Physical exam findings in the dying patient

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A comprehensive list of potential physical exam findings in patients with life threatening illness. Used in conjunction with PPT presentation - Care of the imminently dying patient.

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Physical exam findings in the dying patient

  1. 1. Potential Physical Exam Findings in the Dying Patient<br />Christian Sinclair, MD<br />2010<br />Vital Signs (VS) – Blood Pressure, Heart Rate, Respiratory Rate, I/O, Temp<br />General (GEN): <br />Gender: male, female<br />State of health: acutely ill, chronically ill, robust, vigorous, frail, healthy, cachectic<br />Age relativity: Younger than age, age appropriate, older than age<br />Dress: neatly dressed, +/- hospital gown, disheveled/untidy dress<br />Grooming/hygiene: significant odors (alcohol, acetone/diabetic, ammonia), lack of odors, unshaven, unkempt/uncombed/tousled hair<br />Posture: straight, stooped, rounded shoulders (could be in MSK), sitting forward, upright in bed/chair<br />Alertness: alert, awake, stupor, comatose, lethargic, arousable, obtunded<br />Comfort/Discomfort: appears (un)comfortable, grimacing, no grimace, smiling, frown, no frown<br />Weight: cachectic, slender, obese, morbidly obese<br />+/- sweating<br />+/- chills<br />Skin (DERM):<br />Pale or pallor, jaundice, cyanosis, hyper/hypopigmentation<br />Temperature: warmth, cool<br />Skin turgor<br />Identify lesions (wounds, rash, bruise, skin tear, spider angioma, spider veins, cherry angioma, petichiae, purpura, ecchymosis)<br />Location: arm, leg, torso, back, neck, dermatomal<br />Distribution: Scattered, clustered, diffuse<br />Color +/- ability to blanche<br />Drainage presence/absence<br />Hair:<br />Distribution <br />Quality (fine/coarse)<br />Hair loss / Alopecia / hirsutism<br />Nails:<br />Discolored, pitted, splintered, paronychia, onycholysis<br />Mees’ lines/Beau’s lines<br />Head:<br />Might include hair<br />Scalp, Skull, Face (moon/masked fascies) <br />+/- Omaya reservoir<br />Ears:<br />Auditory acuity: diminished, good, <br />Auricles, canals, drums<br />+/- flattened ear lobes<br />Banded Earring sign<br />Eyes: <br />Check visual acuity<br />Visual fields<br />Position and alignment of the eyes<br />Protrusion, sunken orbits<br />Periorbital edema<br />Lid color/erythema<br />Eyelids – position: dynamically vs. static; open vs. closed vs. slightly ajar/open; coloration/lesions, lid lag, ptosis<br />Sclera/conjunctiva – moist or dry; color (pale, icteric)<br />Cornea, iris, lens – opacified, irregular<br />Pupils reaction to light and accommodation<br />Pupil size (may be important in relation to medications)<br />Anisocoria (unequal pupils)<br />Nystagmus<br />Extraocular movements intact and active, sluggish/delayed<br />Nose/Oropharynx (ENT or NT or OP):<br />+/- nasal cannula/NG/OG<br />+/- epistaxis<br />+/- nasal exudates: clear, mucopurulent, purulent<br />Moist/damp/dry/desiccated/cracked areas including: lips, tongue, oral mucosa<br />Tongue discoloration<br />+/- of OP exudates<br />+/- audible oropharyngeal secretions<br />+/- bleeding gums<br />+/- swelling/warmth/redness of parotid/submandibular sub lingual salivary glands<br />Good/fair/poor dentition, edentulous, upper/lower dentures in place<br />Vocal quality: normal, soft, <br />Peri-oral pallor or cyanosis<br />Fissured/geographic tongue, atrophic glossitis<br />Neck: <br />+/- lymphadenopathy or masses<br />+/- JVD<br />+/- accessory muscle use<br />+/- tracheal deviation<br />Back: <br />Curvature of spine<br />Chest: <br />Presence/Absence of AICD/PPM/Port<br />When indicated by pain, wounds or other symptom examine the breasts<br />Symmetric, masses, tenderness, discharge. Axillary LAD<br />Lungs (PULM):<br />Clear to auscultation bilaterally, no adventitious sounds<br />With Poor/Minimal, fair , good effort<br />Breath sounds: vesicular, broncho-vesicular, bronchial, tracheal<br />+/- prolonged inspiratory or expiratory phase<br />+/- wheeze/stridor, rales, rhonchi including localization and presence of inhalation/exhalation<br />+/- apnea (note frequency and length – i.e 10 sec apnea approx every 20 breaths/few minutes/seconds)<br />+/- breathing pattern/speed – Cheyne Stokes, tachypnea, normal, hyperventilation, bradypnea, ataxic breathing, prolonged expiratory phase<br />+/- fremitus<br />+/- sigh<br />+/- accessory muscle use (inspiratory contraction of the sternomastoids or intercostal retraction)<br />Barrel chest, traumatic flail chest, funnel chest, pigeon chest<br />Cardiovascular (CV/CARD): <br />PMI location/nondisplaced<br />S1S2 quality, <br />Regular/Irregular rhythm<br />JVD <br />Peripheral pulses absent, trace, 1+ 2+ +/1 symmetry and location radial, dorsalis pedis<br />Pulse pressure waves: small, weak, large, bounding, pulsus alternans, bigeminal pulse, paradoxical pulse<br />Edema none trace, 1+ 2+ symmetry and location<br />Venous stasis changes<br />Abdomen (ABD): <br />Soft/firm/hard<br />Non-tender or Tenderness to palpation (location)<br />Scaphoid, flat, rounded or mild/mod/sev distention<br />+/- ventral/umbilical hernias<br />Guarding (location)<br />No/minimal/diminished/normal/hyperactive bowel sounds (location not important)<br />+/- hepatomegaly, +/- splenomegaly<br />+/- Fluid wave<br />Surgical scars (location, length, healed, recent, remote, dehiscence)+/- striae<br />+/- venous hum<br />Rectal:<br />+/- hemorrhoids internal and/or external<br />+/- stool in vault (hard/soft/impacted)<br />Redness/wounds<br />Prolapse<br />Genitourinary (GU):<br />+/- Foley cath<br />Color, volume of urine, sediment, +/- hemmturia<br />+/- hernia<br />scrotal/penile swelling<br />vaginal discharge/bleeding<br />Musculoskeletal (MSK)<br />+/- Cachexia<br />Gait unable to be tested secondary to bed bound/limited ambulation<br />Ambulates independently, +/- assist with walker/cane<br />Stands independently with standby/1+/2+ assist<br />Global muscle wasting<br />+/- Temporal muscle wasting bilaterally<br />+/- Thenar muscle wasting bilaterally<br />Muscle bulk normal/diminished<br />Muscle tone normal/increased/flaccid<br />Contractures (joint involved severity of flexion)<br />Palpate significant joints, tenderness, redness, effusions<br />Range of motion – flexion/extension, joint tested<br />Grip strength + symmetry<br />Guarding of injured body part<br />Fidgeting movements of hands<br />Stature: short/tall/normal<br />Fractured rib squeeze test<br />Extremities (EXT): <br />Cyanosis or pallor<br />Clubbing<br />Erythema<br />Ischemia<br />Mottling<br />Venous stasis changes (brown pigmentation)<br />Neurological (NEURO):<br />CN2-12 intact or deficits<br />DTR 2/4<br />Sensation intact to light touch, sharp<br />Myoclonus (location and frequency)<br />Tremor<br />Posturing<br />Masked fascies<br />Involuntary movements<br />Psych: <br />Speech: spontaneous, responsive, rate fast, slow, delayed, dysarthria, dysphonia, aphasia, monotone, varied tone, circumlocutions, paraphasia, gaps, repetition<br />Mood: sad, melancholy, content, joyful, angry, rage, anxiety, worry, detachment, indifference<br />Affect<br />Judgment<br />Insight<br />Memory recent v. remote, short term v long term)<br />MMSE<br />Orientation to time, person, place<br />Attention<br />Vocabulary<br />Calculating ability<br />Abstract thinking<br />Perception<br />Illusion<br />Hallucinations<br />Thought content<br />Delusions, obsessions, compulsions, phobias<br />Thought processes<br />Circumstantiality, derailment, flight of ideas, neologisms, incoherence, blocking, confabulation, perseveration, echolalia, clanging<br />Lines (LINES): <br />Location and quantity<br />IV access: peripheral, port, PICC, TLC<br />SQ access<br />Foley/Condom cath/suprapubic cath<br />Rectal tube<br />NG/OG<br />PEG/ J-tube<br />Drains<br />Trach/ET tube<br />Wound vac<br />Omaya reservoir<br />

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