Overview of Complete Physical Examintion/ General Survey/ Vital Signs (trans 3)

Question 1

REMEMBER
Tangential lighting is optimal for inspecting structures such as the jugular venous pulse, the thyroid gland, and the apical impulse of the heart.

Answer 1

• It casts light across body surfaces that throws contours, elevations, and depressions, whether moving or stationary, into sharper relief.
• When light is perpendicular to the surface or diffuse, shadows are reduced and subtle undulations across the surface are lost.

Question 2

In preparing for the physical examination make sure to:

Answer 2

1. Reflect on your approach to the patient
2. Adjust the lighting and the environment
3. Make the patient comfortable
4. Check your equipment
5. choose the sequence of examination

Question 3

REMEMBER

Ophthalmoscope and an otoscope

Answer 3

If the otoscope is to be used to examine children, it should allow for pneumatic otoscopy

Question 4

A good stethoscope has the following characteristics:

Answer 4

o Ear tips that fit snugly and painlessly. To get this fit, choose ear tips of the proper size, align the earpieces with the angle of your ear canals, and adjust the spring of the connecting metal band to a comfortable tightness.
o Thick-walled tubing as short as feasible to maximize the transmission of sound: approximately 30 cm (12 inches), if possible, and no longer than 38 cm (15 inches)
o A bell and a diaphragm with a good changeover mechanism

Question 5

The key to a thorough and accurate physical

examination is developing a systematic sequence of examination

Answer 5

Organize your comprehensive or focused examination around three general goals:
o Maximize the patient’s comfort.
o Avoid unnecessary changes in position.
o Enhance clinical efficiency
**In general, move from “head to toe.”

Question 6

Suggested sequence and positioning

Answer 6

1. General survey
2. Vital signs
3. Skin: upper torso, anterior and posterior
4. Head and neck, including thyroid and lymph nodes
5. (optional): nervous system (mse, cranial nerves, upper extremity, motor strength, bulk, tone, cerebellar function)
6. thorax and lungs
7. breasts
8. Musculoskeletal as indicated: upper extremities
9. Cardiovascular, including JVP, carotid upstrokes and bruits, PMI, S1, S2, murmurs and extra sounds (sitting position)
10. Cardiovascular, for S3 and murmur of mitral stenosis (sitting turned partly to left side)
11. Cardiovascular, for murmur of aortic insufficiency (sitting, leaning forward)
12. Abdomen
13. peripheral vascular
14. (optional): skin - lower torso and extremities
15. Nervous system: lower extremity motor strength, bulk, tone, sensation; reflexes; babinski reflex
16. Musculoskeletal, indicated (sitting/standing)
17. women: pelvin and rectal; men: prostate and rectal examination

Question 7

Standard and universal precautions
- The Centers for Disease Control and Prevention (CDC) have issued several guidelines to protect patients and examiners from the spread of infectious disease

Answer 7

A simple, consistent and effective approach to infection control

1. Hand washing
2. Use of gloves
3. Personal protective equipment e.g. gloves and face mask
4. Use of burn resistant gown or apron
5. Safe handling of sharps
6. Safe handling of wastes
7. Safe handling of linen
8. Environmental cleaning

Question 8

Standard Precaution

• Standard precautions are based on the principle that all blood, body fluids, secretions, excretions except sweat, non-intact skin, and mucous membranes may contain transmissible infectious agents.
• They include hand hygiene; when to use gloves, gowns, and mouth, nose, and eye protection; respiratory hygiene and cough etiquette; patient isolation criteria; precautions relating to equipment, toys, and solid surfaces, and handling of laundry; and safe needle-injection practices.

Answer 8

Universal Precautions
- Universal precautions are a set of guidelines designed to prevent transmission of human immunodeficiency virus
(HIV), hepatitis B virus (HBV), and other blood-borne
pathogens when providing first aid or health care.
- The following fluids are considered potentially infectious: all blood and other body fluids containing visible blood, semen, and vaginal secretions; and cerebrospinal, synovial, pleural, peritoneal, pericardial, and amniotic fluids.
- Protective barriers include gloves, gowns, aprons, masks, and protective eyewear
- All health care workers should observe the important precautions for safe injections and prevention of injury from needlesticks, scalpels, and other sharp instruments and devices. Report to your health service immediately if such injury occurs

Question 9

THE PHYSICAL EXAMINATION

General Survey

Answer 9

 Observe the patient’s general state of health, height, build, and sexual development.
 Obtain the patient’s weight. Note posture, motor activity, and gait; dress, grooming, and personal hygiene; and any odors of the body or breath.
 Watch the patient’s facial expressions and note manner, affect, and reactions to people and things in the environment.
 Listen to the patient’s manner of speaking and note the state of awareness or level of consciousness.
**The survey continues throughout the history and
examination.

Question 10

THE PHYSICAL EXAMINATION

Vital Signs

Answer 10

 Measure the blood pressure. Count the pulse and respiratory rate. If indicated, measure the body temperature
 The patient is sitting on the edge of the bed or examining table. Stand in front of the patient, moving to either side as needed.

Question 11

THE PHYSICAL EXAMINATION

Skin

Answer 11

 Observe the skin of the face and its characteristics.
 Assess skin moisture or dryness and temperature.
 Identify any lesions, noting their location, distribution, arrangement, type, and color.
 Inspect and palpate the hair and nails.
 Study the patient’s hands.
 Continue your assessment of the skin as you examine the other body regions.

Question 12

THE PHYSICAL EXAMINATION

Head, Eyes, Ears, Nose, and Throat (HEENT)

Answer 12

Head
 Examine the hair, scalp, skull and face.
Eyes
 Check visual acuity and screen the visual fields.
 Note the position and alignment of the eyes.
 Observe the eyelids and inspect the sclera and conjunctiva of each eye. With oblique lighting, inspect each cornea, iris, and lens.
 Compare the pupils, and test their reactions to light.
 Assess the extraocular movements. With an ophthalmoscope, inspect the ocular fundi.
Ears
 Inspect the auricles, canals, and drums.
 Check auditory acuity.
 Check lateralization (Weber test) and compare air and bone conduction (Rinne test).
Nose and Sinuses
 Examine the external nose; using a light and a nasal speculum, inspect the nasal mucosa, septum, and turbinates.
 Palpate for tenderness of the frontal and maxillary sinuses.
Throat (Mouth and Pharynx)
 Inspect the lips, oral, mucosa, gums, teeth, tongue,
palate, tonsils, and pharynx.
 You may wish to assess the cranial nerves during this portion of examination.

Question 13

THE PHYSICAL EXAMINATION

Neck

Answer 13

 Inspect and palpate the cervical lymph nodes.
 Note any masses or unusual pulsations in the neck.
 Feel for any deviation of the trachea.
 Observe the sound and effort of the patient’s breathing.
 Inspect and palpate the thyroid gland.
 Move behind the sitting patient to feel the thyroid gland and to examine the back, posterior thorax, and lungs.

Question 14

THE PHYSICAL EXAMINATION

Back, Posterior Thorax and Lungs

Answer 14

Back
 Inspect and palpate the spine and muscles of the back.
 Observe shoulder height for symmetry. Posterior Thorax and Lungs
 Inspect and palpate the spine and muscles of the upper back.
 Inspect, palpate, and percuss the chest.
 Identify the level of diaphragmatic dullness on each side.
 Listen to the breath sounds; identify any adventitious (or added) sounds; and, if indicated, listen to the transmitted voice sounds.

Question 15

THE PHYSICAL EXAMINATION

Breasts, Axillae, and Epitrochlear Nodes

Answer 15

 In a woman, inspect the breast with her arms relaxed, then elevated, and then with her hands pressed on her hips.
 In either sex, inspect the axillae and feel for the axillary nodes. Feel for the epitrochlear nodes.
 By this time, you have made some preliminary
observations of the musculoskeletal system.
 You have inspected the hands, surveyed the upper
back, and at least in women, made a fair estimate of the shoulder’s range of motion.
 Use these observations to decide whether a full musculoskeletal examination is warranted.
 With the patient still sitting, examine, the hands, arms, shoulders, neck, and temporomandibular joints.
 Inspect and palpate the joints and check their range of motion (examine upper extremity muscle bulk, tone, strength, and reflexes at this time, or do so later).
 Palpate the breasts, while at the same time continuing inspection.

Question 16

THE PHYSICAL EXAMINATION

Anterior Thorax and Lungs

Answer 16

 Inspect, palpate, and percuss the chest. Listen to the breath sounds, any adventitious sound, and if indicated, transmitted voice sounds

Question 17

THE PHYSICAL EXAMINATION

Cardiovascular System

Answer 17

 Observe the jugular venous pulsations and measure the jugular venous pressure in relation to the sternal angle.
 Inspect and palpate the carotid pulsations. Listen for carotid bruits.
- Elevate head of bed to approximately 30 degrees for cardiovascular examination, adjusting as necessary to see jugular venous pulsations via tangential lighting.
 Inspect and palpate the precordium. Note location, diameter, amplitude, and duration of apical impulse.
 Listen at each auscultatory area with diaphragm of stethoscope.
 Listen at apex and lower sternal border with bell of stethoscope.
 Listen for the first and second heart sounds and for the physiological splitting of the second heart sound.
 Listen for any abnormal heart sounds or murmurs.

Question 18

THE PHYSICAL EXAMINATION

Abdomen

Answer 18

 Inspect, auscultate, and percuss the abdomen.
 Palpate lightly, then deeply.
 Assess the liver and spleen by percussion and then palpation.
 Feel the kidneys and palpate aorta and its pulsations.
 If kidney infection is suspected, percuss posteriorly over the costovertebral angles.
 Palpation is done last because it may exacerbate abdominal pain, such as that caused by appendicitis

Question 19

THE PHYSICAL EXAMINATION
Lower Extremities (supine)

Answer 19

o Peripheral Vascular System. Palpate femoral pulses and, if indicated, popliteal pulses. Palpate the inguinal lymph nodes. Inspect for edema, discoloration, or ulcers. Palpate for pitting edema.
o Musculoskeletal System. Note any deformity or enlarged joint. If indicated, palpate joints, check their range of motion, and perform any necessary maneuver.
o Nervous System. Assess lower extremity, muscle bulk, tone, and strength, sensation, and reflexes. Note any abnormal movement.

Question 20

THE PHYSICAL EXAMINATION
Lower Extremities (standing)

Answer 20

o Peripheral Vascular System. Inspect for varicose veins.
o Musculoskeletal System. Examine the alignment of spine and its range of motion, alignment of legs and feet.
o Genitalia and Hernias in Men. Examine penis and scrotal contents and check for hernias.
o Nervous System. Observe patient’s gait and ability to walk heel-to-toe, walk on toes, walk on heels, hop in place, and do shallow knee bends. Do Romberg test and check for pronator drift

Question 21

THE PHYSICAL EXAMINATION
Nervous System
- Complete examination of nervous system can be done at the end of the physical examination and is made up of 5 components.

Answer 21

o Mental Status. Assess patient’s orientation, mood, thought process, thought content, abnormal perceptions, insight and judgement, memory and attention, information and vocabulary, calculating abilities, abstract thinking, and constructional ability.
o Cranial Nerves. Check sense of smell, strength of temporal and masseter muscles, corneal reflexes, facial movements, gag reflex, and strength of trapezia, and sternomastoid muscles.
o Motor System. Muscle bulk, tone, strength of major muscle groups. Cerebellar function and rapid alternating eye movements (RAMs), point-to-point movements, such as finger to nose and heel to shin; gait
o Sensory System. Pain, temperature, light touch, vibration, and discrimination. Compare right with left sides, and distal with proximal areas on limbs.
o Reflexes. Biceps, triceps, brachioradialis, patellar, Achilles deep tendon, plantar (Babinski)

Question 22

THE PHYSICAL EXAMINATION

Additional Examination

Answer 22

 Rectal and genital examinations are usually done at the end of physical examination.
 In men, inspect sacrococcygeal and perianal areas. Palpate the anal canal, rectum, and prostate. If patient cannot stand, examine genitalia before doing rectal examination.
 In women, examine external genitalia, vagina, and cervix. Obtain Pap smear. Palpate uterus and adnexa bimanually.

Question 23

Components of the Adult Health History - Identifying Data

Answer 23

1. Date and Time of History. The date is always important. Be sure to document the time you evaluate the patient, especially in urgent, emergent, or hospital settings.
2. Identifying Data. These include age, gender, marital status, and occupation. The source of history or referral can be the patient, a family member or friend, an officer, a consultant, or the medical record. Designating the source of referral helps you to assess the type of information provided and any possible biases.
3. Reliability. Document this information if relevant. For example, “The patient is vague when describing symptoms, and the details are confusing.” This judgment reflects the quality of the information provided by the patient and is usually made at the end of the interview.

Question 24

Components of the Adult Health History - Chief Complaint(s).

Answer 24

Make every attempt to quote the patient’s own words. For example, “My stomach hurts and I feel awful.” Sometimes patients have no specific complaints. Report their goals instead. For example, “I have come for my regular check-up” or “I’ve been admitted for a thorough evaluation of my heart.”

Question 25

Components of the Adult Health History - Present Illness.
This section of the history is a complete, clear, and chronologic account of the problems prompting the patient to seek care. The narrative should include the onset of the problem, the setting in which it has developed, its manifestations, and any treatments.
Each principal symptom should be well-characterized, with descriptions of (1) location; (2) quality; (3) quantity or severity; (4) timing, including onset, duration, and frequency; (5) the setting in which it occurs; (6) factors that have aggravated or relieved the symptom; and (7) associated manifestations.

Answer 25

1. Medications should be noted, including name, dose, route, and frequency of use.
2. Allergies, including specific reactions to each medication, such as rash or nausea, must be recorded, as well as allergies to foods, insects, or environmental factors.
3. Note tobacco use, including the type
4. Alcohol and drug use should always be investigated. (Avoid restricting the Personal and Social History to these topics if you place them there.)

Question 26

Components of the Adult Health History - Past History
Childhood illnesses, such as measles, rubella, mumps, whooping cough, chickenpox, rheumatic fever, scarlet fever, and polio, are included in the Past History. Also included are any chronic childhood illnesses.
Provide information relative to Adult Illnesses in each of four areas:
●● Medical: Illnesses such as diabetes, hypertension, hepatitis, asthma, and HIV; hospitalizations; number and gender of sexual partners; and risky sexual practices
●● Surgical: Dates, indications, and types of operations
●● Obstetric/Gynecologic: Obstetric history, menstrual history, methods of contraception, and sexual function
●● Psychiatric: Illness and time frame, diagnoses, hospitalizations, and treatments

Answer 26

Cover selected aspects of Health Maintenance, especially immunizations and screening tests. For immunizations, find out whether the patient has received vaccines for tetanus, pertussis, diphtheria, polio, measles, rubella, mumps, influenza, varicella, hepatitis B, Haemophilus influenzae type B, pneumococci, and herpes zoster. For screening tests, review tuberculin tests, Pap smears, mammograms, stool tests for occult blood, colonoscopy and cholesterol tests, together with results and when they were last performed. If the patient does not know this information, written permission may be needed to obtain prior medical records.

Question 27

Components of the Adult Health History - Family History
Under Family History, outline or diagram the age and health, or age and cause of death, of each immediate relative, including parents, grandparents, siblings, children, and grandchildren

Answer 27

Review each of the following conditions and record whether they are present or absent in the family: hypertension, coronary artery disease, elevated cholesterol levels, stroke, diabetes, thyroid or renal disease, arthritis, tuberculosis, asthma or lung disease, headache, seizure disorder, mental illness, suicide, substance abuse, and allergies, as well as symptoms reported by the patient. Ask about any history of breast, ovarian, colon, or prostate cancer. Ask about any genetically transmitted diseases.

Question 28

Components of the Adult Health History - Personal and Social History.
The Personal and Social History captures the patient’s personality and interests, sources of support, coping style, strengths, and fears. It should include occupation and the last year of schooling; home situation and significant others; sources of stress, both recent and longterm; important life experiences, such as military service, job history, financial situation, and retirement; leisure activities; religious affiliation and spiritual beliefs; and activities of daily living (ADLs). Baseline level of function is particularly important in older or disabled patients.

Answer 28

The Personal and Social History includes lifestyle habits that promote health or create risk, such as exercise and diet, including frequency of exercise, usual daily food intake, dietary supplements or restrictions, and use of coffee, tea, and other caffeinated beverages, and safety measures, including use of seat belts, bicycle helmets, sunblock, smoke detectors, and other devices related to specific hazards. Include any alternative health care practices.

Question 29

Components of the Adult Health History - Review of Systems.

Answer 29

Understanding and using Review of Systems questions may seem challenging at first. These “yes-no” questions should come at the end of the interview. Think about asking a series of questions going from “head to toe.”
Start with a fairly general question as you address each of the different systems. This focuses the patient’s attention and allows you to shift to more specific questions about systems that may be of concern.

Question 30

Components of the Adult Health History - Review of Systems questions
General: Usual weight, recent weight change, clothing that fits more tightly or loosely than before; weakness, fatigue, or fever.
Skin: Rashes, lumps, sores, itching, dryness, changes in color; changes in hair or nails; changes in size or color of moles.
Head, Eyes, Ears, Nose, Throat (HEENT): Head: Headache, head injury, dizziness, lightheadedness. Eyes: Vision, glasses or contact lenses, last examination, pain, redness, excessive tearing, double or blurred vision. Ears: Hearing, tinnitus, vertigo, earaches, infection. Nose and sinuses: Frequent colds, nasal stuffiness, discharge, or itching. Throat (or mouth and pharynx): Condition of teeth and gums, bleeding gums, dentures.
Neck: “Swollen glands,” goiter, lumps, pain, or stiffness in the neck.
Breasts: Lumps, pain, or discomfort, nipple discharge, self-examination
practices.
Respiratory: Cough, sputum (color, quantity), hemoptysis.
Cardiovascular: “Heart trouble,” high blood pressure.
Gastrointestinal: Trouble swallowing, heartburn, appetite, nausea, Bowel movements.

Answer 30

Peripheral vascular: Intermittent claudication; leg cramps; varicose veins
Urinary: Frequency of urination, polyuria, nocturia, urgency, burning or pain during urination, hematuria.
Genital: Male: Hernias, discharge from or sores on the penis, testicular pain or masses, scrotal pain or swelling. Female: Age at menarche, regularity, frequency, and duration of periods.
Musculoskeletal: Muscle or joint pain, stiffness, arthritis, gout, backache.
Psychiatric: Nervousness, tension, mood, including depression, memory change, suicide attempts, if relevant.
Neurologic: Changes in mood, attention, or speech; changes in orientation, memory, insight, or judgment; headache, dizziness, vertigo, fainting.
Hematologic: Anemia, easy bruising or bleeding, past transfusions, transfusion reactions.
Endocrine: “Thyroid trouble,” heat or cold intolerance, excessive sweating, excessive thirst or hunger, polyuria, change in glove or shoe size.