Adult Physical Assessment mean or Neck, 60 The Patient History, 48 Equipment, 53 eee Nodes, 62 General Principles, 48 Vital Signs, 53 Breasts (Male and Female), 63 Interviewing Techniques, 48 Height, Weight, and Waist Caer tinas icoeinchenta Circumference, 53 Hoan, 68 Ending the History, 51 ever Appectnce 53 feplrl ion 70 ties a Abdomen, persis Patminsson 2 tad, Shey Male Genitalia and Hernias, 74 General Principles, 51 yes and Vision, fons Approaching the Patient, 51 Techniques of Examination and Assessment, 51 wee THE PATIENT HISTORY GENERAL PRINCIPLES 1. The first step in caring for a patient and in soliciting active cooperation is to gather a careful and complete history a. Inall patient concems and problems, an accurate his- tory is the foundation on which data collection and the process of assessment are based. b. The comprehensiveness ofthe history elicited depends on the information available in the patient's record and the reliability ofthe patient: 2. Time spent early in the nurse-patient relationship gath- ering detailed information about what the patient knows, thinks, and feels about the problems prevents time-con- suming errors and misunderstanding later 3, Skill in interviewing affects both the accuracy of infor- mation elicited and the quality of the relationship established with the patient. This point cannot be overemphasized; the reader is encouraged to consult other sources for detailed discussion of techniques of health interviewing, 4. The purpose of the interview is to encourage an exchange of information between the patient and the nurse. The patient must feel that his words are under- Mouth, 59. Eors and Hearing, 57 Nose and Sinuses, 59 Musculoskeletal System, 77 Neurologic System, 77 stood and that his concerns are being heard and dealt with sensitively. INTERVIEWING TECHNIQUES 1. Provide privacy in as quiet a place as possible and see that, the patient is comfortable. 2. Begin the interview with a courteous greeting and an introduction. Address the patient as Mr., Mrs., or Ms. and shake hands if appropriate. Explain who you are and the reason for your presence. 3. Make sure that facial expressions, body movements, and tone of voice are pleasant, unhurried, and nonjudgmental, and that they convey the attitude of a sensitive listener s0 the patient will feel free to express his thoughts and feelings. 4. Avoid reassuring the patient prematurely (before you have adequate information about the problem). This only cuts off discussion; the patient may then be unwilling t0 bring up a problem causing concern. 5. At times, a patient, ‘ives cues or suggests information, but doesnot rll enough. Itmay be necessary to probe for nore information to obtain a thorough history; the patient must realize that this is done for his benef. 6 Guide the interview so the necessary information is er without eutting off discussion. Controlling @ Patient is often difficult but, with practice, it can © without jeopandi thon pened, out Jeepardising the quality ofthe informa _COMPONENTS Identifying Information 1. Date and time. 2. Patient's name, address, teley birth date, and age. 3. Name of referring practitioner. 4. lair data. 5. Name of informant—the patient may be the person giv- ing the history: if not, record the name eo ie, hone number, and relationship tothe patiencof te sex son giving the history. (The patienes to record may also bea valuable resumes Joe? ceieal ‘Phone number, race, religion, observations in the physical examination 7. Explain the reasons why the information is help put the patient atease, nn Reeded to Chief Complaint 1. A brief statement of the patient's primary problem or con- cem in the patient's own words, including the dursniaa of the complaint. Example: “hacking cough X 3 weeks” 2. Purpose isto allow the patient ro describe his own prob- lems and expectations with little or no direction from the interviewer and to identify the overriding problem for which the patient is secking help (there may be numer. ous complaints). 3. To obtain information, ask the patient a direct question such as, “For what reason have you come to the facility?” or “What seems to be bothering you most at this time?” a. Avoid confusing questions such as, “What brings you here?” (“The bus.") or “Why are you here?” ("That's what I came to find out.”) b, Ask how long the concern or problem has been pre- sent; for example, whether it has been houts, days, or weeks. If necessary, establish the time of onset pre- cisely by offering such clues as “Did you feel this way a month (6 months or 2 years) ago?" 4. Write down what the patient says using quotation marks to identify patient's words, History of Present Illness 1. A detailed chronological picture, beginning with the time the patient was last well (or, in the case of a problem with an acute onset, the patient's condition just before the onset of the problem) and ending with a description of the patient’s current condition. 2. If there is more than one important problem, each is described in a separate, chronologically organized para- graph in the written history of present illness. 3. Investigate the chief complaint by eliciting more informa- tion through the use of the pneumonic “OLD CARTS’ a. Onset (setting, circumstances, rapidity, or manner in which it began) Pas! 1 10. b. Location (exact place where the symptom is felt, radi- ation pattern) ¢. Duration (how long; if intermittent, the frequency and duration of each episoxle) 4. Character/course (nature or quality of the symptom, such as sharp pain, interference with activity, how it hhas changed or evolved over time; ask to describe a typical episode) geravatinglassociated factors (medications, rest, activity, diet; associated nausea, fever, and other symptoms) f. Relieving factors (lying down, having bowel movement) g. Treatments tried (pharmacologic and nonpharmaco- logic methods attempted and their outcomes) h. Severity (the quantity of the symptom; for example, how severe on scale of 1 to 10) Altemately, use the pneumonic PQRST: provocative/ palliative factors, quality/quantity, region/radiation, severity, timing. . Obtain OLD CARTS data for all the major problems associated with the present illness, as applicable. Clarify the chronology of the illness by asking questions and summarizing the history of present illness for the Patient to comment on. it Medical History To determine the background health status of the Patient, including present status, recent health condi- tions, and past health conditions that will serve as a basis for nursing care planning for holistic patient care. . General health and lifestyle patterns—sleeping pattern, diet, stability of weight, usual exercise and activities, use of tobacco, alcohol, illicit drugs. . Childhood illnesses, such as infectious diseases (if applic- able). Immunization—polio, diphtheria, pertussis, tetanus, measles, mumps, rubella, Haemophilus influenza type b, hepatitis B, hepatitis A, pneumococcal, influenza, vari. cella, meningitis, human papilloma virus, herpes zoster, last purified protein derivative or other skin test, abnor. ‘mal or unusual reactions (give date when possible). . Operation—indications, diagnosis, dates, facility, sur- geon, complications. 9. Previous hospitalizations—physician, facility data (year), diagnosis, treatment. . Injuries—type, treatment, outcome. Major acute and chronic illnesses (any serious or pro- longed illnesses not requiring hospitalization)—dates, symptoms, course, treatment. Medications—prescription drugs from all providers (including ophthalmologist and dentist); nonprescription drugs including vitamins, supplements, and herbal prod- uucts; include dosage, length of use, and adherence. Allergies—environmental allergies, food allergies, drug reactions; give type of reaction (hives, thinits, local reac~ tion, angioedema, anaphylaxis).11. Obstetric history (may appear in review of systems) a. Pregnancies, miscarriages, abortions b. Describe course of pregnancy, labo late, place of delivery: 12, Paychiatric history (may appent in review of systems) and deliverys treatment by a mental health provider, diagnosis, d place, medications Family History 1. Dorpose is to present a pictute of the patient's family health. snclistine that of grandparents, parents, brothers, sisters aunts, and uncles. It ale involves the health of ‘lose relanives hecase some diseases chow a familial ter Seney ot ane hereditary 2. Include age and health status (or age at and cause of death) materal and patemal grandparents, parents, siblings. History, in ieumedtate and close relatives, of heart disease, Hypertension, stroke, diabetes, gout, kidney disease ot stones. thyroid disease, pulmonary disease, Mood prob: tems, cancer (types), epilepsy, mental illness, arte alcoholism, obesity ‘Genetic disorders such as hemophilia ot sickle cell disease Age and health status of spouse and children. Review of Systems 1. Purpose ito obtain detailed information about the cur- ‘ent state of the patient and any past symptoms, of lack of svmptorms, patient may have experienced related to a par- ‘poular hady system. May give clues to diagnosis of multisystem disorders or Progression of a disorder to other areas. 3. Include subjective information about what the patient Jocks or sees with regard to the major systems of the body. @ Skin—rash, itching, change in pigmentation or tex. ‘ture, sweating, hair growth and distribution, condition cf nail, skin care habits, protection from sun b. Skeletal—stifiness of joints, pain, deformity, restric- ‘uon of motion, swelling, redness, heat (If there are problems, ask the patient to specify any activities of daily life that are difficult or impossible to perform.) Head —headaches, dissiness, syncope, head injuries 4. Eyes—vision, pain, diplopia, photophobia, blind spots, itching, burning, discharge, recent change in appearance or vision, glaucoma, cataracts, glasses or ‘contact lenses worn, date of last refraction, infection © Ear—hearing acuity, earache, discharge, tinnitus, vemigo, history of tubes or infection £ Nose—sense of smell, frequency of colds, obstruction, ‘pistaxis, postnasal discharge, sinus pain or therapy, se of nose drops or sprays (type and frequency) # Tecth—pain; bleeding, swollen or receding. gums; recent extractions; dentures; dental hygiene practices, last dental examination ‘Mouth and tongue—soreness of tongue or buccal mucosa, ulcers, swelling & Throat —sore throat, tonsils, hoarseness, dysphagia j. Neck—pain, stiffness, swelling, enlarged glands or mph noes k Roowe goiter, thyroid tenderness, tremors, weak- ness, tolerance to heat and cold, changes in hat or glove size, changes in skin pigmentation, libido, easy bruising, muscle cramps, polyuria, polydipsia, polypha- ia, hormone therapy, unexplained weight change 1. Respiratory-—pain in the chest with breathing, dys- pea, wheesing, cough, sputum (character, quantity), intest or chest X-ray and result (invlicate where obtained), expenure te tuberculosis avascular—pain (aggravating and alleviating fac- tors), palpitations, dyspnea, orthopnea (note number of pillows required for sleeping), history of heart murmur, calema, cyanosis, clauication, varicose veins, exercise tolerance, blood pressure (BP; if known), last elecree. ccaniogram andl results (indicate where obtained) n, Hematologic—anemia (if so, treatment received), tendency to bruise or bleed, thromboses, throm. bophlebitis, any known abnormalities of blood cells ‘. Lymph nodes—enlargement, tenderness, suppuration, duration and progress of abnormality p. Gastrointestinal —appetite and digestion, intolerance to foods, belching, regurgitation, heartburn, nausea, vomit ing, hematemesis, bowel habits, diarrhea, constipation, flatulence, stool characteristics, hemorthoids, jaundice, use of laxatives or antacids, history of ulcer or other con. ditions, previous diagnostic tests, such as colonoscopy 4. Urinary—dysuria, pain, urgency, frequency, hema- turia, nocturia, polydipsia, polyuria, oliguria, edema of the face, hesitancy, dribbling, loss in size or force of stream, passage of stones, stress incontinence ©. Male reproductive—puberty onset, sexual activity, use ‘of condoms, libido, sexual dysfunction, history of vex- ually transmitted diseases (STDs) s. Female reprocuctive—pattern and characteristics of menses, libido, sexual activity, satisfaction with sexual relations, pregnancies, methods of contraception, protection © Breasts—pain, tendemess, discharge, lumps, mammo- grams, breast self-examination \u. Neurologic—history of loss of consciousness, seizures, confusion, memory, cognitive function, incoondina, tion, weakness, numbness, paresthesia, tremors, muscle cramps Poychiatric—how patient views self, mood changes, dificuley concentrating, sadness, nervousness. ton, sion, iritability, change in social interactions nhc sive thoughts, compulsions, manic episodes, suicidal ‘or homicidal thoughts, hallucinations - General constitutional sympeoms—fever, chills night sweats, malaise, fatigablity, recent weight loss or gain Personal and Social History 1. Todevelop plan of care that “fits” the Patient. Flere the interviewer finds out the many personal and family eeresources an individual has to ation and determines what hy may be necessary. 2. Determine personal status—birthplace, education, arme, service affiliation, position in the familyseduentmp ton satisfaction with life situations (home and job), reread 3, Identify habits and lifestyle patterns, a. Sleeping pattern, number of hours of s ley sees f sleep, difficulty b. Exercise, activities, recreation, hobbies. «. Nutrition and eating habits (dit reall fora typical 4d. Alcohol—frequency, amount, type; CAGE ae nite for problem drinking," CAGE suestion- i, Have you ever thought you should ‘ut dowr your drinking? a Sema ii, Have you ever been Annoy criticism of epee noyed by criticism of your iii, Have you ever felt Guilty about your drinking? iv. Do you drink in the morning (ie, an Eye opener)? aid in coping with the situ- lth promotion gett ¢. Caffeine—type and amount per day. £. Illicit drugs (illegal or improperly used prescription or over-the-counter medications). g. Tobacco—past and present use, type (cigarettes, cig- ars, chewing, snuff), pack, years. : h, Sexual habits (can be part of genitourinary history) — relationships, frequency, satisfaction, number of part- ners in past year and lifetime, STD and pregnancy pre- vention 4, Home conditions. a. Marital status, nature of family relationships. b. Economic conditions—source of income; health insurance, Medicare, Medicaid. cc. Living arrangements and housing (owning or renting, heating, sewage, pets). d. Involvement with agencies (name, case worker). ¢. History of physical or sexual abuse. 5. Occupation—past and present employment and working conditions, including exposure to stress and tension, noise, chemicals, pollution. 6. Cultural beliefs, religion or faith—its importance in cop- ing and health practices. ENDING THE HISTORY ‘When you have completed the history, itis often helpful say: “Is there anything else you w “What additional concerns do you patient to end the history by saying what is on what concerns the patient most. jould like to tell me” have?” This allows the hher mind and PHYSICAL EXAMINATION GENERAL PRINCIPLES 1. Acomplete or partial physical exam! lowing a careful comprehensive oF Pr ination is conducted fol- oblem-related history. Percus: PHYSICAL EXAMINATION tirade quiet, well-lit room with considera- tion for patient privacy and comfort. APPROACHING THE PATIENT 1. When possible, begin with the patient in a sitting posi- tion so both the front and back can he examined. 2. Completely expose the part to be examined but drape the rest ofthe body appropriately. 3. Conduct the examination systematically from head to foot so as not to miss observing any system or body part. 4. While examining each der the underlying anatomic structures, the id possible abnor- malities. 5. Because the body is bilaterally symmetric for the most part, compare findings on one side with those on the other. 6. Explain all procedures to the patient while the examina tion is being conducted to avoid alarming or worrying the patient and to encourage cooperation. TECHNIQUES OF EXAMINATION AND ASSESSMENT Use the following techniques of examination, as appropriate, for eliciting findings gion, cons function, Inspection 1. Begins with the fst encounter with the patient and is the most important ofall the techniques. 2. Te is an organized scrutiny of the patient’s behavior and body. 3. With knowledge and experience, the examiner can become highly sensitive to visual clues. 4. The examiner begins each phase of the examination by inspecting the particular part with the eyes. Palpation 1. Involves touching the region or body part just observed and noting whether these are tender to touch and what the various structures feel like. 2. With experience comes the ability to distinguish varia- tions of normal from abnormal 3. Ieis performed in an organized manner from region to region. 1. By setting underlying tissues in motion, percussion helps, in determining the density of the underlying tissue and whether it is air-filled, fluid-filled, or solid. 2. Audible sounds and palpable vibrations are produced, which can be distinguished by the examiner. The five basic notes produced by percussion can be distinguished by differences in the qualities of sound, pitch, duration, and intensity (see Table 5-1, page 52). 3. The technique for percussion may be described as follows: ‘a. Hyperextend the middle finger of your left har, pres- ing the distal portion and joint firmly against the sut- face to be percusedEXAMPLE LOCATION RELATIVE DURATION RELATIVE PITCH. Thigh a ee a the oe High das a - Medium a ‘Medium ng Neto Normal lung Resonan: loud low long Pare fous lung fesononce 4 i :mphysematous lung Hyperresonance Very loud Gest i bubble or pled a : hee Tymphany loud eg *Diesngahed mainly by i musical rinbre. Adopted from Bicley US, ond Szilagyi, PG. (2007), Boes’ guide to physical examination at 4 history taking (th ed). Piledelphi: Lippincott i. Other fingers touching the surface will damp the sound. ii, Be consistent in the degree of firmness exerted by the hyperextended finger as you move it from area to area or the sound will vary. b. Cock the right hand at the wrist, flex the middle finger upward, and place the forearm close to the surface to be percussed. The right hand and forearm should be as relaxed as possible, © With a quick, sharp, relaxed wrist motion, strike the extended left middle finger with the flexed right middle finger, using the tip of the finger, not the pad. Aim at the end of the extended left middle finger (just behind the nailbed) where the sreatetpresture is exerted on the surface to be per 4. Lift the right middle finger rapidly to avoid dampi the vibrations. ee a |. The movement is at the wrist, not at the finger, elbow, or shoulder; the examiner should use the lightest touch capable of producing a clear sound. Auscultation 1. This method uses the stethoscope to augment the sense of hearing. The stethoscope must be constructed well and must fi the user. Earpieces should be comfortable, the length ofthe tubing should be 10 to 15 inches (25 to 38cm), and the head should have a diaphragm and a bell. 2 b The bell is used for low-pitched sounds such as certain heart murmurs. ‘The diaphragm screens out low-pitched sounds and is ‘good i hearing high-frequency sounds such as breath sounds. - Extraneous sounds can be produced by clothing, hair, and movement of the head of the stethoscope.Adult Physical As: EQUIPMENT i soto ck 2 pence * Fleshlight # Ofo-ophthalmoscope Cease = Thermometer 1 Reflex hammer ™ Tongue blade Technique VITAL SIGNS Impertance—Many major therapeutic decisions are based on the vital signs; therefore, accuracy is essential, Temperature Routinely, where accuracy perature will suifice. A rectal temperature isthe most accurate, but may be contraindicated with some rectal problems and cordiac arrhythmias. SS Gare Pulse Palpate the radial pulse and count for at least 30 seconds. IF the pulse is irregular, count for a full minute and note the number of irregular beats per minute. Nole whether the beat ofthe pulse against your finger is sirong or weak, bounding or thready, 's not crucial, an oral or ear tem- Respiration Count the number of respirations taken in 15 seconds and multiply that by 4. Note rhythm and depth of breathing Blood pressure ‘Measure the blood pressure (BP) in both arms. Document the patient's position. Palpate the systolic pressure before using the stethoscope in ‘order fo detect an auscultatory gap. Apply the cuff firmly; if itis too loose, it wil give falsely high reading, Use an appropriate sized cuff: a pediatric cuft for children; a large « . The cuff should be approximately 1 in ‘oniecubital fossa, HEIGHT, WEIGHT, AND WAIST CIRCUMFERENCE Determine the patient's height and weight. Use a measuring stick or tape rather than asking the patient for recent mec- surements. Determine waist circumference by using tape measure just above the umbilicus at the narrowest point GENERAL APPEARANCE : Begin observation on first contact with the patient [in the waiting room or while the patient is in bed}; continue throughout the interview systematically. 1 a log cu for obese peopl Take ose Finch (255 crn] above the *Auscultatory gq ; } hei ‘ound of blood in the artery is sve asionally the sound is not continuous an 3. fone uses ony the auscitotory method and Po sound or when the sound is not continuous, 10 9 imps the re is a gap after the Soe PHYSICAL EXAMINATION “sa = Tuning fork 1 Additional items may include dispos able gloves and lubricant for rectal examination and a speculum for ‘examination of female pelvis. Findings Temperature—may vary with the time of day. Oral: 98.6° F (37° C) is considered normal ‘May vary from 96.4” to 99.1° F (35.8° to 37.3° C). Rectal: Higher than oral by 0.7° to 0.9° F (0.4° to 0.5° C). Pulse—Normal adult pulse is 60 to 80 beats/minute; regular in thythm. Elasticity of the arterial walls, blood volume, and mechanical action of the heart muscle are some of the foc- {ors that affect strength of the pulse wave, which normally is full ond strong. Respiration—Normally 16 to 20 respirations per minute Normal BP is <120/80 mm Hg, A difference of 5 to 10 mm Hg between arms is common, Systolic pressure in lower extremities is usually 10 mm Hg higher thon reading in upper extremities Going from a recumbent fo a standing position can cause the systolic pressure to fall 10 fo 15 mm Hg and the diastolic pressure to rise slightly (by 5 mm Hg) Height and weight can be used to determine body mass index Wit circumference son independent ak ote Ronen vascular disease. Normal is = 40 inches (102 cm) for men ‘and = 35 inches (88 em) for women. by continuous sound unt nothing i audible with the stethoscope, eee frst sound, afer which the sound of blood in the vessel s heard up until the sound is no longer heard, itis possible, when Inee sop Fe iy er gee (continued)CHAPTER 5 = ADULT PHYSICAL ASSESSMENT uaa Pree Technique al physical development, muti 3, affect, evidence of pain, rest lessness, body position, clothes, apparent age, hygions, rooming. Use smell and hearing as well os sight, ‘SKIN |. Examination of the skin is correlated with the information obtained in the history ond other parts ofthe physical ‘exomination, 2.Exomine the skin as you proceed through each body system. Inspection ‘Observe for: skin color, pigmentation, lesions (dishibution, Ps; configuration, size), jaundice, cyanosis, scars, super- ficial vascularity, hydration, edema, color of mucous branes, hair distibution, nails. oe Polpation Examine skin for temperature, texture, elasticity, turgor. HEAD Inspection ‘Observe for: symmetry of face, configuration of skull, hair color and distribution, scalp, Palpation Examine: hair texture, masses, swelling or tenderness of scalp, configuration of skul. EYES AND VISION Equipment ® Ophthalmo: ™ Snellen chart for visual acuily (see page 579) Anatomic landmarks Globes Palpebral fissures lid margins Conjunctivae Sclerae Pupils Inspection 1. Globes—for protrusion 2. Palpebral fissures (oval opening between the upper and lower eyelids)—for width and symmetry. Findings Careful observation of the general state of the individual pro- vides many clues about @ person’s body image, how he bohaves, and also some idea of how well or il he i “Normal” vories considerably depending on racial or ethnic background, exposure fo sun, complexion, pigmentation tendencies (such as freckles) The skin is normally warm, slightly moist, and smooth and returns quickly to its original shape when picked up between two fingers and released. There is a characteristic hair distribution over the body associated with gender and normal physiologic function. Nails are present and smooth cond cared for in some way. Normally, the skull and face are symmetric, with distribution ‘of hair varying from person to person. (However, determine by histor ifthere hos been any change.) The scalp should be free of flaking, with no signs of nits (small, white louse egg), lesions, deformities, or tenderness Solera covered by conjunctiva Lateral canthus Medial ‘canthus Pupil Lower eyelid is 2. Palpebralfssures—appeor equal in si ore open Upper lid—covers Lower lid—margin Limbus when the eyes small portion of the iris and cornea. just below the junction of the cornea ‘ond sclera (limbus). Prosis—drooping of eyelidsPeat ba TT Tochnique Neda EYES AND VISION (continwea) E a Inspocion (cotinuod) 3. lid margins—for scaling, secretions of lashes hema, position 4, Bulbar and palpebral conjunctivae— for congestion and color Bulbar conjunctivamombrensee nos scar (concins blood vessel). Papebral seem lower lids (con el 6: Pupils—for size, shape, symmetry, recetion to igh. d ‘occommodation (ability of the lev, sae accommodation (ably of he lan ooo to objet at 7. Eye movement—extraocular movements, vergence. (Nystagmus: rapid, lateral, horizon cy rolary movement of the eye.) (Convergence eye fo tun in and focus on a very close obj rologic system, page 77.) nystagmus, con- 8. Gross visual felds—by confrontation. (See neurologic system, poge 77.) 9. Visval acui out glosses). ‘check with a Snellen chart (with and with- Palpation 1.Determine the strength of the upper lids by attempting to ‘open closed lids against resistance. 2.Palpate globes through closed lids for tenderness and ten- sion. . Funduscopic examination 1. Red retinal reflex—check the transparency of the anterior cand posterior chambers. 2. Cormea—check for iransparency. 3. Lens—check for transparency. 4, Retina—check for color, pigmentation, hemorrhages, and exudates. 3. Lid margins—are clear; the lacrimal duct openings (puncto) 4 evidont atthe nascl ends of the upper end lower tid Eye lashes—normally ae evenly dstibted and turn out 4, Bulbar conjunctiva (cover of sclora)—consiss of transpar- ‘ent red blood vessels, which may become dilated and produce the characteristic “bloodshot” eye, Palpebral conjunctivae—are pink and clear. Conjunctivitis —inflammation of the conjunctival surkaces. 5, Sclerae—should be white and clear. 6. Pupils—normally constrict with increasing light and ‘accommodation. Pupils are normally round and can range in siz from very small ("pinpoint to large (occu- pying the entire space of the iris). 7. Extraocular movement—movement of the eyes in Expiration Low Sok Most of lungs Bronchovesicular Inspiration = Expiration Medium Medium Near the main stem bronchi (below the clavicles and between the scopulae, especially on the right) Bronchial or tubular Expiration > Inspiration High Usvally loud Over the trachea ‘opted tem tickly LS. ond Szlogy, PG. (2007) Bees’ guide te physical exomination and history taking (9h ed). Plodelphiar Uppincot Willams & Wikins. {Note th paint is unable fo sit wihou assistance fr examincion ofthe posterior chow end lo other as you examine the lung fields. — — ee positon him frst on one side and then onSoteiedbile eine ee Technique Findings eS Rial a THORAX AND LUNGS (continued) Anterior thorax and lungs The patient should be recu errhp okleesrecumbent with his arms at his sides Inspection Tslispec the ches! for any structural deform 2: Note the widih ofthe eentolancias s mY 3. Observe the rate and rhythm of breat of retraction of intercostal spaces on ese of accessory muscles of respiration {slernocleidomastoid and trapezius on inspiration and abdominal muscles on expiration). 4. Note any asymmetry of chest wall Movement on respiration. Palpation 1-To assess expansion, place your hands along the costal margins and note symmetry and degree of expansion as inholes deeply. 2. Palpae fr fremitus withthe ball of he hand conieriorly and laterally. (Underlying structures [hear liver] may damp, or decrease, fremitus.) 3. Compare symmetric areas. 4. lf necessary, displace the female breast gently. ony bulging tion, and Percussion 1. With patient's arms resting comfortably at his sides, per- cuss the anterior and lateral chest, Begin just below the. clavicles and percuss downward from one interspace 10 the next, comparing the sound from the interspace on one side with that of the contralateral interspace. 2. Displace the female breast so breast tissue does not damp the vibration. Continue downward, noting the intercostal space where hepatic dullness is percussed on the right and cardiac dullness on the left. 3. Note the effect of underlying siructures. @ Resonant @ympanic @rat @pbult Percussion of anterior thorax ‘Avscutation i Listen fo the chest anteriorly and laterally forthe distribution of resonance and any abnormal or adventitious sounds. 2. The angle ot the tip ofthe sternum is determined by the fight and left rb margins ot the xiphoid process. Normally, the angle is less thon 90 degrees. 3. There are no bulges or retractions ofthe intercostal spaces. 4. The thorax is normally symmetric and moves easi out impairment on respiration. 2.A tympanic sound is produced over the gastric air bubble on the let somewhat lower than the paint of iver dillness con the right. 3. Percussion over heart will produce a dull sound. The 3 border of the liver will be percussed on the right opera eas (continued)CHAPTER 5 m ADULT PHYSICAL ASSESSMENT Cerne] ON ene Technique Findings HE General approach Manutrium of. Suprasternal rch 1. The examiner must visualize the position of the heart sternum under the sternum and the ribs ond know certain landmarks ody of Sterna angle sternum for identification of specific structures and significant findings 2.1 ols important to identify those “areas” on the ches! ‘oll that will yield the most information initially about the function of the heart ond its valves, ©. In locating the intercostal spaces, begin by identifying the orgie ef tov which nieve sigh fige epproximately 1 inch (2.5 em) below the sternal notch, where the manubrium and the body of the ster num ore joined. 1b The 2nd ribs extend tothe right and left ofthis angle. ©. Once the 2nd rib is locoted, palpate downward and obliquely away from the sternum to identify the remain- ing ribs ond intercostal spaces. Inspection T Inspect the precordium for any bulging, heaving, or thrusting 2. Look for the opical impulse in the Sth or 6th intercostal spoce at or just medial to the midclavicular line. 3 Note ony other pulsations. Tangential lighting is most helpful in detecting pulsations. Palpation 1. Use the boll ofthe hand to detect vibrations, or “thrills,” ‘which may be caused by murmurs. (Use the fingertips or palmar surface to detect pulsations.) 2. Proceed methodically through the examination so no area is omitted. Palpate for thrills and pulsations in each area Joortic, pulmonic, tricuspid, mitral). «@. Begin in the aortic area (2nd right intercostal space, close to the sternum) and proceed to the pulmonic ‘rea (2nd lef intercostal space), and then downward to the opex of the hear. (The mitral area is considered the apex of the heart.) b. In the tricuspid crea, use the palm of the hand to detect any heaving or thrusting of the precordium (ri- cuspid orea—Sth intercostal space next to the sternum). . In the mitral area (5th intercostal space, at or just ‘medial to the midclavicular line) palpate for the opical beat; identify the point of maximal impulse (PMI) and note its size ond force. Percussion 1. Outline the heart border or orea of cardiac dullness. «2. The let border generally does not extend beyond 4, 7, and 10 cm lef of the midsternl line in the 4th, Sih, ‘ond éth intercostal spaces, respecively. b. The right border usvally lies under the sternum. nd rb nik interspace process ‘2nd costal cartlage Costal margin 1. Normally there are no bulges or heaves; these indicate aa aa impulse may or may not be observable. 3. There should be no other pulsations. 1 There should be no thils or other pulsation vibrations caused by turbulence of blood movi valves that are transmitted through the skin, which feels similar to a purring cat.) Ordinarily, no heaving of he ventricle is felt except, possibly, inthe pregnant female. The apical pulse should be felt approximately in the Sth inter- costal space, at or just medial to the midclavicular line. In a young, thin person, its @ sharp, quick impulse no larger than ihe intercostal space. In an older person, the impulse ‘may be less sharp and quick. An apical impulse displaced laterally may indicate left ventricular hypertrophy.PHYSICAL EXAMINATION CUAL Cet eT Technique HEART (contnved) General approach (coninved) Percussion (continued) 2, Percuss outward from the sternum with the s ger Palla fo the inereotal space (sae nger heard. Measure the distance fom Fongor hear Me distance from the midsternal Auscultation 1. Place the stethoscope in the pulmonic stetho Imonic or aortic area, 2. Begin by identlying the frst (S) and second (Sa) heart «: S1 is caused by the closing ofthe ticuspid and miral b, Se results from the closin valves. = 19 of the aortic and pulmonic Pulmonic area, Erb's point Left ventricular (apical) aroa Epigastric area Midsternum | Midolavieular line 3. Once the heart sounds are identified, count the rate ond role the rhythm as discussed under vital signs. If there is an irregularity, try to determine if there is any pattern to the irregularity in relation to the intervals, heart sounds, or Tespirations. Fin 2. The two sounds are separated by a short systolic interval; each pair of sounds is separated from the next pair by 0 longer, diastolic interval. Normally, two sounds are heard—"Iub,” “dub.” = Inthe cortic and pulmonic areas, Sz is usually louder than S. In this way, each of the paired sounds can be distinguished from the other. ~ Inthe tricuspid area, Sy and Sp are of almost equal intensity and, in the mitral area, Sis often slightly louder than So. ‘Systolic interval Diastolic interval Loudness 8; Se Si Sz Aorti¢ area) Pulmonic area Mitral area id pi Loudness SS 1S 3. Normally, the heart sounds are regular, with a rate of 60 4 80 beats/minute (inthe adult). In the athlete or jogger, the resting pulse may be between 40 to 60 beats/minute (continued)Technique HEART (coninved) General approach (contin) ‘Auscultation (continued) ‘4, Once rate and rhythm are datermined, listen in each of the four areas and at Exb’s point (3d lel intorspace, lose tothe sternum) systomatically, frst wih the diaphragm {detects higher pitched sounds) and then with the bell {detects lower pitched sounds). In each area, listen to $, ‘and then to S2 for intensity and spliting. PERIPHERAL CIRCULATION Evcluation of jugular venous distention is most useful in Patients with suspected compromise of cardiac function. Inspection Inspect neck for internal jugular venous pulsations. ular Pulsations Rorely palpable Soft, undulating quality, usualy with two or three outward components (a, c, and v waves) Pulsation eli the sternal end of the clavicle Level of pulsation barely descends with inspiration Pulsations vary with position From Bic Wilioms & Wilkins. 2. Note the highest point at which pulsations ore seen and ‘measure the vertical line between the point and the ster- nol angle. With the head raised 30 degrees, the internal jugular venous pulsations should not be visible more than inch (2.5 cm) above the sternal angle. Increased level of internal jugular pulsations indicates right hear failure. Extremities Inspection 1 Observe skin over extremities or color, hair distribution, pallor, ubor, and swelling. 2. Inspect for ony superficial vessels. inated by light pressure on the vein just above Findings 4. An extra “woosh” sound between S; and Sz indicates sys- tolic murmur; between Sz and S; indicates a diastolic murmur, Noe the area of is greats! intensity [aor pub monic, mitral, tricuspid). An extra sound of short duration Usually indicates an Ss oF Se glo, ‘Occasionally, there may be a spliting of Sain the pul monary area. This is normal. Spliting of S2 (hwo configu: us sounds are heard instead of one) is best heard at the jon, when right ventricular stroke volume is ily increased to delay closure of the pulmonic 1d closure of the aortic valve. sulci valve slightly behin 1 Jugular venous pulsations can be distinguished from carotid pulsations by the following chart: Carotid Pulsations Palpable ‘A more vigorous thrust with a single outward component nated Pulsation not Pulsation not affected by inspiration Pulsations are unchanged by position 7 LS. and Szllogy, PG. (2007). Boles’ guide fo physical examinetion and history taking (9h ed). Philadelphia: Lippincot Highest level Internal jugular vein. External. 1 Extremities should be symmetrically even in color, warmth, ‘and moisture, without sweling. Swelling of feet may occur ‘fer prolonged standing or siting, but will disoppear ready when extremity s elevated (dependent dem)sae PHYSICAL EXAMINATION Extremities (continued) Palpation 1. Note the temperature of the skin over ext ing one side to the other il eT 2.Palpate pulses (radial, femoral, post tor tibi 2. Abuance of perigharl pus indcolasparipharal vse 3.Palpaie the skin over the tibia for edema by squeezing the skin between for 30 to 60 seconds. Run the pads of your fingers over the area pressed and note indentation, IF indentation is noted, repeat the procedure, moving up the extremity, and note the point at which no more swelling is present. 3. Edema is usually graded from trace to 3+ or 4+ piting Trace isa slight indentation that disappears in o short time. Grade 3+ or 4+ is deep pitfing that does not disop- pear readily. At best, these are subjective measurements, which are tried and confirmed through practice and com- parison of findings with associates. (continued)saa en eee Sao et oe ee tea CHAPTER 5 m ADULT PHYSICAL ASSESSMENT Ce eee ere ene ree Technique ABDOMEN General approach 1. Make sure the patient has an empty bladder. 2 The patient should be lying comfortably with his arms at his sides. Bending the knees slightly will help to relox the abdominal muscles and make palpation easier. 3. Expose the abdomen fll, Make sure your ands and the stethoscope diaphragm are warm. ‘4,Be methodical in visualizing the underlying organs as you inspect, auscultate, percuss, and palpate each quadrant or region of the abdomen. Inspection T. Observe the general contour of the abdomen (flat, prot- bran, scaphicd, or concave local bulges). Alo note symmetry, visible peristalsis, aortic pulsations. 2. Chack the umbilicus for contour orheia and th skin for rashes, striae, and scars. ‘Auscultation 1. This is done before percussion and palpation because palpation moy ole the choracer of bowel rounds, 2. Note the frequency and character of bowel sounds (pitch, duration}. 3. Listen over the aorta, renal arteries (ypper quadrants) and iliac arteries (lower quadrants) for brits Percussion a 1. Percussion provides a gener 2. Proceed methodically en tympany and dullness. 3.1m the right upper quadrant (RUG) in the midclavicular line, percuss the borders ofthe liver. 1a. Begin at a point of tympany in the midclavicular line of the right lower quadrant (RLQ) and percuss upward to the paint of duless the lower Iver border) mark the int. b. Pereuss downward from the point of lng resonance above the RUG to the point of dullness (the upper border ofthe liver); mark the point. ‘c. Measure in centimeters the distance between the two marks in the midclavicular line (he liver span). d. Tympany ofthe gastric air bubble con be percussed in the left upper quadrant over the anterior lower border of the rib cage. ral orientation to the abdomen. ‘quadrant to quadrant, noting Findings Right lower quadrant 1 The abdomen may or may not have any scars and should eevfat os sighlly rounded in the nonobese person. 2. Anywhere from 5 to 35 bowel sounds per minute. May have familiar sound of *growling.” 3. Brits indicate arterial narrowing. 2.Tympany usually predominates, possibly with scattered areas of duliness due to fluid and feces. 3. Percussion of the liver should help pation. The liver border in the normally range from 2'% to 4% vide subsequent pal dleviular Ine shouldCa otc Cees (Cree) Technique ABDOMEN (continved) I approach (conned) Parasion nti 4 Assess for on enlarged spleen by ? q n by percussing the lowest intorspace of he right emierior exon hee ieee 'ympanic). Ask the patient fo take a deep brevah ca repeat should sill be tympani) Palpation 1.Perform light palpation in an or 'y muscular resistance (guard fi ial organs or mosses 2.Perform deep palpation to determine location, s sevens mrdoce Mie sion on : users organs ond masses, 2 ve slowly and gently from one quadrant fo the next tlox and recurs the pion Nasten he no 4, Use two hands ifthe abdomen is obese or muscular, wih one hand on top ofthe cther. The upper hand exes tree sure downward while the lower hand feels he elaloree liver Ue Bee by Placing the left hand under the Patient's lower right rib cage and the right hand on th abdomen below the level of liver dullness. Press gory inward and upward with your fingertips while the pan takes 0 deep breath. 7 "9erPs while the patient Spleen 1. Place your eft hand around and under the patient's loft lower rib cage and press your right hand below the lef costal margin inward toward the spleen while the patient takes a deep breath. ie Kidney 1. Next palpate for the left and right kidneys, rganized manner o detect ling), tenderness, or super- 2. Place the left hand under the patient's back between the Caeenie allot z 3. Support the patient while you palpate the abdomen wit ihe Holl peli site of ha trges facing the ht es of the body, 4. Palpate by bringing the left and right hands together as much as possible slightly below the level of the umbilicus on the right and lef 5.lfthe kidney is felt, describe its size and shape and note cny tenderness. 2 6. Cont] vertebral angle fenderess is palptnd wa Pe tient sitting, usually during the examination eee ashes clcennel cee neciag region and strike firmly with the ulnar surface of your hand. Note any tenderness over the area PHYSICAL EXAMINATION Findings ‘4. Change in percussion note fo dullness on inspiration indicate an enlarged spleen. ‘ond involuntary guarding indicate peritoneal inflammation 2. Rebound tenderness (pain on quick withdrawal of the fin- gers following palpation) suggests peritoneal irritation, as in acute appendicitis 3. Palpate painful areas last, Annormal liver edge may be palpable as a smooth, sharp, regular surface. An enlarged liver will be palpable and may be tender, hard, or irregular. ‘A normal spleen is usvally not palpable. Be sure to start low enough so as not to miss the border of an enlarged spleen. - The kidney is usually felt only in people with very relaxed abdominal muscles {the very young, the aged, and mult pparous women). The right kidney is slightly lower than the left. The kidney is fet as solid, firm, smooth elastic mass 6. There should be no costal vertebral angle tendemess. (continued)ABDOMEN (continued) General approach (conned) | Palpation (continued) Aorta 1.Palpate for the aorta with the thumb and index finger. | 2. Fess deeply nh epigastric region roughly the mie line) and feel with the fingers for pulsations, as well a for the contour of the aorta. Other Findings 1.Palpation of the RL@ may reveal the part of the bowel called the cecum. 2. The sigmoid colon may be palpated in the lower left quadrant, 3. The inguinal and femoral areas should be palpated bilat 1 The aorta is soft and pulsatile. 1 The cecum will be sof. 2: The sigmoid colon isropelike and vertical and, i filed * with Feces, may be quite firm. 2a eetTinguinal nodes are present; hey ore ‘i freely movable, and firm. MALE GENITALIA AND HERNIAS This part of the examination, especially for hernias, is best done with the potient standing. (A hernia is the protrusion of a portion ofthe intestine through an abnormal opening.) 1. Drape the patient's chest and abdomen, 2. Expose the groin and genitalia penis. 2.Retract the foreskin, if present. 3. Observe the glans penis and the urethral meatus. Note ‘any vers, masses, or scars. | 4. Note the location of the urethral meatus and any discharge. 5. Observe the skin of the scrotum for ulcers, masses, redness, or swelling. Note size, contour, and symmety. Lift the serotum to inspect the posterior surface. 6. Inspect the inguinal areas and groin for bulges {with and | without the patient bearing down, as hough having bowel movemeni). Palpation Wear gloves. 1.Palpate any lesions, nodules, or masses, nating tenderness, contour, size, and induration. Palpate the shalt of the penis for any induration (firmness in relation to surrounding tissues) 2.Palpate each testis and epididymis separately between the thumb and first two Fingers, noting size, shape, consis- tency, and undue tenderness (pressure on the testis normally produces pain). '3.Palpate the spermatic cord, including the vas deferens within the cord, from the testis to the inguinal ring. Note ‘any nodules or tenderness. 2. The foreskin ofthe penis, if present, should be easily retractable $ 13. The skin of the glans penis is smooth, without ulceration. {A.The urethral meatus normally is located ventrally on the ‘end of the penis. Normally there is no discharge from the urethra. ‘5. The scrotum descends approximately 1% inches (4 cm) in the edhe left side's often larger han the righ side 2. The testes are usually rubbery and of approximately equal mecaaar bere Fecal aeee tet ond i mos easly palpable on he superior perion testis.PUNO eee ee Technique MALE GENITALIA AND HERNIAS (continued) Palpation eee 4,Palpate for inguinal hernias, using the left hand to exam- ine the patients left side and the right hand to anos no the potions nigh «. Insert the right index finger laterally, invagina szrtel sc oth exterelingena ey anon ”e b, Ifthe external rng is large enough, insert the finger alo the inguinal canal toward the inemal ing and ‘sk the patient fo strain down, : oak fe patent to in down, noting any mass ht 5. Palpate the anterior thigh for a herniating in the femoral canal. Ask he ptint a aint ewe tt femoral canal is not palpable; its 6 potential gpening i the anterior thigh, medial to the femoral ertery below the inguinal ligament] PHYSICAL EXAMINATION Lo ings 4, Normally, there is no palpable herniating mass in the inguinal area, ‘Anterior superior spine Inguinal ligament eal inguinal ring 5. Ordinarily, there is no palpable mass in the femoral area. FEMALE GENITALIA See Procedure Guideline 22-1, page 839. RECTUM Equipment Glove = Lubricant Techniques of examination: Male Goneral approach 1 Ifthe patient is ambulatory, have him stand ond bend over the edge of the table with his toes pointed inward. 2. is also possible to examine the onus and rectum with the patient lying on the lef side, knees drawn up and but tocks close fo the edge of the fable. 3. The patient should be draped so only the buttocks ore exposed. Inspection Spread the buttocks and inspect the anus, perianal region, ‘and sacral region for inflammation, nodules, scars, lesions, ulcerations, of rashes. Ask the patient to bear down; note ny bulges. In males and females, the perianal and sacrococcygeal areas are dry, with varying amounts of hair covering them. Anal ‘and perianal lesions include hemorrhoids, abscesses, tags, and sexually transmitted genital lesions. (continued)OC ee eee Sen) tee eS ee Toe (continued) fechniques of examination: (cont {Rem Male (continued) 1.Palpate any abnormal area noted on inspection. 2. Lubricate the index finger of the gloved hand. Rest the fin- ger over the anus as the patient bears down and, as the sphincter relaxes, insert your finger slowly into the rectum. Prostate Bladder 3.Note sphincter tone, any nodules or masses, or tenderness. 4. Insert the finger further and palpate the walls of tum laterally and posteriorly while rotating your index fin- gor. Note ineguaris, mosis, nals, tenderness. 5. Anteriorly, palpate the two lateral lobes of the prostate gland and its median sulcus for irregularities, nodules, swelling, or tenderness. 6. possible, pole the superior portion of the lateral where the seminal vesicles are located. Note induration, swelling, or fendemess. 7 Just above the prostate anteriorly, the rectum lies adjacent paritoneel cavity. If possible, palpate this region for steal masses and tendemess. 8. Continue to insert the finger as far as ible and have the patient bear down so more of the | can be palpated. 9. Gently withdraw your finger. Any fecal material on the ‘glove should be tested for occult blood. Techniques of examination: Female General approach 1 The examination is usually performed following the pelvic, examination with the patient sill in the lithotomy position. Gloves are changed to prevent cross-contamination. 43,The onal canal is approximately 1 inch (2.5 ¢m) long; itis bordered by the external and internal anal sphincters, which are normally firm and smooth. ‘4, The wall of the rectum in males and females is smooth ‘ond moist 5. The mole prostate gland is approximately 1 inch (2.5 em) long, smooth, regular, nonmovable, nontender, and rubbery. 6. The seminal vesicles are generally not palpable unless swollen. 9. There is normally no occult blood in the stools.Cie Cee) Technique RECTUM (continved) Techniques of examination: ener oproech canned) 2.:Ifonly the rectal examination is done, the pation Besttoned larly, a fr examination cf oe male Flt eral position permits beter visualization ofthe ocral gy 3.The technique is bosiccly the same for he famcle se en 4. Anteriorly, the cervix, may be fet Female (continved) ‘and perhaps a retroverted uterus, PHYSICAL EXAMINATION Findings 4, Antariorly, the corvix is round and smooth, MUSCULOSKELETAL SYSTEM General approch 1-Exomine the muscles and joins, keeping in mind the smue- ture and foncions of each HIP in mind tho sue 2. Observe and palpate jens cand examine each joint inl 2. The examination is performne and in motion, moving throug ind muscles for symmel idvaly as indicated.” 2d withthe joins both ot rest Inspection 1. Inspect the upper and lower extrem try, deformity, and muscle mass. 2. Inspect the joints for range of motion (in degrees, enlargement, redness. 3. Note gait and posture; observe the spine for range of motion, lateral curvature, or an) ‘abnormal curvature. 4, Observe the patient for signs of pain during the examination, ties for size, symme- Palpation 1 Palpate the joints of the upper and lower extremities and the neck and back for tendemess, swelling, warmth, ony bony overgrowth or deformity, and range of motion 2. Hold the palm of your hand over the joint as it moves, or move the joint through the fullest range of motion and note any crepitation (crackling feeling within the joint. 3.Palpate the muscles for size, tone, strength, any contrac: tures, and tenderness. 4.Palpate the spine for bony deformities and crepitation. Gently tap the spine with the ulnar surface of your fist from the cervical to the lumbar region and note any pain or tenderness, NEUROLOGIC SYSTEM Equipment © Safety pin ™ Cotton = Tuning fork = Reflex hammer ™ Flashlight "Tongue blade ™ Ophthalmoscope "Vision screener ™ Cloves, coffee, or other scented items 3. Joints should move freely without resistance or pain, (continved)CE pp nn Oe aR br Bee 2 te te era " 7 5 ™ ADULT PHYSICAL ASSESSMENT | BC ee Technique NEUROLOGIC SYSTEM (continued) General information Equipment (continued) 1. The examination described in this section is a screening neurologic examination. It is performed on individuals without specific neurologic complaints. 2. The examination is performed with the patient in either the siting or supine positon 3. Much of the neurologic examination can be performed as different regions of the body are being examined. This facilitates the flow of the entire examination Components ofthe neurologic examination There are six components ofthe neurologic examination: ]. Mental status (cerebral function) 2. Cranial nerve function 3. Cerebellar function 4. Motor function 5. Sensory function 6. Deep tendon reflexes The screening neurologic examination involves testing all of these components at least superficially. Learning these com- ponents in order wil help in organizing the examination ‘and in avoiding the omission of any part. Basic principles 1, Symmetry of function and findings on both sides of the body are important to note. Always compare one side of the body with the other side (for exomple, compare degree of motor strength of the right biceps with that of the left biceps). 2. Integrating the neurologic examination into the examina- on of he varius body regions is edviscble, although the results of the neurologic findings should be recorded together as an ently Mental status ‘Components of the mental status examination include the following: 1 State of consciousness (alert, somnolent,shyporous, comatose) ™ Memory (shortterm, long-term, intermediate) 1 Affect (mood) 1 Ideational content (hallucinations) Ina screening examination, mental stous is evaluated by ‘observing the patient's affect during the history and the content of what she 1 While recording the history, ask he patient for identifying information (how to spell his name, where he lives), and cask what the date is. This test orientation. 2. The patient's ability to remember is also evaluated as the history is taken; ask for his past medical history (longterm memory) and dietary habits: “What did you eat for breakfasi" [intermediate memory) 3. Cognition and ideational content are evaluated through- out the history by what the patient says and by his arficu- lateness, consistency, and reliability in reporting events 1.Normally, the individual s alert, knows who he is ond where he lives, and can tll you the date. 2. The patient remembers recent and past events consistently, and willingly admits forgeting something. Elderly people offen have much better longyterm memory than recent memory.Ca alee ee eT Technique NEUROLOGIC SYSTEM (continued General information (contind) Mantel tes conto 4. Alfect or mood is evaluated by observ fi bol and nonverbal bear ee el sudden noises, and ineruptions. For examde dogs Patient laugh or amle when talking about normaly so events; is he eal storled by unexpected nae Cranial nerve function First aie) nerve The olfactory nerve is not usually to : 5 complains ofa disturbance in sense of amit the Patient 1. the airway must be patent. : 2. Ocelude one nostil ask then present various substar to (coffee, tobacco} Occlude the other nostril cea repose CS : Second (optic) nee Includes tests of visual acuity and of visual fiel nc examination ofthe optic dsc with ncuscepes on Mul as Visual acuity is tested with the use of a Snellen chart [pa uses glasses if required), pepe 1. Have the patient cover one eye at a lime and read the smallest print possible on the chart from a distance of 20 foet (6 m). Visual fields : 1. Have the patient cover his right eye withthe right hand. (You cover your left eye with your lef hand.) 2. Stand approximately 2 feet (60 cm) from the patient and have him fix his gaze on your nose. 3. Bring two wagging fingers in from the periphery (in a plane equidistant from the potient and you} in all quadrants of the visuol field and ask the patient fo tell you when he sees your wagging fingers. Optic aise The optic disc is visualized os port of the funduscopic exam nation. (See page 56.) Third (oculomotor), fourth (trochlear), ond sixth (abducens) nerves These nerves are tested together. They control the movements of the exiraocular muscles of the eye—the superior and Inferior oblique and the medial and loteral rectus muscles. The oculomotor nerve also controls pupillary constriction. 1. Hold your index finger approxim the patient's nose. Ask the patient to hold 2. Ask the patient to follow your finger wih his eyes, 3. Move your finger to the right as far as the patient's eye moves, Before bringing your finger back othe center, move it up and then dovin, so that he poten! glances uP Gnd pexipherlly and then down and peripherally, 4.Repeat the test, moving your finger to the left Findings ‘4. Mood should be appropriate fo the content of the conversation. 2. The patient should be able to identify common smells such ‘as cinnamon and coffee. 1.Normal vision and corrected vision should be 20/20. 3. Assuming your visual fields are grossly normel, the patient ‘and you should see the wagging fingers approxi simultaneously. (The patient’ peripheral vision should’ ‘approximate the examiner's, assuming that its normal.) 4 1 j~!+{ (continued)OCT re etree Cee) Technique NEUROLOGIC SYSTEM (continued) Cranial nerve function (continued) Fifth (rigeminal) nerve The trigeminal nerve controls muscles of mastication and has «© sensory component that controls sensations ofthe face. Motor 1. Have the patient clench teeth while palpating the tempo- ral and masseter muscles of the jaws with both hands. Sensory Sensation to light touch, 1. Have the patient close his eyes. 2. Touch first one side of the patient's face and then the other (forehead, cheek, and chin}, asking the patient if the sensation is present and feels the same on both side 3. Sensation to pain (pinprick) is tested similarly Seventh (facial) nerve ‘Motor function is tested by observing facial expression and symmetry of facial movement. Ask the patient to frown, close his eyes, and smile. Eighth (acoustic) narve The acoustic nerve has two branches. Cochlear {mediates hearing). (See ear examination, page 57,) Vestibular (helps control equilibrium). Romberg tes: Hove he pain sand erect wih his yes closed and feet close together. Ninth (glossopharyngeal) and tenth (vagus) nerves ‘These nerves are tested together because they both have a mater potion inerating he phon 1. Ninth: Test the presence of the gag reflex. 2. Tenth: Ask the patient fo say “ah” and observe the movement of the uvula and palate for deviation and symmetry. Eleventh (spinal accessory) nerve ‘The spinal accessory nerve mediates the stornacleidomastoid ‘and upper portion ofthe trapezius muscle: T Ask the patient to turn his head to the side against resis- tance while you apply pressure to the jaw. 2.Palpaie the sternocleidemastoid muscle on the opposite side. 3. Have the patient shrug his shoulders while you place your hands on his shoulders and apply slight pressure. Findings 1 Musee srengh in he face should be present ond should “be symmetric naation should be present and symmetrical. Always 1 Seen ald ety dre ensafon-—to avoid staring the patient and fo encourage cooperation. Jal muscles should look symmetric when the patient The Fact ss his eves, and smiles. Notice particulary he symmetry of the nasolabial folds. 1 the patient should not fall. (Stand Sight swaying may occur, bu Sea eter fhe begins to fall) close to the patient so you can ass 1. The gag reflex should be present, and there should be no difficulty in swallowing. 2. The palate and uvula should move symmetrically without deviation. 3. Neck and shoulder muscle strength should be symmetric.PHYSICAL EXAMINATION Adult Physical Assessment (conti Te echnique NEUROLOGIC SYSTEM (continued) Cranial nerve function (continued) Twelfth (hypoglossal) nerve This nerve innervates muscles of the noting articulation and by he tongue, noting any deviatior tongue. It is tested ‘ving the po ati OF asymmetry Har fi Purpose: to screen for coordination, 1, Observe posture and goit 2. Ask the patient to walk forward straight line, (and then backward) in a 3. Totes! for muscle coordination inthe lower extrem have the Patient run his right heel down his ef shin sre vice versa 4.To test coordination in upper close his eyes and touch his (starting position: arm rapid succession, extremities, have the patient nose with his index finger ' outstretched) first ef, then right, in Motor function Tested in conjunction the bony deformity will affect mass, fone, strength, and fasciculations, twitching) 1.To assess muscle mass, the body and distibuti 2.Test muscle tone by n fo movement on pass @ skeletal system because any motor function. Evaluote muscle ‘any abnormal movements (tes, ote symmetry between sides of ion distally and proximally, ‘ting the resistance the muscle offers ive motion. 3. Have the patient do deep knee bends; walk on his toes cand then his heels; hop on one foot and then the other 4. Have the patient squeeze your fingers with both hands; compare sides of the body. Also, apply resistance to the Patients outstretched arms and when the patient flexes, the wrist and elbow; compare sides. 5. Unusual muscle movements, if present, are noted both when muscle is at rest and when itis moving, Sensory function Should test sensitivity to light touch [cotton], pain [pinprick], vibration {tuning fork], and position. Compare both sides of the body. 1.Ask the patient fo close his eyes. Brush the skin with a piece of cotton (on the back of hands, forearms, upper arms, dorsal porn of foo! lately and medal, and long the fibia and thigh laterally and medially). Ask the Patient indicate whon sho fel the ction and o com pare the sensation bilaterally. 2. Use a safety pin; touch the skin as lightly os possible fo elicita sharp sensation. Findings The tongue should be symmetric and should not deviate. 2. The patient should be able to perform all the tests described with smooth, even movement and without los- ing balance. 4.The normal person can do this with rapid, smooth move- ‘ments without undershooting or overshooting the target. 1..Muscle mass is usually considered in relation to sex and body build and to use of various muscle groups. 2. Generally there is slight resistance to passive movement of ‘muscles as opposed to laccdity (no resistance) or rigidity (increased muscle tone). 3. Strength will vary from person to person but should be equal bilaterally. 5.Normally, tremors, either at rest or oF fasciculations are not present movement. 1 Patient should feel light touch bilaterally. 2.Pain should be felt bilaterally. (continued)ini echniqu NEUROLOGIC SYSTEM (contd) Sensory function (conned) 3 Test vibration sense by placing a vibrating tuning fork on © bony prominence (wrist, medial and lateral male Ask the patient to tell you when he no longer feels the yibeation. Stop the vibration with your hand. Test positon sense by having the patient close his eyes. Move the patient's digit (finger, great toe) up or down ‘ond oxk the patient fo say in what direction his finger or toe is posnting ~ Place your thumb ond index finger on either side of the digit being moved so the patient will not sense any pres: sure from your finger in the direction in which you are moving the digit Deep tendon reflexes | Hoye the patient relax; provide support for the extremity being tested 2. Compare reflex amplitude of the same tendons on either side of the body. Upper extremities Biceps 1.Place your right thumb on the patient's right biceps tendon located in the antecubital fossa) with the patients, ‘arm slightly flexed. 2. Strike your thumb with the pointed end of the hammer head. Hold the hammer loosely so it pivots in your hand when it is moved with a wrist action. 3. Strike your thumb with the least amount of pressure needed to elicit the reflex. Triceps tendon 1.Have the patient hang his arm freely while you support it with your nondominant hand or rest the slightly floxed corm in the patient's lop. 2. With the elbow flexed, strike the tendon directly, using the pointed end of the hammer. Sl NURSING ALERT /f the reflexes are diminished %4) symmetrically, have the patient grasp hands and contract, corm muscles to relax the lower extremities, or tap feet on the floor to relax the upper extremities. Findings 3. The patient should normally feel no vibration within a very shot time 4. Normally the patient can tell you without hesitation in what direction his digit is pointing, 2. Amplitude ofthe reflex may vary for different tendons but is equal bilaterally 3. The forearm may move, and your thumb should feel the tendon jerk, é 2. The forearm should move slightly.Adult Physical Assessment aren reek ‘SYSTEM Deep tendon reflexes (c Upper extremities (continued) radioed ad tendon 1. Strike the forearm withthe hammer cove the writ over he rad "= SP | inch (2.5 em) 2. Be sue the foreerm sported ond elas Lower extremities Guadhiceps reflex 1. Have the patient sit wih his legs hang tare ts pats ging over the edge aie ote com hile you support the legs of he 2. Srke the tendon just below the patella, (continved) Achilles reflex 1. Support the foot in dorsif 2.Top the Achilles tendon wal Position, re hammer. Plantar reflex 1. Stroke the sole ofthe patient's foot with a lat object such 95 a tongue blade. Findings 1.-The thumb may be observed moving downward, 2. The foot should move downward into your hand. 1.Toes normally flex. Dorsiflexion of the great toe and fan- ning ofthe olher toes is known as a positive Babinski response and indicates a central nervous system problem. 8 eee SELECTED REFERENCES Ang, C.W., et al. (2007). The diagnostic value of digital rectal exami- nation in primary care for palpable rectal tumour. Colorectal Disease. 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