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Health Assessment sign off - Physical Exam
Terms in this set (45)
General Survey - physical appearance / body structure / behavior
- 21 y/o female, appears stated age
- alert in no apparent distress
- appropriate facial expression
- appropriate skin color
- well nourished
- erect posture
- appropriate height and weight
General Survey - mobility
- equal steady gait
- full ROM
General Survey - skin
- skin is pink, warm, dry, smooth, intact
- no lesions
- conjunctiva pink, sclera white
- moist mucous membranes
- turgor >> instant recoil
- cap refill less than 2 seconds
respiratory - inspect
- chest is symmetric
- no deformities
- AP diameter 1:2
- equal expansion bilaterally on inspiration and expiration
- regular rate and rhythm
- no distress, nasal flaring, or use of accessory muscles
- no cyanosis or clubbing
respiratory - palpate
- trachea is midline
- chest expansion equal bilaterally
- no tenderness
- no crepitus
- tactile fremitus vibration is equal bilaterally
respiratory - percuss
- resonant throughout all lung fields
- no dullness
respiratory - ausculate
check bronchial, bronchovesicular, vesicular sounds
- breath sounds clear throughout all lung fields, no crackles, wheezes or rhonchi
- muffled voice sounds on bronchophony and whispered pectoriloquy, equal bilaterally
- no e to a changes in egophony
cardiovascular - inspect
- no heaves or lifts
- apical pulse not visible
- extremities are pink and warm
- no edema, clubbing or hair loss
cardiovascular - palpate
- no thrills
- apical pulse is at the 5th ICS MCL, 1-2 cm
- regular rate and rhythm
cardiovascular - auscultate
- APE To Man
--- sitting + supine (for the test, just do one, but mention BOTH)
--- Bell and diaphragm (do one, but mention both)
- normal S1 and S2. No S3, S4, or murmurs
- no carotid and thyroid bruits
what does APE To Man stand for?
cardiovascular - other assessments
- no JVD (JVP is 0 cm; explain this test)
- pulses 2 + equal bilaterally, regular rate and rhythm
- ulnar artery is patent (via Allen's test)
which pulses to assess?
- posterior tibial
- dorsalis pedis
what is Allen's test?
pressure on radial and ulnar arteries; release one at a time to test blood supply to hand
abdominal - inspect
- patient appears comfortable in no apparent distress
- abdomen is flat, no striae or scars
- umbilicus inverted/everted
- even hair distribution
- no pulsations or movement
abdominal - auscultate
- normal bowel sounds
- no vascular bruits (be sure to hit aortic + renal + iliac + femoral)
abdominal - percuss
- abdomen predominantly tympanic; dullness in RUQ
- liver = percuss down and up MCL to dullness >> "liver span 6-12 cm"
- kidney = CVA thump >> "no tenderness"
abdominal - lightly palpate
- no tenderness, guarding, or masses on light palpation
abdominal - deeply palpate
- no masses on deep palpation
- liver not palpable (pt breathes out, place hands under right ribs, pt breathes in and you press down further)
- aortic pulsation is 2-4 cm (pulsate between thumbs, midline between upper quadrants)
extra abdominal tests
- rebound tenderness tests appendicitis >> "no rebound tenderness"
- iliopsoas muscle (lift right leg against resistance) >> "negative iliopsoas test"
- Murphy's (press in at liver, pt takes deep breath) >> "negative Murphy's sign"
neuro - 5 parts
1. mental status
2. cranial nerves
neuro - assess mental status
- appears pleasant, in no apparent distress
- behavior and speech appropriate
- dressed appropriately for situation
- recent and remote memory intact
- "mini-mental could be performed to test higher cognitive function, judgment, problem solving"
cranial nerves - 1
- would check patency of each nostril and give pt 2 familiar scents to differentiate
cranial nerves - 2
- visual acuity via:
--- Snellen or Rosenbaum
--- confrontation (cover eye on same mirrored side; check peripheral vision with wiggling fingers)
cranial nerves - 3 + 4 + 6
- oculomotor + trochlear + abducens
- 6 cardinal locations >> "extraoccular movements intact, no nystagmus"
cranial nerves - 5
- motor >> TMJ >> "jaw strength equal bilaterally"
- sensory >> close eyes and touch cotton tip to opth, maxillary, and mandibular >> "sensation intact and equal bilaterally"
- corneal >> don't do this (cotton to eye = blink)
cranial nerves - 7
- smile, frown, close eyes tightly, lift eyebrows, show teeth, puff cheeks
"facial muscles intact and symmetric"
cranial nerves - 8
- whisper/finger rub
- Weber = tuning fork on head
- Rinne = tuning fork behind ear on bone, then in front of ear
"whispered words heard bilaterally, Weber midline with lateralization, Rinne AC>BC bilaterally"
cranial nerves - 9 + 10
- glossopharyngeal + vagus
- depress tongue, ahh, check uvula
- don't check gag reflex on
cranial nerves - 11
- spinal accessory
- shrug shoulders against resistance
- move head left and right against resistance
" shoulder shrug and head movement intact and equal bilaterally"
cranial nerves - 12
- stick tongue out and touch to the cheeks and roof of mouth
"tongue protrudes midline, no tremors"
neuro - muscle strength
- appropriate size, strength and tone
- no atrophy, weakness or tremors
(remember to move extrems against resistance)
neuro - gait
- gait smooth and coordinated
- able to tandem walk
neuro - Romberg
-pt eyes closed, one leg up at a time, slight push
neuro - sensory tests (faculty will pick 2)
- finger to nose (close eyes, touch nose)
- finger to finger (index and thumb touch together--different in our section than others)
- RAM (alternating hands on thighs)
- thumb to fingers
- heel to shin
" ... smooth and intact bilaterally"
neuro - sensation to light touch
-upper OR lower extrems
"pain sensation and light touch intact bilaterally"
neuro - motor (faculty picks 2)
- vibration (tuning fork on big toe)
- position (move finger up/down, pt determines direction)
- stereognosis (random objects, eyes closed)
- graphesthesia (write number in hand, eyes closed)
- 2 point discrimination (feeling 2 points or 1?)
- extinction (touching both sides at same time)
- point location (pt points to where you touched)
" ... intact bilaterally"
neuro - DTRs (faculty picks 3)
+ plantar reflex (for Babinski)
" 2+ and equal bilaterally. negative for Babinski"
HEENT 1 - head
- normocephalic, head midline
- pink scalp
- no dandruff, lesions or tenderness
- facial features symmetric
- no anxiety, weakness or tics
- skin pink, warm, dry, intact, smooth with even pigmentation and no apparent lesions
HEENT 1 - eyes
- Snellen or Rosenbaum >> "vision 20/20 OD/OS"
- "facial features symmetric bilaterally. no drooping. lids and lashes evenly distributed. no edema, redness or lesions. no swelling, no discharge. conjunctiva pink, sclera white. cornea free from opacities"
- pupils >> "PERRLA"
- visual fields by confrontation >> "peripheral vision intact and equal to examiners"
- test EOMs with 6 cardinal positions + corneal light reflex (pt gazes far, light into cornea, should be same on both sides) + cover test (cover 1 eye, then uncover and observe for movement)
>> "EOMs intact. corneal light reflex equal bilaterally. no eye muscle weakness"
HEENT 1 - nose/sinus
- inspect nose >> "nose symmetric, midline, proportionate to facial features. no inflammation or skin lesions. no nasal flaring"
- inspect nasal cavity >> "no deviated septum. nasal mucosa pink and moist. no polyps or discharge. nares patent bilaterally"
- palpate >> "no frontal or maxillary sinus tenderness"
HEENT 2 - ears
- "gross hearing intact on whisper test"
- inspect/palpate auricle, tragus, external auditory meatus >> "equal bilaterally with no swelling or thickening, skin color consistent with facial color. no lesions, masses or tenderness. no redness or discharge"
HEENT 2 - neck
- inspect >> "accessory muscles equal bilaterally, symmetric, trachea midline, freely moveable. no scars, visible nodes, or thyroid masses"
- palpate trachea/thyroid >> "no nodules, enlargements, tenderness. thyroid not palpable"
- lymph nodes >> "lymph nodes not palpable"
- auscultate >> "no thyroid or carotid bruits"
HEENT 2 - mouth
- inspect >> "lips pink and mucosa, no ulcers or cracking. buccal mucosa is pink, no ulcers or nodules. tongue midline, pink, no swelling, roughened with papillae. saliva present. gingiva pink and moist, no inflammation or bleeding. teeth are white, straight, evenly spaced, and clean/free of debris and decay. uvula rises symmetrically midline with soft palate. tonsils 1+, no exudate or lesions. pharynx without erythema, no hoarseness"
- gag reflex >> "will not assess this, but would touch posterior wall of pharyngeal wall"
- TMJ >> "TMJ strong and equal bilaterally. no popping or dislocation"
- posterior auricular
- superficial cervical
- deep cervical chain
- posterior cervical
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