Step-by-Step

1. Step-by-Step 52-step exam breakdown Dr. Alex Alexander

2. Steps 1 • Use whatever method you are comfortable with to determine obesity or underweight status RED FLAGS: Unexplained recent weight gain or weight loss

3. Step 2 • Wash hands • Can start step #3 while washing hands and chat • § Family § Occupation § Recreation § Message • MENTAL HEALTH CONCERNS, Level of Consciousness

4. Step 3 • Inspect general appearance • - What you write can help you to remember who each pt is and what they look like. Record signs of distress or anxiety, level of awareness, skin color, odor (body and breath), speech, clarity, wt • Inappropriately dressed, not oriented to time and place, etc

5. Step 4 • Check oral temperature • Alarm bells when: An adult has a fever that doesn't respond to medication, is consistently 103 F (39.4 C) or higher, or lasts longer than three days

6. Step 5 • Palpate, compare, count radial pulse • Normal 60-100 • There are many causes of tachycardia and all need to be evaluated

7. Step 6 • Count respiratory rate • - Check by visual examination Can place hand on shoulder or abdomen • - Normal 14-20 Tachy > 24 Brady < 10 • Tachypnea and Bradypnea must be evaluated.

8. Step 7 • Measure blood pressure • Normal <120 <80 / PreHTN 120-139 80-89 • Stage 1 HTN 140-159 90-99 • Stage 2 HTN >160 >100 • https://www.nhlbi.nih.gov/files/docs/resources/heart/phycard.pdf

9. Step 8 • Inspect skin and nails • - Look for lesions • - Check for capillary refill – indicates perfusion status (nl 2-4 sec) • Refer suspicious looking skin and nail lesions for evaluation

10. Step 9 • Inspect head, hair and face • WORST HEADACHE EVER- refer.

11. Step 10 • Inspect eyes (position, alignment, conjunctiva, sclera, lids)

12. Step 11 • Inspect cornea, lens, PERRLA, corneal reflections • Cornea & lens Shine pen light laterally (oblique lighting) Iris • Pupils: § Test pupillary reactions to light – direct, consensual § Test the near reaction – accommodation • § Chart PERRLA (pupils are equal, round, and reactive to light and accommodation) Corneal reflections • REFER any abnormal finding

13. Step 12 • Examine external ears • - Inspect auricle, ear canal • - Hold and move auricle • - Press on tragus and mastoid process • Red Flag: mastoiditis if tender mastoid process

14. Step 13 • Examine nose & sinuses • transilluminate maxillary and frontal

15. Step 14 • Inspect lips, tongue, teeth, buccal and labial mucosa, pharynx • - Can put on gloves for step #17 now

16. Step 15 • Inspect neck (trachea, veins) • - Inspect trachea • If not deviated, chart “trachea midline” • § Atelactasis is only pathology that causes trachea to deviate towards the affected side

17. Step 16 • Inspect and palpate thyroid • - Inspect thyroid • Use tangential lighting • Inspect region below cricoid cartilage for gland • Ask pt to swallow and can actually see gland moving if there is a mass?

18. Step 17 • Examine posterior chest • - Stand behind pt and open gown to observe post chest wall • - Look at skin • - Note shape and movement during respiration

19. Step 18 • Percuss posterior and lateral chest • Percuss seven areas

20. Step 19 • Auscultate posterior and lateral chest • Vesicular Bronchovesicular Bronchial Tracheal • If you hear something out of place - refer.

21. Step 20 • Inspect precordium • - Pt is supine with head elevated to 30° • - Tangential lighting is best (overhead light off) • - Put L arm over head – externally rotate • - Inspect and palpate apical impulse (AI) • Usually located at 5th ICS, 7-9cm lateral to midsternal line

22. Step 21 • Auscultate heart • - Areas for auscultation • Aortic: R 2nd ICS, Pulmonic: L 2nd ICS, Mitral: apex, 5th ICS 7-9cm L of midsternal line, Tricuspid: lower L border of sternum • Refer back to PCP if murmur heard

23. Step 22 • Auscultate carotid arteries • - Listen w/ bell – common to hear S1 • - Can ask pt to exhale and hold • - Bruit: a murmur-like sound of vascular rather than cardiac origin (a “boom” is okay, a “whish” is not)

24. Step 23 • Auscultate abdomen and mid-epigastrium; Auscultate femoral areas • Bowel sounds first • Absent bowel sounds and abdominal pain may equal obstruction

25. Step 24 • Palpate tibial and pedal pulses • - Palpate both sides at the same time to compare • Dorsalis pedis pulse • Posterior tibial pulse – just posterior to medial malleoli

26. Step 25 • Check for pre-tibial edema • - Use thumbs, squeeze for 5 sec, let go • On top of tibia Dorsum of foot, Post to med malleolus

27. Step 26 • Inspect and percuss abdomen • Patient tells you they have had blood in stool, coffee ground in stool or clay colored stool, refer for possible GI bleed.

28. Step 27 • Palpate abdomen • Chandelier sign over gallbladder (murphy’s), refer. Hepatosplenomegaly refer. Urgent referral if board rigid abdomen.

29. Step 28 • Palpate bimanually for liver

30. Step 29 • Palpate bimanually for spleen

31. Step 30 • Palpate for cervical nodes

32. Step 31 • Palpate axillary and epitrochlear nodes

33. Step 32 • Palpate femoral nodes

34. Step 33 • Examine joints

35. Step 34 • Test ROM of lower extremity

36. Step 35 • Test ROM of upper extremity

37. Step 36 • Inspect and percuss spine and renal angles • Positive “kidney punch” = refer for UTI

38. Step 37 • Test ROM of cervical spine

39. Step 38 • Test ROM of lumbar spine

40. Step 39 • Check visual acuity (CN II)

41. Step 40 • Test EOM (CN III, IV, VI)

42. Step 41 • Check strength of temporalis and masseter (CN V)

43. Step 42 • Check facial muscles (CN VII)

44. Step 43 • Check auditory acuity (CN VIII)

45. Step 44 • Check phonation, uvula, tongue (CN IX, X, XII) • Tongue deviated= refer, sudden change in voice quality (hoarseness) = refer

46. Step 45 • Check strength of SCM and trapezius (CN XI)

47. Step 46 • Check DTR at biceps, triceps, patellar, Achilles (C 6,7,8) (L3,4) (S1)

48. Step 47 • Check sensory with sharp and light touch on face, trunk and extremities

49. Step 48 • Check gait

50. Step 49 • Assess judgment and insight • Can do MMSE or SLUMS