Physical Examination

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Author:
clugger
ID:
258616
Filename:
Physical Examination
Updated:
2014-01-27 12:05:57
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Physical assessment examination
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  1. Sitting
    Sitting upright at side of bed /exam table

    To assess vital signs, head, neck, chest, cardiovascular system, breasts

    If client is weak, he may need assistance to maintain this position
  2. Supine
    (incl. Fowler's and semi Fowler's position)
    • Lying flat on the back with arms and legs fully extended
    • To assess abdomen, breasts, extremities, pulses.

    If client becomes short of breath, raise head of bed (HOB).

    Fowler's Position: head elevated 60 degree

    Semi-Fowler's position: head elevated 30-45 degree
  3. Dorsal recumbent
    Supine with knees flexed

    Assessment of abdomen with abdominal or pelvic pain

    Flexing the knees promotes relaxation of the abdominal muscles
  4. Lithotomy
    Dorsal recumbent position at end of table with feet in stirrups, legs flexed, and widely open

    • Assess female pelvic exam (max.Exposure of genitals),
    • Older patients may need support to assume and maintain position
    • Use privacy drape
  5. Sims'
    • Flexion of the hip and knees in a side-lying position
    • To examine rectal area
    • Female pelvic exam if patient unable to assume lithotomy position
    • Do not use if patient has had total hip replacement
  6. Prone
    • Lying on stomach (small pillow under abdomen makes position mire comfortable)
    • examine musculoskeletal system, especially hip extension, back, buttocks.
    • May be difficult to assume for patients with respiratory problems
  7. Lateral recumbent
    Lying on the side in a straight line

    • Left lateral recumbent: heart murmur evaluation (brings heart closer to chest wall)
    • If client unable to assume this position listen to heart with client seated and bending forward
  8. Knee-chest
    • On hands and knees with head down and buttocks elevated
    • Good for rectal area examination
    • Not often used as uncomfortable and evtl. embarrassing
  9. standing
    • Upright posture with both feet flat on ground
    • To examine musculoskeletal + neurological system, gait , cerebellar function.
    • Some patients not able: weak, poor balance
  10. Confusion + irritability
    • Hypoxia
    • Medication side effect
  11. lethargy
    Medications, depression, neurological, thyroid, liver, kidney, cardiovascular disorder
  12. Bizarre response
    Psychiatric problem
  13. Inability to recall health history/information
    Neurological disorder
  14. weight
    • Minimal clothing
    • No shoes
    • Bed scale if unable to stand
    • Infant: stationary measure
    • Children: growth charts (easy monitoring and comparison)
  15. BMI
    BMI not useful for athletes, pregnant and lactating, growing children, frail and sedentary older adults (fat to muscle proportion)
  16. skin
    Skin color, lesions, unusual odors, (hygiene, wound, disease, excess sweating, thyroid problems, overactive sweatglands, urine-> incontinence...
  17. Variations in skin color neonates/ infants
    • Mongolian spots: benign blue black birth marks at lower back+buttocks of black, Hispanic, native American and Asian babies-> most fade until 2 or early adolsecence
    • Capillary hemangiomas: stork bites, small irregular ping red areas at face and nape of. Neck in newborns-> disappear in infancy or until 5
    • Café-au-laity spots: light brown birthmarks anywhere on body, usually no problems, sometimes signal genetic disorder
  18. Skin temperature
    • With dorsum of hand
    • compare temp of hand with feet, right side with left
    • Should be warm, consider environment and exercise
    • check temperature over any area of erythema-> accompanied with warmth could indicate infection/inflammatory changes
    • too warm: check data, fever, hyperthyroidism,
    • Too cool: poor peripheral circulation, shock, cold environment, hypothyroidism
  19. Skin moisture
    • Normal: warm and dry
    • Excess moisture: hyperthermia, thyroid hyperactivity, anxiety, hyperhidrosis (excessive swearing)
    • oily: acne
    • Dry : dehydration, chronic renal failure, hypothyroidism, excessive exposure, overzealous hygiene
  20. pallor
    • Skin appears white (loss of pink and yellow tones)
    • In dark skinned patients: loss of red tones

    • Poor circulation, low hemoglobin level (anemia),
    • See oral mucous, conjunctiva (the mucous membrane that lines the inner surface of the eyelids and is continued over the forepart of the eyeball), nail beds, palms, soles of feet
  21. cyanosis
    • Blue gray coloration of the skin (ashen)
    • Lips, tongue, mucous membranes, facial features, -> central cyanosis->hypoxia
    • Newborns->acrocyanosis->blue palms and soles in the first few hours->normal
    • Cold-> lips blue but not tongue, also extremities especially hand+feet
  22. Jaundice
    • Yellow orange cast to skin
    • Liver disorders
    • sclera, mucous membrane, hard palate of mouth, palm, soles
    • Newborn usually normal in the first few weeks (unless blood incompatibility or congenital disorder)
  23. Flushing
    • Widespread, diffuse area of redness
    • Face, body
    • Fever, high room temperature, sunburn, polycythemia (increase in red blood cells), exercise, certain skin conditions (e.g. Rosacea)
  24. erythema
    • Reddened area
    • Rashes, skin infections, prolonged pressure to skin, application of heat or cold
  25. ecchymosis
    • Bruised (blue green yellow) area
    • Anywhere on body
    • Varies on age of injury
    • Physical, abuse, internal bleeding, side effect of medication, bleeding disorder
  26. petechiae
    • Tiny, pinpoint re or reddish-purple spots
    • extravasation (leakage from vessels), -> variety of disorders or medications
  27. mottling
    • Bluish marbling
    • Light skinned clients -> cold

    Newborns-> overstimulation of autonomic nervous system
  28. Exposed areas of skin
    Tend to be drier and coarser,

    + elbows and knees
  29. Skin coarse thick dry
    • hyperthyroidism
    • Other endocrine disorder
  30. Smooth, thin, shiny skin with little to no hair
    Impaired circulation (period. Arterial insufficiency)
  31. Thick, rough, hyperpigmented skin
    Venous insufficiency
  32. turgor
    • Elasticity of skin
    • Lift skin
    • Skin stays up (renting)-> dehydration, older age,
    • Cannot pinch skin because of tension-> edema, scleroderma
  33. edema
    Excessive amount of fluid in tissues (abnormal)

    congestive heart failure, kidney disease, peripheral vascular disease, low albumin level,

    -> feels tender so touch, swollen, tight,  (grading system for edema)
  34. Skin lesions
    • Any lesion (variation in pigment or break in continuous tissue) requires assessment.
    • Normal: milia: white raised areas on nose, chin, forehead of newborns (whitehead)-> retention of sebum in sebaceous gland-> disappear in infancy
    • Nevis (moles), freckles, birthmarks, skin tags, striae (silver to pink stretch marks)
    • Abnormal:
    • Primary: result of disease/ irritation e.g. pastels of acne
    • Secondary: develop from primary lesions as a result of illness, exposure, injury, infections... e.g. crusts from ruptured pustules
  35. What shall be observed on a lesion ?
    Size, shape, pattern, color, distribution, texture, surface relationship, exudate, tenderness, pain, itching
  36. Assessing edema
    trace   a minimal depression is noted with pressure

    +1    depression of 2mm, no visible distortion (German: Beule), , rapid return to skin position

    +2    depression up to 4mm, appears 5-10 seconds

    +3.   Depression approx. 6mm, appears 1-2 minutes, appears swollen

    +4    depression up to 8mm, persists 2-3 minutes, grossly edematous
  37. Possibility of malignancy
    Exposed to constant rubbing / other trauma?

    Any newly developed moles/skin lesions/change in appearance

    ABCDE

    • A Assymmetry
    • B Border irregularity
    • C Color variation
    • D Diameter greater than 0.5 cm
    • E Elevation above the skin surface
  38. hair
    • Color, texture, distribution, condition of scalp
    • Free of debris,
    • White hair with very pale skin-> albinism
    • Texture fine to coarse
    • Exceptionally dry->Hypothyroidism
    • Very fine, silky-> hyperthyroidism
  39. alopecia
    • Hair loss
    • Along the temples and in center of scalp (normal balding pattern)
    • Diffuse alopecia-> chemotherapy, nutritional deficiencies, endocrine disorders
    • Thinning hair in women-> perimenopausal when hormone levels are fluctuading
    • Patchy hair loss-> fungal infections, hair pulling, constant wearing of caps
    • Alopecia Arcata-> benign autoimmune disorder
  40. hirsutism
    • Excess facial or trunk hair
    • Might be due to endocrine disorders or steroid use
  41. scalp
    • Normally smooth, firm, symmetrical, non-tender, without lesions
    • Asymmetrical/ bumpy sculpt due to trauma or lesions
    • Scaly flakes or patches -> fungal infection (e.g. dandruff), dermatitis, psoriasis
    • Tenderness -> localized infection or trauma
    • Cradle cap (newborn)-> white patches due to sebum, common -> can be removed with washing and gentle scrubbing
    • Free of debris and head lice infestation
    • Nits deposited on the hair shaft close to scalp
  42. nails
    Normal: levels firm, similar to color of skin, smooth and uniform, 160 degree nail bed angle
  43. Nail color
    • Pink nails with rapid refill ->> good
    • Pale or cyanotic -> circulatory/respiratory disorders (anemia, hypoxia)
    • Half and half nails: distal band of reddish pink cover 20-60%% -> low albumin level or renal disease
    • Mees' lines: -> transverse white lines in the nail bed -> severe illness or nutrition deficiencies
    • Splinter hemorrhage:-> small hemorrhages under nail bed-> bacterial endocarditis or trauma
    • Black nails-> blood under nail, local trauma, nails can also drop
    • White spots: may indicate zinc deficiency
  44. Nail shape
    • Clubbing ( nail plate angle 180 degree or more) -> chronic hypoxic state (e.g. chronic lung disease)
    • spoon shaped nails-> may be iron deficiency
  45. Nail texture
    • Normally smooth
    • Thickened nail -> poor circulation
    • Thick nail with yellowing -> fungal infection (onychomycosis)
    • Brittle (German: sproede)nails ->hyperthyroidism, malnutrition, calcium and iron deficiency, harsh nail products
    • Soft, boggy (German: sumpfig) nails: poor oxygenation
    • Call us formation around nail: chronic nail picking, sometimes inflamed ( paronychia-> Painful, may require drainage)
  46. Head
    HEENT
    • head, eyes, ears, nose, throat
    • All assessment techniques
  47. Skull and face
    • Rounded, symmetrical in appearance and movement, normal head size (other wise measure), head size is familial
    • Large head -> acromegaly ( excess growth hormone
    • Small head -> microcephaly certain types of mental retardation
    • Abnormal shape infants-> trauma during vaginal birth or placing baby in same position for several hours per day
    • Faster growing head in infants/children : hydrocephalus (accumulation of excessive cerebrospinal fluid)
    • Asymmetry-> trauma, surgery, neuromuscular disorder, paralysis, congenital deformity
    • Facial appearance inconsistent with gender, age, race -> inherited or chronic disorder, e.g. Grave's disease, hypothyroidism with myxedema, or Cushing's syndrom
    • Jaw motion symmetrical without pain
    • Irregular jaw movement or cracking of the jaw -> TMJ temporomandibular joint syndrom
  48. Normal eyes
    • Sitting + cranial nerve testing
    • eyelid: moist and pink, short lashes, evenly spaced, curl outward , conjunctiva smooth, glistening, peach, minimal blood. Vessels, no pallor, dryness, edema.
  49. Common abnormal findings on eyelids
    pterygium, ectropion, entropion, ptosis
    • Crusting, scales, or swelling -> infection of eyelids or lashes
    • pterygium -> growth or thickening of conjunctiva form inner cantus toward the iris
    • ectropion -> everted eyelid (often aging) secondary to skin loss tone-> excessive dryness of eyes
    • entropion-> inverted eyelid-> can damage corneal
    • ptosis -> drooping lid (stroke, cerebrovascular accident CVA or Bell's palsy (paralysis of the facial nerve)
  50. Normal sclera
    • Smooth, glistening, blue-white in color with tiny vessels visible.
    • Dark skinned may have yellowish cast or small brown spots more centrally
  51. Abnormal findings in sclera
    • Yellow sclera: -> icteric, elevated bilirubin
    • Blood visible:-> subconjunctival hemorrhage-> trauma or hypertension
  52. Lens and cornea (outermost layer of the eyeball) findings
    • Normal: smooth, transparent, moist
    • White ring around cornea (arcs senilis)-> normal variant in older adults
    • Lens opacities (German:truebe)-> cataracts (with age, impair vision)
    • Roughness or irregularity of cornea-> trauma or corneal abrasion
  53. pupils
    PERRLA
    • PE Pupils equal
    • R round
    • R reactive to light
    • Reactive to accommodation (German, Entgegenkommen)
  54. Papillary abnormailites
    • Sluggish accommodation-> anticholinergic drugs or advanced age
    • Failure of 1/2 to accommodate -> cranial nerve III problem or exophthalmos (associated with hyperthyroidism), congenital cataracts may be seen in children (rare)
    • Cloudy pupils-> cataracts (aging)
    • Mydriasis -> enlarged pupils-> glaucoma (increase in intraocular pressure), medications, mydriatics for eye exam
    • Miosis: -> constricted pupils-> medication to treat glaucoma
    • Anisocoria -> unequal pupils -> stroke (CNS disorders), head trauma, cranial nerve injuries,  (for some people normal)
  55. Myopia
    Diminished distant vision
  56. Hyperopia
    Presbyopia
    • Diminished near vision (also aging)
    • Patient > 45 years called Presbyopia
  57. Strabismus
    • Crossed eye
    • One or both eyes deviate from the object they are looking at (normal within 1-2 months after birth)
    • -> weak intraocular muscle or lesion on the oculomotor nerve
  58. amblyopia
    Constant strabismus may result in "lazy eye', brain does not fully  acknowledge the images seen by the amblyopic eye-> reduced vision (not correctable by glasses)
  59. Abnormalities seen on ears
    • Altered position-> hearing deficit or genetic disorders like down syndrom
    • Blood -> trauma
    • Drainage, redness -> infection
    • Painful article or tragus-> otitis external (outer ear infection)
    • Tenderness behind ear, red bulging tympanic membrane TM-> otitis media (middle ear infection)
    • Presence of pressure equalization tubes in young patients with chronic ear infections
  60. Weber and Rinne test
    Hearing test with tuning fork
  61. Romberg Test
  62. Equilibrium:
    Feet together, eyes closed-> positive Romberg , swaying and moving-> may exam for neurology. system
  63. Abnormal findings in the mouth
    • Pallor-> anemia, inadequate oxygenation
    • Gingivitis -> periodontal disease -> red, swollen, spongy, bleeding gingival and receding gum line
    • parotitis -> inflammation of parroted salivary. gland
    • stomatitis-> inflammation of oral mucosa,
    • leukoplakia -> thick elevated white patches

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