Introduction

Introduce, identify as PA Student, explain PE, wash hands, ask to empty bladder and disrobe, Adequate lighting

General survey

Signs of distress, mental status, race, sex, sexual development, habitus, appearance, development in relationship to chronological age, nutritional status, age, posture, Obvious abnormalities, facial expressions, Height weight comparison, spiritual status

Mental status

speech, mood, sensorium, thought content, behavior

Inspect and palpate Skin

color, temp, texture, turgor, moisture, rashes,  lesions, pigmentation, hair distribution, lower extremity edema

Hands, Nails

cyanosis, capillary refill, clubbing, nail deformities, or tremor

Vital Signs

BP

      - oral temp

shake down to 95 F, under tongue for 3 minutes

      - pulse

Feel bilateral radial pulse for rate, amplitude, and rhythm, check for bounding, count radial for 30s, multiply X 2 for rate/min

      - respirations

count respirations for 30s, multiply X 2 for rate/min

      -Measure

Measure for cuff size

      - BP

Palpatory method, then Auscultatory method (R and L arm sitting, supine, and standing) check for Auscultatory gap

Head

inspect

Scalp for: hair (texture, loss, scaling, lice), facial symmetry, any obvious deformities, nose, mouth, nasolabial fold

palpate

Scalp for: lesions, hair texture, tenderness, size, etc. frontal and maxillary sinuses

CN VII (facial)

smile, raise eyebrows, and wrinkle forehead. Is there asymmetry of facial movement

Neck

inspect

symmetry, masses, tracheal position, thyroid, lesions, abnormal deformities

palpate cervical lymph nodes and glands

preauricular, postauricular, lacrimal, tonsillar, submaxillary, submental, posterior cervical, Anterior cervical, deep cervical, supraclavicular, tenderness, parotid

palpate trachea

trachea deviation

inspect thyroid

visible swelling or mass

palpate thyroid

Thyroid, cricoid, thyroid gland, have pt. Swallow and feel for rise of the isthmus

Eyes

acuity (CN II)

Rosembaum chart (12-14 in.)

Inspect/ palpate

eyebrows, eyelids, conjunctiva, sclera, iris, pupils, conjunctival inflammation, pterygiums, iris lesions, pupillary inequality, nystagmus, or strabismus, also nasalacrimal duct, nasal bone

CN VII (Facial)

Have pt. Close eyes tightly and tell them to not let you open them

pupillary reflexes (CN III)

direct and consensual, note crescent shadowing

accommodative reflex

convergence and pupillary constriction

extraocular muscles

(CN III, IV, VI)

six cardinal positions of gaze.

Note: lid lag

visual fields

8 compass directions. Any gross visual field defects, e.g. hemianopsia

fundoscopy

examine: red reflex, disk, arterioles, veins, retina, macula. Any opacities in ocular media (cataracts), disc cupping,  vessel narrowing, hemorrhages, or macular changes

Nose

inspect

With light inspect: septal deviation or perforations, mucosal inflammation, nasal discharge, or lesions,

CN I (olfactory)

one nostril at a time with choice of two fragrances. Any anosmia?

Mouth and throat

Inspect/ Palpate

Inspect/ Palpate: lips (cyanosis), buccal mucosa, gums, teeth, palate, pillars, posterior pharynx, tonsils, tongue, floor of mouth, Submandibular gland, Worten’s duct, Stensen’s duct. Noting Inflammation, exudate, or lesions,

CN IX, X

(glossopharyngeal, vagus)

Say ahhh, touch post. pharynx. Verbalize Gag Reflex, Does soft palate fail to rise on one side? Is there any hoarseness or dysphonia?

CN XII (hypoglossal)

stick out tongue or push tongue against cheek. Any deviation or atrophy?

CN V (trigeminal)

clinch teeth, bite down hard - palpate masseter muscle contraction. Any asymmetry of masseter muscle contraction?

Ears

hearing (CN VIII)

whispered voice test,  WEBER AND RINNE Test

inspect

auricles: deformity, lesions, discharge from external auditory canal?

palpate

tragus and auricle: tenderness

otoscopic exam

external auditory canals and tympanic membranes. ID landmarks and light reflex. external auditory canal or middle ear lessions, discharge, or inflammation. Tympanic scarring, perforation, bulging, retraction, or air/fluid behind the TM

Chest

inspect

Respiratory Rate: Note rate rhythm and depth, abdominal breathing, look ant., lat., post. Looking for barrel chest (AP diameter increased), muscular symmetry, chest symmetry, expansion, deformities, respiratory pattern, distress, intercostal or supraclavicular retractions, abd vs thoracic breathing

Palpate chest wall

Note any chest wall tenderness or palpable step off

thoracic expansion.

behind seated pt., both hands. (~T12) symmetric bilateral chest expansion?

Pt. Supine test for bilateral chest expansion

tactile fremitus

pt. says "99". Increased or decreased fremitus

4 on back/ 3 on front

percuss chest

unexpected dullness or hyperresonance (PERCUSSING DIAPHRAGMATIC EXCURSION)

7 on back/ 6 on front

Diaphragmatic Excursion

Start at inf. Angle, deep breath, measure.  Expire, percuss, measure

* breath with mouth open

auscultate chest

7 pts. On the post. chest all, 6 pts. On ant. Chest wall, looking for decreased, or abnormal breathe sounds, crackles, wheezes, rhonchi, rubs etc. Note pitch, loudness, and quality of breath sounds

* breath with mouth open

Whisper Pectoriloquy

Whisper 1,2,3 (normal chest will not hear anything

Vocal Fremitus (Bronchophony)

Same as above, but pt. Speaks instead of whispers

Egophony

“EEEE” sounds like “AAAA” over consolidated chest

Cardiovascular

inspect precordium

abnormal motion, lifts, heaves. Identify apical impulse

(Note if PMI differs from the apical impulse)

palpate precordium

using metacarpalphalangeal for thrills, palm for lifts & heaves (noting any pulsations, thrills, or vibrations of aortic valve closure)

Aortic Area

2^nd interspace to the R of the sternum

Pulmonic Area

2^nd L interspace

Erb’s Point

3^rd L interspace

Tricuspid Area

L lower sternal border

Mitral (Apical) Area

5^th interspace in the midclavicular space

Epigastrium

auscultate carotids

any bruits?

precordial auscultation

diaphragm, then bell. A, P, 3-4, T, M.

Is rhythm regular or irregular? Re: first and second heart sounds: loudness, splitting? If splitting, how affected by respiration? Does splitting decrease when pt sits up? Any S3, S4 (gallop) Listening to systole and diastole: any murmurs, clicks, rubs, etc.? What is timing relative to S1, S2? If murmurs, what is their intensity (grade I-VI) and pitch? Is loudness affected by respiration? Does murmur radiate?

special auscultation techniques

pt in left lateral decubitus position. Listen over apical and tricuspid areas with BELL for low pitched diastolic 'rumble' of mitral/tricuspid stenosis or an S3/S4. Detect murmur of aortic regurgitation: sit pt up, lean forward, hold breath out, listen to 7 pattern for high pitched early diastolic murmur of aortic insufficiency

Peripheral

inspect, palpate lower extremities

edema, skin temperature, decreased hair growth, varicosities, capillary refill

(ASSESS COMPETENCY OF VENOUS VALVES)

palpate peripheral pulses

carotids, brachials, radials, femorals, popliteals, dosalis pedis, posterior tibials.

Bilateral, Rate, rhythm, and quality of pulses (ALLEN TEST), palpate the radial and femoral at same time (note any lag)

Auscultate

Bilateral carotid and femoral artery, abdominal aorta, Renal arteries, Iliac arteries

Inspect

The jugular venous pulses with tangential lighting

Measure Jugular venous pressure and pulses

Elevate the bed to 30 or 45 degrees, measure the vertical distance between the sternal angle and the highest level of venous pulsation

Abdomen

inspect

skin, abdominal contour, symmetry. Ascites, pregnancy, Is abdomen flat, scaphoid, or distended? Any angiomata, ecchymoses or scars? Any visible peristalsis or arterial pulsations? Any distended abdominal wall veins?

Auscultate (1^st)

1 min in all four quadrants with diaphragm lightly. Bowel sounds - increased, decreased. Listen over aorta, renal, iliac, and femoral arteries. Any bruit?

Liver

Percuss lower border; begin in R midclavicular line (tympanic—dull), percuss upward, mark.  Percuss upper border; begin in R midthorax and percuss downward, mark (normal 6-12 cm)

Spleen

Just behind L midaxillary line with pt. Supine, splenic dullness: 6-10^th rib

percuss

(Size and density of organs) all four quadrants. Any unusual tympany or dullness? Any change from tympany/resonance to dullness on inspiration suggests splenic enlargement

palpate

LIGHTLY all four quadrants. DEEP all four quadrants. Specifically for liver, spleen, kidneys. Any tenderness, organomegaly, or masses? (SIGNS OF PERITONITIS)

Liver: L hand under rib cage (11-12^th), pressing upward, one hand over the other, tips facing upward. Pt. Breathes deep- may feel liver edge.

Spleen: Pt. Supine, 1st hand on pt. R side, your L hand over pt. L CVA, press upward. Repeat with pt. Lying on R side

Kidney: Capture technique, hands above and below, pt. Supine, as pt. Takes deep breath, press fingers of both hands together, as pt. Exhales, slowly release pressure and feel for the kidney to slip between the fingers

Aorta: Palpalple deeply to the L of midline

CVA tenderness: any significant tenderness? (ascites or appendicitis)

Sensory

pain (sharp or dull) or temperature

test bilaterally with pin (verbalize tubes of warm and cold water)

forehead, mid-face, chin                         CN V

neck                                                     C3

deltoid area of upper arms                       C5

first interspace - dorsum of hands            C6

tip of index finger                                    C7

tip of little finger                                     C8

nipple region of chest                             T4

periumbilical area of abdomen                 T10

anterior upper thigh                                L2

knee                                                     L3       

medial aspect of knee                            L4

lateral aspect of calf to dorsum of foot      L5

lateral border of foot                                S1

any sensory defect?

Light touch

same dermatomes as above with cotton ball: any sensory deficit?

vibratory sensation

test DIP jt.of fingers and greater toe bilaterally with 125 cps tuning fork

joint position sense

great toes, thumbs

tactile discrimination

one or two of these: stereogenesis, graphesthesia, two-point discrimination, point localization, or extinction

Musculoskeletal

Inspection

(erythema, swelling, asymmetry, alignment), deformities, postural, muscular symmetry, 

TMJ, Cervical Spine, Thoracic and lumbar spine (note curvature)

Shoulders (shld. girdle ant. And scapula post.), bicep and tricep, forearm, wrist, hands, and fingers

Hips (ASIS, PSIS, iliac crest, greater trochanter,), knees (note alignment, head of fibula), ankles, forefoot, and toes

Palpation

Palpate for tenderness, swelling, crepitis, temperature differences, palpable clicks, deformities, my spasm

TMJ, Cercvical Spine (note C7 and T1), Thoracic and Lumbar Spine (Note T7 and L4-5)

Shoulders: Ant. And Post. ( Note:SC jt., AC jt., subacromial area, bicepital groove), elbow (at 70 degrees, note: olecranon process, radial head, medial septum), hands and wrists (compress each MCP jt, DIP jt., PIP jt., and each wrist)

Hips (note: ASIS, PSIS, iliac crest, greater trochanter), gently rock the pelvic girdle (note instability), knees (identify the suprapatellar pouch by grasping the soft tissue 10 cm above the knee in your hand and “milking” toward the patella, continue palpation along the sides of the patella, Ankle, foot and toes: compress the foot in your hand applying pressure on the 1^st and 5^th metatarsals, palpate dorsal, and plantar surfaces of each MP jt., palpate the Ant. Aspect of the ankle jt., palpate the Achilles tendon

ROM

Cervical spine (flex, ext, bilateral rotation, ear to shoulder), thoracic and lumbar spine, (flex, ext, lateral bending, rotation),

Shoulder (flex, ext, abd, add, horizontal internal and external rotation, scratch test), elbow (flex, ext, pronation, and supination), hand and wrist (wrist flex and ext), have the pt. make a fist then extend their fingers, abduct and adduct their fingers

Hip and knee (flex, ext, abd, add, internal rotation, external rotation), foot and ankle (dorsiflexion, plantarflexion, eversion and inversion)

Motor

deep tendon reflexes

biceps               C5-C6

brachioradialis    C5-C6

triceps              C6-C7

patellar              L2-L3-L4

ankle                S1

Any increased decreased, or absent reflexes?

ankle clonus

briskly dorsiflex each ankle with knee flexion. Any sustained clonus present?

plantar reflex (Babinski)

stroke lateral sole across ball toward toe.

Normal response: (Babinski absent) flexion of toes and/or withdrawal of foot

Abnormal response: (Babinski present) extension of great toe and fanning out of others

muscle tone

passively flex, extend, pronate, supinate elbows, also flex and extend wrists.

Any decrease in muscle tone? Any spastiscity or rigidity?

muscle strength

test resistance to, and any weakness in:

shoulder elevation or rotation                               CN XI   (accessory)    

shoulder abduction                                             C5

elbow flexion                                                      C5-C6        

elbow extension                                                 C6, C7, C8

wrist extension                                                  C6, C7, C8, radial n.

finger abduction - scissor motion of fingers           C8, T1, ulnar n.

opposition of thumb                                            C8, T1, median n.

Hand Grip                                                          C7, C8, T1   

hip flexion                                                          L2, L3, L4

dorsiflexion of foot                                              L4-5 (Ant. Tibialis)

plantar flexion of foot                                          S1

great toe dorsiflexion                                          L5 (Ext. Hallucis Longus)                 

* alternate screen for upper extremity strength - handgrip strength.

* alternate screen for lower extremity strength - pt rises from chair, walking on toes (gastrocnemius and soleus m.), walking on heels (anter. tibial m.)

Gait & balance

gait

pt walking, turning. Any ataxia, limp, weakness, other abnormal gait?

heel-toe walk

Any ataxia?

station & Romberg

standing w/ feet together, eyes open, then closed. Any difficulty maintaining balance with eyes open or closed? Gentle push backward - able to regain balance?

Pronator drift test

standing - arms extended, palms up, eyes closed. Any pronation or downward drift of arm?

finger-to-nose

eyes closed, arms extended out front, ask pt to touch nose with index finger

Heel-to-shin test

Bilateral (Note: smoothness, accuracy, eyes closed test for position sense)

Rapid alternating movements

Pronation and supination of wrist, and dorsiflexion and plantarflexion of ankle