week 10: head to toe Flashcards
subjective
Tell me your full name, date of birth (biographical data) … occupation, address, phone #
Why are you seeking care? What brings you here today?
How is your present health/tell me the history of your current illness?
Tell me about your past health, if you’ve had any serious/chronic illnesses before/in youth
Have you had any accidents/injuries, like breaking a limb?
Have you been hospitalized, had operations, get immunized, regular checkups?
Do you use any medications, any allergies, or vitamins/herbal remedies?
Do you have any family history of serious illnesses that are hereditary?
If they’re not sure: History in heart, lungs, digestive, neuro, skin, cancers, kidneys/GU
Functional assessment: Do you have any difficulty doing activities of daily living? Or IADLS
Bathing, Toileting, Dressing, Grooming, Eating, Moving, Talking
Transportation, Shopping, Meal Prep, Housekeeping, Finances
How do you feel about your health? Feeling healthy, not healthy?
general appearance: inspect
Do they look like their stated age?
Level of Consciousness: Awake, Drowsy, Asleep?
Skin Colour: Pale, Red, Blue, Normal
Nutritional Status: Underweight, Normal, Overweight
Posture/Position: Upright, slouched, etc
Obvious physical deformities (anything extra or missing)
Mobility: Gait when they came in, any assistive devices, RoM, involuntary movements
Facial Expression: Annoyed, Happy, FLat
Mood and Affect
Speech: Articulation, Patterns, Appropriate responses, first language
Hearing (if they’re having any difficulties, you have to repeat yourself)
Personal Hygiene
head/face palpation and inspection
Scalp, Hair, Cranium
Face for expressions/symmetry (CN7)
Palpate Temporal Artery and TMJ when they open/close mouth
Palpate Sinuses: Frontal, Maxillary, Ethmoid
eyes inspection/palpation
Visual Fields with Confrontation (CN2); eye chart was done earlier
Cardinal Gazes (CN3,4,6)
PERRLA: Pupils Equal, Round, Reactive to Light (Pen light) and Accommodation (Close/Far)
External Eye Structures: Eyebrows, Lids, Lashes
“Look up” and pull eyelids down; Conjunctiva, Sclera, Cornea, Iris
N/A, Ophthalmoscope to inspect ocular fundus (red reflex, disc, vessels, retinal background)
ears inspection/palpation
External ear for position, alignment, condition, discharge from external auditory meatus
Tenderness in auricle, tragus (push, pull, move around)
Whispered voice test (2 syllable words)
Otoscope to inspect canal, tympanic membrane - colour, position, landmarks, integrity
nose inspection/palpation
Nose for symmetry, lesions, piercings, anything
Patency of each nostril - occlude one side, get them to inhale deeply
N/A - Can inspect nares with nasal speculum; mucosa, septum, turbinate bones
mouth/throat inspection and palpation
Use penlight: Look at mouth, buccal mucosa (cheeks), teeth, gums, tongue, mouth floor (under tongue), palate (top), uvula
Tonsils if present
Mobility of uvula - Say “ahhh” (CN9,10) - Don’t test gag reflex
Stick out tongue (CN12)
neck inspection/palpation
Neck for symmetry, lumps, pulsations (possible jugular venous pulse)
Palpate all 10 lymph nodes (3 under jaw, 3 around ear, 4 on neck)
Palpate each carotid pulse (one at a time), auscultate with bell for bruits
Palpate trachea for midline, displace and palpate the thyroid (normally you can’t feel it)
ROM/Muscle Strength: (resistance) Head forward back, turn side/side, shoulder shrug (CN11)
upper extremities
Inspect skin (for lumps, bumps, bruises, tattoos, hair, etc), symmetry, temperature
Palpate for radial, brachial pulses
ROM/Muscle Strength:
Wrist and Hands: Flexion/Extension, Deviation, Finger Flexion/Extension, Abduction
Elbows: Flexion/Extension, Pronation/Supination
Shoulders: Flex/Extend, Internal External Rotation, Abduction/Adduction, Circumduction
Deep Tendon Reflexes:
Biceps, Triceps Brachioradialis
posterior/lateral chest inspection/palpation
Posterior chest, rib cage configuration, skin (lumps, bumps, bruises, tattoos, etc.)
Tactile Fremitus (99), Symmetric Expansion, Lumps or Tenderness, Temperature
Palpate spinous processes (can do it later with MSK/Neuro)
PERCUSSION
Percuss over 10 lung fields for resonance, on diaphragmatic excursion (?)
Percuss CVA tenderness (punch hand on back)
AUSCULTATE:
Breath sounds on 18 spots; 9 spots bilaterally
anterior inspection and palpation
Inspect for respirations, skin characteristics
Tactile fremitus (99), Lumps, tenderness, scars, moles
Percuss lung fields, 10 areas
AUSCULTATION:
Auscultate 10 lung fields
HEART: Get them to lean forward, with bell auscultate base of heart for murmurs
patient upright
- measure
- vitals
- face/head
- eyes
- ears
- nose
- mouth
- neck
- arms
- lungs
patient lying down
heart
abdomen
lungs
heart inspection/palpation/auscultation
Precordium for any pulsations, heaves (already felt temp, skin conditions)
Palpate the apical impulse and note its location
AUSCULTATION:
Auscultate with diaphragm for heart sounds (APTM), (S1-S4), then with bell (murmurs)
Auscultate apical rate and rhythm (may not do it actually, you took pulse earlier)
LEFT LATERAL: Bell on Apex for Murmurs
GI/GU/Abdomen
INSPECTION: (No palpation yet)
Inspect contour, symmetry, skin characteristics, umbilicus (innie/outie), pulsations (aortic)
AUSCULTATE:
Bowel sounds in all 4 quadrants with diaphragm
Vascular sounds (aortic -> renal -> iliac -> femoral) with bell
PERCUSSION:
In all 4 quadrants, zig-zag
PALPATION:
All quadrants lightly
Palpate Femoral pulse in inguinal region
