Physical Assessment: Final Study Guide PDF

Physical Assessment: Final Study Guide Cardiovascular PMH-Cardiac illness or dz, surgery, family hx heat dz, diabetes, and lung/kidney/liver dz Cardiac Risk Factors- High BP, high cholesterol, diabetes, obesity, cigarettes, sedentary lifestyle, age (M>45, F>55), stress, diet and exercise, alcohol/to...

Physical Assessment: Final Study Guide Cardiovascular PMH-Cardiac illness or dz, surgery, family hx heat dz, diabetes, and lung/kidney/liver dz Cardiac Risk Factors- High BP, high cholesterol, diabetes, obesity, cigarettes, sedentary lifestyle, age (M>45, F>55), stress, diet and exercise, alcohol/tobacco and drug use, meds including OTC and herbs, ability to perform activities of daily living ROS-Chest pain, dyspnea, palpitations, orthopnea, cough, weakness or fatigue, recent change in weight, edema, cyanosis or pallor, dizziness/Syncope, nocturia Heart as a Pump Systole – ventricles contract Diastole – ventricles relax SI – closing of AV valves S2 – closing of semilunar valves Right ventricle pumps blood into the pulmonary arteries Blood flows from right atrium —> right ventricle —> —> pulmonic valve is open tricuspid valve is open Left ventricle pumps blood into the aorta —> aortic valve Blood flows from left atrium —> left ventricle —> mitral is open valve is open Systolic BP Diastolic BP Pressure generated by the left ventricle during systole, Pressure generated by blood remaining in the arterial when the LV ejects blood into the aorta and the arterial tree during diastole, when the ventricles are relaxed tree - Pressure waves in the arteries create pulses Pumping Ability - Cardiac Output = Stroke volume x Heart rate - Blood pressure = CO x SVR - Preload = Volume overload - Afterload = Pressure overload Cardiac Conduction - A progressive wave of stimulation or depolarization (cell interiors positive) passes through the heart, causing contraction of the myocardium - When the heart muscle cells are at rest, they are negatively charged (polarized) - The wave of depolarization and repolarization are recorded in the EKG in waves Chest Pain - Patients may be unable to distinguish between cardiac and non-cardiac problems - May originate from heart, aorta, lungs, diaphragm, esophagus, mediastinum, pleura, pericardium, pulmonary artery or chest wall o Chest pain does not always equal heart - If pt reports chest pain (and it not acute), ask them: o When did you have a recent episode? o What is the discomfort like - When did it begin - How frequent do you experience it – Can you bring it on or stop it after it begins. How? o Does the discomfort move anywhere (radiate) – Do you associate other symptoms with it? Physical Assessment: Final Study Guide Cardiac Causes of Myocardial Ischemia —> lack of blood flow to the muscles of the heart Chest Pain - Stable (typical) angina —> take nitroglycerin and it goes away - Unstable angina —> occurs when pt is resting —> need coronary intervention - Variant (Prinzmetal’s angina)-chest pain (usually at rest) that is due to spasms (causing temporary narrowing) of coronary arteries - Myocardial infarction- death of heart tissue caused by coronary artery blockage Cardiac not by Ischemia- Known that these conditions exist - Mitral Valves Prolapse - Pericarditis - Dissecting aneurysm Pulmonary Causes of - Pulmonary embolism —> dyspnea more common, may be asymptomatic Chest Pain - Pleurisy —> worse with breathing, disappears when holding breath - Pulmonary hypertension —> dyspnea more common, pain is described as discomfort, non-radiating tight constricting band across chest o Caused by a type of HTN that causes the arteries in the lung and right side of heart - Pneumothorax —> air in pleural cavity collapses lung - Mediastinal emphysema —> free air in the mediastinum produces chest tightness and dyspnea (Hamman’s sign) Gastrointestinal - Esophageal spasm —> substernal pain and dysphagia, may mimic angina Causes of Chest Pain - Esophageal reflux —> substernal burning or cramping radiates into arms, neck, jaw, relieved with antacids - Gallstone colic —> RUQ radiating to back or right shoulder Dyspnea - Shortness of breath, uncomfortable awareness of Orthopnea breathing - Dyspnea that occurs soon after pt lies down - Feels smothering, causing urgent need to take - Relived by sitting up or standing up another breath - Usually caused by HF fluid accumulation. Fluid goes - If pt reports dyspnea, ask them: with gravity, so when lying supine pressure put on o Does it occur with exercise, rest, night, lungs after you lie down? Paroxysmal Nocturnal Dyspnea o Can you predict what might bring it on? - Dyspnea after lying down for several mins or hrs, o How do you get relief, what do you do for awaken SOB it, do you need to sit up to breath? - Not relieved immediately after sitting up, may walk o Any associated symptoms such as cough, around a bit septum, wheezing, fever, chest pain, or Pulmonary Edema light headedness - Pulmonary congestion (left-sided heart failure) o How long has it been happening? - Pt is anxious dyspneic, diaphoretic pink frothy o What occurred to cause you to seek sputum and fear of impending death medical attention? Valvular heart disease - Dyspnea is principal symptom of mitral stenosis - May occur late in mitral regurgitation or aortic stenosis or regurgitation Physical Assessment: Final Study Guide Other Symptoms That May Be Cardiac Related - Just know that these symptoms can all be caused by chest pains Palpitations- Subjective Gradual Acceleration stated by patient - Exercise - Can be normal or - Anemia abnormal - Sexual activity - If reported - Postural hypotension frequently it can - Anxiety be become a - Use of stimulant drug medical diagnosis Sudden Onset but there is no - Paroxysmal atrial tachycardia objective finding - Ectopic beats - Extra systoles, or premature atrial or ventricular contractions - Syncope or seizures Syncope - Rapid onset, transient loss of consciousness, commonly called blackout or fainting - Experience dimming of vision, face becomes pale, diaphoresis, weakness, inability to stand and the feeling of fainting o Vasovagal- most common ▪ Body overreacts to a stimulus o Cardiovascular causes Edema - Any swelling of your feet and legs? o Excess accumulation of serous fluid in connective tissue in interstitial spaces o Usually, gradual swelling develops in both ankles and legs, worse in evening - Most common cause if CHF (right sided) - Anasarca o Generalized edema along with ascites (open free fluid in abd space) o HF, liver or kidney failure o Whole body is swollen - Nocturia – o The urge to get up an urinate at night→ cause sleep issues o Recumbency at night promotes fluid reabsorption and excretion Cyanosis - Bluish gray discoloration of skin and mucous membranes - Can be lung or - Central cyanosis – decreased pulmonary venous saturation- cardiac related o tetralogy of fallout - Peripheral cyanosis – decreased cardiac output or reduce rate of - blood flow through capillaries and increased local extraction of oxygen o Congestive heart failure, shock, Fatigue - Fatigue due to decreased cardiac output is worse in the evening, whereas fatigue from anxiety or depression occurs all day or is worse in the morning. Hemoptysis Coughing up blood - Multiple causes that could be cardiac, pulmonary of esophagus Physical Assessment: Final Study Guide Cardiac Physical Exam General Order: - General Appearance - Blood Pressure - Neck Vessels - Precordium o Inspect —> Palpate —> Auscultate Blood Pressure Systolic Blood Pressure Diastolic Blood Pressure Pressure generated by left ventricle (LV) during systole, Pressure generated by blood remaining in arterial tree when the LV ejects blood into the aorta and the arterial during diastole, when the ventricles are relaxed (heart is tree (heart is at work) at rest) Orthostatic Hypotension - Drop in SBP ≥ 20 mm Hg or - DBP ≥ 10 mm Hg within 3 minutes of standing up Caused by - Vascular volume loss - Redistribution of blood volume - Prolonged bed rest - Simple vasovagal fainting - Autonomic nervous system dysfunction Take orthostatic readings of pulse and blood pressure when: - you suspect volume depletion - taking hypertensive medications - reports fainting - dehydration - severe vomiting - severe diarrhea - overuse of diuretic meds - prolonged bed rest (supine) Taking Orthostatic Blood Pressure - Rest supine for 3 mins —> take baseline readings of pulse and BP - Wait 2-3 minutes and repeat with person sitting - Repeat within one minute of standing Physical Assessment: Final Study Guide Physical Exam for Neck/Carotid Arteries Physical Exam Step Normal Abnormal Inspect the Neck for Jugular Venous Pulse- Using Internal Jugular Venous Distention Obvious Venous Juglar Vein - Attached more directly to the superior Distention - Healthy value is 2-3 cm H2O vena cava —> most reliable vessel above the sternal angle or 6-8 cm H2O in relation to the right Non-Invasive Approach to Identifying the atrium Pressure in the R side of heart - Estimate Jugular Venous Pressure o Start with the patient’s head elevated to 30° and head turned to the left, raise/lower the head until oscillation of IJ can be seen o Create a 90° angle with your rulers from the oscillation point and the angle of Louis. o JVP is often expressed as the vert ical height (in cm) of the column of blood (the head) in relation to the sternal angle (angle of Louis) - External can be easily palpated OR add 5cm to make in relation to - Internal you use the method the right atrium – this number above and this is more accurate represents the hydrostatic reflection of the pressure in the pressure within the right atrium right side of the heart Palpate the Carotid - Siting or supine Abnormal Grading Arteries- Bilaterally - Place your index and middle - 0 fingers on ONE CAROTID at a - +1 time and feel for pulse - +4 - Never palpate right and left carotid arteries simultaneously Pulse Grading: 0 – absent +1 – weak/thready +2 – normal +3 – full/increased +4 – bounding Auscultate Carotid Listen to carotid arteries using the BELL If the thyroid is enlarged, you will listen for bruits Arteries for Bruits of the stethoscope for bruits on the over the thyroid gland carotid artery Physical Assessment: Final Study Guide Physical Exam for Chest Physical Exam Step Normal Abnormal Inspect & Palpate the Inspect the anterior chest for any visible pulsations and/or lifts (heaves) Precordium - Heart pounding on the chest wall - You may or may not be able to see the apical impulse at the 4th-5th intercostal space MCL (created when the left ventricle rotates against the chest wall during systole) Palpate the general precordium with the palmar aspect of hand in all auscultatory areas for Thrills (felt with loud murmurs)- Abnormal - Thrills- Vibration on the chest wall —> loud murmurs —> feel the turbulent blood flow w/ the palm of your hand Assessing the Point of Use your finger pads, palpate at the apex for the In left ventricular dilation (volume overload), Maximal Impulse (PMI) PMI PMI will be: - Locate the PMI at the 4th or 5th intercostal - Displaced down and to left space at medial to the MCL - Increased size – more than one - Note: intercostal space o Amplitude: should be a short In left ventricular hypertrophy (pressure gentle tap overload), PMI will be: o Duration: should be short, first - Increased force and duration but no half of systole change in location Percussion (not usually Outline heart size Cardiomegaly (enlarged heart) done) Auscultate Cardiac Auscultatory Areas A – Aortic Aortic 2nd Right ICS at sternal P – Pulmonic border E – Erbs Point Pulmonic 2nd Left ICS at sternal T – Tricuspid border M – Mitral Erb’s Point 3rd Left ICS at sternal border Tricuspid 5th Left ICS at sternal border Diaphragm for high-pitched sounds Mitral 5th Left ICS at - Normal S1 and S2 sounds midclavicular line - Most murmurs Bell for low-pitched sounds - S3 and S4 - The rumble of mitral stenosis Auscultate – Sitting / Listen w/ DIAPHRAGM in aortic and pulmonic Murmurs- blowing, swooshing sound that occurs Leaning Forward regions for murmurs and friction rub with turbulent blood flow in the heart or great - Position brings base of heart closer to the vessels chest wall, allowing for the aortic and - Almost always pathologic pulmonic valves to be heart Auscultate – Supine 5 auscultatory areas in supine position using DIAPHRAGM Position - Identify S1 and S2 - Note the rate and rhythm - Note any murmurs 5 auscultatory areas in supine position using BELL - Note extra heart sounds (S3 and S4) S2 is heard loudest the the BASE S1 is heard loudest at the APEX Auscultate – Left Lateral Listen in the mitral area (apex) with the Bell for S3 and S4 sounds or murmur of mitral stenosis Decubitus Physical Assessment: Final Study Guide Heart Sounds Systole Diastole S1 – Closing of the AV valves S2 – Closing of semilunar valves Ventricles Contract Ventricles Relax Right ventricles —> pump blood into pulmonary arteries Blood flows from right atrium —> right ventricle (pulmonic valve is open) (tricuspid valve is open) Left ventricle —> pump blood into aorta (aortic valve is Blood flows from left atrium —> left ventricle (mitral open) valve is open) Identify and Assess S1 and S2 – Normal Heart Sounds S1 S2 - S1 is heard louder than S2 - S2 is heard louder at the base (normally silent) - S1 coincides with carotid artery pulse - Sound is made by closure of semilunar valves - S1 coincides with R wave on ECG (aortic and pulmonic) - Sound is made by the closure of AV valves (mitral and tricuspid) Apex Base LUB – dup lub – DUP Abnormal Sounds – S3 and S4 (AKA Gallops) S3 – Ventricular Gallop S4 – Atrial Gallop - Often associated with LV - Sound created by blood trying to enter and hitting - Failure and volume overload – Caused by blood a stiff, non-compliant left ventricle during atrial from the LA slamming into an already overfilled contraction ventricle during early diastolic filling - Associated with LV hypertrophy resulting from - Heard best with the bell in left lateral recumbent long standing hypertension - Occurs in early diastole, during the rapid filling - Heard in late diastole at the time of the atrial kick phase and sounds just after S2 (immediately before S1) - Might be the earliest physical sign of heart failure - Best heard with the bell at the apex in left lateral position “slosh – ing – IN” A – stiff – wall S1 – S2 – S3 S4 – S1 – S2 Physical Assessment: Final Study Guide Murmurs What are Murmurs - Blowing, swooshing sound Structural Changes that occurs with turbulent blood flow in the heart or great vessels. - almost always pathologic Description of Murmurs - Timing – are the murmurs systolic or diastolic? o Tip: palpate the carotid upstroke (occurs in systole) as you listen – if the murmur coincides with the carotid upstroke = systolic - Duration o Early/ mid/ late = Systolic or Diastolic o Pansystolic (Holosystolic) = lasts from end of S1 to beginning of S2 o Pandiastolic (Holodiastolic) = lasts from end of S2 to beginning of S1 - Location – apex, base, sternal border - Shape – plateau, crescendo, decrescendo, or both o Both-Crescendo-decrescendo systolic murmur of aortic stenosis o Plateau – holosystolic murmur of mitral regurgitation o Crescendo- systolic o Decrescendo- diastolic - Grade and Intensity – grade on a scale of 1 to 6 o Note that grades 4 through 6 must have accompanying thrill Grade Description 1 Softer in volume than S1 and S2, very faint 2 Equal in volume to S1 and S2, quiet, but heard immediately 3 Louder than S1 and S2, moderately loud 4 Louder than S1 and S2 with palpable thrill 5 Louder than S1 and S2 with palpable thrill – might be heard with stethoscope only partially on the skin 6 Louder than S1 and S2 with palpable thrill – might be heard with stethoscope entirely off the skin - Pitch – Apply terms like high-, medium-, or low-pitched - Quality – Apply terms like harsh, musical, soft, blowing, or rumbling - Radiation – to neck - Position of patient – standing, sitting, squatting Physical Assessment: Final Study Guide Types of Murmurs Murmurs Due to Valvular Defects Midsystolic Aortic Ejection Stenosis Murmurs Pulmonic Stenosis Pansystolic Mitral Regurgitant Regurgitation Murmurs Tricuspid Regurgitation Diastolic Mitral Rumbles of Stenosis AV Valves Tricuspid Stenosis Early Aortic Diastolic Regurgitation Murmurs Pulmonic Regurgitation Extracardiac Sounds - Pericardial Friction Rub o From inflammation o Physical Assessment: Final Study Guide Developmental Considerations Older Adults - SBP: A gradual rise in systolic blood pressure is common with aging - DBP: stays consistent, causing a widening of pulse pressure - Older adults are more susceptible to orthostatic hypotension - Increased risk for arrythmias due to a decrease in pacemaker cells, so be careful when palpating and auscultating the carotid artery. Avoid pressure on the carotid sinus area - Secondary to a more barrel chest it may be more difficult to palpate the apical impulse - About 50% of older adults develop systolic murmurs - Occasional extra beats are common and do not mean heart disease - Dorsalis Pedis and Popliteal pulses my become more difficult to palpate. Normal Vital Signs Infant - Acrocyanosis = Normal in Infants Physical Assessment: Final Study Guide Peripheral Vascular System and Lymphatic System PMH-Pain or cramps in arms/legs, intermittent claudication, cold, numbness, pallor in legs, hair loos, skin changes on arm or legs, swelling in calves, legs or feet, color change in fingertips or toes in cold weather swelling with redness or tenderness, lymph node enlargement Physical Exam Step Normal Abnormal Arm – Inspect and Palpate Inspect Pallor - Size/Symmetry/Swellin - Raymond’s disease: reduce g vasospasms and reduce - Skin: color, temp (cool blood flow to the areas or hot), texture Erythema/Swelling - Profile sign (clubbing) - Blood backed up from DVT - Test capillary refill node angle of nail beds widens - Location: antecubital >180 degrees fossa and drains the Spoon Shaped Nails lymphatic tissues of the - Long periods of dec blood hands and the upper O2 levels —> clubbing —> arm spoon shaped nails - Palpate: shake hands with pts and reach hand with opposite hand around medial condyle and humorous Epitrochlear lymph node Abnormal and palpate with tips of - Enlarge with a lesion in the finger area - Local or distal infection - - Physical Assessment: Final Study Guide Grading amplitude of pulses - 4+ bounding - 3+ full - 2+ Brisk, expected (normal) - 1+ Diminished, weaker than expected (thready) - 0 Absent, unable to palpate Abdomen – Palpation of Aortic Pulsation - Opposing thumb and - Caution: prominent lateral finger, slightly left and pulsations and a mass —> above umbilicus do not deep palpate the - Normal: pulsations 2- abdomen 3cms wide - Large aorta = possible aneurysm and do not deep palpate - Aortic aneurysm = can hear bruits - There is a decrease in femoral pulses Physical Assessment: Final Study Guide Physical Exam Step Normal Abnormal Legs – Inspect and Palpate Inspect No Dorsalis Pedis Pulse - Skin for lesions and color - Most distal from the heart - Size and symmetry - Decrease or absent pulse + - Temperature good femoral and popliteal - Hair distribution pulse = occlusive diseases in - Inguinal lymph nodes the branches of popliteal - Associated with diabetes Palpate Pulses - Femoral pulse Sudden Arterial Occlusion o Press deeply in the - Blood clot that causes pain, inguinal ligament and the extremities are cold and midway anterior and numb, and there are no superior spine and pulses —> NEED EMERGENCY synthesis TREATMENT - If the clot travels, it will cause pain and limbs distal to the clot will become cold, pale, and no pulses. - Popliteal pulse Edema o Flex the knee and leg - Press firmly for 5 secs over relax, pt is supine —> dorsum of each foot, behind use 2 hands and press the medial malleolus and over deeply in the popliteal the shins —> if there is pitting fossa = edema - Grade 1+ to 4+ —> 1+ = edema - Causes: - Posterior Tibial pulse o Deep vein thrombosis o Below the ankle bone o Chronic venous insufficiency o Lymphedema o Orthostatic edema o Congestive heart failure - Dorsalis Pedis pulse o Dorsum of the big toe - Pretibial edema Palpate Legs for Temperature - Use dorsum of hand Bilateral coldness = due to coldness or anxiety Unilateral coldness = suggests arterial insufficiency and overall inadequate circulations Brownish color about ankle = chronic arterial insufficiency Physical Assessment: Final Study Guide Palpate Superficial Inguinal - Normal: Nonpalpable nodes but Lymphadenopathy = abnormal Nodes these are usually large and able swelling of the lymph nodes to be felt - Could be cancer, fungal - Inguinal nodes = drains groin and infections, STI, and skin lower extremities, external infections genitalia and anterior abdominal wall Physical Assessment: Final Study Guide Additional Techniques - Peripheral Vascular System Test What’s the use Steps Results Allen Test Use to determine the 1. Make a tight fist Normal – blood patency of the ulnar 2. Both of thumbs compress radial and ulnar returns via ulnar artery prior to arteries artery puncturing the artery 3. Pt open hands and the hand should be pale - Ulnar and radial 4. Release ulnar artery Occluded ulnar artery profuse to 5. If ulnar artery is patent, then blood will return to artery – no blood the fingers the palm within 3-5 secs return - If ulnar is not 6. If occluded ulnar artery, then there is no blood patent enough return, palm is clear to supply blood to the rest of the hand, and the radial is blocked off, there is zero blood flow in the fingers/hand Homan’s Determining Deep Vein 1. Support pt’s thigh with one hand and the foot Normal = Negative Sign Thrombosis- only 35% with other = No calf pain accurate 2. Bend pt’s knee 3. Firmly and abruptly dorsiflex the ankle, point Positive = Probable toes upwards DVT —> calf pain or 4. If there is deep pain elicited in the calf, positive resistance ankle homan’s sign and likely indicates a probable DVT dorsi-flexion or flex 5. Works only about 35% of the time. the knee involuntarily Postural Determines if the pt has If the pt has calf/leg pain or diminished pulses, Normal: Color arterial insufficiency suggesting arterial insufficiency: -Return of color Changes 1. Raise both legs (60 degrees max) until max should return in areas of the body all the blacked up blood flows down with gravity - Pallor with elevation Chronic Arterial Insufficiency VS Chronic Venous Insufficiency Chronic Arterial Insufficiency Chronic Venous Insufficiency Pain Intermittent claudication, progressing to pain at None to an aching pain on dependency rest Pulses Decreased or absent Normal, though may be difficult to feel through edema Color Pale, esp on elevation; dusky red on dependency Normal or cyanotic on dependency. Petechiae and then brown pigmentation appear with chronicity Temperature Cool Normal (blood is there) Edema Absent or mild; may develop as the pt tries to Present, often marked relieve rest pain by lowering the leg Skin Changes Trophic changes: thin, shiny, atrophic skin; loss of Often brown pigmentation around the hair over the foot and toes; nails thickened and ankle (brawny), stasis dermatitis and ridged possible thickening of the skin and narrowing of the leg as scarring develops Ulceration If present, involves toes or points of trauma on If present, develops at sides of ankle, esp feet medially (Distal tissues are the most affected) Gangrene – loss May develop Does not develop of blood supply causes tissue death Physical Assessment: Final Study Guide Developmental Considerations – Older Adult - SBP: A gradual rise in systolic BP is common with aging - DBP: Stays fairly consistent, causing a widening of pulse pressure - Older adults are mor susceptible to orthostatic hypotension - Increased risk for arrhythmia due to a decrease in pacemaker cells, so be careful when palpating and auscultating the carotid artery. Avoid pressure on the carotid sinus area - Secondary to a more barrel chest, it may be more difficult to palpate the apical impulse - About 50% of older adults develop systolic murmurs - Occasional extra beats are more common and do not mean heart disease - Dorsalis pedis and popliteal pulses may become more difficult to palpate Physical Assessment: Final Study Guide Abdomen Location of Organs Location Organ RUQ Liver, gallbladder, ascending colon RLQ Cecum, appendix, bladder LUQ Spleen, stomach, small intestine LLQ Sigmoid Colon Terminology Upper GI Tract: - Anorexia- lack of appetite - Early satiety- feeling full early during a meal (general abdominal fullness) - Dysphasia- difficulty swallowing - Odynophagia- pain with swallowing - Regurgitation-reflux of food and stomach acid back into the mouth; brine-like taste - Retching- spasmodic movement of the chest and diaphragm like vomiting, but no stomach contents are passed) - Emesis- Vomit o If the patient is vomiting - Ask about the quantity and frequency o Ask about the type of vomit: food, green- or yellow-colored bile, mucus, blood, coffee ground emesis (often old blood) - Hematemesis = frank blood or coffee ground (digested blood) emesis o Frank blood = throw up blood from stomach or esophagus o Coffee ground = digested blood Lower GI: - Diarrhea - soft or watery stool - Constipation- hard stool, difficult to pass - Hematochezia- Fresh (bright red) blood (usually per anus) in stool - Melena- Black or tarry looking stools, usually with a foul smell - Acholic-term used to describe white/light/grey colored stool due to lack of bile resulting from liver/gallbladder diseases Describing Abdominal Pain Visceral - Gnawing, cramping, or aching and is often difficult to localize - Can occur when: o Hollow organs (stomach, colon) forcefully contract or become distended. o Solid organs (ie liver, spleen) swell against their capsules Parietal - More severe and usually easily localized (appendicitis) Takeaway – shoulder pain does not - Parietal pain: when there is inflammation from the hollow or always mean the shoulder; it could be solid organs that affect the parietal peritoneum. pancreatitis or liver Referred - Originates at different sites but shares innervation from the same spinal level (gallbladder pain in the shoulder) - When a person gives a history of abdominal pain, the pains location may not necessarily be directly over the involved organ. - Physical Assessment: Final Study Guide Abdominal Physical Exam - Prep: Empty bladder, supine position with knees bent, arms at sides or folded over chest, warm stethoscope, short fingernails - Ask pt to point to any areas of pain —> examine last - I Am PePa —> Inspection, Auscultation, Percussion, Palpation - Asses the area of pain last→ so you can note the difference that may be present @ site of pain Physical Exam Step Normal Abnormal Inspection Demeanor Umbilical Hernia Contour - Weak spots in - Flat, rounded, protuberant, the lining of scaphoid (markedly concave) the bowel wall - Symmetrical - Can be benign Skin (scars, rashes, lesions) and tucked Hair Distribution back in Pulsation or Movement - If bowel is big - Aortic pulse in epigastric region is —> incarcerated and cut off circulation normal however, amplitude is Incisional Hernia increased with an aneurysm - Surgical incision with lump Umbilicus - Defect with Linea alba and bowel can slip - Any obvious bulging (umbilical through it hernia) - Note any inflammation Look from side at eye level Auscultate Bowel Use DIAPHRAGM - Hyperactive = loud, high pitched (as with Sounds Begin in RLQ (at ileocecal valve) diarrhea) Note character and frequency of bowel - Hypoactive = infrequent bowel sounds (as with sounds (clicks or gurgles) recent abdominal surgery, paralytic ileus) - Normoactive -5-30 sounds/minute - Absent - To say a patient has absent bowel - Borborygmi (aka stomach sounds, you MUST listen for a FULL 2-5 growling)- prolonged minutes gurgle/rumbling Auscultate Vascular Listen for bruits with the BELL Sounds over: - Aorta - Left and right renal arteries - Left and right iliac arteries - Left and right femoral arteries Physical Assessment: Final Study Guide Physical Exam Step Normal Abnormal Percuss for Percuss all four quadrants (zip zag approach) Ascites Tympany/Dullness Tympany should predominate due to gas in - Fluid in the abdomen GI tract - Liver failure —> produces albumen — Note any large areas of dullness > water likes to be in free spaces esp - Mass or enlarged organ abdomen - Fluid - Pt laying down, gravity of the water - Feces will follow - Fetus - Fibroid Ovarian mass Ovaries with mass, hear dullness in mass Feces Dullness Pregnancy Dullness Percussion of Liver - At the R midclavicular line, start in Hepatomegaly Span area of lung resonance and percuss - Hepatitis or any failures/fluid build up down until you hear dullness – draw a - COPD – hyperinflated lungs and push mark down the liver - Then percuss upward from abdominal tympany until dullness – draw a mark. - Normal liver span at the R MCL is 6- 12cm - Normal liver span at sternum is 4- 8cm Physical Assessment: Final Study Guide Physical Exam Step Normal Abnormal Liver Scratch Test Can help define liver borders when abdomen is distended or muscles tense - Place stethoscope over liver - Start in RLQ and scratch with fingertip upward When sound becomes magnified, you’ve crossed from hollow organ to solid (liver edge) Percussion of the - Percuss at the left anterior axillary line at Splenomegaly Spleen the lowest interspace – Normally - If dull to percussion, this is a Tympany POSITIVE SPLENIC PERCUSSION - Then ask the patient to take a deep SIGN and may indicate splenomegaly breath in and hold while you percuss the same place again - Normally should still be tympany Percussion of Kidney Costovertebral (CVA) tenderness Kidney Infection or Musculoskeletal Problem - Pressure from fingertips or a thrust of - Tenderness fist may produce tenderness due to a kidney infection but may also be musculoskeletal. Light Palpation in all Visualize what’s in each area Abdominal Tenderness 4 Quadrants Voluntary muscle guarding Start palpating the abdomen using gentle pressure - Mostly bilateral, due to ticklish or cold, – this reassures and relaxes the patient will decrease with exhalation/ relaxation - Identify any superficial organs or masses Involuntary muscle guarding (rigidity) (lymphoma = fatty tumors, benign) - Constant board like hardness of muscles - Note voluntary guarding (conscious - Protective mechanism accompanying flinching) vs involuntary guarding acute (peritonitis) (uncontrolled muscle spasm) Rebound tenderness - Press fingers firmly and slowly into the Use relaxation techniques to assess voluntary abdomen and then quickly withdraw – guarding pain occurs on the withdraw of pressure. - Tell the patient to breathe out deeply - This finding also suggests peritonitis - Tell the patient to breathe through the mouth with the jaw dropped open Peritonitis - Infection, inflammation, or rapture in the Tips if the pt is ticklish and pts w/ trauma abdomen (appendicitis, ruptured colon, - Distract the pt by taking history at the pancreatitis, bacterial infection after same time peritoneal dialysis) - Place the pt’s hand over yours or under - Rigidity + Rebound tenderness = yours with your fingers curled over Peritonitis while palpating Physical Assessment: Final Study Guide Physical Exam Step Normal Abnormal Generalized Deep Palpation - Palpate deeply in the Abnormalities on Palpation periumbilical area and both - Enlarged liver lower quadrants. - Enlarged nodular liver - Bimanual technique – top - Enlarged Gallbladder hand does the pushing, and - Enlarged Spleen bottom hand does the feeling - Rebound tenderness = pain increases when the examiner decreases the pressure against the abdomen - Correlate your palpable findings with your percussion notes Palpation of Liver First Method Hepatomegaly - L hand under the lower - Enlarged liver ribcage lifting upwards to - >3cms support abdominal contents - R hand on RUQ and push in and up under the ribcage as the person breathes in - You should feel the liver edge push down against your fingers as the diaphragm pushes it downwards - Normal- liver edge palpated < 3cm below the costal margin at the MCL with inspiration Hook Method - Stand at the pts R shoulder facing their feet and hook your fingers under the ribcage while the patient breathes in Palpate Spleen The spleen is NOT normally palpable Splenomegaly - Stand on the patients R side Push hand deep under the left rib cage and and reach your L hand over the ask pt to breathe in deeply abdomen, and reach around - Repeat with the patient lying on lower L ribs for support their R side with hips and knees - Place R hand on LUQ with partially flexed – In this position, fingers pointed toward the gravity may bring spleen into a axilla just under the rib margin palpable position Physical Assessment: Final Study Guide Physical Exam Step Normal Abnormal Try to Palpate the Kidneys Capture Technique/ Balloting the Kidney Enlarged Kidney - Use one hand to support the flank - easily palpable, and lift upwards firm/tender kidney - Use the other hand to press downwards into the abdomen lateral to the Rectus Abdominus muscle - Ask the patient to breath in deeply and see if you can feel the kidney pushing downward - Normally the kidneys are NOT easily palpable Palpation of Aortic Normal pulsation is 2-3cm wide Aortic Aneurysm Pulsation→ can do either Caution if: - Visible lump, lateral pulsation here or during the chest - Prominent lateral pulsations examination - Periumbilical or upper abd mass with pulsations, esp if bruit is present - DO NOT DO DEEP PALPATION OR IF YOU SEE A PULSATING MASS Special Techniques Assessing for Ascites Assessing for - McBurney Point Tenderness Appendicitis - Rovsing’s sign - Psoas sign - Obturator test - Rebound tenderness Assessing for Acute Murphy’s sign Cholecystitis Assessing for Ascites - A protuberant abdomen with bulging flanks is suspicious for ascites (free fluid in the abdomen). - Percuss the abdomen for areas of tympany and dullness. - Due to gravity, dullness should be located along the lateral sides (flanks) of the abdomen, while the anterior portion should be tympanic. Physical Assessment: Final Study Guide Assessing for Appendicitis McBurney Point Tenderness Location: 2/3 of the way from umbilicus to Anterior Superior Iliac Spine Appendicitis is 2x more likely when McBurney point tenderness if present REBOUND TENDERNESS IS POSSIBLE Rovsing Sign REFFERED tenderness - Palpate the LLQ and the patient feels (indirect) tenderness or rebound tenderness in the RLQ Psoas Sign POSITIVE PSOAS SIGN = irritation of the R psoas muscle via inflamed appendix= indicative of appendicitis - With the patient in the supine position, place your hand over their RIGHT knee. - Ask the patient to raise their thigh against your hand - This causes contraction of the psoas muscle Obturator Sign POSITIVE OBTURATOR SIGN = R hypogastric pain with the motion = indicative of appendicitis - Flex the patient’s R thigh at the hip - With the knee bent, rotate the hip internally Assessing for Acute Cholecystitis - Murphy’s Sign o If a patient presents with RUQ pain suspicious for acute cholecystitis (inflamed gallbladder) but no tenderness on palpation in the RUQ, test for murphy’s sign: o Deeply palpate the RUQ at the location of the pts pain – ask the patient to take a deep breath in which forces the liver and gallbladder down - POSITIVE MURPHY SIGN = Cholecystitis Physical Assessment: Final Study Guide Musculoskeletal General Order of Examination Inspection – Size and contour of joint – Skin and tissues over joint Palpation – Skin temperature – Muscles, bony articulations, area of joint capsule Range of Motion Muscle Testing – Apply opposing force – Grading muscle strength Notes: Pt reports a problem in a specific joint → pay close attention to the joint above and below it Grading Muscle Strength Muscle strength is graded on a 0 to 5 scale: 0 – No muscular contraction detected 1 – A barely detectable flicker or trace of contraction 2 – Active movement of the body part with gravity eliminated 3 – Active movement against gravity 4 – Active movement against gravity and some resistance 5 – Active movement against full resistance without evident fatigue; this is normal muscle strength - Ask the patient to move actively against your opposing resistance; assign Grade 5 if the patient overcomes your opposing movement - If the patient can only move against gravity, assign Grade 3 Skeletal Muscle Movements Example 1. Flexion – Bending at a joint 2. Extension- straightening at a joint 3. Abduction –limb away from the midline 4. Adduction –limb toward the midline 5. Pronation –palm is down 6. Supination –palm is up 7. Circumduction – moving the arm in a circle around the shoulder 8. Inversion – moving the sole of the foot inward at the ankle 9. Eversion – moving the sole of the foot outward at the ankle 10. Rotation –head around a central axis 11. Protraction –forward and parallel to the ground 12. Retraction –backward and parallel to the ground 13. Elevation – raising 14. Depression – lowering Physical Assessment: Final Study Guide Joints - Upper Joint Physical Exam Notes Temporomandibular Joint - Inspect joint area - Where the mandible and temporal bone - Palpate as person opens come together mouth - Most active joint in the body - Range of Motion: - Permits jaw function for speaking and o Open mouth chewing maximally o Protrude lower jaw and move side to side o Stick out lower jaw o A pop or click as the patient opens their mouth can be normal but there should be no crepitus or pain associated - 3 movements- hinge, gliding -side to - Palpate muscles of side and open and closed mastication Shoulder - Inspect joint - Palpate shoulders and axilla o Note atrophy, swelling, heat, or tenderness - ROM o Place one hand over the shoulder to palpate while pt performs ROM o Arms forward and up o Arms behind back and hands up o Arms to sides and up over head o Touch hands behind head - Assess Strength o Shrug shoulders, flex forward, and abduct against resistance Elbow - Inspect joint in flexed and extended positions - Palpate joint and bony prominences - Motion and expected range o Bend and straighten elbow o Pronate and supinate - Hinge Joint formed by 3 boney hand articulations: humerus, and the radius - Assess strength and ulna - Bone articulations: medial and lateral epicondyle and olecranon proses of the ulna Physical Assessment: Final Study Guide Wrist/Hand - Inspect joints on dorsal - Over half of our bones are in the hands and palmar sides and feet! o Note redness, - Radiocarpal joint (wrist): articulation of swelling, the radius on thumb-side and a row of deformities/nodules carpal bones - Palpate each joint o Use thumb to palpate metacarpal phalangeal joints o Use thumb and forefinger to pinch down the sides of the interphalangeal joints - Motion and expected range o Bend hand up at wrist o Bend hand down at wrist o Bend fingers up, down o Turn hands out, in o Spread fingers, make fist o Touch thumb to each finger - Test strength o Flex wrist against resistance at the palm Physical Assessment: Final Study Guide Joint Abnormal Wrist and Hand Carpal Tunnel Testing for Carpal Tunnel Syndrome Joint - Narrow passageway of the nerve and bones Phalen’s test - Median nerve gets compress from repetitive - Hold this position for 60 movement or injury sec - POSITIVE TEST = palmar surface innervated by the median nerve will go numb Tinel’s Sign - Tap repeatedly over the median nerve - POSITIVE TEST = numbness/tingling over palmar surfaces innervated by the median nerve -Compressed Median nerve -Median nerve innervates planar surface and thumb to ring finger. Osteoarthritis (Degenerative Joint Disease) (Overuse) Heberden’s nodes (DIP), bony overgrowth - Hard, nontender nodules - 2 to 3 mm or more in size - Metacarpophalangeal (MCP) joints are spared - Affects middle-aged or elderly At night, PIP takes a DIP in the OceAn PIP and DIP – large knuckles are spared Bouchard's nodes (PIP), less common - Degenerative joints – noninflammatory localized progressive disorder - Aging increases incidence - Asymmetric affected joints are stiffness, swelling with hard bony protuberances, pain with motion, limitation of mobility Rheumatoid Arthritis (Autoimmune Joint Disease) Boutonniere deformity - Tender, painful, stiff joints worse in morning and Swan Neck Deformity after rest, better with movement Ulnar deviation - PIP and MCP involvement - Chronic systemic inflammatory disease - Symmetrical and bilateral - Associated with fatigue, weakness, weight loss, lymphadenopathy Physical Assessment: Final Study Guide Joints - Lower Joint Physical Exam Notes Hip- - Hip joint is the articulation between the acetabulum and the head of the femur→Wide ROM→ball and socket action - Inspect as person stands o Symmetric iliac crests, gluteal folds, and equally sized buttocks - Palpate with person supine o Tenderness or crepitus is abnormal - Motion and expected range o Raise leg o Knee to chest o Flex knee and hip, swing foot out, in o Swing leg laterally, medially o Stand and swing leg back Knee - Inspect joint and muscle o Lower leg should be in the same axis as upper leg - Palpate o Normal concavities on either side of the patella o Should be no warmth, tenderness, thickening or nodularity - Motion and expected range o Bend knee o Extend knee. o Check knee while ambulate. Articulation of 3 bones: femur, tibia, and patella Ankle/Foot - Inspect with person sitting, standing and walking - Articulation of the tibia, fibula and talus o An imaginary line should fall from mid-patella, to - Hinged synovial joint, limited to flexion and extension between the first and second toes - Landmarks include medial malleolus and lateral - Palpate joints malleolus o support the ankle by grasping the heel while palpating the ankle with thumbs - Motion and expected range o Point toes down, up o Turn soles out, in o Flex and straighten toes - subtalar joint, distal to the tibiotalar joint, gives additional mobility to the foot (inversion and eversion) Physical Assessment: Final Study Guide Spine Spine Joint Physical Exam Notes Landmarks of Spine Abnormal- Cervical Spine - Inspect alignment of head and neck - Palpate spinous processes and muscles - Motion and Expected Range o Chin to chest o Lift chin o Each ear to shoulder o Turn chin to each shoulder - Test strength by doing the above motions against resistance * DO NOT ATTEMPT ROM IF YOU SUSPECT TRAUMA* Spine - Inspect while person stands - Palpate spinous processes o Should be straight and nontender - Motion and expected range o Bend forward, backward o Bend laterally o Twist shoulders to each side - Measure leg length discrepancy o Length discrepancy can cause back pain Straight Leg Raising - Raise the leg with the knee fully (Lasegue Test) extended and foot dorsiflexed– normally this should not produce pain. - POSITIVE TEST = reproduce or worsen sciatic back and leg pain associated with herniated disc. Physical Assessment: Final Study Guide Genitalia Culturally Sensitive Interview Menstrual History - Ask about the age of menarche (when the first menses started); in the United States the range is between the ages of 9 and 16 - Ask about menstruation patterns o How often does the patient have menses? (Every 24 to 32 days is normal.) o How long are the menses? (3 to 7 days is normal.) o How heavy are the menses? (The number of pads or tampons used is an indicator.) - If applicable, at what age did menopause occur? o Menopause is defined as no menses for 12 months. The average age of menopause is 51 years old in the US. Exam Prep Allow the patient to empty their bladder Ensure the exam table is positioned so that exposed areas are not facing a door Allow the patient to undress privately Chaperone should be present Explain that the patient can say STOP at any moment should they feel discomfort May offer the patient a mirror if they want to watch (most applicable for pelvic exams) When inspecting the scrotum/testes, may ask the patient to lift the penis If penis is uncircumcised, ask the patient to retract the foreskin Do not perform any unnecessary assessments Physical Exam Step Normal Abnormal AFAB - Inspect External - Inspect the patient’s external genitalia Genitalia o Mons pubis ▪ Hair distribution appropriate for tanner stage o Labia majora ▪ Symmetric bilaterally ▪ Well formed ▪ Normally stretched following vaginal birth ▪ No lesion, but occasional sebaceous cyst ok o Labia minora ▪ Darker ▪ Symmetrical and moist o Clitoris ▪ No inflammation or swelling o Urethral meatus o Introitus o Perineum - Note any inflammation, discharge, swelling, or nodules; palpate any lesions - Patient in lithotomy position o Lies supine with buttocks at edge of bed o Legs abducted at 30-45 degrees from midline with hips and knees flexed Physical Assessment: Final Study Guide AMAB – Inspect and Inspection of Skin, Hair and Corona Phimosis Palpate External Genitalia Pubic hair distributed appropriately for - Narrowed opening of prepuce, so the tanner stage foreskin cannot retract No ulcerations/lesions present on shaft Paraphimosis Dorsal vein may be visible - painful construction of glans by Glans penis should be smooth without retracted foreskin lesions Foreskin should be pulled back easily Smegma may collect under the foreskin Be sure to replace the foreskin back into it’s original position! AMAB - Inspection of - Note the location of the urethral meatus Urethra o Hypospadias – Ventral location of meatus o Epispadias – Dorsal location of meatus Compress the glans gently between your index finger above and thumb below to open the urethral meatus and allow inspection for discharge (normally there is none) AMAB - Palpation of the - Ask the patient to hold the penis up – lift the Varicocele Scrotum and Testes scrotum to inspect the posterior aspect – should - Dilated spermatic varicose vein, feels heavy be no lesions aside from occasional sebaceous and aching, can lead to impotence, diagnosed with u/s cysts. - Testicles feel like a bag of worms - Palpate each testis and epididymis – note size, shape, consistency, and tenderness; feel for any nodules o Epididymis is a soft, nodular, cordlike structure at the back of the testicle - Palpate each spermatic cord – note nodules or swelling Testicular Torsion - Excruciating unilateral pain, usually sudden onset - May also have lower abdominal pain and nausea/vomiting with no fever - Can happen while sleeping, or usually due to direct trauma - Scrotum is red and swollen, one testis is higher than the other due to rotation and shortening - Cord feels thick and the epididymis may be anterior - Testicular Cancer - A Firm, painless lump and associative swelling found on exam – may have a family history - Usually a solitary mass - Most cancers occur between ages 18 and 35 - Most common in white AMAB patients - Undescended testis (even if surgically corrected) is a known risk factor Physical Assessment: Final Study Guide Hernias - Inspection o Sit comfortably in front of the standing patient o Note any areas of bulging or asymmetry o Ask the patient to strain and bear down, making it easier to detect any hernias Risk Factors: - Palpation Biologic males are 8x more likely, o Inguinal and femoral hernias but biologic females may also develop Age (muscles weaken with age) Frequent straining (Valsalva or due to lifting heavy weights) Obesity Pregnancy Previous abdominal surgeries Trans male - Pelvic exams may be an especially traumatic or anxiety producing procedure if they have not undergone gender affirming surgery - If taking exogenous testosterone without bottom surgery, the patient may be in a hypo- estrogen state which promotes vaginal atrophy and increases vaginal pH which increases the risk for vaginitis and cervicitis → use smallest speculum Trans Female - If h/o vaginoplasty, use an anoscope to visualize the walls of the neo-vagina, inspect for skin changes or scarring - If no bottom surgery and patient practices prolonged tucking, they are at increased risk for urinary reflux and infections (orchitis, prostatitis, cystitis) Physical Assessment: Final Study Guide Rectum and Prostate Physical Exam Step Normal Perianal Inspection - Skin - Anal opening - o Anus looks moist, with coarse folded skin that is more pigmented than the perianal skin. o The anal opening tightly closed. o No lesions/masses Anus and Rectum – Palpate AMAB – Prostate Exam - According to the ACS, AMABs should have their first prostate exam by age 50. - During rectal exam – find the median sulcus and palpate the entire prostate in a fan like motion o The only palpable parts of the prostate are posterior and part of the lateral portion - Press lightly into the gland on each side – note any nodules or abnormal enlargement/tenderness - Normal: o 2.5cms by 4 cms, should not protrude more that 1cm into the rectum o Heart shaped with palpable grove o Smooth, elastic and rubbery o Slightly mobile and nontender Prostate Abnormalities Prostatitis - Fever/chills, malaise, urinary frequency - Tender, enlarged prostate with dull perineal/rectal aching Benign Prostatic Hypertrophy (BPH) - Urinary frequency, urgency, hesitancy - Symmetric, nontender enlargement - Patient is usually “middle aged” - Prostate feels smooth, rubbery, or firm with median sulcus obliterated due to swelling Prostate Cancer - Frequency, nocturia, weak stream, hematuria, hesitancy, pain or burning with urination - Continuous pain in the lower back/pelvis - Usually starts as a single hard nodule on the posterior surface (producing asymmetry on exam) and a change in prostate consistency. - As cancer progresses, there are multiple hard nodules, or the entire gland can feel like a stone. - Median sulcus is obliterated Prostate Cancer Risk Age - Most prostate cancers are diagnosed after age 50 - More that 60% are diagnosed after age 65 Family History - Especially if family member was diagnosed before age 60 - 5-10 of every 100 cases are related to inherited genetic factors Ethnicity - Most common in Black/African American individuals - Black/African Americans are more likely to be diagnosed late stage compared to other race/ethnicities Lifestyle - Risk is increased if you are overweight, eat a high fat diet, or do not exercise regularly Physical Assessment: Final Study Guide Neurologic System As you examine the patient, remember three important questions: 1. Is mental status intact? 2. Are right- and left-sided findings symmetrical? 3. If findings are asymmetric or otherwise abnormal, do the causative lesions lie in the central nervous system or the peripheral nervous system? 7 Components of Exam 1. Mental Status and Behavior 2. Cranial Nerves 3. Motor System 4. Sensory System 5. Coordination 6. Romberg/Gait 7. Reflexes Mental Status and Behavior Level of consciousness how aware the person is of his environment Mood & Affect the observable emotion of a person expressed through facial expression, body movements, and voice Speech/Comprehension quantity, rate, volume, articulation and fluency Wernicke’s Area- Temporal lobe (primary auditory receptor center) Language comprehension Damage- receptive aphasia o Hears sound but has no meaning Broca’s Area Frontal lobe Motor speech Damage- expressive aphasia o Understand and knows what to say, but only produces a garbled sound Cognitive Functions - Orientation: o aware of person (who they are) o place (where they are) o time (when is it); this requires memory and attention - Attention span: the ability to focus or concentrate - Memory: the process of recording and retrieving information ( recent, remote, new learning) Physical Assessment: Final Study Guide Thought Processes and Perceptions Thought processes: the logic, coherence, and relevance of a patient’s thoughts – does this person make sense? – Do I understand this person? Perceptions: the person should be consistently aware of reality and their perceptions should be congruent with yours Screen for: – Anxiety – Depression Suicidal thoughts Judgment Judgment: process of comparing and evaluating different possible courses of action Insight: awareness that thought, symptoms, or behaviors are normal or abnormal – e.g.: distinguishing that a daydream or hallucination is not real Mini-Mental State Examination (MMSE) Expect confusion, infection, or head trauma Test of the cognitive functions of the mental status exam: – Memory – Orientation to time and place – Naming – Reading – Copying or visuospatial orientation – Writing – Ability to follow 3 stage command Quick and easy test, 11 questions take 5-10 minutes to administer V2.0 Improved overall sensitivity and validity easier to translate into other languages and cultures has a brief and expanded versions to adjust difficulty – Includes- Story Memory and Processing Speed – takes 5 minutes and worth 16 points Results Normal result = 24-30 Mild cognitive impairment = 18-23 Severe cognitive impairment = 0-17 Can be used for baseline assessment and re-assessment to detect worsening cognition Abnormal Findings Inability to recall immediate or long-term information