1	Techniques of the Physical Examination Part 2 Medic 1 Paramedic Education Program
2	Objectives Discuss methods of examining each body system Compare normal vs. abnormal findings Review potential abnormal findings and their potential relevance
3	Reminders Keys to the Physical Exam Inspection Palpation Auscultation Percussion Key Tools in the Physical Exam BP cuff & Stethoscope Senses
4	Skin & Nails General Appearance & Potential Abnormalities Jaundice, Cyanotic, Pale, Pink/Norm Moist, dry, exfoliation Hot, warm, cool, cold Lesions Petechiae, Purpura (blanching?) cellulitis, pressure ulcer, burn, scar
5	The Skin
6	Skin Lesions
7	Primary Lesions
8	Primary Lesions
9	Skin Lesions
10	Skin Lesions
11	Skin Lesions
12	Skin Lesions
13	Nails
14	HEENT Head & Face old scar, size/shape, appearance Eyes Pupils Sunken, protruding periorbital ecchymosis or edema visual acuity Nose & throat sounds, growths, tonsils Color (white, red, pink)
15	HEENT
16	HEENT
17	HEENT
18	HEENT
19	Ophthalmoscopic Examination Normal findings Clear, yellow optic nerve disc Reddish pink (European-American) or darkened retina (African-American) Light red arteries Dark red veins 3:2 vein-to-artery ratio
20	HEENT
21	HEENT
22	HEENT What specific testing or examinations should be done with regard to the HEENT exam? What specific abnormalities might you find and why?
23	Neck
24	Neck
25	Neck
26	Chest & Respiratory System
27	Chest & Respiratory System What specific things should you consider evaluating or examining with regard to the chest & respiratory system? What are some abnormal findings and what might they tell you about the patient? Group Discussions
28	Breath Sounds
29	Breath Sounds
30	Breath Sounds
31	Cardiovascular
32	Cardiovascular What specific questions, tests, examinations, etc should you include when assessing the entire cardiovascular system (include peripheral vascular)? What might these findings tell you about your patient? What are the specific organs and structures involved in the assessment? Group Discussions
33	Pulse Auscultate for: Frequency (pitch) Intensity (loudness) Duration Timing in cardiac cycle
34	Heart Sounds S1 Instruct patient to breathe normally and then hold breath in expiration S2 Instruct patient to breathe normally again and then hold breath in inspiration
35	Heart Murmurs Prolonged extra sounds Caused by disruption in flow of blood through heart Most caused by valvular defects Some serious Others benign Have no apparent cause
36	Bruit Abnormal sound or murmur Heard while auscultating carotid artery, organ or gland May be local obstruction Often low pitched Hard to hear
37	Abdominal
38	Abdomen Auscultation Bowel sounds Bruits Percussion and palpation Detect: Fluid Air Solid masses
39	Percussion Evaluate four quadrants of abdomen: Tympany Air in stomach and intestines Dullness Solid abdominal organs and solid masses Proceed from tympany to dullness Change in sound easier to detect
40	Abdominal
41	Nervous System
42
43	Neurologic System Exam
44	Cranial Nerve Assessment Cranial nerve I Olfactory: Test sense of smell with spirits of ammonia Cranial nerve II Optic: Visual acuity Cranial nerve II and III Optic and oculomotor Size and shape of pupils Pupil response to light
45	Cranial Nerve Assessment Cranial nerves III, IV, VI Oculomotor, trochlear, abducens Extraocular movements Six cardinal directions of gaze Cranial nerve V Trigeminal Ask patient to clench teeth while palpating temporal and masseter muscles Test sensation by touching forehead, cheeks, jaw on each side
46	Cranial Nerve Assessment Cranial nerve VII Facial Inspect face: note symmetry, tics, abnormal movements Raise eyebrows, frown, show both upper and lower teeth, smile, puff out cheeks Close eyes tightly so they cannot be opened, gently attempt to raise eyelids Observe for weakness or asymmetry Cranial nerve VIII Acoustic: Assess hearing acuity
47	Cranial Nerve Assessment Cranial nerves IX and X Glossopharyngeal and vagus Ability to swallow with ease; to produce saliva; produce normal voice sounds Patient holds breath: assess for normal slowing of heart rate Testing for gag reflex will test cranial nerves
48	Cranial Nerve Assessment Cranial nerve XI Spinal Accessory Raise and lower shoulders, turn head Cranial nerve XII Hypoglossal Stick out tongue and move it in several directions
49	Eyes—Visual Fields
50	Nervous System What specific questions, tests, examinations, etc should you include when assessing the entire nervous system (exclude equipment testing such as CT, MRI)? What might these findings tell you about your patient? What organs or structures are you assessing? Group Discussions
51	Motor System Observe patient during movement and at rest Abnormal involuntary movements evaluated for: Quality Rate Rhythm Amplitude
52	Motor System Other body movement assessments: Posture Level of activity Fatigue Emotion Muscle strength Bilaterally symmetrical Resistance to opposition
53	Muscle Strength Patient to move against resistance: No muscular contraction detected A barely detectable flicker or trace of contraction Active movement of body part with gravity eliminated Active movement against gravity Active movement against gravity and some resistance Active movement against full resistance This is normal muscle tone
54	Upper Extremity Evaluation Patient to extend elbow and pull it toward the chest against resistance
55	Lower Extremity Evaluation Patient pushes soles of feet against examiner’s palms Patient pulls toes toward head against resistance Should be easily performed by patient without fatigue
56	Muscle Strength Other methods can be used to evaluate muscle strength, including tests for: Flexion Extension Abduction Upper and lower extremities
57	Coordination Point-to-point movements Gait Stance Romberg test Pronator drift test
58	Sensory System Conduct sensations of: Pain Temperature Position Vibration Touch A healthy patient is responsive to these stimuli
59	Sensory System Patient’s response to pain and light touch Response considered in relation to dermatomes Perform light touch on hands and feet If patient cannot feel or is unconscious, gently prick extremities with sharp object that will not penetrate skin Head to toe Compare symmetrical areas
60	Additional Diagnostics Blood glucose level Pulse oximetry ECG Diagnostic (12 Lead) ECG Cincinnati Prehospital Stroke Scale Future Cardiac Enzymes, Predictive instruments, Abdominal Ultrasound
61	Approaching the Pediatric Patient Remain calm, confident Avoid separating child from parent Establish rapport with parents and child Be honest with child and parent Have one paramedic stay with child
62	Approaching the Pediatric Patient Observe child before physical examination Begin assessment without touching patient Note: Skin color Level of consciousness Respiratory rate Assess behavior
63	Approaching the Pediatric Patient Note area of body that appears painful Avoid painful area until end of examination Warn child before you touch painful area(s)
64	General Appearance Assess from a distance: Level of consciousness Spontaneous movement Respiratory effort Skin color Body position Seriously ill or injured child does not hide or disguise condition
65	Birth to 6 Months Maintain body temperature Poor head control normal under 3 months of age Infants are abdominal breathers Stomach protrudes and chest wall retracts during inspiration
66	Birth to 6 Months Assess anterior fontanel: Present up to 18 months Bulges during crying Firm if child is supine If sunken, may be dehydration Bulging fontanel may mean increased intracranial pressure
67	7 Months to 3 Years Usually cooperative Minimal speech, unreliable history May have separation anxiety If possible, have parent hold child for exam May see illness or injury as punishment Approach slowly and speak in reassuring tones Use simple and direct questions
68	4 to 10 Years May be cooperative May provide limited history of event May have separation anxiety and view illness or injury as punishment Approach slowly Speak in quiet, reassuring tones Allow child to "help" Reluctant to show "private parts“ Advise of any expected pain or discomfort
69	Adolescents (11 to 18 years) Generally calm, mature, helpful Concerned about modesty, disfigurement, pain, disability, and death Reassure when appropriate Respect patient's need for privacy If possible, interview privately Consider alcohol, drug use, pregnancy
70	Communicating with the Older Adult Allow time for effective communication Stay close to patient during interview Repetition of questions may be needed Do not patronize or offend patient
71	Patient History Multiple health problems Difficult to isolate injury or illness Decreased sensory function may disguise signs and symptoms Watch for illness from medication use or misuse Consider relationship between drug interactions, disease, and aging process
72	Patient History Functional ability and daily activities Walking Getting out of bed Dressing Driving a car Using public transportation Preparing meals Taking medications Sleeping habits Bathroom habits
73	Physical Examination Try to ensure patient comfort Offer clear explanations Answer questions Be alert to chronic pain If hospital transport necessary Attempt to calm patient Reassure patient he or she will be cared for in hospital Record examination findings
74	Summary Examine each body system area when performing the comprehensive physical exam Consider knowledge of pathophysiologies and apply to the physical exam