Hpe Patient Special Tests

History & Physical Exam

Special Tests

Blood Pressure – Auscultatory Gap * Ask about caffeine use in the past 30 minutes * Ask if patient has been sitting for 5 minutes * Ask if patient has any restrictions to taking BP in either arm * Align correctly sized cuff with brachial artery, palpate radial artery * Inflate until radial artery not palpable, add 20mmHg as starting point for auscultation * Orthostatic hypotension is defined as 20mmHg drop between patient positioning Auditory Function – Rinne & Weber Tests * Weber: Strike 512Hz and place handle on center of patient’s forehead * Ask patient which ear the sound can be heard best in or if it is equal * Rinne (said rin-na): Strike 512Hz and place handle on patient’s mastoid process * Have patient tell you when the sound stops (bone conduction), then move the tines in front of the ear (air conduction) and ask if they can hear the sound

Opthalmoscopic – Fundus Exam * Dim room lights, use opthalmoscope with same eye as patient’s eye being examined * Hold patient’s head with other hand to gauge your distance, adjust to 0 diopters * Come toward patient’s eye at a 15-degree angle, looking for a vessel to cross * Follow vessels to cup and disk, measure ratio to compare with other eye * Examine for abnormalities (AV nicking, cotton wool spots, papillary edema) * Have patient look into light briefly to examine macula and fovea * Anterior chamber (perpendicular) lighting: crescent moon diming with glaucoma

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History & Physical Exam

Special Tests

Otoscope – Ear Canal Exam * Palpate tragus and pinna for pain and examine for exudate * Retract pinna up, out, and back (adult) or down, out, and back (child) * Insert otoscope with inverted hold using backhand method or extended 5th digit * Examine canal (exudate, lesions, erythema, cerumen) * Examine tympanic membrane (color, light reflex, boney structure) * Insufflate for mobility of tympanic membrane

Neck – Auscultation & Thyroid * Auscultate of carotid arteries and thyroid for bruits * Hold thyroid from the back of the patient * Have patient swallow (examine for nodules, thyroidmegaly)

Respiratory – Suspected Consolidation * Bronchophony: sound transmitted louder at area of consolidation * Egophony: patient says “e” and sounds like “a” at areas of consolidation * Whispered pectoriloquy: whispered word sounds louder at area of consolidation

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History & Physical Exam Respiratory – Clinical Scenarios Scenario Tactile fremitus Pneumonia Increased Pneumothorax Decreased Pleural effusion Decreased

Special Tests

Percussion Decreased resonance Increased resonance Decreased resonance

Meningitis – Brudzinski & Kernig Tests * Brudzinski sign: Patient supine, passively flex patient’s neck * Positive Brudzinski sign is pain or restricted flexion * Kernig (K for Knee) sign: Patient supine, knees bend, extend lower leg * Positive Kernig sign is pain

Cardiac – Heart Sounds * S1: closure of the AV valves, marks onset of systole * S2: closure of semilunar valves, aortic and pulmonic * S2 split: right side slightly delayed with decreased pressures (A2>P2) * Have patient exhale and hold to resolve physiologic split (not IHSS) * Ejection click: early systole (diseased aortic valve) * Opening snap: early diastole (mitral disease) * S3: rapid deceleration of blood (decreased compliance in adults) * S4: atrial kick against non-compliant ventricle * Crescendo/decrescendo murmur: aortic stenosis * Plateau murmur: mitral regurgitation, tricuspid regurgitation, septal defect * Radiation to neck (aortic stenosis) or axilla (mitral regurgitation)

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History & Physical Exam

Special Tests

Cardiac – Measuring Jugular Venous Pressure Patient supine at 30-degree angle of recumbency Measure height of jugular venous pulse from sternal angle Upper limit for normal is 6cm at 30-degrees of elevation

Cardiac – Heart Sound Special Positioning Left lateral decubitus: mistral stenosis, S3, S4 Sitting, learning forward, breath out and hold: aortic murmur Standing, squatting, valsalva: MVP, aortic stenosis

Cardiac – Hepatojugular Reflex, Edema Hepatojugular reflex: press on right costal margin, examine for jugular vein distension Scale: 0 = none, 1 = ankle, 2 = tibia, 3 = femoral, 4 = sacrum

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History & Physical Exam

Special Tests

Abdomen – Clinical: Ascites, Cholecystitis, Nephrolithiasis Ascites: shifting dullness and fluid wave test Shifting dullness: Patient on side, percuss for dullness, tympany is normal Fluid wave: Patient’s hand mid-abdomen pressing down, tap on patient’s flank Positive fluid wave test is detection of fluid “shock wave” by clinician Cholecystitis: Murphy sign: push up under RCM and hold, have patient breath in deeply Positive Murphy sign is sudden stop in inspiration Nephrolithiasis, hydronephrosis, pyelonephritis: Costovertebral angle tenderness Lloyds punch: costovertebral angle tenderness with percussion

Abdomen – Clinical: Acute Abdomen * Assess for guarding, rigidity, rebound tenderness (push in then let go quickly) * Ask patient what hurts more: pushing in, pushing in slowly/deep, or letting go quickly * Rovsing sign: pain in RLQ with LLQ pressure * Psoas sign: passively extend the thigh of patient with knees extended * Positive psoas sign is pain in the abdomen * Obturator sign: flex hip and externally rotate (painful)

Musculoskeletal – Arthritis * Heberden nodes: distal interphalangeal joint (osteoarthritis) * Bouchard nodes: proximal interphalangeal join (rheumatoid arthritis)

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History & Physical Exam

Special Tests

Cardiac – Allen Test (Modified) * Patient’s palm up, have them clench their fist * Compress radial and ulnar artery * Have patient relax hand, observe pale palm * Release ulnar artery * Normal is pink within 3-5 second, abnormal: repeat, release radial artery

Musculoskeletal – Clinical: Knee Injury * Anterior drawer test: anterior cruciate ligament stability * Varus and valgus stress test: collateral ligament stability * Posterior drawer test: posterior cruciate ligament stability * McMurray sign and Apley grind: meniscal tear * Ballottement: fluid in joint space * Patellar tracking: listen for crepitus

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History & Physical Exam

Special Tests

Musculoskeletal – Clinical: Back Pain * Straight leg raise: patient supine, provider’s hands under heal of patient * Seated straight leg raise: is suspicious of factitious disorder (malingering)

Musculoskeletal – Clinical: Carpal Tunnel, Tenosynovitis * Carpal Tunnel: Phalen sign, Tinel sign * Phalen test: Wrists flexed and together for 90 seconds, mimics sensory deficits * Tinel test: percussing on the carpal tunnel mimics sensory deficits * Tenosynovitis: deQuervain test (thumb in fist, pain with ulnar deviation)

Neurological – Reflex Testing * Scale +0/4 (lower motor neuron) to +4/4 (upper motor neuron), +2/4 is normal * Biceps (C5-6), brachioradialis (C5-6), triceps (C6-7), patellar (L2-4), Achilles (S1-2) * Babinski sign: stroke lateral plantar surface of foot and cross medially at the ball

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History & Physical Exam

Special Tests

Neurological – Cerebellar Function * Rapid alternating moments: have patient pronate and supinate their forearms * Finger to nose: arms outstretched, eyes closed, patient touches nose alternating arms * Pronator drift: arms forward, palms up, close eyes, watch for pronation and drifting * Heel to shin: patient puts one heal on other shin and goes down with good tracking * Tandem walk: heel walking (L5) and toe walking (S1) * Romberg test: feet together, arms out in front, palms up, close eyes, patient is stable

Neurological – Dementia * Perform mini mental status exam, have patient draw the face of a clock Male Genital – Scrotal Mass, Hernia * Scrotal mass: auscultate for bowel sounds, transilluminate scrotum * Hernia detected on scrotal invagination: direct or indirect * Taps on tip of finger: may indicate indirect inguinal hernia * Taps on side of finger: may indicate direct inguinal hernia

Compiled by James Lamberg Version: 09Apr2009

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