Health Assessment Exam Note PDF

Interview and SOAP ▪ Document pertinent positives and negatives. ◆ Beginning of interview ▪ Must adhere to SOAP note format. o Prepare: review chart n...

Interview and SOAP ▪ Document pertinent positives and negatives. ◆ Beginning of interview ▪ Must adhere to SOAP note format. o Prepare: review chart notes, intake forms, and screening o SOAP questionnaires ▪ Subjective: Information from the patient o Set the stage for the interview (30-60 seconds). ▫ CC, HPI, PMH/PSH, FM, SH (SDOH), ROS o Elicit chief concern and set agenda (1-2 minutes). ▪ Objective: What the clinician observes through physical ▪ Indicate the time available. Forecast what will happen during exam (even other clinicians’ observations included.), data the interview. o ▫ V/S, Ht, Wt, BMI, PE, labs and imaging results | 1 Begin the interview with non-focusing skills that help the patient ▪ Assessment: Diagnosis to express themselves (30-60 seconds). ▪ Plan: Treatment advised by the clinician ▪ Open-ended skills. Obtain data from non-verbal sources. ▫ Medication, labs and imaging, consultations, and o Use focusing skills to learn 3 things: symptom story, personal referrals, instructions, patient education context, and emotional context (3-10 minutes). ▪ Elicit symptom story: “Tell me more about it.” ▪ Elicit personal context ▪ Elicit emotional context: “How are you doing with this?” “How has this affected your life?” ▫ N: Name the emotion Mental health ▫ U: Express that you understand ◆ Mental health in primary care ▫ R: Respect o Screen for mental health conditions ▫ S: Support o Assess, diagnose & treat common conditions ▫ E: Explore ▪ If complex conditions (comorbidity), refer to psychiatry o Transition to the middle of the interview (clinician-centered o Refer high-risk phase) (30-60 seconds). o Collaborate ▪ Brief summary, check accuracy ◆ Mental health screening ◆ Middle of interview o For anxiety: children 8 to 18 years old o Obtain a chronological description of the HPI (History of Present ▪ SCARED (Screening children for anxiety-related disorders) Illness). ▪ Social phobia inventory ▪ Without interpreting it. o For depression: all persons 12 years old + ▪ OLD CHARTS ▪ PHQ-9, PHQ-A (Patient health questionnaire) ▫ O: Onset of the problem ▪ GDS (Geriatric depression scale) ▫ L: Location + radiation ▫ D: Duration ▪ EPDS (Edinburgh postnatal depression scale) ▫ C: Character of the discomfort o For substance use: adults 18+ ▫ A: Aggravating factor ▪ NIDA quick screen (National institute on drug abuse) ▫ R: Relieving factor ▪ TAPS (Tobacco, alcohol, prescription medication, and other ▫ T: Timing substance use) ▫ S: Severity ▪ AUDIT-C (Alcohol use disorders identification test – o PMH (Past Medical History) / PSH (Past Surgical History) consumption) ▪ Past illness, past injuries, past hospitalizations, immunization ▪ SASQ (Single alcohol screening question) history, status of age-appropriate preventative screening, ◆ Mental health assessment current medications, allergies o SH: sleep, appetite, energy, early family life, intimate o FH (Family History) relationships, social relationships, work experiences, education ▪ General inquiry, specific to certain disease states o ROS: anxiety, depression, psychotic disorders, substance use o SH (Social History) disorders, cognitive disorders, somatic + general, cardiac, neuro, ▪ Health promotion (diet, physical activity, functional status), GI sexual history, substance use, health literacy, occupation, o Subjective includes: psychiatric history personal (living arrangement), legal issue, safety, support o Objective includes: MSE (mental status exam), cognitive exam, system, abbreviated physical exam o ROS (Review of System) ▪ MSE: appearance, behavior, speech, affect, thought process, ▪ General, heme, cardiac, vascular, pulmonary, neuro, psych, thought content, cognitive examination GI, GU, endocrine, MSK, HEENT, skin, reproductive, breast ▫ Remember that patients can read their notes. ◆ End of interview ▫ Beware of jargon. o Orient the patient to the end of the interview and ask for ▪ Cognitive exam: attention and concentration, memory, permission to begin the discussion. judgment, insight (on their situation) o Explain the diagnosis/prognosis. o Invite patients to participate in shared decision-making. o Explain testing and/or treatment options until agreement is reached; incorporate patient preferences. o Summarize decisions and provide written plans and instructions. o Acknowledge and support before saying goodbye. ◆ SOAP o Guidelines for SOAP ▪ Keep it clean and concise; it needs to be well-written ▪ Medical jargon is OK Geriatric health ▫ 0 is the most independent, and 6 is the most ◆ Geriatric assessment dependent o Most common o Instrumental ADL ▪ Men: Deafness (423.5) > Arthritis (409.6) > Hypertension ▪ Using the phone, shopping, preparing food, housekeeping, (342.1) > Heart disease (324.3) > Cataract (214.1) transportation, medication management, finances ▪ Women: Arthritis (583.5) > Hypertension (463.3) > Deafness ▪ Lawton IADL Scale (307.3) > Heart disease (247.9) > Cataract (246.9) o Functional reach test: balance o ▪ | 2 It is important to differentiate between the normal physiological A score of 6 or less indicates a significantly increased risk for changes of aging and acute and chronic disease symptoms. falls. o The normal physiology changes of aging are what predispose the ▪ A score between 6-10 indicates a moderate risk for falls. older adult to acute and chronic disease. o Cognitive assessment ▪ E.g., Peripheral arteries tend to lengthen, become tortuous, ▪ 3D and are harder and less resilient, which leads to conditions ▫ Delirium: acute confusion state characterized by like atherosclerosis, temporal arteritis, AAA, PVD, etc. sudden onset, fluctuating course, inattention, and, at o Multifactorial condition that involves the interaction between times, alteration of consciousness; preventable, identifiable situation-specific stressors and underlying age-related treatable risk factors resulting in damage across multiple organ symptoms o Confusion assessment method: CAM test ▫ Dementia: declines in memory and cognitive ability that interfere with ADLs that occur over time; non- preventable, non-treatable, permanent o Dementia assessment method: Mini-Cog, MoCA (Montreal Cognitive Assessment) ▪ Mini-Cog: clock drawing and recall test ▫ Depression: alteration in the usual mood with feelings o Consider: functional status, cognitive testing, frequent of sadness, despair, and lack of enjoyment of previously medication review (reconciliation), risk/benefit of any new test or enjoyed activities, which can cause a vegetative state treatment plan, frequent assessment of goals of care and that impairs functioning prognosis, access to care o Depression assessment method: PHQ (Patient ◆ Screening Health Questionnaire), Geriatric Depression Scale o Vision: "Do you have difficulty driving, reading, or watching TV? ▪ Contributing factors: metabolic abnormalities, medications, etc." substance use ▪ If yes, the Snellen chart ▪ Collateral information: family/friends/caretakers ▪ Positive: Yes to question & inability to read >20/40 on ▪ Caregiver counseling Snellen chart ▪ Referral for neuropsychological testing o Hearing: Whisper test, otoscope, audioscope ▪ Advanced directives: MOLST (Medical Orders for Life- ▪ Positive: any positive finding Sustaining Treatment) o Nutrition/weight loss: "Have you lost 10lbs over the past 6 o Polypharmacy months without trying to do so?” + Weigh patient ▪ A single most common modifiable risk factor associated with ▪ Positive: Yes to question, weight 10 seconds to complete effects in the elderly due to the physiologic changes of o Physical disability: "Are you able to... aging ▫ Do strenuous activities like fast walking or biking? ▫ Intended to be applied to adults 65 years old and older ▫ Do heavy work around the house, like washing in all ambulatories, acute, and institutionalized settings windows? of care, except hospice and end-of-life care settings ▫ Go shopping? ▫ Goal ▫ Get to places out of walking distance? o Reduce older adults’ exposure to Potentially ▫ Bathe (sponge bath/tub/shower)? Inappropriate Medications (PIMs) by improving ▫ Dress yourself (buttoning/zipping)?" medication selection ▪ Positive: No to any questions o Educate clinicians and patients o Depression: "Do you often feel sad or depressed?" o Serve as a tool for evaluating the quality of care, ▪ Positive: Yes to the question cost, and drug use patterns in older adults. ◆ Geriatric assessment o Nutrition o Basic ADL (Activities of daily living) ▪ Physical manifestations of malnutrition ▪ ① Transferring, ② Toileting, ③ Bathing, ④ Dressing, ▫ Unintentional weight loss: BMI and visible loss of ⑤ Continence, ⑥ Feeding muscle mass ▪ Katz basic ADL Index ▫ Fatigue ▫ Total is 6 points, 1 point per section ▫ Feeling cold  ▫ Nutritional deficiencies Genitalia health ▫ Dehydration ◆ Genitalia health assessment ▫ Frequent illness/longer time to recover from illness o PMH/PSH ▪ Contributory factors for malnutrition ▪ Menstrual history: age at menarche, date of last normal ▫ Poor dentition menstrual period, cycle length, cycle duration, cycle flow, ▫ Oral and GI disorders: e.g., dysphagia and any menstrual irregularities or symptoms associated ▫ Depression with menses ▫ Cognitive deficits ▪ Pregnancy history: gravida and para, course of pregnancies ▫ Medication side effects (date, duration, type of birth, complications, newborn’s sex | 3 ▪ Assess dietary history, access to food/food preparation and weight, whether the child is currently alive and well), ▪ Mini nutritional assessment abortions, ectopic pregnancy, molar pregnancy ▪ Other artificial feeding considerations ▪ STI (sexually transmitted infections) history: date, frequency, ▫ Pressure ulcers treatments received, complications ▫ Aspiration PNA ▪ Gynecologic procedures and surgeries ▫ Malnutrition ▪ Cervical cancer screening: date, history of abnormal results ▫ Quality of life o SH ▫ Functional status ▫ Complications ▪ Sexual health: sexual orientation and gender identity, current sexual relationships, types of sex, safer sex practices, o Tube leakage: skin breakdown sexual satisfaction and orgasm, pain with sex, sexual o Gastroesophageal reflux: aspiration concerns o Ileus o Peritonitis/gastric perforation ▪ Contraceptive use (types, duration used, consistency of use, o Diarrhea satisfaction, and side effects) or previous contraceptive use o Fluid overload and metabolic disturbances ▪ Genital hygiene: Vaginal or rectal douching frequency, o Cellulitis medication or solutions used, reasons for douching, pubic o Depression/anxiety over not tasting food or social hair removal, piercings, other products (creams, lubricants, aspects of eating specialty soaps, scented pads or tampons), breast/chest o Site discomfort binding o Abscess/erosion o ROS o Frailty ▪ Urologic and rectal health: infections, urinary or bowel ▪ Age-related lack of adaptive physiological capacity incontinence, others occurring even in the absence of identifiable illness o Consent and chaperones ▫ Loss of muscle mass ▪ Consent: process of communication between a clinician and ▫ Decreased energy a patient that results in the patient’s authorization or ▫ Exercise intolerance agreement to undergo a specific medical intervention. ▫ Decreased physiologic reserve ▪ If someone declines recommended care, further attempts by ▫ Increases vulnerability to stressors the health care provider to obtain acquiescence are coercion ▪ Special consideration unless a new consent process is initiated because of a ▫ Atypical presentations: infections less likely to have change in clinical circumstances. fever, MI does not always cause chest pain ▪ Chaperones are recommended in all health care settings for ▫ Underreporting: use screening tools, EMR, and all intimate examinations regardless of the health care collateral information provider’s sex or gender identity. ▫ Environment: accessibility, temperature, lighting, noise ◆ AFAB (Assigned female at birth) genitalia exam ▫ Communication: pace of visit, slow and clear, eye o Breast exam: CBE (Clinical breast exam) / SBE (self breast exam) contact ▫ Allow time: open-ended questions, reminiscing ▪ Inspection ▫ Sitting position ▫ What matters most: establish goals of care, quality of ▫ Retraction in 4 views (arms at sides, arms overhead, life arms pressed against hips, and leaning forward) ▫ Follow-up and plan: provide clear, large font ▫ Medications: provided the most up-to-date list every ▫ Note: symmetry, swelling, nodules, or ulceration visit ▪ Palpation ▫ Instructions at the end of the visit ▫ Position o Fall o Supine: from the clavicle to the inframammary fold or bra line, from the midsternal line to the ▪ To identify risk for fall: Timed up and go posterior axillary line, and well into the axilla ▪ Required initial assessment for elderlies with a history of o Roll onto the opposite hip, placing her hand on falls: manual pulse assessment, orthostatic BP her forehead: lateral breast ◆ General considerations o Lie with her shoulders flat against the examining o Reasonable goals for the initial office evaluation of an older table and then slide up her flexed elbow until it is patient include all of the following: at the level of her shoulder: medial breast ▪ Medication review o Note nodules (location, size, shape, consistency, ▪ Functional assessment delimitation, tenderness, mobility) ▪ Determining priorities of care ▫ 3 methods for systematic breast exam o Vertical strips ▪ Except for performing a complete physical exam o Pie or Radial Spoke Pattern o Circular Pattern ▫ Palpate each nipple, noting its elasticity o Axillae exam  ▪ Inspection o Male breast exam ▫ Sitting position ▪ Inspection ▫ Note rash, unusual pigmentation, irritation, and ▪ Palpation infection signs. o Genitalia exam ▪ Palpation ▪ Genitalia exam for infant and young toddler ▫ Left axilla: Use your right hand to examine the left ▫ Tanner staging (SMR, Sexual maturity rating): axilla. objective classification system that providers use to ▫ Right axilla: Use your left hand to examine the right | 4 document and track the development and sequence of axilla. secondary sex characteristics of children during o Genitalia exam puberty. ▪ No evidence supports the routine internal examination of ▫ Sports physical exam to see hernia the healthy, asymptomatic patient before age 21 years. ▪ There is no standard or routine screening test for testicular ▪ Avoids intercourse, douching, or use of vaginal cancer. suppositories for 24 to 48 hrs before examination. ▪ Inspection ▪ Empties her bladder before the examination. ▫ Penis: If the patient is uncircumcised, draw back the ▪ Obtain permission and select a chaperone. foreskin. ▪ Lithotomy position: Lies supine, with head and shoulders ▫ Scrotum and scrotal contents elevated, and arms at her sides or folded across the chest to o Transillumination: to see hydroceles enhance eye contact and reduce tightening of abdominal ▪ Palpation muscles. Place one heel, then the other, into the foot ▫ Penis: Palpate the shaft of the penis between your holders. thumb and first two fingers. ▪ Drape the patient from the mid-abdomen to the knees. o Note any induration or tenderness. ▪ External exam ▫ Scrotum and scrotal contents ▫ Epididymis: on the posterior surface of each testicle ▫ Inspection without applying excess pressure o Note swelling, nodules, ulceration, inflammation, or discharge. ▫ Spermatic cord, including vas deferens ▫ Palpation ▪ Hernia exam o Labia minora, clitoris, urethral meatus, vaginal ▫ Inspection opening o Sitting comfortably in front of the patient, with ▪ Internal exam with the speculum the patient standing. ▫ Palpation ▫ Inspection o If you are examining the right inguinal region, o Types of speculum: Graves specula (Duckbill specula), Pederson specula, pediatric place the index finger of your right hand along the spermatic cord, inverting the scrotal skin as o Select an appropriate speculum and introduce the you trace the cord to where it emerges from the closed speculum at approximately 30° downward external ring of the inguinal canal. Move your toward the cervix. o Rotate the speculum into a horizontal position, finger and hand upward toward the external maintaining pressure posteriorly, and insert it to its inguinal ring, invaginating the redundant scrotal full length. Then, slowly open the speculum to skin beneath the peripubic fat pad next to the base of the penis. Ask the patient to cough. Use the visualize the cervix. same techniques with the same dominant finger o Close the speculum before removing it. to examine both sides. ▫ Obtain specimens for Pap smears o Types of device ▪ Anus, rectum, and prostate exam ▪ Brush: Slowly rotate 1/4 to 1/2 turn in one ▫ Ask the patient to lie on his left side with his buttocks direction only. Do not over-rotate the brush. close to the edge of the examining table near you. ▪ Spatula: Rotate 360° around the entire Partially flexing the patient’s hips and knees, especially ectocervix. in the upper leg, stabilizes his position and improves ▪ Broom-like device: Allow the shorter bristles visibility. to fully contact the ectocervix. Push gently ▫ Inspection and rotate 5 times clockwise. o Sacrococcygeal and perianal areas ▪ Q-tip, cotton swab o Note discoloration, inflammation, ulcers, rashes, ▪ BPE (Bimanual pelvic exam) lesions, or excoriations. ▪ Adult perianal skin is normally more ▫ BPE only if young women have a medical history or certain symptoms like pelvic pain and unusual pigmented and coarser. bleeding. ▫ Palpation o Palpate any abnormal areas, noting masses or ▫ Palpation: Insert the lubricated index and middle tenderness. fingers (Close other fingers but the index and middle ▫ DRE (Digital rectal exam) fingers.). Press inward on the perineum with your other o Insert lubricated index fingers. Proceed in the hand of flexed fingers. general direction of the umbilicus. Palpate o Palpate cervix, uterus, each ovary circumferentially. ▫ Assess the pelvic floor muscles for strength and tenderness. Ask the patient to squeeze around your o Ask the patient to squeeze the external anal fingers as long and hard as possible. sphincter to assess muscular tone. o Palpate the prostate gland: Orient your finger to ▪ Rectovaginal exam be directed anteriorly (i.e., toward the patient's ▫ Slowly reintroduce your index finger into the vagina and umbilicus). your middle finger into the rectum. ▪ Normal findings: rubbery, firm prostate ◆ AMAB (Assigned male at birth) genitalia exam noted with a finger sweep Respiratory health o Auscultation ◆ Respiratory assessment ▪ Listening to the sounds generated by breathing. o HPI: changes in breathing, cough, sputum, SOB, fever, weakness, ▫ With the diaphragm of stethoscope chest pain ▫ Always place the stethoscope directly on the skin o Patient’s appearance: any assistive devices, oxygen tank, ability to ▫ Ladder-like pattern ambulate ▫ Posterior: 14 spots o Normal respiratory rate: 14-20/min for adults, 44/min for infants o Normal sound in trachea: bronchial (high-pitched, ▫ harsh, hollow tubular sound) ◆ Respiratory landmark o Normal sound in bronchi: bronchovesicular | 5 (moderately pitched, mixed quality, equally heard o Suprasternal notch / sternal angle (Angle of Louis) / xiphoid on inspiration and expiration) process o Normal sound in peripheral lung areas: vesicular o Inferior tip of scapula generally at 7th rib (low-pitched, soft, wind-like) o Midsternal line, midclavicular line, anterior axillary line, ▫ Anterior midaxillary line, posterior axillary line ▫ Right middle lobe: 4th rib MCL to 5th MAL down to 6th o Scapular line, vertebral line rib MCL or anterior axillae/MCL line between the 4th ◆ Respiratory exam and 6th ribs o Inspection o Normal sound in right middle lobe: vesicular ▪ Posterior chest: with the patient sitting, the patient’s arms ▪ Listening for any adventitious sounds should be folded across the chest with hands resting, if ▪ Listening to the sounds of the patient’s spoken or whispered possible, on the opposite shoulders. voice as they are transmitted through the chest wall ▪ Anterior chest: with the patient supine, the patient should ▫ With the diaphragm of stethoscope lie comfortably with the arms abducted. ▫ Egophony: Ask the patient to say “ee.” You will normally ▪ Observe respiratory efforts, noting rate, rhythm, and depth. hear a muffled, long E sound. If “ee” sounds like “a” and Note the presence of dyspnea, cough, and accessory muscle has a nasal bleating quality, an E-to-A change, or use. egophony, is present. ▪ Inspect for asymmetry, deformities, or discoloration ▫ Bronchophony: Ask the patient to say “ninety-nine.” (ecchymosis). Normally, the sounds transmitted through the chest ▪ Normal AP diameter ratio: 1:2 wall are muffled and indistinct. Louder voice sounds are ▫ Pectus excavatum (funnel chest) called bronchophony. ▫ Pectus carinatum (pigeon chest) ▫ Pectoriloquy: Ask the patient to whisper “ninety-nine” ▫ Barrel chest → COPD or “one-two-three.” The whispered voice is normally heard faintly and indistinctly, if at all. o Palpation ▪ Identify and palpate tender areas to see if it is reproducible. ▪ Note the intensity of the breath sounds, the pitch, and the duration of the inspiratory and expiratory sounds. ▪ Chest expansion: Place palms on the posterior chest wall at ▫ Abnormal lung sounds T9-10 with thumbs facing upward, and slide hands toward o Wheeze: high-pitched, continuous musical sound one another medially to pinch a small fold of skin. heard during expiration ▫ To see lung excursion o Rhonchi: low-pitched, continuous, long, gurgling, ▫ Note the synchrony of expansion and the degree of snoring sounds expansion. o Fine crackles: less loud, shorter duration, ▪ Fremitus refers to the palpable vibrations transmitted discontinuous, interrupted explosive sounds, through the bronchopulmonary tree to the chest wall as the higher pitched than rales but very similar to rales patient speaks and is normally symmetric. o Coarse crackle ▫ Posterior: 4 pairs o Rales: low-pitched, loud, discontinuous, ▫ Anterior: 3 pairs interrupted explosive sounds ▫ E.g., Positive tactile fremitus in left lower lobe → PNA o Pleural rubs o Percussion o Stridor: high-pitched, wheezing sound caused by ▪ Percussion is performed by extending the middle finger of disrupted airflow at supra-glottis, glottis, sub- the non-dominant hand and pressing firmly into the glottis, or trachea intercostal space. Press its distal interphalangeal joint firmly o Decreased breath sounds: obstruction or on the lung surface to be percussed. secretion ▫ Ladder-like pattern o Increased breath sounds: pneumonia ▫ Posterior: 14 spots o Consideration o Omit the areas over the scapulae because the ▪ Common in children: croup, epiglottitis, bacterial tracheitis, thickness of muscle and bone alters the percussion FBA, asthma notes over the lungs. ▪ Common in geriatrics: COPD, bronchiectasis, pulmonary ▫ Anterior: 12 spots HTN, PNA ▫ Normal percussion sound: resonance o Dullness: because fluid or solid tissue replaces air ▪ Annual LDCT (low-dose computed tomography) screening is recommended for current smokers or those who have quit containing lung tissue within the last 15 years if they have smoked an average of o Hyperresonance: indicates that the air is trapped. one pack of cigarettes for 30 years and are aged 55 to 80. ▪ Diaphragmatic excursion: posterior chest, determining the distance between the level of dullness on full expiration and the level of dullness on full inspiration ▫ Normal diaphragmatic excursion: 3 – 5.5 cm ▪ Percussing for liver dullness and gastric tympany: to estimate the size of the liver.  o Physical findings in selected chest disorders Cardiovascular health Condition Trachea Percussio Breath Adven. Trans. ◆ Cardiovascular assessment n sounds Sounds Sounds Normal Midline Resonant Vesicular, None Normal o PMH: hyperlipidemia, hypertension, arrhythmia, CHF, CAD (MI), bronvesi, valvular disease, CVA, DM, CKD, thyroid problems, anxiety bronchia ▪ Acquire the results of any recent diagnostics: EKG, echo, Lt. HF Midline Resonant Vesicular Inspirator Normal y crackle, stress test, catheterizations wheeze o FH: any 1st or 2nd degree relatives died from sudden cardiac Rt. HF Midline Resonant Vesicular Coarse Normal death at a young age (< 50) crackle, o SH: diet, activity, substance use (cocaine, caffeine, nicotine, | 6 Wheeze PNA Midline Dull Bronchial Inspirator Transmitt alcohol, any IV drugs) overinvol y crackles ed sound ved present ◆ Cardiovascular landmark Atelectasi Shifted to Dull Usually None Usually o Aortic area: 2nd ICS + RUSB s affected absent absent Pleural Shifted to Dull Decrease None but Decrease o Pulmonic area: 2nd ICS + LUSB effusion unaffect. to absent pleu. rub to absent o Erb’s point: 3rd ICS + LUSB Pneumo- Shifted to Hyper- Decrease None but Decrease o Tricuspid area: 4th ICS + LLSB thorax unaffect resonant to absent pleu. Rub to absent COPD Midline Hyper- Decrease Crackles, Decrease o Mitral area/apex: 5th ICS + L midclavicular line resonant to absent wheeze, ◆ Cardiovascular exam rhonchi Asthma Midline Resonant Obscured Wheeze, Decrease o BP to hyper- d/t Crackles ▪ After taking rest for at least 5 minutes resonant wheeze ▪ The patient’s unclothed arm at heart level ▪ Consolidation = infiltrate = pneumonia ▫ Heart level: at 4th ICS at the sternum ▫ Dullness on percussion ▪ Listen first for the Korotkoff sounds of at least two ▪ E.g., FB (inhaled a small toy): stridor in the right upper consecutive heartbeats; these mark the systolic pressure. anterior chest, high-pitched unilateral wheezing Then, listen for the disappearance point of the heartbeats, ◆ Stethoscope which marks the diastolic pressure. o Diaphragm: for high-pitched sounds, such as S1, S2, and o HR: palpate radial pulse or auscultate apical pulse regurgitation murmurs, with firm pressure o Inspection o Bell: for low-pitched sounds (by accentuating them), such as S3, ▪ Supine, head angled to 30° S4, and mitral stenosis, with light pressure ▪ Anxiety or shifty, any distress ▪ Labored breathing? ▪ Clutching their chest? o Palpation ▪ Supine, head angled to 30° + provider on the R side ▪ Palpate PMI (point of maximal impulse): most accurate reading of HR, mostly apical pulse ▫ Supine or L lateral decubitus position ▫ Place the tip of the index or middle finger at 4th or 5th ICS in the L midclavicular line ▫ Normal diameter: < 2.5cm ▫ Normal duration: 2/3 of the duration of the S1 heart sound and end before S2 ▪ Palpate anterior precordium ▫ Lift or heave → enlarged cardiac chamber ▫ Thrills (vibration or hum) → turbulent blood flow, severe cardiac murmur o Auscultation: most useful for valvular disease ▪ S1: “lub”; associated with systole; by diaphragm ▪ S2: “dub”; associated with diastole; by diaphragm ▪ S3: just after S2; best heard during diastole; at the apex and Left lower sternal border; indicative of HF (pathologic); but normal in children, pregnant people, athletes; by bell ▪ S4: right before S1; best heard during diastole; at the apex and Left lower sternal border; indicative of hypertensive heart disease or MI (pathologic); by bell ▪ Split S1: Represents the mitral and tricuspid valves not closing in unison; best heard during diastole; at the apex and Left lower sternal border; normal in most adults; by diaphragm ▪ Split S2: Represents the aortic and pulmonic valves not closing in unison; best heard during diastole; at the 2nd and 3rd ICS and Left upper sternal border; physiological during inspiration, but pathological during exhalation; by diaphragm ▪ Opening snap: indicative of stenotic or stiff valve; best heard during diastole; at the apex; by diaphragm  ▪ Cardiac murmur: indicative of turbulent blood flow Neurological system ▫ Murmur grade 1 – 6 ◆ Neurological assessment o Grade 1: quite faint o PMH/PSH o Grade 4: loud; palpable thrill ▪ Medication: any new meds (esp. antipsychotics), any recent o Grade 6: very loud; may be heard without d/c (e.g., SSRI) stethoscope o FH: any 1st or 2nd degree relatives have any significant ▫ Types of murmur neurological history, such as brain aneurysm o Aortic stenosis: R 2nd and 3rd ICS; radiating to o SH: diet, activity, substance use carotid arteries; during mid systolic; medium or | 7 ◆ Anatomy crescendo-decrescendo pitch; harsh sound; best heard with the patient sitting and leaning o CN (Cranial nerve) forward ▪ CN1: olfactory (smell) o Aortic regurgitation: L 2nd and 4th ICS; toward ▫ → smell test (correct identification of smell) apex; during diastole; high pitch, blowing sound; ▪ CN2: optic (ability to see and visual fields) best heard with the patient sitting and leaning ▫ → PERRLA (Pupils are equal, round, and reactive to forward with breath held following exhalation light and accommodation) o Pulmonic stenosis: L 2nd and 3rd ICS; may radiate ▪ CN3: oculomotor (eye movements) to L shoulder; during mid-systolic; medium, ▫ → full smooth movement in all directions crescendo-decrescendo pitch; harsh sound ▪ CN4: trochlear (eye movements) o Mitral stenosis: apex; during diastole; low ▪ CN6: abducens (eye movements) decrescendo pitch; rumbling sound; use the bell of stethoscope at PMI; best heard with patient in L lateral decubitus position o Mitral regurgitation: apex; toward L axilla, during holosystolic; medium or high pitch; harsh sound; murmur should not vary with respiration o Tricuspid regurgitation: LLSB; toward xiphoid process; during holosystolic; medium pitch; blowing sound; murmur will increase with inspiration ▪ CN5: trigeminal (facial sensation) o Assessing JVP (Jugular venous pressure) ▫ → light touch and pinprick (intact and symmetric) ▪ Indicative of an excess of fluid in the cardiovascular system, ▫ → palpate jaw muscles such as CHF ▪ CN7: facial (facial expression, eyelid closing, taste ▪ Raise the head of the bed to 30° to relax the sensation) sternocleidomastoid muscle and turn the patient's head to ▫ → frown, smile, puff out cheeks, show teeth, raise the left. The provider should be on the right. eyebrows, close eyes against resistance (intact and symmetric) ▪ Measured as the vertical distance between the top of the pulsation at the internal jugular vein (aka oscillation point) ▪ CN8: auditory (hearing, sense of balance) and the sternal angle (angle of Louis) with a ruler and an ▫ → whisper test (able to hear soft sounds), Weber, index card Rinne ▪ Normal JVP: < 3 cm ▪ CN9: glossopharyngeal (swallowing, taste sensation) ▫ → ask to swallow and observe o Carotid artery assessment ▪ Medial to the sternocleidomastoid muscle near the cricoid ▪ CN10: vagus (swallowing, taste sensation) ▫ → have the patient say “Ahh” and inspect soft palate cartilage. ▪ Auscultation: auscultate prior to palpation ▪ CN11: accessory (control of neck and shoulder muscles) ▫ → Shoulder shrug, push head against resistance ▫ Not recommended to hold breath. ▫ Use the diaphragm of the stethoscope. ▪ CN12: hypoglossal (tongue movement) ▫ Listen for sounds of turbulent blood flow called bruits. ▫ → push tongue against pressure, protrude tongue o Bruit: murmur-like sound instead of heartbeat o Spinal nerve ▪ Palpation ▪ 31 pairs of spinal nerves arise from the spinal cord and ▫ Palpate contour, amplitude, any thrills? supply all parts of the body ▫ Never palpate both carotid pulses simultaneously or ▫ 8 pairs of cervical spinal nerves use force during this exam because those techniques ▫ 12 pairs of thoracic nerves can induce carotid hypersensitivity and syncope, ▫ 5 pairs of lumbar nerves especially in geriatric patients. ▫ 5 pairs of sacral nerves ▫ Avoid pressing on the carotid sinus, which lies adjacent ▫ 1 pairs of coccygeal nerve to the top of the thyroid cartilage. ◆ Neuro exam o Cognitive test ▪ Cognitive test include ▫ Evaluation of orientation, memory, intelligence, and insight into their medical condition and ability ▫ Evaluation of overall health of patient’s cognitive state ▫ Assessment of appearance, behaviors, and communication ▫ Assessment of conversation fluency and goal-directed thinking ▪ Examples of formal cognitive test ▫ MoCA (Montreal Cognitive Assessment Test)  ▫ MMSE (Mini-Mental State Examination) o Pupillary reflex: test CN2 and CN3; Shine a light in ▫ 6CIT (6-Item Cognitive Impairment Test) each eye. Both eyes should constrict/dilate o Cranial nerve exam symmetrically and with a consensual response. o Fundoscopic exam o Corneal reflex: test CN5 and CN7; Lightly touch the ▪ Papilledema: increased intracranial pressure cornea with a cotton wisp, which should elicit a blink response. ▪ Excessive disc cupping: increased intraocular pressure o Achilles reflex: test S1 and S2; Hold the relaxed ▪ Disc pallor: optic atrophy foot slightly in dorsiflexion and strike the Achilles ▪ Microaneurysms: increased small capillary pressure tendon with the reflex hammer, causing the foot to | 8 ▪ Macular edema: blood vessels leaking contents into the plantar flex. macular region o Plantar reflex: test corticospinal tract: Stimulate o Muscle function test the lateral aspect of the foot across the ball of the ▪ Provider applies pressure foot to the base of the great toe, causing flexion of downward/upward/outward/inward and patient pushes the big toe. upward/down/inward/outward with fists. ▫ Deep tendon reflex ▪ Provider applies pressure downward/upward and patient o Biceps reflex: test C5 and C6; Place thumb directly pushes upward/downward with legs (seated position). over the biceps brachial tendon, then strike thumb with a reflex hammer. ▪ Provider applies pressure down on top of toes and patient o Triceps reflex: test C6 and C7; Tap the triceps dorsiflexes up against pressure. tendon with a reflex hammer while the arm ▪ Provider applies pressure up below toes and patient plantar relaxes. flexes down against pressure. o Brachioradialis reflex: test C6, C7, and C8; Strike ▪ Evaluation the brachioradialis tendon on the radial side of the ▫ Trophic state (bulk): Observe the size, shape, and forearm. symmetry of muscles. o Patella reflex: test L2, L3, and L4; Stike the patellar ▫ Tone: Ask the patient to relax and then passively move tendon, just below the kneecap. the limb. Note any resistance, rigidity, or asymmetry ▪ Evaluation between sides. ▫ Reflex grading ▫ Strength: Scored according to a standardized grading o Grade 0: Mute (No reflex) system from full strength to no voluntary movement. o Grade 1+: Hyporeflexic (Decreased reflexes o Grade 5: Movement against full resistance resulting from a peripheral nerve lesion: nerve o Grade 4 (4-/4/4+): Movement against some root, plexus, or peripheral nerve) resistance ▪ Maybe due to a patient being tense/needing o Grade 3: Movement against gravity only distraction in the moment of testing o Grade 2: Movement with gravity eliminated o Grade 2+: Normal o Grade 1: A trace of voluntary movement o Grade 3+: Hyperreflexic (Excessive reflex o Grade 0: No voluntary movement response, usually a result of a central lesion) o Sensory function test o Grade 4+: Hyperreflexic with clonus (The rapid, ▪ Basic involuntary, rhythmic contraction of a muscle ▫ Light touch: Use a cotton wisp or light touch of the group after a sudden muscle stretch; symptom of fingers to assess light touch receptors spasticity from a lesion in the upper motor ▫ Pinprick/sharp touch: Touch the patient's skin with a neurons.) neuro-tip or unused safety pin to assess pain ▪ Testing usually occurs at the ankles. ▫ Temperature: Use hot water (40°C–45°C), cold water o Cerebellar function test (5°C–10°C), or a cool tuning fork to test temperature ▪ Finger-nose-finger test: Tests the patient for upper sensations extremity coordination and kinetic tremor ▫ Vibration: Hold a tuning fork to the bony aspect of the patient’s foot and wrist. Ask the patient to state when ▪ Rapid alternating hand movements: Ask the patient to rapidly slap their hands on their lap, alternating between the they no longer feel the vibration, which can be judged dorsal and palmar aspects of their hands. against when the examiner no longer feels it. ▪ Higher order ▪ Heel-to-shin test: Evaluates lower extremity coordination. The patient traces a path from the top of the kneecap down ▫ Proprioception Tests: Assess the patient's ability to the full length of the shin with the heel. sense body position. ▫ Stereognosis: the ability to identify an item by feel. ▪ Gait test ▫ Graphesthesia: the ability to discern what is written on ▫ When a patient walks, look for a steady, symmetric gait one’s hand without being able to see. with regular stride length. Evaluate arm swing, which ▫ Point localization: Briefly touch a point on the patient’s should fit the natural rhythm of the walk. skin. Then, ask the patient to open both eyes and point ▫ Measure length of step: measured from one foot's toe to the place touched. Normally a person can do so to the heel's placement (should generally be 14 – 16″). accurately. ▫ Observe how a patient negotiates a 180-degree turn. ▫ Extinction: The inability to sense two simultaneous Look for blocked turns (turns that require more than stimuli after previously sensing each individually. four steps) Normally, both stimuli are felt. The face and legs can ▫ Heel and toe walking: Gastrocnemius muscle testing is also be tested in the same manner. best tested by toe walking, and tibialis anterior strength o Brudzinski’s sign (head up), Kernig’s sign (knee 90°) is best tested by heel walking → meningitis ▫ Tandem walk: a test of balance; Ask the patient to walk a straight line, touching the heel of one foot to the toe o Reflex test of the other foot with each step. ▪ Types of reflex o Balance trouble, reduced sensation in feet, lack of ▫ Superficial reflex proprioception Abdominal system ▪ Note vessel abnormalities. ◆ Abdominal assessment ▫ Prominent vessels on the abdominal wall → disease o PMH/PSH ▫ Spider angiomas → liver cirrhosis ▪ Medication: anticholinergic agents, SSRI, metformin, GLP-1 ▫ Distended vessels or varicosities → hepatic disease, agents, NSAIDs, PPIs heart failure, occlusion of other vessels ▪ Allergies: lactose, perceived gluten intolerance, other foods ▪ Note scar. o FH: cancer, inflammatory bowel disease, autoimmune disease o Auscultation ◆ ▪ Auscultate bowel sounds Anatomy ▫ Use the diaphragm of the stethoscope to assess bowel | 9 o Pain patterns sounds. ▪ Visceral pain: less localized ▫ Listen in all 4 quadrants and note the presence and ▪ Parietal pain: more acute, more specific quality of bowel sounds. ▫ Due to pressure against the peritoneum → the patient ▫ Normal bowel sounds: medium-pitched, occurs up to may avoid moving 12 times/min (every 5-15 seconds) ▪ Referred pain: typically occurs at other areas on the same o If bowel sounds are hypoactive, the examiner spinal level may have to listen for 2 to 5 minutes. ▫ E.g., epigastric pain when the patient is experiencing a o If bowel sounds cannot be heard, try placing the MI stethoscope just to the right of the umbilicus, o The location of abdominal symptoms often gives key diagnostic over the ileocecal valve. clues. ▫ Types of bowel sounds o RUQ: gallbladder, liver, pylorus, duodenum, ascending colon o Hyperactive (greater than 30 times/min): hunger o LUQ: stomach, spleen, pancreas, transverse colon (normal), diarrhea, bacterial or viral o LLQ: descending colon gastroenteritis, intestinal obstruction o RLQ: appendix, ascending colon, cecum o Hypoactive (less than 5 times/min): medications, o Cardinal sings bowel obstruction, postoperative paralytic ileus, peritonitis ▪ Peritonitis: guarding, rebound tenderness, rigidity o Borborygmi: normal digestion, gastric dilatation ▪ Crohn’s disease: weight loss, RLQ tenderness, steatorrhea o Succussion splash: delayed gastric emptying, ▪ Pancreatitis: pain in the upper abdomen that radiates to gastric dilation, obstruction the back o High-pitched rushing sounds: small bowel ▪ Bowel obstruction: abdominal pain, constipation, obstruction abdominal distension, absent bowel sounds, visible o Absent: postoperative paralytic ileus, bowel peristalsis obstruction ◆ Abdominal exam ▪ Auscultate abdominal vessels o General consideration ▫ Use the bell of the stethoscope to listen for bruits in ▪ Drape appropriately. The exam technically spans from just the abdominal vessels. below the nipple line to the symphysis pubis. ▫ Bruits are produced when blood flows through a ▪ Prior to examining a patient with an abdominal complaint, narrowed artery or when a large volume of blood flows ask the patient to point to the painful area. from an area of high pressure to an area of lower ▪ Involves four basic techniques in this order: inspection → pressure. ▫ Listen for bruits over the descending aorta and the auscultation → percussion → palpation renal, iliac, and femoral arteries. ▫ Palpation often causes severe pain and apprehension, so perform it last. o Percussion o Inspection ▪ Used to measure and locate abdominal organs and to assess ▪ General observation: the degree of discomfort, the patient’s for the presence of masses and fluid collections. preferred position ▪ The entire abdomen should be percussed. ▫ Fetal position → renal colic? ▪ Percussion should not be performed if a patient has a ▫ Lying still with flexed knees → peritonitis? transplanted organ or if an abdominal aortic aneurysm is ▪ Inspect abdominal size, contour, shape, and symmetry. Note suspected. masses, bulges, nodules, pulsations, muscle guarding, and ▪ Tympanic sound or dull sound peristalsis. ▫ Tympanic or hollow sound → air-filled areas ▪ Note abdominal distension. ▫ Dull sound → solid areas with organs, masses, or stool, ▫ Lower 1/3 of the abdomen: full bladder, pregnancy, fluid collection such as cysts or ascites ovarian tumor, uterine fibroids o Palpation ▫ Lower 1/2 of the abdomen (below the umbilicus): full ▪ Used to assess tenderness, resistance, abdominal wall bladder, pregnancy, ovarian tumor defects, abdominal masses, organomegaly, and peritoneal ▫ Upper 1/2 of the abdomen (above the umbilicus): irritation splenomegaly, hepatomegaly, pancreatic cyst, gastric ▪ The entire abdomen should be palpated. fullness ▪ Light palpation ▫ Distention of the entire abdomen: obesity, ascites ▫ If the patient is experiencing pain, begin light palpation pregnancy with the fingertips in the area furthest away from the ▫ Others: constipation, bowel obstruction painful region. ▪ Inspect skin changes. ▫ Diagnostic clue: location, depth, guarding, tenderness, ▫ Brusing → internal bleeding referred tenderness (Rosving’s sign), rigidity (sign of ▫ Cullen’s sign and Grey Turner’s sign → retroperitoneal underlying peritoneal inflammation), discomfort or pain bleeding associated with pancreatitis or ruptured ▪ Deep palpation aortic aneurysm  ▫ After lightly palpating the entire abdomen, the patient ▫ If full urinary bladder, dull sounds should be asked to flex the knees, which relaxes the ▪ Palpation: the volume must be 400-600ml to palpate abdominal muscles, allowing for more effective deep ▫ Normal findings: not palpable palpation. ▫ If palpable over symphysis pubis, it indicates an ▪ Evaluating the abdominal aorta enlarged bladder. ▫ During the abdominal exam, the aortic pulsation can be o Assess for appendicitis felt in the epigastric region. ▪ Rebound tenderness on McBurney’s point: Tenderness at a ▫ Average width of abdominal aortic pulsation: < 3cm point located at 1/3 of the distance between the umbilicus o Assess the abdominal wall masses and the anterior superior iliac spine. This distance is | 10 ▪ Determine whether it is in the abdominal wall (intramural) approximately 2 inches. or within the abdominal cavity ▫ Rebound tenderness: more pain when letting go is ▪ Have the patient tense the abdominal muscles (either by positive raising the head or raising both feet). → become more ▪ Psoas sign: The patient experiences pain when the right hip prominent when the abdominal muscles are tense. is passively extended. The patient flexes the hip in response ▪ Note size, shape, consistency (hard, soft, or rubbery), to the pain. location, mobility, tenderness ▪ Obturator sign: The patient experiences suprapubic pain o Assess the liver when the examiner flexes the thigh and rotates the femur ▪ Liver size assessment: using percussion in the R internally and externally. midclavicular line (MCL) ▪ Rosving’s sign: The patient experiences pain in the right ▫ Normal liver span: 6-12 cm in the MCL lower quadrant when the left lower quadrant is palpated. ▪ Liver palpation o Assess for peritonitis ▫ Place the hand below the lower liver border and ask the ▪ Guarding or rigidity on light palpation → peritonitis patient to take a deep breath. The examiner’s hand ▪ Rebound tenderness, percussion tenderness should remain stationary as the patient inhales, which ▪ Cough test allows the liver to be palpated as it passes under the o Assess for ascites examiner’s fingers. ▪ Ascites: fluid collection in the peritoneal cavity due to ▫ “Hooking” method: With the patient supine, stand on cirrhosis or liver failure the patient’s right side, facing the patient’s feet. Curl (or hook) the fingers of one or both hands around the ▪ Sx: bulging flanks, fluid wave, tympany on the superior costal margin or just below the lowest area where liver surface, shifting dullness dullness was percussed. As the patient takes a deep ▪ Ultrasound is the gold standard for ascites. breath, the examiner’s fingers hook inward and up, ◆ Pediatric considerations feeling for the edge of the liver. o Clues of illness: changes in feeding behavior, stool consistency ▫ Palpation of a healthy liver can be painful. o Umbilical hernia: bulging at the umbilicus, usually from a portion ▫ Enlarged and tender liver → hepatitis, congestive of the bowel protruding through the open umbilical ring. heart failure, cancer o Pyloric stenosis: forceful vomiting, olive-shaped mass in the ▫ Irregular liver border or palpable nodules → cirrhosis RUQ upon palpation o Assess for gallbladder disease o Intussusception: intermittent spells of crying accompanied by ▪ Murphy’s sign: With the patient supine, palpate in the severe abdominal pain, sausage-shaped mass in the RLQ upon subcostal region of the RUQ while the patient takes a deep palpation, currant jelly stools which are bloody and filled with breath. This deep inspiration pushes the gallbladder toward mucus. the examiner’s hand. ◆ General consideration ▫ Focal tenderness + stop breathing → cholecystitis o Don’t forget to drape, offer a chaperone if needed, and have the o Assess the spleen patient move clothing/drape. ▪ Percussion: Percuss the lowest intercostal space in the L o Place your hands on top or under the patient’s hands if the anterior axillary line (AAL). Then, Ask the patient to take a patient is overly sensitive/ticklish. deep breath and percuss the same spot again. o To reduce voluntary guarding, have the patient bend their knees ▫ Normal findings: tympanic → remain tympanic to relax the abdominal wall muscles, open their mouth with jaw ▫ Castell’s sign: dullness → enlarged spleen relaxed, or exhale. ▪ Palpation: The patient should lie supine, with arms at the sides and knees slightly flexed to relax the abdominal musculature. Palpate for the spleen at the left costal margin in the MCL. ▫ Normal findings: not palpable o Assess the kidneys ▪ Palpation: similar to the technique for spleen palpation ▫ Normal findings: not palpable ▪ As the patient inhales, capture the kidney by lifting up with the bottom hand while palpating deeply using the upper hand. This maneuver should be done on each side. ▪ CVAT (Costovertebral angle tenderness): place an open palm flat over the CVA and strike the hand with the heel of a closed fist. → if pain, inflammation of renal capsule (pyelonephritis), renal colic ▫ CAV: 12th rib + adjacent lumbar vertebrae o Assess the bladder ▪ Percussion: above the pubis  HEENT & Lymph health ▪ Acute otitis externa (swimmer’s ear): water doesn’t get ◆ Head assessment out, swollen and erythematous ear canal, pain on touch, o Common reasons: trauma (hematoma), pain, abscess, rash, ROM tender tragus deficits, neurologic problems, hair distribution ▪ Serous OM (OM effusion): fluid trapped in the middle ear ▪ Hair distribution: related to anemia, thyroid disease, but not infected ⇒ nasal spray, antihistamine, Mucinex psychiatric disease, Lyme disease without ABX, warm compress o Inspection: positioning, any tremors, symmetry, any deformity, ▪ Acute otitis media (OM): infection of middle ear space and hair pattern, signs of trauma o Palpation: note shape, size, lesions eardrum, ear pain, and fever | 11 ▪ Perforated TM: a hole in the eardrum; heal on its own but, if ▪ Wear the gloves. not, can cause hearing disturbance; with perforation, get ▪ Ask the patient first relief in pain ▪ Never shave hair without permission ▪ Tympanostomy tube (TM tube): for chronic otitis media; to o Auscultation: temporal arteries keep the middle ear aerated to prevent an accumulation of o Common abnormalities fluid in the middle ear, continuously drain fluid, often ▪ Hematoma relieves pain, falls out on its own ▪ Laceration ▪ Cerumenosis: packed ear wax ▪ Psoriasis ▪ Foreign body ▪ Mites ◆ Eye assessment ▪ Tinea capitis: bald patches, itchy; treatable o Common reasons: vision changes (blurred vision, floaters, ▪ Shunt d/t hydrocephalus flashing lights, loss of vision, double vision (diplopia)), eye pain, redness, or tearing ◆ Ear assessment o Inspection o Common reasons: pain, ear discharge, hearing deficit, ringing in the ears (tinnitus), foreign body, dizziness, ataxia, congenital ▪ External eye: lashes, lids, medial and lateral canthus, pupil, iris, sclera, corneal limbus, and periorbital area problem (displacement of ears due to Down syndrome) ▪ Ataxia: If fluids are behind the middle ear, people can start ▪ Internal eye: conjunctiva, cornea feeling woozy since the Vegas nerve lies in the middle ear. o Special tests o Inspection ▪ Visual acuity test with Snellen eye chart: to test distance ▪ Mastoid: untreated infection can cause mastoiditis vision (20 ft) ▫ Patients who wear glasses other than for reading ▪ External ear: pinna, helix, tragus, concha, external canal should put them on. ▪ Internal ear: canal, tympanic membrane (aka. ear drum, ▫ The vision of 20/200 means that, at 20 ft, the patient pink or pearly gray, some wax is normal, cone of light reflex can read prints that a person with normal vision could visible around 5’o clock area at the R eardrum and visible read at 200 ft. around 7’o clock area at the L eardrum) o The larger the second number, the worse the ▪ Any infection related to piercing? vision. o Hearing loss test o “20/40 corrected” means the patient could read ▪ Whisper test: stand at arm’s length (2ft) behind the seated the 20/40 line with glasses (a correction). patient ▪ Visual acuity test with Rosenbaum card: to test near vision ▪ Finger rub test acuity (14 inches) ▪ Weber test: place vibrating tuning form on the top of the ▪ Corneal light reflex (Hirschberg): If the reflection is at six patient’s head o’clock on the patient’s left, it should be at six o’clock on ▫ Normal result: hear the sound equally the patient’s right. ▫ Conductive hearing loss: localizes to the affected ear ▪ Light reaction: to test direct reaction (pupillary