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Chapter 11 Techniques of Physical Examination Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Objectives Describe prehospital physical examination techniques Describe examination equipment Describe the general approach to the physical examination Outline the steps of the comprehensive physical examination Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Objectives Detail the components of the mental status examination Identify abnormal findings in the mental status examination Outline steps in the general patient survey Distinguish between normal and abnormal findings in the general survey Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Objectives Describe examination techniques for specific body regions Identify normal and abnormal findings in the body region examination Describe examination techniques specific to children and older adults Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Scenario You respond to a nursing home for an “unresponsive person.” Your patient is a 92year-old woman who is recuperating from a fractured hip. She takes cardiac and diabetic medications. According to the nurse assistant, she is normally alert, but is now only responsive to pain. She has a bruise on her forehead. The story of this evening’s events seems inconsistent. Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Discussion What priorities will you have in this patient’s physical assessment? Assuming her airway and breathing are managed, what examination techniques will you use to assess this unconscious woman? What equipment will you need to perform your physical exam? What areas will be of particular concern as you complete your comprehensive physical examination? Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Examination Techniques Inspection Palpation Percussion Auscultation Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Inspection Visual assessment of the patient and surroundings Findings that may be significant: Patient hygiene Clothing Eye gaze Body language Body position Skin color Odor Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Inspection If the emergency response was to the patient's home, make a visual inspection for Cleanliness Prescription medicines Illegal drug paraphernalia Weapons Signs of alcohol use Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Palpation A technique in which the hands and fingers are used to gather information by touch Palmar surface of fingers and finger pads are used to palpate for Texture Masses Fluid Crepitus And assess skin temperature Palpation may be either superficial or deep Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Deep Bimanual Palpation Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Percussion Used to evaluate for presence of air or fluid in body tissues Sound waves heard as percussion tones (resonance) Procedure Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Auscultation Best performed in a quiet environment Requires a stethoscope Body sounds produced by movement of fluids or gases in patient's organs or tissues Note: Intensity Pitch Duration Quality Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Stethoscope Used to evaluate sounds created by cardiovascular, respiratory, and gastrointestinal systems Stethoscopes Acoustic Magnetic Electronic Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Stethoscope Position stethoscope between index and middle fingers Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Ophthalmoscope Used to inspect eye structures: Retina Choroid Optic nerve disc Macula Retinal vessels Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Otoscope Used to examine deep structures of the external and middle ear Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Blood Pressure Cuff Sphygmomanometer Measures systolic and diastolic blood pressure Manual or electronic Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Comprehensive Physical Examination Mental status Chest General survey Abdomen Vital signs Posterior body Skin Extremities Head, eyes, ears, nose, and throat (HEENT) Neurological exam Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Mental Status First step in patient care encounter Patient’s appearance and behavior Level of consciousness • A healthy patient is expected to be alert, responsive to touch, verbal instruction, and painful stimuli Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Mental Status Appearance and behavior Posture, gait, and motor activity Dress, grooming, personal hygiene Breath or body odors Facial expression Mood and affect Speech and language Thought and perceptions Memory and attention Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. General Survey Signs of distress Cardiorespiratory insufficiency • Labored breathing • Wheezing • Cough Pain • Wincing • Sweating • Protectiveness of a painful body part or area Anxiety • • • • Restlessness Anxious expression Fidgety movement Cold, moist palms Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. General Survey Apparent state of health Skin color and obvious lesions Height and build Sexual development Weight Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Skin Color Varies from person to person Varies based on ethnicity May range in tone from pink or ivory to deep brown, yellow, or olive Observe for skin not exposed to sun (e.g., palms) Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Skin Lesions Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Height and Build Descriptions include: Average, tall, short, lanky, muscular May also be affected by age and lifestyle Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Sexual Development Determine if age appropriate Observe for normal changes associated with age Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Weight Observe general appearance Obese to emaciated Recent changes may be key finding Recent weight loss or gain Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Vital Signs Pulse Blood pressure Respirations Skin Pupils Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Pulse Rate Rhythm Quality Consider ECG monitoring Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Blood Pressure Locations Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Respirations Adult rate 12-24 breaths per minute Observe Feel for chest movement Auscultate Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Skin Texture Turgor Hair Fingernails and toenails Abnormal findings Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Temperature Measurement Oral temperature Hold thermometer firmly under tongue Tell child to “kiss” Caution to avoid biting Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Axillary Temperature Hold arm down firmly Should be approximately 1° F less than core temp Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Tympanic Temperature Accuracy questionable Pull ear back Insert gently Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Rectal Temperature Risk of perforation Avoid in uncooperative, or immuno-suppressed patient Stabilize thermometer Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Eyes—Visual Acuity Have patient Read printed material Count fingers at a distance Demonstrate ability to tell light from dark Use eye chart • (e.g., Snellen chart) Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Eyes—Pupils Findings may indicate neurological issues Examine response to light (PERRL) Pupils are equal, round, and react to light Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Anatomical Regions Skin Texture Turgor Hair Fingernails and toenails Head, ears, eyes, nose, throat Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Head and Face Inspect skull for shape and symmetry Palpate for swelling, tenderness, lesions, indentations Inspect face for symmetry, expression, edema, involuntary movements Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Eyes Determine if contacts are present Determine that both eyes can see Assess visual acuity Inspect orbital area for edema Examine eyes for drainage or redness Determine structural integrity Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Eyes—Visual Fields Six cardinal fields of gaze Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Visual Fields Ask the patient to look at his or her nose Test peripheral vision by extending your arms with elbows at right angles and wiggle both index fingers simultaneously Observe eyes for normal position and alignment Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Ophthalmoscopic Examination Used to evaluate: Cornea Foreign bodies Lacerations Abrasions Infection Anterior chamber Hyphema Hypopyon Fundus Optic nerve Retina Vitreous Eyelid Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Cornea and Sclera Examine conjunctiva and sclera Palpate lower orbital rim Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Ophthalmoscopic Examination Inspect: Size, color, and clarity of the disc Integrity of vessels Assess for retinal lesions and appearance of the macula Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Ophthalmoscopic Examination Normal findings Clear, yellow optic nerve disc Reddish pink (European-American) or darkened retina (African-American) Light red arteries Dark red veins 3:2 vein-to-artery ratio Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Otoscopic Examination Otoscope used to: Evaluate inner ear for discharge and foreign bodies Assess eardrum Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Otoscopic Examination Select speculum Turn on otoscope Insert speculum into ear canal, slightly down and forward Look for foreign bodies, lesions, discharge Inspect tympanic membrane Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Otoscopic Examination Normal findings Cerumen is dry (tan or light yellow) or moist (dark yellow or brown) Ear canal • Not inflamed Tympanic membrane • Translucent or pearly gray Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Nose Inspect Palpate Discharge from the nose CSF Epistaxis Mucous discharge Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Mouth and Pharynx Lips Gums Mouth and tongue Pharynx Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Neck Inspect Use spinal precautions if trauma is suspected Palpate trachea Midline position normal Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Neck Palpate Place both thumbs along sides of distal trachea Systematically move toward head Do not apply bilateral pressure to carotid arteries Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Head and Cervical Spine Temporomandibular joint (TMJ) Inspect and palpate cervical spine Range of motion Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Chest Ribs Protect thoracic organs Support respiratory movements of diaphragm and intercostal muscles Anatomical landmarks for examination Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Topographical Landmarks Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Thoracic Landmarks—Anterior Chest Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Thoracic Landmarks—Posterior Chest Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Inspection General appearance of chest Chest wall configuration Inspect for symmetry Chest wall should be symmetrical Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Chest Wall Abnormalities Barrel chest Funnel chest (pectus excavatum) Pigeon chest (pectus carinatum) Thoracic kyphosis Scoliosis Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Chest—Palpation Tracheal position Respiratory excursion Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Percussion and Auscultation of Chest Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Respiratory Effort Assess: Respiratory rate, rhythm, symmetry, and quality Patient position Accessory muscles Retractions (intercostal, supraclavicular, or both) Nasal flaring Pausing to take a breath Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Respiratory Patterns Eupnea Tachypnea Bradypnea Hyperpnea Hyperventilation Dyspnea Orthopnea Paroxysmal nocturnal dyspnea Apnea Cheyne-Stokes respiration Kussmaul breathing Biot’s respirations Central neurogenic hyperventilation Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Auscultation Patient in sitting position (if possible) Instruct to breathe deeply and slowly through open mouth Use diaphragm of stethoscope Evaluate anterior and posterior lung fields Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Normal Breath Sounds Classified as: Vesicular Bronchovesicular Bronchial Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Vesicular Breath Sounds Most of lung fields Lungs considered "clear" make normal vesicular breath sounds Harsh vesicular breath sounds Diminished vesicular breath sounds Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Bronchovesicular Breath Sounds Major bronchi and upper right posterior lung field Louder and harsher than vesicular breath sounds Medium pitch Equal inspiration and expiration phases Heard throughout respiration Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Bronchial Breath Sounds Only over trachea Highest in pitch Coarse, harsh, loud sounds Short inspiratory phase and long expiration Bronchial sound anywhere but over trachea is abnormal Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Abnormal Breath Sounds Absent Diminished Incorrectly located bronchial sounds Adventitious Discontinuous Continuous Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Breath Sounds Fig. 11-26 Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Discontinuous Breath Sounds Crackles Formerly called rales High-pitched discontinuous sounds Usually at end of inspiration Disease of small airways or alveoli Coarse crackles: wet, low-pitched sounds Fine crackles: dry, high-pitched sounds Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Continuous Breath Sounds Wheezes Rhonchi Stridor Pleural friction rub Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Heart Assessment includes: Palpation Auscultation Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Pulse Assess: Rate Rhythm Intensity Palpate pulses simultaneously on both sides of body Except carotid Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Pulse Auscultate for: Frequency (pitch) Intensity (loudness) Duration Timing in cardiac cycle Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Auscultating Heart Sounds Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Heart Sounds S1 Instruct patient to breathe normally and then hold breath in expiration S2 Instruct patient to breathe normally again and then hold breath in inspiration Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Pericardial Friction Rub Inflammation of pericardial sac Scratching, grating, or squeaking quality Louder during inspiration Differs from pleural friction rubs by continued presence during breath holding Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Heart Murmurs Prolonged extra sounds Caused by disruption in flow of blood through heart Most caused by valvular defects Some serious Others benign • Have no apparent cause Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Bruit Abnormal sound or murmur Heard while auscultating carotid artery, organ or gland May be local obstruction Often low pitched Hard to hear Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Thrills Vibrations or tremors May indicate blood flow obstruction May palpate over aneurysm or on precordium Serious or benign Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Abdomen Two imaginary lines separate abdominal region into four quadrants Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Abdomen—Inspection Skin Umbilicus Contour Abdominal movement Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Abdomen Auscultation Bowel sounds Bruits Percussion and palpation Detect: • Fluid • Air • Solid masses Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Percussion Evaluate four quadrants of abdomen: Tympany • Air in stomach and intestines Dullness • Solid abdominal organs and solid masses Proceed from tympany to dullness Change in sound easier to detect Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Palpation of the Liver Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Palpation of the Spleen Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Female Genitalia If possible, use same-gender paramedics to examine Chaperone if possible Inspect external genitalia for: Swelling Discoloration or redness Bleeding Trauma Lesions Discharge Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Female Genitalia Normal vaginal discharge Clear or cloudy with little or no odor Yellow-green discharge Frothy, gray-green discharge with foul odor White, curdlike discharge with no odor Gray discharge with fishy, foul odor Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Male Genitalia Inspect for bleeding or trauma Penis Urethral opening Shaft nontender and flaccid Priapism Free of blood and discharge Scrotum Nontender and slightly asymmetrical Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Male Genitalia Anus Exam indicated if: • Rectal bleeding • Trauma to area Most patients find side-lying position most comfortable Protect patient’s privacy Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Male Genitalia Inspect sacrococcygeal and perineal areas for: Lumps Ulcers Inflammation Rashes Excoriations Inflamed external hemorrhoids common Adults and pregnant women Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Musculoskeletal System Assess function and structure Patient position Evaluate head, neck, shoulders, and upper extremities with patient in a sitting position Evaluate chest, back, and ilium with patient standing Evaluate hips, knees, ankles, feet with patient supine Observe general appearance, body proportions, and ease of movement Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. General Principles Examine normal tissues before those injured, inflamed, or otherwise affected Inspect and palpate each body part Then test range of motion and muscle strength Note differences between right and left Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Extremities Evaluate: Skin and tissue over muscles, cartilage, bones Joints for injury, discoloration, swelling, masses Circulatory status • Skin color and temperature • Distal pulses Structural integrity of bones, joints, and tissues Muscle tone Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Abnormal Findings Signs of inflammation Swelling Tenderness Increased heat Redness of overlying skin Decreased function Asymmetry Crepitus Deformities Decreased muscle strength Atrophy Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Joints Bones move freely over one another Move each joint through full range of motion No clicks, crepitation, or pain Normal if no pain, deformity, limitation, or instability Note: Limited range of motion Unusually increased joint mobility Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Hands and Wrists Inspect for swelling, redness, deformity, nodules, muscular atrophy Palpate joint Note swelling, tenderness, deformity Range of motion Test muscle strength by hand grip Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Elbows Inspection Palpation Examine in flexed and extended position Note deformity, swelling, nodules Lateral and medial epicondyles of humerus Groove on sides of olecranon process Range of motion Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Shoulders and Related Structures Inspect shoulders, shoulder girdle, scapulae, and related posterior muscles Symmetry of size and shape Note swelling, deformity, muscular atrophy Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Shoulders and Related Structures Palpate for tenderness in: Sternoclavicular joint Acromioclavicular joint Subacromial area Biceps groove Note any tenderness or swelling Range of motion Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Shoulders and Related Structures Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Ankles and Feet Skin integrity Nodules Contour Swelling Position Calluses Deformities Corns Size Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Ankles and Feet Palpate: Anterior aspects of each ankle joint Achilles tendon Metatarsophalangeal joints Note tenderness, swelling, deformity Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Ankles and Feet Range of motion Dorsiflexion Plantar flexion Inversion Eversion Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Pelvis Pelvic structural integrity Hands on anterior iliac crests • Press down and out Heel of hand on symphysis pubis • Press down Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Hips Inspect for symmetry Palpate: Instability, tenderness, and crepitus Range of motion (supine patient) Raises knee to chest, other leg straight Note flexion at hip and knee Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Knees Inspection Palpation Patella smooth, firm, nontender, midline Alignment, swelling, and deformity Note atrophy of quadriceps Note thickening, swelling, tenderness Range of motion Bend, straighten each knee without pain Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Peripheral Vascular System Arteries, veins, lymphatic system and lymph nodes, fluids exchanged in capillary bed Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Arms Inspect fingertips to shoulders, noting: Size and symmetry Swelling Venous pattern Color of skin and nail beds Skin texture Palpate: Radial pulses bilaterally Epitrochlear node • If palpable, note its size and consistency Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Legs Patient supine and appropriately draped Inspect from groin and buttocks to feet: Size and symmetry Swelling Venous pattern and venous enlargement Pigmentation Rashes, scars, ulcers Color and texture of the skin Presence or absence of hair growth Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Legs Palpate superficial inguinal nodes Palpate pulses: Swelling and tenderness Femoral Popliteal Dorsalis pedis Posterior tibial Temperature of feet and legs Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Legs Check for pitting edema: Press firmly but gently with the thumb for at least 5 seconds • Over dorsum of foot • Behind medial malleolus • Over shins Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Abnormal Findings Swollen or asymmetrical extremities Pale or cyanotic skin Weak or diminished pulses Skin cold to the touch Absence of hair growth Pitting edema Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Spine Inspection Cervical, thoracic, and lumbar curves • Lordosis (swayback) • Kyphosis (hunchback) • Scoliosis (razorback) Height differences of shoulders Height differences of iliac crest Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Cervical Spine Inspection Should be in a midline position Look for deformities and abnormal posture Palpation If patient is alert and denies neck pain, palpate posterior aspect of neck for point tenderness and swelling Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Cervical Spine Range of motion If no suspected injury: • Bend head forward, chin to chest (flexion) • Bend head backward (hyperextension) • Move head side-to-side (lateral bending) Should be no pain or discomfort Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Thoracic and Lumbar Spine Inspect for injury, swelling, discoloration Palpate from first thoracic vertebra Move downward to sacrum Range of motion Bend forward at waist Bend backward at waist Bend to each side Rotate upper trunk in a circular motion Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Nervous System Detail of neurological examination varies Depends on patient’s complaint • Peripheral nervous system vs. CNS problems Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Neurological Examination Mental status and speech Cranial nerves Motor system Sensory system Reflexes Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Mental Status and Speech Oriented to person, place, and time Organizes thoughts and converses freely If no hearing or speech impediments Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Mental Status and Speech Abnormal findings Unconsciousness Confusion Slurred speech Aphasia Dysphonia Dysarthria Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Cranial Nerve Assessment Cranial nerve I Cranial nerve II Olfactory: Test sense of smell with spirits of ammonia Optic: Visual acuity Cranial nerve II and III Optic and oculomotor • Size and shape of pupils • Pupil response to light Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Cranial Nerve Assessment Cranial nerves III, IV, VI Oculomotor, trochlear, abducens • Extraocular movements • Six cardinal directions of gaze Cranial nerve V Trigeminal • Ask patient to clench teeth while palpating temporal and masseter muscles • Test sensation by touching forehead, cheeks, jaw on each side Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Cranial Nerve Assessment Cranial nerve VII Facial • Inspect face: note symmetry, tics, abnormal movements • Raise eyebrows, frown, show both upper and lower teeth, smile, puff out cheeks • Close eyes tightly so they cannot be opened, gently attempt to raise eyelids • Observe for weakness or asymmetry Cranial nerve VIII Acoustic: Assess hearing acuity Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Cranial Nerve Assessment Cranial nerves IX and X Glossopharyngeal and vagus • Ability to swallow with ease; to produce saliva; produce normal voice sounds • Patient holds breath: assess for normal slowing of heart rate • Testing for gag reflex will test cranial nerves Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Cranial Nerve Assessment Cranial nerve XI Spinal Accessory • Raise and lower shoulders, turn head Cranial nerve XII Hypoglossal • Stick out tongue and move it in several directions Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Motor System Observe patient during movement and at rest Abnormal involuntary movements evaluated for: Quality Rate Rhythm Amplitude Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Motor System Other body movement assessments: Posture Level of activity Fatigue Emotion Muscle strength Bilaterally symmetrical Resistance to opposition Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Muscle Strength Patient to move against resistance: No muscular contraction detected A barely detectable flicker or trace of contraction Active movement of body part with gravity eliminated Active movement against gravity Active movement against gravity and some resistance Active movement against full resistance • This is normal muscle tone Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Upper Extremity Evaluation Patient to extend elbow and pull it toward the chest against resistance Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Lower Extremity Evaluation Patient pushes soles of feet against examiner’s palms Patient pulls toes toward head against resistance Should be easily performed by patient without fatigue Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Muscle Strength Other methods can be used to evaluate muscle strength, including tests for: Flexion Extension Abduction Upper and lower extremities Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Coordination Point-to-point movements Gait Stance Romberg test Pronator drift test Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Romberg Test Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Pronator Drift Test Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Sensory System Conduct sensations of: Pain Temperature Position Vibration Touch A healthy patient is responsive to these stimuli Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Sensory System Patient’s response to pain and light touch Response considered in relation to dermatomes Perform light touch on hands and feet If patient cannot feel or is unconscious, gently prick extremities with sharp object that will not penetrate skin Head to toe Compare symmetrical areas Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Approaching the Pediatric Patient Remain calm, confident Avoid separating child from parent Establish rapport with parents and child Be honest with child and parent Have one paramedic stay with child Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Approaching the Pediatric Patient Observe child before physical examination Begin assessment without touching patient Note: Skin color Level of consciousness Respiratory rate Assess behavior Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Approaching the Pediatric Patient Note area of body that appears painful Avoid painful area until end of examination Warn child before you touch painful area(s) Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. General Appearance Assess from a distance: Level of consciousness Spontaneous movement Respiratory effort Skin color Body position Seriously ill or injured child does not hide or disguise condition Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Birth to 6 Months Maintain body temperature Poor head control normal under 3 months of age Infants are abdominal breathers Stomach protrudes and chest wall retracts during inspiration Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Birth to 6 Months Assess anterior fontanel: Present up to 18 months Bulges during crying Firm if child is supine • If sunken, may be dehydration • Bulging fontanel may mean increased intracranial pressure Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. 7 Months to 3 Years Usually cooperative Minimal speech, unreliable history May have separation anxiety If possible, have parent hold child for exam May see illness or injury as punishment Approach slowly and speak in reassuring tones Use simple and direct questions Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. 4 to 10 Years May be cooperative May provide limited history of event May have separation anxiety and view illness or injury as punishment Approach slowly Speak in quiet, reassuring tones Allow child to "help" Reluctant to show "private parts“ Advise of any expected pain or discomfort Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Adolescents (11 to 18 years) Generally calm, mature, helpful Concerned about modesty, disfigurement, pain, disability, and death Reassure when appropriate Respect patient's need for privacy If possible, interview privately Consider alcohol, drug use, pregnancy Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Communicating with the Older Adult Allow time for effective communication Stay close to patient during interview Repetition of questions may be needed Do not patronize or offend patient Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Patient History Multiple health problems Difficult to isolate injury or illness Decreased sensory function may disguise signs and symptoms Watch for illness from medication use or misuse Consider relationship between drug interactions, disease, and aging process Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Patient History Functional ability and daily activities Walking Getting out of bed Dressing Driving a car Using public transportation Preparing meals Taking medications Sleeping habits Bathroom habits Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Physical Examination Try to ensure patient comfort Offer clear explanations Answer questions Be alert to chronic pain If hospital transport necessary Attempt to calm patient Reassure patient he or she will be cared for in hospital Record examination findings Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Conclusion The paramedic must have a wide range of knowledge and skills to perform a comprehensive physical examination and to make effective clinical patient care decisions. Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. Questions? Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
