PHYSICAL ASSESSMENT NOTES

HEALTH HISTORY
bio data
chief complaint
medical history
family history
immunization
medication history
nutrition history
pychosocial history ADL
review body systems

MEMORY TEST
-What is your name
orientation to person
-whats your mothers name
orientation to other people
-whats todays date
orientation to time
-what year is it
orientation to time
-how old are you
memory
-where were you born
remote memory
what did you have for breakfst
recent memory
-who is prime inister of canada
gen knowledge
-can you count backwards from 20
attention span and calculation skills
-why are you here
recent memory

palliative or provocative question
-what provokes,relieves, triggers Sx
quality/quantity question
-what does Sx look,feel like
region/radiation
-where is Sx
severity/scale
-how severe 1~10scale
timing
-Sx when how long
understand pt perception

INTEGUMENTARY SYSTEM
SKIN pigment dry/oily itchy condtn
turgor=pinch skin turgor is skin returning to its shape
HAIR loss texture color distribution
alopecia/hirutism
NAILS clubbing brittle blanch shape bed color tissues around nail test/color return less than 2 second
DIGESTIVE SYSTEM
frenulum tissue connecting tongue to floor of mouth
ABDM auscultate before percussingBDOMIN
RUQ=liver-gallbladder-duadium-pancreas-rt kidney-ascendong transverse colon
LUQ=liver-stomach-spleen-pancreas-lt kidney-transverse colon
RLQ=cecum-appendix-rt kidney-rt ovary-fallopian tube-
LLQ=lt kidney-descending colon-sigmoid colon-lt ovary-falopian tube
girth =level of umbilicus
assess skin integrity,contour symmetry,movement,
-bowel sounds should be heard 1 every5~30seconds in a 3~5 minutes period hyperactive high pitched increased motility
,,fluid masses,pain,
-mouth-symmetry,color,texture-mmucuso,teeth,gums,tongue,
oropharnyx and tonsils
-Anus colr integrity lesions
MUSCULOSKELETAL SYSTEM
-crepatation=grating sound
MOVEMENTS- Flexion=bend limb at joint-extention=straighten at joint
abduction=move limb away from midline body -adduction=move limb toward midline of body-pronation=turning forarm so palm is down -supination=turning forearm so palm is up-circumduction=arm in circle from shoulder-inversion=sole of foot inward at ankle-eversion=sole of foot outward at ankle,rotation=move head around an axis-protraction=move a body part forward and paralel to the ground-retraction=move a body part backward parallel to ground
elevation=raising body part-depression=lowering body part
MUSCLE GRADE
-5=100% 4=75% 3=50% 2=25%
1=10% 0=0%
SEE NERVES
SENSORY SYSTEM
-penlight test reaction to light
-near vision test newspaper
-distant vision snellen lger #poorer vision both eyes then each eye
accomadation test pencil/distance pupil constriction
-convergence finger/nose Xeyed
peripheral how many fingers
ocular movement up/down lt/rt
EYES lacrimal gland lubricates tears
HEARING whispered voice -use otoscope to check for cerumen /wax
NOSE/SINUS patency smell
ENDOCRINE SYSTEM
-thyroid examine lower neck for masses and symmetry
REPRODUCTIVE SYSTEM
-breast exam-genital
-testicular exam
CARDIOVASCULAR SEE HEART
LYMPHATIC SYSTEM
cervical-axillary-inguinal nodes are not observed or palpable
SEE NOTES RESPIRATORY SYSTEM
URINARY SYSTEM
bladder at midline symphysis pubis
-unable to palpate
VITAL SIGNS
T=35.9-37.4 P=76 R=20 BP=110-140/60-90
temp=hypothalmus
surface temp=temp of skin
-rectal/tympanic temp=.5C higher
axillary=.5C lower
-tachacardia=100-180beats
-bradacardia=below60 beats
PULSES-apical.brachial,carotid,
dorsalis pedis-femoral,popliteal,posterior tibial,radial,temporal,ulna
BP marked systolic with a V and diastolic with upside down V on graph
OXYGEN
-pulse oximetry measure O2 saturation of arterial blood
-O2 saturation = amt of O2 bound to hemaglobin in tge blood is expressed as %...95-98%

HT / WT2.2lbs=1kg and 2.5cm = 1 inch

INSPECTION
PALPATION
PERCUSSION
-resonate clear hollow
-hyperresonate booming
-tympany drumlike
-dull muffled thud
-flat dead stop of cound
AUSCULTATION
-pitch high/low
-loudness soft/loud
-quality gurgling /swishing
-duration short/med/long

NERVES
-Olafactory(1) sensory smell
-Optic (11) sensory vision
-Oculomotor(111)motor-eye movement in /out eyelid elevation
pupil constriction
-Trochlear(1V)motor eye movement up/down
Trigeminal(V)jaw movement chewing
sensation on face/neck
-Abducens(V1)motor lateral eye movement
-Facial(V11)motor mucles of face/sensory taste on tongue

-Acoustic(V111)hearing equalibrium
-Glossopharyngeal(1X) motor
swallowing say ah
Vagus(X)motorswallowing speaking
- accessary(X1)-motor-shoulder
-HYPOGLOSSAL(X11) motor-tongue

LOC
1)name called softly loudly 2)lt touch on arm 3)vigourous shake 4)pain 5)persons response 6)what does person on cessation of stimulis
ASSESSMENT SCALE
1)alert 2)lethargic 3)obtunded 4)stupor 5)coma 6)acute confusional state

Respiratury system
BREATH SOUNDSRespiratury system
BREATH SOUNDS
palpate/percuss/auscultate
-thorasic excursion=symmetric expansion 11/2-2 inches/3-5cm
,-tactile fremitus-palpable vibration when saying 99 use 2 hands
-crepititus-crackling sound
-resomance in healthy lung
-crackles-rales-occur with pneumonia
-adventitious abnormal -air secretions
-wheezes rhonchi =asthma
-bronchial-high pitch trachea big inspiration little expiration
-bronchovasilcur-mod pitch-inspiration=expiration over major bronchi
-vesicular low pitch -inspiration is less than expiration
-crackles-bubbling gurgling in trachea bronchi
,wheeze,-squeekking sound larynx
-friction rub grating low pitch
palpate/percuss/auscultate
-thorasic excursion=symmetric expansion 11/2-2 inches/3-5cm
,-tactile fremitus-palpable vibration when saying 99 use 2 hands
-crepititus-crackling sound
-resomance in healthy lung
-crackles-rales-occur with pneumonia
-adventitious abnormal -air secretions
-wheezes rhonchi =asthma
-bronchial-high pitch trachea big inspiration little expiration
-bronchovasilcur-mod pitch-inspiration=expiration over major bronchi
-vesicular low pitch -inspiration is less than expiration
-crackles-bubbling gurgling in trachea bronchi
,wheeze,-squeekking sound larynx
-friction rub grating low pitch

heart
-auscaltate 1)aortic 2nd intercostal at rt sternal border
2) pulmonic,2nd intercostal at lt sternal border
3) tricuspid area-5th intercostal at lt sternal botder
3) mitral-5th intercostal along midclavicular line
-palpate one carotid at a time
-PULSES 1)carotid 2)radial 3)brachial
4)femoral 5)poplateal 6)dorsalis pedis 7)posterier tib
4+ bounding
3+ increased
2+ normal
1+ weak
0 absent
EDEMA 1+=mijd pitting 2+=mod pitting 3+=deep pitting 4+=very deep pitting /swollen
-precordium refers to aortic-pulmonic-tricuspid-apical area of chest
S1 sound -LUBdub beginning of systole closing of valves
S2 sound lubDUB end of systole louder at base
.bruit swishing sound
-murmur blowing
-thrill palpable vibration over heart
VASCULAR
-HOMANS SIGN pain in calf on foot
Dorsalflexion could indicate DVT
-inspect neck veins for distention
-symmetry of pulse volume

dorsalflexion of foot may indicate deep vein thrombosis or clot