physical exam skills Flashcards
Ankle Brachial Index
- to assess presence and severity of PAD
- pt lie supine for 10 minutes before beginning
- measure systolic BP of brachial arteries in R and L arm
- place BP cuff on calf
- locate the dorsalis pedis artery by extending big toe, put gel on area
- place probe on artery, you will hear a swish sound
- inflate the cuff until sound disappears, slowly deflate cuff and record the mmHg when sound returns
- posterior tibial artery posterior and inferior to medial malleous
norm >1.0
abnorm <0.9->/= 1.3
borderline .91-.99
mildly abnormal .7-.9
mod abnorm .4-.69
severe abnorm <.4
Blood Pressure
1 inch above cubital fossa
palpate brachial artery
norms: <120/<80
elevated/preHTN: 120-129/<80
stage 1:130-139/ 80-89
stage 2: >139 or >89
crisis: >179/>20
calf girth measurement
to measure peripheral LE edema
patient supine
- place tape measure 10 cm below tibial tuberosity
- repeat opposite leg and compare
chest mobility: manual
to assess upper and middle lobe mobility
patient seated at edge of bed
look for symmetry
Upper chest - place hands at level of rib 4 with thumbs at sternal angle
- ask pt to breath in and out
- assess for equal and adequate chest wall excursion
Middle chest
- place hands at xiphoid process and take up the skin slack
- ask pt to breath in and out
Lower Lobe
- place hands at level of rib 10 and take up skin slack
Chest Mobility TM
pt seated
Upper Lobe (norm 2.5cm)
- place tape measure over sternal angle, holding tape measure taut
- ask to breathe
Middle Lobe (norm 3-4 cm)
- place TM at xiphoid process
Lower Lobe (norm: 4-5cm)
- place TM midway between xiphoid process and umbilicus
HR and RR
HR
- locate radial pulse, measure for 30 seconds and multiply by 2
Norm - 60-100
RR
- count # of times chest rises for 30 seconds and multiple by 2
Norm - 12-20 while holding HR
Heart Sound Auscultations
to assess for abnormal heart sounds
- use stethoscope to listen
Aortic Area - 2nd intercostal space, right lateral sternal border
Pulmonic Area - 2nd intercostal space, left lateral sternal border
Tricuspid Area - 4th intercostal space, left or right sternal border
Mitral Area - 5th intercostal space, left mid-clavicular line
S3 sound is associated with CHF but normal in children or young adults
S4 - severe HTN or stiff ventricle, normal in elite athlete
Intermittent Claudication
assessment of walking tolerance for pts with diagnosis of IC or PVD in order to create walking program for HEP
- seated in a chair take vitals (BP, HR, O2)
- instruct to walk back and forth for as long as possible even with moderate to severe pain in alf
- use stopwatch to record time before pt has to sit and rest
- assess vitals again
- use 1:1 walk and rest time for HEP
- goal is 30-60 minutes most days
Lung Auscultations normal
- pt seated
- listen to upper, middle, anterior aspect of lower lobes
- listen to upper lobe (above T2/T3) and lower lobe below T3
- consolidation = increased resonance, louder, e sounds like a
Lung Auscultations Abnormal
bronchophony = pt say 99
postive = louder 99
whispered pectoriloqouy = pt whispers 99
positive - louder 99
egophony - pt says e
positive = e sounds like a
Tactile Fremitus
“dull, deepened, hyperresonant”
- place ulnar border on patients chest
- instruct them to say 99
- palpate upper, midd,lower lobes
- can be repeated over posterior wall
positive = increased vibration felt over hand (consolidation)
decreased vibration = air
Mediate Percussion
to assess the resonance in the lungs
pt seates
- place 3rd digit of non-dom hand in between the intercostal space
- with 2nd and 3rd digits of dominant hand, tap over non-dom 2-3x
- percuss upper, middle, and lower lobe both sides
- Positive = dullness in area of consolidation or hyperresonance (air)
Observation
to observe the pts physical appearance when you first enter the room
pt in supine
Face:
- consciousness, expression
- difficulty breathing
- discoloration of lips
- pursed lip breathing
Chest:
- use of accessory muscles
- upper chest vs diaphragm breathing
- barrel chest
Hands:
- discoloration of nail beds
- digital clubbing
Skin and Ankles:
- edema
- skin integrity
Oxygen Saturation
pulse ox over pts finger
- check accuracy for HR and manually take it
- note for dark nail polish or poor circulation can cause inaccurate reading
Norm: >95%
Rubor of Dependency and venous filling time
to assess arterial insufficiency
pt supine
locate a peripheral vein in dorsum of foot
elevate leg so hip is flexed to 60
hold leg for 1 minute (if pt cant tolerate, elevate to 45dg and hold for 3 minutes)
then lower leg and record how long it takes for vein to refill and color to return to normal
Norms: <30 seconds color, <15 seconds vein refill
rubor abnorm after 30 seconds
