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Flashcards in Head to Toe Physical Exam Deck (14)
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1
Q

Subjective

A

HPI:
- O, L, D, C, A, A, A, R, T, S

1) CC/ HPI
2) PMH
3) PSH
4) Meds
5) Allergies
6) Social
7) Family History
8) ROS

2
Q

Objective

A
  • Vital Signs
    - Gen Appearance  (Skin)
    - HEENT
    - (Sinuses)
    - Neck
    - CV
    - (Chest/Breasts)
    - Lungs
    - Abdomen
    - (Genital)
    - (DRE)
  • Ext
    - (Lymphatic)
    - Musculoskeletal
    - Neurologic
    - Psychiatric
    - STRUCTURAL / OSTEOPATHIC!!!!!!!!!!!!
3
Q

Initial Observation

A
  • Posture. Plane
    a) Landmarks, Symmetry
    b) Kyphosis/ Lordosis, Scoliosis
  • Gait
  • Heel/Toe Walk
    a) Balance, Strength
4
Q

Documentation

A

- VITALS: BP, P, T, R

  • GENERAL: NAD, anxious, lethargic….
  •  (SKIN): Intact, warm, dry, (rash, lesion-describe)
  •  HEENT: nc/at, PERRL/EOMI, TM’s clear b/l, nares patent mucosa non-inflamed, throat non-injected no exudate, no maxillary sinus TTP
  •  NECK: Supple, NT, no LAD or JVD, no thyromegaly, no carotid bruit
  • CV: Heart RRR s murmur
     (or RRR with systolic m III/VI)
  • (CHEST/ BREAST): no reproducible TTP, no mass/lump, lesion, discharge, skin changes or axillary LAD
  •  LUNGS: CTAB, no crackles, wheezes, rales, rhonchi
  • ABDOMEN: soft NT/ND, BS x 4, no R/R/G/mass, no HSM, neg murphy’s, no CVA TTP

- (GENITAL): no discharge, ext skin lesions, cervix and vag wall visualized NSSCC (Norm size, shape, color, consistency), biman- no CMT, no adnexal mass or TTP
a) MALE-scrotal swelling, testicular TTP, mass, inghernia

- (RECTAL): good tone, No mass, TTP, or prostate nodule
noted, heme occult neg

  • EXT: + pulses b/l (dp, pt) no C/C/E, FROM (shoulder abduction), no TTP (location)
  •  (LYMPHATIC): no cervical, axillary or inguinal LAD noted
  • NEUROMUSCULOSKELETAL: AXOX3, CN II-XII GIB, DTR’s 2/4 b/l (btpa), MS 5/5, sensation intact b/l UE & LE.
  •  OSTEO: TTA/tension T4-6 on right, L1-3 NRrSl, restricted R shoulder Abduction and ER, TTP cervical paraspinal tissues on L, SLR neg…

a) SPECIAL TESTING for region specific MS complaints can be recorded in ext, NMS, or osteo
i)  SHOULDER – empty can + R…

ii)  ELBOW – neg varus/valgus, + tennis elbow testing…
iii) WRIST/HAND - + Finkelstein’s R…
iv)  KNEE – neg varus/valgus stress, ant/post drawer…
v)  ANKLE/FOOT – squeeze test and ant ankle drawer neg…

5
Q

Physical Diagnosis

A
  • “Putting together” appropriate exam based on Subjective data collected
  • Suggested exam components to include regardless of CC/HPI:

 VITALS:

 (GEN: NAD, restless, lethargic…..)

 HEART: RRR, w/o murmur

 LUNGS: CTAB, w/o wheeze, rhonchi, crackles 

OSTEO/STRUCTURAL:

6
Q

Physical Diagnosis

Osteopathic/ Structural Exam Considerations

A
  • Check for TART – don’t be afraid to PALPATE the AREA of Chief Complaint
    a) Segment or Region above/below
  • If you treat – REASSESS not only by asking the pt if symptoms are better, but check for improvement/resolution of TART findings

- Appropriate Duration of Tx

- Help/assist your patient

  •  Consider appropriate diagnostic testing
    a) Pelvic compression test, SLR, Spurling’s, empty can, varus/valgus stress, finkelstein, scour, ant drawer, talar tilt……..
7
Q

Physical Diagnosis

Case Specific Considerations: HEADACHE

A

1) HEENT Exam:
- NC/AT, PERRL, EOMI, TM’s intact and clear, Nares patent mucosa non-inflammed, Maxillary sinuses non-tender to palpation, Oropharynx- clear w/o exudate or erythema

2) CRANIAL NERVE EXAM (Can be under HEENT or Neuro)
- CN II - XII Intact B/L

3) NEURO EXAM:
- AxOx3
- Biceps and Triceps DTR 2/4 BUE
- Muscle Strength 5/5 BUE, sensation grossly intact BUE (no focal motor/sensory deficits noted)

4) PALPITATION OF AREA (can go under HEENT in this case or structural Exam if you find TART)
- No Reproducible TTP, Ecchymosis, Erythema

5) STRUCTURAL EXAM:
- TART-Include TTP, Tissue text changes, PTP’s, ROM to perhaps OA and cervical spine at minimum, can include specific nomenclature if found – C3FRrSBr

8
Q

Physical Diagnosis

Case Specific Considerations:
BACK PAIN, NECK PAIN

A

1) PALPATE THE SPECIFIC AREA OF CONCER
- Palpate above/below area of concern

2) ABD: (Especially if any of the HPI involves the GI or GU system)
- Soft, NT/ND, Bs+x4, no rebound…. No CVA TTP

3) NEUROMUSCULOSKELETAL:
- Patellar, Achilles DTR 2/4 BLE, or Bicep/ Tricep/ Brachiorad 2/4 BUE

  • Muscle strength 5/5BLE or BUE
  • Sensation grossly intact BLE/BUE
     (no focal motor/sensory deficits noted)
  • Special Test examples: SLR forLBP, Spurlings for neck pain

4) STRUCTURAL EXAM:
- TART-include TTP, tissue text changes, PTP’s, landmark findings, ROM, specific nomenclature if found- (ex-L1-3 NRrSl)

9
Q

Physical Diagnosis

IF AN EXTREMITY IS INVOLVED

A

1) EXT: No C/C/E, Perp Pulses intact B/l 2/4, ROM Symmetric or Restricted R Shoulder Abduction

2) Extremity can have TART as well
- TTP along plantar fascia of R foot, Glenohumeral Glide Restriction, forearm supination dysfunction, Post Fib head, Plantarflexed talus

10
Q

A Few Considerations

A
  • Develop Order/ Routine for your History and Exam
  • Don’t forget to put the things you discussed and examined into the SOAP Note
  • ASSIST the patient when Moving and Changing Positions
  • Don’t forget to tell your Patient what you are doing (Exam and Treatment)
  • Don’t completely FORGET Structural/Osteopathic Exam, and OMT if indicated (Esp on Musculoskeletal Case)
    a) Avoid Tarantula or Itsy-bitsy Spider Technique
11
Q

Assessment (Example)

COUGH

A

1) Cough
- Uri
- Bronchitis
- Post Nasal Drip
- Medication Induced

2) Somatic Dysfunction: Thoracic Spine
3) FH Colon Cancer

12
Q

Assessment (Example)

SHOULDER Pain

A

1) Shoulder Pain
- Rotator Cuff Tendonitis
- Shoulder Impingement
- Glenohumeral Instability
- Shoulder Strain/ Sprain
- Somatic Dysfunction- UE (Shoulder)

2) Hypothyroidism
3) Hypercholesterolemia

13
Q

Physical Diagnosis- Osteopathic Exama nd Tx Documentation

A

JUST and EXAMPLE of a SOAP Note:

S

O :
 Somatic Dysfunction – Lumbar, Pelvis (Innominate)

A:
- Lumbar Spine TTP, R lumbar paraspinal with acute tissue texture changes, muscle spasm, PTP’s noted on R. L1-5 NRrSBl. + Pelvic Compression Test R, R ant rot innominate……

P:
- OMT – MFR to lumbar, ME to pelvis well tolerated with good results

14
Q

Plan

A

Things to Consider, and list IF INDICATED:

  • Labs
  • Diagnostic Studies
  • Medications (Start, Stop, Change)
  • OMT
  • Anticipatory Guidance/ Counseling
  • Follow-Up/ Referral