3 Taking Medication Histories
Chapter 4 Physical Assessment Skills
A, Left peripheral visual fields. B, Right peripheral visual fields
(From Jarvis C: Physical examination and health assessment, ed 5, St Louis, 2008, Saunders.)
Full-size image (30K) Figure 4-30.
Range of Peripheral Vision.
(From Jarvis C: Physical examination and health assessment, ed 5, St Louis, 2008, Saunders.)
•
Assess the extraocular muscles by having the patient follow the movements of your finger with his or her eyes (keeping the head stationary) as the finger is moved in all the six cardinal directions to test elevation, depression, adduction, abduction, extorsion, and intorsion (Figure 4-31) (Box 4-5). The eyes normally follow the finger smoothly and in parallel with the movements; however, lateral nystagmus may occur normally.
Abnormalities indicate either problems with the cranial nerves that supply the eye muscles (II, IV, VI) or problems with the eye muscles themselves. Patients taking phenytoin may have far lateral nystagmus with therapeutic serum drug concentrations;
vertical nystagmus may occur with phenytoin toxicity.
Full-size image (42K) Figure 4-31.
Extraocular Muscles. Associated six cardinal directions of gaze and extraocular muscles.
(From Seidel HM: Mosby’s guide to physical examination, ed 6, St. Louis, 2006, Mosby.)
Box 4-5.
Extraocular Movements Checklist
o
□ Instruct the patient to watch your finger.
o
□ Hold your finger about 10 inches in front of the patient’s face.
o
□ Test each vertical movement.
o
□ Test each lateral movement.
o
□ Test each corner-to-corner movement (upper lateral to lower medial).
o
□ Test each corner-to-corner movement (lower lateral to upper medial).
o
□ Report/record the results. (Example: The extraocular muscles are intact.)
•
Note the position and alignment of the eyes. If exophthalmos (abnormal protrusion of the eyeball) is observed (Figure 4-32), inspect the eye from above and note the relationship of the cornea to the eyelids. Inspect the eyelids for color, lesions, edema, and condition of the eyelashes. Inspect the conjunctiva for color and edema and the cornea and lens for opacities. Assess the corneal blink reflex by lightly touching the cornea with a tissue; the normal reflex is to blink. Exophthalmos is commonly associated with Graves’ disease.
Cataracts (Figure 4-33) are characterized by progressive clouding of the lens.
Conjunctival injection is commonly observed in patients with seasonal and perennial
allergic rhinitis. Bimatoprost, used to treat eyelash hypotrichosis, may darken the eyelid.
Full-size image (13K) Figure 4-32.
Exophthalmos.
(From Stain HA, et al: The opthalmic assistant: fundamentals and clinical practice, ed 6, St Louis, 1994, Mosby.)
Full-size image (20K) Figure 4-33.
Cataract.
(From Swartz MH: Textbook of physical diagnosis: history and examination, ed 6, St Louis, 2004, Mosby.)
•
Inspect the iris and pupil for size, shape, and equality. Assess the iris for abnormal pigment or deposits. Ophthalmic prostaglandins (e.g., latanoprost) may darken the eyelids and increase iris pigmentation. Test the pupillary reaction to light by briefly flicking a light on the pupil and noting the direct and consensual (opposite eye) response;
both pupils normally constrict in response to the light stimulus (Box 4-6). Test the pupillary reaction to accommodation by instructing the patient to focus on an object (usually your finger) from several feet away and then noting the pupillary constriction and convergence (“cross-eyed” response) of the eyes as the object is brought to within a few centimeters in front of the patient’s eyes (see Box 4-6). Drugs with anticholinergic properties (e.g., amitriptyline, imipramine, atropine) cause pupillary dilation (mydriasis).
Drugs that cause pupillary constriction (miosis) include opioid narcotics (e.g., morphine)
and benzodiazepines (e.g., alprazolam). Fixed and dilated pupils indicate brainstem damage, and pupil examination is part of brain death assessment protocols.
Box 4-6.
Pupillary Response to Light and Accommodation Checklist Pupillary Response: Left Eye
o
□ Briefly shine the light on the left eye.
o
□ Report/record the left pupillary response. (Example: The left eye pupil constricted.)
o
□ Report/record the consensual eye response. (Example: The right eye pupil constricted.)
Pupillary Response: Right Eye
o
□ Briefly shine the light on the right eye.
o
□ Report/record the right pupillary response. (Example: The right eye pupil constricted.)
o
□ Report/record the consensual eye response. (Example: The left eye pupil constricted.)
Accommodation
o
□ Hold your finger in front of the patient’s eyes from a distance of about 18 inches.
o
□ Instruct the patient to watch your finger.
o
□ Slowly move your finger in toward the patient’s nose until it almost touches the nose.
o
□ Report/record the pupillary response. (Example: The pupils constricted.)
•
Inspect the fundi with the ophthalmoscope (Box 4-7). Select the appropriate aperture (see Table 4-4) (e.g., select the smallest beam of light to assess the undilated eye). Hold the ophthalmoscope in the right hand to examine the patient’s right eye and in the left hand to examine the patient’s left eye. Place the index finger on the diopter wheel (Figure 4- 34). Look through the ophthalmoscope with the right eye to examine the patient’s right eye; use your left eye to examine the patient’s left eye. Prefocus the ophthalmoscope on the wrinkle of the palm of your hand placed a few inches in front of your face; this adjusts the ophthalmoscope to your eye and saves time when focusing on the patient’s eye. Place the hand not holding the ophthalmoscope on the patient’s forehead; this steadies the patient’s head and prevents you from bumping into the patient’s forehead during the examination. If necessary, use the thumb of this hand to gently lift up the patient’s eyelid. Instruct the patient to look straight ahead. Aim the beam of light at the pupil from a distance of about 15 inches and slightly lateral to the patient’s line of vision (Figure 4-35). The light beam is on target when the eye appears red-orange (the red reflex); the red-orange color is the light reflecting from the retina. Move straight in toward the patient, never losing the red reflex, until your forehead nearly touches the patient’s forehead (Figure 4-36). Focus by changing diopter settings (one diopter at a time) until the internal structures of the eye are in clear focus. The back of the eye is curved; any side to side, in and out, or up and down movement changes the focal distance, requiring constant refocusing.
Box 4-7.
Ophthalmoscopy Checklist
o
□ Instruct the patient to stare straight ahead.
o
□ Select the appropriate beam.
o
□ Focus the scope on the palm of the hand before attempting to look in the patient’s eye.
o
□ Hold the scope correctly (right hand, right eye, right eye; left hand, left eye, left eye).
o
□ Steady the patient’s head by placing the nonscope hand on the patient’s forehead with the thumb on the eyebrow.
o
□ Shine the light on the patient’s eye from about 15 inches and lateral to the eye.
o
□ Move in toward the patient’s eye until about 2 inches from the eye.
o
□ Refocus the scope.
o
□ Inspect all quadrants of the fundus.
o
□ Report/record the results. (Example: Normal vessels, disc, and cup/disc ratio.)
Full-size image (26K) Figure 4-34.
How to Hold the Ophthalmoscope.
Hold the ophthalmoscope in the right hand to inspect the right eye; hold the ophthalmoscope in the left hand to inspect the left eye.
(From Jarvis C: Physical examination and health assessment, ed 5, St Louis, 2008, Saunders.)
Full-size image (30K) Figure 4-35.
Red Reflex.
Locate the red reflex.
(From Swartz MH: Textbook of physical diagnosis: history and examination, ed 6, St Louis, 2004, Mosby.)
Full-size image (29K) Figure 4-36.
Retinal Assessment.
Examine the retina.
(From Swartz MH: Textbook of physical diagnosis: history and examination, ed 6, St Louis, 2004, Mosby.)
•
Inspect the retinal blood vessels, optic disc, physiologic cup, macula, and retina through the ophthalmoscope (Figure 4-37). Inspect the retina, the red-orange area on which the other structures are located, for lesions (Table 4-9). The retinal blood vessels are usually the first structures seen. The retinal arteries and veins emerge from the optic disc and have the highest density in the vicinity of the optic disc. Retinal arteries are thinner and brighter red than retinal veins. Note the size, color, and status of the arteriovenous crossings in all regions of the eyes.
Full-size image (19K) Figure 4-37.
Retinal Anatomy.
(From Jarvis C: Physical examination and health assessment, ed 5, St Louis, 2008, Saunders.)
Table 4-9. Retinal Lesions
Description Cause
Red, linear, or flame shaped Bleeding in nerve fiber retinal layer Red, round Bleeding in deeper retinal layers
Black Retinitis pigmentosa, melanoma, retinal degeneration White cotton-wool appearance Hypertension, diabetes
•
The optic disc, the head of the optic nerve (also known as the blind spot) is a yellowish ovoid 1.5 mm in diameter with sharp margins (the margins closest to the nose may be blurred), The physiologic cup, the depressed center of the optic disc, is lighter in color than the optic disc and normally occupies about one third of the diameter of the optic disc (cup/disc ratio). Inspect the optic disc for size, shape, and sharpness of the borders and estimate the cup/disc ratio. Glaucoma is characterized by an increased cup/disc ratio (Figure 4-38).
Full-size image (23K) Figure 4-38.
Glaucomatous Cupping.
The cup/disc ratio is approximately 50%.
(From Swartz MH: Textbook of physical diagnosis: history and examination, ed 6, St Louis, 2004, Mosby.)
•
The macula is a small, round, and extremely light-sensitive area located about two disc diameters temporally from the optic disc in an area nearly free of retinal blood vessels.
The red-free filter is used to inspect the macula. The fovea is the slightly depressed area in the center of the macula.
Palpation
•
Skull: Palpate the skull for lumps, bumps, and evidence of trauma.
•
Hair: Palpate the hair for texture (coarse, fine, dry, oily).
•
Thyroid gland: Palpate the thyroid gland for size, shape, symmetry, tenderness, and nodules.
•
Lymph nodes: Palpate the lymph nodes (see Figure 4-25) for size, shape, mobility, and tenderness.
•
Sinuses: Palpate the frontal, ethmoid, and maxillary sinuses for tenderness (see Figure 4- 26).
•
External ear: Palpate the external ear for nodules.
Auscultation
•
Thyroid gland: If the thyroid gland is enlarged, auscultate the thyroid for the presence of a thyroid bruit.
•
Carotid arteries: Auscultate the carotid arteries for carotid artery bruits.
Hearing
A commonly used but relatively inaccurate assessment of hearing is to test, one ear at a time, the ability of the patient to hear a sequence of equally accented syllables (e.g., three-five-two-four) whispered from a distance of a couple of feet. The Rinne test compares sensitivity with bone and air conduction (Figure 4-39). Place the tip of a vibrating tuning fork (128 or 512 Hz) on the mastoid process behind the ear; this tests hearing with bone conduction. Instruct the patient to signal when he or she no longer hears the vibrating tuning fork. Remove the tuning fork from the mastoid process and hold the prongs in front of but not touching the ear canal; this tests hearing with air conduction. Normally, hearing is better with air conduction than with bone conduction;
that is, the patient can once again hear the vibrating tuning fork when the tuning fork is moved from the mastoid process to in front of the ear canal. To perform the Weber’s test, place the tip of a vibrating tuning fork on the center of the patient’s forehead (Figure 4-40). Normally, sound is heard equally well in both ears. In conduction hearing loss, the sound is heard best in the impaired ear; in unilateral sensorineural hearing loss, the sound is heard best in the unimpaired ear. Audiometry is used to establish baseline hearing and identify drug-induced hearing loss.
Full-size image (41K) Figure 4-39.
Rinne Test.
Place the tip of the vibrating tuning fork on the mastoid process (A). Hold the prongs in front of the patient’s ear (B) when the patient can no longer hear the vibrating tuning fork on the mastoid process.
(From Swartz MH: Textbook of physical diagnosis: history and examination, ed 6, St Louis, 2004, Mosby.)
Full-size image (72K) Figure 4-40.
Weber’s Test.
A, Conductive hearing loss; the vibrating tuning fork is heard best on the affected side. B, Sensorineural hearing loss; the vibrating tuning fork is heard best on the unaffected side.
(From Swartz MH: Textbook of physical diagnosis: history and examination, ed 6, St Louis, 2004, Mosby.)
Terminology
•
acromegaly: A pituitary disorder characterized by a massive face with enlarged lower jaw, prominent nose and eyebrows, and coarse facial features and large hands and feet
•
arteriovenous (AV) nicking: An abnormality visualized on funduscopic examination and associated with hypertension; at AV crossings the vein appears to stop abruptly on either side of the arteriole
•
arteriovenous (AV) tapering: An abnormality visualized on funduscopic examination and associated with hypertension; at AV crossings the vein appears to taper off on either side of the arteriole
•
astigmatism: A condition characterized by unequal curvature of the cornea
•
audiometry: A test used to determine hearing levels
•
Bell’s palsy: Unilateral paralysis of the facial nerve
•
Chvostek’s sign: Contraction or spasm of the facial muscles associated with tetany and hypocalcemia; elicited by tapping the face sharply with a finger just in front of the external auditory meatus over the facial nerve
•
conjunctival injection: Dilated conjunctival vessels
•
copper wires: An abnormality visualized on funduscopic examination and associated with hypertension; a coppery strip of light appears along the surface of the blood vessel
•
corneal arcus: A thin, gray-white circle around the cornea; associated with aging
•
deep hemorrhage: An abnormality visualized on funduscopic examination and associated with diabetes; appears as small, irregular red spots in the retina
•
exophthalmos: Abnormal protrusion of the eyeball; associated with Graves’ disease
•
fetor hepaticus: A musty odor of the breath associated with severe parenchymal liver disease
•
fissured tongue: Increased tongue fissures; benign; sometimes associated with aging
•
flame hemorrhage: An abnormality visualized on funduscopic examination; associated with hypertension; appears as small, linear retinal hemorrhages
•
geographic tongue: Denuded areas of papillae; benign
•
hairy tongue: Elongated papillae; benign; associated with antibiotic therapy
•
hirsutism: Increased hair growth in androgen-sensitive areas (e.g., beard or mustache areas); associated with ovarian, adrenal, thyroid, and pituitary disorders and some medications
•
hyperopia: Farsightedness
•
Koplik’s spots: Small blue-white spots with red margins found on the mucous
membranes near the parotid duct; associated with measles; appear before the skin lesions are visible
•
microaneurysm: An abnormality visualized on funduscopic examination; associated with diabetes; appears as a tiny red spot in the macular area
•
muddy sclera: Brownish sclera; benign; commonly found in dark-skinned individuals
•
myopia: Nearsightedness
•
normocephalic, atraumatic: A physical examination finding meaning that the head is of normal size and shape and no evidence of trauma is present
•
palpebral fissure: The space between the upper and lower eyelids when the eyes are open
•
periorbital edema: Puffiness of the upper and lower eyelids
•
Rinne test: A hearing test that compares air and bone conduction
•
smooth red tongue: Finding associated with deficiencies of vitamin B12, niacin, and iron
•
Weber’s test: A hearing test that compares bone conduction in both ears
•
xanthelasma: Yellow, raised, well-circumscribed plaques found in the skin around the eyelids; associated with hypercholesterolemia
Chest and Lungs
Assessment of the chest and lungs requires a clear understanding of pulmonary anatomy,
landmarks, and reference points (Figure 4-41). The ribs, clavicle, scapula, and vertebrae serve as useful landmarks (Figure 4-42). Count ribs on the anterior chest by placing a finger in the
substernal notch and sliding the finger from the substernal notch left or right to the space between the first and second ribs; count the intercostal spaces or ribs from that point. On the posterior chest, the spinous process of the seventh cervical vertebra is quite prominent when the neck is flexed forward. The first thoracic vertebra is just below the seventh cervical vertebra;
count the vertebrae from that point. Vertical reference points include the midsternal,
midclavicular, anterior axillary, midaxillary, posterior axillary, scapular, and vertebral lines.
Full-size image (69K) Figure 4-41.
Thorax Topography.
A, Anterior landmarks. B, Posterior landmarks. C, Lateral landmarks.
(From Jarvis C: Physical examination and health assessment, ed 5, St Louis, 2008, Saunders.)
Full-size image (67K) Figure 4-42.
Thorax Topography.