Interview Questions for Physical Examination and Assessment

Assessing a neurologically compromised patient requires a modified approach. Since the patient’s level of consciousness is altered, we cannot rely on verbal responses. The examination focuses on assessing the patient’s level of alertness, response to stimuli, and basic neurological functions. We use the Glasgow Coma Scale (GCS) to quantify the level of consciousness, looking at eye-opening, verbal response, and motor response.

Step-by-step approach:

• Assess Level of Consciousness: Observe the patient’s responsiveness to verbal stimuli, tactile stimuli (gentle touch), and painful stimuli (e.g., sternal rub). Document the response using the GCS.
• Pupillary Response: Check pupillary size, shape, and reaction to light. Unequal pupils or sluggish response can indicate neurological damage.
• Motor Function: Assess motor strength and symmetry in all four extremities by observing spontaneous movements, response to commands (if possible), and assessing for signs of hemiparesis or hemiplegia. Even subtle weakness is important to note.
• Respiratory Effort: Evaluate the patient’s breathing pattern, noting any irregularities like Cheyne-Stokes respiration or ataxic breathing, which can indicate brain stem involvement.
• Vital Signs: Monitor heart rate, blood pressure, and temperature. Changes can signify underlying medical conditions or complications.
• Posturing: Note any abnormal posturing, such as decerebrate or decorticate posturing, which indicates severe brain damage.

Example: Imagine a patient found unresponsive after a fall. We’d start by assessing their GCS score. If they are unresponsive to verbal stimuli but opens their eyes to pain, their eye opening score would be 2. We would then assess their motor response; if they withdraw their arm to pain, their motor score would be 4. We’d continue to assess all aspects to get a full picture of their neurological state and inform further investigation.

Assessing pain is crucial, but subjective. My approach uses a holistic, patient-centered method, acknowledging that pain is a complex, multidimensional experience.

Steps to Assess Pain:

• Ask the Patient: Directly ask the patient about their pain using standardized tools like the numerical rating scale (0-10), visual analog scale (VAS), or verbal descriptor scale (e.g., mild, moderate, severe). Consider their description of the pain – location, quality, intensity, duration, aggravating and relieving factors.
• Observe Non-Verbal Cues: Pay close attention to the patient’s facial expressions, posture, behavior, and vital signs. Increased heart rate, blood pressure, and respiratory rate may accompany pain.
• Consider Context: The patient’s medical history, current medications, and overall condition contribute to the pain experience. A patient with a known history of chronic back pain will present differently than someone with acute appendicitis.
• Use Assessment Tools: Utilize validated pain scales specific to the patient’s age and cognitive abilities. For example, the Faces Pain Scale-Revised is commonly used for children.
• Document Thoroughly: Document the pain assessment comprehensively, including the method used, the patient’s report, and your observations.

Example: A patient describes a sharp, stabbing pain in their chest radiating to their left arm, accompanied by shortness of breath. This, combined with observations like diaphoresis and elevated heart rate, points towards a potential cardiac event. Conversely, a patient describing chronic, dull aching back pain after lifting heavy objects may have a muscular strain.

Assessing for infection involves looking for both local and systemic signs and symptoms. It’s important to note that absence of these signs doesn’t rule out infection.

Assessing for Infection:

• Local Signs: Inspect the area for redness, swelling, warmth, pain, tenderness to palpation, or purulent drainage. The presence of these suggests a localized infection.
• Systemic Signs: Assess for fever (oral temperature > 100.4°F or 38°C), chills, sweating, malaise, fatigue, tachycardia (increased heart rate), tachypnea (increased respiratory rate), and hypotension (low blood pressure). These indicate a more widespread infection.
• Laboratory Tests: Blood tests (complete blood count – CBC, including white blood cell count) and cultures (blood, urine, wound) can confirm the presence and type of infection.
• Imaging: Depending on location and suspicion, imaging studies (X-rays, CT scans, ultrasounds) may be necessary to visualize the affected area and rule out other conditions.

Example: A patient presents with a red, swollen, and painful leg wound with yellow pus. This is suggestive of a localized cellulitis. Combined with a fever and elevated white blood cell count, a systemic inflammatory response confirms a more severe infection.

Assessing nutritional status involves evaluating multiple aspects of a patient’s intake, metabolism, and overall health.

Assessing Nutritional Status:

• Anthropometric Measurements: This includes height, weight, body mass index (BMI), waist circumference, and skinfold thickness. BMI provides an estimate of body fat based on height and weight.
• Dietary History: Obtain a detailed dietary history, including the types and amounts of food consumed over the past 24 hours, days, or week. Consider the patient’s appetite, any dietary restrictions, and ability to prepare and afford food.
• Biochemical Data: Blood tests, such as albumin, prealbumin, transferrin, and hemoglobin levels, can indicate the body’s protein stores and nutritional status.
• Clinical Examination: Observe for signs of malnutrition, such as dry skin, hair loss, muscle wasting, edema, and poor wound healing.
• Functional Assessment: Evaluate the patient’s ability to perform activities of daily living, which can be affected by malnutrition.

Example: A patient with a BMI of 17 (underweight), pale conjunctiva, and reports of poor appetite and significant weight loss over the past month would be flagged for potential nutritional deficiencies. Further investigation through blood tests and dietary history would be needed.

Congestive heart failure (CHF) leads to fluid buildup in the body. A physical examination reveals various telltale signs related to this fluid overload and the heart’s compromised function.

Physical Examination Findings in CHF:

• Jugular Venous Distention (JVD): Increased pressure in the jugular veins, visible as bulging neck veins, signifies increased venous return to the heart.
• Edema: Swelling in the lower extremities (pedal edema) and sometimes in the abdomen (ascites) is caused by fluid retention.
• Crackles/Rales in the Lungs: These abnormal breath sounds are indicative of fluid in the alveoli (air sacs) due to pulmonary edema.
• S3 Gallop Rhythm: An extra heart sound, an S3 gallop, can be heard early in diastole and often suggests heart failure.
• Tachycardia: The heart rate may be increased as the heart works harder to compensate for reduced function.
• Hepatomegaly: An enlarged liver, from congestion, can be palpated.
• Orthopnea and Paroxysmal Nocturnal Dyspnea (PND): The patient may experience shortness of breath when lying down (orthopnea) and sudden attacks of breathlessness at night (PND).

Example: A patient with CHF might present with swollen ankles, shortness of breath when lying flat, and a rapid, irregular heartbeat. Auscultation would likely reveal crackles in the lungs and a possible S3 gallop.

Breath sounds are assessed using a stethoscope. Different sounds indicate various lung conditions.

Types of Breath Sounds and Significance:

• Vesicular: Soft, low-pitched, and breezy sounds heard over most of the lung fields during inspiration. They are normal breath sounds.
• Bronchovesicular: Intermediate intensity and pitch, heard over the main bronchi. They are typically normal, but their presence in unexpected locations can be significant.
• Bronchial: Louder, higher-pitched, and harsher sounds heard over the trachea. Their presence in the peripheral lung fields is abnormal.
• Crackles (Rales): Discontinuous, popping sounds, often heard during inspiration. These usually indicate fluid in the alveoli (pulmonary edema, pneumonia).
• Wheezes: Continuous, whistling or musical sounds, usually heard during expiration. These are common in asthma and other obstructive lung diseases.
• Rhonchi: Continuous, low-pitched, rumbling sounds. They often suggest mucus in larger airways. They can clear with coughing.
• Stridor: A high-pitched, crowing sound, often heard during inspiration. It indicates upper airway obstruction.
• Pleural Friction Rub: A grating or creaking sound. This is caused by inflamed pleural surfaces rubbing together (pleuritis).

Example: A patient with pneumonia might exhibit crackles in their lungs. A patient with asthma would show wheezes. Stridor indicates a serious upper airway problem.

Assessing a patient with suspected stroke requires a rapid and thorough neurological examination to determine the type and severity of the stroke. Time is critical, as early intervention can significantly improve outcomes.

Assessing Suspected Stroke (using the FAST acronym):

• Facial Drooping: Ask the patient to smile. Asymmetry or drooping on one side of the face suggests a stroke.
• Arm Weakness: Ask the patient to raise both arms. Weakness or inability to raise one arm indicates possible stroke.
• Speech Difficulty: Ask the patient to repeat a simple sentence. Slurred speech or difficulty speaking suggests a stroke.
• Time: Note the time symptoms began. This is crucial for determining treatment eligibility (thrombolytic therapy has a time window).
• Detailed Neurological Exam: Following FAST, perform a complete neurological exam focusing on cranial nerves, motor and sensory function, reflexes, and coordination. This helps pinpoint the affected area of the brain.
• Assess Level of Consciousness: Using the Glasgow Coma Scale to assess the patient’s consciousness level.
• Vital Signs: Monitor heart rate, blood pressure, and respiratory rate for any abnormalities.

Example: A patient presents with sudden onset of right-sided weakness, slurred speech, and facial droop on the right side. This suggests a stroke affecting the left side of the brain. Immediate attention is needed for appropriate imaging and potential treatment.

Assessing a patient’s level of consciousness (LOC) is crucial for determining their neurological status. We use the Glasgow Coma Scale (GCS), a standardized tool, to objectively assess this. The GCS evaluates three key areas: eye opening, verbal response, and motor response, each scored individually and then summed for a total score ranging from 3 (deep coma) to 15 (fully alert).

For instance, a patient who opens their eyes spontaneously (4 points), speaks coherently (5 points), and obeys commands (6 points) would have a GCS score of 15, indicating full alertness. Conversely, a score of 8 or less typically suggests severe brain injury requiring immediate medical attention. Beyond the GCS, observing the patient’s responsiveness to stimuli, their orientation to person, place, and time, and their overall alertness provides a valuable clinical picture. A lethargic patient might require gentle stimulation to respond, while a stuporous patient responds only to painful stimuli, and a comatose patient doesn’t respond at all.

A focused physical exam centers on a specific complaint or system. It’s efficient and targeted, unlike a comprehensive exam which covers all body systems. Key elements depend on the presenting problem, but generally include:

• Vital signs: Heart rate, blood pressure, respiratory rate, temperature, and oxygen saturation provide a baseline of physiological function.
• Pertinent system review: Focuses on the system directly related to the chief complaint. For example, for chest pain, this would involve a thorough cardiac and respiratory exam, including auscultation of the heart and lungs.
• Relevant physical findings: This includes inspection, palpation, percussion, and auscultation, tailored to the specific complaint. If a patient is complaining of abdominal pain, the focus would be on abdominal assessment.
• Neurological assessment (if indicated): This could range from a brief assessment of mental status and cranial nerves to a more detailed neuro exam depending on the concern.

For example, a patient with a cough might warrant a focused exam concentrating on respiratory system assessment, including lung auscultation and assessing for any signs of respiratory distress.

Assessing bowel sounds involves listening to the abdomen with a stethoscope to detect the presence, frequency, and character of bowel motility. Place the diaphragm of the stethoscope lightly on the abdomen, starting in the right lower quadrant (RLQ) and moving systematically to the other quadrants – RLQ, RUQ, LUQ, LLQ.

Normal bowel sounds are high-pitched gurgles or clicks occurring irregularly at a rate of 5-30 per minute. Increased bowel sounds (hyperactive) suggest increased motility, possibly due to diarrhea or early bowel obstruction. Absent or decreased bowel sounds (hypoactive) may indicate ileus (paralytic ileus) or peritonitis. High-pitched tinkling sounds might be indicative of bowel obstruction. It is important to listen for at least 5 minutes in each quadrant before concluding that bowel sounds are absent.

Abdominal palpation requires a systematic approach, starting with light palpation to assess tenderness and muscle tone, followed by deep palpation to identify organomegaly (enlarged organs), masses, or tenderness.

Light palpation: Use the pads of your fingertips to gently palpate the abdomen in all four quadrants. Note any tenderness, guarding (muscle rigidity), or masses. Observe the patient’s facial expressions for any signs of discomfort. Deep palpation: Use a deeper, more forceful pressure to assess for organomegaly, masses, or deeper tenderness. For example, gently palpate the liver in the right upper quadrant.

Remember to always warm your hands to increase patient comfort, and explain the procedure before beginning. If the patient reports pain in a specific area, palpate that area last to minimize discomfort.

Assessing for lymph node enlargement involves systematic palpation of lymph node groups throughout the body. Use the pads of your fingers to gently palpate the lymph nodes. Note their size, consistency, tenderness, and mobility.

The key areas to assess include:

• Cervical nodes: Located along the sides of the neck.
• Axillary nodes: Located in the armpits.
• Inguinal nodes: Located in the groin.
• Supraclavicular nodes: Located above the clavicles (collarbones).

Enlarged, tender, and fixed lymph nodes can indicate infection, inflammation, or malignancy. For example, palpable, tender lymph nodes in the neck might be indicative of a throat infection. A hard, fixed, non-tender lymph node could raise suspicion for a malignancy, requiring further investigation.

Assessing range of motion (ROM) involves evaluating the extent of movement at a particular joint. It’s important to observe the patient’s ability to actively move the joint through its full ROM and to passively move the joint to check for any limitations.

The assessment should be symmetrical, comparing both sides to identify any discrepancies. For example, when assessing shoulder ROM, the examiner would observe the patient’s ability to flex, extend, abduct, adduct, internally rotate, and externally rotate the shoulder. Any pain, crepitus (grating sound), or limitations in ROM should be noted. The documentation would include a clear description of the ROM assessment, specifically indicating the degrees of motion achieved or any limitations.

Performing a physical examination has several limitations and challenges:

• Patient factors: Pain, anxiety, obesity, or limited cooperation can hinder a thorough exam. For example, a patient in significant pain might be unable to fully participate in the assessment.
• Examiner factors: Lack of experience, insufficient training, or fatigue can affect the accuracy and thoroughness of the examination. Subjective interpretation is also a potential challenge.
• Technical limitations: Some conditions might not be easily detectable through physical examination alone and require advanced imaging techniques. For instance, early-stage cancers often require imaging for detection.
• Cultural considerations: Understanding cultural differences in communication styles and body language can be crucial for obtaining a complete history and performing an effective exam. Some cultures might have different perceptions about physical contact.
• Time constraints: Time limitations in busy clinical settings can restrict the comprehensiveness of the exam.

It is essential to recognize these limitations and use additional diagnostic tools, when needed, to ensure a complete and accurate diagnosis.