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7/30/2019 Introduce Self http://slidepdf.com/reader/full/introduce-self 1/17 o Abdomen and femoral arteries, before palpation or percussion o Bowel sounds start RLQ then to RUQ, LUQ, LLQ—irregular, gurgling and high-pitched. 5- 30X/min Hyperactive—loud, high pitched Hypoactive—slow and sluggish—bowel obstruction Absent bowel sound---paralytic ileus o ***Use BELL***Vascular sounds start with aortic directly under xiphoid process mid chest  down a tad & left then to right for renal arteries  down more left and right more for iliac arteries  down & left to right for femoral arteries. o Listening for –should be no Bruit – pulsatile and blowing Friction rub—rough grating sound –organs rubbing together Palpate o Abdomen systematically Percussion o Abdomen systematically, including percussion of organs Start in RLQ & percuss thru all remaining quadrants Normal sounds over abdomen--- Tympany, a loud hollow sound Dullness heard of liver & spleen Dullness in LLQ=presence of stool in colon ask about last BM o Percuss for liver dullness—Right side Define the lower edge of liver dullness in the mid-clavicular line, starting at a level below the umbilicus Define the upper edge of liver dullness in MCL, starting in the area of lung resonance Gently displace a woman’s breast as necessary Measure in centimeters with a ruler the vertical span of liver dullness in the MCL o Percuss for splenic dullness—Left side relax Percuss along the L lower chest wall between the lung resonance above and the costal margin moving laterally Ask the patient to take a deep breath and percuss again in this area Dull sound=splenomegaly o Musculoskeletal system and extremities Assess o ROM All extremities o Strength all extremities Gross Palpate o Skin temp & edema o Pulsesbilateral radial, femoral, popliteal, posterior tibal, and dorsalis pedis Spine and gait Inspect Spine contour, position, motion o Inspect scapulae, spine, back and hips as the patient bends forward, backward and from side to side o Should have full ROM, easy flexibility and signs of scoliosis or varicosities o Detects musculoskeletal abnormalities Observe o Barefoot gait o Heel walk, toe walk, and heel to toe walk  Look straight ahead and not at floor Should have steady gait, good balance and no signs of muscle weakness or pain while walking
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Introduce Self

Apr 14, 2018

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Page 1: Introduce Self

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o Abdomen and femoral arteries, before palpation

or percussion

o Bowel sounds start RLQ then to RUQ, LUQ,

LLQ—irregular, gurgling and high-pitched. 5-

30X/min

Hyperactive—loud, high pitched

Hypoactive—slow and sluggish—bowel

obstruction

Absent bowel sound---paralytic ileus

o ***Use BELL***Vascular sounds start with

aortic directly under xiphoid process mid chest  

down a tad & left then to right for renal arteries  

down more left and right more for iliac arteries  

down & left to right for femoral arteries.

o Listening for –should be no

Bruit – pulsatile and blowing

Friction rub—rough grating sound –organs

rubbing together

• Palpate

o Abdomen systematically

• Percussion

o Abdomen systematically, including percussion

of organs

Start in RLQ & percuss thru all remaining

quadrants

Normal sounds over abdomen--- Tympany, a

loud hollow sound

Dullness heard of liver & spleen

Dullness in LLQ=presence of stool in colon 

ask about last BM

o Percuss for liver dullness—Right side

Define the lower edge of liver

dullness in the mid-clavicular

line, starting at a level below the

umbilicus

Define the upper edge of liver

dullness in MCL, starting in the

area of lung resonance

Gently displace a woman’s

breast as necessary

Measure in centimeters with a

ruler the vertical span of liver

dullness in the MCL

o Percuss for splenic dullness—Left side

relax

Percuss along the L lower chest

wall between the lung resonance

above and the costal margin

moving laterally

Ask the patient to take a deep

breath and percuss again in this

area

Dull sound=splenomegaly

o

• Musculoskeletal system and extremities

• Assess

o ROM All extremities

o Strength all extremities Gross

• Palpate

o Skin temp & edema

o Pulsesbilateral radial, femoral, popliteal,

posterior tibal, and dorsalis pedis

• Spine and gait

• Inspect

• Spine contour, position, motion

o Inspect scapulae, spine, back and hips as the

patient bends forward, backward and from side to

side

o Should have full ROM, easy flexibility and signs

of scoliosis or varicosities

o Detects musculoskeletal abnormalities• Observe

o Barefoot gait

o Heel walk, toe walk, and heel to toe walk 

Look straight ahead and not at floor

Should have steady gait, good balance and no

signs of muscle weakness or pain while walking

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Checks cerebellum and motor system &

vertebral disk problems

• Neurological system

• Assess

• Deep tendon reflexes

• Biceps

o Pt arm slightly flexed w/ palm up a little; myhand around elbow w/ thumb pressing in on bicep

tendon, briskly tap my thumb w/ pointed side of 

reflex hammer or stethoscope.

• Triceps

• Patellar

• Achilles

• Brachoradialis

• Pathological reflex

• Babinski or clonus

• Neurosensory loss, face and all four extremities

• Cerebellar function using upper and lower

extremities

• Finger-nose

o Test coordination and equilibrium. “aka” pass

point test

o Pt. in sitting position

o Eyes openExtend both arms straight out then

touch tip of nose w/ right and then left index finger

then return to extended position.

o Eyes closedRepeat above

• Rapid, Alternating movements

o Alternate movements of both palms from down

to up from slower to faster pace.

o Motor neuron weakness

• Proprioception

o Romberg

Patient stand straight up w/ feet together and

arms at sides with eyes open

Stand next to pt. prevent fall—observe for

swaying

Have pt. close both eyes w/o changing position

Should have steady stance with minimal

weaving

Assess coordination and equilibrium (cranial

nerve 8)

Possible disease of posterior columns of spinal

cord

o Position sense in lower extremities bilaterally

Posterior thorax

1) The patient should be sitting with the posterior

thorax exposed.

2) The doctor assumes a midline position behind the

patient

3) Inspect the cervical, thoracic and upper lumbar spine

(you will check for ROM of the thoracic and lumbar

spine towards the end of the complete physical when

the patient is standing up)

4) Palpate the spinous processes of each vertebra for

tenderness with your thumb or by thumping with theulnar surface of your fist (Bates p 503)

5) Assess for costovertebral tenderness

a) Place the ball of one hand in the costovertebral

angle and strike it with the ulnar surface of your

fist (Bates p 344)

6) Inspect the shape and movement of the chest wall

a) Place your thumbs at the level of the 10th ribs

with your fingers loosely grasping the rib cage

and gently slide them medially.

b) Ask the patient to inhale deeply and observe

whether your thumbs move apart symmetrically

Posterior thorax – lung exam

1) Examination techniques MUST be performed on

bare skin

2) Palpate for tactile fremitus

a) Use either the ball of your palm or the ulnar

surface of your hand for palpation

b) Ask the patient to repeat the words “ninety-nine”

c) You may palpate one side at a time or use both

hands simultaneously to compare sidesd) Palpate in four locations on both sides of the

chest and compare (Bates p 223)

3) Percuss

a) Ask the patient to keep both arms crossed in

front of the chest

b) Press the DIP joint of the left middle finger

firmly against the chest wall, avoiding contact

with other fingers (Bates p 223)

c) Strike this DIP joint with the tip of the right

middle finger, swinging from the wrist

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d) Percuss in seven areas on each side (Bates p

225)

4) Auscultate for breath sounds

a) Instruct the patient to breathe deeply through an

open mouth

b) Listen with the diaphragm of the stethoscope in

the same seven areas in which you percussed

Anterior thorax—lung exam1) Examination techniques MUST be performed on

bare skin

2) The patient may be either sitting or supine. The

drape should be adjusted to allow exposure of the

area being examined

3) Inspect the shape of the patient’s chest and

movement of the chest wall (NB when moving from

the post chest when you have completed

auscultating, it is acceptable to auscultate the ant

chest before inspection or palpation)

4) Palpate for tactile fremitus

a) Use the ball of the palm or ulnar surface of thehand to palpate in 3 areas on each side of the

anterior chest (Bates p 231)

5) Percuss the anterior and lateral chest, comparing

sides, in 6 areas on each side (Bates p 231)

a) Displace a woman breast with your left hand or

ask her to move her breast for you

6) Auscultate the anterior chest, comparing sides in the

6 areas on each side where you percussed.

EXTENDED EXAM TECHNIQUES FOR THE

THORAX AND LUNGS1) Percussion for diaphragmatic excursion (Bates, p

226)

a) Determine the level of diaphragmatic dullness

during quiet respiration

b) Have the patient take in a deep breath and hold it

and again determine the level of dullness

c) Have the patient exhale completely and hold it

and determine the level of dullness

d) Measure the distance between the levels of 

dullness at maximal exhalation and maximal

inhalation

2) Egophonya) Ask the patient to say “ee” while auscultating

over the lung

3) Whispered pectoriloquy

a) Ask the patient to whisper “one-two-three” or

“ninety-nine” while listening over the lung

Axillae – examination of the axillae can be performed at

the present juncture. It is sometimes performed at the

end of the exam, or as part of a breast exam in a female

1) Inspect the skin of each axilla (Bates, pp 310-311)

2) Palpation L axilla

a) Ask the patient to relax with the L arm down

b) Support the L wrist or hand with your left hand

c) Cup together the fingers of your right hand and

reach as high as you can toward the apex of the

axilla

d) Press your fingers toward the chest wall and

slide down to feel potential LN

e) To palpate for lateral group of LN, feel along theupper humerus

3) Palpation R axilla – reverse your hands and follow

the steps above

Cardiovascular

1) The patient should be supine with the upper body

raised by elevated the table to about 30°. The drape

should be arranged to expose the precordium.

EXAM TECHNIQUES MUST BE PERFORMED

ON BARE SKIN.

2) The examiner should stand tat the patient’s right side

3) Inspect the precordiuma) look for apical impulse

b) look for any other movements

4) Palpate for precordium

a) Use the palmar surfaces of several fingers to

locate the PMI—can switch to one fingertip

when located

i) Displace a woman’s breast upward or

laterally, or ask her to do this for you

ii) Note location of PMI, amplitude and

duration

b) Palpate for the RV impulse along the lower leftsternal border

5) Auscultation of the heart

a) Listen to the heart with the diaphragm of your

stethoscope in the R 2nd ICS, L 2nd ICS, L 3rd or

4th ICS, and the lower left sternal border (5th 

ICS) and at the apex (may also start at the apex

and proceed to the base of the heart)

b) Listen to the heart with the bell of your

stethoscope in the same five listening areas

6) Inspect the neck for jugular venous pulsations

a) Turn the patient’s head slightly away from the

side you are inspecting (Bates p 267)b) Raise or lower the bed until you identify the

pulsations

c) Identify the highest point of pulsation

i) Measure the vertical distance of this point

above the sternal angle

7) Inspect the neck for carotid pulsations

8) Palpate the carotid pulsation

a) Place your left index and middle fingers (or

thumb) on the right carotid artery

i) Note amplitude and contour of the pulse

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wave

ii) Never palpate both carotids simultaneously

b) Use your right fingers or thumb to palpate the

left carotid artery

9) Auscultate the carotid arteries for bruits with the bell

of the stethoscope

a) Ask the patient to take a deep breath and hold it

to eliminate breath sounds

EXTENDED EXAM TECHNIQUES FOR THE

CARDIOVASCULAR EXAM

1) Steps for assessing the JVP (Bates, p 267)

2) Use of left lateral decubitus position to enhance

apical sounds (Bates, p 271)

3) Use of sitting position to enhance the murmur of AI

4) Timing of S3 and S4 (Bates, p 280)

5) Attributes of classical heart murmurs of SEM, AS,

AI, MR, MS (Bates, p 281 and Tables)

Abdomen

1) The patient should be in a supine position with armsat side or folded across the chest

2) The drapes should be arranged to expose the

abdomen from above the xyphoid process to the

symphysis pubis.

3) Approach the patient from his right side

4) Inspect the abdomen

5) Auscultate the abdomen as the next step in the exam

after inspection

a) Place the diaphragm of the stethoscope gently on

the abdomen

b) Listen for bowel soundsi) Listening in one spot is sufficient

c) Listen for an aortic bruit on the midline just

above the naval

6) Percuss the abdomen lightly in four quadrants and in

the suprapubic and epigastric areas

Percuss for liver dullness

Define the lower edge of liver dullness in the mid-

clavicular line, starting at a level below the

umbilicus

Define the upper edge of liver dullness in MCL,

starting in the area of lung resonance

Gently displace a woman’s breast as necessaryMeasure in centimeters with a ruler the vertical span

of liver dullness in the MCL

Percuss for splenic dullness

Percuss along the L lower chest wall between the

lung resonance above and the costal margin moving

laterally (Bates p 341)

Ask the patient to take a deep breath and percuss

again in this area

7) Palpate the abdomen lightly in four quadrants

a) Use a gentle, light dipping motion (Bates p 335)

8) Palpate the abdomen deeply in all four quadrants

a) Use a firmer dipping motion

9) Palpate for the liver edge

a) Place your R hand on the right abdomen lateral

to the rectus muscle, beginning more than 3

fingerbreadths below the costal margin

b) Ask the patient to take in a deep breath

c) Palpate upwards trying to feel the descending

liver edge, using a rocking motioni) May also use the “hooking technique”

described in Bates p 340

10) Palpate for a spleen tip

a) Reach over and around the patient with your left

hand to support and press forward the lower left

rib cage

b) Press inward towards the spleen with your right

hand, beginning at least 3 finger breadths below

the L costal margin

c) Ask the patient to take in deep breaths, trying to

feel the spleen tip as it comes down to meet your

fingertips.11) Palpates for aorta by pressing deeply with one hand

on each side of the aorta (Bates, p 344)

12) Palpate for the superficial inguinal lymph nodes

(Bates, p 452)

13) Palpate for both femoral artery pulses

a) Press deeply below the inguinal ligament (Bates,

p 452)

EXTENDED EXAMINATION TECHNIQUES FOR

THE ABDOMEN

1) Palpation for the kidneysa) Left Kidney (Bates, p 343)

i) Move to the patient’s left side

ii) Place your R hand behind the patient, just

below and parallel to the 12 th rib with your

fingertips reaching the costovertebral angle,

and lift, trying to displace the kidney

anteriorly

iii) Place your L hand in the LUQ, lateral and

parallel to the rectus muscle

iv) Ask the patient to take a deep breath

v) At the peak of inspiration, press your left

hand firmly and deeply into the LUQ justbelow the costal margin and try to capture

the kidney between your two hands

vi) Ask the patient to breathe out and then hold

it, while you release the pressure of your L

hand, allowing the kidney to slide back into

its expiratory position

b) Right kidney

i) Move to the patient’s right side

ii) Switch the positions of your hands and

proceed as above

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2) Assess for possible ascites (Bates, p 345-347)

a) Test for shifting dullness

i) With the patient supine, map the borders of 

tympany and dullness, by percussing

outward from the central area of tympany

ii) Ask the patient to turn onto one side and

percuss and mark the borders of dullness

one more

b) Test for a fluid wavei) Ask the patient or an assistant to press the

edges of both hands firmly down the midline

of the belly

ii) Tap one flank sharply with your fingertips

and feel on the opposite flank for an impulse

transmitted through the fluid

c) Balottement of organs in ascitic fluid

i) Make a brief jabbing movement with the

fingers of one hand into the protuberant

abdomen towards the anticipated organ

3) Psoas sign (Bates, p 348)

a) Place your hand just above the patient’s rightknee and ask the patient to raise that thigh

against your hand

4) Obturator sign (Bates, p 348)

a) Flex the patient’s right thigh at the hip, with the

knee bent, and rotate the leg internally at the hip

Upper extremity—MSK and Partial Neurological

(these maneuvers must be repeated on both upper

extremities

1) Inspect the hands, including each finger, its skin and

 joints, and nailsa) Palpate any abnormal joints

2) Inspect the wrist

3) Palpate the distal radius and snuff box; palpate the

distal ulna

4) Palpate the radial pulse on the flexor surface of the

wrist, laterally

a) Compare the pulses in both arms

5) Check ROM of the fingers

a) Ask the patient to make a tight fist with each

hand

b) Extend and spread the fingers

c) Ask the patient to spread the fingers apart andback together

d) Ask the patient to move the thumb across the

palm and touch the base of the 5th finger, and

then back across the palm and away from the

fingers

e) Have the patient touch the thumb to each of the

other fingertips

6) Check ROM of the wrist (Bates p 499)

a) Flexion

b) Extension

c) Ulnar and radial deviation

7) Check ROM of the elbow (Bates p 497)

a) Flexion and extension: ask the patient to bend

and straighten the elbow

b) Pronation and supination: with arms at his side,

and elbows flexed, ask the patient to turn the

palms up and then down

8) Palpate for epitrochlear lymph nodes (Bates p 451)

a) Flex the elbow to 90°b) Palpate in the groove between the biceps and

triceps

9) Inspect the shoulder (Bates, p 492)

10) Palpate the shoulder (Bates, p 493)

a) Locate the acromion process and the

acromioclavicular joint

b) Locate the greater tubercle of the humerus

c) Locate the coracoid process of the scapula

11) Check ROM of the shoulder (Bates, p 493)

a) Watch for smooth, fluid movement as you stand

in front of the patient and ask:

i) Raise the arms to shoulder level (abduct)with palms facing down

ii) Raise the arms to a vertical position above

the head with the palms facing each other

iii) Place both hands behind the neck with

elbows out to the side (external rotation and

abduction)

iv) Place both hends behind the small of the

back (internal rotation and adduction)

12) Test Muscle strength in the upper extremity (Bates

pp 574-575). You must compare sides

a) Test grip—ask the patient to squeeze two of your fingers as hard as possible and not let them

go

b) Test finger abduction—position the patient’s

hand with palms down and fingers spread. Try

to force the fingers together

c) Test opposition of the thumb—the patient

should try to touch the little finger with the

thumb against your resistance

d) Test extension of the wrist by asking the patient

to make a fist and resist you pulling it down

e) Test flexion and extension of the elbow by

having the patient pull and push against yourhand

EXTENDED EXAM OF JOINTS OF THE UPPER

EXTREMITY

1) Shoulder (Bates, Table 15-4, page 526-527)

a) Acromioclavicular joint (Bates, p 494)

i) Palpate and compare both joints for swelling

or tenderness

ii) Adduct the patient’s arm across the chest

b) Rotator cuff (Bates, p 494)

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i) With the patient’s arm at the side, palpate

the three “SITS” muscles that insert of the

greater tuberosity of the humerus

ii) Passively extend the shoulder by lifting the

elbow posteriorly

iii) Once again palpate the SITS muscle

insertions

iv) Check the “drop arm” sign by asking the

patient to fully abduct the arm to shoulderlevel and lower it slowly

c) Bicipital tendonitis (Bates, p 495)

i) Rotate the arm and forearm externally and

locate the biceps muscle distally near the

elbow

ii) Track the muscle and its tendon proximally

into the bicipital groove along the anterior

aspect of the humerus

iii) Check for tendon tenderness

d) Glenohumeral joint

i) Inspect the shoulder from above

ii) Palpate the capsule and synovial membranebeneath the ant and post acromion

2) Elbow (Bates, p 496 and Table 15-5, p 528)

a) Lateral epicondylitis (tennis elbow)

i) Pain and tenderness at the lat epicondyle and

possibly in the extensor muscles close to it

ii) Pain increases when the patient tries to

extend the wrist against resistance

b) Medial epicondylitis (pitcher’s, golfer’s or Little

League elbow)

i) Tenderness at the medial epicondyle

ii) Wrist flexion against resistance increases thepain

c) Ulnar neuropathy at elbow

3) Wrist (Bates, p 497)

a) Carpal tunnel syndrome

i) Pain and numbness on the ventral surface of 

the first three digits, especially at night, due

to median nerve compression in the carpal

tunnel

ii) Weakness of abduction of the thumb

iii) Tinel’s sign – percuss lightly over the course

of the median nerve in the carpal tunnel

4) Fingers (Bates, Table 15-6, p 530-531)a) Trigger finger

b) Felon

c) Paronychia

d) Flexor tendon sheath

e) Ganglion

Lower extremity—MSK and Partial Neurological

(these maneuvers must be repeated on both lower

extremities

1) The patient may be sitting or lying down and draped

so that the external genitalia are covered with the

legs fully exposed during the exam

2) Inspect both feet and ankle—compare sides

3) Palpate the feet and ankles (Bates, p 517)

a) Assess for pedal edema—press firmly with your

thumb over the dorsum of the foot, behind each

medial malleolus and over the shins (Bates, p

455)

b) Palpate the anterior aspect of each ankle jointc) Palpate the heel, especially the post and inf 

calcaneus

d) Palpate the MTP joints

e) Palpate the heads of the five metatarsals

4) Palpate for the peripheral pulses of the legs

a) Dorsalis pedis—feel the dorsum of the foot just

lateral to the extensor tendon of the great toe

b) Posterior tibial—feel below the medial

malleolus of the ankle

5) Check ROM of the ankle (Bates, p 518)

a) Dorsiflex and plantar flex the foot at the ankle

b) Invert and evert the footc) Flex the toes

6) Inspect the knee for alignment and contours

7) Palpate the knee with the knee in flexion (Bates, p

511-513)

a) Identify the medial femoral condyle and the

medial tibial plateau

b) Identify the tibial tubercle

c) Identify the lateral femoral condyle and lateral

tibial plateau

d) Identify the patellar tendon and ask the patient to

extend the lege) Palpate the medial collateral and lateral

collateral ligaments and menisci

f) Feel for swelling above and to the sides of the

patella

g) Check the prepatellar, anserine and popliteal

bursae (Bates p 513)

8) Check ROM of the knee (Bates p 515)

a) Ask the patient to flex and extend the knee while

sitting (or by asking the patient from a standing

position to squat and then stand up again

b) Check internal and external rotation by asking

the patient to rotate the foot medially andlaterally

9) Inspect the hip by observing the patient’s gait at

some time during the exam (Bates p 506)

10) Palpate the surface landmarks of the hip

a) Anterior surface: locate the iliac crest, iliac

tubercle and anterior superior iliac spine

b) Posterior surface: locate the posterior superior

iliac spine, the greater trochanter and the ischial

tuberosity

11) Check ROM of the hip (Bates, p 509-510)

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a) Flexion—with the patient supine, ask him to

bend each knee in turn up to the chest and pull it

firmly against the abdomen

b) Abduction—grasp the ankle and abduct the

extended leg until you feel the iliac spine move

c) Adduction—hold one ankle and move the leg

medially across the body and over the opposite

extremity

d) Rotation—flex the leg to 90°

at hip and knee;stabilize the thigh with one hand, grasp the ankle

with the other and swing the lower leg, medially

and laterally

12) Check muscle strength in the LE (Bates, p 576-578)

a) Test flexion at the hip—place your hand on the

patient’s thigh and asking the patient to raise the

leg against your hand

b) Test adduction at the hips—place your hands

firmly on the bed between the patient’s knees.

Ask the patient to bring both legs together

c) Test abduction at the hips—place your hands

firmly on the bed outside the patient’s knees.Ask the patient to spread both legs against your

hands

d) Test extension at the hips—have the patient push

the posterior thigh down against your hand

e) Test extension at the knee—support the knee in

flexion and ask the patient to straighten the leg

against your hand

f) Test flexion at the knee—place the patient’s leg

so that the knee is flexed with the foot resting on

the bed. Tell the patient to keep the foot down

as you try to straighten the legg) Test dorsiflexion and plantar flexion at the ankle

—ask the patient to pull down and push down

against your hand

EXTENDED EXAM OF JOINTS OF THE LOWER

EXTREMITY

1) Knee

a) Prepatellar bursitis (housemaid’s knee) –

swelling over the patella is suggestive

b) Patellar tendonitis – tenderness over the patellar

tendon

c) Chondormalacia – pain with patellar movementduring quadriceps contraction is suggestive

d) Pes anserine bursitis – swelling postero-medial

to the tibial tubercle (usually from running)

e) Abduction Stress Test for the MCL (Bates, p

515)

f) Adduction Stress Test for the LCL (Bates, p

515)

g) Anterior Drawer Sign for the ACL (Bates, p

515)

h) Lachman Test (Bates, p 516)

i) Posterior Drawer sign (Bates, p 516)

Neurological – some parts of the neurological exam

have been woven into exam of the head and neck and

extremities (i.e. Cranial Nerve exam and motor testing).

The remaining components of the neurological exam are

covered here

1) Mental Status Exam

a) Level of alertnessb) Language function (fluency, comprehension,

repetition and naming)

c) Memory (short-term and long-term

d) Calculation

e) Visuospatial processing

f) Abstract reasoning

2) Motor function

a) Gait – see below

b) Coordination

i) Fine finger movements

ii) Rapid alternating movements and point-to-

point – described below undercerebellar/coordination

c) Involuntary movements

d) Pronator drift (Bates, p 582)

e) Tone – resistance to passive manipulation

f) Bulk  

g) Strength – incorporated into regional exams of 

LE and UE

3) Reflexes (Bates, p 588-591)

a) Biceps reflex (C5, C6) — with patient’s arm

partially flexed at the elbow and palm down,

place your thumb or finger firmly on the bicepstendon and strike with reflex hammer

b) Triceps reflex (C6, C7) – flex the patient’s arm

at the elbow with palm towards the body and

pull it across the chest. Strike the triceps tendon

above the elbow

c) Brachioradialis (C5, C6) –The patient’s hand

should rest on the abdomen or the lap with the

forearm partly pronated. Strike the radius about

1-2 inches above the wrist

d) Knee (Patellar) reflex (L2, L3, L4) – patient may

be either sitting or supine with knee flexed. Tap

the patellar tendon just below the patellae) Ankle (Achilles) reflex (S1) – dorsiflex the foot

at the ankle and strike the Achilles tendon

f) Plantar (Babinski) response (L5, S1) – with a

key or the tip of the shaft of a reflex hammer,

stroke the lateral aspect of the sole from the heel

to the ball of the foot, curving medially across

the ball

4) Sensory (Bates, p 583-584)

a) Pain – Create a sharp from a broken tongue

blade

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i) Compare symmetrical areas on the two sides

of the body, including arms, legs and trunk 

ii) Compare the distal with the proximal areas

of the extremities

iii) Vary the pace of your testing and

occasionally substitute the blunt end for the

point, while asking “Is this sharp or dull?”

or “Does this feel the same as this?”

b) Light touch – using a fine wisp of cotton, touchthe skin lightly, avoiding pressure

i) Ask the patient to respond whenever a touch

is felt.

ii) Compare one area with another

c) Vibration – Use a low-pitched tuning fork (128

Hz)

i) Set the fork vibrating and place it firmly

over a DIP of a finger and of the great toe

ii) Ask what the patient feels

iii) If vibration sense is impaired, move to more

proximal bony prominences

d) Joint position sensei) Grasp the patient’s big toe, holding it by its

sides and pull it away from the other toes so

as to avoid friction.

ii) Demonstrate “up” and “down”

iii) With patient’s eyes closed ask him to

identify up and down movements

iv) Compare sides

v) Move more proximally if joint position is

impaired

vi) Test JPS in the UE by moving a finger joint

e) Proprioception (Bates, p 585)5) Cerebellar/Coordination (Bates, p 578-580)

a) Rapid alternating movements

i) UE – Show patient how to strike one hand

on the thigh, first with the palm, then with

the back of the hand. Have the patient repeat

these alternating movements as rapidly as

possible. Repeat with opposite hand

(1) OR Show the patient how to tap the

distal joint of the thumb with the tip of 

the index finger as rapidly as possible.

Have the patient perform the action.

Check the opposite hand

ii) LE – ask the patient to tap your hand as

quickly as possible with the ball of each foot

in turn

b) Point-to-point movements

i) UE – ask the patient to touch your indexfinger and then his nose alternately several

times. Move your finger about.

ii) LE – Ask the patient to place one heel on the

opposite knee and then run it down the shin

to the big toe. Repeat on the other side

6) Gait

a) Ask the patient to walk across the room, then

turn and come back 

b) Walk heel-to-toe in a straight line

c) Walk on toes then on heels

7) Romberg Test

a) The patient should first stand with feet togetherand eyes open and then close both eyes for 20-

30 secs without support

Back

1) ROM (Bates, p 505)

a) Flexion – with patient standing, ask him to bend

forward to touch the toes

b) Extension – place your hand on the posterior

superior iliac spine and with your fingers

pointing towards the midline, ask the patient to

bend backward as far as possiblec) Lateral bending – ask the patient to lean to both

sides as far as possible

NOTE THAT BREAST, GENITAL AND RECTAL

EXAMS HAVE NOT BEEN INCLUDED IN THIS

CHECKLIST

 

Nursing Assessment in Tabular Form

ASSESSMENT FINDINGS

Integumentary

• Skin When skin is pinched it goes to previous state immediately (2

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seconds).With fair complexion.With dry skin

• HairEvenly distributed hair.With short, black and shiny hair.With

presence of pediculosis Capitis.

• Nails

Smooth and has intact epidermisWith short and clean

fingernails and toenails.  Convex and with good

capillary refill time of 2 seconds.

SkullRounded, normocephalic and symmetrical, smooth and has

uniform consistency.Absence of nodules or masses.

FaceSymmetrical facial movement, palpebral fissures equal in

size, symmetric nasolabial folds.

Eyes and Vision

• EyebrowsHair evenly distributed with skin intact.Eyebrows are

symmetrically aligned and have equal movement.

• Eyelashes Equally distributed and curled slightly outward.

• EyelidsSkin intact with no discharges and no discoloration.Lids close

symmetrically and blinks involuntary.

• Bulbar conjunctiva Transparent with capillaries slightly visible

• Palpebral Conjunctiva Shiny, smooth, pink  

• Sclera Appears white.

• Lacrimal gland, Lacrimal sac,

Nasolacrimal duct

No edema or tenderness over the lacrimal gland and no

tearing.

Cornea

• Clarity and texture

Transparent, smooth and shiny upon inspection by the use of 

a penlight which is held in an oblique angle of the eye and

moving the light slowly across the eye.Has brown eyes.

• Corneal sensitivityBlinks when the cornea is touched through a cotton wisp from

the back of the client.

Pupils

Black, equal in size with consensual and direct reaction,pupils equally rounded and reactive to light and

accommodation, pupils constrict when looking at near

objects, dilates at far objects, converge when object is moved

toward the nose at four inches distance and by using penlight.

Visual Fields

When looking straight ahead, the client can see objects at the

periphery which is done by having the client sit directly

facing the student nurse at a distance of 2-3 feet. The right

eye is covered with a card and asked to look directly at the

student nurse’s nose. Hold penlight in the periphery and ask 

the client when the moving object is spotted.

Visual Acuity

Ableto identify letter/read in the newsprints at a distance of 

fourteen inches. She was able to read the newsprint at a

distance of 8 inches.

Ear and Hearing

• Auricles

Color of the auricles is same as facial skin, symmetrical,

auricle is aligned with the outer canthus of the eye, mobile,

firm, non-tender, and pinna recoils after it is being folded.

• External Ear Canal Without impacted cerumen.

• Hearing Acuity Test Voice sound audible.

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• Watch Tick Test

Able to hear ticking on right ear at a distance of one inch and

was able to hear the ticking on the left ear at the same

distance

Nose and sinuses

• External NoseSymmetric and straight, no flaring, uniform in color, air

moves freely as the clients breathes through the nares.

• Nasal CavityMucosa is pink, no lesions and nasal septum intact and in

middle with no tenderness.Mouth and Oropharynx Symmetrical, pale lips, brown gums and able to purse lips.

• Teeth With dental caries and decayed lower molars

• Tongue and floor of the mouthCentral position, pink but with whitish coating which is

normal, with veins prominent in the floor of the mouth.

• Tongue movementMoves when asked to move without difficulty and without

tenderness upon palpation.

Uvula Positioned midline of soft palate.

Gag ReflexPresent which is elicited through the use of a tongue

depressor.

Neck  Positioned at the midline without tenderness and flexeseasily. No masses palpated.

Head movementCoordinated, smooth movement with no discomfort, head

laterally flexes, head laterally rotates and hyperextends.

Muscle strength With equal strength

Lymph Nodes Non-palpable, non tender

• Thyroid GlandNot visible on inspection, glands ascend but not visible in

female during swallowing and visible in males.

Thorax and lungs

Posterior thorax Chest symmetrical

• Spinal alignment Spine vertically aligned, spinal column is straight, left andright shoulders and hips are at the same height.

Breath Sounds With normal breath sounds without dyspnea.

• Anterior Thorax Quiet, rhythmic and effortless respiration

AbdomenUnblemished skin, uniform in color, symmetric contour,

undistended.

Abdominal movements Symmetrical movements cause by respirations.

• Auscultation of bowel sounds With audible sounds of 23 bowel sounds/minute.

Upper Extremities Without scars and lesions on both extremities.

Lower Extremities With minimal scars on lower extremities

Muscles

Equal in size both sides of the body, smooth coordinated

movements, 100% of normal full movement against gravity

and full resistance.

Bones and Joints No deformities or swelling, joints move smoothly.

Mental Status

Language Can express oneself by speech or sign.

Orientation Oriented to a person, place, date or time.

Attention spanAble to concentrate as evidence by answering the questions

appropriately.

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Level of ConsciousnessA total of 15 points indicative of complete  orientation and

alertness. E4V5M6

Motor Function

Gross Motor and Balance

• Walking gaitHas upright posture and steady gait with opposing arm swing

unaided and maintaining balance.

Standing on one foot with eyes closed Maintained stance for at least five (5) seconds.

Heel toe walking Maintains a heel toe walking along a straight line

Toe or heel walking Able to walk several steps in toes/heels.

Fine motor test for Upper Extremities

Finger to nose test Repeatedly and rhythmically touches the nose.

Alternating supination and pronation of 

hands on kneesCan alternately supinate and pronate hands at rapid pace.

Finger to nose and to the nurse’s finger Perform with coordinating and rapidity.

Fingers to fingers Perform with accuracy and rapidity.

Fingers to thumb Rapidly touches each finger to thumb with each hand.

Fine motor test for the Lower Extremities

Pain sensationAble to discriminate between sharp and dull sensation when

touched with needle and cotton.

 

Thorax and Lungs

• Lungs / Chest:

o The spine is vertically aligned. The right

and left shoulders and hips are of the

same height.

• The chest wall is intact with no tenderness and

masses. There’s a full and symmetric expansion

and the thumbs separate 2-3 cm during deep

inspiration when assessing for the respiratory

excursion. The client manifested quiet, rhythmic

and effortless respirations.

• Heart: There were no visible pulsations on the

aortic and pulmonic areas. There is no presence

of heaves or lifts.

o The jugular veins are not visible.

o When nails pressed between the fingers

(Blanch Test), the nails return to usual

color in less than 4 seconds.

• Abdomen: The abdomen of the client has an

unblemished skin and is uniform in color. The

abdomen has a symmetric contour. There were

symmetric movements caused associated with

client’s respiration.

NECK

The neck is inspected for position symmetry and obvious

lumps visibility of the thyroid gland and Jugular Venous

Distension.

Normal Findings:

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1. The neck is straight.

2. No visible mass or lumps.

3. Symmetrical

4. No jugular venous distension (suggestive of 

cardiac congestion).

The neck is palpated just above the suprasternal note

using the thumb and the index finger.

The neck is palpated just above the suprasternal noteusing the thumb and the index finger.

Normal Findings:

1. The trachea is palpable.

2. It is positioned in the line and straight.

Lymph nodes are palpated using palmar tips of 

the fingers via systemic circular movements.

Describe lymph nodes in termsof size, regularity,

consistency, tenderness and fixation to surrounding

tissues.

Normal Findings:1. May not be palpable. Maybe normally palpable

in thin clients.

2. Non tender if palpable.

3. Firm with smooth rounded surface.

4. Slightly movable.

5. About less than 1 cm in size.

6. The thyroid is initially observed by standing in

front of the client and asking the client to swallow.

Palpation of the thyroid can be done either by

posterior or anterior approach.

A. Posterior Approach:

1. Let the client sit on a chair while the examiner

stands behind him.

2. In examining the isthmus of the thyroid, locate

the cricoid cartilage and directly below that is the

isthmus.

3. Ask the client to swallow while feeling for any

enlargement of the thyroid isthmus.

4. To facilitate examination of each lobe, the

client is asked to turn his head slightly toward the

side to be examined to displace the

sternocleidomastoid, while the other hand of the

examiner pushes the thyroid cartilage towards the

side of the thyroid lobe to be examined.

5. Ask the patient to swallow as the procedure is

being done.

6. The examiner may also palate for thyroid

enlargement by placing the thumb deep to and

behind the sternocleidomastoid muscle, while the

index and middle fingers are placed deep to and in

front of the muscle.

7. Then the procedure is repeated on the other side.

A. Anterior approach:

1. The examiner stands in front of the client and

with the palmar surface of the middle and index

fingers palpates below the cricoid cartilage.

2. Ask the client to swallow while palpation isbeing done.

3. In palpating the lobes of the thyroid, similar

procedure is done as in posterior approach. The

client is asked to turn his head slightly to one side

and then the other of the lobe to be examined.

4. Again the examiner displaces the

thyroid cartilage towards the side of the lobe to be

examined.

5. Again, the examiner palpates the area and hooks

thumb and fingers around thesternocleidomastoidmuscle.

Normal Findings:

1. Normally the thyroid is non palpable.

2. Isthmus maybe visible in a thin neck.

3. No nodules are palpable.

Auscultation of the Thyroid is necessary when there is

thyroid enlargement. The examiner may hear bruits, as a

result of increased and turbulence in blood flow in an

enlarged thyroid.

Check the Range of Movement of the neck.

Lung borders

In the anterior thorax, the apices of the lungs extend for

approximately 3 – 4 cm above the clavicles. The inferior

borders of the lungs cross the sixth rib at the

midclavigular line.

In the posterior thorax, the apices extend of T10 on

expiration to the spinous process of T12 on inspiration.

In the Lateral Thorax, the lungs extend from the apex of 

the axilla to the 8 th rib of the midaxillary line.

Lung Fissures

The right oblique (diagonal) fissure extend from the area

of the spinous process of the 3 rdthoracic vertebra,

laterally and downward unit it crosses the 5 th rib at the

midaxillary line. It then continues ant medially to end at

the 6th rib at the midclavicular line.

The right horizontally fissure extends from the 5th rib

slightly posterior to the right midaxillary line and runs

horizontally to thee area of the 4 th rib at the right sternal

border.

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The left oblique (diagonal) fissure extend from the

spinous process of the 3rd thoracic vertebra laterally and

downward to the left mid axillary line at the 5th rib and

continues anteriorly and medially until it terminates at

the 6th rib in the midclavicular line.

Borders of the Diaphragm.

Anteriorly, on expiration, the right dome of the

diaphragm is located at the level of the 5th

rib at themidclavicular line and he left dome is at the level of the

6th rib. Posteriorly, on expiration, the diaphragm is at the

level of the spinous process of T10; laterally it is at the

8th rib at the midaxillary line. On inspiration the

diaphragm moves approximately 1.5 cm downward.

Inspection of the Thorax

For adequate inspection of the thorax, the client should

be sitting upright without support and uncovered to the

waist.

The examiner should observe:A.

1. Shape of the thorax and its symmetry.

2. Thoracic configuration.

3. Retractions at the ICS on inspiration.

(suprasternal, costal, substernal)

4. Bulging structures at the ICS during

expiration.

5. position of the spine.

6. pattern of respiration.

Normal Findings:

The shape of the thorax in a normal adult is

elliptical; the anteroposterior diameter is less than

the transverse diameter at approximately a ratio of 

1:2.

Moves symmetrically on breathing with no

obvious masses.

No fail chest which is suggestive of rib fracture.

No chest retractions must be noted as this may

suggest difficulty in breathing.

No bulging at the ICS must be noted as this may

obstruction on expiration, abnormal masses, or

cardiomegaly.

The spine should be straight, with slightly

curvature in the thoracic area.

There should be no scoliosis, kyphosis, or

lordosis.

Breathing maybe diaphragmatically of costally.

Expiration is usually longer the inspiration.

Palpation of the Thorax

1. General palpation – The examiner should

specifically palpate any areas of abnormality. The

temperature and turgor of the skin should be

assessed. Palpate for lumps, masses and areas of 

tenderness.

2. Palpate for thoracic expansion or lung excursion

A. Anteriorly, the examiner’s hands are placed

over the anterolateral chest with the thumbsextended along the costal margin, pointing

to the xyphoid process. Posteriorly, the

thumbs are placed at the level of the 10th rib

and the palms are placed on the

posterolateral chest.

B. Instruct the client to exhale first, then to

inhale deeply.

C. The examiner the amount of thoracic

expansion during quiet and deep inspiration

and observe for divergence of the thumbs onexpiration.

D. Normally, symmetry of respiration between

the left and right hemithoraces should be felt

as the thumbs are separated are separated

approximately 3 – 5 cm (1 – 2 inches)

during deep inspiration.

1. Palpate for the tactile fremitus.

A. Place the palm or the ulnar aspect of the

hands bilaterally symmetrical on the chest

wall starting from the top, then at then

medial thoracic wall, and at the anterolateral

B. Each time the hands move down, ask the

client to say ninety-nine.

C. Repeat the procedure at the posterior thoracic

wall.

D. Normally, tactile fremitus should be

bilaterally symmetrical. Most intense in the

2ndICS at the sternal border, near the area of 

bronchial bifurcation. Low pitched voices of

males are more readily palpated than higher

pitched voices of females.

E. Basic abnormalities like increased tactile

fremitus maybe suggestive of consolidation;

decreased tactile fremitus may be suggestive

of obstructions, thickening of pleura, or

collapse of lungs.

Percussion of the Thorax

Anterior thorax:

A. Patient maybe placed on a supine position.

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B. Percuss systematically at about 5 cm intervals

from the upper to lower chest, moving left to right to

left. (Percuss over the ICS, avoiding the ribs. Use

indirect percussion starting at the apices of the lungs.

C. The examiner notes the sound produced during

each percussion.

Whispered Pectorioquy – Ask the client top whisper “1-

2-3” Over normal lung tissue it would almost beindistinguishable, over consolidated lung it would

be loud and clear.

Inspection of the Heart

The chest wall and epigastrum is inspected while the

client is in supine position. Observe for pulsation and

heaves or lifts

Normal Findings:

1. Pulsation of the apical impulse maybe visible.

(this can give us some indication of the cardiac size).

2. There should be no lift or heaves.

Palpation of the Heart

The entire precordium is palpated methodically using the

palms and the fingers, beginning at the apex, moving to

the left sternal border, and then to the base of the heart.

Normal Findings:

1. No, palpable pulsation over the aortic, pulmonic,

and mitral valves.

2. Apical pulsation can be felt on palpation.

3. There should be no noted abnormal heaves, and

thrills felt over the apex.

Percussion of the Heart

The technique of percussion is of limited value in

cardiac assessment. It can be used to determine borders

of cardiac dullness.

Auscultation of the Heart

 Anatomic areas for auscultation of the heart:

Aortic valve – Right 2nd ICS sternal border.

Pulmonic Valve – Left 2nd ICS sternal border.

Tricuspid Valve – – Left 5 th ICS sternal border.

Mitral Valve – Left 5th ICS midclavicular line

Positioning the client for auscultation:

If the heart sounds are faint or undetectable, try

listening to them with the patient seated and learning

forward, or lying on his left side, which brings the

heart closer to the surface of the chest.

Having the client seated and learning forward s

best suited for hearing high-pitched sounds related to

semilunar valves problem.

The left lateral recumbent position is best suited

low-pitched sounds, such as mitral valve problems

and extra heart sounds.

Auscultating the heart

A.

1. Auscultate the heart in all anatomic

areas aortic, pulmonic, tricuspid and mitral

2. Listen for the S1 and S2 sounds (S1closure of AV valves; S2 closure of semilunar

valve). S1 sound is best heard over the mitral

valve; S2 is best heard over the aortric valve.

3. Listen for abnormal heart sounds e.g.

S3, S4, and Murmurs.

4. Count heart rate at the apical pulse for

one full minute.

Normal Findings:

1. S1 & S2 can be heard at all anatomic site.

2. No abnormal heart sounds is heard (e.g.Murmurs, S3 & S4).

3. Cardiac rate ranges from 60 – 100 bpm.

Inspection of the Breast

There are 4 major sitting position of the client used for

clinical breast examination. Every client should be

examined in each position.

1. The client is seated with her arms on her side.

2. The client is seated with her arms abducted over

the head.

3. The client is seated and is pushing her hands into

her hips, simultaneously eliciting contraction of the

pectoral muscles.

4. The client is seated and is learning over while

the examiner assists in supporting and balancing her.

While the client is performing these maneuvers,

the breasts are carefully observed for symmetry,

bulging, retraction, and fixation.

An abnormality may not be apparent in the

breasts at rest a mass may cause the breasts, through

invasion of the suspensory ligaments, to fix,

preventing them from upward movement

in position 2 and 4.

Position 3 specifically assists in eliciting

dimpling if a mass has infiltrated and shortened

suspensory ligaments.

Normal Findings:

1. The overlying the breast should be even.

2. May or may not be completely symmetrical at

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rest.

3. The areola is rounded or oval, with same color,

(Color va,ies form light pink to dark brown

depending on race).

4. Nipples are rounded, everted, same size and

equal in color.

5. No “orange peel” skin is noted which is present

in edema.6. The veins maybe visible but not engorge and

prominent.

7. No obvious mass noted.

8. Not fixated and moves bilaterally when hands

are abducted over the head, or is learning forward.

9. No retractions or dimpling.

Palpation of the Breast

Palpate the breast along imaginary concentric

circles, following a clockwise rotary motion, from

the periphery to the center going to the nipples. Besure that the breast is adequately surveyed. Breast

examination is best done 1 week post menses.

Each areolar areas are carefully palpated to

determine the presence of underlying masses.

Each nipple is gently compressed to assess for

the presence of masses or discharge.

Normal Findings:

No lumps or masses are palpable.

No tenderness upon palpation.

No discharges from the nipples.

 NOTE: The male breasts are observed by adapting the

techniques used for female clients. However, the various

sitting position used for woman is unnecessary.

abdomen

In abdominal assessment, be sure that the client has

emptied the bladder for comfort. Place the client in a

supine position with the knees slightly flexed torelax abdominal muscles.

Inspection of the abdomen

Inspect for skin integrity (Pigmentation, lesions,

striae, scars, veins, and umbilicus).

Contour (flat, rounded, scapold)

Distension

Respiratory movement.

Visible peristalsis.

Pulsations

Normal Findings:

Skin color is uniform, no lesions.

Some clients may have striae or scar.

No venous engorgement.

Contour may be flat, rounded or scapoid

Thin clients may have visible peristalsis.

Aortic pulsation maybe visible on thin clients.

Auscultation of the Abdomen This method precedes percussion because bowel

motility, and thus bowel sounds, may be increased

by palpation or percussion.

The stethoscope and the hands should be

warmed; if they are cold, they may initiate

contraction of the abdominal muscles.

Light pressure on the stethoscope is sufficient to

detect bowel sounds and bruits. Intestinal sounds are

relatively high-pitched, the bell may be used in

exploring arterial murmurs and venous hum.Peristaltic sounds

These sounds are produced by the movements of air and

fluids through the gastrointestinal tract. Peristalsis can

provide diagnostic clues relevant to the motility of 

bowel.

Listening to the bowel sounds (borborygmi) can be

facilitated by following these steps:

1. Divide the abdomen in four

quadrants.

2. Listen over all auscultation sites,

starting at the right lower quadrants,

following the cross pattern of the

imaginary lines in creating the

abdominal quadrants. This direction

ensures that we follow the direction

of bowel movement.

3. Peristaltic sounds are quite irregular.

Thus it is recommended that the

examiner listen for at least 5

minutes, especially at the

periumbilical area, before

concluding that no bowel sounds are

present.

4. The normal bowel sounds are high-

pitched, gurgling noises that occur

approximately every 5 – 15 seconds

It is suggested that the number of 

bowel sound may be as low as 3 to

as high as 20 per minute, or roughly

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one bowel sound for each breath

sound.

Percussion of the abdomen

Abdominal percussion is aimed at detecting

fluid in the peritoneum (ascites), gaseous distension,

and masses, and in assessing solid structures within

the abdomen.

The direction of abdominal percussion followsthe auscultation site at each abdominal guardant.

The entire abdomen should be percussed lightly

or a general picture of the areas of tympany and

dullness.

Tympany will predominate because of the

presence of gas in the small and large bowel. Solid

masses will percuss as dull, such as liver in the RUQ,

spleen at the 6th or 9th rib just posterior to or at the

mid axillary line on the left side.

Percussion in the abdomen can also be used inassessing the liver span and size of the spleen.

Percussion of the liver

The palms of the left hand is placed over the region of 

liver dullness.

1. The area is strucked lightly with a fisted right

hand.

2. Normally tenderness should not be elicited by

this method.

3. Tenderness elicited by this method is usually a

result of hepatitis or cholecystitis.

Renal Percussion

1. Can be done by either indirect or direct method.

2. Percussion is done over the costovertebral

 junction.

3. Tenderness elicited by such method suggests

renal inflammation.

Palpation of the Abdomen

Light palpation

It is a gentle exploration performed while the

client is in supine position. With the examiner’s

hands parallel to the floor.

The fingers depress the abdominal wall, at each

quadrant, by approximately 1 cm without digging,

but gently palpating with slow circular motion.

This method is used for eliciting slight

tenderness, large masses, and muscles, and muscle

guarding.

Tensing of abdominal musculature may occur because

of:

1. The examiner’s hands are too cold or are pressed

to vigorously or deep into the abdomen.

2. The client is ticklish or guards involuntarily.

3. Presence of subjacent pathologic condition.

Normal Findings:

1. No tenderness noted.

2. With smooth and consistent tension.

3. No muscles guarding.Deep Palpation

It is the indentation of the abdomen performed

by pressing the distal half of the palmar surfaces of 

the fingers into the abdominal wall.

The abdominal wall may slide back and forth

while the fingers move back and forth over the organ

being examined.

Deeper structures, like the liver, and retro

peritoneal organs, like the kidneys, or masses may be

felt with this method. In the absence of disease, pressure produced by

deep palpation may produce tenderness over the

cecum, the sigmoid colon, and the aorta.

Liver palpation:

There are two types of bi manual palpation

recommended for palpation of the liver. The first one is

the superimposition of the right hand over the left hand.

1. Ask the patient to take 3 normal breaths.

2. Then ask the client to breath deeply and hold.

This would push the liver down to facilitate

palpation.

3. Press hand deeply over the RUQ

The second methods:

1. The examiner’s left hand is placed beneath the

client at the level of the right 11th and 12thribs.

2. Place the examiner’s right hands parallel to the

costal margin or the RUQ.

3. An upward pressure is placed beneath the client

to push the liver towards the examining right hand,

while the right hand is pressing into the abdominal

wall.

4. Ask the client to breath deeply.

5. As the client inspires, the liver maybe felt to slip

beneath the examining fingers.

Normal Findings:

The liver usually can not be palpated in a normal

adult. However, in extremely thin but otherwise well

individuals, it may be felt a the costal margins.

When the normal liver margin is palpated, it

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must be smooth, regular in contour, firm and non-

tender.

Has equal contraction and even.

Can perform complete range of motion.

No crepitus must be noted on joints.

Can counter act gravity and resistance on ROM.