GeneralPhysicalExam

Introduceyourself WashHands ExplainPhysicalExamProcedure Keeppatientcoveredwheneverpossible

PatientSittingonExamTable
GENERALAPPEARANCE
1. Notetheapparentstateofhealth,levelofconsciousness,signsofdistress,height,build,weight, skincolor,obviouslesions,dress,grooming,personalhygiene,facialexpression,odors,posture, gait,andmotoractivity.(P109111)

VITALSIGNS
1. Examineradialpulses(P482) Noterate,rhythm,andstrength. 2. Takebloodpressureinonearm(P116117) Estimatesystolicbypalpationandrelease.Thenpumpto30mmHgaboveestimatedsystolic andslowlyrelease. 3. Determinerespiratoryrate(P119) Noterate,rhythm,andeffort.

SKINEXAM
1. Checkskincolor(P163169) 2. Checkskintextureandturgor(P169) 3. Checkskinformolesandotherlesions(P169188)

Page2GeneralAssessment

HEADEXAM
1. Examinethescalp,hair(P192),andbonyconfigurationofskull(P205) 2. ExamineforFrontalandMaxillarySinusTenderness(P231)

EYESEXAM
1. Estimatevisualacuity(nearorfar)ineacheyeseparately(P211212),usingahandheldeye chart.Coveroneeye,andreadthesmallestlinepossible.Note:Ifpatientwearsglassesother thanforreadinghavethemputtheirglasseson 2. Inspecteyelids,sclera,andconjunctivawithpenlight(P213214) Askpatienttolookup.Notecolor,vascularpattern,nodules,andswelling. 3. Checkpupilsforreactiontolightandaccommodation(P215216) Askpatienttolookinthedistanceandshinepenlightintoeachpupil.Notedirectand consensualreactionforeacheye.

EARSEXAM
1. AuditoryAcuity(P226) Toestimatehearing,testoneearatatime.Askpatienttoclosetheireyes.Placeyourfingers nearpatientsears,rubyourfinger,askpatientwhatsidetheyhearfingerrub.Dootherear Ifhearingisdiminished,conducttheWeberandRinnetests. a. Webertest(P227) Placelightlyvibrating512Hztuningforkontopofpatientshead.Askpatientifthe soundisheardononeorbothsides.Soundlateralizestowardsimpairedsidein conductivehearingloss,andawayfromimpairedsideinsensorineuralhearingloss. b. Rinnetest(P227) Presslightlyvibrating512Hztuningforkbehindpatientsear.Whenpatientcanno longerhearthesound(viaboneconduction),movingtuningforknexttoearcanaland askpatientifthesoundcanbeheardagain.TheUoftheforkshouldfaceforwardto maximizeitssoundforthepatient. 2. Inspectearandexternalauditorycanal(P225) Inspecttheauricleandsurroundingtissuesfordeformities,lumps,orskinlesions.Ifearpain dischargeorinflammationispresent,movetheauricleupanddown,pressthetragus,andpress firmlyjustbehindtheear. 3. Usingotoscopeinspecttheexternalauditorycanalandtympanicmembranes(P225) Gentlypullauricleup,back,andout.Insertspeculumgentlyintoearcanal.Lookforlightreflex tofindeardrum.Visualizeeardrumandmalleus.


Page3GeneralAssessment

NOSEEXAM
1. Checkfortendernessoffrontalandmaxillarysinuses(P231) Presspadsofthumbsfirmlyontosinuses.Askaboutanytenderness. 2. Inspectnasalvaultsusingtheotoscope(P229230)

THROATEXAM
1. Usetonguebladetoinspect:(P231236) a. mucousmembranes b. salivaryducts c. tonsils d. teeth e. gums

NECKEXAM
2. Notethepositionofthetracheabypalpatinginsternalnotch(P240) Runonefingeralongeachsideofthetrachea.Thespacebetweenthetracheaand sternomastoidmuscleshouldbeequalonbothsides. 3. Inspectthyroid(P241) Tiltthepatientsheadbackslightly.Thethyroidisvisiblejustbelowthecricoidcartilage. 4.Palpatethyroidforisthmusandsizeandmovement(P242) Askpatienttoswallowandfeelformovementofthethyroidgland.Displacetracheatoone side,thentheothertopalpatelobes.Usefingersofbothhandstofeelforisthmusofthyroid. 1. Palpatethelymphnodesinthe:(P236240) a. Anteriortriangles b. Supraclavicularareas c. Submandibularareas d. Posteriorcervicalnodes

Page4GeneralAssessment

PatientSitting,(youarebehindpatient)

RespiratoryExam

1. Inspectposteriorchestforsymmetryordeformity(P297) 2. Checkthoracicexpansion(P298).Placehandsonbackwiththumbson10thrib.Askpatientto inhaledeeply,watchingandfeelingforsymmetryandrangeofmotion. 3. Palpatefortacticalfremitus(P298),Askpatienttorepeatthewordsninetynineoroneone one.Feelforvibrationwithulnarsurfaceofhand.Comparesidesat4locationsasshown. 4. Percussposteriorlungfieldsbothsides(P299302) Presslastjointofmiddlefingeronskin.Strikejointwithtipofothermiddlefinger(maysound flat,dull,resonant,hyperresonant,ortympanic).Comparefromsidetoside. 5. Measureexcursionofthediaphragm(P302),Percusslevelofdullness(diaphragm)atfull inspiration.Dobothsides 6. Auscultatetheupper,mid,lowerlungfields(P302304) Listenforcrackles,wheezes,andrhonchi.Notedurationofinspirationandexpiration.Compare sidesasshownabove.

Withthepatientlyingdown30degreesofelevation:

RespiratoryExam
1. Auscultateanteriorlungfieldsfromsupraclavicularareato6thrib(P308)

CardiovascularExam
1. Observetheneckveins(P349351) Visualizethehighestpointofbiphasicpulsationinrightinternaljugularvein. 2. Measurethejugularvenouspressure,Measureverticaldistanceabovesternum(normalis <4cmabovesternalangle) 3. Palpatecarotidpulses(P352) Gentlypressmedialtothesternomastoidmuscle,belowtheAdamsapple. Notepresenceofthrills.Onlypalpateonesideatatime! 4. Auscultatecarotidpulses(P355356),ListenforBruitsortransmittedmurmurs 5. Inspectandpalpateprecordium(P355356) Noteanylifts,thrillsandheaves.Gentlydisplacethebreastifnecessary.

 Page5GeneralAssessment

(Continue)Withthepatientlyingdown30degreesof elevation:
6. Palpatetheapicalimpulse(P357) Note:Ifyoucannotidentifytheapicalpulsewiththepatientsupine,askthepatienttorollpartly ontotheleftsideandpalpateagainusingyourfingers. 7. RollpatientleftLateralPosition,usetheBellpartofyourstethoscopetoauscultateoverthe apex 8. Auscultatetheheartwiththediaphragm:(P361368) a. Apex(M) b. Lowerleftsternalborder(T) c. 2ndleftinterspace(P) d. 2ndrightinterspace(A)

WiththePatientSittingandLeaningForward:
CardiovascularExam
1.Duringexhalationauscultateleftsternalborderwithdiaphragm(P364)(A)

Withpatientlyingflat:
AbdominalExam
1. Inspectabdomen(P434435) Lookforbulges,massesandskinlesions.Watchforperistalsisandpulsations.Notethecontour aswellasanyscars,striae,ordilatedveins. 2. Auscultatebowelsounds(P436) Usediaphragm,listenforbowelsounds 3. Auscultateepigastriumandeachupperquadrantforbruits(P436) Usediaphragm,listenforbruits 4. Percussall4quadrants(P437) Noteareasoftympanyordullness. 5. Palpategentlyinall4quadrants(P437) Useonehandtofeelfortendernessorresistance.Noteanysuperficialmasses.

 Page6GeneralAssessment

(Continue)withthePatientlyingflat:
6. Palpatedeeplyinall4quadrants(P438) Usetwohandstofeelformasses.Notelocation,size,shape,consistency,tenderness, pulsations,andmobility. 7. Palpatetheaorta(P447),Identifyaorticpulsationsinupperabdomen.Measurewidthofaorta bypressingdeeplywithonehandoneachsideoftheaorta(shouldnotbemorethan3cm wide). 8. Percussliverspan(P439440) Findthelowerborderofdullnessalongtherightmidclavicularline,startingatthelevelofthe umbilicus.Identifytheupperborder,startingatthenippleline. 9. Palpateliveredge(P441442)Placeyourlefthandbehindthepatient.Pressyourrighthand belowtheborderofliverandfeelforliveredgeaspatientinhales. 10. Percussspleen(P443444).Percussthelowestinterspaceintheleftanterioraxillaryline. Percussionnoteistympanitic,andshouldremaintympaniticwhenpatientinhales. 11. Palpatespleen(P444445) Withlefthandunderpatient,pressrighthandbelowleftcostalmargin.Askpatienttoinhale andfeelfortipofspleen. 12. Palpatetheinguinalareaforlymphnodes(P483) 13. Palpatethefemoralpulses(P484) 14. Palpatethepoplitealpulse(P484) 15. Palpateposteriortibialpulses(P485) 16. Palpatedorsalispedispulses(P485)