Now, we will move onto the objective data collection of this physical examination. I will be first examining the posterior chest.

Transcription

1 FOCUSED EXAMINATION OBJECTIVE DATA THORAX AND LUNGS Now, we will move onto the objective data collection of this physical examination. I will be first examining the posterior chest. I would like to kindly ask you to sit upright and raise your shirt up to expose your back. POSTERIOR CHEST Inspection I will begin by inspecting the posterior chest, specifically the thoracic cage. I will be noting the shape and configuration of the chest wall. The spinous processes appear in a straight line. The thorax is symmetrical, elliptical shape with downward sloping ribs angled at approximated 45 degrees. The scapulae are placed symmetrically in each hemithorax. The neck and trapezius muscles are normally developed. My client is breathing with a relaxed posture, and is supporting her own weight comfortably. The skin colour is consistent with the rest of the body. No cyanosis or pallor. I do not see any lesions. Palpate Now moving onto palpating of the posterior chest I am going to confirm symmetrical chest expansion by placing my warmed hands on the patient s posterolateral chest wall, with my thumbs at the level of T9 or T10. I am sliding my hands medially to pinch a small fold between my thumbs. I am asking the patient to take a deep breath. I can notice that my thumbs are moving apart symmetrically, and I do not notice any lag in expansion. Percuss

2 I will first determine the predominant note over the lung fields. I am going to start at the apices and percuss the band of normally resonant tissue across the tops of both shoulders. Then, I am going to percuss bilaterally, comparing from side to side. Now, I am moving down the lung region, percussing at 5 cm intervals, avoiding the damping effects of the scapulae and ribs. In healthy lung tissues in adults, I should hear resonance, a low pitched, clear, hollow sound. I can hear resonance on both sides. Small lesions are not detectable through percussion. I do not hear any hyper resonance or dull note, which indicate abnormal findings. Approaching the area of T9 to T10, I am hearing some dullness, this is expected because this left area is visceral dullness and the right area is liver dullness. Auscultate Now moving onto auscultation, I am asking the client to sit, leaning forward slightly with arms resting comfortably across lap. I need the client to breathe through the mouth, a little bit deeper than usual. If the client begins to feel dizzy or hyperventilating, the client may rest and momentarily pause. Now with my clean stethoscope warmed, I will listen to breath sounds with the diaphragm. I am listening to at least one full respiration. I am going to listen to the breath sounds from the apices to T10, then laterally from the axilla down to the 7 th rib. Beginning with the apices, I am hearing vesicular sounds, soft rustling like leaves. I continue to hear vesicular sounds. As I move down the vertebrae, I am hearing some bronchovesicular sounds, which is harsh, rustling, hollow sounds. Then continuing down, I am hearing more vesicular sounds, so rustling, soft, low pitch, inspiration greater than expiration. I can hear breath sounds throughout the posterior thoracic cage, and I do not hear any decreased or absent breath sounds in any of the regions. I do not hear wheeze, crackles, or any other adventitious sounds. ANTERIOR CHEST Inspect I am inspecting the anterior chest, and noting the shape and configuration of the chest wall. The ribs are sloping downward with symmetrical interspaces. The costal angle is

3 within 90 degrees. The abdominal muscles are developed according to client s age, weight and athletic condition. The patient has a relaxed facial expression. The patient is alert and cooperative. No skin lesions are observed. I would like to inspect your hands. The lips and nail beds have no sign of cyanosis or unusual pallor. The nails are normal configuration. Now assessing the quality of respirations, the client is relaxed when breathing. Her breathing is automatic, regular, even and effortless. Her chest expands symmetrically with no lag in expansion. There is no retraction or bulging of the interspaces. Accessory muscles are not used for respiration. Palpate the Anterior Chest I am palpating for symmetrical chest expansion. I am placing my hands on the anterolateral wall with thumbs along the costal margins and pointing toward the xiphoid process. I am asking the patient to take a deep breath. I can see that m thumbs are moving apart symmetrically with smooth expansion. Percuss I am beginning to percuss at the apices in the supraclavicular areas. I am percussing between the interspaces, and comparing bilaterally, moving down the chest. I would like to kindly request the client to shift her breasts to the side. I hear resonance over the lung fields. Moving down the anterior chest, some dullness can be heard due to the location of the liver in the right hemithorax. Tympany can also be heard in the left hemithorax due to stomach. Auscultate I am auscultating the lung field from the apices down to the sixth rib in the same sequence as percussion. I am asking the client to sit upright leaning forward slightly, arms resting comfortably. I am listening to at least one full respiration. I need the client to move her breasts to the

4 side, so I am not auscultating directly over her breast tissues. Take deep breaths. In the anterior chest, I am hearing vesicular sounds, rustling like leaves in the wind. Inspiration is longer than expiration. I do not hear any adventitious sounds such as wheezing or crackles. THE ABDOMEN Now we will move onto the objective data collection of the examination. I am instructing the client to lie supine with the knees bent, and the arms resting at the side. Do you have any painful areas? Inspect I am first looking at the contour of the abdomen. I will first stand on the patient s right side, and then I will stoop to gaze across the abdomen. The contour of this patient is flat. Using my penlight, I am shining a light across the abdomen lengthwise across the patient. I can see that the abdomen is symmetrical bilaterally, no bulging, no visible mass. Then, I am stepping to the foot of the table to recheck symmetry. Once again, the abdomen is symmetrical, no masses, no bulging. The umbilicus is midline and inverted, with no sign of discoloration, inflammation, or hernia. It is not red or crusted. The skin is smooth and even. Skin color is consistent. No redness, jaundice, lesions. I am pinching the skin, and the skin has good turgor. I do not see any pulsation or movement, a little bit of respiratory movement. Pubic hair growth has the pattern of inverted triangle shape. Patient is relaxed quietly on examining table, slow and even respirations. Auscultate Bowel Sounds and Vascular Sounds When examining the abdomen, auscultation is performed first, because percussion and palpation can increase peristalsis, which would give false interpretation of bowel sounds. I am using the diaphragm to hear the higher pitched bowel sounds. I will listen to all four quadrants, beginning with the RLQ then moving clockwise. In all four quadrants, the bowel sounds are high pitched, gurgling, cascading sounds, occurring irregularly about times a minute.

5 I will now listen to vascular sounds with the bell of the stethoscope to go over the aorta, renal, iliac, femoral arteries. I do not hear any bruits, any blowing sounds. Percuss I am percussing to assess the relative density of abdominal contents. I am agoing to percuss lightly in all four quadrants. I hear tympany and I do not hear any dullness. SCRATCH TEST I am conducting the scratch test to define the liver border. I am placing my stethoscope over the liver, and with one fingernail, I am scratching short strokes over the abdomen, starting in the RLQ and moving slowly towards the liver. The sound was magnified at about the area of the lowest rib cage. So the liver is within healthy span. Palpation Finally, I am going to lightly palpate in all the quadrants. Using 4 fingers, I am making gentle rotary motion, sliding the skin and fingers together. I am moving clockwise to the next location. I am forming an overall impression of the skin surface and superficial musculature. There is no voluntary rigidity. COSTOVERTEBRAL ANGLE TENDERNESS The last test will be the costovertebral angle tenderness. I am assessing the kidney by making indirect fist percussions. I am asking the client sit up. I am placing one hand over the twelfth rib at the costovertebral angle on the back, then I am thumping with the ulnar edge of my other hand. I am asking the client if she experiences any pain. HEART AND NECK VESSELS I will now collect objective data of the heart and neck vessels. I will begin with neck vessels, where the patient will sit upright, then with precordium, the patient will lie supine. I will stand on patient s right side. The Neck Vessels Auscultate the Carotid Artery *Clean stethoscope

6 I am going to auscultate each carotid artery for the presence of a bruit, which is a swishing sound. Using the bell of the stethoscope, I am lightly placing the bell at three levels. I am asking the patient to take a deep breath, exhale and hold. First, I am listening at the angle of the jaw, then at the midcervical area, and finally at the base of the neck. Exhale. I am going to do the same thing again on the other cartotid artery. Inhale, exhale, hold. Angle of the jaw, midcervical area, and base of the neck. No presence of bruit can be noted. Palpate the Carotid Artery I am palpating each carotid artery one at a time, which is medial to the sternomastoid muscle in the neck. I am palpating gently to avoid excessive pressure on the carotid sinus. I am feeling the contour and amplitude of the pulse. The contour is smooth with a rapid upstroke and slow downstroke. The strength is 2+ or moderate. Then, I am palpating the carotid artery on the other side, smooth contour and moderate strength. Therefore, the findings are the same bilaterally. The Precordium Inspect the Anterior Chest Using my penlight for tangential lighting, I am noting for any pulsations. No heaves or lifts can be seen. Palpate the Apical Pulse I am going to localize the apical pulse with one finger pad, and I am asking the client to exhale and then hold it. I need the client to also hold her left breast to the side to avoid listening over the breast tissue. The apical pulse is located at the fourth or fifth interspace, and medial to the midclavicular line. So I am going to count downwards to the fifth intercoastal space. I am going to roll the client laterally to help me locate the apical pulse. It is slightly shifted to the left. The size is about 1 times 2 cm. It is a short, gentle tap. Palpate Across the Pericordium

7 Using the palmar aspects of my four finger, I am gently palpating over the apex, the sternal border, and the base, searching for any other pulsations. No pulsations can be noted. Auscultation When auscultating, I will first listen to the apical pulse with the diaphragm. Then I am going to listen to the 4 valve areas with both the diaphragm and the bell in a Z pattern. I always listen to the hear tin a number of places on the chest. Just because I am listening for a long time, this does not mean that I am detecting a problem. Please remain relaxed. Beginning with the apical pulse, I am locating the apical pulse at the fifth intercoastal space, medial to the midclavicular line. The rate is 80 bpm and the rhythm is regular. Now, I am listening to the each of the four valves beginning with the diaphragm. The first valve area is the aortic valve area. It is located at the second right interspace. The second is the pulmonic valve area. It is located at the second left interspace. The third is the tricuspid valve area which is at fifth interspace left sternal border. The fourth is the mitral valve area, which is at the fifth interspace left midclavicular line. I was able to identify S1 and S2 separately. S1 is start of systole, closure of AVs valve. S1 is louder than S2 at the apex. S2 is the closure of semilunar valves. S2 is louder than S1 in the base. Clear S1 an S2 sounds, no splitting, no extra heart sounds, no murmurs, blowing, swooshing sounds. Both S1 and S2 were not accentuated or diminished. Now I am going to auscultate the four valves again with the bell. Aortic right 2 nd interspace Pulmonic left 2 nd interspace Tricupsid left sternal border 5 th interspace Mitral left midclavicular line 5 th interspace Clear S1 an S2 sounds, no splitting, no extra heart sounds, no murmurs, blowing, swooshing sounds. Both S1 and S2 were not accentuated or diminished.

8 THE MUSCULOSKELETAL SYSTEM Order of Examination Inspection Size and contour of joint. Inspect the skin and tissues over the joints for colour, swelling, and any masses or deformity. Palpation I am palpating each joint for temperature, muscles, bony articulations, and the area of joint capsule. No heat, tenderness, swelling or masses. Range of Motion I am testing for active ROM while stabilizing the body are proximal to the joint being moved. Muscle Testing I am testing the strength of the prime mover muscle groups of the joint by performing ROM testing again but with resistance. Strength is equal bilaterally. GRADE 5 FULL ROM AGAINST GRAVITY WITH FULL RESISTANCE TEMPOROMANDIBULAR JOINT 1. The temporomandibular joint anterior to the tragus of the ear is smooth and same contour on both sides. No redness, consistent skin colour, no tenderness, no swelling, no deformity, no masses. 2. Palpate by placing the tips of my first two fingers in front of each ear. I am asking the client to open and close the mouth. At the depressed area over the joint, there is smooth motion of the mandible. 3. TEST ROM: a. Open mouth maximally. Vertical motion. The space should fit 3 fingers sideways about 3 6 cm. b. Partially open mouth and move the jaw side to side. Lateral motion. 2cm c. Stick out lower jaw. Forward movement without deviation.

9 4. MUSCLE TESTING (Masseter and Temporalis) a. Ask the client to clench teeth, and palpate the contracted masseter and temporalis muscles. Both sides are same size, firm and same strength. b. Open the jaw with resistance applied. c. Move jaw laterally with resistance 5. Full ROM with Grade 5 strength. Full ROM against gravity, full resistance. CERVICAL SPINE 1. Inspect the alignment of head and neck. The spine is straight and head is erect. Skin is consistent with the rest of the body. No redness, pallor, cyanosis. No swelling, bulging, or deformity. 2. Palpate the spinous processes and the STERNOMASTOID, TRAPEZIUS and PARAVERTEBRAL muscles. The muscles feel firm, with no muscle spasm or tenderness. 3. TEST ROM a. Touch chin to chest. Flexion of 45 degrees b. Lift chin toward ceiling. Hyperextension 55 degrees c. Move each ear toward corresponding shoulder. Shoulder should not be lifted. Lateral bending 40 degrees d. Turn the chin toward each shoulder. Rotation 70 degrees. 4. MUSCLE TESTING above with resistance GRADE 5 FULL ROM WITH FULL RESISTANCE UPPER EXTREMITY SHOULDERS 1. Inspect and compare both shoulders posteriorly and anteriorly. Check the size and contour of the joint. Compare both sides for bony landmarks. No redness, muscular atrophy, deformity, or swelling. Check joint capsule and subacromial bursa for swelling.

10 2. Palpate BOTH shoulders. Note any muscle spasm or atrophy, swelling, heat, masses, or tenderness. a. Clavicle b. Acromioclavicular joint c. Scapula d. Greater tubercle of humerus e. Subacromial bursa f. Biceps groove g. Anterior glenohumeral joint h. Axilla 3. TEST ROM (cup one hand over shoulder) a. With arms at sides and elbow extended, move both arms forward and up in arcs and back. Forward flexion 180. Hyperextension 50. b.