Head to Toe Physical Exam Flashcards
Subjective
HPI:
- O, L, D, C, A, A, A, R, T, S
1) CC/ HPI
2) PMH
3) PSH
4) Meds
5) Allergies
6) Social
7) Family History
8) ROS
Objective
- Vital Signs
- Gen Appearance (Skin)
- HEENT
- (Sinuses)
- Neck
- CV
- (Chest/Breasts)
- Lungs
- Abdomen
- (Genital)
- (DRE) - Ext
- (Lymphatic)
- Musculoskeletal
- Neurologic
- Psychiatric
- STRUCTURAL / OSTEOPATHIC!!!!!!!!!!!!
Initial Observation
- Posture. Plane
a) Landmarks, Symmetry
b) Kyphosis/ Lordosis, Scoliosis - Gait
- Heel/Toe Walk
a) Balance, Strength
Documentation
- VITALS: BP, P, T, R
- GENERAL: NAD, anxious, lethargic….
- (SKIN): Intact, warm, dry, (rash, lesion-describe)
- HEENT: nc/at, PERRL/EOMI, TM’s clear b/l, nares patent mucosa non-inflamed, throat non-injected no exudate, no maxillary sinus TTP
- NECK: Supple, NT, no LAD or JVD, no thyromegaly, no carotid bruit
- CV: Heart RRR s murmur
(or RRR with systolic m III/VI) - (CHEST/ BREAST): no reproducible TTP, no mass/lump, lesion, discharge, skin changes or axillary LAD
- LUNGS: CTAB, no crackles, wheezes, rales, rhonchi
- ABDOMEN: soft NT/ND, BS x 4, no R/R/G/mass, no HSM, neg murphy’s, no CVA TTP
- (GENITAL): no discharge, ext skin lesions, cervix and vag wall visualized NSSCC (Norm size, shape, color, consistency), biman- no CMT, no adnexal mass or TTP
a) MALE-scrotal swelling, testicular TTP, mass, inghernia
- (RECTAL): good tone, No mass, TTP, or prostate nodule
noted, heme occult neg
- EXT: + pulses b/l (dp, pt) no C/C/E, FROM (shoulder abduction), no TTP (location)
- (LYMPHATIC): no cervical, axillary or inguinal LAD noted
- NEUROMUSCULOSKELETAL: AXOX3, CN II-XII GIB, DTR’s 2/4 b/l (btpa), MS 5/5, sensation intact b/l UE & LE.
- OSTEO: TTA/tension T4-6 on right, L1-3 NRrSl, restricted R shoulder Abduction and ER, TTP cervical paraspinal tissues on L, SLR neg…
a) SPECIAL TESTING for region specific MS complaints can be recorded in ext, NMS, or osteo
i) SHOULDER – empty can + R…
ii) ELBOW – neg varus/valgus, + tennis elbow testing…
iii) WRIST/HAND - + Finkelstein’s R…
iv) KNEE – neg varus/valgus stress, ant/post drawer…
v) ANKLE/FOOT – squeeze test and ant ankle drawer neg…
Physical Diagnosis
- “Putting together” appropriate exam based on Subjective data collected
- Suggested exam components to include regardless of CC/HPI:
VITALS:
(GEN: NAD, restless, lethargic…..)
HEART: RRR, w/o murmur
LUNGS: CTAB, w/o wheeze, rhonchi, crackles
OSTEO/STRUCTURAL:
Physical Diagnosis
Osteopathic/ Structural Exam Considerations
- Check for TART – don’t be afraid to PALPATE the AREA of Chief Complaint
a) Segment or Region above/below - If you treat – REASSESS not only by asking the pt if symptoms are better, but check for improvement/resolution of TART findings
- Appropriate Duration of Tx
- Help/assist your patient
- Consider appropriate diagnostic testing
a) Pelvic compression test, SLR, Spurling’s, empty can, varus/valgus stress, finkelstein, scour, ant drawer, talar tilt……..
Physical Diagnosis
Case Specific Considerations: HEADACHE
1) HEENT Exam:
- NC/AT, PERRL, EOMI, TM’s intact and clear, Nares patent mucosa non-inflammed, Maxillary sinuses non-tender to palpation, Oropharynx- clear w/o exudate or erythema
2) CRANIAL NERVE EXAM (Can be under HEENT or Neuro)
- CN II - XII Intact B/L
3) NEURO EXAM:
- AxOx3
- Biceps and Triceps DTR 2/4 BUE
- Muscle Strength 5/5 BUE, sensation grossly intact BUE (no focal motor/sensory deficits noted)
4) PALPITATION OF AREA (can go under HEENT in this case or structural Exam if you find TART)
- No Reproducible TTP, Ecchymosis, Erythema
5) STRUCTURAL EXAM:
- TART-Include TTP, Tissue text changes, PTP’s, ROM to perhaps OA and cervical spine at minimum, can include specific nomenclature if found – C3FRrSBr
Physical Diagnosis
Case Specific Considerations:
BACK PAIN, NECK PAIN
1) PALPATE THE SPECIFIC AREA OF CONCER
- Palpate above/below area of concern
2) ABD: (Especially if any of the HPI involves the GI or GU system)
- Soft, NT/ND, Bs+x4, no rebound…. No CVA TTP
3) NEUROMUSCULOSKELETAL:
- Patellar, Achilles DTR 2/4 BLE, or Bicep/ Tricep/ Brachiorad 2/4 BUE
- Muscle strength 5/5BLE or BUE
- Sensation grossly intact BLE/BUE
(no focal motor/sensory deficits noted) - Special Test examples: SLR forLBP, Spurlings for neck pain
4) STRUCTURAL EXAM:
- TART-include TTP, tissue text changes, PTP’s, landmark findings, ROM, specific nomenclature if found- (ex-L1-3 NRrSl)
Physical Diagnosis
IF AN EXTREMITY IS INVOLVED
1) EXT: No C/C/E, Perp Pulses intact B/l 2/4, ROM Symmetric or Restricted R Shoulder Abduction
2) Extremity can have TART as well
- TTP along plantar fascia of R foot, Glenohumeral Glide Restriction, forearm supination dysfunction, Post Fib head, Plantarflexed talus
A Few Considerations
- Develop Order/ Routine for your History and Exam
- Don’t forget to put the things you discussed and examined into the SOAP Note
- ASSIST the patient when Moving and Changing Positions
- Don’t forget to tell your Patient what you are doing (Exam and Treatment)
- Don’t completely FORGET Structural/Osteopathic Exam, and OMT if indicated (Esp on Musculoskeletal Case)
a) Avoid Tarantula or Itsy-bitsy Spider Technique
Assessment (Example)
COUGH
1) Cough
- Uri
- Bronchitis
- Post Nasal Drip
- Medication Induced
2) Somatic Dysfunction: Thoracic Spine
3) FH Colon Cancer
Assessment (Example)
SHOULDER Pain
1) Shoulder Pain
- Rotator Cuff Tendonitis
- Shoulder Impingement
- Glenohumeral Instability
- Shoulder Strain/ Sprain
- Somatic Dysfunction- UE (Shoulder)
2) Hypothyroidism
3) Hypercholesterolemia
Physical Diagnosis- Osteopathic Exama nd Tx Documentation
JUST and EXAMPLE of a SOAP Note:
S
O :
Somatic Dysfunction – Lumbar, Pelvis (Innominate)
A:
- Lumbar Spine TTP, R lumbar paraspinal with acute tissue texture changes, muscle spasm, PTP’s noted on R. L1-5 NRrSBl. + Pelvic Compression Test R, R ant rot innominate……
P:
- OMT – MFR to lumbar, ME to pelvis well tolerated with good results
Plan
Things to Consider, and list IF INDICATED:
- Labs
- Diagnostic Studies
- Medications (Start, Stop, Change)
- OMT
- Anticipatory Guidance/ Counseling
- Follow-Up/ Referral
