Next Level Medic - Next Level Medic

 General Survey & Mental Status:Introduction- wash hands, introduce myself and explain.Mental status- Asses for time, person , place, & situationVital Signs: Ask patient to sit.Have patient sit in chair. Check Temp.Check Radial pulse X 60 seconds (normal 60-80 bpm)Check Respirations X 60 seconds (normal 12-20 bpm)Check Blood Pressure- (normal 100-140/60-90 mm Hg)Sitting: First estimate systolic BP by palpating brachial pulse. Then add 20mmHg to that # & check BP with Bell of stethoscope on both arms.Supine BP in both arms (may be lower) and have patient return to sitting on table.General Inspection- Ask the patient to disrobe and continue what inspection that began at introduction. Quickly inspect the body for any signs of distress or obvious abnormalities including: discolorations and texture of skin, hair distribution along the body, muscle mass and size.Head & Face:Inspection- head for size and shape, hair for texture and distribution, scalp for masses, lesions, redness, face for color edema, and neck for swelling or lumpsPalpation- Skull and scalp for any masses, lesions, tenderness. Hair for texture and signs of infestation. TMJ- ask patient to open and close mouth. Ask patient to clench teeth and palpate temporal and masseter muscle (CN 5-M)Neuro- Have patient open eyes (CN 3),open against resistance and raise eyebrows. Close eyes,Smile, frown, and puff out cheeks. (CN7). With eyes closed check light touch on forehead, cheeks, and jaw bilaterally (CN 5-S) Check corneal reflex unless they have contacts (CN5-S & CN7-M)Eyes:Inspection- Eyebrow, eyelashes, lids, conjunctivae (pull lid down and have patient look up), sclera, cornea, and lacrimal glands for symmetry, moisture, ptosis, discharge.Assessment-Visual Acuity (CN2)= Snellen ChartExtraocular muscles (CN3,4,6)= H testVisual fields by confrontation= checking peripheral vision/ birds (CN2)Pupillary accommodation constriction and convergence (CN3)= patient looks at wall and then at my finger. And Cross eyes.Pupillary reaction to light direct and consensual (CN3)= patient looks forward, use penlight to note constriction.Ophthalmic Exam(CN2) DIM LIGHTS= Have patient look over my shoulder and look for red reflex, locate retina and its optic disc, macule and vessels (use my rt hand and rt eye to examine patient’s rt eye). Have them look at light to check fovea.Ears:Inspection- external appearance for shape, position and symmetryPalpation- auricle, tragus and mastoid for tendernessAssessment- CN8-Gross hearing =Occlude one ear and test open ear by whispering 1,2,3-Weber test- place fork on top of head patient should hear sound equally in both ears, conductive hearing loss patient can hear better in affected ear, sensorineural loss will lateralize in normal ear.-Rinne test=place fork on mastoid bone, patient tells you when sound stops and time with watch. Put fork in front of ear and ask patient to tell you when it stops now. Air conduction should be 2X bone.-Otoscopic Exam= pull ear up,out, back for adult and inspect auditory canal and tympanic membrane- noting cerumen, discharge, redness Inspect contour, landmarks umbo, handle of malleus, cone of light of ear drum.Nose:Inspection- external shape, position of nares and septumAssess- Use Otoscope to inspect septum, turbinates, color of nasal mucosaPalpate- ask patient to close eyes and palpate frontal and maxillary sinusesAssess- Nasal patency (CN1) sense of smellMouth & Throat:Inspection- Use gloves and inspects, lips, teeth, buccal mucosa, salivary gland ducts. Use tongue blade and pen light to inspect, hard & soft palate, uvula, pharynx. Have patient say AAH to inspect uvula for position ( CN9/10)Assess- Gag reflex while inspection uvula and pharynx (CN 9/10)Assess CN12- have patient stick out tongue.Neck:Inspection= external neck, ask patient to swallow (thyroid should move up in midline).Assess ROM- (flexion, extension, lateral flexion (ear to shoulder), lateral rotation ,a second time against resistance CN11 to SCM muscles, and shrug shoulders against resistance CN11 trapezius muscle)Palpate Lymph Nodes (pre auricular, post auricular, submandibular, submental, superficial cervical , posterior cervical, deep cervical, supraclavicular *ask patient to take a deep breath*, Occipital)Palpate Thyroid- position at suprasternal notch, palpate posterior and ask patient to swallow during palpationChest:Posterior approach pt.sitting-Inspection of rate,rhythm, shape, color of skin, scars. Inspect during deep inspirationPalpationchest expansion during deep inspiration (place hands at 10th rib) look for symmetryTactile Fremitus- patient says 99 (4 areas –apices, posterior, and lateral) checks for consolidation (lung air spaces fill with exudat)Percussion- apices, posterior, lateral & diaphragmatic excursion (after finding diaphragm ask patient to exhale completely and percuss up, mark with pen, inhale deeply, percuss down and normal should be 3-5 cm)Auscultation- with diaphragm of stethoscope 7 places: ask patient to breath through mouth.Vocal Fremitus-“99”Egophony- “e”Whispered Pectoriloquy- “1,2,3”Anterior Approach pt. lying down-InspectionPalpation of thorax- sternum, clavicle, ribs & Tactile fremitus (3 areas)Percussion-Auscultate- Note any crackles, wheezing, stridor, pleural friction rub, or areas of consolidationHeart and Neck VesselsInspect neck jugular veins for distention (enlarged) and carotid arteries for pulsation and chest for heaves (labored respiration).Palpation:-Feel for Thrills with palm over patient’s chest (At base, left sternal border & Apex)-PMI (point of max. impulse) located at Apex or 5th ICS midclavicular line. Point where impulse of left ventricle is strongest.-Suprasternal notch for pulsationAuscultate Heart- With Patient sitting, noting any S3 or S4 heart sound, rubs, clicks.-Aortic @ Rt 2nd ICS-Pulmonic @ Lt 2nd ICS-Erb’s point @ Midclavicular 3rd ICS-Tricuspid @ Lt 4th ICS-Mitral & Apex @ Midclavicular 5th ICS-Carotid Arteries with BELL of stethoscope for bruits (low pitched sound due to obstruction of vessel)Auscultate- with patient supineHeart (5 areas)CarotidsPalpate Carotid Artery pulsationsAbdomenInspect skin for scars, lesions, striae, contour, umbilicus character, and pulsationsAuscultate4 Quadrants (2 in each quadrant) for bowel soundsAbdominal AortaSwitch to Bell for next arteriesRt/Lt renal arteries (10th rib) shouldn’t hear anything, iliac arteries (umbilicus) and Femoral arteriesPercussion4 Quadrants and over left rib cage for gastric air bubblesLiver borders (begin at low midclavicular line percuss up to find lower border of liver, begin at lung and percuss down to find upper liver border which is 5-7th ics) 6-12 cmSpleen (begin at mid axillary line)Palpation, LIGHT (ask patient to relax muscles) Note any masses, tenderness-Spleen-liver- General Abdomen (4 quadrants)-aortaPalpation, Deep /Note masses, tenderness, organ size and character- Spleen- Liver (ask patient to inhale)- General Abdomen (4 quadrants, 2 hands rolling back and forth)-Rebound tenderness- aorta-Femoral pulses bilaterally and Inguinal lymph nodes (NAVeL)Musculoskeletal: Upper ExtremitiesInspect nails (capillary refill), fingers, palms, forearms, upper arms, shouldersPalpation- (joints, muscle tone, pulses and nodes-Fingers and joints: DIP, PIP, MCP-Wrist (snuff box)-Radial pulse-forearm muscles-Brachial pulse & epitrochlear lymph nodes-Upper arm muscles-Shoulder muscle and joint-Clavicle joints ( acromioclavicular and sternoclaviclar joints)Assess Range of Motion:- Fingers ( E, F, ABd, ADd)-Wrists (E,F, Ulnar flexion and radial flexion)-Elbow (E,F,Supin, Pronat)-Shoulders (ABd, Add, Internal rotat, external rotat)Assess Muscle strength:-fingersAbduction (grasp hand and have pt. spread fingers)Opposition (thumb to middle finger)Grip-Forearms- flexion of wrist against resistance- Upperarms- flex and extend elbow against resistance-Shoulder- Abduct and Adduct against resistanceMusculoskeletal: Lower ExtremitiesInspect toenails(capillary refill), feet, ankles, leg, thighPalpation – for crepitus and temp.-Toes (metatarsal head)-ankles-knee- Lower leg muscle-Upper leg muscles-hipsPalpate pulses-Posterior tibial-dorsalis pedis-pretibial for pitting edema-popliteal pulseAssess ROM-Toes (E,F)-Ankle (DorsiFlex, PlantarFlex, Eversion, Inversion)-Knee (E,F)-Hip (E, F, ABD, ADD, Ext. rotation, Int. rotation)Assess Muscle strength:-Toes flex and extend against resistance-Lower leg Dorsi and plantar flex against resistance-Upper leg flex and extend knee “”-Hip (ask patient to stand) Extend, flex, ABDuct and ADDuctBack: Patient should remain standing and exam is done posteriorlyInspect spine and skin of back.Palpate the spine, ribs of thorax, lumbosacral regionPercuss CVA for tendernessAssess ROM of spine--Extension, Flexion (noting any spinal curving), Lateral bending, and rotation (stabilizing patient’s waist)NeurologicalAssess Cerebellar function (Patient should remain standing)-Gait- walk across room and back normal, on Toes, on Heels, and with one foot in front of the other.-Rhomberg Test- Stand w/ feet together and eyes closed-Pronator drift- stand with arms out and close eyes-Have patient sit back down-Rapid Alternating movement (hands)-Finger-to-nose (eyes open and then closed)-Heel-to-shin (bilateral w/ eyes closed)Assess Sensation & Proprioception-Upper extremities & Lower extremities with light touch (cotton ball), sharp & dull touch, and vibration-Upper & Lower proprioception by moving DIP of fingers and toes with pt’s eyes closedStereognosis- one hand at a time with eyes closedReflexes (bilaterally)-Biceps C5,6= place thumb over slightly flexed tendon and tap thumb.-Brachioradial C5,6= Hold slightly pronated arm with my arm & tap 2 inches above wrist-Triceps C6-8= Hold arm up and above antecubital fossa & strike just above elbow .-Patellar L2-4-Achilles L4-5, S1-2= Keep knee flexed and hold sole of foot & stike at level of malleoli-Plantar reflex/ Babinski sign= stroke lateral foot from heel to ball to medial side. Should see plantar flexion.Breast, Skin, and AxillaeInspect breasts while sitting for skin, nipple changes with arm at sides, pressed against hips and arms overhead.Palpation--Tail of Spence-Axillary lymph nodes – while patient still sitting-breast in a circular & wedge pattern ( shoulder is propped up and hand is over head on side being examined)-nippleMale Genitourinary and rectalInspection (with patient standing) of penis and retract skin if uncircumcised, pubic hair distribution, scrotal skin, and meatal openingPalpation of penile shaft (dorsal & ventral surface),compress glans for meatus, scrotum (lift), testes, vas deferens, cord and feel for herniasInspection of perianal region and rectum -have patient turn and lean forward onto examining table.Rectal Examination- Lubricate gloved hand, place finger at anus until sphincter relaxes, examine rectal wall, Prostate gland & sphincter toneOccult Blood testFemale Genitourinary and rectalHave patient empty bladder and get in lithotomy position.Inspection of mons pubis and hair distribution and texture, labia minora and majora,clitoris,urethral orifice, vaginal introitus.Palpation- Bartholin’s glands by inserting index finger into vagina and Skene’s (periurethral)Speculum Examination-Insert Speculum- used appropriate size, warm instruments and gloves, No lube, explain as you go. 1. Place 2 fingers inside introitus and press down on perneal body. 2. With other handplace closed speculum in at 45 degree angle. 3. Pressure exerted towards posterior wall, remove fingers, and open speculum for view of cervix.-Inspection of Cervix noting position,color, muscous membrane, Cervical os appearance and any discharge.-Pap Smear- Ectocervical specimen (spatula) and Endocervical (brush)-Inspection of Vaginal wall as speculum is withdrawn. For color, inflammation, ulcers, masses, dischargeBimanual Examination to palpate vagina, ovaries, uterus-Palpate cervix-Palpate uterus- place fingers in anterior fornix and other hand push on abdomen, should feel fundus-Palpate ovaries-slide fingers into lateral fornix and abdominal hand push down in RLQ . They maybe slightly tender normally.Rectovaginal examination-Inspect perinanal region and rectum for hemorrhoids, fissures, etc- Intoduce index finger into vagina and middle into rectum.-Examine, rectum, sphincter tone, rectouterine pouch-Occult Blood Test ................
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