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(Revised 2/2004)

Physical Diagnosis Second Year


Physical Examination Sequence (Regional Approach) 1. Introduction (if not previously accomplished) in a friendly manner. a. Refer to patient by Mr., Mrs., Miss and last name, clarifying pronunciation, if necessary. b. Shake hands. Explain purpose of exam to gather additional information on health status by thorough examination that should take ____ minutes. Explain that questions (from the patient) are welcome now and at any point throughout the exam. Assure patient comfort eg. Need to use rest room, telephone, etc. Optimize lighting favor natural over fluorescent. Assure privacy close door, draw curtains. Wash hands in presence of patient. Optimize bed position raise if necessary; put down rails. Lay out equipment sequentially: BP cuff Otoscope, ear specula, 512 Hz tuning fork Penlight, tongue blade Ophthalmoscope, Snellen chart Reflex hammer, 128 Hz tuning fork, tongue blade for sensory testing, 10 g monofilament (used in patients with diabetes mellitus). Cup of water for thyroid exam Ruler (cm) Glove, lubricant, guaiac card, guaiac solution Patient properly gowned (most useful approach) Gown with open side in back underwear depending on extent of exam Additional bed sheet available Height, weight, temperature previously measured by staff Assessment of general appearance from first contact with patient: Gender Apparent age Body habitus Any respiratory distress Presence/extent of pain (1-10 scale, as indicated by patient, where 1 = barely noticeable and 10 = worst pain imaginable or experienced) this may have been previously determined by staff. Specific identifying features Level of consciousness if abnormal Skin if abnormal Posture, movements if abnormal Speech Behavior 1

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Hygiene, odors PROVIDE FEEDBACK/DIRECTION TO PATIENT DURING EXAM AS TO EXAM SEQUENCING AND POSSIBLE FINDINGS PATIENT SEATED in chair with back supported, feet flat on floor (legs not crossed). EXAMINER FACING PATIENT 12. Palpate both radial pulses with index finger simultaneously for a few seconds to confirm equal pulse volume, then count rate for at least 30 seconds in one radial pulse (multiply by 2), noting any irregularities. Characterize the rhythm as regular, regularly irregular, or irregularly irregular. If pulse is irregularly irregular, use stethoscope to count the cardiac apical rate for 30 seconds. 13. Count respiratory rate unobtrusively while ostensibly measuring pulse rate, observing chest if patient in sitting position (chest or abdomen if patient in supine position) for 30 60 seconds. a. Assess for nasal flaring in patients with cardiopulmonary disease. 14. Measure BP in both arms (need to determine maximal inflation pressure in one arm only). a. Proper patient preparation (comfortable environment, removal of sufficient clothing, and appropriate timing relative to stimulant or food intake). b. Optimal patient position: seated, back supported in straight-back chair, arm supported by arm-rest or examiner so that midpoint of BP cuff at heart level, feet flat on floor. (1) Measure supine BP if patient unable to sit; be sure midpoint of BP cuff at heart level. (2) Measure supine and standing BP later in exam if sitting BP is elevated. c. Appropriate cuff size for arm circumference. d. Appropriate cuff placement (bladder center over brachial artery and 2.5 cm above elbow crease); cuff should not touch stethoscope. e. Determine maximum inflation level (systolic BP by palpation 30 mm Hg). f. Determine BP by auscultation, using bell of stethoscope, rapidly inflating cuff to maximal inflation pressure, deflating at 2 mm Hg/sec., recording Korotkov I and V phases, rounded up to nearest 2 mm Hg. (record Korotkov phase IV muffling if sounds continue to very low diastolic values). g. If blood pressure elevated to > 140/90 mm Hg (or 130/80 in patients with diabetes or chronic kidney disease), recheck BP in supine and standing position. h. Thyroid exam: prior to exam explain that thyroid gland will be examined and that there may be some mild discomfort (1) Identify landmarks: Thyroid cartilage (Adams Apple) Cricothyroid membrane (site of emergency tracheostomy) Cricoid cartilage (isthmus of thyroid located just below) (2) Inspect lower neck for visible gland, enlargement, asymmetry at rest and during swallow, optimally with H2O PATIENT SEATED EXAMINER MOVES BEHIND PATIENT

(3) (b)

Examine thyroid using posterior approach (a) First, palpate both lobes of thyroid simultaneously both at rest and during swallow Then, palpate each lobe individually at rest and during swallow

MOVE PATIENT FROM CHAIR TO EXAM TABLE 15. Examination of hands, wrists, elbows a. Inspect dorsum of hands for clubbing cyanosis, joint inflammation; then inspect palmar side. b. MCP squeeze test across MCP finger joints. c. Assess range of motion: (1) Make a fist (finger flexion) to examine MCP joints in detail). (2) Make a claw (finger flexion to examine PIP and DIP joints in detail). (3) Prayer sign (finger extension) (4) Wrist flexion and extension during passive (examiner-assisted) movement. d. Elbow extension to 0 and flexion to 145 e. Palpate for epitrochlear lymph nodes, rheumatoid nodules, or tophi in appropriate sites. 16. Palpate in the axillae bilaterally for lymphadenopathy. 17. Examine shoulder ROM a. Place hands behind head b. Place hands behind back as high as possible. 18. Examine neck ROM touch each ear to shoulder on same side, achieving 30 - 60 of range. 19. Partial neurologic exam in sitting position. (Alternatively, the entire neurologic exam can be done as a single maneuver at another time in the physical exam.) Cranial Nerves a. Observe for ptosis b. Check ocular motility in 6 cardinal directions for weakness and nystagmus c. Test peripheral visual fields by confrontation d. Test masseter muscle on both sides or test corneal reflexes or test facial sensation e. Observe facial symmetry: Raise eyebrows Close eyes against resistance Puff up cheeks f. Test sternocleidomastoid strength rotating head against resistance in each direction or elevating shoulders against resistance g. Protrude tongue in midline. Check strength of R, L tongue protrusion into R, L cheeks Motor strength: Observe for atrophy, involuntary movements h. Plantar flex feet against resistance i. Dorsiflex feet against resistance j. Extend knees against resistance Flex knees against resistance k. Flex each hip against resistance

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(Alternatively, lower extremity motor strength may be assessed by asking the patient to walk on toe tips, walk on heels, and do a squat toward the end of the exam.) l. Check bilateral grip strength Check lumbricals, interossei abduct and adduct fingers against resistance m. Check wrist strength for flexion and extension o. Check bilateral biceps flexion strength p. Check triceps strength p. Shrug shoulders against resistance Cerebellar exam: q. Bilateral finger to nose r. Bilateral heel to shin Deep tendon reflexes: s. Biceps Triceps Brachioradialis Knees Ankles Plantar responses Sensory exam: t. Test vibration at R, L 1st MTP with 128 Hz tuning fork u. Test position sense at great toes HEENT exam a. Inspect scalp for skin lesions, trauma, hair pattern b. Use penlight or neck of otoscope light (otoscope light may not be sufficiently bright with some otoscopes): 1) Assess pupillary size, roundness, reactivity to light directly and consensually 2) (a) Inspect sclerae and conjunctivae, depressing lids slightly to see palpebral conjunctivae (b) Use oblique light to visualize cornea and anterior chamber (c) Ask patient to close eyes to determine adequacy of closure. 3) Examine oropharynx using tongue blade and light: (a) Check lips, gums, teeth, beneath tongue, sides of tongue, lateral walls of cheeks for any abnormalities (b) With tongue remaining in mouth (i.e., do not protrude tongue), place tongue blade in middle third of tongue, pressing down and slightly posteriorly: 1. Inspect pharynx, tonsillar areas 2. Check phonation and observe palate for symmetric elevation; may facilitate by having patient inspire quickly (c) Ask patient to protrude tongue looking for lateral movemen c. Ear exam: explain to patient what will be done during ear exam (1) Inspect pinna for skin lesions, especially skin cancers/pre-cancers (2) Use otoscope with maximal illumination and largest speculum that will fit in ear; should be clean speculum (3) Pull pinna with opposite hand up and back with thumb, forefinger (4) Insert speculum otoscope with same-side hand under direct vision and adjust angle as move forward to see drum. Maintain ulnar border of

hand firmly applied to patients head to stabilize it against sudden movement (5) Discard speculum in sight of patient (6) Test auditory acuity on each side using finger rub at arms length; if abnormal, repeat at 6 inches. d. Nasal exam: Examine external structures of nose Test each side for patency by compression of other side (3) Inspect nasal mucosa, turbinates using otoscope with new speculum, looking straight back and upwards at turbinates (4) Discard used speculum in sight of patient e. Visual acuity/ophthalmoscopic exam (1) Test visual acuity of each eye separately with pocket screener at 14 inches (2) Ophthalmoscopic examination (a) Explain exam to patient Darken the room, but not total darkness (c) Ask patient to focus on a single spot and try not to blink (d) Assess red reflex (e) Examine retina/optic disc (f) Examine macula/savea by asking patient to look directly into light 21. Neck Exam (upright position) q. Lymph node palpation bilaterally (1) Pre-auricular (2) Post-auricular (3) Occipital (4) Posterior cervical (5) Submandibular (6) Submental (7) Anterior cervical (8) Supraclavicular caution patient there may be mild discomfort (9) (Axillary-epitrochlear - done previously) (10) (Inguinal - done later) r. Tracheal exam (1) Assess mid-line position: palpate with index finger pushed straight back in sternal notch. s. Accessory muscle use note any accessory muscle use of sternocleidomastoids or scalenus medius (just above clavicle in supraclavicular fossa) 22. Chest exam a. Assess symmetry of posterior chest from a central point above the seated patient (1) Note kyphosis, scoliosis

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Assess diaphragmatic movement: palpate lower posterior rib cage with thumbs 1 inch away from and parallel to the spine with fingers parallel to ribs and ask patient to take deep breath. Percuss alternate sides of the posterior chest from just above the scapulae caudad to the point where dullness begins, looking for asymmetry Percuss diaphragmatic movement (normal = 4 5 cm) for both left and right sides (1) Deep inspiration and hold (2) Percuss to dullness (3) Full exhalation and hold (4) Percuss to dullness (5) Measure distance between sites of dullness CVA tenderness palpate deeply in bilateral soft tissue below junction of posterior costal margin and spine Auscultate posterior chest side-to-side, 2 breaths/site with mouth open and deep inspirations (instruct patient by example) (1) Apices (2) Upper posterior lung zone (3) Mid-zone medial to scapula (4) Lower lung zones Auscultate lateral chest wall in axillae and at lower site toward lung bases (ie, high axillary low axilla)

PATIENT SEATED EXAMINER MOVES TO FACE PATIENT AGAIN Expose chest of male patients 23. Inspect anterior chest wall for asymmetry, pectus excavatum, carinatum a. Anterior percussion at 2 sites above and below the nipple line in males. 24. a. Ask patient to lean forward, exhale fully, and stop breathing while you listen with diaphragm of stethoscope at lower left sternal border, 4th ICS (listening for aortic insufficiency). This lets patient rest to avoid hyperventilation from auscultation of breath sounds. b. Auscultate anterior chest wall over RUL, LUL, RML, and lingula, 2 breaths/site with mouth open and deep inspirations (you will be auscultating above and below the nipple line in males). PATIENT LIES ON BACK, HEAD OF BED at 30 ANGLE (You may need to adjust this angle up or down to see neck veins; if you suspect the patient does not have heart failure, adjust the angle downward; if you suspect the patient may have heart failure, adjust the angle upward.) EXAMINER ON PATIENTS RIGHT SIDE 25. Assess jugular venous pulsations and pressure, focusing first on the right internal jugular; you may use right external jugular if internal jugular not visible. a. Estimate JVP height in cm PATIENT SUPINE, BED FLAT

EXAMINER ON PATIENTS RIGHT SIDE 26. Auscultate carotid arteries for bruits with light pressure on stethoscope at 2 sites between angle of jaw and base of neck on R and L (ask patient to briefly stop breathing during the period of auscultation remind him/her to breathe again as soon as you complete auscultation of each artery). 27. Palpate carotid arteries (turn head slightly to opposite side to facilitate) for no more than 5 seconds to characterize: a) upstroke velocity, b) pulse amplitude and volume, and c) pulse contour. 28. Inspect chest: a. Symmetry of R and L chest from head or front of bed MOVE PATIENT TO SUPINE POSITION 29. Inspect left precordium for visible cardiac impulse(s) 30. Breast exam this exam always requires a chaperone. 31. Precordial palpation a. Check for precordial thrills with fingers in interspaces: (1) R second intercostal space (aortic area) (2) L second intercostal space (pulmonic area) (3) L third intercostal (Erbs point) (4) L fifth intercostal space (tricuspid area) b. Place heel of R hand in mid L parasternal region, depressing area 1.0 1.5 cm to detect upward systolic movement of RVH, grade as absent or as present. c. Place distal finger pads at visualized apical impulse or 5th ICS, MCL. If needed, move about peri-apical impulse area to find apical impulse. Record location, size, duration or absence of apical impulse. (1) If no apical impulse, consider percussion from anterior axillary line medially to detect dullness representing L cardiac border. 32. Auscultate precordium a. Place diaphragm of stethoscope at over apical impulse. Listen for S1 and S2 and their characteristics, listen for extra heart sounds and murmurs. Then auscultate this site with bell. b. Auscultate with diaphragm and bell in tricuspid area c. Auscultate with diaphragm at Erbs point and in pulmonic and aortic areas. d. If unable to palpate apical impulse, roll patient to left lateral decubitus position, supporting patient with left elbow, attempt to find PMI again, then listen with both bell and diaphragm. 33. Abdominal examination a. Position patient properly: (1) Supine (2) Arms at sides (3) If needed for relaxation, flex hips and knees resting feet on exam table or bed (4) Abdomen must be sufficiently exposed for inspection b. Inspect: (1) Cutaneous abnormalities (2) Visible pulsations, especially in epigastrium

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(3) Contour (4) Hernias Auscultate, depressing skin 1 cm with diaphragm (1) Bowel sounds (pitch, frequency) can listen for bowel sounds in same sites as for bruits (2) Bruits: (a) Epigastrium (aorta) (b) 2 inches superior from umbilicus, then 2 inches laterally to auscultate right and left renal arteries (c) Midway between umbilicus and midpoint of inguinal ligaments on both right and left for iliac arteries Percuss four quadrants of abdomen briefly for tenderness or unexpected dullness Light palpation in four quadrants, depressing skin 1 cm Deep palpation in four quadrants to a depth that patient comfort will allow; facilitate by palpating more deeply during exhalation, leaving hand still during inspiration Examine liver: (1) Percuss from 2nd interspace caudad along MCL until reach dullness (usually 7th 8th ICS) and continue percussing until tympanitic; mark upper and lower margins and measure total span (2) Palpate inferior liver edge: (a) Proceed cephalad from R iliac fossa (b) Hold palpating hand steady during inspiration (c) Move cephalad in increments during expiration (d) Note tenderness, nodularity, and pulsatility if the liver is palpated Examine spleen: (1) Percuss continuously during deep inspiration and exhalation at Castells spot in lowest intercostal space at anterior axillary line dullness indicates possibility of splenomegaly (2) Palpate from RLQ progressively toward LUQ; hold palpating hand steady during inspiration; move in increments toward LUQ during expiration until reaching palpable spleen or L costal margin (3) Consider (in patients especially at risk for splenomegaly, or if uncertain whether spleen was palpable) moving patient into R lateral decubitus position and repeating palpation technique to increase sensitivity of exam Examine aorta: (1) Locate aortic pulse with flat palm in epigastrium (2) Orient both hands vertically on either side of midline with distal fingers at edge of pulsation; apply equal pressure with distal fingers until aortic pulsations palpated; estimate lateral width between index fingers Examine kidneys: (1) Left hand under costovertebral angle and right hand under anterolateral costal margin; move your right hand more deeply during exhalation;

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sufficient pressure needs to be exerted as kidney is deep. Do not need to palpate for left kidney. Examine both inguinal areas: a. Palpate for lymph nodes b. Palpate femoral arteries c. Compare timing of right radial and right femoral arteries (looking for sign of coarctation of aorta d. Auscultate femoral arteries for bruits Examine feet: a. Check dorsalis pedis pulses b. Check posterior tibial pulses c. Inspect plantar and dorsal surfaces for deformities look at soles of feet for callosity or other lesions d. Metatarsal squeeze to each foot for tenderness e. In patients with diabetes, annually perform a test of protective sensation using the 10 gm monofilament. Check for peripheral edema in foot, just above ankle, with 30 60 seconds of continuous pressure. Palpate popliteal arteries (both hands, with thumbs meeting at tibial plateau and finger tips of both hands searching for pulse in popliteal fossa. Inspect thighs, calves for asymmetry Examine knee and hip: a. Passively flex knee, noting any crepitance (R hand supporting foot, L hand palpating knee) b. Passively flex hip to 90. Holding foot with R hand and steadying thigh with left hand; then slowly rotate lower limb outward; ie, internal rotation, (normal is medial rotation of 30 and no pain), then rotate outward (external rotation) c. Passively extend knee, noting any crepitance Measure supine blood pressure in R arm now, if orthostatic blood pressure measurement desired, or if sitting BP was elevated.

PATIENTS STANDS EXAMINER STANDS 41. Measure BP standing, arm supported, if sitting BP was elevated 42. Inspect patient standing: a. Front b. Side (lordosis, kyphosis) c. Back -straight spine (no scoliosis) -normal, symmetric paraspinal muscles normal shoulder and gluteal bulk and symmetry level iliac crests no popliteal swelling no hindfoot swelling or deformity 43. Ask patient to bend down and touch toes while you observe from behind 44. Gait: observe patient

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Walking away Turning Walking toward you Doing tandem gait (heel-to-toe) If you choose to assess motor strength in this way, you may also do the following at this time: (1) Walk on toes (2) Walk on heels (3) Do deep knee bend Romberg exam Male hernia and genitalia exam Male rectal exam Or Female pelvic exam / rectal exam

EXAMINER BRINGS CLOSURE TO THE EXAM: 48. Assists patient back to bed 49. Places bed rails in up position; lower bed back to standard position 50. Attends to patients comfort, eg., repositioning bedside table 51. Asks patient if any questions or other needs.

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