Complete Physical Exams info for Medical Students

1
Patient Evaluation Physical Psychological
Evaluation

• IMEC INC.

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Interview

• The interview is essential in establishing a
  relationship and trust between the patient and
  caregiver.
• Talking with the patient and obtaining their
  health histories is usually the first and often
  the most important part of the health care process

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Patient Evaluation

• Enables one to accurately assess the potential
  risk presented by a patient, prior to the start
  of treatment

4
Physical Evaluation

• Medical history
• Dialogue history
• Physical examination

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Immediate Questions

• Medical History Questionnaire
• 1. Are you having pain or discomfort at this
  time?
• 2. Do you feel nervous about having to see a
  physician ?
• 3. Have you ever had a bad experience in
  reference to your health ?

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Other Questions

• Diet
• Weight gain or loss
• Sleep pattern
• Sexual appetite/companionship
• Family History
• Recent physical or psychological concerns
• Medications
• Exercise
• Allergies
• Tobacco and Alcohol Use

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Medications

• Make sure you get a clear understanding of
  medications, past and present and what the
  patient and previous physician were attempting to
  achieve

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Goals of Physical Examination

• To determine patient's ability to physically
  tolerate any treatment
• To determine patient's ability to psychologically
  tolerate any treatment

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Goals of Physical Examination

• To determine whether a treatment modifications
  are required
• To seek other medical consultation if indicated

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Routine Monitoring

• Blood pressure BP (both arms)
• Heart rate / rhythm along with abnormal Heart
  sound
• Respiratory rate Rales/rhonchi/crackles, O2
  Saturation and dyspnea on exertion

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Heart Rate

• Radial - Ventrolateral wrist
• Brachial - Medial antecubital fossa
• Carotid - Groove between trachea
  sternocleidomastoid muscle
• Femoral- Femoral triangle

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Heart Rythym

• Determine if pulse beats are evenly spaced,
  record as regular,
• If pulse beats are uneven, record as irregular

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Respiration

• Monitor respiratory rate
• Observe movement of chest wall/Symettry
• Cough

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HISTORY TAKING
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Systemic Problems

• Heart failure
• Heart disease or attack
• Angina pectoris
• High blood pressure

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Systemic Problems

• Dysrhythmia
• Congenital heart lesions
• Rheumatic fever
• Scarlet fever
• Pacemaker

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Systemic Problems

• Renal disease
• Stroke
• Ulcers
• Emphysema

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Systemic Problems

• Tuberculosis
• Asthma
• COPD
• Hay fever

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Systemic Problems

• Sinus trouble
• Diabetes
• Thyroid disease
• Chemotherapy or Radiation therapy

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Systemic Problems

• Seizure disorder
• Liver disease
• Sickle Cell disease
• Pregnancy

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Recognition of Anxiety

• History- Does the patient have any previous
  episodes of anxiety or mental illness
• Observation- Shakes, itching- confabulated speech

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Severe Anxiety

• Usually does not hide their fear
• Appears with severe infection or toothache
• Increased heart rate and blood pressure
• Excessive sweating, trembling
• Dilated pupils

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Moderate Anxiety

• Usually try to hide their fears
• Cold and sweaty palms
• Nervous appearance
• "White Knuckle" Syndrome

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INITIAL EXAM
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The Skin

• Initial examination of the skin may reveal a lot
  of pertinent information
• Sores, moles, impetigo, uticaria, tinea etc. the
  dermatologic list goes on and on.
• Even age to physical age, via wrinkles and
  pigments can tell as does spider veins, vitiligo,
  and erythema

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The Head

• Rotation of the head is very important, as well
  as upward/downward movements
• Look at the eye sockets and the midline symmetry
  of the nose.
• Have then give a chewing motion to check the
  buccinator and masseter muscles.
• But remember we are doing more than just checking
  the cranial nerves!!!
• Ask if the patient has had headaches, and/or head
  injuries in the past?

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The Eyes

• Ask How is your vision?
• On Fundescopic exam, look for the Fovea and
  Macula and around at the vessels. Not if you see
  any abnormalities of foreign vitreous floater.
  Check for cataract.
• Ask about vision.
• Check peripheral vision, note if any macular
  degeneration.
• Have them read a chart and see how far
  sightedness is.
• Then ask if they have been having any double
  vision?

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NORMAL EYE


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VISUAL ACCUITY TEST
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The Ears

• Ask How is your hearing?
• Persons with sensorineuro loss have particular
  troble understanding speech.
• Ask them if they have been felling dizzy, as in
  vertigo
• (refer to the cochlear nerve)
• As them if they perceive any ringing the ears, as
  with tinnitus.

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The Nose and Sinus

• Ask How much nasal drainage are you having, Be
  specific as to color, smell, and time of day
• Ask if they are having itching
• Palpatate the sinuses, and see if there is
  congestion.
• Ask them if the sinuses cause headaches
• Remember that epitaxis is bleeding from the nose,
  and is normal in small amounts

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The Mouth, Throat and Neck

• Although the mouth and teeth are better looked at
  by a dentist, it is important that the physician
  check the Gingiva arounud the teeth and the
  tongue
• Ask Have you noticed any swollen glands
• Check for an enlarged thyroid and paramandibular
  lymph swelling

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The Breast

• In the female patient ask do you do self breast
  exams and how often
• Is there sicharge of bleeding at nipple
• If over 40, the latest mammography
• Surgeries (lumpectomy)
• If no experience with breast exam, supply
  information on how to do a selfexam!!
• Make sure you check axillary lymph!!

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The Chest

• Pain in the chest frequently raises concern about
  heart disease, yet there are other structures as
  well we must consider
• Costonondritis
• Aneurysm
• Pleurisy
• Pericarditis
• Anxiety
• Esophageal reflux to name a few.

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The Heart

• The standard for evaluation of the heart is the
  12 Lead EKG.
• When this is not available, we must use our
  trusty stethoscope in which we can evaluate heart
  sounds ( S1-S4)

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Heart Sounds

• S1 is accentuated in tachycardia, and diminished
  in Heart Block
• The second heart sound (S2, "dup") occurs when
  the semilunar (aortic and pulmonary) valves
  close. S2 is normally split because the aortic
  valve closes slightly earlier than the pulmonary
  valve.
• S2 may be covered up by S
• Mid systolic murmurs may be due to an Aortic or
  Pulmonic Stenosis
• Pan Systolic murmers may be due to Mitral
  Regurgitation, Tricuspid Regurgitation, and VSD,
  Venticular Sepal Defect
• Diastolic Murmers include the rumpling of Mitral
  Stenosis and blowing sound with Aortic
  Regurgitation
• You may also hear pericardial friction rub which
  is scratchy, and or a venous hum, which none the
  less sounds like a hum.

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The Lungs

• Besides evaluating Breath Sounds, with the lungs
  we must also evaluate chest shape, and bilateral
  symmetry. We must also evaluate the use of
  accessory muscle (sternoclido mastoid muscle) and
  excessive use of the diaphragm
• It is also important to get an AP Lateral X-RAY
  of Chest
• The standard for Lung Volumes is a standard
  spirometry, yet in the event that we need the FRC
  and RV to evaluate the extent of unused volume,
  helium dilution and Nitrogen washout are
  available at some facilities.

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Breath Sounds

• Rales- Wet low pitched popping, associated with
  CHF, Pneumonia etc
• Wheezes- asthma type BS , may be also associated
  with bronchial sounds
• Rhonchi- associated with wheezes, narrowing of
  the airway with mucous plug movement, more
  associated with COPD patients
• Stridor- upper airway closure causes stridorous
  BS
• Bronchovesicular- Normal flow sound over R apex

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Percussion Technique

• Various Percussion techniques have been
  established as a way to identify dullness,
  resonance, hyper-resonance, and tympanic sounds
• Resonant sounds are low pitched, hollow sounds
  heard over normal lung tissue.
• Resonant sounds are low pitched, hollow sounds
  heard over normal lung tissue.
• Hyper-resonance would be heard in situations like
  COPD

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The Abdomen

• Remember that when inspecting the, it is more
  than the GI system that we are inspecting.
• Yes we must inspect the continuity beneath the
  rectus abdominis abdomen muscles, but we must
  also have an understanding of the abdominal
  quadrants, as well as epi-gastric, umbilical, and
  hypo-gastric areas

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Liver percussion
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Abdominal Pain

• Potential causes of abdominal pain include, but
  are not limited to, appendicitis, cholecystitis
  (inflamed gall bladder), gastritis (inflamed
  stomach), gastroenteritis (inflamed stomach and
  bowels), bowel obstruction, malignancy (cancer),
  pancreatitis, pelvic inflammatory disease,
  ruptured uterus or ovary, gastrointestinal
  ulcers, and peritonitis (inflammation of the
  membrane lining the abdomen).  Abdominal pain may
  also be caused by less severe afflictions such as
  anxiety, flatulence and constipation.

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The Female Genitalia
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QUESTIONS FOR WOMEN

• OnsetAn  unusually  late  or  early menarche
  (beginning of menstrual function)
• Although  the  typical  menstrual interval is 28
  days, there are many variations.
• The  quantity  of the flow frequently parallels
  the duration   
• Character  of  Menstrual  FlowNormal appearance
  of  menstrual  blood  is  dark  venous  and
  unclotted. Bright red, clotted blood is the type
  of flow seen in excessive menstruation.
• Menstrual  PainPainful  menstruation(dysmenorrhea
  ) is  one  of  the  most  frequently encountered
  of all gynecologic  complaints.  The character of
  the  pain  or  cramps,  onset,  and duration
   should  be  determined  

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Questions for women 

• Intermenstrual  BleedingIntermenstrual bleeding
  is a serious symptom. Even light bleeding
  frequently can  indicate  organic  causes,  such
   as polyps,  erosion  of  the  cervix,  and
   occasionally cervical   malignancy
•  First  Day  of  the  Last  Menstrual  Period
  (LMP)Many  women  are  unsure  of  the  exact
  date  their  LMP  began  however,  it  is
   important to establish it. Dates are necessary
  to determine whether the cycle is irregular as
  well as to establish the  time  of  conception.

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Pelvic Exam

• Ask patient to empty bladder before exam
• Drape patient accordingly
• The patients arm should be across chest
• Explain the procedure
• Choose appropriate size speculum
• Use warm hand and warm speculum
• Monitor the patients face for grimaces
• Be as gentle as possible

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Look For

• External
• Venereal warts
• Chancre
• Herpatic lesions
• Internal
• Discharge
• Color (Blue/Pregnancy) (Red/Inflammation)
• Cyst
• Polyps

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The Male Genitalia
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The Male Exam

• Assessment of sexual maturity, ie. adult male
  growth hair pattern?
• Investigation of inguinal or scrotal incisions
• Evaluation of penis for any signs of hypospadias
  or epispadias or Cordis.
• Examination of testicles for consistency and size
  Palpation of the epididymis bilaterally (an
  irregular eididymis may indicate infection or
  obstruction).
• Evaluation for inguinal hernias.
• Examination of the scrotum for possible
  varicocele with the patient in a standing and
  supine position, employing the Valsalva maneuver.
  
• Examination of the prostate to rule-out
  prostatitis. Transrectal ultrasound to rule-out
  ejaculatory duct cyst.

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The Peripheral Vascular System

• When evaluating the periphery it is important to
  look at skin, muscle tone, and flexibility not to
  mention chck the following pulse regimen
• Upper Extremities
• Brachial
• Ulnar
• Radial
• Lower Extremities
• Femoral
• Popiteal
• Dorsal Pedis
• Posterior Tibial

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The Peripheral Vascular System

• It is also important to check inguinal lymphatics
• Check for signs of incompetent varicose veins
• Check for superficial and deep phlebitis
• Check for any ulcerations
• Check for Edema

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EDEMA

• Edema come in many forms
• Right sided heart failure
• Hypoalbuminemia
• Excessive retention of Salt Water
• Venous statis secondary to obstruction
• Lymphatic Stasis
• Orthostatic Edema
• Increased Capillary Permeability

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The Musculoskeletal System

• In evaluating the Musculo-skeletal system it is
  important to understand the specific types of
  joints, (synovial) and otherwise
• It is important to understand normal flexion and
  extension of the movement of each joint (age
  specific), of course.
• It is also noted that the various joint, like the
  shoulder for instance, have inputs from at least
  5 major muscle
• And last but not least the nerve innervention
  must be noted for movement

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REFLEXES

• Essential when checking reflexes we are checking
  a spinal reflex arc
• Biceps Reflex
  Cervical 5, 6
• Supinator Reflex Cervical
  5, 6
• Triceps Reflex
  Cervical 6, 7, 8
• Knee Reflex Lumbar
  2, 3 , 4
• Ankle Reflex Lumbar
  5, Sacral 1, 2
• Plantar Reflex
  Lumbar4, 5, Sacral 1, 2

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Glenohumoral Joint
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HIP and FEMUR
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Knee Anterior and Posterior
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Neck and Back Pain

• In understanding back pain, it is also important
  to understand the Spinal Column, nervous
  intervention, and normal leg movement.

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Lordosis of Spine
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Kyphosis of Spine
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SCOLIOSIS of SPINE
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Dermatomes
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Upper arm Dermatomes
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Dermatomes of Legs
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The Hematological System

• Refer to Hematology

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The Endocrine System

• Refer to Endocrinology

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BABINSKIs SIGN
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KERNIGs SIGN for Meningitis
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BRUDINSKIs SIGN for Meningitis
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