StepbyStep 52 step exam breakdown Dr Alexander Steps

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

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

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

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

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

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

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.

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

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

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

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

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

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

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

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

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

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?

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

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

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

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 5 th ICS, 7 -9 cm lateral to midsternal line

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

Step 22 • Auscultate carotid arteries • - Listen w/ bell – common to hear S 1 • - 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)

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

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

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

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.