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Complete Physical

Head to Toe

Head Inspection Hair distribution, shape/contour of skull
Head Palpate Hair, skull for lumps/bumps/depressions occiput moving down to face, look for symmetry, involuntary facial mvmts, lesions, scarring
Head Palpate (cont) temporal pulse/artery, temporomandibular joint (TMJ) - open/close, max/frontal sinus - pressure/pain
Eye Inspection eyebrows/eyelashes - symmetry, sclera - white, no yellow, jaundice, Conjunctivae - pull down lower lid, pink, clear
Opthalmascope Exam Obliquely - look at lens for foreign bodies/symm/color diff. Look for reflex in pupil - symm. Light across pupils - PERRLA with direct and consensual - both constrict and individually
Fundoscopic Exam Set dial to '0" (adjust if blurry). Come in at angle L to L, R to R. Look for red reflex which is light shining in pupil, move and adjust. See blood vessels. optic disc, move nasal to see macula & filvia
Visual Field Confrontation testing (CNII) - peripheral, post/sup view. Cardinal Views of gaze (6) - test EOM (CN 3,4,6). Convergence Test - 5cm-15cm move finger to bridge of nose- look for constriction too. Near Test - look at finger, then object far. Constrict w/ near
Ear Inspection Placement, s/s infection/inflam, drainage, damage. Tug test - pull pinna back/down, auricle too, check b4 scope for tenderness. Whisper test - occl ear, whister "apple", pt repeat
Otoscope Adult - pinna up/back. Child - pinna down/back. Look at TM, bony prominence malleus/umbo, light reflex. Look for inf/redness/bulging
Tuning Fork Weber Test & Rhinne Test Weber - for conduciton of ear/lateralization. Strike, top of crown - which ear feel/hear (should be both). Rhinne - AC> BC, strike, back of ear lobe - ask when no longer hear, then place front of ear - should hear vibration.
Nose inspection symm (CN 7), ala for deformities. Shine light look for polyps, abn discharge, mucosa, turbinates, septum for deviation
Mouth Inspection cracks, sores, lesions. Shine light in mouth, tongue out "Ahh" - view tonsils, pillars, uvula (rise, midline), hard/soft palate, dentition, mucosa. Test gag (CN 9, 10)
Mouth Palpate Gloves: feel mucosa for masses, under tongue, submandibular/sublingual glands/ducts
Neck Inspection trachea alignment, no masses/lesions, torticollus (twisting of head)
Neck Palpation Lymph nodes - pea size or + (mobile/nontender), pre/post auricular (front/back ear), tonsilar, submandibular, submental, ant/post cervical (front neck), deep clavicle (turn head push into sternoclidoid muscle), supra/infraclavicular (above/below), occipital (behind neck)
Neck Palpation (cont) Trachea Ant thyroid (displace to one side, midline) Posterior thyroid: hands below isthmus, cricoid. Pt swallow (should rise, smooth) no masses, enlarged
Neck Palpate (cont) ROM/muscle strength - head forward/back, side/side, shoulder shrug (CN 2) against resistance Listen for bruit first - Carotid pulse. Palpate (never both at same time)
Chest Inspection Anterior - skin, breathing rate, effort, symm, intercostal muscle use
Chest Palpation Ant - crepitus, tactile fremitus - "99" side/side, feel vibrations Post - spinous processes, symmetric expansion, tactile fremitus
Chest Percussion Post - apices to bases, side/side, resonance, no hyperresonance/dull Diaphragmatic Excursion: observe insp/exp diaphragm, Pt inhale & hold - percuss down til snd change. Mark. Pt exhale & hold - percuss from spot down to change to dull. Mark. Do other side. Equal is 3-5cm. Abn can mean fluid or atelectasis of LL.
Chest Auscultation Post - (diaphragm) start above clavicle , side/side to rib 6. Mostly lower lobe and vesicular. Bronchophony: "99" (consolidation=clr/distinct) Egophony: "eee" (consol. = "AAA") Whispered Pectoriloquy: "1,2,3" (distinct/clr)
Chest Auscultation (cont) Ant - supraclavicular area down to 6th rib, side/side & full respiration, BV - near sternum, V - lung fields,
Upper Extremities Inspection ROM/strength - hands(cap refills)/arms/shoulders [Pt lay down flat] Stand on right, pt turn head to left, jugular venous pressure (JVP) - find highest pulsating point
Upper Extremities Palpation Carotid pulses - 1 side at a time, Listen for bruits(bell & diaphragm), feel for thrills. Radial Pulses, brachial pulses
Cardio Inspection precordium for vent pulsations (if see Point of maximal inpulse PMI @ 5th ICS midclavicular)
Cardio Palpation Start at sternal border @ 2nd ICS, move to L 2nd ICS, then down 3rd, 4th, 5th ICS. (feel for thrills, heaves, lifts/pulsations)
Cardio Markers 1. Aortic area: R sternal border, 2nd ICS 2. Pulmonic: L 2nd ICS 3. Erb's Point: 3rd, 4th, 5th, ICS Tricuspid: sternal border 5th ICS 4. Mitral (PMI, apex): 5th ICS midclavicular
Cardio Auscultation Diaphragm then Bell 1-5 [Pt Sit Up] or [Decubitus or Left lateral position] L Erb's Point [Pt lean forward] L 2nd ICS for murmurs
Peripheral Vascular Inspection [Pt supine] abdomen for aortic pulsations
Peripheral Vascular Auscultate for bruits Bell/Diaphragm - above umbilicus
Peripheral Vascular Palpate above umbilicus - then separate to feel iliac, renal, femoral pulses
Abdomen Inspection [Pt flex knees to relax abd muscles] Inspect skin, contour, peristalsis, pulsation of aorta, distension, massess, hernias (raise head)
Abd Auscultation Diaphragm, all 4 quadrants (5 min. for "absent") Bell - aorta for bruits
Abd Percussion Percuss 4 quadrants, then percuss for size of liver, should be bn 6-12cm
Abd Palpation 4 quads lightly/deeply. then palpate for liver, spleen, L/R kidneys, aorta [Pt take in deep breath]
Abd palpation Femoral pulses and hernia and nodes. Auscultate for femoral bruits.
Lower Extremities Inspection symmetry, hair distribution, warmth, lesions, redness, swelling, hair on calves/toes (none = bad), varicose veins, between toes
Lower Ext Palpation Edema, popliteal (use both hands), dorsalis pedis (ant foot), post tibialis (medial malleolus) Holman Sign - flexion of foot + squeeze calf for pain, Babinski sign, coord/sensa, ROM hips/knees/ankles/ft [SIT ON SIDE AND DANGLE LEGS]
Neuro (hammer) tendon reflexes: biceps/tri/brachioradialis, patellar, achilles
Neuro (cont) MEND - finger to nose, count fingers, sens [STAND/WALK]
Neuro (cont) Walk, walk on tiptoes, Romberg, knee bends, touch toes, inspect spine, stabilize pelvis, ROM hyperextends, rotates, laterally bends
Created by: palmerag