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History taking and physical examination > Physical examination 1 > Flashcards

Physical examination 1 Flashcards

1
Q
  1. Physical examination-> stages
A
  1. General survey
  2. Vital signs
  3. Mental status
  4. Skin
  5. HEENT
  6. Neck
  7. Thorax
  8. Extremities and peripheral vascular system
  9. Abdomen
  10. Musculoskeletal system
  11. Nervous system
  12. Additional examinations
    1) rectal
    2) genital
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2
Q

General survey

A
  1. Overall impression
  2. Grooming
  3. Physical qualities
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3
Q

General survey -> overall impression

A
  1. Apparent condition (stan ogólny)
    1) good or moderate or bad
  2. Level of consciousness
    - > Glasgow coma scale
  3. Signs of distress
  4. Obvious lesions
  5. Acute or chronic disease
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4
Q

Glasgow coma scale categories

A
  1. Eye opening
  2. Best motor response
  3. Best verbal response

Min. 3 points
Max 15 points
-> 3-8 -> coma

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4
Q

Glasgow coma scale eye opening

A
  1. None
  2. To pain
  3. To speech
  4. Spontaneous
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6
Q

Glasgow coma scale motor response

A
  1. No motor response
  2. Extension to pain (decerebrate)
  3. Flexion to pain (decorticate)
  4. Withdraw from pain
  5. Localizes pain
  6. Obeys commands
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7
Q

Glasgow coma scale verbal response

A
  1. None
  2. Incomprehensible (moans/ groans, no speech)
  3. Inappropriate (intelligible, no sustained sentences)
  4. Confused, disoriented
  5. Oriented
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8
Q

Signs of distress

A

1) Cardiac or respiratory
1. Clutching of the chest
2. Diaphoresis (excessive sweating)
3. Labored breathing
4. Wheezing
5. Coughing

2) Pain
3) Anxiety or depression of CNS

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9
Q

Obvious lesions

A
  1. Pallor
  2. Cyanosis
  3. Jaundice
  4. Rashes
  5. Bruises
  6. Skin lesions
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10
Q

General survey -> grooming

A
  1. Dress
  2. Personal hygiene
  3. Odors of the body or breath
  4. Facial expression
  5. Mood
  6. Attitude to other people and environment
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11
Q

General survey -> physical qualities

A
  1. Posture
  2. Motor activity
  3. Heigh
  4. Weight
  5. BMI
    (6. Waist circumference)
  6. Sexual development (voice)
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12
Q

Vital signs

A
  1. BP - blood pressure
  2. HR - heart rate
  3. RR - respiratory rate
  4. Temperature
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13
Q

HEENT

A
  1. Head
  2. Eyes
  3. Ears
  4. Nose and sinuses
  5. Thorax and mouth
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14
Q

Head examination steps

A
  1. Hair
  2. Scalp
  3. Skull
  4. Face
  5. Skin
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15
Q

Hair examination

A
  1. Quantity
  2. Distribution
  3. Texture and patterns of loss
  4. Evidence of dandruff (Łupież), nits
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16
Q

The scalp examination

A
  1. Lesions ->
    1) scaling
    2) redness
    3) lumps
    4) nevi
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17
Q

Skull examination

A
  1. General size and contour
  2. Lesions:
    1) deformities
    2) depressions
    3) lumps
    4) tenderness
  3. Look for irregularities
  4. Palpate
  5. Percussion
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18
Q

The face

A
  1. Facial expressions
  2. Contours
  3. Lesions
    1) masses
    2) involuntary movements
    3) asymmetry
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19
Q

Eye examination

A
  1. General look - elements of the eye
  2. Visual fields
  3. Extraocular movements
  4. Test for convergence
  5. Endocrine reflexes
  6. Visual acuity
  7. Fundus -> with ophthalmoscope
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20
Q

Eye examination - General look - elements of the eye

A

1) External
1. Eyebrows
2. Eyelids
3. Lacrimal apparatus
4. Conjunctivas
5. Sclera and cornea

2) Internal
1. Iris
2. Pupils
3. Lens

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21
Q

Eye examination - pupils

A
  1. Size
  2. Shape
  3. Symmetry of both
  4. The light reaction
    1) in the same eye
    2) in the opposite eye
    3) light reflexion in corneas
  5. Accommodation
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22
Q

Eye examination reflexes

A
  1. Graeffe’s sign (lid lag sign) -> lagging of the upper eyelid on downward rotation of the eye -> visible upper part of sclera
  2. Kocher’s sign -> convulsive retraction of the eyelid in fixation on a fast upwards movements-> visible lower part of the sclera
  3. Möbius sign -> inability to maintain convergence
  4. Stellwag’s sign -> infrequent or incomplete blinking
  5. Dalrymple’s sign -> wider eyelid opening (spasm) -> abnormal wideness of palpebral fissure
  6. Joffroy’s sign -> inability to wrinkle the forehead when the patient looks up

-> all in Graves orbitopathy

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23
Q

Eye examination - fundus

A
  1. Optic disc and cup
  2. Retina
  3. Retinal vessels
  4. Macula
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24
Q

Ear examination

A
  1. The external ear
  2. Otoscope -> tympanic membrane + middle ear
  3. Hearing
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25
Q

Ear examination - the external ear

A
  1. Auricle

2. Ear canal

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26
Q

Ear examination - otoscope

A
  1. Ear canal
    1) Cerumen -> quantity, color
    2) Lesions -> redness, discharge, swelling, foreign bodies
  2. Tympanic membrane
    1) color
    2) contour and margins
    3) pars flaccida (up)
    4) cone of light
    5) lesions -> perforations
  3. Middle ear
    1) Malleus -> umbo, handle, short process
    2) (Incus) -> sometimes can be visible
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27
Q

Ear examination - hearing

A
  1. Ask patient about hearing
  2. Whisper Voice test
  3. Conductive Versus Neurosensory hearing Loss tests
    1) Weber test -> test for lateralization
    2) Rinne test -> Air versus Bone conduction test
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28
Q

Nose and sinuses examination

A
  1. General
  2. Pressure on the tip of the nose -> check swelling or tenderness
  3. Ask patient about rrhinorrhoea
  4. Test nasal obstruction
  5. Inspect the inside of the nares -> otoscope
    1) mucosa
    2) septum
    3) lesions
    4) exudate
  6. Sinuses -> pallets for tenderness
    1) frontal
    2) maxillary
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29
Q

Mouth and throat examination

A
  1. External
  2. Vestibule of mouth and teeth
  3. Posterior part of mouth and pharynx
  4. Tongue and floor of the mouth
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30
Q

Mouth and throat examination - external

A
  1. The lips
    1) color
    2) moisture
    3) lesions
  2. Corners of mouth
    1) inflammation
    2) symmetry
  3. Mandible -> protrusion -> prognathism
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31
Q

Mouth and throat examination - vestibule and teeth

A
  1. Teeth
    1) missing
    2) discolored
    3) abnormalities
  2. The gums
    1) color
    2) margins and papillae
    3) abnormalities
  3. Buccal mucosa
  4. Openings of the parotid ducts
  5. Saliva (Xerostomia)
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32
Q

Mouth and throat examination - posterior mouth and pharynx

A
  1. The roof of the mouth
    1) hard palate
    2) soft palate
  2. Uvula
    1) color
    2) deviation
    3) rise when eee
  3. Pillars
  4. Tonsils
  5. Posterior pharynx
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33
Q

Mouth and throat examination - tongue and floor of the mouth

A
  1. Tongue -> ask to put out
    1) symmetry
    2) color and texture
    3) lesions
    4) ask to touch corners of mouth
  2. Floor of the mouth -> ask patient to uplift the tongue
    1) Openings of ducts of submandibular glands
    2) Vein
    3) Lingual frenulum
    4) lesions
34
Q

Neck examination

A
  1. General look
  2. The lymph nodes
  3. Thyroid
  4. Jugular vein and carotid artery
35
Q

Neck - the lymph node examination

A
  1. Occipital
  2. Posterior auricular
  3. Preauricular
  4. Tonsillar
  5. Submandibular
  6. Submental
  7. Superficial cervical
  8. Posterior cervical
  9. Deep cervical chain
  10. Supraclavicular
  11. Infraclavicular
36
Q

Thyroid examination

A
  1. Inspection -> anterior
    1) Inspect the neck for thyroid
    2) Observe the patient swallowing
  2. Palpation -> anterior & posterior
    1) Palpate
    2) Ask to swallow
    3) Displace the trachea to one side and palpate on the other
  3. Auscultation -> anterior
37
Q

Thorax examination

A
  1. Breasts and axillae
  2. Posterior thorax
  3. Anterior thorax
38
Q

Breasts and axillae examination

A
  1. Breasts inspection
    1) arms over head
    2) hands pressed against hips
    3) leaning forward
  2. Breasts palpation-> supine position
  3. Axillae inspection
  4. Axillae palpation
39
Q

Breast palpation-> look for

A
  1. Consistency of the tissue
  2. Tenderness
  3. Nodules
    1) location
    2) size
    3) shape
    4) consistency
    5) delimitation
    6) tenderness
    7) mobility
40
Q

Posterior and anterior thorax examination - inspection -> check:

A
  1. Shape of the chest
  2. Skin lesions
  3. Skin color -> look for cyanosis/pallor (General or lips, mucosa, fingers)
  4. Depth and effort of breathing
  5. Respiratory rate and rhythm
  6. Contraction or impairment movement of the accessory muscles eg. sternocleidoomastoideus, intercostal or abdominal
  7. Displacement of the trachea
41
Q

Posterior thorax examination -> palpation

A
  1. Palpate -> look for tender areas and skin lesions
  2. Check chest expansion -> place hands under scapulae and look for symmetry of respiratory movements
  3. Test fremitus (44 in PL or 99 in ENG)
42
Q

Posterior thorax examination

A
  1. Inspection
  2. Palpation
  3. Percussion and descent of the diaphragm
  4. Auscultation
43
Q

Thorax examination breath sounds -> look for

A
  1. Breath sounds
    1) duration of sounds (inspiratory and expiratory)
    2) intensity (especially of expiratory)
    3) pitch of sounds (especially of expiratory)
    4) silent gap between inspiratory and expiratory
  2. Additional breath sounds
  3. Transmitted voice sounds
44
Q

Normal breath sounds

A
  1. Vesicular
  2. Bronchovesicular
  3. Bronchial
  4. Tracheal
45
Q

Additional breath sounds

A
  1. Crackles (Rales, rzężenia)
    1) Fine crackles (trzeszczenia, rzężenia drobnobańkowe)
    2) Coarse crackles (rzężenia grubobańkowe)
  2. Wheezes (świsty) and Rhonchi (furczenia)
    1) Inspiratory eg. stridor
    2) Expiratory
  3. Mediastinal crunch (Hamman Sign)
  4. Pleural Rub
46
Q

Transmitted voice sounds

A
  1. Egophony -> change eee to aaa
  2. Bronchophony-> louder 99
  • > localized both in lobar pneumonia
    3. Whispered pectoriloquy -> louder and clearer heard whispered sounds
47
Q

Fine crackles

A
  1. Generated by sudden inspiratory opening of small airways
  2. Heard from mid to late inspiration
  3. Causes
    1) interstitial lung diseases
    2) Pneumonia
    3) Pulmonary edema
  4. Egophony -> present in pneumonia but not in the interstitial lung diseases
48
Q

Coarse crackles

A
  1. Result from boluses of gas passing through airways as they open and close intermittently
  2. Appear in early inspiration and last throughout expiration -> biphasic
  3. Causes:
    1) COPD
    2) Asthma
    3) Bronchiectasis
    4) Heart failure
    5) Pneumonia
49
Q

Wheezes

A
  1. Result from narrowing of bronchi almost to the point of closure
  2. Can be inspiratory, expiratory or biphasic
  3. Causes of INSPIRATORY -> narrowing the airways outside the thorax
    1) laryngitis
    2) pressure on trachea from outside
    3) inflammation of trachea
    4) Paralysis of the voice cords or their dysfunction
    5) tracheal stenosis eg from intubation, edema
    6) epiglottis
    7) foreign body
    8) anaphylaxis
    eg. Stridor
50
Q

EXPIRATORY Wheezes

A

-> narrowing the airways inside the thorax

  1. Asthma
  2. Bronchitis
  3. COPD
  4. Aspiration
  5. Peribronchial edema
  6. Heart failure
  7. Pulmonary thromboembolism
51
Q

Rhonchi

A
  1. Variant of wheezes, arising from the same mechanism but lower in the pitch -> narrowing the middle-sized bronchi usually with secretion
  2. May disappear when coughing
  3. Causes:
    1) Bronchitis (bacterial or viral)
    2) COPD
    3) Bronchiectasis
52
Q

Causes of pleural rub

A
  1. Inflammation or roughening of the visceral pleura as it slides against the parietal pleura
  2. Biphasic -> heard during inspiration and expiration
  3. Cause ->
    1. Inflammation of the pleura
    2. Neoplasm of the pleura
    3. Pneumothorax
53
Q

Mediastinal Crunch

A

-> Hamman sign

  1. Series of precordial crackles synchronous with the heartbeat not with respiration
  2. Best heard in the left lateral position
  3. Arises from air entry into the mediastinum causing emphysema (pneumomediastinum)
  4. Usually produces severe central chest pain
  5. Causes:
    1) spontaneous
    2) tracheobronchial injury
    3) blunt trauma
    4) pulmonary disease
    5) use of recreational drugs
    6) childbirth
    7) rapid ascent from scuba diving
54
Q

Anterior thorax examination

A
  1. Skin inspection
  2. Respiratory system
  3. Cardiovascular system
55
Q

Anterior thorax examination -> respiratory system

A
  1. Inspection
  2. Palpation and assessment of chest expansion and fremitus
  3. Percussion with heart and liver dullness
  4. Auscultation
56
Q

Percussion voices

A
  1. Flat
    1) normally above thigh
    2) abnormally in large pleural effusion
  2. Dull
    1) normally above liver
    2) abnormally in lobar pneumonia
  3. Resonant
    1) normally above healthy lungs
    2) abnormally in chronic bronchitis
  4. Hyperresonant
    1) normally none
    2) abnormally in COPD, pneumothorax
  5. Tympanitic
    1) normally above stomach
    2) abnormally in large pneumothorax
57
Q

Heart sounds

A
  1. S1 -> closure of the mitral valve (and tricuspid)
  2. S2 -> closure of the aortic valve (and pulmonary valve-> can be heard later -> split)
  3. S3
  4. S4 -> atrial contraction -> just before S1
    - > rarely heard
    - > can reflect a pathological change in ventricular compliance
58
Q

S3 heart sound

A
  1. Caused by rapid deceleration of the column of blood against the ventricular wall
    - > or in older pathologic change in ventricular compliance
  2. Heard just after S2 -> when the mitral valve opens and there is a period of rapid ventricular filling
  3. Can be physiological in children and young adults
  4. After age 40 -> usually pathological
59
Q

Splitting of the heart sounds

A
  1. Right-sided cardiac events usually occur later than those on the left
  2. S2 can be physiologically split (first A2 and then P2) -> A2 is normally louder
    - > best heard in the 2rd and 3rd left interspaces close to the sternum
    - > best heard in inspiration
  3. S1 can be also split -> rarely
    - > best heart in the lower left border of sternum
    - > it doesn’t vary with respiration
60
Q

Thorax - Cardiovascular system examination

A
  1. The heart
  2. Jugular veins
  3. Carotid arteries
61
Q

The heart examination

A

-> patient supine, stand at the patient’s right side

  1. Inspection
  2. Palpation
  3. Percussion
  4. Auscultation
    - > 2 more position:
    1) turn patient to left side -> brings ventricular apex closer to the chest wall
    2) ask patient to sit down, lean forward and exhale -> better heard aortic regurgitation
62
Q

Base and apex S1 and S2 loudness difference

A
  1. Base S2 louder than S1

2. Apex S1 louder than S2

63
Q

Heart examination palpation

A
  1. With fingerpads-> heaves and lifts (enlarged chambers/ ventricular aneurysms)
  2. With the ball of the hand -> look for vibration (caused by turbulent flow)
  3. Palpate S1 and S2
  4. Palpate apical impulse (PMI-> point of maximal impulse) -> if PMI cannot be identify -> left lateral decubitus position
64
Q

Heart examination-> auscultation

A

-> feel the carotid or radial pulse then auscultate

  • > move from apex to base
    1. Apex (5L)
    2. Tricuspid area (4L-Erb’s point and 5L) -> can be also 4R
    3. Pulmonic area (2L)
    4. Aortic area (2R)
  1. Ask patient to roll into the left lateral decubitus position
    1) listen with bell on the apical impulse (S3, S4, mitral stenosis)
    2) listen with bell on the 2R (aortic stenosis)
  2. Ask patient to sit up, lean forward and exhale completely-> listen with diaphragm along left sternal border and at the apex (aortic regurgitation)
  3. Special techniques -> differences between mitral prolapse, hypertrophic cardiomyopathy and aortic stenosis (systolic murmur
    1) ask to stand up
    2) ask to squat
    3) valsalva maneuver
65
Q

Heart examination-> auscultation -> listen to:

A
  1. S1 and S2
    - > intensity and splitting
    - > S2 splitting in 2L, 3L
  2. Heart rate and regularity
  3. Extra sounds:
    1) S3 and S4 and other
    2) murmurs
66
Q

Heart examination-> auscultation -> murmurs

A
  1. Time of the murmur:
    1) systolic -> midsystolic or late systolic or holosystolic (pansystolic)
    2) diastolic -> early/ middiastolic/ late
    3) both-> continuous
  2. Shapes of the murmurs
  3. Location -> where it’s best heard and where it radiates
  4. Intensity of the murmur (1-6)
  5. Pitch and quality
67
Q

Heart examination-> auscultation -> Shape of the murmurs

A
  1. Crescendo eg. mitral stenosis
  2. Decrescendo eg. aortic regurgitation
  3. Crescendo-decrescendo eg. aortic stenosis and innocent flow murmurs
  4. Holosystolic (pansystolic) = plateau
    eg. mitral regurgitation
68
Q

Heart examination-> auscultation -> radiation

A
  1. Murmur of aortic stenosis often radiates to the neck, especially right side
  2. Murmur of mitral regurgitation otter radiates to the Axillae
69
Q

Heart examination-> auscultation -> murmur intensity

A

Grade 1 -> very faint, may not be heard in all positions, heard only after listener has “tuned in”

Grade 2 -> quiet, but heard immediately after placing the stethoscope on the chest

Grade 3 -> moderately loud

Grade 4 -> loud with palpable thrill

Grade 5 -> very loud with thrill, may be heard when stethoscope is partly off the chest

Grade 6 -> very loud with thrill, may be heard when stethoscope is entirely off the chest

70
Q

Heart examination-> auscultation -> murmur pitch and quality and other qualities

A
  1. Pitch -> high, medium or low
  2. Quality -> blowing, harsh, rumbling and musical
  3. Right sided -> increase with inspiration
  4. Left sided -> increase with expiration
71
Q

Types of systolic murmurs

A
  1. Midsystolic murmurs
    1) usually from semilunar valves (aortic and pulmonic)
    - > gap between S1 and S2
  2. Pansystolic (holosystolic) murmurs
    1) regurgitant flow across the AV valves
    - > no gap between S1 and S2
  3. Late systolic murmur
    1) mitral valve prolapse (regurgitation)
72
Q

Causes of midsystolic murmurs

A
  1. Innocent murmurs
  2. Physiologic murmurs
  3. Aortic stenosis
  4. Pulmonary stenosis
  5. Hypertrophic cardiomyopathy
73
Q

Causes of holosystolic murmurs

A
  1. Mitral regurgitation
  2. Tricuspid regurgitation
  3. Ventricular septal defect
74
Q

Types of diastolic murmurs

A
  1. Early diastolic murmur
    1) regurgitation of semilunar valves
  2. Middiastolic murmur
    1) turbulent flow across the AV valves (stenosis)
  3. Late diastolic murmur
    1) turbulent flow across the AV valves (stenosis)
75
Q

Causes of diastolic murmurs

A
  1. Aortic regurgitation
  2. Mitral stenosis

Less common:

  1. Tricuspid stenosis
  2. Pulmonic regurgitation
76
Q

Causes of continuous murmurs

A
  1. Patent ductus arteriosus
    1) with silent interval late in diastole
    2) loudest in late systole -> crescendo-decrescendo
    3) beast heard 2L
    4) harsh machinery-like
  2. AV fistulas (Common in dialysis patients)
  3. Pericardial friction rub -> scratchy, 2 or 3 coarse grating sounds (ventricular systole, diastole and atrial systole)
  4. Venous hums
    1) louder in diastole,
    2) best heard in sitting position,
    3) disappears when patient is supine,
    4) best 2R,
    5) common in children
77
Q

Maneuvers to distinguish systolic murmurs

A
  1. Squatting and Valsalva release phase
    1) increased venous return and LV volume
    2) increase of aortic stenosis murmur
    3) decrease of hypertrophic cardiomyopathy murmur
    4) mitral valve prolapse murmur shortens
  2. Standing and Valsalva strain phase
    1) decreased venous return and LV volume
    2) decrease of aortic stenosis murmur
    3) increase of hypertrophic cardiomyopathy murmur!!!!! only like this (increases with increase of patient’s abdomen work)
    4) mitral valve prolapse murmur lengthens
78
Q

Extra heart sounds systolic

A

1) Early systolic ejection
- > shortly after S1-> opening of semilunar valves -> indicates CVD
1. Aortic ejection -> dilated aorta or aortic valve disorder
- > doesn’t vary with respiration

2. Pulmonary ejection -> dilation of pulmonary artery, pulmonary hypertension or pulmonic stenosis  - > 2L and 3L  - > soft, decreases with inspiration

2) Systolic clicks -> mid to late systolic
1. Mitral valve prolapse
- > can be single or followed by late systolic murmur
2. Earlier when patient stands

79
Q

Extra heart sounds diastolic

A
  1. Opening snap (OS)
    1) opening of a stenotic mitral valve
    2) very early diastolic
    3) high pitch and snapping quality, better heard with diaphragm
  2. S3
    1) rapid ventricular filling
    2) later than OS, but early diastolic
    3) low pitch, dull
    4) physiological in children and young adults (<35)
  3. S4
    1) atrial contraction
    2) late diastolic
    3) low pitch, dull
    4) hypertensive heart disease, aortic stenosis, IHD, hypertrophic cardiomyopathy
80
Q

Jugular veins examination

A
  1. External jugular veins-> turn patient head to left then right and identify the external veins -> and their filling
  2. Try to see oscillations -> internal jugular vein pulsations in the lower part of the neck (suprasternal notch)
    - > raise the patient’s head to 30 degrees or more if it isn’t visible
  3. Identify the highest point of pulsation in the right jugular vein -> measure the vertical distance between it and sternal angle and add 5cm -> it’s JVP (jugular venous pressure)
  • > 5cm because sternal angle is 5 cm above the RA
  • > JVP> 8cm is elevated
  1. Look for jugular vein pulsations

History taking and physical examination (12 decks)

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