Virtual Naval Hospital

"Shipwreck's Go-By" Physical Examination Guide 2nd Edition

Medical symbol

by Frank Carvalho, LT, MSC, USN

Physician Assistant, Former HMC(SW), DDG-40
Copyright 1996 by Frank Carvalho, LT, MSC, USN

For use by Hospital Corps personnel in examination procedures during patient evaluation.

While not all inclusive, this guide provides pertinent assessment guidelines.

Peer Review Status: Internally Peer Reviewed
Creation Date: 1996
Last Revision Date: 1996


This Booklet is dedicated:

This booklet can be downloadable at the end of this page - SHPWRCKGBY.zip


Table of Contents
History
Subjective
Objective
Skin/Nails/Hair
Head
Eyes
Ears
Nose
Throat
Neck
Chest and Lungs
Heart
Peripheral Vascular system
GI
GU- Male
GU- Female
Back (low) &Hip Exam with Neuro
Knee
Ankle & Foot
Shoulder (upper back) with Neuro
Elbow & Hand
Mental/Neuro status exam with CranialNerves &Cerebellar status
The ULTIMATE SOAP NOTE


History

Subjective
All important: Depending on the chief complaint consider everything, document the essential. Consider Abdominal, Genitourinary, Respiratory, Cardiovascular, Neurological, Musculoskeletal, and Psychiatric involvement. Document presence or absence of fever, chills, nausea, vomiting, diarrhea, chest pain, shortness of breath and headaches. If you don't ask, they might not tell!

Focus on History of Present Illness

P- What Provokes discomfort?
Q- What is the Quality of the discomfort?
R- Where is the Region of the discomfort?
S- What is the Severity of the discomfort?
T- What is the Time sequence?

-What was the mechanism of injury?
-What was the pt doing prior to incident?
-Are there any associated symptoms?
-Are there any aggravating/relieving factors?
-Is this a recurrent illness or injury?
-Is the patient on any medications?
-Note pt's ETOH, caffeine and smoking habits.
-Allergies? ASK FOR YOURSELF!

Review of System: To help you focus your exam, consider a ROS.

General: First Impression. Nutritional status, weight gain/loss, weakness, fatigue, hydration status & overall condition?
Skin: Changes in skin/nail/hair texture appearance and color. Rashes, itching, lumps or infection? Cellulitis, Lymphangitis, lymphadenopathy?
Head: Loss of consciousness? Lightheaded, vertigo, headaches, symmetry, Hx of Injury, PMH, sinus pain? Visual disturbance?
Eyes: Visual changes, diplopia, epiphoria, pain, discharge, injection, light halos, trauma, photophobia, glaucoma, cataracts, last eye exam? Iritis, visual acuity, and Glasses/contacts?
Ears: Acoustic trauma, hearing loss, tinnitus, drainage, pain, infection, discharge, vertigo? Hearing aids? Last exam?
Nose/Sinuses: Olfactory changes, stuffiness, drainage, itching, obstruction, hx of trauma, hay fever, nosebleeds, sinus problems.
Throat/Mouth: Hoarseness, dysphagia, enlarged tonsils, bleeding gums, sores, leukoplakia, dental condition, caries, sore tongue changes, dry mouth, hx of sore throat? Hx of trauma?
Neck: Goiter, pain, masses, nodules, adenopathy, thyroid problems, stiffness, creptitus? Hx of Injury?
Respiratory: Cough, dyspnea, pleurisy, sputum (amt, type, color), asthma, bronchitis, COPD, emphysema, TB, last CXR? Coccidiomycosis, Histoplasmosis and smoking history?
Cardiac: HTN, hyperlipidemia, rheumatic fever, murmurs, chest pain/discomfort, orthopnea, dyspnea, edema, last ekg/stress test? CHF, pericarditis. Hx of surgeries/procedures/monitors
Peripheral vascular: Nocturnal pain, claudication, varicose veins, thrombophlebitis, leg cramps? CHF? Venous insuffieciency? DVT? Swelling, tenderness and parathesias?
Gastrointestinal: Heartburn, dsyphagia, appetite, indigestion, belching, flatulence, hememesis, stool changes, hemechezia, melena, diarrhea, constipation, nausea, regurgitation, vomiting? Hx of gallbladder, liver, pancreatic disease, PUD?
Genital (male): Hernias, sores, lesions, penile discharge, pain, testicular/mass discomfort, scrotal mass/discomfort? hx of STD's. Sexual hx, function, problems?
Genital (female): Birth control, sexual hx/function, STD's, itching, sores, dishcarge, dyspareunia, last pap/pelvic exam? Menarche, menopause, LMP, GPA, menstrual regularity, frequency, duration, amt? Dys/amenorrhea, metromenorrhea and PMS?
Urinary: Dysuria, polyuria, frequency, stones, pattern change, incontinence, nocturia, STD, hesitancy, dribbling, hematuria, infections? Flank discomfort?
Hematologic: Bleeding, bruising, anemias, hx of transfusions, sickle cell,thalasemias?
Endocrine: Thyroid, adrenal, hormonal. Heat/cold intolerance, edema, hirsutism, sweating, excessive thirst, hunger, polyuria, pigment changes?
Musculoskeletal: Myalgia, stiffness, gout, arthritis, backache. Hx of swelling, pain, erythema, tenderness, decreased ROM? Hx of trauma, overuse.
Neurologic: Syncope, vertigo, seizures, blackouts, parasthesias, paralysis, tremors, weakness, involuntary movements, equilibrium, LOC?
Psychiatric: Anxiety, mood swings, mania, depression, memory loss, insomnia, suicidal ideations, delusions, hallucinations?

Other Problems and past medical history:
Consider any other problems which are currently active, comments should include functional impairment, childhood /adult illnesses, Hx of trauma, surgeries, hospitalizations.

Document environmental exposures and Family History when appropriate.

Objective:
Always start your objective with a opening statement concerning the patients general appearance and condition.

Example: Well developed, well nourished male in no acute distress. Pt is alert x3, cooperative, and shows no gross mental status changes. Pt appears hydrated. Vital signs noted.

Remember, its not what you find that gets you in trouble. ITS WHAT YOU MISS!


Skin/Nail/Hair

Inspect for color changes: brown, gray, bronze, blue reddish blue, red, yellow, hypo/hyperpigmentation.
Palpate skin to check for changes in moisture, temperature, texture, and turgor.
Inspect and palpate nails for changes in texture, color and shape. Look for infections.
Inspect and Palpate hair for changes in quantity, quality, texture and distribution. Look for infections.

Primary Skin Lesions include: macules, patch, papule, plaque, nodule, tumor, wheal, vesicle, bullae, pustule.

Secondary Skin Lesions include: Erosion, ulcer, fissure, crust, scale, lichenification, atrophy, scar, keloid.

Pertinent Positives and Negatives


Head/Face

Inspect for symmetry, lesions, rashes, edema, erythema, twitching, involuntary movements, evidence of trauma/infection.
Palpate for masses, nodules, lymph nodes, salivary glands, Sinus tenderness, temporal artery tenderness, step-off.

Pertinent Positives and Negatives


Eyes

Visual Acuity: Gross exam at 14" tests only near vision! Snellen Chart is more reliable.
Document as 20/_ OS, 20/_OD, 20/_OU with and without correction if applicable.

Inspect the Eyebrows, eyelids, lacrimal apparatus, conjunctiva, sclera, cornea for edema, erythema, injection, abrasion, infection. Note pupils for dilation/constriction.

Inspect for position and alignment of eyes. Orthophoric vs evidence of Strabismus.

Hirschberg's test: Look for the light reflection on corneas. Are They Symmetrical?

Cover/Uncover Test: Tests for Strabismus. Exotropia, Esotropia, Hypertropia, Hypotropia?

Fields of Confrontation: Cranial nerve II, Tests for peripheral vision. Evaluate both eyes (8 fields) Are they equal to yours?

Extra Ocular Movements: Check the 6 cardinal fields of gaze. Check for nystagmus, convergence, lidlag.

 

Cranial Nerve III responsible for opening the eye, pupillary constriction, most extraocular movements.
Cranial Nerve IV responsible for downward, inward movement of eye. (Superior oblique)- SO4.
Cranial Nerve VI responsible for lateral deviation of eye. (Lateral rectus) LR6.

Fundoscopic Exam: Note the Optic disc for sharp margins, 2:1 cup to disc ratio. Is there any evidence of Retinal changes (AV nicking, copper wiring, exudates, wool spots, tapering, banking, neovascularzations.) Is there any papilledema, retinal detachment, drusen?

PERRLA: Pupils, Equal, Reactive, Round to Light and Accommodation. Did you really check them all?

Pertinent Positives and Negatives


Ears

Inspect Auricles and External canal for lesions, nodules, foreign bodies, deformities, erythema, edema , wax, ecchymosis, discharge.

Palpate for tenderness and masses. Note preauricular and post auricular nodes.

Auditory Acuity (conductive vs neuro loss)

Whisper test: (gross exam)
Weber test: lateralization to which ear?
Rinne test: is AC>BC?

Suspected Hearing Loss

Weber Test

Lateralizes Left (Do Rinne)

No Lateralization (Do Rinne)

Lateralizes Right (Do Rinne)

Rinne

Rinne

Rinne

If AC>BC R=Neuro L=Normal
If BC>AC L=Cond Loss R=Normal

If AC>BC Bilat=Normal
If BC>AC Bilat=Cond Loss

If AC>BC L=Neuro R=Normal
If BC>AC L=Normal R=Cond Loss

Tympanogram: Evaluate Eustachian tube function.

Conductive Loss: may be due to wax, foreign body, tympanosclerosis, otitis media, cholesteatoma.

Neuro Loss: may be due to Cranial Nerve VIII dysfunction, cochlear damage, acoustic trauma.

Pertinent Positives and Negatives


Nose/Sinuses

Inspect for masses, lesions, edema, erythema, deformity. Visualize the mucosa, note color, consistency, lesions, masses, discharge, exudate, abrasion, lacerations

Palpate for tenderness, Percuss frontal and maxillary sinuses. Have patient bend forward. Note increase in discomfort to sinuses.Transluminate with otoscope

Pertinent Positives and Negatives


Throat

Inspect lips, gums, teeth, buccal mucosa, tongue, soft/hard palate, ant/post pillars, tonsils, uvula, posterior pharanyx, frenulum, salivary glands. Note any lesions, masses, edema, erythema, pustules, exudates, ecchymosis, nodules, masses, discharges, ulcerations, color variations.

Pertinent Positives and Negatives


Neck

Inspect skin, trachea, thyroid, SCM, anterior/posterior triangles.
Note symmetry, lesions, nodules, masses, edema, ecchymosis, erythema.
Palpate all landmarks for tenderness, crepitus, spasm, nodules, masses, nodes.
Lymph node examination: Preauricular, postauricular, occipital, tonsillar, submandibular, submental, anterior cervical, posterior cervical, supraclavicular.

Assess Range of Motion: Flexion, extension, lateral rotation, lateral bending. (active and passive)

Pertinent Positives and Negatives


Chest and Lung

Inspect anterior/posterior/lateral. Observe rate, rhythm, depth symmetry of respirations, AP-LAT ratio. Look for retraction/bulging of intercostal spaces, masses, lesions, deformity. Palpate for tenderness.

Auscultate all lobes, for pneumo/consolidation, consider AP/LAT CXR. If suspect effusion, include lateral decubitus view.

Percussion: Listen for dull, tympanic, resonant, hyperresonant, flat sounds.

Pertinent Positives and Negatives


Heart

Inspect for heaves, thrusts, obvious deformity. Note PMI (LMCL at 5th ICS) location and activity.

Palpate valve areas:

(A) AORTIC -- RUSB at the 2nd ICS
(P) PULMONIC -- LUSB at the 2nd ICS
(M) MITRAL -- LMCL at the 5th ICS
(T) TRICUSPID -- LLSB at the 5th ICS

ERB's Point LMSB at the 3rd ICS
Point of Ectopy midway between P and M

Auscultate valves with:
Diaphragm for High Pitched sounds.
examples- S1, S2, regurgitant murmurs
Bell for Low Pitched sounds:
examples- S3, S4, stenotic murmurs

Murmurs are graded 1-6, note location, pitch, intensity, shape, quality, timing.

Systolic Murmurs vs Diastolic Murmurs

(A) stenosis

(A) regurgitant

(P) stenosis

(P) regurgitant

(M) regurgitant

(M) stenosis

(T) regurgitant

(T) stenosis

Pertinent Positives and Negatives

EKG Pertinent Positives and Negatives


Peripheral Vascular System

Inspect, Palpate and Auscultate carotids, abdominal aorta, renal, iliac, femorals, popliteal, posterior tibial, dorsal pedis, radial, ulnar, brachial pulses.

Look for edema, symmetry, venous, patterns, varicosities, change in temperature, color, texture differences on all extremities. Include nailbed assessment.

Palpate for sensory changes, varicosities, pulse differences, cord tenderness.

Pertinent Positives and Negatives


Gastrointestinal

Inspect abdomen for lesion, masses, distension, erythema, edema, ecchymosis, color changes, striae.
Auscultate all four quadrants for bowel sounds, listen to aorta, renals, iliac arteries.
Palpate (light/deep) for guarding, rigidity, masses, tenderness.
Percuss entire abdomen, liver and spleen.

Pertinent Positives and Negatives

Rectal Exam


Genitourinary (Male)

Inspect entire pubic area. note lesions, masses, edema, erythema, ecchymosis, excoriation, lichenification, discharge, drainage.
Palpate entire pubic area for tenderness, masses, nodules, cysts, lymphadenopathy.

Pertinent Positives and Negatives


Genitourinary (Female)

Inspect entire pubic area. note lesions, masses, edema, erythema, ecchymosis, excoriation, lichenification, discharge, drainage.
Palpate entire pubic area for tenderness, masses, nodules, cysts, lymphadenopathy.

Pertinent Positives and Negatives


Low Back/Hip Exam with Neuro

Be familiar with all landmarks: iliac crest, ant/posterior iliac spines, sacrum, lumbars, coccyx, paraspinals, latissimus dorsi, greater trochanter, Sacral-iliac junction, Sciatic notch.

Pertinent Positives and Negatives

Distraction Maneuvers


Neuro Check L4, L5, S1

L4
Motor- Inversion of foot
Sensory- Medial aspect of foot/calf
Reflex- Patellar

L5
Motor- Dorsiflexion of big toe
Sensory- Dorsum of foot and lateral calf
Reflex- None

S1
Motor- Eversion of foot
Sensory- Lateral aspect foot and sole
Reflex- Achilles

S5- Sphincter tone

If any discrepancies, consider doing sensory specific testing.


Knee

Observe patient presentation, consider mechanism of injury. Palpate all landmarks. Consider hip, ankle involvement. Do neurovascular check (L3, L4, L5, S1, S2). Consider Sensory Specific testing.

Pertinent Positives and Negatives

IF no history of direct trauma, consider OVERUSE conditions.


Ankle/Foot

Observe patient presentation, consider mechanism of injury (MOI). Palpate all landmarks. Consider knee, hip, back involvement. Do neurovascular check ( L4, L5, S1). Consider Sensory Specific testing.

Inspect and Palpate all landmarks

Pertinent Positives and Negatives


Shoulder Exam with Neuro

Observe patient presentation, consider mechanism of injury (MOI). Palpate all landmarks. Consider neck, elbow involvement. Do neurovascular check (C5, C6, C7, C8, T1, T2). Consider Sensory Specific testing.

Pertinent Positives and Negatives

Do both active and passive ROM testing, Document findings. Note when you are able to reproduce discomfort. This is essential for accurate diagnosis.

Shoulder Neuro Exam

C5
Motor- Abduct Arm, Bicep flexion
Sensory- Lateral Arm (Axillary nerve)
Reflex- Bicep

C6
Motor- Wrist extension, Bicep flexion
Sensory- Lateral forearm/1st, 2nd digit (musculocutaneous nerve)
Reflex- Brachioradialius

C7
Motor- Wrist flexors, finger extensors, tricep ext.
Sensory- Middle finger
Reflex- Tricep

C8
Motor- Hand Instrinsics, finger flexors
Sensory- Medial forearm/ 4th and 5th digits (medial antebrachial cutaneous nerve)
T1-2
Motor- Hand intrinsics, finger abd/adduction
Sensory- Medial Arm ( med.brach cutaneous nerve)

If abnormal findings occur do Sensory Specific, on page 32??????.


Elbow/Hand

Observe patient presentation, consider mechanism of injury (MOI). Palpate all landmarks. Consider neck, Wrist involvement. Do neurovascular check (C5, C6, C7, C8, T1, T2). Consider Sensory Specific testing.

Pertinent Positives and Negatives

Establish tendon, muscle, ligament, neurovascular integrity prior to any attempt at reducing or closing an injury.


Neuro/Mental Status

Do all 6 components:

1st- Mental Status Exam

Always check this on all patients: Observation is your best tool, These can be assessed without provoking the pt. Observe the following:

If anything does not seem right in the routine MS exam then check these cognitive Functions:

2nd Cerebellar Functions

  1. Station
  2. Romberg
  3. Pronator sign
  4. Heel to toe walk
  5. Heel to shin drag
  6. Rapid alternating movements (RAM's)

3rd Motor Testing

4th Sensory Testing

Sensory specific tests: Sharp/dull, 2 point discrimination, Temperature, Vibratory, Pain, Light touch, Proprioception, Stereognosis, Graphesthesia

5th Reflex Testing

Bilaterally check:

Cranial nerves V, IX, X,

Deep Tendon Reflexes:

C5 - Biceps
C6 - Brachioradialis
C7 - Triceps
L4 - Patellar
S1 - Achilles

Superficial reflexes:

Abdominal reflex -upper T7 - T10
-lower T10 - L1
Cremasteric reflex
- L1, L2
Superficial Anal reflex
- S2, S3, S4
Bulbocavernosus reflex
- sacral sparring
Babinski sign
- upper motor neuron lesion

6th Cranial Nerve Exam

I- Olfactory
Sensory - smell
II- Optic
Sensory - Visual Acuity, Peripheral vision by confrontation.-- Fundoscopic
III- Oculomotor
Motor - EOM, accommodation.(lateral rectus, superior oblique)
IV- Trochlear
Motor - EOM (superior oblique)
V- Trigeminal
Motor- clench teeth (palpate)
Sensory- bilateral 3 sections of face
Reflex- corneal
VI- Abducens
Motor- EOM (lateral rectus)
VII Facial
Motor- raise eyebrow, frown, smile, puff cheeks, show teeth, shut eyes tightly.
Sensory: taste to anterior of tongue
VIII Vestibulocochlear
Sensory- watch tick, rub fingers, weber, rinne.
IX/X Vagus/Glossopharyngeal
Motor- Listen to voice, say "AH"
Sensory- Taste to Posterior tongue
Reflex- gag
XI Spinal accessory
Motor- Turn head, Shrug shoulders
XII Hypoglossal
Motor- stick out tongue


The Ultimate S.O.A.P. Note

Be sure to include something in each section and you've just about covered all bases!

Subjective:

Objective:

-Physical Exam/ vital signs
Impression: Justify ancillary services
Obtain consent for:
Procedures, IV's, Labs, X-rays (time)
-Ancillary service interpretation
-Pt condition during/after procedure

Assessment: -Findings listed in order from worst to least critical

Plan:


Click the link below to download your own compressed copy of SHIPWRECK'S GO-BY in booklet size, MS Word 97 format.
SHIPWRECK'S GO-BY (shipwrck.zip)!

Suggestions/feedback to the Author:
Send Email to Frank Carvalho at SHPWRCK@aol.com

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