Physical Exam In House P1 PDF

Patient Centered Communication - 3 questions on Final Nonfocusing: ​silence, nonverbal encouragment, neutral utterances Focusing: ​echoing, open-ended requests, summary Symptom - ​phenomenon that is experienced by the individual affected by the disease Sign -​ phenomenon that can be...

Patient Centered Communication - 3 questions on Final Nonfocusing: ​silence, nonverbal encouragment, neutral utterances Focusing: ​echoing, open-ended requests, summary Symptom - ​phenomenon that is experienced by the individual affected by the disease Sign -​ phenomenon that can be detected by someone other than the individual affected by the disease Medical Documentation (1Q) - ​2 on final Full H&P (first office visit, admission note) Focused H&P - SOAP: subjective, objective, assessment, plan - does not mean brief ○ Problem focused (daily medical progress note) ○ Task focused (operative note, labor and delivery note) Intro to Physical Exam (5Q) - ​2 on final General appearance: the rounded facies of Cushing's disease, the prominent jaw and frontal bossing of acromegaly, or the exophthalmos of hyperthyroidism. Note: frail, cachectic (extreme muscle wasting and weight loss), emaciated (abnormally thin due to food deprivation), weak, fatigued, older than stated age There is generalized fat distribution in simple obesity and truncal fat with relatively thin limbs in ​Cushing syndrome​ and ​metabolic syndrome. Underweight: 40 >35kg/m2 - measure waist circumference: >35 inches (88 cm) in women and >40 inches (102 cm) in men = increases diabetes, hypertension, and cardio risk W-H ratio: >.9cm in men and >.85 in women Apple more dangerous than pear Vitals: BP, HR, RR, and temp (add pulse ox and blood ox sat sometimes) HR = radial pulses simultaneously ○ Less than 60 is bradycardia. Greater than 100 is tachycardia. ○ Pulse volume: in hypovolemia the PV is relatively thready and can vary with systolic heart failure ○ Metronomic, irregularly irregular (Atrial fibrillation), regularly irregular (extra beats - when impulses originating from ventricle are interposed at regular junctions on the normal rhythm) RR: normal is 12-20 BP:  ○ Width of ​inflatable​ bladder (40% of upper arm circumference) 12-14 cm average; length (80% of upper arm) ○ Cuff over brachial artery ​2.5 cm above antecubital crease​ -support for light elbow bend ○ Cuff too small - readings too high Too large (read low on small arm and high on large arm) ○ Avoid smoke & coffee= 30 min prior ○ Sit quietly 5 min; arm free of clothing, feet flat on floor, arm at heart level Arm 7-8cm too low (Bp 6cm higher); arm 6-7cm ​too high​ (bp 5cm lower) ○ Inflate to 160, deflate 2-3mm/sec, first ​Korotkoff sound​ - systolic bp (disappears at diastolic bp) Palpate radial pulse while inflating (to above 10mm disappearing pulse); when pulse reappears SBP ○ Bell = low frequency, Diaphragm = high frequency (some function as both with pressure determining function) Temp = normal is 98.6 (27C) - changes 1degree (lowest in morn, highest in evening) - women wider range (AORT) axillary, oral, rectal, tympanic in order of temperature (cold to hot) ○ Fever >100.4 and hypothermia 50yo (2 dosses 2-6months apart) ○ Zoster vaccine live (ZVL, Zostavax): >60yo Psoriasis: symmetric bilateral; raised erythematous patches with scaly plaques Annular with erythematous border = ring worm or tinea infection Nail clubbing suggests pulmonary disease (COPD) or inflammatory bowel disease Splinter hemorrhage and ​Janeway’s lesions.​ These findings should stimulate a work-up for endocarditis. Abdominal striae (pink, red, or purple stretch marks) seen in Cushing’s disease, truncal obesity, moon facies, fat pads or buffalo hump MELANOMA: ○ ABCDE: asymmetry, borders, color, diameter (>6mm), evolving ○ Risk: personal or FHx, >50 common moles, red/light hair, freckles (brown macules), sun tanning booths, severe blistering childhood sunburns ○ Dysplastic nevi (larger than regular moles); at least 50% arise de novo ○ Use of indoor tanning beds, especially before age 35 years, increases risk of melanoma by as much as 75%. BASAL CELL: most common (80%)- ​pearly ○ Sun exposed areas and rarely metastasizes; open sore, red patch, shiny nodule, pink growth, scar like  SQUAMOUS CELL: 16% ○ Metastasize in scalp, lips and ears, ○ smooth but firm order (wart like); open sore, elevated with ​central depression MSK Exam (6Q) - ​(5 on final) Acute= 6 weeks; chronic =12 weeks Inflammation = pain, redness, swelling, warmth ○ Vignette: septic arthritis due to disseminated gonococcal infection Neurologic disease/nerve damage: numbness, tingling, prickling, burning, itching, skin crawling Back pain red flags: saddle anesthesia, bowel/bladder incontinence ○ Fever, chills, unexplained weight lost, cancer history, 50 ○ Persistent despite treatment Approach: inspect, palpate, ROM, special testing Bursa = sac of fluid Inflammation:(B-->H) ○ Bouchard’s node (proximal interphalangeal joint) ○ Heberden’s node (distal interphalangeal joint) Carpal tunnel: ​flexor retinaculum,​ carpal tunnel, median nerve Atrophy ○ Interosseous atrophy (between fingers) ○ Thenar atrophy (by thumb) ○ Hypothenar atrophy Anatomical snuff box: ​extensor pollicis longus and brevis, abductor pollicis longus (radial aa) ○ Can determine scaphoid fracture Crepitus: grating sound or crunching sensation by bone and cartilage friction (can be normal unless accompanied by pain) Ballard Score to assess babies HEENT (6Q) - ​(4 on final) Double vision = diplopia Ear ringing = tinnitus Room spinning = vertigo Nosebleed = ​epistaxis Runny nose = ​rhinorrhea Sore throat = ​pharyngitis Posterior fontanel = closes ​2-3 months after birth;​ anterior fontanel = closes ​1-3 years of age Snellen chart: ○ 1st # is distance from chart ○ 2nd # is distance normal eye can read line ​(20/200 is legally blind) PERRLA = symmetric response to sensory input - ​Pupils are equal, round, and reactive to light and accommodation. Near effort also causes pupillary constriction Extraocular eye movement: 6 EOM ○ Nystagmus ​(rapid involuntary movement) Corneal reflex: can test for ​Strabismus (​eye muscle imbalance) ○ Esotropia (turn in) ○ Exotropia (turn out) ○ Hypertropia (turn up)  My​d​riasis = ​d​ilation; miosis = constriction EAR: otoscope; palpate auricle, tragus, and mastoid process ○ Handle and short process of malleus ○ Incus sometimes seen ○ Tympanic membrane (pars tensa and pars flaccida) ○ Motility - assessed with pneumatic otoscope Rinne and weber tests: ○ Rinne (conduction) ○ Webber (localization) Hearing impairment: ○ Conductive loss: external or middle ear issue; better in loud environment ○ Sensorineural loss: problems in inner ear, cochlear nerve, or central brain connection Hair: ○ Hyperthyroidism: fine hair ○ Hypothyroidism: coarse hair NODE sequence: PPOTSSSPDS ○ Preauricular ○ Posterior auricular ○ Occipital ○ Tonsillar ○ Submandibular ○ Submental ○ Superficial cervical ○ Posterior cervical ○ Deep cervical chain ○ Supraclavicular (enlargement suggests malignancy) Tender = inflammation, hard/fixed = malignancy Cardio (9Q) - position at 30 degree (​8 on final) Bradycardia: ​myxedema (severe hypothyroidism​), heart block, athlete Tachycardia: sinus tach - increased SA node beat (fever, anemia), Atrial/ventricular arrhythmia Carotid: medial to SCM (sternocleidomastoid) ○ Double contour sign of leaky aortic valve ○ Rush sound (bruit): sign of plaque Peripheral at foot: dorsalis pedis and posterior tibialis Jugular venous pulses (RH function) ○ 1. Atrial contraction ○ 2. Atrial filling ○ Narrow tricuspid means larger A waves (stenosis); regurgitation means larger filling ○ Central venous pressure: Measure vertical height: mid RA = 0, sternal angle = 5cm; normal 15cm Compress abdomen = abnormal rise in CVP and 4cm fall after compression Decreased preload (hypokinetic):​ decreased preload, decreased contractility, aortic stenosis Increased LV preload​: apex inferolaterally displaced and enlarged (LV dilated); due to volumed loaded LV, LV failure Diaphoresis = cold sweat Pulm (4Q)- ​6 on final 5A: Ask, advise, assess, assist, arrange  Tachypnea: fast breathing Stridor: harsh breathing sound Normal O2 stat = >95% on room air Barrel chest;​ pectus excavatum ​(funnel chest) Chest expansion: butterfly fingers over lower ribs and ask to inhale Fremitus: ulnar aspect of hands and have patient say 99 Normal lung = ​resonant percussion; only one with present breath sounds; normal fremitus ○ Consolidated (liquid filled​)= ​dull; ​PNA (pneumonia), severe inflammation, alveoli filled with pus/fluid; ​increased fremitus ○ Pulmonary edema ​= ​dull​; congestive heart failure,edema fluid; ​increased fremitus ○ Pleural effusion ​= ​dull​; alveoli clear, but fluid fills potential space between parietal and visceral pleura;​ decreased fremitus ○ Pneumothorax​ = ​hyper-resonant​; air fills space between parietal and visceral pleura; decreased fremitus Fremitus = transmission of voice vibrations to chest wall Pitches of breath sounds from highest to lowest: ○ Tracheal: neck ○ Bronchial: rarely heard ○ Bronchovesicular: rarely heard, maybe near hila ○ Vesicular: most of the chest Sounds: ○ Crackles/rales: high pitched discontinuous popping from alveoli popping ○ Wheeze: high pitched, continuous musical from air moving through narrow airways ○ Rhonchi: low pitched continuous snoring from mucus sloshing in large airway Abdominal (5Q) - (​5 on final) ​REMEMBER TO AUSCULTATE before percussion and palpation Epigastric, umbilical, hypogastric/suprapubic Visceral: hollow organ affected ○ Stimulated by distension, inflammation, ischemia ○ Dull, poorly localized, moderate achy pain ○ Periumbilical pain in early appendicitis Parietal: peritoneum affected ○ Aggravated by movement or coughing ○ Acute, sharp, severe, localized ○ RLQ pain and rebound tenderness in late appendicitis Referred pain:distant to original pathology but same spinal innervations ○ Usually localized; develops as initial pain intensifies and radiates ○ Right scapular pain in cholecystitis; epigastric pain from MI Terms: ○ Hematemesis: vomiting blood ○ Hemoptysis: coughing up blood ○ Anorexia: loss of appetite ○ Dysphagia: difficult swallowing ○ Odynophagia: painful swallowing ○ Dyspepsia: indigestion or discomfort ○ Melena: black stool ○ Hematochezia: red blood per rectum Colon cancer screening:  ○ Annual fecal occult blood test or fecal immunochemical test (FIT) ○ Flexible sigmoidoscopy every 5 years ○ Colonoscopy every 10 years Examination: ○ Expose from xiphoid process to pubic symphysis, flex knees, relax arms Clinical correlates: ○ Ecchymoses​: skin discoloration usually due to bruising ○ Ascites: ​swelling of abdomen due to fluid ○ Note: dilated abdominal wall veins ○ Spider angioma : spiderweb looking red spots ○ Palmar erythema: red palms due to liver disease ○ Asterixis​: motor impairment due to liver failure (flapping wrists) Normal sounds: clicks and gurgles ○ Borborygmi: stomach growling or rumbling (listen for up to 2 mins) ○ Decreased/absent = abnormal ○ Bruits = vascular occlusion disease Percussion sounds: ○ Tympanitic (drum-like): over air filled structures ○ Dull: over solid structure (liver) or fluid (ascites) Rigidity: an involuntary muscle tightening/spasm in response to underlying inflammation (red flag for peritoneal inflammation) 5% adults have palpable spleen tip Kidneys: not usually palpable ○ Assess for CVA tenderness (costovertebral angle) ○ Positive finding in patients with acute pyelonephritis (inflammation due to bacterial infection) Liver span: ○ 4- 8cm midsternal ○ 6-12 cm right midclavicular BLS/EM/RAPID/SBAR (5Q) - None on final CAB: Compressions, Airway, and Breaths ○ Star compressions w/in 10 sec - lower half of sternum ○ 100 to 120/min ○ 2 inches (5cm) for adults (no more than 2.4 inches/6cm) ○ Also 2inches (5cm) for children or ⅓ depth of chest for children ○ Infants: ⅓ depth of chest, 1.5 inches (4cm) ○ Limit interruptions to