H and P Semester I cummulative exam

Card Set Information

Author:
BostonPhysicianAssist
ID:
140703
Filename:
H and P Semester I cummulative exam
Updated:
2012-03-17 19:25:32
Tags:
Practical
Folders:

Description:
H and P Semester I cummulative Exam (Note:the asterix on a question means it has shown up on a practical last semester)
Show Answers:

Home > Flashcards > Print Preview

The flashcards below were created by user BostonPhysicianAssist on FreezingBlue Flashcards. What would you like to do?


  1. Your patient presents with feelings of malaise, pain in "their cheeks" and a runny nose. What exams will you perform?
    • Vitals: especially Temperature
    • Transillumination of the sinuses: (will reveal decreased illumination in maxillary sinus with sinus infection)
    • Percussion of the sinuses: causes pain with sinus infect.
    • Palpation of the sinuses: causes pain with sinus infect.
    • Nasal exam: looking for signs of polyps
    • Test patency bilaterally: will show decreased patency with infection
    • Look in the throat: looking for signs of post nasal drip
    • Palpate lymph nodes: nodes of the head and neck prauricular, post auricular, occipital, tonsilar, submandibular, submental, anterior cervical deep cervical, posterior cervical, and supraclavicular
    • Otoscopy: (maybe maybe not) for effusion behind tympanic membrane
  2. Test cranial nerve I
    • Test patency first
    • Occlude nostril, have pt close eyes, have them smell two different scents
    • scents must be non-acidic
  3. Do the test that tests the Sensory of CNV and the motor of CN VII
    corneal reflex: take a piece of cotton and lightly touch the cornea (not the sclera) with the cotton and watch for the pt to blink
  4. What are the 3 things you should do at the beginning of ANY exam?
    • Wash your hands
    • Introduce yourself to the patient and explain what you are going to do
    • consider personal protective equipment
  5. Perform a General Survey of the patient (the no touch approach, what are the components?/explain what you notice about the patient)
    • Apparent state of health
    • Level of consciousness
    • Signs of distress
    • Skin color and obvious lesions
    • Dress, grooming, and personal hygine
    • Facial expression
    • Odors of body and/or breath
    • Posture, gait and motor activity
  6. Take the patient's vitals (9 vitals list them if you don't have a patient)
    • Height
    • Weight
    • Body mass index
    • Blood pressure
    • Heart rate and rhythm
    • Respiratory rate and rhythm
    • Temperature
    • Pulse Oximetry
    • and Pain scale
  7. Your patient has been complaining of syncope upon standing, test for orthostatic hypotension (may not be on exam takes awhile to perform)
    • Have patient lay quietly for 5-10 minutes
    • record baseline blood pressure while supine
    • have patient stand carefully
    • repeat blood pressure upon standing within 3 mins (may perform sitting if unable to stand)
    • Positive findings: a drop of systolic > 20 or diastolic >10 or presence of symptoms
  8. If a blood pressure is high then the reading should be taken again and in two different spots, after taking the BP in the opposite arm you decide to take a lower extremity BP perform this proceedure
    • Patient lays prone on the table
    • Thigh BP cuff is placed mid-thigh
    • Bell of stethoscope is placed over the popliteal artery
    • Pressure is obtained as in the arm
    • (note: bp that is lower in the LE than the UE is concerning for possible coarctation of the aorta)
  9. Perform an ankle brachial index
    • Patient rests supine for 10 minutes
    • blood pressure is obtained in both upper extremities
    • highest arm pressure is recorded
    • blood pressure cuff is applied to each ankle
    • pressure is obtained using a vascular doppler device

    • The ABI is calculated for each lower extremity by dividing the ankle pressure by the highest arm pressure
    • (0.9-1.3 is normal
    • 0.89-0.6 is mild PAD
    • 0.59-0.40 is moderate PAD
    • less than 0.39 is severe PAD)
  10. Your patient has an IRREGULAR rhythm how would you take their pulse?
    count the number of pulsations in 60 seconds
  11. Take the patient's pulse
    count the number of pulsations in 30 seconds and multiply by 2
  12. Test Cranial nerve II (4 tests)
    • Test Distant vision
    • Test Near vision
    • Visual fields by confrontation
    • Fundoscopic exam
  13. Test Cranial Nerve III, VI, IV (8 tests)
    • Pupils (size, shape, direct and consensual constriction): note pupil size and shape, shine penlight in eye watch that eye constrict, shine penlight in that eye again watch the other eye constrict repeat on the other side
    • Swinging flashlight test:
    • Ptosis: look for droopy eyelid
    • Near reaction: hold an object in front of the patients nose ask them to focus on something far away and then something close look for convergence of the eyes and constriction of the pupils
    • Extraocular movements: Big H in front of the patient
    • Nystagmus: at 45-90 degrees from straight look for eye movements
    • Cover Test: cover the eye look for the deviated eye to shift forward to look at you
    • Cover/uncover test: for phorias, cover and uncover the eye
    • Convergence: ask patient to focus on pen tip, bring it from 3 feet to their nose see where they loose the ability to converge on the object
  14. Test Cranial Nerve V (4 motor tests, 4 sensory)
    • Motor:
    • palpate temporalis muscle ask pt to clench teeth
    • palpate masseter muscle ask pt to clench teeth
    • ask pt to open mouth and close against resistance
    • Jaw Jerk open mouth again place finger over chin with slight downward pressure hit finger
  15. Test Cranial Nerve VII
    • Ask pt to:
    • wrinkle their forehead
    • close eyes and open against resistance
    • puff out cheeks
    • smile
    • frown
    • grimace
  16. Test Cranial nerve VIII
    • Wispered voice test
    • Webber
    • Rinne
  17. Test Cranial nerves IX and X
    • Symmetrical rise of uvula/soft palate when pt says ahh
    • Gag reflex
    • Swallowing
  18. Test Cranial nerve XI
    • Shoulder shrug against resistance
    • Head turn against resistance (SCM)
  19. Test Cranial nerve XII
    • Stick out tounge
    • push against cheek with tounge
  20. Perform a Rapid Lower Extremity Strenght Test
    • Push to toes (hold for 5 seconds)
    • Push to heels (hold for 5 seconds)
    • Squat and raise without assistance
  21. Augment an S4 murmur*
    • Listen at the 5th ICS MCL using the BELL!
    • listen with the pt in left lateral position
    • Right Ventricular S4 Gallop: rapid deep inspiration and exercise; will not be heard if pt is in afib
    • present in active myocardial infarction and ischemia
  22. Test the motor function of Cranial Nerve 5*
    • Temporalis
    • Masseter
    • Pterygoids (open mouth and close against resistance)
    • Jaw Jerk
  23. Try to illicit clonus and explain what it means if it is present.*
    • Have the pt laying or with feet dangling and knees flexed in a relaxed position for the lower leg, take the ankle and foot and quickly alternate plantarflexing and dorsiflexing the feet
    • Check for clonus when DTR of ankle are hyperactive
    • if positive the foot will continue to jerk up and down after you stop moving it.
    • more than 2-3 beats is abnormal and suggests upper motor neuron disease
    • Video: http://www.youtube.com/watch?NR=1&feature=endscreen&v=kA7GQ8aCYKo
  24. Percuss/auscultate the boarder of the left lower lobe of the lung*
    • Posteriorly the left lower lobe extends from spinus process of T3 down to T10
    • Anteriorly the LLL is found from the 4th ICS to the 6th ICS
    • Laterally the oblique fissure runs diagonally downward from the T3 spinus process to the 6th ICS MCL below is the LLL which is boarderd form the bottom by the 6th rib at the MCL and the 8th rib MAL
  25. Percuss/ausculate the LUL of the lung*
    • Left upper boarder
    • Anteriorly: from 2-4cm above the clavical to the oblique fissure
    • Posteriorly: everything above T3
    • Laterally: above the boarder of the oblique fissure
    • The oblique fissure runs from the T3 spinus process obliquely down and around the chest to the 6th rib at the midclavicular line
  26. Percuss/auscultate the boarders of the RUL*
    • Anteriorly: 2-3cm above the clavical to the horizontal fissure
    • Posteriorly: upper shoulder down to spinus process leve T3 (oblique fissure)
    • Laterally: above the 4th rib to the 5th rib MAL (above the horizontal fissure)
    • The horizontal fissure runs along the 4th rib from anterior to posterior until it meets the oblique fissure at the 5th ICS MCL
  27. Percuss/auscultate the boarders of the RML*
    • Anteriorly: 4th rib down to the 6th rib
    • Laterally: 4th or 5th rib down to 6-7th rib and then boarded posteriorly by the oblique fissure
    • cannot listen to middle lobe posteriorly
  28. Percuss/auscultate the boarders of the RLL*
    • Posteriorly: T3 to T10
    • Anteriorly: small portion in the AAL
    • Laterally: boardered below by the 6th rib midclavicular line and 8th rib midaxillary line, upper boarder follows the oblique fissure
    • Oblique fissure: runs from T3 spinus process obliquely down and around the chest to the 6th rib at the midclavicular line.
  29. Test strenght against resistance of the lower extremity
    • Pt seated
    • push down on pts thigh have them lift it off the table
    • put your hands under their thigh and lift it have them return their leg to the table
    • place your hand on the side of the pts thigh have them push outwards
    • place your hand on the inside of the pts knee have them flex inwards
    • put your hand on the pts shin have the push against you
    • put your hand on the pts calf and have them pull it back towards the table
    • Have pt dorsiflex feet against resistance
    • Have pt plantarflex feet against resistance
    • Have pt invert feet and evert feet
    • have pt lift big toe up then all toes up
  30. Perform a rapid lower extremity strenght test*
    • Have pt push to toes and hold for 5 seconds
    • have pt push to heals and hold for 5 seconds
    • have pt squat and raise without assistance
  31. Perform a rapid upper extremity neuro screen
    • Elbow flexion (C5)
    • Wrist extension (C6)
    • Elbow extension (C7)
    • Finger flexion and thumb opposition (C8)
    • Little finger abduction (T1)
  32. Perform a rapid lower extremity neuro screen
    • Hip flexion (L2)
    • Knee extension (L3)
    • Ankle dorsiflexion (L4)
    • Great toe extension (L5)
    • Ankle plantar flexion (L6)
  33. Perform a sensory neurological screening in any dermatome, assume it is abnormal what would you do next?
    • Sharp/dull in each dermatome
    • Light touch in each dermatome
    • if any abnormalities also do a hot cold in that dermatome and make sure to map out the dermatome boarders of the deficit
  34. Test vibrational sense at either the big toe or the thumb, what do you do if it is abnormal? who is most likely to have an abnormality?
    • Use a 128Hz tuning fork, tap it and then place it on the distal interphalangeal joint of the thumb or the great toe. Ask the pt if they feel anything? what do they feel? now ask them to tell you when the vibration stops.
    • touch the fork to stop it
    • If they cannot feel it or cannot feel when it stops then proceed to more proximal bony prominences
    • Pts with vit B12 and diabetic neuropathy
  35. Test the pts proprioception
    • Can be tested at the great toe and the thumb.
    • grasp the great toe holiding it by its sides between hyour thumb and index finger and then pull it away from the other toes. Demonstrate "up" to the patient and "down". Ask pt to close their eyes move the patients toe to a new position and ask them where it is. Repeat on each side and move proximally to the ankle joint if not normal
  36. test the pt's sterognosis
    • place a familiar object in the pts hand such as a coin, paperclip, key, pencil or cotton ball and ask the pt to tell you what it is
    • normally the pt should be able to identify what it is within 5 sec
  37. Test the pts graphesthesia
    • use to test discriminative sensation when the pt has arthritis, or other condition that prevents them from manipulating an object
    • with the blunt end of a pen or reflex hammer draw a number in the pts palm with them not looking ask them to tell you what the number was
  38. Test the pt's two point discrimination
    • using the ends of an opened paper clip touch the finger pad in two places simultaneously
    • move the two points further apart until the pt can recognize it as two points
    • normally less than 5mm on the finger pads
    • lesions of the sensory cortex increase the distance between two points
  39. Test the pts point localization
    • touch a point on teh patient's skin then ask the patient to open both eyes and point to the place touched.
    • Lesions of the sensory cortex impair this ability.
    • test the upper extremity, lower extremity and trunk both sides
  40. Test extinction
    • simultaneously stimulate the corresponding area on both sides of the body ask the pt where they feel the touch usually both sides are felt
    • lesion of the sensory cortex may cause only one stimulus to be regocnized the stimulus that is absent is on the opposite side of the lesion
  41. Test the Bicepts Reflex
    • (C5, C6)
    • Pts arm should be slightly flexed at the elbow iwth the palm down.
    • place your thumb or finger on the bicepts tendon and strike your reflex hammer over your thumb
    • observe flexion of the elbow and watch/feel for contraction of the bicepts muscle
    • Grading scale of reflexes
    • 4+ very brisk or hyperactive with clonus
    • 3+ brisker than average but not nessisarily indicative of disease
    • 2+ average or normal
    • 1+ somewhat diminished but low normal
    • 0+ no response
  42. Test the Tricepts reflex
    • C6, C7
    • pt sitting flex the arm at the elbow and support it at the distal humerus
    • strike the tricepts tendon with the reflex hammer look for extension of the forearm
    • Grading scale of reflexes
    • 4+ very brisk or hyperactive with clonus
    • 3+ brisker than average but not nessisarily indicative of disease
    • 2+ average or normal
    • 1+ somewhat diminished but low normal
    • 0+ no response
  43. Test the Supinator/brachioradialis reflex
    • C5, C6
    • the pts hand should rest on the abdomen or lap
    • forearm partially pronated
    • strike the radius with the point or flat edge of the relfex hammer 1-2 inches above the wrist
    • wtch for the flexion and supination of the forearm
    • Grading scale of reflexes
    • 4+ very brisk or hyperactive with clonus
    • 3+ brisker than average but not nessisarily indicative of disease
    • 2+ average or normal
    • 1+ somewhat diminished but low normal
    • 0+ no response
  44. Test the patellar reflex
    • L2, L3, L4
    • pt sitting with knee flexed and lower leg dangling
    • briskly tap the patellar tendon below the patella
    • place hand on pts anterior thight
    • Grading scale of reflexes
    • 4+ very brisk or hyperactive with clonus
    • 3+ brisker than average but not nessisarily indicative of disease
    • 2+ average or normal
    • 1+ somewhat diminished but low normal
    • 0+ no response
  45. Test the ankle relfex
    • S1
    • pt is sitting dorsiflex the foot at the ankle
    • persuade pt to relax
    • strike the achilles tendon
    • watch and feel for plantarflexion at the ankle note the speed of relaxtion after muscular contraction
  46. Test the Abdominal reflex
    • Test the abdominal reflex by lightly but briskly stroking each side of the abdomen
    • Upper: T8, T9, T10
    • Lower: T10, T11, T12
    • note the contraction towards the umbilicus, obesity may limit this relfex
  47. Test the plantar response describe what a positve finding is called and what it is.
    • L5 and S1
    • with the end of the reflex hammer firmly with one motion stroke the lateral aspect of the sole from the heel to the ball of the foot, curving medially across teh ball of the foot
    • normal: plantar flexion of the big toe and all other toes also withdraw
    • Babinski response: dorsiflexion of the big toe (seen in lesion in the corticospinal tract also in the central nervous system lesion also unconcious states from drug or alcohol intoxication or the postictal period following a seizure)
  48. Anal Reflex (will not perform describe only)*
    • useing a dull object such as a cotton swab stroke outward in teh four quadrants from the anus watch for relfex contraction of the anal musculature
    • loss of the anal reflex suggests a lesion in the S2-3-4 reflex arc as in cauda equina syndrome
  49. Cremasteric reflex (will not perform describe only)
    stroke the inside of the thigh note contraction of the scrotum and elevation of the testes
  50. Test the pts Gait/Cerebellar function *
    • Normal gait
    • Heel to toe
    • Heel walk
    • Toe walk
    • Hop on one foot
    • Shallow knee bend
    • Rise from chair without hands
  51. Test rapid alternating movements for cerebellar function
    • Hands: have pt turn hands over from palmar to dorsal position on thigh as quickly as possible
    • Fingers: tap the distal joint of the hum with the tip of the index finger as rapidly as possible
    • Feet: ask pt to tap your hand as quickly as possible with the ball of each foot in turn
  52. Perform point to point test for cerebellar function
    • ask pt to touch your index finger and then to his or her nose alternatly several times move your finger sot that the pt has to alter the direction of the movement, make sure pt has to extend arm fully for some
    • now hold finger in one place so that the patient can touch it with one arm and finger outstretched ask pt to raise the arm overhead and lower it agin to your finger have them repeat a few times then have them do it with their eyes closed
    • Heel to shin test: ask the pt to place one heel on teh opposite knee then run it down the shin to the big toe repeat with the pts eyes closed
  53. Romber test
    • test position sense
    • stand with feet together and eyes open then close both eyes for 30 to 60 seconds without support normally minimal swaying occurs positve romberg in cerebellar ataxia
  54. Test for pronator drift
    • stand for 20-30 seconds with both arms straight forward and palms up with eyes closed a person with a positve test has pronation of the one forearm
    • now tap the arms briskly and see if they return to normal or if they overshoot
  55. Test cerebellar function name at least 5
    • Gait: normal gait, heal to toe, heel walk, toe walk, one foot hop, shallow knee bend, rise from chair withotu hands
    • Rapid alternating movements: Hands over and over, Fingers O.K. tap, Feet tap
    • Finger to nose
    • Finger to nose eyes closed
    • Heel to shin
    • Romberg
    • Pronator drift
  56. Demonstrate a stright leg raise
    pt lays supine lift leg straight up positive is pain
  57. Demonstrate a Brudzinski's sign
    • as your flex the neck with the pt laying supine, watch teh hips and knees inthe reaction to the head raise
    • normally they should remain relased and motionless
    • positive is a knee raise or hip flexion
  58. Demonstrate a Kernig's sign
    • Flex teh patient's leg at both the hip and the knee and then straighten the knee.
    • discomfort behind the knee during full extension may be normal but should not cause pain or head raise
    • postive is pain and resistance to knee extension if bilateral suggests meningeal irritation
  59. Palpate the TMJ
    • Just anterior to the ear palpate the TMJ
    • ask the patient to open and close their mouth
    • then open and move their jaw side to side
    • feel clicking and popping
  60. Check the muscles of mastication
    • Masseter
    • Temporalis
    • Pterygoid
  61. Palpate the manubrium, the sternoclavicular joint, the clavicle, the tip of the acromion the greater tubricle of the humerus and the coracoid process
  62. Palpate the bony landmarks of the shoulder
    • Manubrium
    • Sternoclavicular joint
    • Clavicle
    • Tip of the acromion
    • Greater tubricle of the humerus
    • Coracoid process
    • Biciptial groove
    • Bicepts Tendon
    • Subacromion bursa
  63. Demonstrate the ranges of motion of the shoulder
    • Flexion to 180
    • Extension to 50
    • Abduction to 180
    • Adduction to 50
    • Internal rotation to 90
    • External rotation to 90
    • Shoulder shrug
  64. Palpate the bony structures of the elbow and palpate the palpable nerve that runs through the structure
    • Medial epicondyle
    • Lateral epicondyle
    • Olecrenon process
    • Ulnar nerve
  65. Demonstrate the ROM of the elbow
    • Flexion to 160
    • Extension to 180
    • Supination to 90
    • Pronation to 90
  66. Palpate the boney landmarsk of the wrist and hand
    • Bony tip of the radius and ulna
    • carpal bones
    • metacarpal bones
    • MCP joints
    • PIP joints
    • DIP joints
    • Anatomical snuffbox
    • look for flexor and extensor tendons too
  67. Demonstrate ROM of the wrist
    • Flexion of the wrist to 90
    • Extension of the wrist to 70
    • Radial deviation to 20
    • Ulnar deviation to 55
  68. Demonstrate ROM of the thumb
    • Appose base of 5th digit
    • Flexion
    • Extension
    • Abduction
    • Adduction
    • compare to opposite hand
  69. Demonstrate ROM of the fingers
    • Finger flexion to 90
    • Finger extension to 30
  70. Identify C7
    first prominate vertebrae in the neck
  71. Identify L4
    In the same horizontal line as both illiac crests
  72. Palpate the greater trocanter
    bony prominence on the lateral aspect of the thigh
  73. Palpate the sciatic nerve
    Find the pt's greater trochanter and ischial tuberosity in between these two landmarks is the sciatic nerve palpation will cause pain in a pt with sciatica
  74. Test the ROM of the C-spine
    • Flexion to 45
    • Extension to 55
    • R/L lateral bending to 40
    • R/L rotation to 70
  75. Test the ROM of the L-spine
    • LOCK OUT THE HIP!
    • Flexion to 75
    • Extension to 30
    • R/L lateral bending to 35
    • R/L rotation to 30
  76. Palpate the ASIS, the greater trocanter, the illiac crest, ichial tuberosity, coccyx, posterior superior illiac spine, and sacroilliac joint
  77. Check for ROM at the hip
    • Flexion to 90
    • Extension to 30
    • Flexion with the knee flexed to 120
    • Abduction to 45
    • Adduction to 30
    • Internal rotation to 40 (remember foot out hip in)
    • External rotation to 45 (remember foot in hip out)
  78. Palpate the bony landmarks of the knee:
    Adductor tubercle
    Medial epicondyle
    Medial condyle
    Patella
    Pattelar tendon
    Tibial Tuberosity
    Lateral epicondyle
    Lateral condyle
  79. Palpate the following knee structures:
    medial meniscus
    tibial plateau
    Bursae: prepatellar, Pes anserine, semimembranosus
    Ligaments
    Quadracepts
    Hamstrings
    Gastrocnemius
    Soleus
    Achilles Tendon
  80. Demonstrate the ROM of the knee
    • Flexion to 130
    • Extension to 0
    • Hyperextension to 15
  81. Palpate the following bony landmarks of the ankle
    Medial malleolus
    Lateral malleolus
    calcaneous
    head of the metatarsals
    MTP joints
    PIP joints
    DIP joints
    Plantar fascia
    Achilles tendon
  82. Demonstrate the ROM of the Ankle
    • Dorsiflextion to 20
    • Plantar flexion to 45
    • Eversion to 20
    • Inversion to 30
    • Internal rotation to 10
    • Internal rotation to 20
  83. Check for renal artery stenosis
    • Listen for a bruit
    • over the renal arteries, move up from the belly button midline to the
    • level of the false/floating ribs, this is the aorta move laterally by about an
    • inch this should be directly over the renal artery. Repeat on the opposite side
  84. Listen for abdominal bruits
    Remember to listen to the aorta, the two renal arteries, the iliac artery and the femoral artery

    • Note if the bruit is systolic or diastolic, systolic can be
    • normal especially in children but a diastolic indicates turbulent flow
  85. Check for renal artery stenosis
    Listen for a bruit over the renal arteries, move up from the belly button midline to the level of the false/floating ribs, this is the aorta move laterally by about an inch this should be directly over the renal artery. Repeat on the opposite side
  86. Listen for abdominal bruits
    • Remember to listen to the aorta, the two renal arteries, the iliac artery and the femoral artery
    • Note if the bruit is systolic or diastolic, systolic can be normal especially in children but a diastolic indicates turbulent flow
  87. Auscultate the abdomen
    • Use the diaphragm of the stethascope
    • Perform this portion of the exam before the rest of the exam
    • Listen in all 4 quadrants preferably all 9 sections
    • Note number of bowel sounds 5-30 clicks or gurgles is normal
  88. Percuss the abdomen
    • Percuss the abdomen lightly in all four quadrants to determine the distribution of tympany and dullness.
    • If the abdomen is protuberant then note where the abdominal tympany changes to the dullness of solid posteior structures
    • Cal also percuss liver and spleen
  89. Assess the liver
    • Percussion of boarders: starting at a level below the umbilicus MCL percuss upward toward the liver mark the first dull note in this series it is the lower boarder. Now start again a the nipple line and percuss from lung resonance down toward liver dullness to determine upper boarder. Normal is 6-12cm MCL
    • Scratch test: same as percussion of the liver except place your stethascope on the liver boarder and scratch the pts skin with your finger nail until you hear changes in pitch
  90. Percuss Traube�s space
    Percuss the lowest interspace in the left anterior axillary line it should be tympanic
  91. Percuss the spleen
    Percuss traubes space then ask the pt to take a deep breath and percuss again when spleen size is normal this area usually remains tympanic. Splenomegally will reveal dullness
  92. Assess CVA tenderness
    Locate the last costovertebral joint and place your nondominant hand flat over this area. Ask the pt to sit with arms across chest and lean forward slightly. Take your fist and thump it over the hand restin on the patient. Tenderness indicates Kidney infection.
  93. Percuss the bladder
    Begin percussing at the symphysis pubis and percuss upward listening for a change in tonal quality of the note
  94. Palpate the Abdomen
    • Position pt in a supine position with knees flexed
    • First palpate lightly with one hand feeling superficially for superficial lesions or obvious guarding
    • Deep palpation place one hand on top of the other and push with the top hand while feeling with the bottom, feel for the abdominal organs and deep lesions, feel for shape, size consistency and mobility and pulsations
  95. Palpate the liver with the direct method
    • Place one hand behind the patient supporting the 11th and 12th ribs
    • Place your right hand on the pts abdomen with fingertips below the liver boarder of dullness
    • Press with fingers at 90 degrees to liver firmly in and upwards
    • Ask the pt to take a deep breath and try to feel the liver edge as it comes down to meet your fingertips
    • (on inspiration the liver is palpable approximately 3 cm below the right costal margin)
    • you may feel an obstructed distended gallbladder as an oval mass, firmness bluntness or irregularity in liver contour suggests pathology
  96. Palpate the liver with the Oblique method
    • Place one hand behind the patient supporting the 11th and 12th ribs
    • Place your right hand on the pts abdomen with fingertips below the liver boarder of dullness
    • Press with fingers at an oblique angle to the liver, and firmly in and upwards
    • Ask the pt to take a deep breath and try to feel the liver edge as it comes down to meet your fingertips
    • (on inspiration the liver is palpable approximately 3 cm below the right costal margin)
    • you may feel an obstructed distended gallbladder as an oval mass, firmness bluntness or irregularity in liver contour suggests pathology
  97. Palpate the liver with the hooking method
    • (hooking is useful for obese pts )
    • stand to the right of the pts chest
    • place both hands side by side on the right abdomen below the boarder of liver dullness
    • press in with your fingers and up towards the costal margin
    • ask the pt to take a deep breath the liver edge should become palpable with the finger pads
  98. Palpate the spleen
    • Reach over and around the pt with your left hand to support and press forward the lower left rib cage
    • With your right hand below the costal margin press in toward the spleen
    • Begin palpation low so that you don�t miss an enlarged spleen
    • Ask the pt to take a deep breath, now try to feel the tip or edge of the spleen as it comes down to meet your fingertips
    • Note tenderness, splenic contour, measure lowest point and left costal margin
  99. Palpate the spleen with Rt lateral decubitus position
    • Put pt lying on rt side and with legs somewhat flexed as in a fetal position
    • Reach over and around the pt with your left hand to support and press forward the lower left rib cage
    • With your right hand below the costal margin press in toward the spleen
    • Begin palpation low so that you don�t miss an enlarged spleen
    • Ask the pt to take a deep breath, now try to feel the tip or edge of the spleen as it comes down to meet your fingertips
    • Note tenderness, splenic contour, measure lowest point and left costal margin
  100. Attempt to palpate a kidney
    • Move to pts left side
    • Place rt hand behind the pt just below and parallel to the 12th rib (under the pt)
    • Place your left hand gently in the left upper quadrant lateral and parallel to the rectus muscle
    • Ask the pt to take a deep breath
    • At the peak of inspiration press left hand firmly and deeply into the left upper quadrant just below the costal margin and force hands together trying to �capture� a kidney
    • Ask pt to breath out and then hold their breath
    • While they are doing that feel for the kidney to slide back into its expiratory position
    • (attempt to capture the right kidney in the same manner)
  101. Palpate the bladder
    Cannot be examine unless it is distended above the symphysis pubis, should be round and smooth, check for tenderness.
  102. Palpate/measure the aorta
    • Press with both hands firmly and deeply on the upper abdomen, slightly left of the midline and feel for pulsations
    • Assess the width by by pressing deeply in the upper abdomen with one hand on each side of the aorta.
    • The aorta should not be more than 3 cm,
  103. Assess central tympany
    Percuss outwards in a half moon type pattern radiating from just below the xyphoid of the protuberant abdomen you should hear tympanic notes in the center of your arc and dull notes at the edges if the pt truly had acites
  104. Test for shifting dullness
    • After mapping the borders of tympany and dullness ask the pt to turn onto one side and percuss downward
    • In acites dullness shifts to the more dependant side and tympany shifts to the top, whereas a normal abdomen would remain constant
  105. Test for fluid wave
    • Ask the pt or an assistant to press the edges of both hands firmly down the midline of the abdomen
    • Tap one side of the flank sharply with your fingertips and feel the other side for an impulse transmitted through the fluid
  106. Test for Ballotment
    • Identify an organ or mass in the acitic abdomen often liver will be enlarged enough to perform this test on it
    • With straight fingers make a brief jabbing motion directly downward toward the anticipated structure this quick movement often displaces fluid so that your finger tips can briefly touch the surface of the structure through the abdominal wall
  107. Perform 1 point localization
    • Ask pt to point with one finger to where it hurts
    • If they cannot point to a specific location, or point to umbilicus it is probably visceral pain
    • If they point to a particular tender spot it is probably peritoneal pain
  108. Perform Rebound tenderness
    • Push into an area of the abdomen and release suddenly
    • Ask pt if it hurts more to push in or more to release
    • Ask pt where it hurts if they localize a spot distant from where you palpated it is probably peritoneal pain and the point they pointed to is the location
  109. Rovsing sign
    • Push into an area of the abdomen and release suddenly
    • Ask pt where it hurts if Rovsing�s sign is positive then pain will localize to McBurney�s point
  110. Psoas sign
    • Pt is laying supine
    • Ask them to raise their leg against resistance
    • If the appendix is inflamed and lays over the psoas muscle this will cause pain and the pt will pull legs back
    • Obturator Sign
    • Pt laying supine
    • Bring leg up and rotate the leg internally at the hip this stretches the obturator muscle and causes pain
  111. Cutaneous Hyperesthesia
    Light touching of the skin in the rt lower quadrant causes pain or tenderness = positive for appendicitis
  112. Heel tap
    • Pt laying supine.
    • Firmly tap heel
    • Pain is positive for appendicitis
  113. What might you ask a pt who you are seeing for an ear complaint?
    • How is your hearing?
    • Have you had any trouble with your ears
    • does the hearing loss happen in one or both ears?
    • sudden or gradual
    • any associated symptoms?
    • Any discharge?
    • Do you feel dizzy?
  114. When inspecting the ears what should you be looking for?
    • Size, shape, color, symmetry, landmarks
    • look for any deformites, lumps or skin lesions
    • Look for correct positioning (top of the auricle should be in line with the bottom of the ipsilateral pupil and the ear should be canted back 10 degrees)
  115. Palpate the Ear
    • move the auricle up and down
    • press the tragus
    • pull gently on the helix and lobule
    • 2 point discrimination?
    • Swelling
    • Nodules- the auricle should be firm mobile and nontender witout nodules and should recoil easily
  116. Palpate the Mastoid
    • bone process posterior to the auricle
    • Insepect for discoloration, redness, protrusion or proptosis of the auricle or lesions or masses(nodules cysts, abscesses, keloids BCC, SCC etc)
  117. What Steps should you do in an ear exam before you perform otoscopy?
    • Inspect the ear
    • look for discharge
    • palpate the ear
    • palpate the mastoid
  118. Perform Otoscopy
    • Use largest ear speculum that the canal accomodates
    • hold the otoscope between your thumb and fingers upsidown with your hand bracing the pts face
    • pull the ptatients auricle gently upward, and backward slightly away from the head to straighten out the canal
    • Insert the speculum
    • Avoid contacting the inner 2/3 of the canal with the speculum
    • Inspect:
    • External canal for cerumen, d/c, fb, color lesions or masses or scaling
    • Tympanic membrane for color clarity, landmarks, and light reflex, contour, perforations and presence of fluid
    • Mobility valsalva or pneumatic otoscopy in children or elderly pars flaccida should move
  119. Test the pts hearing
    • destinguish between conductive hearing loss and sensorineural loss
    • Gross hearing with wispered voice:
    • occlude or have pt occlude ear on the side not being tested
    • stand 1-2 feet away from pt on teh side you are testing wisper a word with two distinct syllables "baseball"
    • Repeat in the opposite ear

    • Weber:
    • Assess in a quiet room using a 512 Hz tuning fork
    • Test for lateralization
    • place the base of a ligthly vibrating tuning fork on the vertex of the skull or the mid forehead
    • ask pt if they hear a sound: equally in both ears or more on one side?
    • Confirm by occluding an ear and repeating test (should be louder in occluded ear)
    • if sound lateralizes without occlusion it indicates a problem but does not tell you what problem specifically
    • the sound lateralizes away from sensorineural issue and towards a conductive hearing loss

    • Rinne:
    • Compares AC to BC
    • place a ligthly vibrating tuning fork on the mastoid bone
    • time how long it takes until the pt can no longer hear the tone
    • not rehitting the tuning fork or stopping it move the fork to directly in front of the pts ear 1-2cm from the ear
    • AC>BC is normal it should be 2x longer than BC
    • BC>AC conductive hearing loss check for cerumen or ossicle fusion or earing infection etc
    • AC>BC but not by 2x sensorineural hearing loss
  120. Perform the Rinne test and explain results
    Compares AC to BCplace a ligthly vibrating tuning fork on the mastoid bonetime how long it takes until the pt can no longer hear the tonenot rehitting the tuning fork or stopping it move the fork to directly in front of the pts ear 1-2cm from the ear AC>BC is normal it should be 2x longer than BCBC>AC conductive hearing loss check for cerumen or ossicle fusion or earing infection etcAC>BC but not by 2x sensorineural hearing loss
  121. Gross hearing test
    Gross hearing with wispered voice:occlude or have pt occlude ear on the side not being testedstand 1-2 feet away from pt on teh side you are testing wisper a word with two distinct syllables "baseball" Repeat in the opposite ear
  122. Perform a Weber test
    Weber:Assess in a quiet room using a 512 Hz tuning forkTest for lateralizationplace the base of a ligthly vibrating tuning fork on the vertex of the skull or the mid foreheadask pt if they hear a sound: equally in both ears or more on one side?Confirm by occluding an ear and repeating test (should be louder in occluded ear) if sound lateralizes without occlusion it indicates a problem but does not tell you what problem specificallythe sound lateralizes away from sensorineural issue and towards a conductive hearing loss
  123. Inspect nose and sinuses
    Insepect for Size, Shape, color, symmetry and deformity, discharge, flaring, or swelling
  124. Palpate the sinuses
    • Palpate the bridge and soft tissue for deformity, asymmetry and crepitus
    • Palpate nares for lesions and tenderness
    • Palpate sinuses:
    • Press on sinuses frontal and maxillary to elicit pain
    • percuss the sinuses- sinuses may be gently percussed to elicit tenderness and pressure
  125. Test patency
    occlude one ala nasi by placing a finger on the side of the nose ask pt to breath in gently breathing should be noiseless and effortless without collapse of the ala nasi
  126. Inspect Nares and internal nose
    • Ensure you brace agains the pts face
    • insert the speculum slowly into the nose straight back and maybe a little inferior
    • Inspect the mucosa for color, discharge, swelling, bleeding, exudate
    • Inspect the septum for deviation, inflammation, perforation, or crusting in the anterior portion (kiesselbachs plexus) DO NOT touch the septum BLEEEDS like WOW
    • Inspect turbinates for color palor or cyanosis indicate allergic conditions, look for swelling or boggieness
    • look for ulcers or polyps
  127. Transilluminate the sinuses
    • If these are full of pus there wont be patency/lucency
    • frontal and maxillary
  128. Number the Teeth
  129. Examine the Oral cavity
    • Observe breath odors
    • Identify teeth by name and number
    • Palpate and percuss the teeth with a toung blade look for mobility and tenderness
    • Inspect the dentition for oral health the lips oral mucosa gums and gingiva, roof of the mouth and floor of the mouth
    • Palpate: bimanual exam of the tounge using gloves and a gauze, bimanual exam of the buccal mucosa, palpate teh parotid (Stenson's ducts) and the submandibular (Wharton's) ducts, Hard palate, soft palate
    • Inspect all sides of the tounge and floor of the mouth
  130. Examine the pharynx verbilize what you are looking for
    • Soft palate
    • Uvula
    • Anterior and posterior pillars
    • Tonsils
    • CN IX and X: gheck gag reflex/watch midline rise when pts says ahhh
    • CN XII: Have pt stick out tounge it should remain midline tounge will deviate toward side of lesion if you suspect this have them push agains the inside of each cheek while you feel the outer cheek with your hand
    • Note tonsil Size
    • Note mallampati Classification
  131. What is your pts Tonsil size?
  132. What is your pts Mallampati Classification?
  133. Examine the neck
    • Inspect the neck for symmetry, swelling, masses, scars, visible lymph nodes, parotid or submandibular glands or jucular venous distention
    • check for range of motion
    • palpate the cricothyroid membrane
    • palpate the lymph nodes
    • palpate teh carotid pulse
    • Check the trachea inspect for midline location, palpate for tugging
    • Test CN XI: neck should turn agains resistance shoulder shrug against resistance
  134. Examine the Thyroid
    • Inspect for visible enlargment or asymmetry
    • Palpate for enlargment, nodules, masses, tenderness, symmentry
    • Have pt flex neck forward slightly
    • place fingers just below cricoid cartilage
    • ask pt to swallow (may sip water)
    • palpate teh isthmus
    • have pt look slightly down and to the right palpate the right side laterally
    • repeat process on the left
    • Auscultate the thyroid for bruits
  135. Assess neck ROM
  136. Palpate lymph nodes of the head and neck
  137. Measure JVP
    • Elevate the head of the bed to 30 degrees
    • identify the external then internal jugular venous pulsations (for hypovolemic patient lower the head of the bed for hypervolemic patient raise the head of the bed)
    • Turn head slightly away from teh side you are examining
    • Use tangental lighting to help identify the pulsations
    • Starting with the right internal jugular vein
    • identify the meniscus (highest point of palpation)
    • measure the height of the column in relation to the sternal angle (put your ruler straight up from teh sernal andle and use a straight edge to complete the triangle between the pt, the hypotenuse and the ruler and the straight edge (which forms the base)
    • Ensure a 90 degree angle between the ruler and the straight edge
    • the measurment on the ruler plus 5cm, the distance between the sternal angle and the right atrium, is the JVP it reflects the right atrial pressure
    • normal value is less than 9
    • Conditions that elevate JVP:
    • Heart failure, tricuspid valve disease, pulmonic stenosis, pericardial disease,
  138. Test for Kussmaul's sign
    • JVP that rises with inspiration
    • Observe the JVP meniscus and instruc the pt to inspire deeply while watchign to see if there is a decrease or increase in teh height of the column
    • Normally JVP falls with inspiraiton due to reduced pressure in the expanding throacic cavity
    • positive Kussmaul's sign indicates impaired filling of the right ventricle due to either fluid in the pericardial space or a poorly compliant myocardium or pericardium
  139. Determine if a hepatojugular reflex is present
    • Observe the JVP with the head of the bed so that the JV column is visible
    • apply firm pressure to the right upper quadrant of the abdomen while watchign the column the incresased pressure augments the venous return to the right atrium
    • Normal: the increased volume of the blood return is accomodated by the right atrium and only a transient increase in JVP is observed
    • Pathologic: with impaired right cardiac function there is a progressive rise in return to the right atrium that cannot be accomodated and thus backs up causing an increase in the JVP waveform
    • perform on pts with subacute right sided heart failure and passive hepatic congestion
  140. Palpate the carotid pulse
    • pt is lying at 30 degrees head of bed elevation
    • inspect for visible pulsations
    • palpate the right carotid artery in the lower 1/3 of the neck
    • Avoid upper 1/3 and do not press on both carotids at once
  141. Palpate for thrills
    using the ulnar surface of the hand place hands just below the clavicle feeling for deep rumbling or vibration caused by heart murmur
  142. Listen for Carotid bruits
    • Have pt hold breath
    • place the bell of the stethascope over carotid
    • auscultate for a murmur
  143. Find the apical pulse
    • Also called the PMI
    • 5th intercostal space 1cm medial to the MCL
    • note displacement of the pulse or multiple impulses
    • use tangental lighting
    • Note heaves or lifts
  144. Percuss Heart boarder
    • percuss from the left anterior axillary line in the 3rd 4th 5th and 6th intercostal space twoard the sternum for dullness
    • percuss from the right midaxillary line towards the sternum usually the sternum will be the first dull note on the right
    • Pathology: if there are dull notes past the sternum on the right then the heart may have right sided hypertrophy
  145. Perform and Allen Test
    • Occlude both the ulnar and radial arteries of the pts hand
    • ask the pts to rapidly open and close their hand until it goes white
    • let go of the radial side and observe how long it takes for the hand to return to color
    • If it takes more than a second or 2 to regain color the pt does not have adequate collateral circulation
  146. inspect the lower extremity
    • Size
    • symmetry
    • swelling or edema
    • venous pattern/engorgement
    • color of skin and nail beds
    • skin texture
    • hair distribution
  147. Palpate the lower extremity
    • Femoral pulse
    • Inguinal nodes
    • Popliteal pulse
    • dorsalis pedis pulse
    • posterior tibialis pulse
    • pitting edema
    • temperature
    • measure bilateral calf circumference
  148. Rapid color blind test
    see if pt can tell the difference between red and green
  149. Visual fields by confrontation
    • Seated facing pt or at eye level to pt stand 2 ft away
    • Ask pt to cover one eye
    • show them either 1 or 2 fingers in the in the each quadrant of their peripheral vision and ask how many fingers you are holding up
    • to determine the pts peripheral vision cover the opposite eye on yourself and use your peripheral vision as a guide
  150. Perform a Hirshberg Test
    • Shine penlight directly at bridge of the nose
    • note the reflection of the light in both eyes
    • is it symmetrical?
  151. Perform a Cover test
    • Looks for Tropias
    • Cover one eye look for the eye that is uncovered to deviate toward you from its original position
  152. Perform a cover uncover test
    • Tests for phorias
    • on one side cover one eye then uncover that eye look at the eye you are testing for deviation
    • if it does deviate you have a phoria
  153. Perform a cross cover test
    • Occlude one eye then the other then the first again rapidly
    • this breaks the communication between the two eyes and reveals subtle phorias
    • nifty eye video
    • http://www.ophthobook.com/videos/tropias-and-phorias-video
  154. Describe eyebrows
    eyebrow quality, distribution, scaling, infestation etc
  155. Describe the eyelids and lashes
    no ptosis, edema, discoloration, lesions, eye lashes, are outward and clean, no ectropion, entropion, chalazion, hordeoleum, or xanthelasma
  156. Test for lid lag
    • Look for lid lag as you do the cardinal fields of gaze
    • lid lag is when the eyelid cannot keep up with the rotation and movement of the eye
    • Video: http://www.youtube.com/watch?v=oFy2U_0II9k
  157. Check Lacrimal apparatus
    • observe teh lagrimal apparatus for signs of edema, erythema, or purulent discharge
    • palpate the lacrimal duct for regurgitation
  158. Examine the conjunctiva
    • Look at lower palpebral lid
    • describe bulbalar conjunctiva
    • describe the upper lid invert the upper eyelid
  159. Describe the cornea
    • flourescein stain if abrasion is suspected
    • no arcus senilis, kayser flesher ring corneal ulcer or abrasions
  160. Inspect the iris
    iris should be round no nodules no vascularity
  161. Inspect anterior chamber
    no hyphema no hypopyon
  162. Inspect anterior chamber depth
    • use tangential lighting
    • observe for cresent shadow if there is no cresent shadow the chamber is shallow and you cannot dialate their eyes it will precipitate acute closed angle glaucoma
  163. Inspect the lens
    • oblique lighting
    • will look like a pearly blue grey (similar to a soap bubble and clear) on the inside of the pupil if there is a cataract you may see an opacity of this pearly gray
  164. Check pupils
    • Inspect shape, symmetry
    • Direct and consensual light reflex: when you shine light in the eye pupil constricts when you shine light in opposite eye pupil in observed eye constricts
    • Test for Relative afferent pupilary defect: swinging flashlight test, when you move your flashlight rapidly from one eye to the other the pupils should hold their level of constriction constant. If there is a RAPD they will alternately constrict and dialate.
  165. Test for Relative afferent pupilary defect
    • Test for Relative afferent pupilary defect: swinging flashlight test,
    • when you move your flashlight rapidly from one eye to the other the
    • pupils should hold their level of constriction constant. If there is a
    • RAPD they will alternately constrict and dialate.
  166. Perform Cardinal fields of gaze
    • ask pt to follow your finger or pen or flashlight etc
    • Draw a big H encompassing the 6 cardinal fields of gaze
    • holding for one beat at each of the 6 fields
    • note pt for ability to move both eyes, symmetry, lid lag and nystagmus
  167. Check for nystagmus
    • hold finger 45 degrees from pts direct gaze
    • ask pt to look at your finger without moving their head
    • nystagmus will be 1 or 2 beats to the side
    • abnormal is rotary or verticle or more than two pulses of nystagmus
  168. Test for convergence
    • ask pt to follow an object such as your finger from a distance of one foot to directly to their nose
    • note where they are no longer able to focus both eyes on the object this is their convergence point
  169. Perform fundoscopic exam
  170. Assess AP diameter
    • measure the distance from anterior to posterior
    • compare the left to right
    • AP diameter should be < L-R diameter
  171. Hoover's sign
    • refers to inward movement of the lower rib cage during inspiration
    • if present the pt has a flat but functioning diaphragm
    • Thumbs will also come off chest when palpating for chest expansion
  172. Palpate for chest expansion
    • have pt breath out and in normally
    • place hands equidistant apart across lungs below the nipples thumbs pointing toward the xiphoid process
    • watch for areas that are not moving apart symmetrically during inspiration
  173. Tactile fremitus
    • place ulnar pad of hand across chest
    • lay hands on rib spaces and have the pt say 99 or mickey mouse
    • There should be vibratory sensation when pt talks
    • Increased: indicates consolidated pneumonia or tumor
    • Decresed: pneumothorax, pleural effsuion, bronchial obstruction, COPD
  174. Diaphragmatic excurison
    • percuss lung interspaces from above the diaphragm to below with pt exhailed
    • compare to inhailed
    • normal excursion should be 3-5 cm
  175. what is the 579 rule?
    • 5th ICS midclavicular line
    • 7th ICS midaxillary line
    • 9th ICS scapular line
    • are the liver boarders percuss this area
    • if the liver is displaced downward the pt may have COPD
  176. Auscultate the lungs
    • Auscultate in a latter pattern on the back in 4 pairs of spaces (8 total locations)
    • Auscultate 3 pairs on the front (6 total)
    • listening for normal brochovesicular sounds
  177. Bronchophony
    • 99 and mickey mouse
    • will be heard clearly in a solid area but will not be heard clearly in normal lungs
    • Consolidation: louder clearer voice sounds
    • Increased air: distant quiet sounds
  178. Egophony
    When pt says E it sounds like AH in areas of consolidation
  179. Wispered pectriloquy
    pt wisperes 1,2,3 but it sounds lout as a normal voice through stehtascope if consolidation is present
  180. Examine axillary lymph nodes
    • pull arm all the way up provider puts their hand inside the axilla and have pt drop their arm
    • feel deep to the axilla feel aterior to the axilla under the clavical etc
    • axillary nodes are breast cancer until proven otherwise
    • make sure to do a bimanual exam on the anterior and posterior axillary folds

What would you like to do?

Home > Flashcards > Print Preview