual palpation
How would you perform light palpation?
Apply tactile pressure slowly, gently and deliberately.
The hand is placed on the part to be examined and depressed about 1-2cm
How would you perform deep palpation?
It is done after light palpation.
It is used to detect abdominal masses.
Technique is similar to light palpation except that the finger are held at a greater angle to the body surface and the skin is depressed about 4-5 cm.
How would you perform bimanual palpation?
It involve using both hand to trap a structure between them. This technique can be used to evaluate spleen, kidney, breast, uterus and ovary.
Sensing hand – Relax & place lightly over the skin.
Active hand – Apply pressure to the sensing hand.
what is percussion?
Percussion involve tapping the body with the fingertips to evaluate the size, border and consistency of body organs and to discover fluid in body cavity.
What would you evaluate for when performing percussion?
Used to evaluate for presence of air or fluid in body tissues
– Sound waves heard as percussion tones (resonance)
