6 positions for a Physical Exam
1) Sitting
2) Standing
3) Prone
4) Supine
5) Left Lateral Recumbent (Left side down)
6) Right Lateral Recumbent (Right side down)
4 techniques of examination
1) INSPECTION:
- Asses appearance of Age, Posture, Mobility, Asymmetry, and Color Changes
2) AUSCULTATION:
- Performed with the Stethoscope
- Listen to Lung Heart, GI, and Vascular Sounds
3) PERCUSSION:
- Performed with your hands
- Flatten fingers over Thorax/ Abdomen
- Strike the distal knuckle with 3rd finger to Elicit Sound
- Note the sound different when percussing over a Hollow Organ vs Bone
- Dull Sounding: Fluid
- Flat Sounding: Solid
- Tympanic Sounding: Air
4) PALPITATION:
- Performed with you hands
- Superficial and deep Palpitation
Understand goal of Osteopathic Structural Exam
- integrates information about the Musculoskeletal System even when dealing with non-musculoskeletal compaints
Opthalmoscope
- Used to exam the Fundus, Retina, Posterior Chamber as well as the Pupillary Reflex (Direct and Consensual), and Red Reflex, which is the normal Reflection off of the Retina
- Have patient look over examiner’s Shoulder, place hand on patient’s head
- Hold Ophthalmoscope in RIGHT hand and use RIGHT eye to examine patient’s RIGHT eye (Then left hand and eye to examine the left eye)
- Move light Lateral to Medial until over the Iris then move toward patient
- IDENTIFY PUPILARY REFLEX (DIRECT and CONSENSUAL) and RED REFLEX
- MAKE SURE TO PERFORM BILATERALLY
- DIRECT PUPILLARY LIGHT REFLEX: When light shined in eye, that pupil constricts
- CONSENSUAL PUPILLARY LIGHT REFLEX: When light shined in eye, Pupil of the OTHER EYE also Constricts
Snellen Eye Chart
- Asses Visual ACUITY (20/20 is Normal, 20/40 vision means that the test subject sees at 20 feet what normal person sees at 40 feet)
- Held at about 14 inches from eyes
- Be sure to test both eyes open, then covering one eye at a time
Otoscope
- Gently Grasp auricle. Pull up, out and back
- Insert Approximately 1/4 to 1/2 length of SPECULUM
- Identify Canal and Tympanic Membrane
- Remove Speculum
- Use tongue depressor for Oropharyngeal exam. Ask the patient to say “AHHH” to raise the SOFT PALATE. Identify structure of the Oral Cavity
Tuning Fork
- Air Conduction: lasts longer, hold fork at external auditory Meatus
- Bone Conduction: less than sit conduction, hold handle at Occipital Condyle behind ear
- Vibratory sense: place handle on Patella and compare Left and Right for duration
Reflex Hammer
- Identify Patellar Tendon
- Strike patellar tendons BILATERALLY and COMPARE
- Other Deep Tendon Reflexes Include: Achilles, Bicep, Tricep, Brachioradialis
Stethoscope
- DIAPHRAGM: Larger circle,for HIGHER Frequency sounds such as breath sounds and heart sounds
- BELL: Smaller circle, for LOWER Frequency sounds such as BRUITS
Blood Pressure Cuff/ Sphygmomanometer
- There are multiple sizes of Blood Pressure cuffs, you should choose a cuff in which the WIDTH of the BLADDER is about 40% of the upper arm CIRCUMFERENCE, Length about 80%
- Appropriate body position means the patient’s arm is between you and the patient
- The arrow of the cuff should be align with the BRACHIAL ARTERY of the patient
- Hold the Patient’s arm at the LEVEL of their heart
- Ask the patient to relax
- Place the Diaphragm of the Stethoscope JUST BELOW the Cuff over the BRACHIAL ARTERY
- Inflate the cuff
- Listen for the 1st KOROTKOFF SOUNDS (Systolic Number) and the LAST KOROTKOFF Sounds (Diastolic Number)
- Deflate cuff
Universal Precautions
- Protect the patient and provider from spread of Infectious Disease
- Gloves used in presence of Blood or Bodily fluids
- Hand washing BEFORE and AFTER wearing gloves
Proper Glove Use
- Wash and Dry hands
- Remove Glove and Hold it at Open End
- Pull cuff OVER HAND
- Dispose in proper container
SOAP NOTE
S: Subjective
- What you learn by taking the patients history
O: Objective
- Exam including structural findings, Laboratory and radiology data
A: Assessment
- What you think is going on with the patient
P: Plan
- What you and the patient agree to do about the problem, including the OMT performed
Subjective
- Chief Complaint
- HPI “This (age/race/gender)” OLD CARTS
- Past medical History (Other active problems)
- Past Surgical History (operations)
- Medications (Prescription, over the counter, vitamins)
- Allergies (Medication allergies, and food or environment)
- Social history (Tobacco, Alcohol, Illicit drugs, Occupation, Marital Status, Sexual history)
- Family History (Parents, Siblings, Children)
- Review of Systems
Objective
- Exam Findings: Full vs Focused
- Laboratory Data
- Radiology Data
1) Vital Sings: BP, Pulse, respiration Rate, and Temp
2) Heart:
3) Lungs:
4) Osteopathic Structural Exam (OSE)
Assessment
- An assessment is NOT ALWAYS a Diagnossis
- Assessment: Basic Description of the Problem
- Can be a restatement of the Chief Complaint
- Diagnosis:
- The art or act of identifying a disease from its Signs and Symptoms
- **Assessment #1 should ALAYS be a restatement of the Chief Complaint followed by three differential diagnoses, most likely to least likely
- Ex: Knee Pain—> Derangement, Osteoarthritis, Gout
- *Second and Third Assessment Possibilities:
- Other active problems (hypertension, Diabetes)
- Family History (cancer, diabetes)
- Lifestyle issues (obesity, Tobaccoism, Alcohol use)
Differential Diagnosis
- The process of weighing the probability of one disease versus that of other diseases possibly accounting for a patient’s illness
Plan
- What the doctor PLANS to do about the problems identified in the assessment
History and Physical
- Done upon Hospital Admission
- Required once a year for all nursing home residents
- Some consultants make their consult notes a lot like H&Ps, but they concentrate on their areas of expertise
- Same information you gathered from your SOAP note but much more complete and broken into Paragraph forms
- Same abbreviations as elsewhere in medical terminology
