<p>Physical Exam: – WASH HANDS BEFORE AND AFTER – Vital signs: BP palpation/auscultation/sitting/stand/right/left/thigh (patient will be dead or angry now), RR, P regular/irregular, strong/weak, T °F/°C, height/weight</p><p>General Appearance: inspect, ask height/weight if not measured Height/weight, apparent age, thin/obese/cachexic, pale/red-faced, no acute stress, cooperative and alert</p><p>Skin: inspect moist/dry, coarse/smooth, color, lesions, scars/tattoos, hair(fine/soft), nails</p><p>Head: inspect, palpate Normocephalic, hair, tenderness/masses, signs of trauma</p><p>Eyes: visual acuity(Snellen), fields(confrontation), EOMs, light reflex, near reflex, opthalmascope/funduscope Acuity OD/OS, fields by confrontation normal, Extraocular movements intact, pupils PERRLA. Disc margins sharp, normal cup to disc ratio, vasculature normal </p><p>Ears: inspect, palpate, rubbed fingers, Rinne(mastoid), Weber(forehead), otoscope Normal position, no tender/mass/pain.whisper heard without difficulty. AC>BC, Weber midline, external canal: no red/tender/swell/discharge/foreign body, tympanic membrane gray translucent</p><p>Nose: external/internal inspect, palpate sinuses Straight, no masses, discharge. Pink mucosa. No sinus tenderness.</p><p>Mouth/Throat: inspect buccal mucosa/gingivae/teeth/floor/palates/tonsils, CN XII(stick out tongue), assess TMJ(open/close mouth while touching tragus) Lips pink/normal, buccal mucosa pink/firm, no ulcers/lesions/masses; good dentation/oral hygiene, tongue midline, no ulcers/lesions/masses. Uvula midline. Pharynx normal.</p><p>Neck: inspect(neck, neck veins), palpate(nodes,thyroid,supraclavicular), range of motion(6 directions) Trachea midline. No adenopathy/tender/masses/thyroid nodules. Neck veins flat while sitting up.”a” wave seen while lying at 45°. Use of accessory muscles.</p><p>Chest: inspect(expression, posture, configuration, clubbing?), palpate(post chest excursion, tactile fremitus), percuss(posterior), auscultate(post) Repeat palpate/percuss/auscultate for anterior chest. Normal anteroposterior diameter. Symmetrical excursion. No tenderness. Increased/decreased tactile fremitus. Chest resonant/hyperresonant/dull bilaterally, clear on percussion and auscultation. Egophony(e becomes a), Bronchophony(words heard louder), Whispered pectoriloquy(whisper heard clearly) p.339-341 Swartz for breath sound analysis. </p><p>Breasts: inspect(skin,contour,symmetry), palpate axilla, palpate(breast, nipple), squeeze nipple Symmetrical, nipples pointing outward. Skin is normal, no dimpling/red/tender/mass. No discharge. Axillary examination reveals no lymphadenopathy. </p><p>Heart: inspect (general, skin), ausculate then palpate carotids, palpate(PMI, heaves, thrills), ausculate(4 areas,rubs,gallops), pitting edema? Patient in acute distress/labored breathing. Pallor.. PMI fifth intercostal space. S1 and S2 normal, no murmurs, rubs or gallops. No clubbing, cyanosis or edema Levine’s sign demonstrated. p. 382-388 Swartz for heart sound analysis.</p><p>Abdomen: inspect, auscultate(bowel sounds, bruits, rubs), ausculate abdominal bruit(above umbilicus), percuss liver, palpate(light, deep, rebound x 4 areas), palpate abdominal aorta, palpate(liver,spleen,kidneys), rectal exam. Scaphoid/protuberant. Soft/rigid, no guarding or tenderness. Bowel sounds present. No abdominal bruits. Liver not felt; approximately 6 cm by percussion. Abdominal striae present. Spleen not felt. Rectal exam deferred. Stool guaiac test negative.</p><p>Musculoskeletal: Arms/Hands: inspect extremities (symmetry, appearance), assess temperature, palpate hand joints, spread fingers against resistance/squeeze doc’s fingers, assess cotton/pin sensation/proprioception on fingers, palpate wrist, flex/extend wrists against resistance, flex/extend forearms against resistance, pronate/supinate forearm, palpate brachial pulse, Test biceps tendon reflex/brachioradialis reflex/triceps tendon reflex, abduct arms placing hands together above head/adduct arms to sides Spine: inspect(stand, bend forward/to sides), rotation of lumbar spine(stabilize hips, turn shoulders) Observe gait. Legs/Feet: inspect extremities (symmetry, appearance, varicosities), assess temperature, assess strength(have patient squat & stand), dorsiflex/plantar flex against resistance, invert/evert foot against resistance, assess cotton/pin sensation/proprioception on toes, palpate popliteal/dorsalis pedis/posterior tibial pulse, test Achilles heel reflex/Babinski’s reflex, extend/flex knee against resistance, test patellar tendon reflex, flex knee & rotate ankle inward/outward, palpate femoral pulse, raise knee against resistance/rise from seated position unassisted.</p><p>Joints have full range of motion. No joint or muscle deformities/tenderness. pulses are grade 2 and bilateral. No clubbing/cyanosis/edema. Arm and leg strength grade 2 bilaterally. P.608 Swartz for muscle strength scale.</p><p>Neurological: Assess LOC(date,day,hospital name or responds to Verbal/Painful stimulus/unresponsive), CN I(smells), CN II,III, IV, VI (EOMs), CN V(corneal reflex, sensory – cotton/pin over face, motor – clench jaw & palpate masseter/temporalis), CN VII(motor – smile/bare teeth, puff cheeks against resistance, raise brow, resist opening eyes), CN VIII(hearing/balance – not done), CN IX, X(“Ah” elevates uvula in midline), CN XI(turn head/shrug shoulders against resistance), CN XII(stick out tongue) **Test biceps tendon reflex/brachioradialis reflex/triceps tendon reflex/patellar tendon reflex/Achilles heel reflex/Babinski’s if not done previously** ** assess cotton/pin sensation/proprioception on fingers and toes if not done previously** Assess cerebellar function(finger to nose with eyes open/closed, rapid alternating move, Romberg’s(feet together, extend hands palms up eyes closed)</p><p>Oriented to person, place and time. Cranial Nerves II to XII intact (cranial nerve I not tested). P.616 Swartz for reflex grading scale. Motor examination revealed normal gait and reflexes bilaterally. Babinski’s sign is intact. Sensory examination is normal, with pain and light touch intact. Cerebellar function is normal. Romberg’s test is positive.</p>