Physical Exam Flashcards
What are the objectives of health assessment?
Describe physical examination techniques
Describe examination equipment
Describe the general approach to the physical examination
Outline the steps of the comprehensive physical examination
Detail the components of the mental status examination
Identify abnormal findings in the mental status examination
Outline steps in the general patient survey
Distinguish between normal and abnormal findings in the general survey
What are the two components of health assessment?
Health history
Physical assessment
What is the purpose of health assessment?
- Establish a client relationship.
- Gather data about the patient’s general health status, integrating physiologic, psychological, cognitive, socio cultural, development and spiritual dimensions.
- Identify patient’s strengths.
- Identify actual and potential health problem.
- To evaluate the physiological outcome of care.
What is included in general examination?
Gender/race
Extremes of Age
Signs of distress
Body type Posture
Gait
Body movement
Hygiene/grooming
Dress
Body odors
Speech
Affect/Mood
Client abuse
Substance abuse
Skin cancer is 20% higher in _______ than _______
Caucasian Americans
African Americans
Prostate cancer is higher in _______ than _________
African American
Caucasian American
Examples of “signs of distress” during your general exam would be:
Pain, difficulty breathing
When we say body type, we mean:
Thin or fat
When we talk about posture, we want to know if the pt is:
Standing
Upright position
Knee flexed
What are some things you can tell by the way someone walks/gait?
Stroke
Injuries
Chronic back pain
What are some examples of a pt’s gait during the general exam?
Coordination, proper or not?
Is the person walking normally with arms swinging freely at their sides, with head/face leading the body?
We worry about sensory/motor weakness in pts with:
Diabetes
Significant neuro history
We can detect ___ from someone with NO body movement
Pain
No control (contractions)
What are examples of body movement during general exam?
Is their movement purposeful?
Is any part of them immobile?
What are examples of hygiene and grooming during general exam?
Is their person hygiene maintained or not?
Do they have any cosmetics used?
What are some factors of “dress” during general exam?
Culture, lifestyle, socioeconomic status
Dress for pts should be appropriate according to __________
weather conditions
Factors included in body odor in the general exam
Unpleasant odor
Poor hygeine
Bad breath
Poor oral hygiene
Remember unpleasant odor may be a ________, as they may not consider it unpleasant
Cultural thing
Factors included in “speech” in the general exam
Pressure
Tone
Speed
Factors included in “affect and mood” in the general exam
Feeling’s to others
Emotional expression
Mood appropriate as per the situation
What would cause you to suspect client abuse during the general exam?
Any problem during growing and serious health problem during childhood
Neglect can include:
Ulcers, malnutrition
Examples of substance abuse
Drugs, alcohol, smoking, ganja
When asking a pt if they smoke, it’s easy to ask what type of questions?
Yes or no questions!
Don’t worry about how much or how often; your focus is if it interacts with anesthetics
Define health history
A collection of subjective and objective data that provides a detailed profile of the client’s health status
What are some common pt identifiers/social history questions?
Pt name
Age
Sex
Hospital Name
File #/MRN
Source providing history
Date/time of admission
Language
Marital Status
Educational status
Occupation
Monthly income
It’s important to obtain history prior to _______
Administration of any mind altering substances
What would be included in the details of a pts admission that is important to us?
How did they arrive? (wheelchair/stretcher/ambulatory)
LOC? (conscious/semiconscious/unconscious)
From where did they arrive? (Admitting room, ER, home, etc)
Baseline data includes:
Weight
Height
Abdominal Girth
Respiration
Pulse
BP
Temperature
In critically ill and injured pts, what type of temperatures are often inaccurate?
Peripheral
Inaccurate temperature measures in post op can effect us as providers, as it is:
A QI measure
Anthropometry includes:
Height
Weight
Abdominal girth
Mid arm circumference
Define anthropometry:
The scientific study of the measurements and proportions of the body
What anthropometric measures affects our anesthetics?
Positioning
How meds are delivered
Are they an 80 year old with a BMI of 20 or an 8 year old with a BMI of 20?
Descriptions used to describe height and build:
Average
Tall
Short
Lanky (long & thin)
Muscular
Height and build may also be affected by _________
Age and lifestyle
Redudant neck tissue and snoring often mean the pt is prone to:
Airway obstruction with sedation
What are the 2 “extremes” used to describe weight?
Emaciated
Obese
T/F
We don’t care if a pt has had recent weight loss/gain
False!
Recent changes may be key finding
What could cause a pt to lose weight quickly?
Cancer
Diabetes
What could cause a pt to gain weight quickly?
Heart failure
Hypothyroid
Extremes of weight may have issues with _____ and are prone to what type of injuries?
Wound healing
Positioning
Factors included when we are thinking about pulses
Rate
Rhythm
Quality
Factors included when we think about respirations
Adult rate
Observe how they are breathing
- is it difficult for them to breathe?
Feeling for chest movement
Auscultation
Factors that may impact the ability to measure BP
Movement
Neuro monitoring
Hypo-perfusion
Where all can you check a BP? (with a cuff)
Radial artery
Brachial artery
Dorsalis pedis artery/Posterier tibial artery
Popliteal artery
Considerations when checking an oral temperature
Hold thermometer firmly under tongue
For children, tell them to “kiss”
Caution to avoid biting
Considerations when taking an axillary temp
Hold the arm down firmly
Should be approx. 1F less than core temp
Some thermometers are calibrated for axillary use, know your devices!
What’s a potential issue in someone who is hypothermic?
Impaired coagulation
Considerations for taking a rectal temp
Risk of perforation
Avoid in uncooperative or immune-suppressed pts
Stabilize the thermometer
Who might you check rectal temps on?
Children
Pt’s who are so cold it won’t register
Reason for admission includes:
Onset
Duration
Earlier treatments attempted
Why is it important to ask pt’s what their symptoms are to an “allergy”?
A lot of people believe common side effects of medications are allergies
What are common vices?
Drugs
Tobacco
Cigarettes
Drugs
We are concerned about pt’s that smoke because it puts them at risk for _______
Vascular issues
Focus on yes or no questions for vices, EXCEPT:
Cigarettes
We need to know how many packs per day and for how long!
Define a pack year for a smoker
1 PPD x 365 days = 1 pack year. Anyone with 55 years or older with a 30+ PPD history = high risk lung cancer
Family information includes:
Name of family members
Relationship with pt
Age
Type of family
Education
Occupation
Marital status
Health status
Family income per year
Family interpersonal relationship/any disharmony?
Family history of illness
Family information is particularly important in which type of pts?
Pediatric pts
Those in which discharge planning may be a concern
Many disease processes have a significant _________ component
genetic
Environmental factors include:
Housing
- type of house
- lighting
- ventilation
Water facilities
Sanitation
- pets/animals
- food
- personal hygiene practices
Community resources include:
Transport
Health facilities
Educational facilities
What do we need to know when asking about someone’s current medications?
Medication
Dose/frequency
Route
Last dose take
One of the leading causes of beta blocker ODs is _______
Accidental excess intake
Special assistive devices include:
Wheelchair
Braces
Crutches
Contacts
Hearing aids
Prosthesis
Glasses
Dentures (total/partial)
Ensure all dentures are removed preop to reduce the risk of _____
Aspiration
Ensure contacts are removed preop to reduce the risk of ________
Corneal abrasion
Questions to ask when assessing psychosocial history:
Any recent stress?
Who is with the pt in the hospital?
Does the pt have anybody who will give financial support if needed?
Who will care for the pt at home?
What are ways that we physically assess our pts?
Inspection
Palpation
Percussion
Auscultation
Olfaction
Define inspection
Visual assessment of the pt and surroundings
Inspection findings that may be significant:
Pt hygiene
Clothing
Eye gaze
Body language
Body position
Skin color
Odor
Make sure to make a visual inspection for:
Cleanliness
Prescription medicines
Illegal drugs
Weapons
Signs of alcohol use
Inspect each area of what 6 things?
Size
Shape
Color
Symmetry
Position
Abnormalities
Define palpation
A technique in which the hands and fingers are used to gather information by touch
Palmar surface of fingers and finger pads are used to palpate for:
Texture
Masses
Fluid
Assessing skin temp
What are the types of palpation?
Light palpation
Deep palpation
Bimanual palpation
Define light palpation
1-2 cm deep
- feeling for something right under the skin (arteries)
Define deep palpation
4-5 cm deep
- used to detect abdominal masses
Define bimanual palpation
Using both hands to trap structure between them
- used to evaluate spleen, kidney, breast, uterus, ovary
Define percussion
Involves tapping the body with the fingertips to evaluate the size, border, and consistency of body organs and to discover fluid/air in body cavity
When using percussion, there is going to be a different sound between ___ and ____
Air
Tissue
What are the methods of percussion?
Mediate or indirect percussion
Immediate percussion
Fist percussion
How is mediate or indirect percussion performed?
Using the finger on one hand as a striking finger and the middle finger of the other hand as the finger being struck
What is mediate or indirect used to evaluate?
Abdomen or thorax
What is immediate percussion used to evaluate?
Sinus or infant thorax
What is fist percussion used to evaluate?
Back and kidney for tenderness
Common sounds from percussion (coming from air containing space, enclosed area, gastric air bubble, puffed out cheek)
Sound : Tympany
Intensity : Loud
Pitch : High
Duration : Moderate
Quality : Drumlike
Common sounds from percussion (coming from normal lungs)
Sound : Resonance
Intensity : Moderate to Loud Pitch : Low
Duration : Long
Quality : Hollow
Common sounds from percussion (coming from emphysematous lungs)
Sound : Hyper Resonance
Intensity : Very Loud
Pitch : Very Low
Duration : Longer than resonance
Quality : Booming
Common sounds from percussion (coming from the liver)
Sound : Dullness
Intensity : Soft to moderate
Pitch : High
Duration : Moderate
Quality : Thudlike
Common sounds from percussion (coming from muscle)
Sound : Flatness
Intensity : Soft
Pitch : High
Duration : Short
Quality : Flat
Auscultation sounds to note:
Intensity
Pitch
Duration
Quality
How does auscultation work?
Frequency or the number of oscillation generated per second by a vibrating object
While assessing a pt, you should be familiar with the _______ and ______ of body odors
Nature
Source
Cyanosis in infants is usually seen where?
Around the mouth, especially above the upper lip
Can also be seen on their hands and feet
Liver issues can cause:
Clotting issues
Third spacing
Ascites
Fluid shifts (from recent paracenthesis)
Underlying conditions that may cause jaundice include:
Acute inflammation of the liver
Inflammation of the bile duct
Obstruction of the bile duct
Hemolytic anemia
Gilbert’s syndrome
Cholestasis
What is Gilbert’s syndrome:
inherited condition that impairs the ability of enzymes to process the excretion of bile
Rarer conditions that may cause jaundice:
Crigler-Najjar syndrome: inherited condition that impairs the specific enzyme responsible for processing bilirubin
Dubin-Johnson syndrome: inherited form of chronic jaundice that prevents conjugated bilirubin from being secreted into the cells of the liver
Pseudojaundice: harmless form of jaundice; due to excess of beta-carotene
Causes of pallor:
Anemia
Hypoperfusion
Nauseated
MI
Define vitiligo
An autoimmune disorder in which the systems in the body that fight off infection begin to fight off the healthy cells that control the coloring of the skin, hair, mucous
Vitiligo first shows up after a _______________
Triggering event
Cut, scrape, bruise
Causes of ecchymosis
Basilar skull fracture
Abuse
Facial trauma
Orbital fracture
Entrapment
Optic nerve ischemia
Causes of petechiae
Impaired/excessive clotting
Infection
Leukemia
Prolonged straining
Medications
Causes of skin lesions:
Normal process
Cigarette burn (abuse)
AIDS/HIV
Diabetic foot ulcer
Poor vasculopath
Poor turgor could be _____ or _________
Dehydration
Chronic condition
Causes of bilateral edema
CV compromise
Pregnancy
People who spend all day on their feet
Causes of unilateral edema
DVT
Lymphatic obstruction
Bugs/ants/bees/snakes
When assessing the nails, this includes:
Shape
Angle
Texture
Color
Capillary refill
Describe koilonychia
Spoon nails
anail diseasethat can be a sign ofhypochromicanemia, especiallyiron-deficiency anemia. It refers to abnormally thin nails (usually of the hand) which have lost their convexity, becoming flat or even concave in shape. In a sense, koilonychia is the opposite ofnail clubbing. In early stages nails may be brittle and chip or break easily.
Describe nail clubbing
a deformity of the finger or toenailsassociated with a number of diseases, mostly of theheartandlungs. When it occurs together withjoint effusions, joint pains, and abnormal skin and bone growth it is known ashypertrophic osteoarthropathy.
Describe paronychia
an inflammation of theskin around the nail, which can occur suddenly, when it is usually due to the bacteriumStaphylococcus aureus, or gradually when it is commonly caused by the fungusCandida albicans
Describe Beau’s lines
can develop as a result of injuries, illnesses, or environmental factors such as:
picking at the nails or cuticles
getting an infection around the edge of the nail
getting a manicure
If you have more than one nail with Beau’s lines, this can be indicative of:
Acute kidney failure
Mumps
Thyroid disease
Syphilis
Side effect of chemotherapy
Endocarditis
Melanoma
Diabetes
Pneumonia
Scarlet fever
Zinc deficiency
Causes of lack of hair:
Cancer
Alopecia
Malnutrition
Hirsutism may be caused by:
PCOS
Cushing’s syndrome
Congenital adrenal hyperplasia
Medications
Assess the scalp for:
Unusal scalp lesions
Lumps
Trauma
Moles
Lice
How does anesthesia cause ptosis?
- A persistently small pupil (miosis)
- A notable difference in pupil size between the two eyes (anisocoria)
- Little or delayed opening (dilation) of the affected pupil in dim light
- Drooping of the upper eyelid (ptosis)
- Slight elevation of the lower lid, sometimes called upside-down ptosis
- Sunken appearance to the eye
- Little or no sweating (anhidrosis) either on the entire side of the face or an isolated patch of skin on the affected side
Symptoms of Horner’s syndrome
Ptosis
Miosis
Loss of temperature sensation
Diaphoresis
What is ectropion?
Eversion; lid margin turned out
What is entropion?
Inversion; lid margin turns inwards
What is ptosis?
Abnormal dropping of lid over pupil
Bleeding in the eye can be caused by:
Ocular sx
Face mask being pushed onto face
Eye trauma
What is accommodation referring to?
Your eyes’ ability to see things that are both close up and far away
Anticholinergics causes the eyes to _____
Dilate
Opioids cause your eyes to ______
Constrict
Snellen test? Random E test?
Snellen = this is the letter chart you use to assess vision
E = vision test, you use a capital E and rotate it and you have to visually identify it’s position
Basic causes of peripheral vision loss include:
Glaucoma
Retinitis Pigmentosa
Eye strokes or occlusions
Detached retina
Brain damage from stroke, disease, or injury
Neurological damage such as optic neuritis
Compressed optic nerve head
Concussions (head injuries)
Webers vs Rinnes test?
W = Tuning fork on the head and feel for vibrations
R = Tuning fork outside the ear or placed on the post-auricular bone
Nitrous can diffuse into air trapping spaces. What can this cause?
In someone with increased ICP, this can increase ICP further
increased pressure in the sinus
Concerns with nose/sinuses
Barotrauma
Air trapping
Bleeding
Possible issues with the lips
Lesions
Pallor (anemia)
Cyanosis (resp/CV problems)
Cherry colored
Possible issue with the buccal mucosa, gums, and teeth
Look for alignement
Dental caries
Visualize jaundice and pallor
Leukoplakia
Funny colors in the tongue can be caused by:
Thrush
Dehydration
Vitamin (B12, iron) deficiency
Abx
Necrosis
Piercings/infections
When assessing the nose, we check:
Shape
SIze
Lesions
Inflammation
Deformity
Edema
Mucus color
Patency of nair
Epistaxis
Discharge
Polyps
What do cherry colored lips mean?
Carbon monoxide poisoning
What does pallor colored lips mean?
Anemia
What does cyanotic lips mean?
Hypoxia and hypoperfusion
When assessing teeth, we are looking for:
Arrangement
Dental Hygiene
Loose teeth
Color of teeth
Halitosis
Dentures
Healthy gums are ____, _____, and _____
pink, smooth, moist
Spongy gums ______ easily
Bleed
Define leukoplakia
Thick white patches on the gums because of smoking or alcohol
How do you assess the function of the sternocleidomastoid muscle?
Ask the pt to flex the neck with the chin to the chest
How do you assess the function of the trapezius muscle?
Movement of the head sideways so that the ear moves toward the shoulder
How do you assess the anterior part of the thyroid gland?
using the pads of the index and middle finger, palpate the left lobe with the right hand and right lobe with left hand.
How do you assess the posterior part of the thyroid gland?
Both hands are kept around the neck with two finger of each hand on the side of trach
What are we assessing during the assessment of the breast?
Symmetry
Pain
Lump
Discharge
Swelling
Trauma
History of breast disease
Surgery
We see barrel chest in what disease?
What is it caused by?
COPD
Caused by air trapping
Describe pectus excavatum
Chest is pushing on the heart, can result in CV compromise
When assessing the thorax and lungs, we are looking at:
Thorax size
Thorax shape
Chest movement
Respiratory rate
Rhythm
Breathing pattern
Breath sounds
Chest pain with breathing
Cough (productive vs non productive)
Hemoptysis
What can cause hemoptysis?
TB, pulmonary edema, CV/pulm system issue, trauma
How do you find the apical pulse?
locate the 5th ICS just to the left to the sternum and move the fingers laterally, just medial to the left mid- clavicular line
When assessing the abdomen, we are looking for:
Size
Shape
Abdomen distention
Surgical mark
Stool frequency/character
Last movement
Ostomy present
Bowel sounds
When assessing the GU system, we are looking at:
Urinary complaints
Discharge
Anuria
Hematuria
Dysuria
Urinary incontinence
Urinary retention
Describe rombergs sign:
sign: arms out, feet together, shut eyes
* positive: very unsteady on feet or they fall; if pt has a stroke, arms may droop
With curvatures in the spine, observe for:
Lordosis
Scoliosis
Kyphosis
What does a + pronator drift test indicate?
Disconnect or damage between the brain and nerves communicating to the arms
Reflexes include:
Biceps
Triceps
Patellar
Achilles
Planter
Gluteal
