H & P skills

Question 1

Wash Hands, Introduce self to Patient

Answer 1

1. Vital Signs: Take temperature, BP (bilaterally), pulse, respiratory rate
2. Conduct General Survey

Skin: color, temperature, turgor, texture, lesions, scars

Nails: color, shape, lesions

Question 2

HEENT

Answer 2

• Scalp/Skull: contour, scaliness, lesions, lumps, tenderness
• Hair: texture, color, distribution, quantity
• Face: symmetry, color, expression, edema, involuntary movement
• Eyes: 1. Visual Acuity
  2. External Eye: a. Eyebrows/lashes: flakiness, loss of hair

b. Eyelids: swelling, lid position, lid closure, tenderness
c. Lacrimal apparatus: duct, lacrimal sac, tenderness, tearing
d. Conjunctiva and sclera color
3. Cornea: opacities, surface characteristics
4. Iris: shape, color consistency

Eyes: (cont)

5. Pupil: shape, bilateral size, reaction to light- both direct and consensual, corneal light reflection
6. EOMs, lid lag, nystagmus, convergence, accommodation
7. Visual Fields: by confrontation, one eye at a time
8. Internal Eye: dim room light; left eye, left hand, patient’s left eye; right eye, right hand, patient’s right eye
   a. Red reflex: cornea, lens, aqueous and vitreous humors
   b. Retinal structures: 1. Optic disc and fovea: clarity, color
9. Vessels: color, size, light reflex, artery vs. vein

Ears: 1. Gross hearing acuity
2. External ear: deformities, lumps, lesions, tragal tenderness, mastoid tenderness
3. Otoscopy: pull auricle up and back; condition of external canal TM landmarks: umbo, color of drum
4. Cone of light, valsalva (pinch nose, close mouth and exhale)
5. Weber and Rinne tests (bilaterally)
Nose and Sinuses: 1. External exam: symmetry, lesions, discharge, tenderness
2. Nasal patency of each nostril
3. Rhinoscopy: polyps, deviated septum, mucosa color, discharge- must perform exam with light source
4. Paranasal sinuses: maxillary and frontal tenderness

Mouth:1. Lips: color, symmetry, moisture, lesions, pigmentation

2. Oral mucosa: moisture, color, lesions, odor (use gloves, tongue blade and light source)
3. Gums and teeth: number, color, surface characteristics
4. Roof of mouth, uvula
5. Pharynx and tonsils: landmarks, swelling, color, exudate
6. Parotid duct (Stensen’s duct)
7. Tongue: symmetry, color, surface characteristics8. Floor of mouth, Wharton’s ducts, frenulum
8. Palpate oral cavity (gloved, 2x2 gauze pad, bimanual exam)

Neck1. C-spine: a. Inspect profile for symmetry

b. Palpate for swelling, heat, tenderness, deformities, atrophy, asymmetry
c. ROM to include flexion, extension, rotation, L and R lateral bending

2. Lymph nodes: size, shape, mobility, tenderness, consistencyState and palpate nodes: (1) preauricular; (2) postauricular; (3) occipital; (4) tonsillar; (5) submandibular; (6) submental; (7) superficial cervical; (8) posterior cervical; (9) deep cervical chain; (10) supraclavicular
3. Thyroid gland: inspect anterior for symmetry, rises with swallowing. Palpate use posterior approach for tenderness, enlargement with patient’s neck flexed and rotated bilaterally

Question 3

THE THORAX AND LUNGS

Answer 3

1. Inspection: anterior-posterior versus lateral diameter, chest configuration, skin color, chest symmetry; retraction, use of accessory muscles
   Posterior/Lateral Thorax:2. Palpation: respiratory expansion, tenderness to firm palpation, tactile fremitus (4 areas posterior)
2. Percussion: posterior only in 7 areas
3. Auscultation: with patient breathing through open mouth Anterior 6 locations, Posterior 7 locations (same locations as percussion). Do not move stethoscope until patient has fully exhaled.

Question 4

Breast and axilla

Answer 4

state, but will omit exam

Question 5

CARDIOVASCULAR EXAM

Answer 5

1. Carotid arteries bilaterally:
   a. palpate pulses one at a time
   b. auscultate with bell, with patient holding breath
2. Inspect anterior chest: PMI (use tangential light)
3. Palpate PMI
4. Auscultate (5 cardinal areas, diaphragm and bell):
   a. 2nd ICS right sternal border: aortic valve
   b. 2nd ICS left sternal border: pulmonic valve
   c. 3rd ICS left sternal border: Erb’s point, S2 is loudest heard
   d. 4th ICS left sternal boarder: tricuspid valvee. 5th ICS left mid-clavicular line: mitral valve
5. Aortic valve murmurs: have patient sitting up and leaning forward, ask patient to exhale and hold breath while you listen with diaphragm of stethoscope
6. Mitral valve murmurs: have patient in left lateral decubitus position, listen with bell of stethoscope at the apical impulse

Question 6

PERIPHERAL VASCULAR SYSTEM

Answer 6

1. Pulses: correct location and palpation for radial, brachial, femoral (state and point to, but do not examine), popliteal, posterior tibial, and dorsalis pedis. All pulses are to be
   performed bilaterally
2. Extremities: note temperature, color, size, symmetry, varicosities
3. Check for edema: hands, ankles
4. Capillary refill

Question 7

ABDOMEN

Answer 7

1. Inspection: skin color, contour, scars, midline umbilicus, visible defects
2. Auscultate (diaphragm) x 4 quadrants for bowel sounds
3. Auscultate (bell) aorta, renal, iliac, and femoral (state but omit) arteries for bruits
4. Palpation x 4 quadrants: light, then deep
5. Palpate for liver, spleen, kidneys
6. Percussion x 4 quadrants and gastric bubble
7. Percuss liver span: 4-8 cm mid sternal line; 6-12 cm mid clavicular line (6-12 cm)
8. Percuss spleen at left anterior axillary line
9. CVA tenderness (light fist percussion)