Chapter 11 Techniques of Physical Examination Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Chapter 11Chapter 11Techniques of Physical ExaminationTechniques of Physical Examination

Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

ObjectivesObjectives Describe prehospital physical examination Describe prehospital physical examination

techniquestechniques

Describe examination equipmentDescribe examination equipment

Describe the general approach to the physical Describe the general approach to the physical examinationexamination

Outline the steps of the comprehensive Outline the steps of the comprehensive physical examinationphysical examination


ObjectivesObjectives Detail the components of the mental status Detail the components of the mental status

examinationexamination

Identify abnormal findings in the mental status Identify abnormal findings in the mental status examinationexamination

Outline steps in the general patient surveyOutline steps in the general patient survey

Distinguish between normal and abnormal Distinguish between normal and abnormal findings in the general surveyfindings in the general survey


ObjectivesObjectives Describe examination techniques for specific Describe examination techniques for specific

body regionsbody regions

Identify normal and abnormal findings in the Identify normal and abnormal findings in the body region examinationbody region examination

Describe examination techniques specific to Describe examination techniques specific to children and older adultschildren and older adults


ScenarioScenarioYou respond to a nursing home for an “unresponsive person.” Your patient is a 92-year-old woman who is recuperating from a fractured hip. She takes cardiac and diabetic medications. According to the nurse assistant, she is normally alert, but is now only responsive to pain. She has a bruise on her forehead. The story of this evening’s events seems inconsistent.


DiscussionDiscussion What priorities will you have in this patient’s physical What priorities will you have in this patient’s physical

assessment?assessment?

Assuming her airway and breathing are managed, what Assuming her airway and breathing are managed, what examination techniques will you use to assess this examination techniques will you use to assess this unconscious woman?unconscious woman?

What equipment will you need to perform your physical What equipment will you need to perform your physical exam?exam?

What areas will be of particular concern as you complete What areas will be of particular concern as you complete your comprehensive physical examination?your comprehensive physical examination?


Examination TechniquesExamination Techniques InspectionInspection

PalpationPalpation

PercussionPercussion

AuscultationAuscultation


InspectionInspection Visual assessment of the patient and surroundingsVisual assessment of the patient and surroundings

Findings that may be significant:Findings that may be significant: Patient hygienePatient hygiene ClothingClothing Eye gazeEye gaze Body languageBody language Body positionBody position Skin colorSkin color OdorOdor


InspectionInspection If the emergency response was to the If the emergency response was to the

patient's home, make a visual inspection forpatient's home, make a visual inspection for CleanlinessCleanliness Prescription medicinesPrescription medicines Illegal drug paraphernaliaIllegal drug paraphernalia WeaponsWeapons Signs of alcohol useSigns of alcohol use


PalpationPalpation A technique in which the hands and fingers are used A technique in which the hands and fingers are used

to gather information by touchto gather information by touch

Palmar surface of fingers and finger pads are used to Palmar surface of fingers and finger pads are used to palpate forpalpate for TextureTexture MassesMasses FluidFluid CrepitusCrepitus And assess skin temperatureAnd assess skin temperature

Palpation may be either superficial or deepPalpation may be either superficial or deep


Deep Bimanual PalpationDeep Bimanual Palpation


PercussionPercussion Used to evaluate for Used to evaluate for

presence of air or presence of air or fluid in body tissuesfluid in body tissues Sound waves heard Sound waves heard

as percussion tones as percussion tones (resonance)(resonance)

Procedure Procedure


AuscultationAuscultation Best performed in a quiet environmentBest performed in a quiet environment

Requires a stethoscopeRequires a stethoscope Body sounds produced by movement of fluids or gases in Body sounds produced by movement of fluids or gases in

patient's organs or tissuespatient's organs or tissues

Note:Note: IntensityIntensity PitchPitch DurationDuration QualityQuality


StethoscopeStethoscope Used to evaluate sounds created by Used to evaluate sounds created by

cardiovascular, respiratory, and cardiovascular, respiratory, and gastrointestinal systemsgastrointestinal systems

StethoscopesStethoscopes Acoustic Acoustic MagneticMagnetic ElectronicElectronic


StethoscopeStethoscope

Position stethoscope Position stethoscope between index and between index and middle fingersmiddle fingers


OphthalmoscopeOphthalmoscope

Used to inspect eye Used to inspect eye structures:structures: RetinaRetina ChoroidChoroid Optic nerve discOptic nerve disc Macula Macula Retinal vesselsRetinal vessels


OtoscopeOtoscope Used to examine Used to examine

deep structures of deep structures of the external and the external and middle earmiddle ear


Blood Pressure CuffBlood Pressure Cuff

SphygmomanometerSphygmomanometer

Measures systolic and Measures systolic and diastolic blood pressurediastolic blood pressure

Manual or electronicManual or electronic


Comprehensive Physical ExaminationComprehensive Physical Examination

Mental statusMental status

General surveyGeneral survey

Vital signsVital signs

SkinSkin

Head, eyes, ears, nose, Head, eyes, ears, nose, and throat (HEENT)and throat (HEENT)

ChestChest

AbdomenAbdomen

Posterior bodyPosterior body

Extremities Extremities

Neurological examNeurological exam


Mental StatusMental Status First step in patient care encounter First step in patient care encounter

Patient’s appearance and behaviorPatient’s appearance and behavior Level of consciousnessLevel of consciousness

• A healthy patient is expected to be alert, responsive to A healthy patient is expected to be alert, responsive to touch, verbal instruction, and painful stimulitouch, verbal instruction, and painful stimuli


Mental StatusMental Status Appearance and behaviorAppearance and behavior Posture, gait, and motor activityPosture, gait, and motor activity Dress, grooming, personal hygieneDress, grooming, personal hygiene Breath or body odorsBreath or body odors Facial expressionFacial expression Mood and affectMood and affect Speech and languageSpeech and language Thought and perceptionsThought and perceptions Memory and attentionMemory and attention


General SurveyGeneral Survey Signs of distressSigns of distress

Cardiorespiratory insufficiencyCardiorespiratory insufficiency• Labored breathingLabored breathing• WheezingWheezing• CoughCough

PainPain• WincingWincing• SweatingSweating• Protectiveness of a painful body part or areaProtectiveness of a painful body part or area

AnxietyAnxiety• RestlessnessRestlessness• Anxious expressionAnxious expression• Fidgety movementFidgety movement• Cold, moist palmsCold, moist palms


General SurveyGeneral Survey Apparent state of healthApparent state of health

Skin color and obvious lesionsSkin color and obvious lesions

Height and buildHeight and build

Sexual developmentSexual development

WeightWeight


Skin Color Skin Color Varies from person to personVaries from person to person

Varies based on ethnicityVaries based on ethnicity

May range in tone from pink or ivory to deep May range in tone from pink or ivory to deep brown, yellow, or olivebrown, yellow, or olive

Observe for skin not exposed to sun (e.g., Observe for skin not exposed to sun (e.g., palms)palms)


Skin LesionsSkin Lesions


Height and BuildHeight and Build Descriptions include: Descriptions include:

Average, tall, short, lanky, muscularAverage, tall, short, lanky, muscular

May also be affected by age and lifestyleMay also be affected by age and lifestyle


Sexual DevelopmentSexual Development Determine if age appropriateDetermine if age appropriate

Observe for normal changes associated with Observe for normal changes associated with ageage


WeightWeight Observe general appearanceObserve general appearance

Obese to emaciatedObese to emaciated

Recent changes may be key findingRecent changes may be key finding Recent weight loss or gainRecent weight loss or gain


Vital SignsVital Signs PulsePulse

Blood pressureBlood pressure

RespirationsRespirations

SkinSkin

PupilsPupils


PulsePulse RateRate

RhythmRhythm

QualityQuality

Consider ECG monitoringConsider ECG monitoring


Blood PressureBlood PressureLocations


RespirationsRespirations Adult rateAdult rate

12-24 breaths per minute12-24 breaths per minute

Observe Observe

Feel for chest movementFeel for chest movement

AuscultateAuscultate


SkinSkin TextureTexture

TurgorTurgor

HairHair

Fingernails and toenailsFingernails and toenails Abnormal findingsAbnormal findings


Temperature MeasurementTemperature Measurement

Oral temperatureOral temperature

Hold thermometer firmly Hold thermometer firmly under tongueunder tongue

Tell child to “kiss”Tell child to “kiss”

Caution to avoid bitingCaution to avoid biting


Axillary TemperatureAxillary Temperature Hold arm down Hold arm down

firmlyfirmly

Should be Should be approximately 1approximately 1° ° F F less than core templess than core temp


Tympanic TemperatureTympanic Temperature Accuracy questionableAccuracy questionable

Pull ear backPull ear back

Insert gentlyInsert gently


Rectal TemperatureRectal Temperature Risk of perforationRisk of perforation

Avoid in Avoid in uncooperative, or uncooperative, or immuno-suppressed immuno-suppressed patientpatient

Stabilize thermometerStabilize thermometer


EyesEyes——Visual AcuityVisual Acuity Have patientHave patient

Read printed materialRead printed material Count fingers at a Count fingers at a

distancedistance Demonstrate ability to tell Demonstrate ability to tell

light from darklight from dark Use eye chartUse eye chart

• (e.g., Snellen chart)(e.g., Snellen chart)


EyesEyes——PupilsPupils Findings may indicate neurological issuesFindings may indicate neurological issues

Examine response to light (PERRL)Examine response to light (PERRL) Pupils are equal, round, and react to lightPupils are equal, round, and react to light


Anatomical RegionsAnatomical Regions Skin Skin

Texture Texture TurgorTurgor HairHair Fingernails and toenailsFingernails and toenails

Head, ears, eyes, nose, throatHead, ears, eyes, nose, throat


Head and FaceHead and Face Inspect skull for shape and symmetryInspect skull for shape and symmetry

Palpate for swelling, tenderness, lesions, Palpate for swelling, tenderness, lesions, indentationsindentations

Inspect face for symmetry, expression, Inspect face for symmetry, expression, edema, involuntary movements edema, involuntary movements


EyesEyes Determine if contacts are presentDetermine if contacts are present

Determine that both eyes can seeDetermine that both eyes can see

Assess visual acuityAssess visual acuity

Inspect orbital area for edemaInspect orbital area for edema

Examine eyes for drainage or rednessExamine eyes for drainage or redness

Determine structural integrityDetermine structural integrity


EyesEyes——Visual FieldsVisual FieldsSix cardinal fields of gaze


Visual FieldsVisual Fields Ask the patient to look at his or her noseAsk the patient to look at his or her nose

Test peripheral vision by extending your arms with Test peripheral vision by extending your arms with elbows at right angles and wiggle both index elbows at right angles and wiggle both index fingers simultaneouslyfingers simultaneously

Observe eyes for normal position and Observe eyes for normal position and alignmentalignment


Ophthalmoscopic ExaminationOphthalmoscopic Examination Used to evaluate:Used to evaluate:

CorneaCornea Foreign bodiesForeign bodies LacerationsLacerations AbrasionsAbrasions InfectionInfection Anterior chamberAnterior chamber

HyphemaHyphema Hypopyon Hypopyon FundusFundus Optic nerveOptic nerve RetinaRetina VitreousVitreous EyelidEyelid


Cornea and ScleraCornea and Sclera Examine conjunctiva Examine conjunctiva

and scleraand sclera

Palpate lower orbital rimPalpate lower orbital rim


Ophthalmoscopic ExaminationOphthalmoscopic Examination

Inspect:Inspect: Size, color, and clarity Size, color, and clarity

of the discof the disc Integrity of vesselsIntegrity of vessels Assess for retinal Assess for retinal

lesions and appearance lesions and appearance of the maculaof the macula


Ophthalmoscopic ExaminationOphthalmoscopic Examination

Normal findingsNormal findings Clear, yellow optic nerve Clear, yellow optic nerve

discdisc Reddish pink Reddish pink

(European-American) or (European-American) or darkened retina darkened retina (African-American)(African-American)

Light red arteriesLight red arteries Dark red veinsDark red veins 3:2 vein-to-artery ratio3:2 vein-to-artery ratio


Otoscopic ExaminationOtoscopic Examination Otoscope used to:Otoscope used to:

Evaluate inner ear for discharge and foreign Evaluate inner ear for discharge and foreign bodiesbodies

Assess eardrumAssess eardrum


Otoscopic ExaminationOtoscopic Examination Select speculumSelect speculum

Turn on otoscopeTurn on otoscope

Insert speculum into ear canal, Insert speculum into ear canal, slightly down and forwardslightly down and forward

Look for foreign bodies, lesions, Look for foreign bodies, lesions, dischargedischarge

Inspect tympanic membrane Inspect tympanic membrane


Otoscopic ExaminationOtoscopic Examination Normal findingsNormal findings

Cerumen is dry (tan or light yellow) or moist (dark Cerumen is dry (tan or light yellow) or moist (dark yellow or brown)yellow or brown)

Ear canalEar canal• Not inflamed Not inflamed

Tympanic membrane Tympanic membrane • Translucent or pearly grayTranslucent or pearly gray


NoseNose Inspect Inspect

PalpatePalpate

Discharge from the noseDischarge from the nose CSF CSF EpistaxisEpistaxis Mucous dischargeMucous discharge


Mouth and PharynxMouth and Pharynx LipsLips

GumsGums

Mouth and tongueMouth and tongue

PharynxPharynx


NeckNeck Inspect Inspect

Use spinal precautions Use spinal precautions if trauma is suspectedif trauma is suspected

Palpate tracheaPalpate trachea Midline position normalMidline position normal


NeckNeck Palpate Palpate

Place both thumbs along sides of distal tracheaPlace both thumbs along sides of distal trachea Systematically move toward headSystematically move toward head Do not apply bilateral pressure to carotid arteries Do not apply bilateral pressure to carotid arteries


Head and Cervical SpineHead and Cervical Spine Temporomandibular joint (TMJ)Temporomandibular joint (TMJ)

Inspect and palpate cervical spineInspect and palpate cervical spine

Range of motion Range of motion


ChestChest RibsRibs

Protect thoracic organs Protect thoracic organs Support respiratory movements of diaphragm and Support respiratory movements of diaphragm and

intercostal musclesintercostal muscles Anatomical landmarks for examinationAnatomical landmarks for examination


Topographical LandmarksTopographical Landmarks


Thoracic LandmarksThoracic Landmarks——Anterior ChestAnterior Chest


Thoracic LandmarksThoracic Landmarks——Posterior ChestPosterior Chest


InspectionInspection General appearance of chestGeneral appearance of chest

Chest wall configurationChest wall configuration Inspect for symmetryInspect for symmetry Chest wall should be symmetricalChest wall should be symmetrical


Chest Wall AbnormalitiesChest Wall Abnormalities Barrel chest Barrel chest

Funnel chest (pectus Funnel chest (pectus excavatum) excavatum)

Pigeon chest (pectus Pigeon chest (pectus carinatum)carinatum)

Thoracic kyphosisThoracic kyphosis

ScoliosisScoliosis


ChestChest——PalpationPalpation

Tracheal positionTracheal position

Respiratory excursionRespiratory excursion


Percussion and Auscultation of ChestPercussion and Auscultation of Chest


Respiratory EffortRespiratory Effort Assess:Assess:

Respiratory rate, rhythm, symmetry, and qualityRespiratory rate, rhythm, symmetry, and quality Patient positionPatient position Accessory musclesAccessory muscles Retractions (intercostal, supraclavicular, or both)Retractions (intercostal, supraclavicular, or both) Nasal flaringNasal flaring Pausing to take a breathPausing to take a breath


Respiratory PatternsRespiratory Patterns EupneaEupnea Tachypnea Tachypnea BradypneaBradypnea HyperpneaHyperpnea HyperventilationHyperventilation Dyspnea Dyspnea OrthopneaOrthopnea Paroxysmal nocturnal Paroxysmal nocturnal

dyspneadyspnea

ApneaApnea Cheyne-Stokes Cheyne-Stokes

respirationrespiration Kussmaul breathingKussmaul breathing Biot’s respirationsBiot’s respirations Central neurogenic Central neurogenic

hyperventilationhyperventilation


AuscultationAuscultation Patient in sitting position (if possible)Patient in sitting position (if possible)

Instruct to breathe deeply and slowly through Instruct to breathe deeply and slowly through open mouth open mouth

Use diaphragm of stethoscope Use diaphragm of stethoscope

Evaluate anterior and posterior lung fieldsEvaluate anterior and posterior lung fields


Normal Breath SoundsNormal Breath Sounds Classified as:Classified as:

VesicularVesicular BronchovesicularBronchovesicular BronchialBronchial


Vesicular Breath SoundsVesicular Breath Sounds

Most of lung fieldsMost of lung fields Lungs considered "clear" Lungs considered "clear"

make normal vesicular make normal vesicular breath soundsbreath sounds

Harsh vesicular breath Harsh vesicular breath soundssounds

Diminished vesicular Diminished vesicular breath soundsbreath sounds


Bronchovesicular Breath Sounds Bronchovesicular Breath Sounds

Major bronchi and Major bronchi and upper right posterior upper right posterior lung fieldlung field Louder and harsher than Louder and harsher than

vesicular breath soundsvesicular breath sounds Medium pitchMedium pitch Equal inspiration and Equal inspiration and

expiration phasesexpiration phases Heard throughout Heard throughout

respirationrespiration


Bronchial Breath SoundsBronchial Breath Sounds

Only over tracheaOnly over trachea

Highest in pitchHighest in pitch

Coarse, harsh, loud sounds Coarse, harsh, loud sounds

Short inspiratory phase and Short inspiratory phase and long expirationlong expiration Bronchial sound anywhere Bronchial sound anywhere

but over trachea is abnormal but over trachea is abnormal


Abnormal Breath SoundsAbnormal Breath Sounds AbsentAbsent

DiminishedDiminished

Incorrectly located Incorrectly located bronchial soundsbronchial sounds

Adventitious Adventitious DiscontinuousDiscontinuous ContinuousContinuous


Breath SoundsBreath Sounds

Fig. 11-26Fig. 11-26


Discontinuous Breath SoundsDiscontinuous Breath Sounds CracklesCrackles

Formerly called ralesFormerly called rales High-pitched discontinuous soundsHigh-pitched discontinuous sounds Usually at end of inspirationUsually at end of inspiration Disease of small airways or alveoliDisease of small airways or alveoli Coarse crackles: wet, low-pitched soundsCoarse crackles: wet, low-pitched sounds Fine crackles: dry, high-pitched soundsFine crackles: dry, high-pitched sounds


Continuous Breath SoundsContinuous Breath Sounds WheezesWheezes

RhonchiRhonchi

StridorStridor

Pleural friction rubPleural friction rub


HeartHeart Assessment includes:Assessment includes:

PalpationPalpation AuscultationAuscultation


PulsePulse Assess:Assess:

RateRate RhythmRhythm IntensityIntensity

Palpate pulses simultaneously on both sides Palpate pulses simultaneously on both sides of body of body Except carotid Except carotid


PulsePulse Auscultate for:Auscultate for:

Frequency (pitch)Frequency (pitch) Intensity (loudness)Intensity (loudness) DurationDuration Timing in cardiac cycleTiming in cardiac cycle


Auscultating Heart SoundsAuscultating Heart Sounds


Heart SoundsHeart Sounds S1S1

Instruct patient to breathe normally and then hold Instruct patient to breathe normally and then hold breath in expirationbreath in expiration

S2S2 Instruct patient to breathe normally again and then Instruct patient to breathe normally again and then

hold breath in inspiration hold breath in inspiration


Pericardial Friction RubPericardial Friction Rub Inflammation of pericardial sacInflammation of pericardial sac

Scratching, grating, or squeaking qualityScratching, grating, or squeaking quality Louder during inspirationLouder during inspiration

Differs from pleural friction rubs by continued Differs from pleural friction rubs by continued presence during breath holdingpresence during breath holding


Heart MurmursHeart Murmurs Prolonged extra sounds Prolonged extra sounds

Caused by disruption in flow of blood through Caused by disruption in flow of blood through heartheart Most caused by valvular defectsMost caused by valvular defects Some seriousSome serious Others benign Others benign

• Have no apparent causeHave no apparent cause


BruitBruit Abnormal sound or Abnormal sound or

murmur murmur

Heard while Heard while auscultating carotid auscultating carotid artery, organ or glandartery, organ or gland May be local obstructionMay be local obstruction Often low pitched Often low pitched Hard to hearHard to hear


ThrillsThrills Vibrations or tremorsVibrations or tremors

May indicate blood flow obstructionMay indicate blood flow obstruction May palpate over aneurysm or on precordiumMay palpate over aneurysm or on precordium Serious or benignSerious or benign


AbdomenAbdomen

Two imaginary lines Two imaginary lines separate abdominal separate abdominal region into four region into four quadrantsquadrants


AbdomenAbdomen——Inspection Inspection SkinSkin

UmbilicusUmbilicus

ContourContour

Abdominal movementAbdominal movement


AbdomenAbdomen AuscultationAuscultation

Bowel soundsBowel sounds BruitsBruits

Percussion and palpationPercussion and palpation Detect:Detect:

• FluidFluid

• AirAir

• Solid massesSolid masses


PercussionPercussion Evaluate four quadrants of abdomen: Evaluate four quadrants of abdomen:

TympanyTympany• Air in stomach and intestinesAir in stomach and intestines

DullnessDullness• Solid abdominal organs and solid massesSolid abdominal organs and solid masses

Proceed from tympany to dullnessProceed from tympany to dullness Change in sound easier to detectChange in sound easier to detect


Palpation of the LiverPalpation of the Liver


Palpation of the SpleenPalpation of the Spleen


Female GenitaliaFemale Genitalia If possible, use same-gender paramedics to If possible, use same-gender paramedics to

examineexamine Chaperone if possibleChaperone if possible

Inspect external genitalia for:Inspect external genitalia for: SwellingSwelling Discoloration or rednessDiscoloration or redness BleedingBleeding TraumaTrauma LesionsLesions DischargeDischarge


Female GenitaliaFemale Genitalia Normal vaginal dischargeNormal vaginal discharge

Clear or cloudy with little or no odorClear or cloudy with little or no odor

Yellow-green dischargeYellow-green discharge

Frothy, gray-green discharge with foul odorFrothy, gray-green discharge with foul odor

White, curdlike discharge with no odorWhite, curdlike discharge with no odor

Gray discharge with fishy, foul odorGray discharge with fishy, foul odor


Male GenitaliaMale Genitalia Inspect for bleeding or traumaInspect for bleeding or trauma

PenisPenis Shaft nontender and flaccidShaft nontender and flaccid PriapismPriapism

Urethral openingUrethral opening Free of blood and dischargeFree of blood and discharge

ScrotumScrotum Nontender and slightly asymmetricalNontender and slightly asymmetrical


Male GenitaliaMale Genitalia AnusAnus

Exam indicated if:Exam indicated if:• Rectal bleedingRectal bleeding

• Trauma to areaTrauma to area

Most patients find side-lying position most Most patients find side-lying position most comfortablecomfortable

Protect patient’s privacyProtect patient’s privacy


Male GenitaliaMale Genitalia Inspect sacrococcygeal and perineal areas for:Inspect sacrococcygeal and perineal areas for:

LumpsLumps UlcersUlcers InflammationInflammation RashesRashes ExcoriationsExcoriations

Inflamed external hemorrhoids commonInflamed external hemorrhoids common Adults and pregnant womenAdults and pregnant women


Musculoskeletal SystemMusculoskeletal System Assess function and structureAssess function and structure

Patient positionPatient position Evaluate head, neck, shoulders, and upper Evaluate head, neck, shoulders, and upper

extremities with patient in a sitting positionextremities with patient in a sitting position Evaluate chest, back, and ilium with patient standingEvaluate chest, back, and ilium with patient standing Evaluate hips, knees, ankles, feet with patient supineEvaluate hips, knees, ankles, feet with patient supine

Observe general appearance, body proportions, Observe general appearance, body proportions, and ease of movementand ease of movement


General PrinciplesGeneral Principles Examine normal tissues before those injured, Examine normal tissues before those injured,

inflamed, or otherwise affectedinflamed, or otherwise affected

Inspect and palpate each body partInspect and palpate each body part Then test range of motion and muscle strengthThen test range of motion and muscle strength

Note differences between right and left Note differences between right and left


ExtremitiesExtremities Evaluate: Evaluate:

Skin and tissue over muscles, cartilage, bonesSkin and tissue over muscles, cartilage, bones Joints for injury, discoloration, swelling, massesJoints for injury, discoloration, swelling, masses Circulatory status Circulatory status

• Skin color and temperatureSkin color and temperature

• Distal pulsesDistal pulses

Structural integrity of bones, joints, and tissuesStructural integrity of bones, joints, and tissues Muscle toneMuscle tone


Abnormal FindingsAbnormal Findings

Signs of inflammationSigns of inflammation SwellingSwelling TendernessTenderness Increased heat Increased heat Redness of overlying Redness of overlying

skinskin Decreased functionDecreased function

AsymmetryAsymmetry CrepitusCrepitus DeformitiesDeformities Decreased muscle Decreased muscle

strengthstrength AtrophyAtrophy


JointsJoints Bones move freely over one anotherBones move freely over one another

No clicks, crepitation, or painNo clicks, crepitation, or pain

Move each joint through full range of motionMove each joint through full range of motion Normal if no pain, deformity, limitation, or Normal if no pain, deformity, limitation, or

instabilityinstability

Note:Note: Limited range of motionLimited range of motion Unusually increased joint mobility Unusually increased joint mobility


Hands and WristsHands and Wrists Inspect for swelling, Inspect for swelling,

redness, deformity, redness, deformity, nodules, muscular atrophynodules, muscular atrophy

Palpate jointPalpate joint Note swelling, tenderness, Note swelling, tenderness,

deformitydeformity

Range of motionRange of motion

Test muscle strength by Test muscle strength by hand griphand grip


ElbowsElbows InspectionInspection

Examine in flexed and extended Examine in flexed and extended positionposition

Note deformity, swelling, Note deformity, swelling, nodulesnodules

PalpationPalpation Lateral and medial epicondyles Lateral and medial epicondyles

of humerusof humerus Groove on sides of olecranon Groove on sides of olecranon

process process

Range of motionRange of motion


Shoulders and Related StructuresShoulders and Related Structures

Inspect shoulders, shoulder girdle, Inspect shoulders, shoulder girdle, scapulae, and related posterior muscles scapulae, and related posterior muscles Symmetry of size and shapeSymmetry of size and shape Note swelling, deformity, muscular atrophyNote swelling, deformity, muscular atrophy


Shoulders and Related StructuresShoulders and Related Structures Palpate for tenderness in:Palpate for tenderness in:

Sternoclavicular jointSternoclavicular joint Acromioclavicular jointAcromioclavicular joint Subacromial areaSubacromial area Biceps grooveBiceps groove Note any tenderness or swellingNote any tenderness or swelling Range of motionRange of motion


Shoulders and Related StructuresShoulders and Related Structures


Ankles and FeetAnkles and Feet

Skin integritySkin integrity

ContourContour

PositionPosition

DeformitiesDeformities

NodulesNodules

SwellingSwelling

CallusesCalluses

CornsCorns

SizeSize


Ankles and FeetAnkles and Feet Palpate:Palpate:

Anterior aspects of each ankle jointAnterior aspects of each ankle joint Achilles tendonAchilles tendon Metatarsophalangeal jointsMetatarsophalangeal joints

Note tenderness, swelling, deformityNote tenderness, swelling, deformity


Ankles and FeetAnkles and Feet Range of motionRange of motion

DorsiflexionDorsiflexion Plantar flexionPlantar flexion InversionInversion EversionEversion


PelvisPelvis

Pelvic structural Pelvic structural integrity integrity Hands on anterior iliac Hands on anterior iliac

crestscrests• Press down and outPress down and out

Heel of hand on Heel of hand on symphysis pubissymphysis pubis• Press downPress down


HipsHips Inspect for symmetryInspect for symmetry

Palpate:Palpate: Instability, tenderness, and crepitusInstability, tenderness, and crepitus

Range of motion (supine patient)Range of motion (supine patient) Raises knee to chest, other leg straight Raises knee to chest, other leg straight Note flexion at hip and kneeNote flexion at hip and knee


KneesKnees InspectionInspection

Patella smooth, firm, nontender, midlinePatella smooth, firm, nontender, midline Alignment, swelling, and deformityAlignment, swelling, and deformity Note atrophy of quadricepsNote atrophy of quadriceps

PalpationPalpation Note thickening, swelling, tendernessNote thickening, swelling, tenderness

Range of motionRange of motion Bend, straighten each knee without painBend, straighten each knee without pain


Peripheral Vascular SystemPeripheral Vascular System Arteries, veins, Arteries, veins,

lymphatic system lymphatic system and lymph nodes, and lymph nodes, fluids exchanged in fluids exchanged in capillary bedcapillary bed


ArmsArms Inspect fingertips to shoulders, noting:Inspect fingertips to shoulders, noting:

Size and symmetrySize and symmetry SwellingSwelling Venous patternVenous pattern Color of skin and nail bedsColor of skin and nail beds Skin textureSkin texture

Palpate:Palpate: Radial pulses bilaterallyRadial pulses bilaterally Epitrochlear nodeEpitrochlear node

• If palpable, note its size and consistencyIf palpable, note its size and consistency


LegsLegs Patient supine and appropriately drapedPatient supine and appropriately draped

Inspect from groin and buttocks to feet:Inspect from groin and buttocks to feet: Size and symmetrySize and symmetry SwellingSwelling Venous pattern and venous enlargementVenous pattern and venous enlargement PigmentationPigmentation Rashes, scars, ulcersRashes, scars, ulcers Color and texture of the skinColor and texture of the skin Presence or absence of hair growthPresence or absence of hair growth


LegsLegs Palpate superficial inguinal nodesPalpate superficial inguinal nodes

Swelling and tendernessSwelling and tenderness

Palpate pulses: Palpate pulses: Femoral Femoral PoplitealPopliteal Dorsalis pedis Dorsalis pedis Posterior tibialPosterior tibial

Temperature of feet and legsTemperature of feet and legs


LegsLegs Check for pitting edema:Check for pitting edema:

Press firmly but gently with the thumb for at least 5 Press firmly but gently with the thumb for at least 5 secondsseconds• Over dorsum of footOver dorsum of foot

• Behind medial malleolusBehind medial malleolus

• Over shinsOver shins


Abnormal FindingsAbnormal Findings Swollen or asymmetrical extremitiesSwollen or asymmetrical extremities

Pale or cyanotic skinPale or cyanotic skin

Weak or diminished pulsesWeak or diminished pulses

Skin cold to the touchSkin cold to the touch

Absence of hair growthAbsence of hair growth

Pitting edemaPitting edema


SpineSpine InspectionInspection

Cervical, thoracic, and Cervical, thoracic, and lumbar curveslumbar curves• Lordosis (swayback)Lordosis (swayback)

• Kyphosis (hunchback)Kyphosis (hunchback)

• Scoliosis (razorback) Scoliosis (razorback)

Height differences of Height differences of shouldersshoulders

Height differences of iliac Height differences of iliac crestcrest


Cervical SpineCervical Spine InspectionInspection

Should be in a midline positionShould be in a midline position Look for deformities and abnormal postureLook for deformities and abnormal posture

PalpationPalpation If patient is alert and denies neck pain, palpate If patient is alert and denies neck pain, palpate

posterior aspect of neck for point tenderness and posterior aspect of neck for point tenderness and swellingswelling


Cervical SpineCervical Spine

Range of motionRange of motion If no suspected injury:If no suspected injury:

• Bend head forward, chin Bend head forward, chin to chest (flexion)to chest (flexion)

• Bend head backward Bend head backward (hyperextension)(hyperextension)

• Move head side-to-side Move head side-to-side (lateral bending)(lateral bending)

Should be no pain or Should be no pain or discomfortdiscomfort


Thoracic and Lumbar SpineThoracic and Lumbar Spine Inspect for injury, swelling, discolorationInspect for injury, swelling, discoloration

Palpate from first thoracic vertebra Palpate from first thoracic vertebra Move downward to sacrumMove downward to sacrum

Range of motionRange of motion Bend forward at waistBend forward at waist Bend backward at waist Bend backward at waist Bend to each side Bend to each side Rotate upper trunk in a circular motionRotate upper trunk in a circular motion


Nervous SystemNervous System Detail of neurological examination variesDetail of neurological examination varies

Depends on patient’s complaintDepends on patient’s complaint• Peripheral nervous system vs. CNS problemsPeripheral nervous system vs. CNS problems


Neurological ExaminationNeurological Examination Mental status and speechMental status and speech

Cranial nervesCranial nerves

Motor systemMotor system

Sensory systemSensory system

ReflexesReflexes


Mental Status and SpeechMental Status and Speech Oriented to person, place, and timeOriented to person, place, and time

Organizes thoughts and converses freelyOrganizes thoughts and converses freely If no hearing or speech impedimentsIf no hearing or speech impediments


Mental Status and SpeechMental Status and Speech Abnormal findingsAbnormal findings

UnconsciousnessUnconsciousness ConfusionConfusion Slurred speechSlurred speech AphasiaAphasia DysphoniaDysphonia DysarthriaDysarthria


Cranial Nerve AssessmentCranial Nerve Assessment Cranial nerve ICranial nerve I

Olfactory: Test sense of smell with spirits of ammoniaOlfactory: Test sense of smell with spirits of ammonia

Cranial nerve IICranial nerve II Optic: Visual acuity Optic: Visual acuity

Cranial nerve II and IIICranial nerve II and III Optic and oculomotorOptic and oculomotor

• Size and shape of pupilsSize and shape of pupils

• Pupil response to lightPupil response to light


Cranial Nerve AssessmentCranial Nerve Assessment Cranial nerves III, IV, VICranial nerves III, IV, VI

Oculomotor, trochlear, abducensOculomotor, trochlear, abducens• Extraocular movements Extraocular movements • Six cardinal directions of gazeSix cardinal directions of gaze

Cranial nerve VCranial nerve V TrigeminalTrigeminal

• Ask patient to clench teeth while palpating temporal and Ask patient to clench teeth while palpating temporal and masseter musclesmasseter muscles

• Test sensation by touching forehead, cheeks, jaw on Test sensation by touching forehead, cheeks, jaw on each sideeach side


Cranial Nerve AssessmentCranial Nerve Assessment Cranial nerve VIICranial nerve VII

FacialFacial• Inspect face: note symmetry, tics, abnormal movementsInspect face: note symmetry, tics, abnormal movements

• Raise eyebrows, frown, show both upper and lower Raise eyebrows, frown, show both upper and lower teeth, smile, puff out cheeksteeth, smile, puff out cheeks

• Close eyes tightly so they cannot be opened, gently Close eyes tightly so they cannot be opened, gently attempt to raise eyelidsattempt to raise eyelids

• Observe for weakness or asymmetryObserve for weakness or asymmetry

Cranial nerve VIIICranial nerve VIII Acoustic: Assess hearing acuity Acoustic: Assess hearing acuity


Cranial Nerve AssessmentCranial Nerve Assessment Cranial nerves IX and XCranial nerves IX and X

Glossopharyngeal and vagusGlossopharyngeal and vagus• Ability to swallow with ease; to produce saliva; produce Ability to swallow with ease; to produce saliva; produce

normal voice soundsnormal voice sounds

• Patient holds breath: assess for normal slowing of heart Patient holds breath: assess for normal slowing of heart raterate

• Testing for gag reflex will test cranial nervesTesting for gag reflex will test cranial nerves


Cranial Nerve AssessmentCranial Nerve Assessment Cranial nerve XICranial nerve XI

Spinal AccessorySpinal Accessory• Raise and lower shoulders, turn headRaise and lower shoulders, turn head

Cranial nerve XIICranial nerve XII HypoglossalHypoglossal

• Stick out tongue and move it in several directionsStick out tongue and move it in several directions


Motor SystemMotor System Observe patient during movement and at restObserve patient during movement and at rest

Abnormal involuntary movements evaluated Abnormal involuntary movements evaluated for:for: QualityQuality RateRate RhythmRhythm AmplitudeAmplitude


Motor SystemMotor System Other body movement assessments:Other body movement assessments:

PosturePosture Level of activityLevel of activity FatigueFatigue EmotionEmotion Muscle strengthMuscle strength

Bilaterally symmetricalBilaterally symmetrical

Resistance to oppositionResistance to opposition


Muscle StrengthMuscle Strength Patient to move against resistance:Patient to move against resistance:

No muscular contraction detectedNo muscular contraction detected A barely detectable flicker or trace of contractionA barely detectable flicker or trace of contraction Active movement of body part with gravity Active movement of body part with gravity

eliminatedeliminated Active movement against gravityActive movement against gravity Active movement against gravity and some Active movement against gravity and some

resistanceresistance Active movement against full resistanceActive movement against full resistance

• This is normal muscle toneThis is normal muscle tone


Upper Extremity EvaluationUpper Extremity Evaluation Patient to extend Patient to extend

elbow and pull it elbow and pull it toward the chest toward the chest against resistanceagainst resistance


Lower Extremity EvaluationLower Extremity Evaluation Patient pushes Patient pushes

soles of feet against soles of feet against examiner’s palmsexaminer’s palms Patient pulls toes Patient pulls toes

toward head against toward head against resistanceresistance

Should be easily Should be easily performed by patient performed by patient without fatiguewithout fatigue


Muscle StrengthMuscle Strength Other methods can be used to evaluate Other methods can be used to evaluate

muscle strength, including tests for:muscle strength, including tests for: FlexionFlexion ExtensionExtension AbductionAbduction Upper and lower extremitiesUpper and lower extremities


CoordinationCoordination Point-to-point movementsPoint-to-point movements

GaitGait

StanceStance

Romberg testRomberg test

Pronator drift testPronator drift test


Romberg TestRomberg Test


Pronator Drift TestPronator Drift Test


Sensory SystemSensory System Conduct sensations of:Conduct sensations of:

PainPain TemperatureTemperature PositionPosition VibrationVibration TouchTouch

A healthy patient is responsive to these A healthy patient is responsive to these stimulistimuli


Sensory SystemSensory System Patient’s response to pain and light touchPatient’s response to pain and light touch

Response considered in relation to dermatomesResponse considered in relation to dermatomes

Perform light touch on hands and feetPerform light touch on hands and feet If patient cannot feel or is unconscious, gently If patient cannot feel or is unconscious, gently

prick extremities with sharp object that will not prick extremities with sharp object that will not penetrate skinpenetrate skin

Head to toeHead to toe

Compare symmetrical areasCompare symmetrical areas


Approaching the Pediatric PatientApproaching the Pediatric Patient

Remain calm, confidentRemain calm, confident

Avoid separating child from parent Avoid separating child from parent

Establish rapport with parents and childEstablish rapport with parents and child

Be honest with child and parentBe honest with child and parent

Have one paramedic stay with childHave one paramedic stay with child



Observe child before physical examinationObserve child before physical examination Begin assessment without touching patientBegin assessment without touching patient

Note:Note: Skin colorSkin color Level of consciousnessLevel of consciousness Respiratory rateRespiratory rate Assess behaviorAssess behavior



Note area of body that appears painfulNote area of body that appears painful Avoid painful area until end of examinationAvoid painful area until end of examination Warn child before you touch painful area(s) Warn child before you touch painful area(s)


General AppearanceGeneral Appearance Assess from a distance:Assess from a distance:

Level of consciousnessLevel of consciousness Spontaneous movementSpontaneous movement Respiratory effortRespiratory effort Skin colorSkin color Body positionBody position

Seriously ill or injured child does not Seriously ill or injured child does not hide or disguise conditionhide or disguise condition


Birth to 6 MonthsBirth to 6 Months Maintain body temperatureMaintain body temperature

Poor head control normal under 3 months of Poor head control normal under 3 months of ageage

Infants are abdominal breathersInfants are abdominal breathers Stomach protrudes and chest wall retracts during Stomach protrudes and chest wall retracts during

inspirationinspiration


Birth to 6 MonthsBirth to 6 Months

Assess anterior Assess anterior fontanel:fontanel: Present up to 18 monthsPresent up to 18 months Bulges during cryingBulges during crying Firm if child is supineFirm if child is supine

• If sunken, may be If sunken, may be dehydrationdehydration

• Bulging fontanel may Bulging fontanel may mean increased mean increased intracranial pressureintracranial pressure


7 Months to 3 Years7 Months to 3 Years Usually cooperativeUsually cooperative Minimal speech, unreliable historyMinimal speech, unreliable history May have separation anxietyMay have separation anxiety If possible, have parent hold child for examIf possible, have parent hold child for exam May see illness or injury as punishmentMay see illness or injury as punishment Approach slowly and speak in reassuring Approach slowly and speak in reassuring

tonestones Use simple and direct questionsUse simple and direct questions


4 to 10 Years4 to 10 Years May be cooperative May be cooperative May provide limited history of eventMay provide limited history of event May have separation anxiety and view illness May have separation anxiety and view illness

or injury as punishmentor injury as punishment Approach slowlyApproach slowly Speak in quiet, reassuring tonesSpeak in quiet, reassuring tones Allow child to "help" Allow child to "help" Reluctant to show "private parts“Reluctant to show "private parts“ Advise of any expected pain or discomfortAdvise of any expected pain or discomfort


Adolescents (11 to 18 years)Adolescents (11 to 18 years) Generally calm, mature, helpfulGenerally calm, mature, helpful Concerned about modesty, disfigurement, Concerned about modesty, disfigurement,

pain, disability, and deathpain, disability, and death Reassure when appropriateReassure when appropriate Respect patient's need for privacyRespect patient's need for privacy If possible, interview privately If possible, interview privately Consider alcohol, drug use, pregnancyConsider alcohol, drug use, pregnancy


Communicating with the Older AdultCommunicating with the Older Adult

Allow time for effective communicationAllow time for effective communication

Stay close to patient during interviewStay close to patient during interview

Repetition of questions may be neededRepetition of questions may be needed

Do not patronize or offend patientDo not patronize or offend patient


Patient HistoryPatient History Multiple health problemsMultiple health problems

Difficult to isolate injury or illnessDifficult to isolate injury or illness

Decreased sensory function may disguise signs and Decreased sensory function may disguise signs and symptomssymptoms

Watch for illness from medication use or misuseWatch for illness from medication use or misuse

Consider relationship between drug interactions, Consider relationship between drug interactions, disease, and aging processdisease, and aging process


Patient HistoryPatient History Functional ability and daily activitiesFunctional ability and daily activities

WalkingWalking Getting out of bedGetting out of bed DressingDressing Driving a carDriving a car Using public transportationUsing public transportation Preparing mealsPreparing meals Taking medicationsTaking medications Sleeping habitsSleeping habits Bathroom habitsBathroom habits


Physical ExaminationPhysical Examination Try to ensure patient comfortTry to ensure patient comfort Offer clear explanations Offer clear explanations Answer questionsAnswer questions Be alert to chronic painBe alert to chronic pain If hospital transport necessaryIf hospital transport necessary

Attempt to calm patientAttempt to calm patient Reassure patient he or she will be cared for in Reassure patient he or she will be cared for in

hospital hospital Record examination findings Record examination findings


ConclusionConclusionThe paramedic must have a wide range of The paramedic must have a wide range of

knowledge and skills to perform a knowledge and skills to perform a comprehensive physical examination and to comprehensive physical examination and to make effective clinical patient care decisions.make effective clinical patient care decisions.


Questions?Questions?


Chapter 11 Techniques of Physical Examination Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

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