Physical Examination Demonstration

Systems Approach

1. A. PRELIMINARY Washes hands before starting examination (in front of patient)

2. B. VITAL SIGNS Blood pressure done - 1 arm3. Systolic BP estimated by palpation of brachial or radial arteries

with BP cuff4. BP done correctly (not over clothing, cuff tight, arm correct

relaxed position, etc.)5. Patient seated with back supported and both feet flat on ground6. Blood pressure taken with the bell of the stethoscope7. Heart rate - at least 15 seconds checking radial pulse with

fingers, not thumb8. Respiratory rate - inconspicuously watching chest movement

(at least 20-30 seconds)9. Temperature (done correctly – will beep when done if

electronic)

10. C. HEAD Palpates scalp:

11. Palpates thoroughly (temples, including over temporal arteries), parietal – sides above ears, crown, occipital – back, palpate temporomandibular joint as patient opens and closes jaw

Eyes

• Inspect

• Visual acuity

• Extraoccular movements, accommodation

• Visual fields

• Pupillary response, swinging flashlight

• Fundoscopic exam

Inspect, Visual acuity

Inspect, Visual acuity

12. D. EYES Inspects external ocular (eye) structures (lids, conjunctiva, iris cornea, pupils)

13. Gently moves eyelids up and down to obtain better view

14. Checks acuity with Snellen and from proper distance (12-14 inches and any printed material is acceptable)

15. Checks acuity both eyes separately

Extraoccular movements, accommodation

16. Evaluates extraocular movement (big H)

17. Checks convergence and accommodation (follows finger from far to near)

Six Cardinal Positions of Gaze

Need our picture

Convergence and Accommodation

Needs illustration

Visual Fields

Visual fields

18.Visual fields - both eyes independently

19. Visual fields - eight cardinal directions for each eye (N,NE, E, SE, S, SW, W NW)

20. Visual fields - simultaneous stimulation (each eye should only be able to see on hand – the one on that side)

21. Visual Fields – Examiners hands or object to view introduced in the plane half-way between patient and examiner

Pupillary response, swinging flashlight

Swinging Flashlight Test

Pupillary response, swinging flashlight

22. Pupillary response to light – direct (same eye the light is directed into)

23. Pupillary response – indirect (eye light is not directed into)

24. Swinging flashlight test (start in one eye, quickly move to other eye, wait then fast back to original eye and wait)

Fundoscopic exam 25. Ophthalmologic Examination: Lights are dimmed26. Examiner uses R hand R eye to look in R eye27. Inspects anterior structures ophthalmoscope - R eye (start at +

15-40 to see anterior structures and move toward 0)28. Inspects optic nerve - R eye (comes in at 15 0 with lens at 0 or

moving from the positive towards 0)29. Traces vessels to all four quadrants - R eye30. Observes macula - R eye (credit to be given if #28 and look

laterally)31. Examiner uses L hand L eye to look in L eye32. Inspects anterior structure ophthalmoscope - L eye (start at + 15-

40 to see anterior structures and move toward 0)33. Inspects optic nerve - L eye (comes in at 15 0 with lens at 0 or

moving from the positive towards 0)34. Traces vessels to all four quadrants - L eye35. Observes macula - L eye (credit to be given if #33 and look

laterally)

Fundoscopic exam

Fundoscopic exam 25. Ophthalmologic Examination: Lights are dimmed26. Examiner uses R hand R eye to look in R eye27. Inspects anterior structures ophthalmoscope - R eye (start at +

15-40 to see anterior structures and move toward 0)28. Inspects optic nerve - R eye (comes in at 15 0 with lens at 0 or

moving from the positive towards 0)29. Traces vessels to all four quadrants - R eye30. Observes macula - R eye (credit to be given if #28 and look

laterally)31. Examiner uses L hand L eye to look in L eye32. Inspects anterior structure ophthalmoscope - L eye (start at + 15-

40 to see anterior structures and move toward 0)33. Inspects optic nerve - L eye (comes in at 15 0 with lens at 0 or

moving from the positive towards 0)34. Traces vessels to all four quadrants - L eye35. Observes macula - L eye (credit to be given if #33 and look

laterally)

Ears

Inspect

Palpate

Acuity

Otoscope

Ears

36. E. EARS: Inspects externally bilaterally (including behind ears)

37. Palpates auricles bilaterally38. Otoscopic examination bilaterally39. Otoscopic examination performed without pain40. Auricles pulled superiorly, posteriorly, and

away from patient41. Auditory acuity tested (eyes closed if finger rub

and you can see movement of hands or arm)42. Auditory acuity tested correctly (each ear

independently, etc.)

Nose and Sinuses

• Nasal Speculum

• Palpate sinuses

Nose and Sinuses

43. F. NOSE Otoscope used with nasal speculum to inspect nasal vault or may use otoscope ear speculum

44. Nasal speculum examination done without causing pain

45. Palpate frontal sinus for tenderness (medial brow left and right, be sure not too high)

46. Palpate maxillary sinus for tenderness (correct position)

47. Palpate ethmoid sinus (bridge of nose) for tenderness

Mouth

• Look everywhere

• Say “ah”

Mouth

48. G. MOUTH Should use light source for inspection

49. Inspect lips, gums, buccal mucosa, teeth

50. Inspect tongue, posterior pharynx

51. Inspect floor of mouth (under tongue)

52. Elevation of palate ("ah")

52. Examination done with minimal discomfort

Neck

• Inspect

• Carotids: palpate, auscultate (2)

• Thyroid: isthmus and both lobes

• 10 lymph node areas

Carotids

10 Lymph Node Areas

Thyroid

Neck54.H. NECK Inspects anterior neck for symmetry55.Carotid arteries palpated56.Carotid arteries correctly palpated, singly, (lower third of neck), fingers or thumb57.Auscultation of carotid arteries (lower carotids bilaterally)58.Auscultation of carotid arteries (upper carotids bilaterally)59.Thyroid gland palpated: Palpation from behind, chin is slightly extended (can palpate from front)60.Hands in proper position (below the cricoid cartilage)61.Palpates the isthmus and has patient swallow62.Palpates the lobes and has patient swallow63. I. LYMPH NODES - HEAD AND NECK Periauricular (in front of the ear)64.65.Posterior auricular (behind the ear)66.Occipital (base of skull)67.Tonsillar (angle of jaw)68.Submaxillary (mid-jaw)69.Submental (under chin)70.Posterior cervical (back of neck)71. Superficial cervical (on top of the sternomastoid muscle)72. Deep cervical (deep in the sternomastoid muscle)73. Supraclavicular

Chest

• Posterior, anterior, lateral• Inspection• Chest expansion • Proper position • Start at apices • Tactile fremitus• Percussion

– Diaphragmatic movement – Costovertebral angle

• Auscultation

Chest Expansion

A. B.

Tactile Fremitus

Diaphragmatic Movement

CVA Tenderness

Posterior Chest84. K. CHEST - Posterior Chest: Inspection: For symmetry85. Palpation: Bilateral movement chest wall (hands on sides, try to bring thumbs

together, moderate pressure)86. Palpation: For tactile fremitus (attempted)87. Palpation: Alternates from side to side or may use both hands simultaneously88. Percussion: Check diaphragmatic movement bilaterally89. Percussion: Posterior lung fields (attempted)90. Percussion: Alternates from side to side91. Percussion: Done correctly bilaterally, symmetrically, good tone92. Auscultation: Bilaterally (attempted)93. Auscultation: Done correctly (above scapula, 3 - 4 places, throughout inspiration and

expiration)94. Auscultation: Patient instructed deep slow breaths, mouth open95. Auscultation: Alternates from side to side96.Auscultation: At least 3 - 4 areas auscultated posteriorly97. Arms crossed for tactile eremites, percussion and auscultation98.Lateral Chest. Percussion laterally can be done as part of anterior or posterior99.Auscultation laterally can be done as part of anterior or posterior100.Other: Stethoscope placed examiner's ears correctly101.Other: Correct order of inspection (palpation or percussion), auscultation102.Percussion over costovertebral angle

Anterior Chest73.J. CHEST -- Anterior Chest (lying or sitting or at 30 0) Inspection:

For symmetry74.Palpation: For tactile fremitus (attempted)75.Palpation: Alternates from side to side or may use both hands

simultaneously76.Percussion: Anterior chest (attempted)77.Percussion: Alternates from side to side78.Percussion: Done correctly (bilaterally, symmetrically, good tone)79.Auscultation: Bilaterally (attempted)80.Auscultation: Done correctly (above clavicle, 3-4 places, listens

throughout inspiration and expiration)81.Auscultation: Patient instructed slow, deep breath, mouth open82.Auscultation: Alternates from side to side83.Auscultation: At least 3-4 areas auscultated on each side

Cardiac Exam

• Jugular venous pulsation

• Inspection

• Palpation

• Auscultation

• Special maneuvers

Cardiac Exam

• Jugular venous pulsation• Inspection• Palpation

– Valve areas– PMI

• Left lateral decubitus

• Auscultation– Diaphragm – Bell

• Tricuspid, mitral

• Special maneuvers – Left lateral decubitus, apex, bell– Sit up, lean, LLSB, exhale, diaphragm

Jugular Venous Pulsations

Jugular Venous Pulsations

PMI

Auscultation Areas

Auscultation Areas

Special Maneuvers: MS

Special Maneuvers: AR (AI)

CV Exam103.L. CARDIAC Inspection jugular vein (remember can be done at 0, 15, 30, will likely

move table position)104. Inspection done correctly; right side, head tilted left, patient elevated105. Inspection, palpation and auscultation for rest of cardiac examination performed at

30 degrees106.Inspection of all 4 areas107.Palpation of aortic area (right second intercostal space just lateral to sternum)108. Palpation of pulmonic area (left second intercostal space just lateral to sternum)109.Palpation of right ventricular area (left lower sternal border)110.Palpation of apical area (about fifth intercostal space mid-clavicular line)111.If apical impulse not palpable, patient in left lateral decubitus112.Palpation done with fingerpads in all 4 areas113.Auscultation with Diaphragm Aortic area114.Auscultation with Diaphragm Pulmonic area115.Auscultation with Diaphragm Tricuspid area (left lower sternal border)116.Auscultation with Diaphragm Mitral area (apical area)117.Auscultation with Diaphragm Sitting, left lower sternal border, patient fully exhaled118.Auscultation with bell. Tricuspid area119.Auscultation with bell. Mitral area120.Auscultation with bell. Mitral area in the left lateral decubitus position121.Done correctly - Bell applied light pressure, not heavy (remember newer

stethoscopes diaphragm lightly OK)122Other. Stethoscope placed in examiner's ears correctly

Abd Exam

• Inspection

• Auscultation

• Percussion

• Palpation

Abd Exam

• Inspection• Auscultation• Percussion

– All 4 quadrants– Liver span

• Palpation– All 4 quadrants– Liver– Spleen

• Right lateral ducubitus

– Kidneys– Aorta

Palpation: Liver

Palpation: Spleen

Palpation: Kidneys

Palpate R Kidney Palpate L Kidney

Palpation: Aorta

Abd123. M. ABDOMEN. Inspection with adequate exposure (lower chest to pelvis)124. Auscultation: Listens at least 10 secs. (one place or can move to several areas,

must listen for at least 10 secs)125. Percussion: L abdomen above below umbilicus126.Percussion: R abdomen above below umbilicus127. Percussion: Liver span (measure liver span, may do scratch test)128. Palpation: Lightly, all 4 quadrants129.Palpation: Deeply, all 4 quadrants130. Palpation: Liver (attempts to do)131. Palpation: Liver (correctly – palpating deepest full inspiration, 1 hand under one

hand palpating or 2 palpating)132. Palpation: Spleen (attempts to do)133. Palpation: Spleen (correctly - position, breaths, palpating deepest full inspiration, 1

hand under L side, 1 feeling)134. Palpation: Spleen (if not palpable, R lateral decubitus)135. Palpation: R kidney (take a deep breath, capture kidney, exhale, slowly release

kidney136. Palpation: L kidney (take a deep breath, capture kidney, exhale, slowly release

kidney)137. Palpation: For abdominal aorta (to feel both the left and right walls of the aorta)138. Palpation: Inspects patient’s face during palpation (at least 50% of the time)139. In correct order: Inspection, auscultation, percussion and palpation140. Abdominal Examination was done at 0.