Physical Exam

Inspect the JVP

-Patient is sitting at 30 degrees

-head is turned to the left

-With pen light look for pulsations or distention at the jugular vein

-Can indicate Right sided heart failure

Measuring the JVP (Verbal)

-Patient is sitting at 30 degrees

-Head is turned to the left

-Place ruler at sternal notch (jugular notch)

-place popsicle stick at the point of pulsation and measure

-more than 3 cm indicates a problem (right sided heart failure)

Inspect the PMI

-patient is sitting at 30 degree angle

-locate 5th intercostal space at the midclavicular line

-Use pen light to locate the little pulsation

Palpate the Right Ventricle of the Heart

-Patient is sitting upright at 30 degree angle

-Palpate the 2nd, 3rd, 4th intercostal space

Auscultate Heart Points

-Aortic is at the 2nd intercostal space on the right side

-Pulmonic is at the 2nd intercostal space on the left side

-Erb’s Point is at the 3rd intercostal space on the left

-Tricuspid is at the 4th intercostal space on the left

-Mitral is at the 5ht intercostal space and midclavicular line

-APETM

-Use both the diaphragm and bell

Auscultate the Carotids

-Using the bell (use diaphragm if instructed)

-Find carotid pulse then using stethoscope listen for any bruit (can indicate hypertension/ atherosclerosis)

Auscultate the Apex of the heart

-Patient is sitting upright at an angle of 30 degrees

-using Bell find 5th intercostal space and at the midaxillary line auscultate (PMI/Mitral)

Perform Chest Expansion

-Have patient seated and put both hands at the costovertebral angle and have the patient take a deep breath in and out and look to see if the thumbs move uniformly

-With tape measure go right below the nipple line and have the patient expel all the air then have them take a deep breathe in and measure the amount

Perform Tactile Fremitus

-Patient is sitting up and Dr. is behind the patient using a hypothenar contact

-Instruct patient to say “99” every time you touch them

-Assess three points down the spine and one lateral around the 11th/12th rib

-Looking for increased thrills/vibration

-This could indicate consolidation (Cancer or pneumonia)

Percuss the Lung Posterior

-Skin contact

-Patient is sitting up and Dr. will start on asymptomatic side first

-place middle finger parallel to ribs within the costal space and strike the contact finger with other hand and move in a ladder pattern/H pattern (side to side before going down a level)

-Loss of resonance can indicate consolidation (Cancer/Pneumonia)

Perform Whispered Pectoriloquy

-Skin Contact

-Patient is sitting up

-With stethoscope (Diaphragm) auscultate the apex of the lung (asymptomatic side) and go down in an H pattern and every time you touch the patient have them whisper “99” under their breath

-Increased sound suggests possible consolidation

Bronchophony

-Skin Contact

-Patient is sitting up

-with a stethoscope (Diaphragm) start at the apex of the lung on the asymptomatic side first and travel in an H pattern and every time you touch the patient have them say “Scooby-Doo”

-Changes in sound could indicate consolidation?

Egophony

-Skin Contact

-Patient is sitting up

-with a stethoscope (Diaphragm) start at the apex of the lung on the asymptomatic side first and travel in an H pattern and every time you touch the patient have them say “EEE”

-Sounds not consistent with EEE can suggest consolidation (cancer/pneumonia)

Auscultate the Abdominal Aorta

-Patient is laying down with knees bent

-Midway between the xiphoid and the belly button then about an inch over is where the abdominal aorta is located

-this is where you will use the bell to auscultate assessing for any bruit or abnormal sounds

Auscultate the Renal Arteries

-Patient is laying down with knees bent

-From abdominal aorta go about an inch to the left and to the right and auscultate using the bell

Auscultate the Iliac Arteries

-Patient is laying down with knees bent

-from belly button go about an inch inferolateral on both sides and auscultate using the bell

Auscultate the Liver

-Patient is laying down with knees bent

-Auscultate using the bell/diaphragm Up under right anterior rib angle

-Assess for bruit or friction rub which could suggest inflammation

Auscultate the Spleen

-Patient is laying down with knees bent

-Auscultate using the bell/diaphragm up under the left anterior rib angle

-Assess for any bruit or abnormal sound that might suggest inflammation

Perform Light Palpation of the Abdomen

-Patient is laying down with knees bent

-Start on asymptomatic side

-Palpate in each quadrant superficially (about an inch) 1 to 2 times in a circular pattern

-looking for any areas of tenderness or masses

Perform Deep Palpation of the abdomen

-Patient is laying down with knees bent

-Start on asymptomatic side

-Palpate in each quadrant deep (about 2 inches) in a circular pattern

-Looking for any areas of tenderness or masses

Perform Rebound Tenderness/Blumbers Rebound Tenderness

-Patient is laying down with knees bent

-Start on asymptomatic side first

-In each of the 4 quadrants palpate and quick release

-Looking for pain/tenderness

McBurney’s Point

-Patient is laying down with knees bent

-About 2/3rds of the way from belly button to ASIS you will palpate

-Appendicitis is suspected if increased pain and tenderness is in this area

Rosving Sign

-Patient is laying down with knees bent

-Perform rebound tenderness on the left side and pain / tenderness will be felt in the right side

-Indicates Appendicitis

Psoas Sign

-Patient is laying down with knees bent

-bring the right knee/hip into flexion and have the patient resist and then extend the hip

-Increased pain will indicate appendicitis

Obturator Sign

-Patient is laying down with knees bent

-Flex the knee of the patient and internally rotate the right leg and have them cough

-Increased pain/tenderness can indicate appendicitis

Murphy’s Sign

-Patient is laying down with knees bent

-Hook fingers up under the right inferior rib angle, have patient take a big breath in (if patient hitches/avoids the breath can indicate cholecystitis)

Murphy’s Punch

-Patient is sitting upright

-Find costovertebral angle and place hand over the area and strike lightly with a closed fist

-Increased pain/tenderness can indicate kidney stones or other kidney pathology

Assess for Ascites

-Patient is laying down with knees bent

-From belly button in a star pattern percuss the abdomen toward the belly button and look for any fluid rippling

Direct (eye)

-Tests Cranial nerve II

-Have patient divide the eyes using there hand from left and right, with a penlight shine into the eye and watch for the pupil to contract/constrict on the same side

Indirect (eye)

-Test Cranial Nerve III

-Have patient divide the eyes using their hand from left and right, with a penlight shine into the eye and on the opposite side look for pupil constriction

Accommodation/ Near Reaction

-Have patient look at the tip of the penlight then look at an object in the distance

-look to see if the eyes are constricting when looking closer and dilating when looking far

Convergence

-Have patient look at tip of the penlight and bring it towards the patients nose

-Looking for constriction of the pupil

H Test (Motor for III, IV, VI)

-Have patient look at tip of penlight and move in a H pattern

Romberg

-Patient starts with eyes open with feet together

-Patient then closes their eyes and holds this position for about 30 seconds or as long as they can

-Assesses proprioception and balance and failure of this test can indicate a posterior column pathology

Pronator Drift

-Have patient raise arms in front of them palms up and close eyes

-observe patient for 30 seconds to see if hand pronates and arm drops

-movement can indicate loss of proprioception due to UMN lesion or Ipsilateral cerebellar or DCML lesion

Weber’s Test

-Using a 256 tuning fork, strike for then place on top of patient’s head

-Sound normally should be heard in both ears, but can lateralize to one side due to a conduction issue in that ear or a sensorineural issue in the opposite ear

Rinne’s Test

-Using 256 tuning fork, strike fork then place on the mastoid process and have patient tell you when they can no longer hear it, then move tuning fork in front of patients ear (time it and the ratio should be 2:1; 10 seconds on mastoid they should hear it 20 seconds in front of ear)

Palpate Sinuses

-Frontal: above eyebrows

-Ethmoidal: Superior bridge of nose

-Sphenoidal: just inferior to ethmoidal sinuses

-Maxillary: on either side on nose below orbit

Diaphragmatic Excursion

-Have patient take big breath in and hold, then percuss down each side until you reach a dull point and note level

-Then have patient let all their breath out while percussing up each side until you reach a dull point and note level

-then you would measure the distance between the 2 points