PHYSICAL AND NEUROLOGICAL EXAMINATION Prof. Ridulme PHYSICAL ASSESSMENT GENERAL CONCEPTS 1.

Approach the client calmly and confidently 2. Provide privacy 3. Make sure that all needed instruments are available before starting the PE 4. Be systematic and organized when assessing the client. (Inspection, Palpation, Percussion, Auscultation) 5. If a client is seriously ill, assess the systems of the body that are more at risk. 6. Perform painful procedures at the end of the examination. General Survey 1. State of awareness and level of consciousness 2. Signs of distress 3. Stature and habitus 4. Weight 5. Dress, grooming and personal hygiene 6. Odors of body and breath 7. Facial expression 8. Gait and posture 9. Speech VITAL SIGNS: BP, RR, PR, Temp, Pain PHYSICAL CHANGES OF THE SKIN AMONG THE ELDERLY

1. 2. 3. 4. 5. 6.

Warty lesions (seborrheic keratosis) with irregularly shaped borders and scaly surface often occur on the face, shoulders and trunk. Flat tan to brown-colored macules, referred to as senile lentigines or melanotic freckles. Vitiligo tends to increase with age and thought to result from an autoimmune response. Cutaneous tags (acrochordons) are most commonly seen in the neck and axillary regions. Actinic keratoses: dry, scaly and rough-skin colored to reddish-brown bump on the skin, are often sensitive or touchy, may appear often on the face, ears, backs of the hands, and arms. Telangiectasias: visible bright red, fine dilated blood vessels commonly occurs a result of the thinning of the dermis and the loss of support for the blood vessels walls.

SKULL, SCALP AND HAIR

1. 2. 3.
4.

Hair: Quantity, pattern, distribution of loss Scalp: Scales, lumps, lesions Skull: Size, fontanelles, lumps, tenderness Face

EYES 1. position and alignment of the eyes 2. Eyebrows 3. Eyelids 4. Conjunctiva and sclera 5. Pupils 6. Extraocular muscles 7. Visual Acuity,Visual Field SKIN ANDAPPENDAGES 1. color 2. moisture 3. temp 4. texture 5. mobility and turgor 6. lesions a. Primary b. Secondary Elderly: Physical Changes of the Eyes and Vision 1. Accommodation to far objects often improves, but accommodation to near objects decreases. 2. Color vision declines; they are less able to perceive purple colors and to discriminate pastel colors. 3. The cornea tends to cloud with age. 4. The iris may appear pale with brown discolorations. 5. Pupils can appear smaller in size, unequal and irregular in shape. EARS: WEBER TEST

1. 2.

If hearing loss is detected one should: Test for lateralization. Weber Test: Patients with normal hearing will hear the sound in mid-line or equally on both sides.

EARS: RINNES TEST

1. 2. 3.
4.

Compare air and bone conduction: Rinne test Place a vibrating tuning fork on the mastoid bone behind the ear in the grove firmly. Once the patient claims not to hear any sound quickly test whether he can hear the sound when placed close to ear canal. Normally the sound is heard longer through air than through bone conduction. Also, caution patient to listen to the sound and not the vibration.

5.

INTERPRETATION OF EAR TESTS

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1. 2.

Rinnes and Weber tests help to distinguish between nerve deafness and conduction problems due to middle ear disease. Nerve deafness: a. On Weber's test sound lateralizes to good ear. b. Air conduction lasts longer than bone conduction (Aging, drugs, tumors). Conduction deafness: a. Weber test lateralizes to diseased ear. b. Bone conduction lasts longer than air conduction (Otitis media, otosclerosis).

2. 3. 4.

Shape and symmetry of the chest Spinal alignment for deformities Retraction of interspaces

Types of breathing according to rate and rhythm 1. Eupnea

3.

2.

Hyperventilation

Elderly: Physical Changes of the Ears and Hearing 1. Tympanic membrane is more transluscent and less flexible. 2. Earwax is drier. 3. The pinna increases in both width and length and earlobe elongates. 4. Sensorineural hearing loss occurs.

3.

Cheyne-Stokes Respiration

5.

Presbycusis occurs in all frequencies, although the first symptom is the loss of high-frequency sounds: the f, s, sh and ph sounds.

4.

Ataxic/Biots Breathing

NOSE AND PRANASAL SINUSES 1. Nasal septum 2. Nasal mucosa 3. Nasal turbinates

4.

Sinuses: Frontal, ethmoid and maxillary

SPINAL CURVATURES 1. kyphoscoliosis 2. kyphosis 3. gibbus SHAPE OF THORAX 1. pigeon 2. barrel 3. funnel POSTERIOR THORAX: Palpation 1. Identify tender areas 2. Masses or sinus tracts 3. Chest excursion 4. Tactile fremitus

Elderly: Physical Changes of the Nose and Sense of Smell 1. Sense of smell markedly diminishes because of a decrease in the number of olfactory nerve fibers and atrophy of the remaining fibers. Older persons are less able to identify and discriminate odors. 2. Nosebleeds may result from hypertensive disease of other arterial vessel changes. MOUTH 1. Lips 2. Buccal mucosa 3. Gums and teeth 4. Roof of the mouth 5. Tongue 6. Pharynx Elderly: Physical Changes of the Mouth and Sense of Taste 1. The oral mucosa may be drier because of decreased salivary gland activity. Some receding of the gums, giving an appearance of increased toothiness. 2. Brownish pigmentation to the gums, especially in black persons. 3. Taste sensations diminish. Sweet and salty tastes are lost first.

Increased pneumonia, tumor Decreased pleural effusion

POSTERIOR THORAX: Percussion 1. Normal- resonance 2. Dull (pneumonia, tumor, etc) 3. Hyperresonance - COPD POSTERIOR THORAX: Auscultation

4.
5.

Caviar spots: tiny purple or bluish black swollen areas (varicosities) under the tongue. Gag reflex may be slightly sluggish

NECK 1. Neck 2. Lymph nodes 3. Trachea 4. Thyroid LANDMARKS OF THE THORAX 1. sternal angle of Louie 2. anterior axillary line 3. midclavicular line POSTERIOR THORAX 1. Observe rate, rhythm and regularity of breathing
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NORMAL BREATH SOUNDS Vesicular soft, low pitch Bronchovesicular medium pitch Bronchial loud, high pitch ABNORMAL BREATH SOUNDS Crackles dependent lobes Rhonchi trachea,

lung periphery larger airways blowing trachea

random, sudden reinflation of alveoli, fluids fluid, mucus

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Wheezes Pleural friction rub

bronchi all lung fields lateral lung fields

severely narrowed bronchus inflamed pleura

Other abnormal breath sounds 1. Egophony 2. Bronchophony 3. Whispered Pectoriloquy Elderly: Physical Changes of Thorax and Breathing Patterns 1. Kyphosis 2. Anteroposterior diameter of the chest widens 3. Breathing rate and rhythm are unchanged at rest 4. Inspiratory muscles become less powerful, and inspiration reserve volume decreases. 5. Expiration may require the use of accessory muscles 6. Deflation of the lung is incomplete. 7. Small airways lose their cartilaginous support and elastic recoil 8. Elastic tissue of the alveoli loses its stretchability and changes to fibrous tissue. Exertional capacity also decreases.

Chronic Arterial Insufficiency Pain Intermittent claudication Pulse Decreased Color Pale Temperature Cool Edema Absent or mild Skin Changes Thin, shiny atrophic skin, hairloss, thickened nails Ulceration Toes/points of trauma Gangrene May develop

9.

Chronic Venous Insufficiency Pain None to aching pain on dependency Pulse Normal Color Normal to cyanotic; petechiae or brown pigmentation Temperature Warm Edema Present Skin Changes Dermatitis skin pigmentation Ulceration Medial side of ankle Gangrene Does not develop BREAST Inspect: 1. Asymmetry and size 2. Color, thickening, dimpling 3. Lesions, discharges Palpate: 1. Masses 2. Lymph nodes 3. tenderness

Cilia in the airways decrease in number and are less effective in removing mucus greater risk for pulmonary infections.

Cardiac inspection, palpation and percussion 1. Jugular venous pressure (normal-3-4 cms.) 2. Thrills

a. b.
3. PMI Test for JVP

Apical left side lying pulmonic/aortic sitting leaning forward

Cardiac Auscultation 1. S1 - mitral and tricuspid closure 2. S2 - aortic and pulmonic closure 3. S3, S4 - may be normal in children and athletes 4. S4 - considered normal in older adults S1>S2 apex S2>S1 base Murmurs Regularity of heart beat Peripheral Circulation Inspect: 1. Color 2. Edema 3. Stasis ulcers/lesions 4. Varicosities 5. Hair/nail changes Palpate: 1. Temperature 2. Edema 3. Tenderness 4. Symmetry of pulses Peripheral Pulses 1. carotid 2. radial 3. brachial 4. femoral 5. popliteal 6. posterior tibialis 7. dorsalis pedis TESTING FOR EDEMA PERIPHERAL CIRCULATION
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ABDOMEN: INSPECTION

1.
2. 3. 4. 5. 6.

Contour of abdomen Inspect skin Umbilicus Masses Peristalsis Pulsations

ABDOMEN: AUSCULTATION 1. Bowel motility (5-34/minute) 2. bruits ABDOMEN: PERCUSSION 1. Percuss all quadrants of the abdomen. 2. Percuss for liver dullness (4-8 cm midsternal line; 6-12 RMCL line) 3. Percuss for splenic dullness ABDOMEN: PALPATION 1. Masses 2. Tenderness

3.

Palpate the liver palpable 4 cm below right subcostal area

4.
5.

Palpate the spleen enlarged if palpable 2cms below L subcostal margin Aorta

ABDOMEN: PALPATION Ascites Fluid wave Shifting dullness Special Maneuvers Rovsings sign Psoas Sign Obturators sign Murphys sign Elderly: Physical Changes in the GI Tract 1. The side effects of drugs are often manifested in the gastrointestinal tract, (eg, nausea, vomiting, and diarrhea) 2. Gastrointestinal pain needs to be differentiated from cardiac pain. 3. Difficulty swallowing is a common complaint of older adults. 4. Older individuals have increased esophageal spasms and less efficient action of the lower esophageal sphincter. GENITALIA Inspect: 1. Size 2. Lesions 3. Discharges 4. Swelling and signs of inflammation 5. Position of urethral meatus Palpate: 1. Masses 2. Tenderness 3. lymphadenopathy MUSCULOSKELETAL SYSTEM Inspect 1. Structural deformities 2. symmetry 3. Nodes 4. Swelling/signs of inflammation Palpate 1. Crepitus 2. Tenderness Test 1. Muscle strength/ROM *Osteoarthritis vs Rheumatoid Arthritis QUESTION AND ANSWER 1. You assess the pulse of a 1-year-old infant. The normal range of pulse for this infant is: A. 60-80 bpm B. 80-110 bpm C. 80-140 bpm D. 100-200 bpm Answer: C 2. Before you take Mr. Sys VS, you ask him what medications he is taking. He responds by saying that he is taking digitalis once a day in the morning. Which of the following VS changes would you expect to find when assessing his vital signs? A. Increased BP B. Decreased PR C. Decreased RR D. Increased temperature Answer: B

3. You are teaching Mr. C to monitor his fluid retention by weighing himself everyday. Which of the following instructions would be appropriate during this teaching episode? A. Weigh yourself at the same time each day wearing the same type of clothing. B. Make sure you eat first before you weigh yourself C. The time of day is not important, however, make sure you wear the same type of clothing each day Answer: A 4. Which of the following routes of temperature measurements is least accurate? A. Axillary B. Oral C. Tympanic D. Rectal Answer: A 5. Which of the following techniques is appropriate to use when measuring an adult temperature using a tympanic thermometer? Before inserting the probe, A. Pull the pinna upward and back B. Pull the pinna down and back C. Pull the pinna down and forward D. Pull the pinna upward and forward Answer: A 6. Which of the following methods is the proper technique to determine if a client is experiencing a pulse deficit? A. Simultaneously have one person count the apical pulse and another person count the radial pulse B. Measure the apical pulse, wait 20-30 minutes, and re-measure the apical pulse rate C. Measure the radial pulse in each arm and subtract the difference. D. Measure the distal pulse with a pulse oximeter and compare this to the apical heart rate. Answer: A 7. The proper placement of the stethoscope diaphragm when auscultating an apical pulse is at the 5th ICS on the left side of the anterior chest wall. A. True B. False Answer: A 8. When measuring the BP, the BP cuff should be inflated to 80 mmHg above the clients baseline diastolic blood pressure prior to deflation: A. True B. False Answer: B 9. When a client has 20/40 vision, it means that the client can read at a distance of 20 ft what a person with normal vision can read at a distance of 40 feet. A. True B. False Answer: A 10. As you review a clients record, you read the notation PERLA. Which of the following organs does this notation pertain to? A. Eyes B. Ears C. Mouth D. Lungs Answer: A 11. In the report you hear that your patient has hypoactive bowel sounds. Which of the following is the appropriate length of time you would listen to accurately assess bowel sound? A. 15 sec in each quadrant
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N124 - PHYSICAL AND NEURO EXAMINATION

B. 30 sec in each quadrant C. 45 sec in each quadrant D. 1 minute in each quadrant Answer: D 12. What is the minimum length of time to wait before measuring the oral temp of a client who has taken a drink of ice water? A. No wait is necessary B. 5 minutes C. 15 minutes D. 45 minutes Answer: C

2. 3. 4. 5. 6. 7. 8.

Cranial Nerves Sensory Motor Strength DTR Cerebellars Meninges Autonomics

GLASGOW COMA SCALE

MATCHING TYPE B Eupnea D Bradypnea A Hypoventilatio F n C Tachypnea G Hyperventilati on E Diaphtagmatic H breathing Costal breathing dyspnea

a. respirations b. c. d. e. f. g. h.

Shallow Easy respirations of a normal rate Deep rapid respirations A respiratory rate of 10 or lower Thoracic breathing RR of 24 or above Breathing from the abdomen Labored or forceful breathing using accessory muscles in the chest and neck Heard over predominantly the base of the lungs as a fine, high-pitched popping sound of short duration Highpitched musical sounds that can be heard over all the lung fields A crowing sound heard predominantly on inspiration Accumulati on of fluid in the interstitial and air spaces of the lung Accumulati on of pus in the pleural cavity Dilation and destruction of the bronchial walls Localized dilation of the aortic wall Collapse of lung tissue and decreased gas exchange Heard predominantly on expiration over the trachea and bronchi as alow-pitched musical sound. Heard as a continuous creaking, grating sound over the anterior chest wall.

G H F E D C J B I A

Aortic aneurysm Atelectasis Bronchiectasi s Empyema Pleural effusion Stridor Pleural friction rub Wheezes Rhonchi Crackles

a.

b. c. d. e. f. g. h. i.

LEVELS OF CONSCIOUSNESS NORMAL -alert, awake, and aware of both self and CONSCIOUSNESS the environment, and response to external stimuli DROWSINESS -not fully alert to their environment; consciousness is clouded and attentiveness impaired; they think more slowly and less clearly; spontaneous movement is diminished; responsive but tend to fall asleep afterward STUPOR -marked reduction in mental and physical activity; pain is needed to elicit responses; these responses are markedly reduced, slowed, inadequate, or even absent COMA -completely unconscious and cannot be aroused even by painful stimuli; no voluntary movements DELIRIUM -acute confused state in which consciousness is clouded; not fully aware of all aspects Neurologic Exam: Mental Status 1. Appearance 2. Behavior 3. Affect and Mood 4. Orientation 5. Memory 6. Speech/ Sensorium/ Attention 7. Insight to illness 8. Judgment 9. Intellect 10. Thought Process 11. Thought Content 12. Perceptual disturbances Neurologic Exam: Cranial Nerves CN I Sensory: Smell (Olfactory) CN II Sensory: Vision (Optic) With eyes closed, identify odor Visual acuity: Snellen Chart Visual fields: Confrontation
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j.

NEUROLOGIC EXAM 1. Mental Status Examination

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CN III, IV, VI (Oculomotor, Trochlear, Abducens) CN III (Oculomotor)

Motor: Eye movement Motor: Upper eyelid elevation Pupillary constriction Sensory: Facial sensation Motor: muscle of mastication Sensory: taste on anterior 2/3 of teeth Motor: facial expression Sensory: hearing and balance Sensory: taste on posterior 1/3 of tongue, sensation to pharynx, soft palate Motor: Swallowing Sensory: sensation behind the ear and thoracic/abdomi nal viscera Motor: Swallowing and phonation Motor: Sternocleidoma stoid and trapezius muscles Motor: tongue

Color vision Assess eye movement

14. Will produce crossed-eye appearance when damaged - CN

VI

Check for ptosis Check for direct and consensual light reflexes** (** also checks CN II) Check for corneal reflex** (**Also checks CN VII) Check sensation of face Ask client to clench teeth Check for taste sensation tip of tongue Ask client to wrinkle forehead, close eyes against resistance, puff out cheek, show teeth Listen to watch ticking Check for balance while walking or standing Check for taste sensation post. 1/3 of tongue Check for gag and swallowing reflex** Check for equal palatal elevation** Check for swallow and gag reflex** Check for equal palatal elevation** (**CN IX and X checked together)

CN V (Trigeminal)

15. Turns the head - CN XI 16. Sticks the tongue out - CN XII 17. Decreases heart rate - CN X 18. Must be tested before feeding - CN IX and CN X 19. Blows a candle - CN VII 20. Gives dyspepsia - CN X
Sensory System: Two Point Discrimination Technique 1. Test patient's ability to distinguish 2 points 2. Test on the pulp of the digits at decreasing distance Interpretation 1. Normal 2 point discrimination: 4-5 mm

CN VII (Facial)

2.

Abnormal 2 point discrimination suggests Neuropathy

CN VIII (Acoustic or vestibulecochlear) CN IX (Glossopharyngeal)

Sensory System: 1. Two Point Discrimination 2. Sharp and dull discrimination 3. Proprioception (finger up or down?) 4. Stereognosia 5. Graphesthesia Neurologic Exam: Motor System Assess Muscle tone 1. Normal tone, Flaccid (decreased), cogwheel, spastic, rigid (increased) Assess Muscle strength 1. Grades 0 : no muscular contraction graded 1: a barely detectable flicker or trace of contraction 2: active movement of the body part with gravity eliminated 3: active movement against gravity 4: active movement against gravity and some resistance 5: active movement against full resistance without evident fatigue (normal) 2. Expressed as a fraction (e.g. 2/5) Neurologic Exam: Reflexes Deep Tendon Reflexes Biceps Triceps Brachioradialis Patella (knee) Ankle Superficial Reflexes Clonus Plantar Reflex Abnormal: (+) Babinski Neurologic Exam: Grading of Reflexes: 4+ hyperactive reflexes with sustained clonus 3 + hyperactive reflexes 2+ normal reflexes 1+ hypoactive reflexes Neurologic Exam: Cerebellars The cerebellum is responsible for balance and coordination. Rombergs Test - proprioception and cerebellar function (balance) Cerebellar function: Tests of coordination 1. finger-to-nose (FTNT) test 2. Heel to shin test

CN X (Vagus)

CN XI (Spinal accessory) CN XII (Hypoglossal)

Have the client shrug the shoulders and turn the head to each side against resistance Have client move tongue and check for deviation, fasciculation

Test time: What cranial nerve/s?

1. 2.

Shrugs the shoulders - CN XI Assess pupillary reaction to light - CN II (sensory) and III (motor)

3. Gives Corneal reflex - CN V (sensory) and VII (motor) 4. Chews - CN V 5. Gives ptosis if damaged - CN III 6. Gives the gag - CN IX and X 7. Tastes at the ant.2/3 tongue - CN VII 8. Affected by glaucoma - CN II 9. Moves the eye - CN III, IV and VI 10. Gives pain with Tic doloreaux - CN V 11. Will prevent eyes from closing in stroke - CN VII 12. Gives vertigo - CN VIII 13. Tastes at the posterior 1/3 of tongue - CN IX
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3.
4.

Tandem walking also test of gait Rapid alternating movement

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N124 - PHYSICAL AND NEURO EXAMINATION

If uncoordinated, (+) for dysdiadochokinesia

2. 3.

Neurologic Exam: Meningeal signs 1. Nuchal Rigidity 2. Brudzinskis Sign 3. Kernigs Sign Elderly: Changes in the Neurologic System 1. Coordination changes in older clients, including a reduced speed of fine finger movements. Standing balance remains intact, and Rombergs test remain negative.

May show loss of the Achilles reflex, and the plantar reflex may be difficult to elicit. Normally, older clients have unaltered perception of light touch and superficial pain, decreased perception of deep pain & decreased perception of temperature stimuli.

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Prof. Ridulme