Chapter 11Chapter 11Techniques of Physical ExaminationTechniques of Physical Examination
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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
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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
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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
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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.
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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?
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Examination TechniquesExamination Techniques InspectionInspection
PalpationPalpation
PercussionPercussion
AuscultationAuscultation
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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
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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
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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
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Deep Bimanual PalpationDeep Bimanual Palpation
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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
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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
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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
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StethoscopeStethoscope
Position stethoscope Position stethoscope between index and between index and middle fingersmiddle fingers
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OphthalmoscopeOphthalmoscope
Used to inspect eye Used to inspect eye structures:structures: RetinaRetina ChoroidChoroid Optic nerve discOptic nerve disc Macula Macula Retinal vesselsRetinal vessels
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OtoscopeOtoscope Used to examine Used to examine
deep structures of deep structures of the external and the external and middle earmiddle ear
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Blood Pressure CuffBlood Pressure Cuff
SphygmomanometerSphygmomanometer
Measures systolic and Measures systolic and diastolic blood pressurediastolic blood pressure
Manual or electronicManual or electronic
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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
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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
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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
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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
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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
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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)
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Skin LesionsSkin Lesions
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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
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Sexual DevelopmentSexual Development Determine if age appropriateDetermine if age appropriate
Observe for normal changes associated with Observe for normal changes associated with ageage
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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
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Vital SignsVital Signs PulsePulse
Blood pressureBlood pressure
RespirationsRespirations
SkinSkin
PupilsPupils
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PulsePulse RateRate
RhythmRhythm
QualityQuality
Consider ECG monitoringConsider ECG monitoring
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Blood PressureBlood PressureLocations
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RespirationsRespirations Adult rateAdult rate
12-24 breaths per minute12-24 breaths per minute
Observe Observe
Feel for chest movementFeel for chest movement
AuscultateAuscultate
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SkinSkin TextureTexture
TurgorTurgor
HairHair
Fingernails and toenailsFingernails and toenails Abnormal findingsAbnormal findings
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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
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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
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Tympanic TemperatureTympanic Temperature Accuracy questionableAccuracy questionable
Pull ear backPull ear back
Insert gentlyInsert gently
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Rectal TemperatureRectal Temperature Risk of perforationRisk of perforation
Avoid in Avoid in uncooperative, or uncooperative, or immuno-suppressed immuno-suppressed patientpatient
Stabilize thermometerStabilize thermometer
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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)
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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
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Anatomical RegionsAnatomical Regions Skin Skin
Texture Texture TurgorTurgor HairHair Fingernails and toenailsFingernails and toenails
Head, ears, eyes, nose, throatHead, ears, eyes, nose, throat
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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
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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
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EyesEyes——Visual FieldsVisual FieldsSix cardinal fields of gaze
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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
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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
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Cornea and ScleraCornea and Sclera Examine conjunctiva Examine conjunctiva
and scleraand sclera
Palpate lower orbital rimPalpate lower orbital rim
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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
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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
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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
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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
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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
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NoseNose Inspect Inspect
PalpatePalpate
Discharge from the noseDischarge from the nose CSF CSF EpistaxisEpistaxis Mucous dischargeMucous discharge
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Mouth and PharynxMouth and Pharynx LipsLips
GumsGums
Mouth and tongueMouth and tongue
PharynxPharynx
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NeckNeck Inspect Inspect
Use spinal precautions Use spinal precautions if trauma is suspectedif trauma is suspected
Palpate tracheaPalpate trachea Midline position normalMidline position normal
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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
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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
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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
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Topographical LandmarksTopographical Landmarks
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Thoracic LandmarksThoracic Landmarks——Anterior ChestAnterior Chest
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Thoracic LandmarksThoracic Landmarks——Posterior ChestPosterior Chest
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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
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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
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ChestChest——PalpationPalpation
Tracheal positionTracheal position
Respiratory excursionRespiratory excursion
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Percussion and Auscultation of ChestPercussion and Auscultation of Chest
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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
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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
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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
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Normal Breath SoundsNormal Breath Sounds Classified as:Classified as:
VesicularVesicular BronchovesicularBronchovesicular BronchialBronchial
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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
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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
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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
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Abnormal Breath SoundsAbnormal Breath Sounds AbsentAbsent
DiminishedDiminished
Incorrectly located Incorrectly located bronchial soundsbronchial sounds
Adventitious Adventitious DiscontinuousDiscontinuous ContinuousContinuous
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Breath SoundsBreath Sounds
Fig. 11-26Fig. 11-26
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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
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Continuous Breath SoundsContinuous Breath Sounds WheezesWheezes
RhonchiRhonchi
StridorStridor
Pleural friction rubPleural friction rub
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HeartHeart Assessment includes:Assessment includes:
PalpationPalpation AuscultationAuscultation
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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
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PulsePulse Auscultate for:Auscultate for:
Frequency (pitch)Frequency (pitch) Intensity (loudness)Intensity (loudness) DurationDuration Timing in cardiac cycleTiming in cardiac cycle
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Auscultating Heart SoundsAuscultating Heart Sounds
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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
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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
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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
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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
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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
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AbdomenAbdomen
Two imaginary lines Two imaginary lines separate abdominal separate abdominal region into four region into four quadrantsquadrants
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AbdomenAbdomen——Inspection Inspection SkinSkin
UmbilicusUmbilicus
ContourContour
Abdominal movementAbdominal movement
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AbdomenAbdomen AuscultationAuscultation
Bowel soundsBowel sounds BruitsBruits
Percussion and palpationPercussion and palpation Detect:Detect:
• FluidFluid
• AirAir
• Solid massesSolid masses
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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
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Palpation of the LiverPalpation of the Liver
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Palpation of the SpleenPalpation of the Spleen
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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Shoulders and Related StructuresShoulders and Related Structures
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Ankles and FeetAnkles and Feet
Skin integritySkin integrity
ContourContour
PositionPosition
DeformitiesDeformities
NodulesNodules
SwellingSwelling
CallusesCalluses
CornsCorns
SizeSize
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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
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Ankles and FeetAnkles and Feet Range of motionRange of motion
DorsiflexionDorsiflexion Plantar flexionPlantar flexion InversionInversion EversionEversion
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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Neurological ExaminationNeurological Examination Mental status and speechMental status and speech
Cranial nervesCranial nerves
Motor systemMotor system
Sensory systemSensory system
ReflexesReflexes
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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
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Mental Status and SpeechMental Status and Speech Abnormal findingsAbnormal findings
UnconsciousnessUnconsciousness ConfusionConfusion Slurred speechSlurred speech AphasiaAphasia DysphoniaDysphonia DysarthriaDysarthria
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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CoordinationCoordination Point-to-point movementsPoint-to-point movements
GaitGait
StanceStance
Romberg testRomberg test
Pronator drift testPronator drift test
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Romberg TestRomberg Test
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Pronator Drift TestPronator Drift Test
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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
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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
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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
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Approaching the Pediatric PatientApproaching the Pediatric Patient
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
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Approaching the Pediatric PatientApproaching the Pediatric Patient
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)
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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.
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Questions?Questions?
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