General Inspection, Vital Signs & Skin through Cardiac Flashcards
GENERAL START: Introduce self to patient
- Wash hands before touching patient.
- Ask how he/she would like to be addressed.
- Inquire about why patient is being seen, in patient’s own words.
General Inspection
Observe patient - noting general state of health, facial expression, stature, build posture, level of distress, hygiene, speech, mobility, mental alertness, etc.
• “I am inspecting the patient for general state of health, stature, signs of distress, hygiene, and mental alertness.”
Vital Signs: Height, weight, & temperature
• “I have noted your ht, wt, and temperature.”
Radial pulse (apical pulse if radial pulse is questionable)
- Palpate the patient’s radial pulse, using the pads of the distal 1st and 2nd fingers.
- Count for 15 seconds and multiple by 4 (if any irregularity noted, count for 60 seconds).
- “I am noting the patient’s pulse by counting for 15 seconds and multiplying by 4.”
Radial pulse statement
• “I am noting the patient’s pulse by counting for 15 seconds and multiplying by 4.”
Respirations
- While continuing to palpate the radial pulse, count the patient’s respirations for 15 seconds and multiple by 4.
- “The patient’s respirations are ___ and unlabored.”
Respiration statement
• “The patient’s respirations are ___ and unlabored.”
Blood Pressure
- 1st use the BP cuff to estimate BP or ask the patient what his/her usual BP reading is. Inflate cuff to 30 mmHg above this # before determining BP.
- “The patient’s blood pressure is ___.”
BP Statement
• “The patient’s blood pressure is ___.”
SKIN START: Inspect skin - noting color, rashes, any lesions including color, type, location, and distribution. (and statement)
- Expose legs and torso if necessary.
* “I am inspecting the skin noting the color and looking for any rashes or lesions.”
Skin statement- general
• “I am inspecting the skin noting the color and looking for any rashes or lesions.”
Palpate skin – noting temperature, texture, and turgor
- Palpate the skin of the upper and lower extremities using the dorsum of the hands.
- Check skin turgor on the dorsum of the forearm.
- “The skin is warm and dry and turgor is normal.”
Skin palpation statement
• “The skin is warm and dry and turgor is normal.”
HEAD START: Inspect the facial features (and statement)
• “I am inspecting the facial features noting that they are symmetric.”
Test function of facial muscles (CN VII)
- Ask patient to squeeze eyes shut, wrinkle forehead, smile, puff out cheeks.
- “CN 7 is intact.”
Facial muscles statement
• “CN 7 is intact.”
Test light touch on the face (CN V sensory)
- Ask patient to close eyes. Using a Q-tip, lightly touch the patient’s forehead, cheeks, and chin.
- Ask patient to say “now” each time he/she feels the light touch.
- “CN 5 sensory is intact.”
Light touch on face statement
• “CN 5 sensory is intact.”
Palpate the facial bones and sinuses
• Ask the patient if he/she experiences any tenderness.
Palpate the TMJ and test ROM
• While palpating the TMJ, ask the patient to move his/her jaw from side to side.
Palpate the masseter muscles (CN V, motor)
• Ask patient to clench his/her teeth.
Inspect and palpate the hair, scalp, and skull
and statement
• “The head is normocephalic. The hair is course and straight with symmetric hair distribution.”
EYES START: Inspect external eyes
- Inspect the lids, conjunctivae, sclera, cornea, and iris.
* “I am inspecting the eyes for symmetry, exophthalmos, ptosis, injection (hyperemia), and icterus.”
Inspect external eyes statement
• “I am inspecting the eyes for symmetry, exophthalmos, ptosis, injection (hyperemia), and icterus.”
Test visual acuity (CN II)
- Hold hand-held eye chart 14” from patient’s eyes. Ask him/her to cover 1 eye and read the lowest line that he/she can, then cover the other eye and read the lowest line that he/she can.
- “The patient’s vision is ___.”
Visual acuity statement
• “The patient’s vision is ___.”
Assess depth of the anterior chambers
- Shine light toward side of patient’s eye (bilaterally) and look for a shadow on the medial aspect of iris.
- “No crescent shadows noted.”
Depth of ant. chambers statement
• “No crescent shadows noted.”
Corneal light reflection (and statement)
• “Corneal light reflections are symmetric.”
Direct and consensual pupillary light reflexes (and statement)
• “Pupils are equal round and reactive to light.”
EOMs (CNs III, IV, VI) and accommodation
- Using H pattern, evaluate EOMS in 6 cardinal positions.
- “EOMs are intact bilaterally, without nystagmus.”
- “Eyes converge and accommodate to near vision.”
EOMs (CNs III, IV, VI) and accommodation statements
- “EOMs are intact bilaterally, without nystagmus.”
* “Eyes converge and accommodate to near vision.”
Ophthalmoscopic examination bilaterally
- Use correct technique.
- “Red reflex is present. Disc margins are sharp, cup to disc ratio is 1:2, AV ratio is 2:3 and there are no hemorrhages or exudates.”
Ophthalmoscopic examination bilaterally statement
• “Red reflex is present. Disc margins are sharp, cup to disc ratio is 1:2, AV ratio is 2:3 and there are no hemorrhages or exudates.”
EARS START: Check hearing (CN VIII)
• Ask patient to repeat whispered words or to indicate when they hear you rub your fingers.
Inspect external ears
- Inspect the auricle and surrounding tissue.
* “I am inspecting the ear for masses or lesions.”
Inspect external ears statement
• “I am inspecting the ear for masses or lesions.”
Palpate ears
- Palpate the auricle, tragus, and mastoid.
* “There is no ecchymosis or discoloration of the mastoid.” (“Battle sign” suggests basilar skull fracture)
Palpate ears statement
• “There is no ecchymosis or discoloration of the mastoid.” (“Battle sign” suggests basilar skull fracture)
Otoscopic examination bilaterally
- Use correct technique.
* “Canal is patent. Light reflex and landmarks are noted, and the TM is pearly gray and translucent.”
Otoscopic examination bilaterally statement
• “Canal is patent. Light reflex and landmarks are noted, and the TM is pearly gray and translucent.”
NOSE START: Inspect external nose (and statement)
• “Nose is midline and without deformities.”
Test nasal patency
• Ask patient to occlude 1 nostril and sniff, then occlude the other nostril and sniff.
Palpate external nose
No instructions on script
Nasal speculum exam bilaterally
- Inspect the nasal mucosa, septum, and turbinates.
* “The nasal mucosa is pink with scant clear rhinorrhea present.”
Nasal speculum exam bilaterally statement
• “The nasal mucosa is pink with scant clear rhinorrhea present.”
MOUTH START: Inspect the mouth and pharynx
- Inspect the lips, teeth, gums, mucosa, and tonsils.
- Note breath odor and tap teeth with tongue blade if indicated.
- “The lips are red without lesions and the teeth are in good repair.”
- “I am inspecting the buccal mucosa, Stenson’s (parotid) duct, the posterior pharynx, and tonsils.”
- “The floor of the mouth and Wharton’s duct are normal.”
Inspect the mouth and pharynx statements
- “The lips are red without lesions and the teeth are in good repair.”
- “I am inspecting the buccal mucosa, Stenson’s (parotid) duct, the posterior pharynx, and tonsils.”
- “The floor of the mouth and Wharton’s duct are normal.”
Examine soft palate and uvula (CN IX, X) and statement
- Ask the patient to stick out his/her tongue and move it from side-to-side.
- “CN 12 is intact.”
Palpate the oral cavity
- Use a clean glove (individual glove should not be placed on countertop).
- Palpate the floor of the mouth and buccal mucosa, between gloved fingers inside mouth and other fingers outside mouth (bimanual technique).
NECK START: Inspect neck
- Observe for neck symmetry, fullness, masses, thyromegaly, JVD, tracheal alignment.
- “I am inspecting the neck for symmetry, fullness, masses, and JVD.”
Inspect neck statement
• “I am inspecting the neck for symmetry, fullness, masses, and JVD.”
Assess neck ROM
- Assess flexion, extension, lateral rotation, and lateral flexion.
- Ask patient to: touch his/her chin to chest, look up at ceiling, look to the R and L, and tilt head to shoulder on both sides.
Test lateral rotation against resistance bilaterally (CN XI)
• Ask patient to turn his/her head into your hand as you provide resistance.
Test shoulder shrug against resistance (CN XI)
No instructions given in script
Palpate lymph nodes
- Palpate each group of lymph nodes.
- Palpate occipital, post-auricular, and pre-auricular nodes.
- Palpate tonsillar (retropharyngeal), submaxillary (submandibular), and submental nodes.
- Palpate anterior cervical (superficial and deep), posterior cervical (superficial and deep), and supraclavicular nodes.
- Verbalize each group being palpated.
- “I am palpating the lymph nodes, occipital (as they are palpated), post-auricular (as they are palpated), pre-auricular (as they are palpated), etc.”
Palpate lymph nodes statements
“I am palpating the lymph nodes, occipital, post-auricular, and pre-auricular nodes, tonsillar (retropharyngeal), submaxillary (submandibular), and submental nodes, anterior cervical (superficial and deep), posterior cervical (superficial and deep), and supraclavicular nodes
Palpate carotid arteries (and statement)
• “Carotid pulses are 2+ bilaterally.”
Auscultate carotid arteries (and statement)
- Use the diaphragm and bell of the stethoscope.
* “No carotid bruits appreciated.”
Palpate tracheal position (and statement)
- Examine while facing patient.
* “Trachea is midline.”
Palpate thyroid (and statement)
- Use posterior approach and ask patient to swallow during palpation.
- “The thyroid is not enlarged and no nodules are appreciated.”
PULMONARY/CHEST START: Inspect the patient’s chest, body habitus, and skin (and statement)
• “I am observing the patient noting chest symmetry, AP diameter, and any deformities or lesions.”
Observe the patient’s breathing pattern and effort (and statement)
• “Respirations are regular and unlabored without intercostal retractions or use of accessory muscles.”
Palpate the posterior and lateral thorax
- Using finger pads (not tips), palpate across the posterior and lateral thorax.
- Ask pt to report any tenderness.
Percuss the posterior and lateral lung fields for resonance (comparing sides)
- Percuss posterior lung fields in at least 6 locations.
- Percuss lateral lung fields in at least 4 locations (2 on each side).
- Note – dullness replaces resonance when fluid or solid tissue replaces normally air-filled lung or occupies the plueral space [e.g. lobar pneumonia (lung filled with fluid); plueral effusion (fluid in the pleural space)].
- Hyperresonance occurs over hyperinflated lungs (e.g. COPD, pneumothorax).
Perform fist percussion of the spine and CVAs
- Use gentle to moderate fist percussion.
* Ask pt to report any tenderness.
Auscultate the posterior and lateral lung fields
- Must auscultate on skin.
- Ask pt to take a moderate-sized breath in and out through his/her mouth each time you move your stethoscope.
- Listen in at least 6 places posteriorly and 4 places laterally (2 on each side).
- Listen for a full respiratory cycle with each placement of the stethoscope.
- “Breath sounds are clear and symmetric.”
Auscultate the posterior and lateral lung fields statement
• “Breath sounds are clear and symmetric.”
Inspect the anterior chest
- Expose pt’s chest and drape appropriately.
- May need to pull gown down to inspect upper chest of female and pull gown up to inspect lower chest of female.
- “I am inspecting the anterior chest noting any skin lesions or deformities.”
- “Breathing remains symmetric and unlabored.”
Inspect the anterior chest statements
- “I am inspecting the anterior chest noting any skin lesions or deformities.”
- “Breathing remains symmetric and unlabored.”
Palpate the anterior chest
• Using finger pads (not tips), palpate across the anterior chest wall.
Percuss the anterior lung fields for resonance (comparing sides)
• Percuss the anterior lung fields in at least 6 locations.
Auscultate the anterior lung fields
- Must auscultate on skin.
- Listen in at least 6 locations.
- “Breath sounds are clear and symmetric.”
Auscultate the anterior lung fields statement
• “Breath sounds are clear and symmetric.”
CARDIAC START:
Auscultate the heart
• Auscultate heart in all 4 areas, 1st with the diaphragm, then with the bell.
• Stethoscope on skin.
1. Aortic [2nd R. ICS, RSB (below 2nd rib)]
2a. Pulmonic (2nd L. ICS, LSB)
2b. 2nd pulmonic (3rd L. ICS, LSB)
3. Tricuspid (4th and 5th L. ICS, LSB)
4. Mitral (or apex) (5th L. ICS in MCL)
Ask pt to lie down. Expose chest.
Drape appropriately. Examiner on R. side of pt.
In-between instruction
Inspect chest wall
- Observe for PMI (point of maximum impulse) or precordial heaves.
- “PMI is noted in the 5th intercostal space (ICS) at the midclavicular (MCL) line. There is no precordial heave.”
Inspect chest wall statement
• “PMI is noted in the 5th intercostal space (ICS) at the midclavicular (MCL) line. There is no precordial heave.”
Palpate the precordium (and statement)
- Note any lifts or thrills.
* “There are no thrills or lifts.”
Auscultate the heart
- Auscultate the heart in all 4 areas, 1st with the diaphragm, then with the bell.
- Stethoscope on skin
Palpate the axillary lymph nodes
male pt or female not having a breast exam
**For practical, verbalize only (do not perform).****
- Use 4 sweep technique.
- Palpate along ant., mid., and post.axillary lines, and medial upper arm
- “At this point in the exam, I would normally palpate the axillary nodes.”
Palpate the axillary lymph nodes
(male pt or female not having a breast exam) statement
“At this point in the exam, I would normally palpate the axillary nodes.”
