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12/08/08
Dr G
Document and share your findings
- Quantifiable objective information obtained from patient
- Vital signs
- Head to toe survey
Exam techniques
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Scene survey
- Your safety
- Look at bystanders, read faces, etc get clues
- Sick or not sick
- Signs of significant distress
- Other aspects worth noting; dress, hygiene, expression, size, posture, odors, overall state of health
- Skin; quickest and most reliable initial evaluation tool, color, moisture, temp
- Mental status, AVPU
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Inspection
- Look at the patient
- General or specific area
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Palpation
- Ask patient to point out area of pain, where it started, etc
- Touching or the purpose of obtaining information
- Tenderness, deformity, crepitance, masses, pulse quality, organ enlargement
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Percussion
- Listen for level of organ (hollow vs. solid)
- i.e. lungs , pleural effusion will sound very dull
- bowel obstruction, can sound very typaninic (like a drum)
- normal lungs sounds
- bone sounds
- muscle sounds
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Auscultation
- High pitched and low pitched sounds
- Bowel sounds, listen for normal peristaltic sounds
- Paralytic illus – bowel not working properly (look up)
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Vital
signs
- Need baseline and changes
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Pulse rate rhythm and quality (brady – could be head trauma, tachy, fever, fluid loss, etc. ) (thyroidism – hypo vs hyper , slows body vs quickens vitals)is pulse present at extremity? Check diabetics for distal pulses
- Check pulse vs. apical heart rate
- Basic way evaluate perfusion and CO
- Carotid = 70 -BP
- Radial = 90-100 BP
- Maximum Sustainable Heart Rate – 220 – Age
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Respiratory rate rhythm and quality (tachycardia and tachypnea – until proven otherwise don’t miss pulmonary embolism (smokers, travelers) any head issues can affect resp rate, cva, head injury, etc. Also secondary to pulmonary problems, asthma, pneumonia, etc
- Try to distract patient
- Look at chest, look for abdominal breathing, accessory muscle use, nasal flaring
- Quality of efforts
- Cheyne-Stokes – real fast and deep and then apnea and repeat
- Blood pressure –(orthostatic changes – can be due to GI bleed or other internal bleed, dehydration, fluid loss, some meds) (Unequal BP or pulses could be sign of aortic or abdominal aneurism)use right size cuffs – will affect reading
- Temp – febrile? OD (cocaine will raise temp) hyperthyroidism, infection – Lower – hypothyroidism, drowning, hypothermia, sepsis
- Spo2 – don’t trust the machine; always look at your patient! Weather, peripheral circulation, etc,
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Skin, Hair & Nails
- Largest organ system
- Regulates temp of body
- Transmits info about the environment to the brain
- Exam by inspection and palpation
- Color, moisture, temp, texture, turgor, significant lesions, mottling, crepitus
- Vasodilation – Blushing, body trying to let heat escape,
- Hair – inspect and palp, quantity, texture, distribution, recent hair loss, thinning,
- Nails – Color, shape, texture, pitting, cracked, etc.
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HEENT
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Head: brain, eyes, sensory organs, upper airway
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Cranium
- Foramen magnum
- Occiput
- Temporal areas
- Layer of muscle covers skull
- Scalp
- Meninges
- Dura matter
- Arachnoid and pia matter
- CSF
- Face – DCAP-BTLS (if orbital bones are broken could affect eye movement by entrapment of ocular muscles)
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Eyes: both motor and sensory functions, (20% of population have unequal pupils)
- Hyphema – blood across middle of eye – transport sitting up – serious injury
- PEARL
- Pain, loss of vision, diplopia, photophobia (seen in migraines, meningitis), burring, discharge, contact lens
- Lids, Lashes tear ducts, foreign bodies, clarity, conjunctivae, extra ocular range of motion,
- Ears: Check for changes in hearing, balance –
look for Blood , fluid, CSF
- Nose: sensory organ, important role in breathing – look anteriorly and inferiorly – asymmetry, deformity, wounds, foreign bodies, discharge, etc
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Throat: respiratory and digestive systems,
- inspect back of oropharynx
- overall hydration status
- foreign body or aspiration
- begin with lips
- (Adult thrush – could be HIV)
- Gums – pink. Tongue size color and moisture, uvula for swelling
- External anatomy, posterior – tracheal deviation, etc, posterior.
- If trauma , maintain C-spine
- JVD – sign of increased venous pressure – seen in CHF
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C-Spine
- Spinal cord exits head
- Spinal nerves emanate and innervate the rest of the body
- Spine supported by large mass of muscle
- Evaluation – MOI, Pain, AMS, inspect and palpate, midline posterior tenderness – most concerning
- Pain tenderness or tingling – stop and protect – transport immediately
- Range of motion – first passively then actively – find something; stop
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Chest
- Base of neck to diaphragm (costal arch)
- Inspect for DCAP-BTLS, paradoxical motion, symmetry
- Expose, inspect percuss, palpate and auscultate
- Breath sounds, equal and bilateral, stridor, rubs, diminished or absent
- Heart, lungs….
- Heart sounds (bruit, mumurs)
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Abdomen
- Divided into quadrants
- Umbilicus is center ref point
- Diaphragm at top, pelvis at bottom
- Abdominal wall
- Peritoneum
- Intraperitoneal organs
- Extraperitoneal organs
- Abdominal pain is very common – History relevant to incident is critical – OPQSRT, SAMPLE – make patent comfortable
- Inspect, palpate percuss, auscultate –
- Guarding
- Aneurisms, hernias – common
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Female Genitalia
- Suspect ectopic pregnancy – can kill patient
- Discreet, partner of same sex as patient
- Limit to inspection only
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Male genitalia
- Viagra – extended erections
- Infections
- Testicular torsion – especially minors, very severe emergency
- Discharge, swelling, lesions, inflammation
- Priapism
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Anus
- Inspection – hemorrhoids, foreign objects etc
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Musculoskeletal
- DCAP-BTLS, pulses, temp, perfusion, shortening, rotation,
- Structure and function, range of motion, PMS, asymmetry, atrophy
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- Pain
- Pulselessness
- Pallor
- Paresthesias/Paralysis
- Polar sensation (coldness)
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Neuro exam
- Not needed in every case – cases specific, mental status, PMS, reflexes
- Initial posture, body position, body motions
- Strength, ROM, abduction, adduction flexion
- Sensation , relative to where
- Deep tendon reflexes
- AMS –acute or chronic, delirium, dementia
- Global changes – intracranial, local changes – spinal injury
