Physical Assessment

Question 1

Head + Neck Assessment (9)

Answer 1

1. Inspect head position and facial features to look for symmetry.
2. Assess eyes (position, color, conjunctiva condition), movement
3. Pupils for size, shape, and equality (normal are round, equal in size/shape, consensual response to light)
4. Test pupillary reflexes - dim light, penlight from side of patient face and direct light on pupil, observe response noting briskness and quality of reflex
5. Assess ears
6. Assess nose
7. Assess mouth
8. Assess/palpate the neck
9. Assess lymph nodes

Question 2

Thorax and Lung Assessment - Crackles

Answer 2

Most common in dependent lobes, right and left lung bases; caused by random, sudden reinflation of alveoli groups; also related to increase in fluid in small airways. Sound like fine, short, interrupted crackling sounds heard during end of inspiration, expiration, or both. May or may not change with coughing. Medium crackles = lower, wet sounds heard during middle of inspiration, not cleared with coughing; coarse crackles, loud bubbly sounds heard during inspiration, not cleared with coughing

Question 3

Lung Assessment - Rhonchi (sonorous wheeze)

Answer 3

Heard primarily over trachea and bronchi; if loud enough. can be heard over most lung fields

Caused by fluid or mucus in larger airways, causing muscular spasm/turbulence

Loud, low pitched, continuous; heard more during expiration, sometimes cleared by coughing; sounds like blowing air through fluid with a straw

Question 4

Lung Assessment - Wheeze (sibilant wheeze)

Answer 4

Heard all over lung fields but more distinct over posterior lung fields

High velocity airflow through severely narrowed or obstructed bronchus (asthma)

High pitched, musical sounds like a squeak, heard continuously during inspiration or expiration, usually louder on expiration, not cleared during coughing

Question 5

Lung Assessment.- Pleural Friction Rub

Answer 5

Heard over anterior lateral lung field (if patient is sitting upright)

Caused by inflamed pleura, parietal Plura rubbing against visceral pleura

Grating quality heard best during inspiration, doesn’t clear during coughing, heard loudest over lower lateral anterior surface

Question 6

Thorax Assessment

Answer 6

Stand behind patient and inspect for size/symmetry. Note deformities, position of spine, slope of ribs, retraction of intercostal spaces during inspiration and bulging during expiration. Symmetrical expansion during inspiration.

Palpate to find any masses, unusual movement, tenderness

Question 7

Auscultation of Breath Sounds - Normal Bronchial Breath Sounds

Answer 7

Loud and high pitched; hollow quality, expiration lasts longer than inspiration. Best heard over trachea

Question 8

Auscultation of Breath Sounds - Normal Bronchovesicular Breath Sounds

Answer 8

Medium pitched and blowing sounds of medium intensity; inspiratory phase equal to expiratory phase. Best heard posteriorly between scapulae and anteriorly over bronchioles lateral to sternum at first and second intercostal spaces

Question 9

Auscultation of Breath Sounds - Normal Vesicular Lung Sounds

Answer 9

Soft, breezy, low pitched; inspiratory phase 3 times longer than expiratory phase. Best heard over periphery of lung (except over scapula)

Question 10

Cardio Assessment - Auscultate Heart Sounds

Answer 10

Patient sits up and leans slightly forward, then lie supine, then end exam with patient in left lateral recumbent position. Patient doesn’t speak, breathes comfortably. Begin with diagram of stethoscope, alternate with bell

Begin at apex or PMI, move systematically to aortic area, pulmonic area, Erb point, tricuspid area, mitral area.

Listen for S2 at each site, loudest at aortic area

If heart rate is irregular, compare apical and radial pulses; difference in pulse rates is the pulse deficit

Question 11

Cardio Abnormality - AFib (atrial fibrillation)

Answer 11

Rapid, random contractions of atria cause irregular ventricular beats over 100 BPM and atrial beats at 200-350 BPM

Question 12

Sinus Artythmia

Answer 12

Pulse rate changes during respiration, increasing at peak of inspiration and decreasing during expiration

Question 13

Sinus Bradycardia

Answer 13

Pulse rhythm is regular, but rate is under 60 BPM

Question 14

Sinus Tachycardia

Answer 14

Pulse rythmicités is regular, but rate is over 100 BPM

Question 15

Premature Ventricular Contraction

Answer 15

Premature beat occurs before regulatory expected heart contraction; underlying rhythm can be any rate

Question 16

Signs of venous insufficiency

Answer 16

Venous

Pain (aching, increases in evening and with dependent position)

No paresthesia

Temp is normal to touch

Color is normal or cyanotic

Pulses present

Brown pigmentation around ankles

Shallow ulcers around ankles, edema apparent

Question 17

Signs of atrial insufficiency

Answer 17

Pain - burning, throbbing, cramping, increases with exercise

Numbness, tingling, decreases sensation (most common in foot and toes)

Temp is cool to touch

Color pis pale

Capillary refill over 2 seconds

Pulses decreased or absent

Skin is thin and shiny, decreased hair growth, thickened nails

Deep ulcerations, well defined at site of trauma or tips of toes

Question 18

What is the edema scale?

Answer 18

2 mm = 1+
4 mm = 2+
6 mm = 3+
8 mm = 4+

Question 19

Strength of pulse rating scale

Answer 19

0 - absent, not palpable
1+ - diminished, pulse barely palpable, weak and thready, easy to obliterate
2+ - normal, easy to palpate
3+ - full, easy to palpate, increases
4+ - strong, bounding, cannot be obliterated

Question 20

What causes distended abdomen?

Answer 20

9Fs - fat, flatus, feces, fluids, fibroid, full bladder, false pregnancy, fatal tumor, fetus. If gas, flanks don’t bulge. They urge with fluid. Tumor may cause more unilateral bulging or distention, pregnancy causes symmetrical bulge in lower abdomen.

Question 21

Listening to bowel sounds with NG or NI tube

Answer 21

Make sure to turn off suction temporarily if it’s connected to suction to check bowel sounds

Question 22

Listening to abdomen

Answer 22

Listen to each quadrant until you can hear the normal gurgling/bubbling. Describe as normal, hyperactive, hypoactive, absent. Listen 5 minutes over each quadrant before deciding they’re absent.

Question 23

Components of musculoskeletal system assessment

Answer 23

Generally observe
Hand grasp strength
Strength of lower arms and legs - patient resists as you apply force, maintain pressure until told to stop. Note symmetrical muscle groups and compare left and right weakness
Observe body alignments for sitting, supine, prone, or standing
Inspect gait

Question 24

Neuro Assessment - Patient Orientation Questions

Answer 24

Name, location, day of week and year, note behavior and appearance

Question 25

Cranial Nerves I (olfactory), II (optic) and VII (auditory) are assessed during head and neck exam

Question 26

CN III (oculomotor), IV (trochlear) and VI (abducens) assessment

Answer 26

Assess extra ocular muscles (EOMs). Ask patient to log straight ahead without moving head and follow movement of finger through six cardinal positions of gaze; measure pupil reaction to light reflex and accommodation using penlight

Question 27

CN V (trigeminal)

Answer 27

Apply light sensation with cotton ball to symmetrical areas of face

Question 28

CN VII (facial)

Answer 28

Note facial symmetry, have patient frown, smile, puff out cheeks, raise eyebrows

Question 29

CNs IX (glossopharyngeal) and X (vagus)

Answer 29

Have patient speak and swallow. Ask them to say AH while you use tongue blade and penlight, check for midline uvula and symmetrical rise of uvula and soft palate. Use tongue blade and place on posterior tongue to elicit gag reflex

Question 30

CN XII (hypoglossal)

Answer 30

Inspect tongue for symmetry, tremors, and movement towards nose and chin

Question 31

CNs XI (spinal accessory)

Answer 31

Patient shrugs shoulders against resistance, then have patient turn head towards each side against resistance

Question 32

Assessing extremities for sensation

Answer 32

Patient’s eyes are closed. Patient discerns between sharp or dull
Light touch to diff points on extremities
Position - grasp finger or toe, holding it by sides with thumb and index finger. Alternate moving finger or toe up and down. Ask patient to state when finger is up or down, repeat with toes

Question 33

Assess motor or cerebellar function

Answer 33

Gait: patient walks, turns, comes back

Question 34

Romberg test

Answer 34

Patient stands with feet together, arms at sides, both eyes open and eyes closed for 20-30 seconds; observe for swaying. Should be negative.