Download Hello, My name is seth I`m a physician assistant student

Hello, My name is Mark I’m a physician assistant student. I’m going to perform a
physical exam on you today.
I’ll just wash the old hands here.
Gen:
Pt is a twenty- old --- presenting for physical examination. Pt appears healthy, well
nourished with no apparent signs of distress.
Checking vitals for HR, RR, BP and temp. All within normal ranges.
Looking now at the skin. Skin is warm, moist with normal turgor. No abnormal color,
lesions or scars. Nails show no sign of clubbing pitting or cyanosis. Good capillary refill.
Hair has normal texture, is well distributed and without infestations. Head is NC/AT no
apparent lesions on the scalp. Face is symmetrical, without swelling or tics. Eyes are
symmetrical, without ptosis or exopthalmous or palpebral edema. Eyebrows and lashes
are well distributed and without scales
I’m going to test you vision now. Please cover your left eye and read the smallest line of
print that you can. Thank you. Now please cover your right eye and read the smallest line
of print that you can. Good. Pt has 20/20 visual acuity in both eyes and cranial N 2 is
intact.
Now please keep your head still, facing forward and follow my finger with your eyes
only. I’m testing extra ocular muscles – no strabismus or nystagmus noted on lateral or
upward gaze, no lid lag and normal convergence noted. Please look at my finger. Now
look over this shoulder. Look at my finger….and over my shoulder. Now point up when
you see my hands come in to view. I’m checking visual fields by confrontation (Getting
fundoscope) I’m gonna shine a little light in your eyes now. I’m testing now for direct
response. Good. And consensual response. Thank you. And now tangential inspection of
the cornea. All clear. No opacities. Pupils equally round and reactive to light and
accommodation. Direct and consensual papillary responses intact and cranial nerves 3,4
and 6 intact.
I’m going to perform a fundoscopic examination now. I’ll dim the lights and I’m going to
place my hand on your shoulder and shine the light in your eye ok? Please look straight
ahead. Light reflex good. Arteries and veins noted and normal. No AV nicking,
papilledema, exudates, optic disc is clear and physiologic cup has sharp margins.
I’m going to examine your ears now. The ears have bilateral symmetry no apparent
lesions, tenderness or doughiness in the pinna tragus or mastoid process. No discharge.
Please repeat what I whisper to you, “99 2X” If there was any deficit I would now
perform the Webber Rinne tests. Cranial nerve 8 intact. I’m going to look in your ear
now. No abnormal erythema, edema or cerumen impaction. No foreign bodies. TM
appears clear and grey, no retraction and the handle of the malleus is visible as well as a
good cone of light bilaterally.
I’m now inspecting the patient’s nose. No asymmetry discharge or erythema noted.
Breath in – 2x. Nostril patent bilaterally. What do you smell? Good CN 1 is intact. Tilt
your head back please. Terbinates non boggy septum midline, nasal mucosa – pink and
non injected. No exudates, polyps or lesions. Thank you.
Lips are moist pink and well perfused. Dentition intact no gingivitis noted, buccal
mucosa pink – without lesions. Stick out your tongue and say “aaahh”. No fasiculations,
deviation or asymmetry. Soft palate rise and falls normally. Now I’m testing the gag
reflex. Gag reflex is intact. Tongue is midline and Cranial Nerves 9 and 10 intact.
Oropharynx pink and non-erythematous. No post nasal-drip No exudates on throat or
tonsils.
And I’m now palpating the thyroid and trachea. No nodules, enlargement or tenderness
noted. Trachea is midline swallow. Good. Cranial nerves 9 and 10 intact.
Now I’m palpating the frontal and maxillary sinuses. Tell me if there’s any pain. …look
up please- Conjunctiva are pink and moist, sclera are non injected and non icterus and the
lacrimal ducts appear patent and nontender, without excessive tearing or drying.
I’m checking for lymph adenopathy. I’m palpating the pre-auricular, post-auricular,
occipital, tonsillar, submandibular, submental, anterior cervical chain, posterior cervical
and deep cervical, supra clavicular, infra clavicular lymph nodes. No LAD noted. Please
raise your shoulders against my hands. CN 11 intact.
Clench your jaw (3x) cranial nerve 5 intact. Smile. Frown. Puff out your cheeks. Stick
out your tongue. Now push your tongue against my hand. Again. Turn your head against
my hand. Again. Raise your shoulders against my hand. Good. Close your eyes and don’t
let me open them. Good. Cranial Nerves 7, 9, 10 and 12 are intact.
Listening to the carotid arteries with bell for Bruits. None noted bilaterally. Now
palpating. Carotid pulse is 2+ and tapping with no thrills.
LUNGS
Posterior chest shows no signs of trauma, lesions or respiratory distress. . Deep breath in.
Excursion is adequate bilaterally. I’m going to tap on your back tell me if there’s any
pain. (CVA test)
Please cross your arms across your chest. Each time I place my hand on your back please
say 99 and stop me if there is any pain or discomfort. 4x. No tenderness to palpation and
fremitus is normal. I’m now persussing 7 locations in the posterior lung fields. Lung
sounds are resonant throughout. Now each time I place my stethoscope on your back
please take a normal breath with your mouth open. I’m listening to 7 locations bilaterally.
Good Lung sounds are vesicular with no rales wheezes, rhonchi or stridor noted
ANTERIOR CHEST
When I place my hands say 99 and stop me if there’s any pain. 99 (3x). Percussing 6
locations bilaterally. Lung fields and apices are resonant. Same again with the
stethoscope. Open mouth. Normal breath. 6 locations. Still no Adventitious breath
sounds. If there were would now perform egophany, bronchopany and whispered
pectoriloquy.
At this point I would perform a breast examination.
Please lay back. (JVD? Maybe – with pen light…) PMI visible anda tapping at the 5th
intercostal space at the MCL. I’m now palpating for heaves, thrills or lifts at the aortic
region in the 2nd right intercostal space, the pulmonic region in the 2nd left intercostal
space. The tricuspid region in the 3rd, 4th and 5th intercostal spaces at the left sternal
border and the mitral region at the 5th intercostal space at the MCL and the PMI is
palpable, about 2 cm and there are no thrills or heaves noted. Auscultating with he
diaphragm in the 4 regions. Now with the bell. Regular rate and rhythm. Normal s1 and
s2. No s3 or s4, rubs gallops or murmurs noted.
ABDOMEN
Lift up your knees. No venous abnormalities, lesions or bulging flanks. Aortic pulsations
noted with tangential lighting. Listening to bowel sounds in all four quadrants. Normal
throughout. Listening for bruits at the aorta, renal arteries, iliac and femoral arteries. No
bruits noted. I’m now percussing all 4 quadrants. Normal tympany heard and at the
gastric bubble. Percussing the liver span which is 8 cm at the MCL. Deep breath. Splenic
sign negative. I’m now going to palpate lightly let me know if there’s any discomfort.
Deeper this time. Take a deep breath. I’m now palpating the lover border. It’s beautiful..
Turn on your right side. Take a deep breath. No splenomegaly noted. Lay back. No Lad
noted at the femoral or inguinal lymph nodes.
At this point I would perform a pelvic and rectal exam.
And now I’m inspecting for cyanosis, erythema and hair loss particularly in the pre tibial
region. And I’m checking the extremities for edema and I see none. I’m inspecting the
finger and toenail beds for capillary refill. Less than 2 seconds in each. And now I’m
palpating the radial arteries. The brachial arteries. Both 2+. And now the posterior tibialis
and dorsalis pedis. All are 2 + bilaterally tapping with good upstroke.
Now I’ll palpate the axillary lymph nodes. The Anterior, posterior, central and lateral. No
lad noted.
MUSCULO SKELETAL
I’m inspecting the joints bilaterally for purposes of comparison for erythema, swelling or
derformities. None noted. Now I’m palpating for warmth tenderness or crepitus at the
TMJ, the shoulders the elbows the wrists, the carpals, metacarpals and phelanges. The
hips the knees the ankles, tarsals metatarsals and phelanges. No erythema, crepitus or
calor noted.
ROM
Please follow my movements to assess for range of motion. Shoulder- Flexion –
extension – abduction – adduction – external rotation and internal rotation. All intact.
Elbows. Flexion and extension. Flex your wrists – extend. Ulnar deviation – radial
deviation. Fingers – flex extend abduct adduct. Thumb opposition, thumb flexion. Upper
extremities full range of motion.
NEURO
What is your name? Where are you? What day is it? The patient is alert and oriented time
three (person, place and time). What day were you born? What did you have for dinner
last night? The patient’s remote and recent memories are intact. Please spell “WORLD”
backwards. Attention and concentration are intact.
(Patient sitting)- Now I am checking the sensory function of the 3 trigeminal branches of
CN 5 by asking “sharp or dull” in the 3 regions bilaterally. Good. Now I’m checking the
sensory function in all dermatomes by asking “sharp or dull.”
(Patient sitting with feet hanging)- Please drag your left heel from your right knee to your
right ankle. Now touch your nose then touch my finger, repeat. Now close your eyes and
touch my finger. Cerebellar function intact. Now I’m going to assess rapid-alternating
movements. Good. Now I’m assessing the DTRs of the triceps, biceps, brachioradialis,
patellar and Achilles bilaterally. Reflexes are symmetrical and 2+. Now I’m testing the
Babinski reflex. Good. Now I’m going to check the muscle strength using resistance
starting with the lower legs working my way up to the upper extremities bilaterally. I’m
going to stabilize the joint above when applicable. Strength is symmetrical and a 5 out of
5.
(Patient standing)- Please walk normally to this line. Gait, posture and arm swing are all
normal. Now walk heel to toe back. Now walk back to this line on your toes. And now
return walking on your heels. Good. Please stand tall with your feet together facing me.
Now close your eyes. Now open your eyes and put your arms in front of you like this.
Close your eyes. Romberg test and pronator drift are negative.