Chapter 11
Techniques of Physical Examination
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Objectives

Describe prehospital physical examination
techniques

Describe examination equipment

Describe the general approach to the physical
examination

Outline the steps of the comprehensive
physical examination
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Objectives

Detail the components of the mental status
examination

Identify abnormal findings in the mental status
examination

Outline steps in the general patient survey

Distinguish between normal and abnormal
findings in the general survey
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Objectives

Describe examination techniques for specific
body regions

Identify normal and abnormal findings in the
body region examination

Describe examination techniques specific to
children and older adults
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Scenario
You respond to a nursing home for an
“unresponsive person.” Your patient is a 92year-old woman who is recuperating from a
fractured hip. She takes cardiac and diabetic
medications. According to the nurse
assistant, she is normally alert, but is now
only responsive to pain. She has a bruise on
her forehead. The story of this evening’s
events seems inconsistent.
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Discussion

What priorities will you have in this patient’s physical
assessment?

Assuming her airway and breathing are managed, what
examination techniques will you use to assess this
unconscious woman?

What equipment will you need to perform your physical
exam?

What areas will be of particular concern as you complete
your comprehensive physical examination?
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Examination Techniques

Inspection

Palpation

Percussion

Auscultation
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Inspection

Visual assessment of the patient and surroundings

Findings that may be significant:







Patient hygiene
Clothing
Eye gaze
Body language
Body position
Skin color
Odor
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Inspection

If the emergency response was to the
patient's home, make a visual inspection for

Cleanliness
 Prescription medicines
 Illegal drug paraphernalia
 Weapons
 Signs of alcohol use
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Palpation

A technique in which the hands and fingers are used
to gather information by touch

Palmar surface of fingers and finger pads are used to
palpate for






Texture
Masses
Fluid
Crepitus
And assess skin temperature
Palpation may be either superficial or deep
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Deep Bimanual Palpation
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Percussion

Used to evaluate for
presence of air or
fluid in body tissues


Sound waves heard
as percussion tones
(resonance)
Procedure
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Auscultation

Best performed in a quiet environment

Requires a stethoscope


Body sounds produced by movement of fluids or gases in
patient's organs or tissues
Note:




Intensity
Pitch
Duration
Quality
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Stethoscope

Used to evaluate sounds created by
cardiovascular, respiratory, and
gastrointestinal systems

Stethoscopes



Acoustic
Magnetic
Electronic
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Stethoscope

Position stethoscope
between index and
middle fingers
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Ophthalmoscope

Used to inspect eye
structures:

Retina
 Choroid
 Optic nerve disc
 Macula
 Retinal vessels
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Otoscope

Used to examine
deep structures of
the external and
middle ear
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Blood Pressure Cuff

Sphygmomanometer

Measures systolic and
diastolic blood pressure

Manual or electronic
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Comprehensive Physical Examination

Mental status

Chest

General survey

Abdomen

Vital signs

Posterior body

Skin

Extremities

Head, eyes, ears, nose,
and throat (HEENT)

Neurological exam
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Mental Status

First step in patient care encounter


Patient’s appearance and behavior
Level of consciousness
• A healthy patient is expected to be alert, responsive to
touch, verbal instruction, and painful stimuli
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Mental Status









Appearance and behavior
Posture, gait, and motor activity
Dress, grooming, personal hygiene
Breath or body odors
Facial expression
Mood and affect
Speech and language
Thought and perceptions
Memory and attention
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General Survey

Signs of distress

Cardiorespiratory insufficiency
• Labored breathing
• Wheezing
• Cough

Pain
• Wincing
• Sweating
• Protectiveness of a painful body part or area

Anxiety
•
•
•
•
Restlessness
Anxious expression
Fidgety movement
Cold, moist palms
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General Survey

Apparent state of health

Skin color and obvious lesions

Height and build

Sexual development

Weight
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Skin Color

Varies from person to person

Varies based on ethnicity

May range in tone from pink or ivory to deep
brown, yellow, or olive

Observe for skin not exposed to sun (e.g.,
palms)
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Skin Lesions
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Height and Build

Descriptions include:


Average, tall, short, lanky, muscular
May also be affected by age and lifestyle
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Sexual Development

Determine if age appropriate

Observe for normal changes associated with
age
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Weight

Observe general appearance


Obese to emaciated
Recent changes may be key finding

Recent weight loss or gain
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Vital Signs

Pulse

Blood pressure

Respirations

Skin

Pupils
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Pulse

Rate

Rhythm

Quality

Consider ECG monitoring
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Blood Pressure
Locations
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Respirations

Adult rate

12-24 breaths per minute

Observe

Feel for chest movement

Auscultate
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Skin

Texture

Turgor

Hair

Fingernails and toenails

Abnormal findings
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Temperature Measurement

Oral temperature

Hold thermometer firmly
under tongue

Tell child to “kiss”

Caution to avoid biting
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Axillary Temperature

Hold arm down
firmly

Should be
approximately 1° F
less than core temp
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Tympanic Temperature

Accuracy questionable

Pull ear back

Insert gently
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Rectal Temperature

Risk of perforation

Avoid in
uncooperative, or
immuno-suppressed
patient

Stabilize thermometer
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Eyes—Visual Acuity

Have patient




Read printed material
Count fingers at a
distance
Demonstrate ability to tell
light from dark
Use eye chart
• (e.g., Snellen chart)
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Eyes—Pupils

Findings may indicate neurological issues

Examine response to light (PERRL)

Pupils are equal, round, and react to light
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Anatomical Regions

Skin

Texture
 Turgor
 Hair
 Fingernails and toenails

Head, ears, eyes, nose, throat
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Head and Face

Inspect skull for shape and symmetry

Palpate for swelling, tenderness, lesions,
indentations

Inspect face for symmetry, expression,
edema, involuntary movements
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Eyes

Determine if contacts are present

Determine that both eyes can see

Assess visual acuity

Inspect orbital area for edema

Examine eyes for drainage or redness

Determine structural integrity
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Eyes—Visual Fields
Six cardinal fields of gaze
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Visual Fields

Ask the patient to look at his or her nose


Test peripheral vision by extending your arms with
elbows at right angles and wiggle both index
fingers simultaneously
Observe eyes for normal position and
alignment
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Ophthalmoscopic Examination

Used to evaluate:

Cornea
 Foreign bodies
 Lacerations
 Abrasions
 Infection
 Anterior chamber







Hyphema
Hypopyon
Fundus
Optic nerve
Retina
Vitreous
Eyelid
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Cornea and Sclera

Examine conjunctiva
and sclera

Palpate lower orbital rim
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Ophthalmoscopic Examination

Inspect:

Size, color, and clarity
of the disc
 Integrity of vessels
 Assess for retinal
lesions and appearance
of the macula
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Ophthalmoscopic Examination

Normal findings

Clear, yellow optic nerve
disc
 Reddish pink
(European-American) or
darkened retina
(African-American)
 Light red arteries
 Dark red veins
 3:2 vein-to-artery ratio
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Otoscopic Examination

Otoscope used to:


Evaluate inner ear for discharge and foreign
bodies
Assess eardrum
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Otoscopic Examination

Select speculum

Turn on otoscope

Insert speculum into ear canal,
slightly down and forward

Look for foreign bodies, lesions,
discharge

Inspect tympanic membrane
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Otoscopic Examination

Normal findings



Cerumen is dry (tan or light yellow) or moist (dark
yellow or brown)
Ear canal
• Not inflamed
Tympanic membrane
• Translucent or pearly gray
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Nose

Inspect

Palpate

Discharge from the nose

CSF
 Epistaxis
 Mucous discharge
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Mouth and Pharynx

Lips

Gums

Mouth and tongue

Pharynx
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Neck

Inspect


Use spinal precautions
if trauma is suspected
Palpate trachea

Midline position normal
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Neck

Palpate



Place both thumbs along sides of distal trachea
Systematically move toward head
Do not apply bilateral pressure to carotid arteries
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Head and Cervical Spine

Temporomandibular joint (TMJ)

Inspect and palpate cervical spine

Range of motion
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Chest

Ribs



Protect thoracic organs
Support respiratory movements of diaphragm and
intercostal muscles
Anatomical landmarks for examination
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Topographical Landmarks
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Thoracic Landmarks—Anterior Chest
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Thoracic Landmarks—Posterior Chest
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Inspection

General appearance of chest

Chest wall configuration

Inspect for symmetry
 Chest wall should be symmetrical
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Chest Wall Abnormalities

Barrel chest

Funnel chest (pectus
excavatum)

Pigeon chest (pectus
carinatum)

Thoracic kyphosis

Scoliosis
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Chest—Palpation

Tracheal position

Respiratory excursion
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Percussion and Auscultation of Chest
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Respiratory Effort

Assess:

Respiratory rate, rhythm, symmetry, and quality
 Patient position
 Accessory muscles
 Retractions (intercostal, supraclavicular, or both)
 Nasal flaring
 Pausing to take a breath
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Respiratory Patterns








Eupnea
Tachypnea
Bradypnea
Hyperpnea
Hyperventilation
Dyspnea
Orthopnea
Paroxysmal nocturnal
dyspnea





Apnea
Cheyne-Stokes
respiration
Kussmaul breathing
Biot’s respirations
Central neurogenic
hyperventilation
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Auscultation

Patient in sitting position (if possible)

Instruct to breathe deeply and slowly through
open mouth

Use diaphragm of stethoscope

Evaluate anterior and posterior lung fields
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Normal Breath Sounds

Classified as:



Vesicular
Bronchovesicular
Bronchial
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Vesicular Breath Sounds

Most of lung fields

Lungs considered "clear"
make normal vesicular
breath sounds

Harsh vesicular breath
sounds

Diminished vesicular
breath sounds
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Bronchovesicular Breath Sounds

Major bronchi and
upper right posterior
lung field

Louder and harsher
than vesicular breath
sounds
 Medium pitch
 Equal inspiration and
expiration phases
 Heard throughout
respiration
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Bronchial Breath Sounds

Only over trachea

Highest in pitch

Coarse, harsh, loud sounds

Short inspiratory phase and
long expiration

Bronchial sound anywhere but
over trachea is abnormal
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Abnormal Breath Sounds

Absent

Diminished

Incorrectly located
bronchial sounds

Adventitious


Discontinuous
Continuous
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Breath Sounds
Fig. 11-26
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Discontinuous Breath Sounds

Crackles

Formerly called rales
 High-pitched discontinuous sounds
 Usually at end of inspiration
 Disease of small airways or alveoli
 Coarse crackles: wet, low-pitched sounds
 Fine crackles: dry, high-pitched sounds
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Continuous Breath Sounds

Wheezes

Rhonchi

Stridor

Pleural friction rub
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Heart

Assessment includes:


Palpation
Auscultation
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Pulse

Assess:




Rate
Rhythm
Intensity
Palpate pulses simultaneously on both sides
of body

Except carotid
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Pulse

Auscultate for:




Frequency (pitch)
Intensity (loudness)
Duration
Timing in cardiac cycle
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Auscultating Heart Sounds
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Heart Sounds

S1


Instruct patient to breathe normally and then hold
breath in expiration
S2

Instruct patient to breathe normally again and then
hold breath in inspiration
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Pericardial Friction Rub

Inflammation of pericardial sac

Scratching, grating, or squeaking quality


Louder during inspiration
Differs from pleural friction rubs by continued
presence during breath holding
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Heart Murmurs

Prolonged extra sounds

Caused by disruption in flow of blood through
heart



Most caused by valvular defects
Some serious
Others benign
• Have no apparent cause
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Bruit

Abnormal sound or
murmur

Heard while
auscultating carotid
artery, organ or gland



May be local obstruction
Often low pitched
Hard to hear
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Thrills

Vibrations or tremors

May indicate blood flow obstruction

May palpate over aneurysm or on precordium
 Serious or benign
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Abdomen

Two imaginary lines
separate abdominal
region into four
quadrants
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Abdomen—Inspection

Skin

Umbilicus

Contour

Abdominal movement
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Abdomen

Auscultation



Bowel sounds
Bruits
Percussion and palpation

Detect:
• Fluid
• Air
• Solid masses
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Percussion

Evaluate four quadrants of abdomen:



Tympany
• Air in stomach and intestines
Dullness
• Solid abdominal organs and solid masses
Proceed from tympany to dullness

Change in sound easier to detect
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Palpation of the Liver
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Palpation of the Spleen
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Female Genitalia

If possible, use same-gender paramedics to
examine


Chaperone if possible
Inspect external genitalia for:






Swelling
Discoloration or redness
Bleeding
Trauma
Lesions
Discharge
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Female Genitalia

Normal vaginal discharge

Clear or cloudy with little or no odor

Yellow-green discharge

Frothy, gray-green discharge with foul odor

White, curdlike discharge with no odor

Gray discharge with fishy, foul odor
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Male Genitalia

Inspect for bleeding or trauma

Penis



Urethral opening


Shaft nontender and flaccid
Priapism
Free of blood and discharge
Scrotum

Nontender and slightly asymmetrical
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Male Genitalia

Anus



Exam indicated if:
• Rectal bleeding
• Trauma to area
Most patients find side-lying position most
comfortable
Protect patient’s privacy
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Male Genitalia

Inspect sacrococcygeal and perineal areas for:

Lumps
 Ulcers
 Inflammation
 Rashes
 Excoriations

Inflamed external hemorrhoids common

Adults and pregnant women
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Musculoskeletal System

Assess function and structure

Patient position




Evaluate head, neck, shoulders, and upper
extremities with patient in a sitting position
Evaluate chest, back, and ilium with patient standing
Evaluate hips, knees, ankles, feet with patient supine
Observe general appearance, body proportions,
and ease of movement
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
General Principles

Examine normal tissues before those injured,
inflamed, or otherwise affected

Inspect and palpate each body part


Then test range of motion and muscle strength
Note differences between right and left
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Extremities

Evaluate:





Skin and tissue over muscles, cartilage, bones
Joints for injury, discoloration, swelling, masses
Circulatory status
• Skin color and temperature
• Distal pulses
Structural integrity of bones, joints, and tissues
Muscle tone
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Abnormal Findings

Signs of inflammation

Swelling
 Tenderness
 Increased heat
 Redness of overlying
skin
 Decreased function

Asymmetry
 Crepitus
 Deformities
 Decreased muscle
strength
 Atrophy
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Joints

Bones move freely over one another


Move each joint through full range of motion


No clicks, crepitation, or pain
Normal if no pain, deformity, limitation, or
instability
Note:


Limited range of motion
Unusually increased joint mobility
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Hands and Wrists

Inspect for swelling,
redness, deformity,
nodules, muscular atrophy

Palpate joint

Note swelling, tenderness,
deformity

Range of motion

Test muscle strength by
hand grip
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Elbows

Inspection



Palpation



Examine in flexed and extended
position
Note deformity, swelling,
nodules
Lateral and medial epicondyles
of humerus
Groove on sides of olecranon
process
Range of motion
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Shoulders and Related Structures

Inspect shoulders, shoulder girdle,
scapulae, and related posterior muscles


Symmetry of size and shape
Note swelling, deformity, muscular atrophy
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Shoulders and Related Structures

Palpate for tenderness in:






Sternoclavicular joint
Acromioclavicular joint
Subacromial area
Biceps groove
Note any tenderness or swelling
Range of motion
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Shoulders and Related Structures
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Ankles and Feet

Skin integrity

Nodules

Contour

Swelling

Position

Calluses

Deformities

Corns

Size
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Ankles and Feet

Palpate:




Anterior aspects of each ankle joint
Achilles tendon
Metatarsophalangeal joints
Note tenderness, swelling, deformity
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Ankles and Feet

Range of motion
 Dorsiflexion
 Plantar flexion
 Inversion
 Eversion
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Pelvis

Pelvic structural
integrity

Hands on anterior iliac
crests
• Press down and out

Heel of hand on
symphysis pubis
• Press down
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Hips

Inspect for symmetry

Palpate:


Instability, tenderness, and crepitus
Range of motion (supine patient)

Raises knee to chest, other leg straight
 Note flexion at hip and knee
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Knees

Inspection




Palpation


Patella smooth, firm, nontender, midline
Alignment, swelling, and deformity
Note atrophy of quadriceps
Note thickening, swelling, tenderness
Range of motion

Bend, straighten each knee without pain
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Peripheral Vascular System

Arteries, veins,
lymphatic system
and lymph nodes,
fluids exchanged in
capillary bed
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Arms

Inspect fingertips to shoulders, noting:






Size and symmetry
Swelling
Venous pattern
Color of skin and nail beds
Skin texture
Palpate:


Radial pulses bilaterally
Epitrochlear node
• If palpable, note its size and consistency
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Legs

Patient supine and appropriately draped

Inspect from groin and buttocks to feet:

Size and symmetry
 Swelling
 Venous pattern and venous enlargement
 Pigmentation
 Rashes, scars, ulcers
 Color and texture of the skin
 Presence or absence of hair growth
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Legs

Palpate superficial inguinal nodes


Palpate pulses:





Swelling and tenderness
Femoral
Popliteal
Dorsalis pedis
Posterior tibial
Temperature of feet and legs
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Legs

Check for pitting edema:

Press firmly but gently with the thumb for at least 5
seconds
• Over dorsum of foot
• Behind medial malleolus
• Over shins
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Abnormal Findings

Swollen or asymmetrical extremities

Pale or cyanotic skin

Weak or diminished pulses

Skin cold to the touch

Absence of hair growth

Pitting edema
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Spine

Inspection



Cervical, thoracic, and
lumbar curves
• Lordosis (swayback)
• Kyphosis (hunchback)
• Scoliosis (razorback)
Height differences of
shoulders
Height differences of iliac
crest
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Cervical Spine

Inspection



Should be in a midline position
Look for deformities and abnormal posture
Palpation

If patient is alert and denies neck pain, palpate
posterior aspect of neck for point tenderness and
swelling
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Cervical Spine

Range of motion

If no suspected injury:
• Bend head forward, chin
to chest (flexion)
• Bend head backward
(hyperextension)
• Move head side-to-side
(lateral bending)

Should be no pain or
discomfort
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Thoracic and Lumbar Spine

Inspect for injury, swelling, discoloration

Palpate from first thoracic vertebra


Move downward to sacrum
Range of motion

Bend forward at waist
 Bend backward at waist
 Bend to each side
 Rotate upper trunk in a circular motion
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Nervous System

Detail of neurological examination varies

Depends on patient’s complaint
• Peripheral nervous system vs. CNS problems
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Neurological Examination

Mental status and speech

Cranial nerves

Motor system

Sensory system

Reflexes
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Mental Status and Speech

Oriented to person, place, and time

Organizes thoughts and converses freely

If no hearing or speech impediments
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Mental Status and Speech

Abnormal findings

Unconsciousness
 Confusion
 Slurred speech
 Aphasia
 Dysphonia
 Dysarthria
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Cranial Nerve Assessment

Cranial nerve I


Cranial nerve II


Olfactory: Test sense of smell with spirits of ammonia
Optic: Visual acuity
Cranial nerve II and III

Optic and oculomotor
• Size and shape of pupils
• Pupil response to light
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Cranial Nerve Assessment

Cranial nerves III, IV, VI


Oculomotor, trochlear, abducens
• Extraocular movements
• Six cardinal directions of gaze
Cranial nerve V

Trigeminal
• Ask patient to clench teeth while palpating temporal and
masseter muscles
• Test sensation by touching forehead, cheeks, jaw on
each side
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Cranial Nerve Assessment

Cranial nerve VII

Facial
• Inspect face: note symmetry, tics, abnormal movements
• Raise eyebrows, frown, show both upper and lower
teeth, smile, puff out cheeks
• Close eyes tightly so they cannot be opened, gently
attempt to raise eyelids
• Observe for weakness or asymmetry

Cranial nerve VIII

Acoustic: Assess hearing acuity
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Cranial Nerve Assessment

Cranial nerves IX and X

Glossopharyngeal and vagus
• Ability to swallow with ease; to produce saliva; produce
normal voice sounds
• Patient holds breath: assess for normal slowing of heart
rate
• Testing for gag reflex will test cranial nerves
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Cranial Nerve Assessment

Cranial nerve XI


Spinal Accessory
• Raise and lower shoulders, turn head
Cranial nerve XII

Hypoglossal
• Stick out tongue and move it in several directions
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Motor System

Observe patient during movement and at rest

Abnormal involuntary movements evaluated
for:




Quality
Rate
Rhythm
Amplitude
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Motor System

Other body movement assessments:

Posture
 Level of activity
 Fatigue
 Emotion
 Muscle strength

Bilaterally symmetrical

Resistance to opposition
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Muscle Strength

Patient to move against resistance:






No muscular contraction detected
A barely detectable flicker or trace of contraction
Active movement of body part with gravity
eliminated
Active movement against gravity
Active movement against gravity and some
resistance
Active movement against full resistance
• This is normal muscle tone
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Upper Extremity Evaluation

Patient to extend
elbow and pull it
toward the chest
against resistance
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Lower Extremity Evaluation

Patient pushes
soles of feet against
examiner’s palms


Patient pulls toes
toward head against
resistance
Should be easily
performed by patient
without fatigue
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Muscle Strength

Other methods can be used to evaluate
muscle strength, including tests for:

Flexion
 Extension
 Abduction
 Upper and lower extremities
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Coordination

Point-to-point movements

Gait

Stance

Romberg test

Pronator drift test
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Romberg Test
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Pronator Drift Test
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Sensory System

Conduct sensations of:

Pain
 Temperature
 Position
 Vibration
 Touch

A healthy patient is responsive to these
stimuli
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Sensory System

Patient’s response to pain and light touch


Response considered in relation to dermatomes
Perform light touch on hands and feet

If patient cannot feel or is unconscious, gently
prick extremities with sharp object that will not
penetrate skin

Head to toe

Compare symmetrical areas
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Approaching the Pediatric Patient

Remain calm, confident

Avoid separating child from parent

Establish rapport with parents and child

Be honest with child and parent

Have one paramedic stay with child
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Approaching the Pediatric Patient

Observe child before physical examination


Begin assessment without touching patient
Note:




Skin color
Level of consciousness
Respiratory rate
Assess behavior
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Approaching the Pediatric Patient

Note area of body that appears painful


Avoid painful area until end of examination
Warn child before you touch painful area(s)
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
General Appearance

Assess from a distance:






Level of consciousness
Spontaneous movement
Respiratory effort
Skin color
Body position
Seriously ill or injured child does not
hide or disguise condition
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Birth to 6 Months

Maintain body temperature

Poor head control normal under 3 months of
age

Infants are abdominal breathers

Stomach protrudes and chest wall retracts during
inspiration
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Birth to 6 Months

Assess anterior
fontanel:



Present up to 18 months
Bulges during crying
Firm if child is supine
• If sunken, may be
dehydration
• Bulging fontanel may
mean increased
intracranial pressure
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
7 Months to 3 Years







Usually cooperative
Minimal speech, unreliable history
May have separation anxiety
If possible, have parent hold child for exam
May see illness or injury as punishment
Approach slowly and speak in reassuring
tones
Use simple and direct questions
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
4 to 10 Years








May be cooperative
May provide limited history of event
May have separation anxiety and view illness
or injury as punishment
Approach slowly
Speak in quiet, reassuring tones
Allow child to "help"
Reluctant to show "private parts“
Advise of any expected pain or discomfort
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Adolescents (11 to 18 years)






Generally calm, mature, helpful
Concerned about modesty, disfigurement,
pain, disability, and death
Reassure when appropriate
Respect patient's need for privacy
If possible, interview privately
Consider alcohol, drug use, pregnancy
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Communicating with the Older Adult

Allow time for effective communication

Stay close to patient during interview

Repetition of questions may be needed

Do not patronize or offend patient
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Patient History

Multiple health problems

Difficult to isolate injury or illness

Decreased sensory function may disguise signs and
symptoms

Watch for illness from medication use or misuse

Consider relationship between drug interactions,
disease, and aging process
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Patient History

Functional ability and daily activities

Walking
 Getting out of bed
 Dressing
 Driving a car
 Using public transportation
 Preparing meals
 Taking medications
 Sleeping habits
 Bathroom habits
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Physical Examination





Try to ensure patient comfort
Offer clear explanations
Answer questions
Be alert to chronic pain
If hospital transport necessary



Attempt to calm patient
Reassure patient he or she will be cared for in
hospital
Record examination findings
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Conclusion
The paramedic must have a wide range of
knowledge and skills to perform a
comprehensive physical examination and to
make effective clinical patient care decisions.
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Questions?
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.