*History and Physical Exam Flashcards
GEN
HEENT
Cardiopulmonary symptoms/disease
Gastrointestinal disease
Urinary disease
Musculoskeletal disease
GEN - Fevers, chills, fatigue, weight (changes) loss, and anorexia would be concerning for infection, malignancy, or systemic illnesses (eg, inflammatory bowel disease [IBD]).
HEENT - Dizziness, lightheaded, excessive nosebleeds, headaches, colds, nasal stuffiness, nosebleeds, sinus pain, last dental exam? dry mouth, hoarseness, stiff neck
Cardiopulmonary – Cough, shortness of breath, orthopnea, and exertional dyspnea suggest a pulmonary or cardiac etiology. Wheezing, chest pain, palpitations, chest tightness.
Gastrointestinal – Nausea, vomiting, diarrhea, constipation, hematochezia, melena, and changes in stool caliber, jaundice, bowel habit,
Urinary disease – Dysuria, frequency, and hematuria are more likely have a genitourinary cause for abdominal pain.
Musculoskeletal – Arthritis, joint swelling, redness, pain, tenderness, stiffness, witness, limitation, trauma
“Physical Exam”
VITALS BP, HR rhythm and quality, RR 120/80 85 12 T 37*C, volume depletion [For “the list” looking for: temp, respiratory rate range, urine output [L (2.8)/weight (Kg)/hr], record each drain
GEN ASSESSMENT – “Ill or well appearing?” level of distress, nutritional status, Skin, Hair, Nails for color, lesions and moisture
HEENT
Head
Inspection: head and scalp, SAD
Eyes
Inspection: The eyes should be examined for scleral icterus and the skin for jaundice. Inspection of orbital area, conjunctiva, sclera, iris, pupils (edema, lesions, cemetery, discharge, shape)Pupillary reaction to light (consensual)
Ears
TM mobility: (Pneumatic insuflator): When pressure in the middle ear space is equivalent to ambient air pressure, the normal TM moves laterally and medially with a pressure pulse from the bulb as low as 10 to 15 mm H2O.
Reduced TM mobility is caused by fluid, a solid mass in the middle ear space, retraction, atrophy, or sclerosis.
Perforation also causes the TM to become immobile, although this may be obscured by otorrhea.
Hearing: Whisper, webber, rhine
Mouth
Inspection: oral cavity, lips, teeth, gums (color, exudates, lesions, tonsil size), lymph nodes (submandibular, anterior cervical, supraclavicular), palpate thyroid (size, symmetry, nodules, enlargement, tenderness)
Neck
Trachea (pleural effusion pneumothorax)
sinuses, TMJ
CARDIO
Palpate precordium, PMI (lifts, thrills, heaves)
Auscultation at 2nd intercostal space, RSB, LSB, fourth and fifth ICS LSB apex, bell;
Pulses – R, PT, DP, C, B, F, P
Capillary refill
Edema
Cyanosis
Clubbing: Digital clubbing describes bulbous enlargement and broadening of the fingertips due to connective tissue proliferation at the nail bed and distal phalanx. It is diagnosed when the angle between the nail fold and the nail plate is >180° (Lovibond angle). Clubbing can occur by itself or associated with hypertrophic osteoarthropathy, which presents with painful joint enlargement, periostosis of long bones, and synovial effusions. Clubbing may be hereditary, but is most often due to pulmonary or cardiovascular diseases. The most common causes of secondary clubbing are lung malignancies, cystic fibrosis, and right-to-left cardiac shunts.
Pathophysiology involves megakaryocytes that skip the normal route of fragmentation within pulmonary circulation (due to circulatory disruption from tumors, chronic lung inflammation) to enter systemic circulation. Megakaryocytes become entrapped in the distal fingertips due to their large size and release platelet-derived growth factor (PDGF) and vascular endothelial growth factor (VEGF). PDGF and VEGF have growth-promoting properties that increase connective tissue hypertrophy and capillary permeability and vascularity, ultimately leading to clubbing.
Hypertrophic pulmonary osteoarthropathy (HPOA) is a subset of HOA where the clubbing and arthropathy are attributable to underlying lung disease like lung cancer, tuberculosis, bronchiectasis, or emphysema.
Documentation: cor (heart) nsr (normal sinus rhythm), -m, r, g
PULMONARY
Inspection of chest wall, ribs (SAD), accessory muscles, retractions, respiratory distress (tachypnea, hyperpnia, paradoxical breathing, pursed lips, cyclical breeding patterns [kussumal/cheyene stokes], possible skeletal abnormalities scoliosis kyphosis, pectus excuvatum),
Percussion (fluid or solid tissue in lung or pleural space, dullness to percussion {lobar pneumonia}, resonance, pneumothorax, emphysema)
Auscultation (vesicular, wheezes, asthma, bronchitis, bronchial breath sounds {pneumonia}, rales rhonchi mucous obstruction).
Rales = fine crackles
Ronchi = Coarse
Vesicular = normal
Tubular = Bronchial
The best areas to listen for right middle lobe findings would be (1) the right anterior midclavicular line between the fifth and
sixth ribs and (2) the right midaxillary line between the fourth and sixth ribs. The right middle lobe is not heard posteriorly, and the lung examination is incomplete if
the physician does not listen anteriorly or medially.
SpecialTests Stromal notch angle costosternal tactile fremitus 99 E Toy boat
Tactile fremitus: Decreased or absent when vibrations from the larynx to the chest surface are impeded by chronic obstructive pulmonary disease, obstruction, pleural effusion, or pneumothorax.
ABDOMEN
Inspection (drape) general appearance and level of comfort or discomfort – lesions, scars, dilated veins, echymoses, muscle separation,
Auscultation - bowel sounds, (clicks gurgles - detection of ileus/obstruction)
Percussion peritonitis/ascites/hepatosplenomegaly
Palpation – light, deep, liver edge (start by examining the quadrant of the abdomen where the patient is experiencing the least pain - Guarding is typically absent with deeper sources of pain such as renal colic and pancreatitis)
Documentation: “Abd nondistended, +bs, +tender RLQ; rectal guaiac -nl tone, -mass -
Shoulder
Inspection (Atrophy, symmetry, Bruising, Swelling, Erythema)
(“step-off deformity”, Glenohumeral dislocation,
Other deformity (scapular winging)
Palpation
The sternoclavicular joint is formed by the medial aspect of the clavicle articulating with the manubrium of the sternum. This is the only skeletal connection between the axial skeleton and the upper extremity.
Clavicle
The acromioclavicular (AC) joint is the only articulation between the clavicle and scapula. It is formed by the distal clavicle articulating with the acromion of the scapula.
Subacromial Bursae
Bicipital Groove
The glenohumeral joint is the main articulation of the shoulder joint. It is the multiaxial ball-and-socket synovial joint formed by the articular surfaces of the glenoid cavity and the head of the humerus.
Greater/lesser tuberosity
Range of Motion (active/passive)
Flexion [0-180]
External rotation (adduted, abducted)
Cross body adduction
Internal rotation (up back)
Scapular dyskinesis [up back]
Cervical [neck]
[Other – drop test]
Strength
Deltoid (abduction)
Empty can test (supraspinatus)
Lift-off test (subscapularis)
Drop arm test (supraspinatus)
Rhomboid (hands on hips)
Special Tests
Neer’s Impingement (depress scapula while elevating the arm; compresses greater tuberosity against ant. acromion)[Impingement syndrome; rotator cuff tear]
Hawkins’ (90-90 +internal rotation)
Biceps Tendinitis [supinate]
Speed’s [palm up][90 degrees][bowling w/ resistance]
Yergason’s [supinate while palpating bicep tendon]
Labral Tear: People that participate in repetitive overhead activities such as swimming or throwing a ball have an increased risk of labral tear. A labral tear may be asymptomatic or manifest as shoulder instability, pain, or crepitus.
O’Brien’s test [supinate/pronate like empty can]
Apprehension test (180-90)[Impending dislocation]
Instability Test
Apprehension test [relocate it]
Relocation Maneuver
Neurovascular
Sensory
Motor [radial =thumbs up; median = buttin shirt; ulnar = pad dab]
Distal pulses
Back
Inspection
Lumbar lordosis
Thoracic kyphosis [leaning forward]
Scoliosis
Pelvic asymmetry/tilt [pelvic brim]
Palpation
Spinous processes [C7]
Sacroiliac joints
Paraspinous muscles
Range of Motion
Lumbar flexion — Full/limited
Lumbar extension — Full/limited
[goniometer - ROM]
Strength
Hip flexion (L2)
Hip adduction (L2)
Knee extension (L3)
Ankle dorsiflexion (L4)
Great toe extension (L5) [EHL]
Ankle plantarflexion (S1)
Great toe flexion (S2) [FHL]
Ankle eversion (S1)
Neurovascular
Proximal anterior thigh (L2)
Anterior middle thigh (L3)
Medial ankle (L4)
Dorsum foot (L5)
Lateral foot/sole (S 1)
Reflexes
Patellar reflex
Achilles reflex
Saddle anesthesia (ask only) [pee, poo, anal sensation]
Special Tests
Straight leg raise (R) [shooting pain?]
Slump test
Straight leg press (L)
Trendelenberg test [abductor strength = glutes]
Patrick’s (FABER) test [SI joint]
Knee
Inspection
Genu valgum [knocked]/varum [bow]
Genu recurvatum [knee hyperextension (0 – 130)][procurvatum]
Palpation
Joint lines- medial and lateral
Patellar tendon
Pes anserine bursa “SGT” Attaches: Sartorious, gracillis
Medial and lateral collateral ligaments
Tibial tuberosity
Fibular head/common peroneal nerve
Range of Motion
Flexion/extension [meniscus; ant, body, and posterior horn]
Strength
Quadriceps/hamstrings
Assessment of fluid/effusion
Ballottement of patella [touch medial see lateral]
Meniscal Integrity
McMurray’s test [both ways]
Hyperflexion test [meniscus – does this hurt?]
Bounce test
Apley’s [twist ankle]
Bulge sign
Flexibilitv
Hamstring tightness (popliteal angle)
Ely test (rectus femoris tightness/contracture) [maximal flexion from prone position]
Assessment of ligament instability
Anterior cruciate ligament
Anterior drawer [90 degrees decreased sensitivity]
Lachman’s test [30 degrees increased sensitivity][pull tibia forward]
Posterior cruciate ligament:
Posterior drawer
Posterior sag sign [tibia not forward]
Medial collateral ligament:
Valgus stress at 0 [cruciate + MCL] & 30 degrees [MCL]
Lateral collateral ligament:
Varus stress at O & 30 degrees [LCL]
Assessment of Patellofemoral Mechanism
Patellar grind/crepitus
Patellar apprehension
Palpate medial & lateral facets
Foot
Inspection (Bunion, cyst, corn, toenails; metatarsus adductus, cavus foot, accessory navicular).
Range of Motion (+intrinsics)
Palpation
Medial Malleolus
Posterioir/Inferior to: lies anterior tibial nerve [Tarsal tunnel syndrome] tapping produces shooting pains (paresthesias) in the heel and plantar foot.
Deltoid Ligament
Peroneal Tendon
Achilles
Retrocalcaneal Bursae: sides of achilles tendon [Squeeze test]
Lateral Maelleolus
Fibular Fracture
ATFL (Anterior talofibular)[“Ankle Drawer test”]
CFL (Calcaneal fibular)
PTFL (Posterior talofibular)
Fifth Metatarsal (“Jones Fracture”)
“Is there anything at all that could have gone better today from your point of
view in the care you experienced?”
Firmly vest in patients and families control over decisions
about care in all its aspects. Take over control only rarely and with permission
freely granted.
Third, extend transparency to all aspects of care, including science,
costs, outcomes, processes, and errors
Volume Depletion
Children are at risk for intravascular volume depletion due to the high frequency of gastroenteritis, a higher surface area-to-volume ratio resulting in increased insensible losses, and an inability to access fluids themselves or communicate their needs. In gastroenteritis, volume depletion occurs when the extracellular losses exceed the fluid intake. As a result, oral or intravenous fluid therapy is required in order to replenish the normal intravascular volume.
The initial step in managing children with dehydration is to determine its severity. The ideal method of assessing dehydration is to determine the measured change in weight because 1 kg of acute weight loss equals 1 L of fluid loss. A child’s weight, however, changes constantly, making it difficult to obtain an accurate recent “well” weight. Therefore, the degree of dehydration often has to be determined by the clinical history and physical examination, which can be divided into the following categories:
Mild dehydration (3-5% volume loss) presents with a history of decreased intake or increased fluid loss with minimal or no clinical symptoms.
Moderate dehydration (6-9% volume loss) presents with decreased skin turgor, dry mucus membranes, tachycardia, irritability, a delayed capillary refill (2-3 seconds), and decreased urine output.
Severe dehydration (10-15% volume loss) presents with cool, clammy skin, a delayed capillary refill (>3 seconds), cracked lips, dry mucous membranes, sunken eyes, sunken fontanelle (if still present), tachycardia, lethargy, and minimal or no urine output. Patients can present with hypotension and signs of shock when severely dehydrated.
Oral rehydration therapy should be the initial treatment in children with mild to moderate dehydration. Children with moderate to severe dehydration (which is the category that this patient is in) should be immediately resuscitated with intravenous fluids to restore perfusion and prevent end organ damage. Isotonic crystalloid is the only crystalloid solution recommended for intravenous fluid resuscitation in children, which explains why isotonic saline is the best answer of the choices given.
