Physical Exams Flashcards
1
Q
Neuro - Cranial Nerves
A
CN1: Olfactory
- 1 nostril at a time
CN2: Optic
- Visual acuity: Snellen, w glasses
- Visual fields: by confrontation at 2 ft, 1 eye covered, bring finger from extreme into sight, or hold up #s on your fingers in 4Q
- Fundoscopy: at 15° laterally, R-R eye + L-L eye, can dilate eye, assess optic disc, etc
CN3/4/6: Occulomotor, Trochlear, Abducens
- Horner’s, ptosis, saccades
- Extra-ocular mvmnts: 6 positions, ex: H shape, check for nystagmus, diplopia, smooth pursuit
- Accommodation: 30cm to 5-10 cm towards nose, assess convergence + constriction
- Pupillary light reflex: direct + consensual constriction
CN5: Trigeminal
- Sensory: dull/ sharp on V1 (oph, forehead), V2 (maxillary, upper lip/ cheeks), and V3 (mandibular, lower lip/ chin)
- Motor: muscles of mastication (temporalis + masseter)
- Reflexes: corneal (cotton tip, also 7), jaw jerk
CN7: Facial
- Sensory: ant ⅔ taste on tongue
- Motor: raise eyebrows, show teeth, puff cheeks, bury eyelids
- Reflexes: corneal (also 5)
CN8: Vestibulocochlear
- Rub fingers at each ear
- Rinne + Weber
- Romberg
CN9/10: Glossopharyngeal + Vagus
- Look at soft plate + uvula, uvula should rise with “ahh”
- Post ⅓ taste on tongue
- Check swallowing + hoarseness
- Reflex: gag
CN11: Spinal Accessory
- Shrug shoulders + rotate head, with + w/o resistance
CN12: Hypoglossal
- Strength, symmetry, mvmnt of tongue
2
Q
Neurology - Motor
A
Inspect
- Atrophy/ hypertrophy, tremor, fasciculations, symmetry
Tone
- Passive mvmnt throughout all joints - rigidity, spasticity, cog-wheeling
Power (0-5)
- Upper: C5 elbow flex, C6 wrist ext + pronation, C7 elbow ext + wrist flex, C8 finger flex, T1 finger aB/aD
- Lower: L2 hip flex, L3 knee ext, L4 ankle dorsiflex, L5 great toe ext, S1 ankle plantarflex
Check for Clonus
- Quick + powerful ankle dorsiflexion
3
Q
Neurology - Sensory
A
- Upper: C5 lat epi, C6 thumb/ index, C7 middle, C8 pinkie, T1 medial epi
- Lower: L3 medial femoral condyle, L4 medial malleolus, L5 1st webspace, S1 lateral malleolus
- Assess via sharp/ dull, vibration, temp, 2 pt discrimination
- Start distal + move proximal if they can’t feel
4
Q
Neurology - Reflexes
A
- Upper: C5 biceps, C6 brachoradialis/ pronator, C7 triceps
- Lower: L4 patellar, L5 hamstrings, S1 achilles
- Babinski
- UMN issue = increase, LMN = decrease
- 5+ sustained clonus, 4+ hyper-reflexive + clonus, 3+ hyper-reflexive, 2+ normal, 1+ hypo-reflexive, -0.5+ reflex only with reinforcement, 0 none
5
Q
Neurology - Cerebellum
A
Gait
- Romberg
- Walk heel to toe, just heels, just toes
- Balance, posture, arm swing
Other
- Nose to moving finger
- Rapid flipping hands
- Heel along shin
- Each finger to thumb
6
Q
Neurology - Special Tests/ Other
A
- Nuchal rigidity (flex neck)
Meningitis
- Kernig’s sign (flex hip + knee –> does head come up)
- Brudzinski’s sign (head towards chest –> do hip + knee flex)
Mental Status
- Orientation: time, place
- MMSE
- Observe speech, behaviour, mood, alertness, interaction, mvmnts
7
Q
HEENT - Head
A
- Head: proportion, contour, symmetry, masses, scars, lesions, deformity
- Hair: amount, distribution
- Scalp: lesions, lice
- Face: expression, edema, tics, colour
- CN5+7
8
Q
HEENT - Ears
A
- Pinna, auricle, tragus, discharge, mastoid
- Otoscope: pull auricle post + sup, ear drum (colour, otitis media), canal (discharge, FB, swelling, red)
- CN8: hearing test, Rinne + Weber
9
Q
HEENT - Eyes
A
- Symmetry, eyelids, conjuctiva/ sclera (jaundice), cornea, lens, iris
- Pupils: equal, round, reactive to light + accomodation
- Ophthalmoscope: dark room, at 15°, R-R eye + L-L eye, dilate. Red reflex, corneal light reflex, optic disc (outline, colour, cup:disc ratio, papilledema), BVs, AV nicking, exudate, hemorrhage, lesions, macula/ fovea
- CN2, 3, 4, 6
10
Q
HEENT - Nose
A
- Mucosa, turbinates, septum –> inspect + otoscope
- Occlude 1 nostril at a time for breathing
- CN1
11
Q
HEENT - Mouth
A
- Lips, mucosa, gums/ teeth, roof, tongue, floor, tonsils, jaw mvmnt
Palpate
- Glands (submandibular, submental, parotid)
- TMJ, tongue, cheek, teeth
- CN9, 10, 12
12
Q
HEENT - Neck
A
- Inspect: swallowing, thyroid, pulsations
- Palpate: thyroid, tracheal deviation hyoid
- Nodes: 10 spots. Size, shape, etc
- Auscultate: carotid bruits, aortic stenosis
- CN11
13
Q
Vitals
A
Heart Rate
- N = 60-100
- Palpate radial 30sec x2
- Pulse: regular/ irregular, strong/ weak
Resp Rate
- N = 12-20
- Rate, rhythm, quality
Temp
- N = 90 (85-92 if COPD)
Blood Pressure
- N = 91-120/ pump up until disappears, wait 5 mins
- Pump again, +20mmHg (to exclude auscultatory gap), dec at 2-3mmHg/ sec
- Systole is taken at the 1st clear taping sound (phase 1 Korotkoff), diastole is when the sound disappears (phase 5 Korotkoff)
- Repeat on other arm –> higher arm is used in future
- Pulsus paradoxus: BP drops >10 on inspiration
- Orthostatic hypotenstion: dec BP when standing (cardio, dehydration) (30: 20: 10)
14
Q
Cardiology
A
Inspection
- Chest: scars, skin colour, AP/ lateral diameter
- Pacemaker
- Cyanosis - central + peripheral
- Hands: clubbing, endocarditis (Osler’s nodes, Janeway lesions), nicotine stain
- Abnormal mvmnt over precordium, apex beat - lift/ heaves
- JVP: non-palpable, double wave-form, inc with hepato-jugular reflex, dec with inspiration, can obliterate, bw 2 heads of SCM, N = light tap, size of nickel, duration ⅔ of systole
Palpation
- Palpate the other 3 areas for heaves/ thrills/ lifts also
- Pulses: radial (rate + rhythym), carotids (auscultate for bruits first), brachial, femoral, popliteal, post-tib, dorsalis pedis
Auscultation
- APTM areas
- Diaphragm for high pitch (S1, S2)
- Bell for low pitch (S3, S4, MS)
- Murmurs, S3, S4, opening snaps, ejection clicks, rubs
- HR
- Bruits: carotid, femoral, abdo
15
Q
Respiratory
A
Inspection
- Breathing: rate/ rhythm, symmetry, insp = exp (obstructive = longer exp), AP/ lateral diameter, shape (barrel chest, spinal curves, pectus excavatum/ carinatum), paradoxical breathing, pursed lips/ flared nostrils, accessory muscles
- Cyanosis: central + peripheral
- Clubbing (lung CA, disease)
Palpation
- Trachea: deviation, descent (obstruction), tug (aortic aneurysm)
- Chest wall expansion: hands on back, symmetrial, 4-5 cm bw thumbs
- Tactile fremitus: “99”, 4 spots on back + 3 on front w ulnar side of both hands.
- -> Inc = pneumonia, consolidation, atelectasis
- -> Dec = pleural effusion
- Supraclavicular lymph nodes
Percussion
- Back: 7 on each side (including sides), w pts arms crossed
- Front: 6 on each side (including above clavicle)
- -> Resonant = normal
- -> Hyper-resonant = pneumothorax, COPD
- -> Dull = pleural effusion, pneumonia, atelectasis
- Diaphragmatic excursion: pt exhales, percuss down back until dull, pt inhales, percuss further down until dull again. N = 3-5cm.
Auscultation
- Instruct pt to only use mouth + cross arms
- Do same spots as percussion
- Duration, intensity, pitch, symmetry
- Bronchial breathing in abnormal spots = consolidation, atelectasis, tension pneumo, massive pleural effusion
- Vesicular breathing (normal over lung tissue)
- Crackles/ rales (like velcro), wheezing (exp), stridor (insp), pleural rub, ronchi (like snoring)
Other
- Sputum sample, PFTs, CXR
16
Q
Abdominal
A
Inspection
- Scars, rashes, masses, hernia
- Peristalsis, distention, shape
- Umbilicus symmetry
- Liver: BVs, caput medusa, jaundice, ascites, teres nails, scleral icterus, asterixis
Auscultation
- Bowel sounds (4Q)
- Bruits: esp if htn, aorta (AAA), renal arteries (L+R)
- Liver: friction rub, hepatic bruit
Percussion
- 4Q
- -> Tympany = gas/ air
- -> Dull = fluid, feces, mass, organomegaly
- Liver: assess size from above and far below via dullness, at R mid clavicular line. N = 6-12cm
- Spleen: move midline to lateral, then percuss at lowest ICS continuously while pt breathes. Should NOT be able to percuss via dullness (should be resonant/ normal).
Palpation
- 4Q, superficial + deep, watch pts face, do areas of complaint last
- Guarding, tenderness, rebound pain, mass, muscle resistance
- Liver: on inspiration, regular edge w smooth surface.
- Fluid wave/ shifting dullness: distended abdomen with ascites.
- Murphy’s sign: hook fingers around rib cage for gall bladder/ liver inflamm
- Spleen: L hand on back/ side, R moving up diagonally to L from midline. NOT normally palpable.
- Kidneys: on inspiration, pancake the sides with both hands
- Aorta: N = 3cm
Other
- DRE, urine sample, hernia orifices, pregnancy test
17
Q
Cervical Spine
A
Inspection
- N = lordosis/ 2° curve
- Rotation + flexion
Palpation
- Spinous processes: tenderness, spasm, masses, end at prominent C7
- Muscles: trapezius, SCM, paraspinal
ROM (active, passive, power)
- Flex/ ext, lat flex, rotation
Reflexes
- C5 = biceps, C6 = brachoradialis, C7 = triceps
Motor
- C4 scapula elevation, C5 elbow flexion, C6 wrist ext + pronation, C7 elbow ext + wrist flex, C8 finger flex, T1 finger aB/aD
Sensory
- C4 necklace, C5 lat epi, C6 thumb/ index, C7 middle, C8 pinkie, T1 medial epi
Special Tests
- Occiput wall distance (ank spond)
- Spurling’s sign: rotate + lat flex (impinge)
- Compression test: downward pressure on head (impinge)
- Electrical shocks down back from flexion
18
Q
Thoracic + Lumbar Spine
A
Inspection
- N = thoracic kyphosis/ 1° curve + lumbar lordosis/ 2° curve
- Lumbosacral tuft of hair = spina bifida
- Symmetry (ribs, shoulders, scapula, iliac crests)
Palpation
- Spinous processes, C7 down
- PSIS, SI joints (tenderness/ step deformity = spondylolisthesis paraspinal muscles
- Can hit each vertebra w hypothenar of closed fist checking for pain (non-specific)
ROM
- Forward flexion (touch toes). Watch for lordosis switch to kyphosis. Can measure finger to floor distance over time. Interspinous distance should inc on palpation.
- Extension, lat flex, rotation, chest expansion w breath
Reflexes
- L4 patella, S1 achilles, Babinski
Motor
- L2 hip flex, L3 knee ext, L4 ankle dorsiflex, L5 great toe ext, S1 ankle plantarflex
Sensory
- L3 medial femoral condyle, L4 medial malleolus, L5 1st webspace, S1 lateral malleolus
Special Tests
- Sacroilitis: flex hip/ knee on unaffected side, affected leg extend off table + pushed down. + = pain
- FABER
- Schober’s test: dimples to 10cm above, should become 15cm after bend
- Radicular pain: straight leg raise, bowstring sign
19
Q
Vascular
A
Inspection
- Colour, cyanosis (central + peripheral)
- Raynaud’s, vericose veins
- Skin integrity, hair loss, pigment
- Ulcers, blisters, gangrene
- Edema, atrophy
Palpation
- BP, cap refill, temperature
- Pulses: brachial, radial, ulnar, femoral, popliteal, dorsalid pedis, post tib
Muscles/ nerves
- Sensory (vibration distal to prox), strength, reflexes, parasthesia
Special tests
- Allen test (occlude ulnar + radial, release 1 at a time)
Other
- Cardio risk factors, atherosclerosis, MI, stroke, pain, claudication, swelling, cold, numbness, colour changes
20
Q
Diabetes
A
Foot
- Filament
- Sensation
Eye
- Fundoscopy
Labs
- HbA1C
- Urea, Cr
