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Sequence and Structure of Physical Assessment

Introduction

  • Importance of verbalization during the assessment process.
  • Reinforcement of checklist format (Yes/No).

Initial Steps

  • Introduction of the Student: Inquiry if they want the vitals verbalized or performed.
    • If yes, proceed with vitals only after confirming the patient's preferences.
  • Washing Hands: Critical first step.

Vital Signs Assessment

  • Blood Pressure: Measure in both sitting and standing positions if requested by the patient.
    • State: "I will do blood pressure in sitting and standing positions. Do you want both?"
  • Respiration Rate: Count for 15 seconds, multiply by 4.
  • Pulse: Measure and verbalize findings while conducting.
  • Temperature: Insert thermometer in the mouth for ten seconds; verbalize process.

Skin Examination

  • Skin Turgor: Pull skin to assess elasticity.
  • Texture and Moisture: Use the palm for both to check skin integrity.
  • Superficial Masses: Also assess with the palm.
  • Temperature of Skin: Mention using dorsum of the hand if required.

Nail Assessment

  • Nail Bed Inspection: Observe for shape, signs of clubbing, pitting, and capillary refill.
    • Clarification on technique: Do not cover the nail while pushing on the pad for capillary refill.

Hair Inspection

  • Characteristics: Observe quantity, distribution, and palpate for texture, especially for patients wearing hijabs.

Head and Face Examination

  • Inspection of the Head and Face: Check for symmetry; palpate scalp and facial bones for tenderness.
  • Cranial Nerve Assessments:
    • Cranial Nerve VII (Facial Nerve): Ask patient to raise eyebrows, frown, smile, puff cheeks.
    • Cranial Nerve V (Trigeminal Nerve): Test sensation across V1, V2, V3 regions.
    • Assess with motor tests: Ask patient to clench teeth to feel the masseter muscle.

Eye Inspection

  • Upper and Lower Eyelids: Inspect both eyelids, lacrimal duct, sclera, and conjunctiva.
  • Visual Acuity: Use a pocket screening test at 14 inches; have patient cover one eye, reassure about glasses.
    • Clarify: "I would normally do both eyes; do you want me to continue?"
  • Cranial Nerves II, III, IV, VI: Evaluate extraocular muscle movements using specified motions.
    • Remember: "LR 6, SO 4, A 3", referencing the muscles involved.

Accommodation and Pupils

  • Pupil Accommodation: Monitor constriction to convergence.
  • Peripheral Field by Confrontation: Conduct either by covering eyes or bow ties with a finger approach.

Ear Examination

  • Otoscopic Exam: Inspect the tympanic membrane; description should include color: "tympanic membrane pearly gray with light reflex."
  • External Ear: Inspect and palpate for abnormalities. Pull the ear up for accurate otoscopic inspection.

Nose Examination

  • Inspection: Look for polyps, palpate for tenderness on the sinuses, check nasal passage patency and smell.

Mouth Examination

  • Inspection of Oral Cavity: Assess lip, teeth, gums, tongue, and soft/hard palates.
  • Visual Aid: Use a flashlight and tongue depressor.

Neck Assessment

  • Inspection: Check for symmetry, swelling, and assess range of motion (flexion, extension, lateral bending).
  • Palpation of Nodes: Describe palpation method for different nodes.
    • Function: Detail the importance of palpating the trachea and thyroid, noting the need for the patient to swallow during thyroid assessment.

Chest Assessment

  • Inspection: Evaluate for movement, discoloration, and symmetry.
  • Palpation: Check fremitus (have patient say '99').
  • Percussion: Auscultate for lung sounds in various regions (apex, lateral, posterior).

Cardiac Assessment

  • Inspection: Neck veins for distention, precordium for abnormalities.
  • Palpation: For thrills, apical impulse at the fifth intercostal space midclavicular line.
  • Auscultation: Use diaphragm for high-pitched sounds, bell for low-pitched sounds in proper locations.

Abdominal Examination

  • Inspection: Observe for discoloration, masses—clarify focus areas like liver span and gallbladder assessment.
  • Auscultation and Percussion: Renal arteries, iliac arteries, and abdominal sounds using the appropriate techniques.
  • Special Test: Shifting dullness and fluid wave tests explained, with an emphasis on modern diagnostic reliance.

Musculoskeletal and Neurological Assessment

  • Basic Movements: Observe symmetry of the spine, check range of motion in joints.
  • Special Tests: Include details of the Near test, Hawkins test, and documented signs for stability and movement.

Conclusion

  • General Advice: Encourage practice of verbalization to increase confidence and fluency in physical examinations. Emphasize close attention to detail and proper techniques to ensure accuracy in assessment operations.