Transcript Basic Health Assessment: The Physical Exam

Basic Health Assessment:
The Physical Exam
ALLWISE Publications
Pat Camillo PhD,RNC,ARNP-BC
May 1, 2003
Important Points
Before You Begin!
• Purpose of the PE is to uncover variations from
normal – SO, you must know the range of
normal!
• The history is a continuous process and will
continue throughout the PE
• Surprises should be avoided – always explain
what you are doing
• Professional demeanor is critical- maintain eye
contact, avoid inappropriate jokes, watch non
verbal behavior
• Be prepared!
The General Survey
• Begins the moment the person enters the office!
• Observe for the following:
– Appearance (frail, posture, stature, weight, gait, facial
expression)
– Behavior (agitated, restless, argumentative,
oppositional)
– Odors (alcohol, acidosis, poor hygiene)
– Speech (fast, slow, hoarse)
– Signs of distress (pain, breathing, limping)
– Determine if an in depth mental status exam is
needed prior to continuing.
Vital Signs
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Pulse
Respiratory rate
Temperature
Blood pressure
Key Techniques
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Inspection
Palpation
Percussion
Auscultation
Inspection
• Must learn to inspect and observe, not just
see!
• Be aware of symmetry and asymmetry.
• Need adequate lighting
• Need adequate exposure
• Helpful instruments: penlight, otoscope,
opthalmoscope, nasal speculum, vaginal
speculum.
Palpation
• Touch is a diagnostic tool!
• Characteristics to note: hard, soft, hot,
cold, rough, smooth
• Fingertips are the most sensitive to touch
• The palm is most sensitive to vibrations
• Then ulnar and dorsal surface of the hand
is most sensitive to temperature
How to Palpate
• Always start with light palpation!
• Deep palpation follows (esp. in abdominal
exam)
• Technique for deep palpation:
Place the fingers of one hand over the
area to be palpated – then place the
fingers of the other hand right in front of
the first set of fingers and push deeply with
both hands.
Percussion
• The process of striking a portion of the
body to evaluate the condition of
underlying structures.
• Blunt percussion can produce pain when
an underlying structure is inflamed (as in a
kidney infection)
• Commonly, percussion uses the fingers to
create vibrations on the body surface
How to Percuss
• Place the middle finger of the left hand firmly
over the area to be percussed. This is called the
pleximeter finger.
• The percussion blow is struck by the tip of the
middle finger of the right hand.
• If you are left handed you need to switch the
above instructions .
• You want to use the tip of the finger – not the
pad – otherwise you won’t get a good, clear
sound. SO……….nails must be short!
• Hint: The action is in your wrist – not your arm!
Sounds Produced with Percussion
• The action must be brisk and short in
order to produce a sharp, clear sound.
• The kind of sounds produced depend on
the nature of the tissue under the
pleximeter.
• PRACTICE…..PRACTICE….PRACTICE
Normal Percussion Sounds
• Resonance – low pitched – normal in the
lung. To hear this - try percussing the right
anterior thorax above the level of the
breast.
• Dullness – Higher pitched sound heard
over solid tissue……..try the heart or liver.
• Tympany – VERY low pitched – often in
the abdomen, in areas where air
dominates.
Other Percussion Sounds
• Flatness – ABSOLUTE dullness…….what
you hear when you percuss the thigh.
• Hyperresonance – Even lower than
resonance – what you would hear if you
percussed an air-filled lung as in a
pneumothorax.
NOTE: Percussion only goes so far –
structures smaller than 4 or 5 cm or more
than 4 or 5 cm deep – are out of reach!
Auscultation
• The stethoscope should be fairly thick,
about 12-15 inches long and should have
both a bell and diaphragm.
• It should fit YOU properly – ear canals
come in all sizes 
• The most important part of auscultation is
what goes on between your ears!
Uses and Sounds
• The diaphragm – transmits higher pitched sounds better
than lower frequency sounds.
• The diaphragm should be pressed firmly against the
chest wall.
• The bell transmits low pitched sounds – should be
placed lightly on the skin – just to make contact.
• Both bell and diaphragm are used for heart sounds.
• The diaphragm is sufficient for lung sounds since most of
what you hear in the chest is a higher pitch.
Equipment
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Penlight
Reflex hammer
Tuning fork
Tape measure
Transparent ruler
Blood pressure set
Otoscope/opthalmoscope set
Something to carry it all in 
Skin, Hair and Nails
• Two essential techniques:
–Inspection
–Palpation
Inspection
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Good lighting is essential!
Skin color and tint (uniform, pigmented
Lesions (location, extent, characteristics)
Don’t forget fingernails, toenails, arm pits,
back of the neck.
• Inspect hair for color, amount, texture
Palpation
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Skin temperature
Moisture
Texture
Pay attention to symmetry
Note skin turger (normal loss in elders)
Edema
Normal Findings
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Uniform skin color
Intact, without inflammation
Smooth, soft and dry
Reactive hyperemia
Free of lesions
Without edema
No obvious extremes
Transcultural Considerations
• The darker the skin – the greater the melanin
and the less risk for skin cancer.
• Interesting note: Eskimos sweat less on their
trunks and extremities and more on their face as
compared to say people who are not eskimos.
Why? It’s an environmental adaptation that
allows temperature regulation without causing
perspiration and dampness in their clothes,
which would decrease their ability to insulate
themselves from the cold weather!
Remember
• Sexual skin areas are typically darker,
especially among dark skinned and asian
races…….this includes the nipples, areola,
scrotum and labia.
• Observe for signs of possible abuse: a
concern would be multiple bruises at
different stages of healing.
Hints: Possible Concerns
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Cold – arterial insufficiency
Warm – hyperthyroidism
Increased moisture – anxiety, hyperthyroidism
Dry skin – hypothyroid
Poor turger – dehydration, scleroderma
Hair loss or excess – endocrine problems
Clubbing nails – emphysema, heart disease
Pits, lines in nails – possible nutritional problems
Primary Skin
Lesions
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Macules
Papules
Patch
Plaque
Nodule
Wheal
Tumor
Vesicle
Pustule
Bulla
Cyst
Secondary Skin
Lesions
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Crust
Scale
Fissure
Erosion
Ulcer
Excoriation
Scar
Lichenification
Keloid
Reminder
• The focus in Basic Health
Assessment is on
NORMALS……….don’t get too
distracted or spend too much time
with abnormal findings…….that’s
what we’ll do in Practicum I and
Clinical Decision Making!
Head and Neck Exam
• Primarily use Inspection and Palpation in a
routine exam – although some people will
routinely auscultate for bruits along the carotid
arteries.
• Always expect a little asymmetry in faces
• The skull, however, should be symmetric and
smooth
• The trachea should be midline – not deviated to
the left or right.
• Ask person to take a drink of water and inspect
for any deviations from normal with swallowing.
• Thyroid tissue will move up with swallowing.
Palpating the Thyroid Gland
• A normal thyroid gland is neither visible or
palpable!
• How to find it: It lies in the anterior lower
neck on both sides of the trachea, with the
isthmus overlying the trachea. The 2
lateral lobes are butterfly shaped and
joined by the isthmus at the lower part.
Most of the lobes are covered by the
sternocleidomastoid muscles.
Technique for Palpating the
Thyroid
• Can be done from the front of the person
or from behind them – your preference.
• Try this simple procedure:
Press gently on one side of the gland,
displacing the larynx and trachea laterally.
The opposite side is then palpated lightly.
Ask the person to swallow. This motion will
move the gland past your finger tips and
help you to identify nodules – if any!
Lymph Nodes –
Know Your Anatomy!
• Preauricular – in front of
the ear
• Postauricular – superficial
to the mastoid process
• Occipital – at the base of
the skull
• Submental – midline,
behind the tip of the
mandible
• Submaxillary – Halfway
between the angle and
the tip of the mandible.
• Tonsilar – at the angle of
the mandible
• Superficial cervical –
overlying the
sternomastoid muscle
• Posterior cervical – in the
posterior triangle along
the edge of the trapezius
muscle
• Supraclavicular – just
above and behind the
clavicle
Nose, Sinuses, Mouth, Throat
• Primarily inspection and palpation
• Again – know your anatomy:
– Temporal sinuses
– Maxillary sinuses
– Temporomandibular joint
– Buccal mucosa
Normal Findings
• Nose: midline, intact, no discharge, no
redness, no tenderness
• Sinuses: no tenderness or inflammation
• Lips: pink, moist, symmetrical, no lesions
• Oral Mucosa: pink, smooth, no lesions or
odors
NOTE: In dark skinned persons, it’s normal
to have some patchy pigmentation or
bluish coloration to the mucosa.
More Normals
• Gingivae: pink, withour bleeding or lesions
• Teeth: intact and present!
• Tongue: smooth, midline, pink, without
lesions – don’t forget to look under the
tongue (common for cancers to hide
there!)
• Throat: pink, moist, no exudate or lesions,
note presence of tonsils, movement of
uvula and gag reflex
Lymph Nodes
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Note:
Location
Size
Shape
Mobility
Consistency
Tenderness
Normal Lymph Glands
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Moveable
Discrete
Soft
Non tender
Less than 1 cm
Ear and Auditory Exam
• Again, primarily inspection and palpation
• Note deformities, trauma, lesions,
tenderness.
• Always inspect before you touch!
• After the history, you should have some
indication of whether or not this person
can hear 
Some Easy Tests
• Whisper Test: whisper something standing about
a foot or two away and ask the person to repeat
it – while they are facing away from you.
• Weber Test: This test is also not usually done in
a general exam, but here is how it works:
Place a vibrating tuning fork in the midline of the
skull and ask the person to tell you if she hears
the sound equally in both ears. If she doesn’t
note the ear in which the sound is louder.
A Word About Hearing Tests
• These exams are crude, screening tests
that really don’t tell the examiner more
than this: if there is a problem with either
the whisper or the weber test, refer this
person for a complete hearing evaluation
and don’t waste their time or yours by
playing with this tuning fork .
Using an Otoscope
General guidelines:
1. Tilt the persons head away from you.
2. Hold the otoscope between the thumb
and fingers of one hand.
3. Hold the auricle between the thumb and
finger of the other hand – use other
fingers to steady the head.
4. Pull the pinna up and back in order to
straighten the canal and get a good view.
Normal Findings
• External Ear and canal: no inflamation,
lesions or drainage. Some grey-brown
cerumen may be present.
• Tympanic membrane: Intact, pearly grey,
no bulging, bleeding, retraction, or lesions
• Malleus: dense whitish streak originating
from the superior hemisphere of the
tympanic membrane
Eye Exam
• Again, inspection and palpation dominates
the exam for this system.
• Remember – you are not expected to be
an expert in this area!
• The role of the primary care provider is to
identify deviations from normal and
REFER!!
Visual Acuity
• Use of the Snellen Chart: if the person can
read most or all of the letters in line 8 at 20
feet, vision is considered normal.
• There are now cards that can also be used
to test near vision as well and can come in
handy to help people identify whether or
not they should be suing reading glasses.
Visual Fields
The confrontation method:
Place yourself in front of the person, about 2 feet
away, and about the same height. Ask the
person to cover one eye with something opaque
and have the other eye look directly at you. Hold
a pencil midline between you and the other
person, and slowly move it in from the periphery
in several directions (up, down, laterally). Ask
her to tell you when she sees the pencil – it
should be the same time as you see it. If not,
she may have some peripheral vision loss.
Using the Opthalmoscope
Important Points:
1. Usually you do not have the advantage
of being able to medically dilate the
persons pupils……..so once again, this
is a very crude exam!
2. Darken the room – that will help. It will
also help if the person has big brown
eyes – much more difficult in persons
with light eyes.
More Guidlines
• If you have a dog who doesn’t mind, they are
usually good specimens - easy to see!
• DO not wear your eyeglasses when using this
instrument. There is a built in diopter setting that
can compensate for you.
• There are lots of interesting settings on this
instrument – most of which you will never use.
Mostly you will use the large round aperture with
the white light for routine exams.
• Ask the person to stare at a distant object – this
will help to dilate the pupil and keep the retina
still.
Even More!
• ALWAYS match sides with the person:
Use your right eye to look into their right eye
and hold the opthalmoscope in your right
hand.
Place your free hand on the persons
forehead. This helps to stabilize you in
space – since it can get a little
disorientating and you don’t want to bump
heads .
In Search of the Optic Disc!
• Once you are in position, and still about a
foot away, use your instrument to first find
the red reflex. You should be able to see
this before you get too close to the person.
• Then gradually move in, following that red
reflex and until you start to see vessals.
• Once you see vessels, follow one of them
– it will lead you to the optic disc!
Normals
• Arteries are a brighter red than veins.
• Arteries have a thin strip of light down the middle
– the arterial light reflex.
• The ratio of artery to vein width (A:V ratio) is 2:3
• Sometimes an artery and a vein will cross but
they should not be nicked and should not be
more than 2 disc diameters (DD) away.
• It’s normal to see pulsations in veins as you get
near to the disc.
More Normals!
• The optic disc is a creamy colored round
or oval structure with distinct margins.
Once you see it – you will know!
• The macula is off temporal to the disc.
This can cause some discomfort for the
person if you stay there too long – it’s
very sensitive, so you want to do it last,
take a look and move on. Tends to be a
little darker than the rest of the fundus.
Examining the Thorax and Lungs
Here is where you will use all of the
techniques for the physical exam:
Inspection
Palpation
Percussion
Auscultation
Normal Breath Sounds
• Vesicular Sounds: soft, low pitched, heard
over most of the chest
• Bronchial Sounds: loud, high pitched,
heard only over the trachea and major
bronchi.
• Broncho-vesicular Sounds: a combination
of the above, can be heard over portions
of the chest where a bronchus is near lung
parenchyma (the upper anterior chest).
Testing for Tactile Fremitus