Physical Examination

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Physical Examination
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The Four Parts of the Chest Exam

• Inspection
• Palpation
• Percussion
• Auscultation

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Inspection

• Cyanotic?
• Finger clubbing?
• Caused by certain
• lung disorders

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Inspection

• How is the patient breathing?
• Rate, Rhythm, Effort
• Any abnormal sounds?
• What muscles are being used?
• Is there any chest deformity or asymmetry?

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Tracheal Deviation
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Palpation

• Palpate the ribs and sternum for pain or
  deformity
• Check for symmetry by palpating lung expansion

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Palpation

• Tactile fremitus
• Have the patient say ninety-nine while
  palpating the base of their lungs
• Use the ball of your hand
• Increased vibration indicates increased mucus
  production

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Percussion

• A technique for determining tissue density

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Percussion
Posterior
Anterior
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Percussion

• Percussion Notes and Their Meaning
• Flat or Dull Pneumonia (dense)
• Normal Healthy Lung
• Hyperresonant Emphysema (trapped air)

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Auscultation - Lungs

• Use the diaphragm of the stethoscope
• Compare one side to the other

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Auscultation - Lungs

• Abnormal Findings
• Decreased sounds presence of air, as in
  emphysema
• Crackles sounds like rubbing hair between your
  fingers pneumonia
• Wheezes such as in asthma
• Rhonchi snoring or gurgling sound
• LISTEN

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Auscultation - Heart

• Four Main Sites
• Aortic Valve
• Pulmonic Valve
• Tricupsid Valve
• Mitral Valve

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Auscultation - Heart
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Auscultation - Heart

• The Heart Sounds
• S1 the tricuspid valve closing
• S2 the aortic valve closing
• LISTEN

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Physical Exam
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The Abdominal Exam

• Inspection
• Auscultation
• Percussion
• Palpation

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The Quadrants of the Abdomen
Right Upper Quadrant
Left Upper Quadrant
Left Lower Quadrant
Right Lower Quadrant
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Inspection

• Are there any
• Scars
• Rashes/lesions
• Pulsations
• What is the contour?
• Flat/protruding

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Auscultation

• Use the diaphragm to listen to
• Bowel sounds (increased, decreased, absent?)
• Arterial pulses

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Percussion

• Percuss for areas of unusual dullness
• This may be a sign of an abdominal mass
• Percuss the area over the liver to check for
  enlargement

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Palpation

• Light and deep palpation of the abdomen
• Check for
• Tenderness
• Abdominal masses

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Liver Palpation
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Special Tests

• Rebound tenderness
• Press deeply into the abdomen and release quickly
• A painful response is a sign of peritoneal
  inflammation

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Special Tests

• Shifting Dullness
• Percuss for areas of dullness
• Have the patient roll to one side
• If the dullness shifts this is a sign of excess
  fluid

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Special Tests

• Psoas Sign
• Have patient flex their hip against resistance
• Obturator Sign
• Rotated leg internally at the hip
• Pain in either case denotes appendicitis

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The Physical Exam

• Neurologic Exam

1. Mental Status
2. Cranial Nerves
3. Motor
4. Reflexes
5. Sensory
6. Special Tests

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Mental Status

• AVPU
• Alert
• Verbal respond to voice?
• Pain respond to pain?
• Unconscious no response

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Cranial Nerves

• 12 Cranial Nerves

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I - Olfactory Nerve

• Not normally tested

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II - Optic Nerve

• Acuity
• Visual Fields
• Pupillary Reactions

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III, IV, VI Oculomotor, Trochlear Abducens
Nerve

• Test eye movements

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V - Trigeminal Nerve

• Three Divisions Test Each For
• Muscle Strength
• Jaw Temple
• Pain Sensation
• Test Corneal Reflex
• Use a cotton wisp
• Normal blinking

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VII Facial Nerve

• Facial asymmetry?
• Test the following movements
• Raising eyebrows
• Smiling
• Frowning
• Showing your teeth
• Puffing your cheeks

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VIII Auditory Nerve

• See hearing test notes

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X Vagus (IX Glossopharyngeal)

• Ask Pt. to Swallow
• Say Ah
• Test Gag Reflex

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XI Accessory

• Have pt. turn their head
• Have pt. shrug their shoulders

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XII - Hypoglossal

• Ask pt. to protrude tongue
• Move tongue from side to side

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Motor Exam

• Check for
• Symmetry
• Atrophy
• Strength
• Tone

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Dermatomes

• Areas of the skin supplied by nerves from
  specific levels of the spinal cord

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Deep Tendon Reflexes

• Biceps C5,C6
• Triceps C6,C7
• Brachioradialis
• C5, C6
• Abdominal T8-12
• Knee L2-4
• Ankle S1, S2

Diminished reflexes can indicate the presence of
a lesion
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Babinski Reflex
Indicator of severe central nervous system damage
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Sensory

• By dermatomes test
• Pain
• Temperature
• Light touch
• Vibration
• Test each side with pts eyes closed

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Graphesthesia Stereognosis

• Draw a letter or number on the patients palm
• The patient should be able to identify