A -Patient-Doctor II-History

At the end of the session, the students should be able to: Analysis of a symptom
1. Enumerate the general objectives of Patient-Doctor II 1. Onset
2. Enumerate the three general sources of information for an 2. Characteristics
adequate assessment of patient. 3. Course since onset
3. Enumerate the components of patients history.
4. State a good chief complaint Onset
5. Conduct an orderly history taking. 1. Date of onset
6. Analyze symptom 2. Manner of onset (gradual or sudden)
7. Produce a good medical record 3. Precipitating and predisposing factors related to onset (
General Objectives emotional disturbance, physical exertion, fatigue, bodily
At the end of the course, the students shall demonstrate: function, pregnancy, environment, injury, infection, toxins
1. Understanding of the therapeutic nature of the Patient- and allergens, therapeutic agents, and so on.
Doctor relationship and the impact on that relationship of
the individual characteristics of both patient and doctor. Characteristics
2. The ability to listen and identify issues of concern to 1. Character (quantity, consistency, quality, appearance or
patients, families and caregivers and to respond to those other)
concerns using whatever means are necessary for effective 2. Location and radiation( of pain)
communication. 3. Intensity or severity
3. 3. The ability to elicit and interpret clinical symptoms and 4. Timing (continuous or intermittent, duration of each,
signs by interviewing and examining patients systematically temporal relationship to other events)
and with sensitivity and to use this information to guide 5. Aggravating and relieving factors
further investigation. 6. Associated symptoms
4. 4. The ability to perform clinical procedures, particularly
those vital in life threatening situations. Course since onset
5. 5. Ethical behavior in meeting the needs of patients and 1. Incidence
their families, concerns for confidentiality and respect for a. Single acute attack
individual autonomy, enabling patients and their families to b. Recurrent acute attacks
make informed decisions in relation to their medical care. c. Daily occurences
d. Periodic occurences
The three general sources of information necessary for an adequate 2. Effect of therapy
patient assessment: 3. Progress
Patient history
Physical examination 4 phases of history taking
Laboratory data Phase 1: Obtain an account of the symptoms as the patient
experiences them, without introducing any bias by the interviewers
Components of a patient history: questions.
1. Chief complaint Phase 2: Provide a detailed analysis of the symptoms described by
2. Source and reliability of the history the patient through a series of direct and detailed questions.
3. Patient profile Phase 3: Test diagnostic possibilities suggested by the information
4. Present problem or problems secured during the first two phases of the interview by inquiring about
5. Past health history other symptoms or events that form part of the history of the
6. Family history suspected problem or problems.
7. Review of system Phase 4: Provide detailed analysis of symptoms important to the
present problem that were first revealed only during the review of
Guidelines for recording the chief complaint: systems.
1. It is limited to a brief statement.
2. It is usually restricted to a single symptom or to two
symptoms at most. B- Vital Signs
3. It uses the patients own words as nearly as possible. Objectives
4. It refers to a concrete complaint. At the end of the session, the students should be able to:
5. It avoids the use of diagnostic terms or names of diseases. 1. Measure the vital signs accurately
6. It include the duration of the symptom. Blood Pressure
Heart Rate
The Patient Profile Temperature
Birth date, birthplace, sex, race
Education and employment history, sources of income Selecting the Correct Blood Pressure Cuff
Relevant family information Width of inflatable bladder of the cuff: about 40% of upper
Habits, such as eating, sleeping, alcohol, tobacco, caffeine, arm circumference (12-14 cm)
drugs Length : about 80% of upper arm circumference ( long enough to
Living environment encircle the arm)
Description of average day
Width of the inflatable bladder of the cuff should be about 40% of
History of Present Problem upper arm circumference (about 12-14 cm in the average adult
Begins with an elaboration of he patients chief complaint Length of the inflatable bladder should be about 80% of upper arm
that supplies somewhat greater detail. circumference (almost long enough to encircle the arm)
All signs and symptoms or significant events from the onset The standard cuff is 12 x 23 cm, appropriate for arm circumference up
of the problem to the time of the interview to 28 cm
Those signs and symptoms or events that occurred prior to
the onset of the problem and subsequently disappeared but Technique for measuring blood pressure
that are, in the light of the development of the history,
significant to the present problem. 1. Inflatable bladder centered over the brachial artery. Lower
A full description of the current status of the problem. border of cuff about 2.5 cm above the antecubital crease.
A summary of all significant positive or negative information. Secure cuff snugly.

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 2. Estimate the systolic pressure by palpation of the radial - Patch
pulse. Inflate cuff up to 30 mm Hg above the disappearance Palpable Elevations: Solid Masses
of radial pulse. - Papule
Center the inflatable bladder over the brachial artery. The - Plaque
lower border of the cuff should be about 2.5cm above the - Nodule
antecubital crease. Secure the cuff snugly. - Cyst
Estimate the systolic pressure by palpation to determine how - Wheal
high to raise the cuff pressure. As you feel the radial artery Palpable Elevations with Fluid-Filled Cavities
with the fingers of one hand, rapidly inflate the cuff until the - Vesicle
radial pulse disappears. Read this pressure on the - Bulla
manometer and add 30 mmHg to it. - Pustule
3. Use the bell of a stethoscope lightly over the brachial artery. - Burrow
4. Deflation rate: about 2-3 mmHg per second. Describe and identify secondary skin lesions
5. Appearance, muffling and disappearance of the Korotkoff - Scales
sounds. - Crust
6. Read both the systolic and the diastolic levels to the nearest - Scars
2 mmHg. - Lichenification
7. Wait 2 or more minutes before repeating. Average the - Keloids
readings. - Erosion
8. Blood pressure should be taken in both arms at least once. - Excoriation
9. Place the bell of a stethoscope lightly over the brachial - Fissure
artery, taking care to make an air seal with its full rim. - Ulcer
Because the sounds to be heard, the Korotkoff sounds, are Describe and identify vascular and purpuric skin lesions
relatively low in pitch, they are generally heard better with - Spider angioma
the bell. - Spider vein
10. Deflate the cuff promptly and completely and wait 15-30 - Cherry angioma
seconds - Petechia
11. Inflate the cuff rapidly again to the level just determined, - Purpura
and then deflate it slowly at a rate of about 2-3 mmHg per - Ecchymosis
second. Note the level at which you hear the sounds of at
least 2 consecutive beats. This is the systolic pressure. Parts of the Skin
12. Continue to lower the pressure slowly until the sounds
become muffled and then disappear. The diasappearance
point, which is usually only a few mmHg below the muffling
point, provides the best estimate of true diastolic pressure in
adults.
13. Read both the systolic and the diastolic levels to the nearest
2 mmHg. Wait 2 or more minutes and repeat. Average the
readings.
14. Blood pressure should be taken in both arms at least once.

Heart rate

The radial pulse is commonly used to assess the heart rate

With the pads of your index and middle fingers, compress
the radial artery until a maximal pulsation is detected

Respiratory Rate and Rhythm

Observe the rate, rhythm, depth, and effort of breathing
Count the number of respirations in 1 minute either by visual
inspection or by subtly listening over the patients trachea
The skin contains three layers
with your stethoscope during your examination of the head
1. epidermis
and neck or chest
2. dermis
3. subcutaneous tissues
C- Skin, hair and nails
Objectives: At the end of the session, the students should be able to: Epidermis, most superficial layer, is thin, devoid of blood
1. Describe the anatomic location and distribution of skin
vessels, and itself divided into two layers:
lesions outer horny layer of dead keratinized cells
2. Describe and identify skin colors
inner cellular layer where both melanin and keratin are
3. Describe and identify patterns and shapes of skin lesions formed.
4. Describe and identify primary skin lesions
Dermis is well supplied with blood that contains connective
5. Describe and identify vascular and purpuric skin lesions tissue, sebaceous glands, sweat glands, and hair follicles. It
6. Describe common features of hair loss
merges below with subcutaneous, or adipose, tissue, also known
7. Identify parts of the nail and its common pathologic findings as fat.
Patterns and shapes
Examination of the Skin
- Linear
Inspect the entire skin surface in good light
- Geographic
Note the following characteristics:
- Clustered 1. Color
- Serpiginous
Look for skin pigmentation
- Annular, arciform - Redness
Describe and identify primary skin lesions
- Pallor
Flat, nonpalpable lesions - Cyanosis
- Macule
- Yellowing of the skin

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 2. Moisture Cyanosis
- Dryness - Bluish color that is visible in toenails and toes
- Sweating
- Oiliness
3. Temperature
- Use the backs of your fingers to make this assessment
4. Texture
- Roughness
- Smoothness
5. Mobility and Turgor
- Lift a fold of skin and note the ease with which it lifts up
(mobility) and the speed with which it returns into place
(turgor)
6. Lesions
- Observe any lesions of the skin and note its characteristics

Skin Colors: Changes in Pigmentation Compare this color with the normally pink fingernails and fingers
Caf-Au-Lait Spot of the same patient..
- A slightly but uniformly pigmented macule or patch with a Impaired venous return in the leg caused this example of
somewhat irregular border, usually 0.5 to 1.5 cm in diameter; peripheral cyanosis. Cyanosis, especially when slight, may be
benign. hard to distinguish from normal skin color

Jaundice
- makes the skin diffusely yellow.
- seen most easily and reliably in the sclera
- it may also be visible in mucous membranes.

Six or more such spots, each with a diameter of >1.5 cm,

however, suggest neurofibromatosis

Tinea Versicolor
- Hypopigmented, slightly scaly macules on the trunk, neck, and
upper arms (short-sleeved shirt distribution).

Causes include liver disease and hemolysis of red blood cells.

Carotenemia
- The yellowish palm of carotenemia is compared with a normally
pink palm, sometimes a subtle finding.
- Unlike jaundice, carotenemia does not affect the sclera, which
remains white.

Common superficial fungal infection of the skin

Easier to see in darker skin and in some are more obvious
after tanning. In lighter skin, macules may look reddish or
tan instead of pale.

Vitiligo
- Depigmented macules appear on the face, hands, feet, extensor The cause is a diet high in carrots and other yellow vegetables or
surfaces, and other regions and may coalesce into extensive fruits. Carotenemia is not harmful but indicates the need for
areas that lack melanin assessing dietary intake.

Erythema
- Red hue, increased blood flow, seen here as the slapped cheeks
of erythema infectiosum (fifth disease).

The brown pigment is normal skin color; the pale areas are
vitiligo. The condition may be hereditary. These changes may be
distressing to the patient

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Heliotrope
- Violaceous eruption over the eyelids in the collagen vascular
disease dermatomyositis.

Skin Lesions
Anatomic Locations and Distribution

Patterns and Shapes

4
Primary Lesions

5
 It looks like a short (5-15 mm), linear or curved gray line and
may end in a tiny vesicle. Skin lesions include small papules,
pustules, lichenified areas, and excoriations. With a magnifying
lens, look for the burrow of the mite that causes scabies.

Secondary Lesions

Secondary lesions are seen in overtreatment, excess

scratching, infection of primary lesions

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 Ex. Cat scratches

Ex. Athletes foot

Examples: Stasis ulcer of venous insufficiency, syphilitic chancre

Vascular Lesions
Spider Angioma

Example: Aphthous stomatitis, moist area after the rupture of a

vesicle, as in chickenpox

Often seen in center of the spider, when pressure with a glass

slide is applied. Pressure on the body causes blanching of the
spider.

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Liver disease, pregnancy, vitamin B deficiency; also occurs normally in
some people

Spider Vein

Cherry Angioma

Purpuric Lesions
Petechia/Purpura

Ecchymosis

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 The Nails

The firm, rectangular, and usually curving nail plate gets its pink
color from the vascular nail bed to which the plate is firmly
attached
Lunula or whitish moon and the free edge of the nail plate.
Roughly one fourth of the nail plate (the nail root) is covered by
the proximal nail fold.
Cuticle extends from the fold and, functioning as a seal, protects
the space between the fold and the plate from external moisture.
Lateral nail folds cover the sides of the nail plate.

The Hair

Represents the most common infection of the hand, usually from

Staphylococcus aureus or Streptococcus species, and may spread
until it completely surrounds the nail plate. Creates a felon if it
extends into the pulp space of the finger. Arises from local
trauma due to nail biting, manicuring, or frequent hand
immersion in water.

The mechanism is still unknown but involves vasodilatation with

increased blood flow to the distal portion of the digits and
changes in connective tissue, possibly from hypoxia, changes in
innervation, genetics, or a platelet-derived growth factor from
fragments of platelet clumps.
Seen in congenital heart disease, interstitial lung disease and lung
cancer, inflammatory bowel diseases, and malignancies.

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 Local causes include trauma from excess manicuring, psoriasis,
fungal infection, and allergic reactions to nail cosmetics. Systemic
causes include diabetes, anemia, photosensitive drug reactions,
hyperthyroidism, peripheral ischemia, bronchiectasis, and syphilis.
Arising from the disrupted matrix of the proximal nail, they vary
in width and move distally as the nail grows out. Seen in arsenic
poisoning, heart failure, Hodgkin's disease, chemotherapy, carbon
monoxide poisoning, and leprosy

Commonly affects all fingers, although may appear in only one

finger. Seen in liver disease, usually cirrhosis, congestive heart
failure, and diabetes.
May arise from decreased vascularity and increased connective
tissue in nail bed.

As with Mees' lines, timing of the illness may be estimated by

measuring the distance from the line to the nail bed (nails grow
approximately 1 mm every 6 to 10 days). Seen in severe illness,
trauma, and cold exposure if Raynaud's disease is present.

Spots in the pattern illustrated are typical of overly vigorous and

repeated manicuring. The curves in this example resemble the
curve of the cuticle and proximal nail fold.

Usually associated with psoriasis but also seen in Reiter's

syndrome, sarcoidosis, alopecia areata, and localized atopic or
chemical dermatitis.

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D- Cardiovascular System
At the end of the session, the student should be able to:
1. Visualize the underlying structures of the heart and great
vessels as one inspects the anterior chest.
2. Describe findings on inspection, palpation and percussion of
the anterior chest.
3. Identify the areas of cardiac auscultation.
4. Identify S1 and S2.
5. Count the heart rate.
6. Measure the jugular venous pressure.
7. Palpate and describe the carotid, brachial and radial pulses

Pregnancy or a high left diaphragm may displace the apical

impulse upward and to the left.
Lateral displacement from cardiac enlargement in congestive
heart failure, cardiomyopathy, ischemic heart disease.
Displacement in deformities of the thorax and mediastinal shift.
Lateral displacement outside the midclavicular line increases the
likelihood of cardiac enlargement and a low-left ventricular
ejection fraction by 3-4 and 10, respectively.
In the left lateral decubitus position, a diffuse PMI with a
diameter greater than 3 cm indicates left ventricular enlargement.

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 Physiologic splitting of S2 in the 2nd or 3rd left interspace.
The pulmonic component of S2 is usually too faint to be heard at
the apex or aortic area, where S2 is a single sound derived from
aortic valve closure alone. Normal splitting is accentuated by
inspiration and usually disappears on expiration. In some
patients, especially younger ones, S2 may not become single on
expiration. It may merge when the patient sits up

Variations in the First Heart SoundS1

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Abnormalities of the Arterial Pulse and Pressure Waves

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 d. Femoral
e. Popliteal
f. Dorsalis pedis
g. Posterior tibial
2. Grade the amplitude of arterial pulses
3. Perform an Allen Test
4. Demonstrate postural color changes in both legs
5. Trace the saphenous veins from the dorsum of the foot to the
inguinal area

The radial and ulnar arteries are interconnected by two vascular

arches within the hand. Circulation to the hand and fingers is
thereby doubly protected against possible arterial occlusion.

Palpation of Brachial Pulse

Flex the patients elbow slightly
With the thumb of your opposite hand palpate the artery
just medial to the biceps tendon at the
antecubital crease

The brachial artery can also be felt higher in the arm in the
groove between the biceps and triceps muscles.
Palpation of radial pulse
Put pads of fingers on the flexor surface of the wrist
laterally.
Compare the pulses in both arms.

E- The Peripheral Vascular System

Objectives: At the end of this session, the students should be able : Partially flexing the patients wrist may help you feel this
1. To palpate the following arterial pulses: pulse.
a. Brachial
b. Radial
c. Ulnar

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 Atherosclerosis (arteriosclerosis obliterans) most commonly
obstructs arterial circulation in the thigh. The femoral pulse is
then normal, the popliteal decreased or absent.

The dorsalis pedis artery may be congenitally absent or may

branch higher in the ankle. Search for a pulse more laterally.
Decreased or absent foot pulses (assuming a warm environment)
with normal femoral and popliteal pulses suggest occlusive
disease in the lower popliteal artery or its branches a pattern
often associated with diabetes mellitus.
Palpate the pulses in order to assess the arterial circulation.
A diminished or absent pulse indicates partial or complete
occlusion proximally; for example, at the aortic or iliac level, all
pulses distal to the occlusion are typically affected. Chronic
arterial occlusion, usually from atherosclerosis, causes
intermittent claudication,
(pp. 460461), postural color changes (p. 458), and trophic
changes in the skin (p. 462)
An exaggerated, widened femoral pulse suggests a femoral
aneurysm, a pathologic dilatation of the artery.

Grade of the Amplitude of the Arterial Pulses

The popliteal pulse is often more difficult to find than other

pulses. It is deeper and feels more diffuse.
An exaggerated, widened popliteal pulse suggests an aneurysm
of the popliteal artery. Neither popliteal nor femoral aneurysms
are common.
They are usually due to atherosclerosis, and occur primarily in
men over age 50.

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 If pain or diminished pulses suggest arterial insufficiency, look for
postural color changes.
Marked pallor on elevation suggests arterial insufficiency.

1. Extending the hand fully may cause pallor and a falsely positive
test.
2. Persisting pallor indicates occlusion of the ulnar artery or its distal
branches.

F- Thorax and lungs

Objectives:
At the end of the session, the student shall be able to:
1. Identify the surface anatomy of the thorax (anterior and
posterior)
2. Localize surface projections of important structures of the
chest and lungs
3. Localize findings in the thorax
4. Perform a complete physical examination of the thorax and
lungs
Inspection
Palpation

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 Percussion
Auscultation
5. Discuss some sample cases on the PE of the thorax and
lungs
Anatomy of the Thorax and Lungs

Useful anatomical landmarks (bony markers):

scapula inferior tip usually lies at the level of the 7th rib
or interspace
spinous processes of the vertebrae when the neck is
flexed forward, the most protruding process is usually the
Study the anatomy of the chest wall, identifying the structures that can vertebra of C7; If two processes are equally prominent, they are C7
be palpated. and T1. You can often palpate and count the processes below them,
Manubrium of sternum especially when the spine is flexed.
Suprasternal notch Locating findings on the Chest
Sternal angle Describe abnormalities of the chest in two dimensions:
Sternum (body) along the vertical axis
Ribs around the circumference of the chest.
Costochondral junctions
Xiphoid process
Note that an interspace between two ribs is numbered by the rib
above it.

Again, note that an interspace between two ribs is numbered by the

rib above it. (Knowing the exact interspace will help you locate /
localize findings on the chest.)
To make vertical locations, you must be able to count the ribs and
interspaces.
First, locate the sternal angle, also termed the angle of Louis, is
the best guide. (Then follow the steps as enumerated.)
Additional TIPS:
Do not try to count interspaces along the lower edge of the
sternum; the ribs there are too close together.
REVIEW: In a woman, to find the interspaces either displace the
The costal cartilages of the first seven ribs articulate with breast laterally or palpate a little more medially than
the sternum; illustrated.
The cartilages of the 8th, 9th, and 10th ribs articulate with Avoid pressing too hard on tender breast tissue.
the costal cartilages just above them.
The 11th and 12th ribs, the floating ribs, have no anterior
attachments.
The cartilaginous tip of the 11th rib can usually be felt
laterally, and the 12th rib may be felt posteriorly.
On palpation, costal cartilages and ribs feel identical.
Note that an interspace between two ribs is
numbered by the rib above it.

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 Posteriorly, the 12th rib is another possible starting point for
counting ribs and interspaces: it helps locate findings on the
lower posterior chest and provides an option when the anterior
approach is unsatisfactory.
Again, we can also use anatomical landmarks or bony markers
(scapula and spinous processes) to locate some of the ribs and
interspaces.

Each lung is divided roughly in half by an oblique (major) fissure

(right and left).
This fissure may be approximated by a string that runs from
the T3 spinous process obliquely down and around the chest
to the 6th rib at the midclavicular line.
The right lung is further divided by the horizontal (minor) fissure.
Anteriorly, this fissure runs close to the 4th rib and meets
the oblique fissure in the midaxillary line near the 5th rib.

The right lung is thus divided into upper, middle, and lower lobes.
The left lung has only two lobes, upper and lower.

Locations on the Chest. Learn the general anatomic terms used to

locate chest findings, such as:
o Supraclavicularabove the clavicles
o Infraclavicularbelow the clavicles
o Interscapularbetween the scapulae
o Infrascapularbelow the scapula
o Bases of the lungsthe lowermost portions
Upper, middle, and lower lung fields
You may then infer what part(s) of the lung(s) are affected by an
abnormal process.
Signs in the right upper lung field, for example, almost certainly
originate in the right upper lobe.
Signs in the right middle lung field laterally, however, could come from
any of three different lobes.

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 Inspect the neck. During inspiration, is there contraction
of the sternomastoid or other accessory muscles, or
supraclavicular retraction? Is the trachea midline?
Also observe the shape of the chest. The anteroposterior (AP)
diameter may increase with aging.

Examination of the Posterior Chest

INSPECTION
From a midline position behind the patient, note the shape of the chest
and the way in which it moves, including:
Deformities or asymmetry
Abnormal retraction of the interspaces during inspiration.
Retraction is most apparent in the lower
interspaces.
Supraclavicular retraction is often present.
Impaired respiratory movement on one or both sides or a
unilateral lag (or delay) in movement.
*Deformities of the Thorax
Breath sounds over the trachea and bronchi have a different
PALPATION
quality than breath sounds over the lung parenchyma. Be sure
As you palpate the chest, focus on areas of tenderness and
you know the location of these structures.
abnormalities in the overlying skin, respiratory expansion, and
The trachea bifurcates into its mainstem bronchi at the levels of
fremitus.
the sternal angle anteriorly and the T4 spinous process
Identify tender areas.
posteriorly.
Assess any observed abnormalities
Test chest expansion.
Feel for tactile fremitus.
Palpate and compare symmetric areas.
Test chest expansion
1. Place your thumbs at the level of the 10th ribs, with fingers
loosely grasping and parallel to the lateral rib cage.
2. As you position your hands, slide them medially just enough
to raise a loose fold of skin on each side between your
thumb and the spine.
3. Ask the patient to inhale deeply. Watch the distance
between your thumbs as they move apart during inspiration,
and feel for the range and symmetry of the rib cage as it
expands and contracts.

Normal breathing is quiet and easybarely audible near the open

mouth as a faint whish. When a healthy person lies supine, the
breathing movements of the thorax are relatively slight. In
contrast, the abdominal movements are usually easy to see. In
the sitting position, movements of the thorax become more
prominent.
The sternomastoids are the most important of these, and the
scalenes may become visible. Abdominal muscles assist in
expiration. Feel for tactile fremitus
1. Use either the ball (the bony part of the palm at the base of
Techniques of Examination the fingers) or the ulnar surface of your hand
Initial Survey of Respiration and the Thorax 2. Ask the patient to repeat the words ninety-nine or one-
Observe the rate, rhythm, depth, and effort of breathing. one-one.
Always inspect the patient for any signs of respiratory 3. Identify and locate any areas of increased, decreased, or
difficulty. absent fremitus (comparing both sides).
Assess the patients color for cyanosis.
Listen to the patients breathing.
Inspect the neck.
Even though you may have already recorded the respiratory rate when
you took the vital signs, it is wise to again observe the rate, rhythm,
depth, and effort of breathing. A normal resting adult breathes quietly
and regularly about 14 to 20 times a minute. An occasional sigh is
to be expected. Note whether expiration lasts longer than usual.
Always inspect the patient for any signs of respiratory
difficulty.
Assess the patients color for cyanosis. Recall any
relevant findings from earlier parts of your examination,
such as the shape of the fingernails.
Fremitus refers to the palpable vibrations transmitted through
Listen to the patients breathing. Is there any audible the bronchopulmonary tree to the chest wall when the patient
wheezing? If so, where does it fall in the respiratory cycle?
speaks.

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 To detect fremitus, use either the ball (the bony part of the palm
at the base of the fingers) or the ulnar surface of your hand to
optimize the vibratory sensitivity of the bones in your hand.
Ask the patient to repeat the words ninety-nine or one-one-
one. If fremitus is faint, ask the patient to speak more loudly or
in a deeper voice.
Use one hand until you have learned the feel of fremitus. Some
clinicians find using one hand more accurate. The simultaneous
use of both hands to compare sides, however, increases your
speed and may facilitate detection of differences.
Palpate and compare symmetric areas of the lungs in the pattern
shown in the photograph. Identify and locate any areas of
increased, decreased, or absent fremitus.
Fremitus is typically more prominent in the interscapular
area than in the lower lung fields, and is often more
prominent on the right side than on the left. It disappears
below the diaphragm. 4. Strike using the tip of the plexor finger, not the finger pad.
Tactile fremitus is a relatively rough assessment tool, but as a Withdraw your striking finger quickly to avoid damping the
scouting technique it directs your attention to possible vibrations you have created.
abnormalities. Later in the examination you will check any
suggested findings by listening for breath sounds, voice sounds,
and whispered voice sounds. All these attributes tend to increase
or decrease together.

PERCUSSION
1. Hyperextend the middle finger of your left hand (pleximeter
finger). Press its distal interphalangeal joint firmly on the
surface to be percussed.
2. Position your right forearm quite close to the surface, with
the hand cocked upward. The middle finger should be
partially flexed, relaxed, and poised to strike.

Your finger should be almost at right angles to the pleximeter. A

short fingernail is recommended to avoid self-injury.
In summary, the movement is at the wrist. It is directed,
brisk yet relaxed, and a bit bouncy.
Percussion technique:
With your plexor or tapping finger, use the lightest
percussion that produces a clear note.
o A thick chest wall requires heavier percussion than
a thin one.
o However, if a louder note is needed, apply more
pressure with the pleximeter finger (this is more
Percussion is one of the most important techniques of physical effective for increasing percussion note volume
examination. Percussion of the chest sets the chest wall and than tapping harder with the plexor finger).
underlying tissues into motion, producing audible sound and When percussing the lower posterior chest, stand somewhat
palpable vibrations. to the side rather than directly behind the patient.
Percussion helps you establish whether the underlying tissues are o This allows you to place your pleximeter finger
air-filled, fluid-filled, or solid. It penetrates only about 5 cm to 7 more firmly on the chest and your plexor is more
cm into the chest, however, and therefore will not help you to effective, making a better percussion note.
detect deep-seated lesions. The technique of percussion can be When comparing two areas, use the same percussion
practiced on any surface. As you practice, listen for changes in technique in both areas.
percussion notes over different types of materials or different o Percuss or strike twice in each location. It is easier
parts of the body. to detect differences in percussion notes by
3. With a quick sharp but relaxed wrist motion, strike the comparing one area with another than by striking
pleximeter finger with the right middle finger, or plexor repetitively in one place.
finger. Percuss one side of the chest and then the other at each
Aim at your distal interphalangeal joint. You are trying to level in a ladder-like pattern (as shown by the numbers).
transmit vibrations through the bones of this joint to the Omit the areas over the scapulaethe thickness
underlying chest wall. of muscle and bone alters the percussion notes
over the lungs.
Identify and locate the area and quality of any
abnormal percussion note.

20
 about 5 cm or 6 cm. This estimate does not correlate well,
however, with radiologic assessment of diaphragmatic movement.

An abnormally high level suggests pleural effusion, or a high

diaphragm as in atelectasis or diaphragmatic paralysis.

Learn to identify five percussion notes.

AUSCULTATION
Involves
1. listening to the sounds generated by breathing,
2. listening for any adventitious (added) sounds,
3. if abnormalities are suspected, listening to the sounds of the
patients spoken or whispered voice as they are transmitted
through the chest wall.
Auscultation of the lungs is the most important examining
Learn to identify five percussion notes. You can practice four of technique for assessing air flow through the tracheobronchial
them on yourself. tree. Together with percussion, it also helps the clinician to assess
These notes differ in their basic qualities of sound: intensity, the condition of the surrounding lungs and pleural space.
pitch, and duration.
Train your ear to distinguish these differences by concentrating
on one quality at a time as you percuss first in one location, then
in another.
Normal lungs are resonant.

Identify the descent of the diaphragms (diaphragmatic excursion)

determine the level of diaphragmatic dullness during quiet
respiration
percuss downward in progressive steps until dullness clearly
replaces resonance.
Confirm this level of change by percussion near the middle
of the hemithorax and also more laterally.

You will learn to identify patterns of breath sounds by their intensity,

their pitch, and the relative duration of their inspiratory and expiratory
phases.
Normal breath sounds are:
Vesicular, or soft and low pitched. They are heard through
inspiration, continue without pause through expiration, and
then fade away about one third of the way through
expiration.
Note that with this technique you are identifying the boundary Bronchovesicular, with inspiratory and expiratory sounds
between the resonant lung tissue and the duller structures below about equal in length, at times separated by a silent interval.
Differences in pitch and intensity are often more easily
the diaphragm. You are not percussing the diaphragm itself. You
detected during expiration.
can infer the probable location of the diaphragm from the level of
Bronchial, or louder and higher in pitch, with a short
dullness. silence between inspiratory and expiratory sounds.
Expiratory sounds last longer than inspiratory sounds.
Now, estimate the extent of diaphragmatic excursion by
determining the distance between the level of dullness on full Listen to the breath sounds with the diaphragm of a
expiration and the level of dullness on full inspiration, normally stethoscope after instructing the patient to breathe deeply
through an open mouth

21
 moving from one side to the other and comparing symmetric
areas of the lungs
If you hear or suspect abnormal sounds, auscultate adjacent
areas so that you can fully describe the extent of any
abnormality.
Listen to at least one full breath in each location

Examination of the Anterior Chest

INSPECTION
Observe the shape of the patients chest and the movement of the
chest wall. Note:
* Be alert for patient discomfort due to hyperventilation (e.g., light Deformities or asymmetry
headedness, faintness), and allow the patient to rest as needed. Abnormal retraction of the lower interspaces during
Note the intensity of the breath sounds. Breath sounds are inspiration
usually louder in the lower posterior lung fields and may also vary Local lag or impairment in respiratory movement
from area to area. If the breath sounds seem faint, ask the *Deformities of the Thorax
patient to breathe more deeply. You may then hear them easily. PALPATION
When patients do not breathe deeply enough or when they have Has four potential uses:
a thick chest wall, as in obesity, breath sounds may remain Identification of tender areas
diminished. Assessment of observed abnormalities
Is there a silent gap between the inspiratory and expiratory Further assessment of chest expansion
sounds? Assessment of tactile fremitus
Listen for the pitch, intensity, and duration of the expiratory and Chest expansion
inspiratory sounds. Are vesicular breath sounds distributed 1. Place your thumbs along each costal margin, your hands
normally over the chest wall? Or are there bronchovesicular or along the lateral rib cage.
bronchial breath sounds in unexpected places? If so, where are 2. As you position your hands, slide them medially a bit to raise
they? loose skin folds between your thumbs.
3. Ask the patient to inhale deeply.
Adventitious sounds 4. Observe how far your thumbs diverge as the thorax
expands, and feel for the extent and symmetry of respiratory
movement.

If you hear crackles, especially those that do not clear after cough,
listen Tactile fremitus
carefully for the following characteristics. These are clues to the Compare both sides of the chest, using the ball or ulnar
underlying surface of your hand.
condition: Fremitus is usually decreased or absent over the precordium.
Loudness, pitch, and duration (summarized as fine or When examining a woman, gently displace the breasts as
coarse crackles) necessary.
Number (few to many)
Timing in the respiratory cycle
Location on the chest wall
Persistence of their pattern from breath to breath
Any change after a cough or a change in the patients
position
In some normal people, crackles may be heard at the lung bases
anteriorly after maximal expiration. Crackles in dependent portions of
the lungs may also occur after prolonged recumbency.
If you hear wheezes or rhonchi, note their timing and location. Do they
Percussion
change with deep breathing or coughing?
Percuss the anterior and lateral chest, again comparing both
sides.
The heart normally produces an area of dullness to the left
of the sternum from the 3rd to the 5th interspaces.

22
 Percuss the left lung lateral to it.
Clinical correlates:
Dullness replaces resonance when fluid or solid tissue
replaces air-containing lung or occupies the pleural space.
Because pleural fluid usually sinks to the lowest part of the
pleural space (posteriorly in a supine patient), only a very
large effusion can be detected anteriorly.
The hyperresonance of COPD may totally replace cardiac
dullness.
PERCUSSION
In a woman, to enhance percussion, gently displace the
breast with your left hand while percussing with the right.
Alternatively, you may ask the patient to move her breast for
you.
Identify and locate any area of abnormal percussion note.
Clinical correlate:
The dullness of right middle lobe pneumonia typically occurs behind
the right breast. Unless you displace the breast, you may miss the
abnormal percussion note.
PERCUSSION
percuss in progressive steps downward in the right
midclavicular line.
Identify the upper border of liver dullness.
As you percuss down in the left side of the chest, the
resonance of normal lung usually changes to the tympany of
the gastric air bubble.
Clinical correlate:
A lung affected by COPD often displaces the upper border of the liver
downward. It also lowers the level of diaphragmatic dullness
posteriorly.
AUSCULATION
Compare symmetric areas of the lungs
Listen to the breath sounds
Identify any adventitious sounds
Listen for transmitted voice sounds, if indicated
Listen to the chest anteriorly and laterally as the patient breathes
with mouth open, somewhat more deeply than normal. Compare
symmetric areas of the lungs, using the pattern suggested for
percussion and extending it to adjacent areas as indicated.
Listen to the breath sounds, noting their intensity and
identifying any variations from normal vesicular breathing. Breath
sounds are usually louder in the upper anterior lung fields.
Bronchovesicular breath sounds may be heard over the large
airways, especially on the right.
Identify any adventitious sounds, time them in the
respiratory cycle, and locate them on the chest wall. Do they
clear with deep breathing?
If indicated, listen for transmitted voice sounds.
The Abdomen
OBJECTIVES:
At the end of the session, the students should be able to:
1. Identify surface anatomy
2. Identify surface projection of internal organs
3. Identify and divide the abdomen into 4 quadrants and 9
sections.
4. Identify specific landmarks of the abdomen
5. Learn how to perform PE of the abdomen (inspection,
auscultation, percussion and palpation). These includes:
a. Assessment of peritoneal inflammation
b. Assessment of the liver
c. Assessment of spleen
d. Assessment of kidneys
6. Learn how to perform special techniques or assessment for:
a. Ascites
b. Appendicitis
c. Acute cholecystitis
d. Ventral hernia
e. Mass in the abdominal wall
ANATOMY
23
 urethral sphincter, the thickness of the urethral mucosa, and in
women, sufficient support to the bladder and proximal urethra
from pelvic muscles and ligaments to maintain proper anatomical
relationships. Striated muscle around the urethra can also
contract voluntarily to interrupt voiding.
Neuroregulatory control of the bladder functions at several levels.
In infants, the bladder empties by reflex mechanisms in the sacral
spinal cord. Voluntary control of the bladder depends on higher
centers in the brain and on motor and sensory pathways between
the brain and the reflex arcs of the sacral spinal cord. When
voiding is inconvenient, higher centers in the brain can inhibit
detrusor contractions until the capacity of the bladder,
approximately 400 to 500 ml, is exceeded. The integrity of the
sacral nerves that innervate the bladder can be tested by
assessing perirectal and perineal sensation in the S2, S3, and S4
dermatomes (see p. 702).

INSPECTION

In the right upper quadrant:

- soft consistency of the liver makes it difficult to feel.
- the liver edge, is often palpable at the right costal margin.
- NOT PALPABLE: gallbladder, which rests against the inferior
surface of the liver, and the more deeply lying duodenum.
- At a deeper level, the lower pole of the right kidney may be felt,
especially in thin people with relaxed abdominal muscles.
- Medially, the examiner encounters the rib cage.
- Abdominal aorta often has visible pulsations and is usually
palpable in the upper abdomen.
In the left upper quadrant:
- spleen is lateral to and behind the stomach, just above the left
kidney in the left midaxillary line. Its upper margin rests against
the dome of the diaphragm. The 9th, 10th, and 11th ribs protect
most of the spleen. The tip of the spleen may be palpable below
the left costal margin in a small percentage of adults.
- pancreas in healthy people is not palpableescapes detection.
- PALPABLE: sigmoid colonoften feel the firm, narrow, tubular;
portions of the transverse and descending colon.
In the lower midline are the bladder, the sacral promontory, the A. SKIN
bony anterior edge of the S1 vertebra sometimes mistaken for a Scars. Describe or diagram their location
tumor, and in women, the uterus and ovaries. Striae
In the right lower quadrant are bowel loops and the appendix at Dilated veins
the tail of the cecum near the junction of the small and large Rashes and lesions
intestines. In healthy people, there will be no palpable findings. B. UMBILICUS
A distended bladder may be palpable above the symphysis pubis. Observe its contour and location.
The bladder accommodates roughly 300 ml of urine filtered by Any inflammation or bulges suggesting a hernia.
the kidneys into the renal pelvis and the ureters. Bladder C. CONTOUR OF THE ABDOMEN
expansion stimulates contraction of bladder smooth muscle, the Is it flat, rounded, protuberant, or scaphoid?
detrusor muscle, at relatively low pressures. Rising pressure in Check bulges
the bladder triggers the conscious urge to void. Survey the inguinal and femoral areas
Increased intraurethral pressure can overcome rising pressures in Symmetry
the bladder and prevent incontinence. Intraurethral pressure is Visible organs or masses
related to factors such as smooth muscle tone in the internal

24
D. PERISTALSIS and PULSATIONS
Observe for several minutes, peristalsis may be visible How to do palpation?
normally in very thin people. 1. Percuss the abdomen lightly in all four quadrants to assess the
normal aortic pulsation is frequently visible in the distribution of tympany and dullness.
epigastrium. EXAMPLES OF ABNORMALITIES: A protuberant abdomen
that is tympanitic throughout suggests intestinal obstruction.
AUSCULTATION 2. Note any large dull areas that might indicate an underlying mass or
1. Place the diaphragm of your stethoscope gently on the enlarged organ. This observation will guide your palpation.
abdomen. EXAMPLES OF ABNORMALITIES: Pregnant uterus, ovarian
2. Listen for bowel sounds and note their frequency and tumor, distended bladder, large liver or spleen
character. Normal sounds occurring at an estimated 3. On each side of a protuberant abdomen, note where abdominal
frequency of 5 to 34 per minute. tympany changes to the dullness of solid posterior structures.
- Bowel motility EXAMPLES OF ABNORMALITIES: Dullness in both flanks
- Bruits prompts further assessment for ascites.
- Friction Rub 4. Briefly percuss the lower anterior chest, between the lungs above
and costal margins below. Right: dullness of the liver; Left: the
tympany that overlies the gastric air bubble and the splenic flexure of
the colon.
EXAMPLES OF ABNORMALITIES: In situs inversus (rare),
organs are reversed: air bubble on the right, liver dullness on the left.

Auscultation provides important information about bowel motility.

Listen to the abdomen before performing percussion or palpation
because these maneuvers may alter the frequency of bowel sounds. PALPATION
Practice auscultation until you are thoroughly familiar with variations in TYPES OF PALPATION
normal bowel sounds and can detect changes suggestive of A. LIGHT PALPATION
inflammation or obstruction. Auscultation may also reveal bruits, or 1. Feel the abdomen gently.
vascular sounds resembling heart murmurs, over the aorta or other 2. Keep your hand and forearm on a horizontal plane, with fingers
arteries in the abdomen. together and flat on the abdominal surface.
Occasionally you may hear borborygmiprolonged gurgles of 3. Palpate with a light, gentle, dipping motion.
hyperperistalsis 4. Move hand from place to place, raise it just off the skin. Move
Bruits smoothly, and feel all quadrants.
- vascular occlusive disease- If high blood pressure, listen in 5. Identify:
the epigastrium and in each upper quadrant for bruits. - superficial organs or masses
- Epigastric bruits confined to systole may be heard - any area of tenderness or increased resistance to your
normally; hand.
- A bruit in one of these areas that has both systolic and
diastolic components strongly suggests renal artery stenosis as the
cause of hypertension
- Changes suggestive of inflammation or obstruction
Listen for bruits over the aorta, the iliac arteries, and the femoral
arteries. Bruits confined to systole are relatively common, however,
and do not necessarily signify occlusive disease.

EXAMPLES OF ABNORMALITIES
- Bruits with both systolic and diastolic components suggest
the turbulent blood flow of partial arterial occlusion or arterial
insufficiency. - If resistance is present, try to distinguish voluntary guarding from
Listen over the liver and spleen for friction rubs. involuntary muscular spasm.
- Friction rubs in liver tumor, gonococcal infection around - EXAMPLES OF ABNORMALITIES
the liver, splenic infarction - Involuntary rigidity (muscular spasm) typically persists despite
these maneuvers. It indicates peritoneal inflammation.
PERCUSSION - Feel for the relaxation of abdominal muscles that normally
assess the amount and distribution of gas in the abdomen. accompanies exhalation.
identify possible masses that are solid or fluid-filled. - Ask the patient to mouth-breathe with the jaw dropped open.
use in estimating the size of the liver and spleen. - Voluntary guarding usually decreases with these maneuvers.
How to do percussion?
1. Percuss the abdomen lightly in all four quadrants. B. DEEP PALPATION
2. Assess the distribution of tympany and dullness. - used to delineate abdominal masses
Note any large dull areas that might indicate an - using the palmar surfaces of your fingers, feel in all four
underlying mass or enlarged organ. quadrants.
3. Percuss on each side of a protuberant abdomen - Identify any masses and note:
Note where abdominal tympany changes to the 1. location
dullness of solid posterior structures. 2. size and shape
4. Briefly percuss the lower anterior chest, between the lungs 3. consistency
above and costal margins below. 4. tenderness
5. pulsations

25
EXAMPLES OF ABNORMALITIES
Abdominal masses may be categorized in several ways: physiologic
(pregnant uterus), inflammatory (diverticulitis of the colon), vascular
(an abdominal aortic aneurysm), neoplastic (carcinoma of the colon),
or obstructive (a distended bladder or dilated loop of bowel).
ASSESSMENT OF PERITONEAL INFLAMMATION
Abdominal pain and tenderness, especially when associated
with muscular spasm inflammation of the parietal
peritoneum
Localize the pain as accurately as possible.
1. First, before palpation, ask the patient to cough and
determine if the cough produces pain.
2. Palpate gently with one finger to map the tender area.
(Pain produced by light percussion has similar localizing
value)
EXAMPLES OF ABNORMALITIES
Abdominal pain with coughing or light percussion
suggests peritoneal inflammation.
If not, look for rebound tenderness.
1. Press down with your fingers firmly and slowly, then
withdraw quickly.
2. Watch and listen to the patient for signs of pain.
Ask the patient Which hurts more, when I
press or let go?
3. Have the patient locate the pain exactly.
Pain induced or increased by quick withdrawal
constitutes rebound tenderness caused by rapid
movement of an inflamed peritoneum.
EXAMPLES OF ABNORMALITIES
Rebound tenderness suggests peritoneal inflammation. If tenderness is
felt elsewhere than where you were trying to elicit rebound, that area
may be the real source of the problem.
ASSESSMENT OF LIVER
LIVER
Liver size and shape can be estimated:
- percussion
- palpation
ASSESSMENT OF LIVER SPAN
1. Locate the midclavicular line.
2. Percuss upward towards the liver starting at a level below
the umbilicus.
3. Identify the lower border of dullness in the midclavicular
line.
4. Percuss downward towards the liver starting at the nipple
line towards the liver dullness
5. Identify the upper border of liver dullness in the
midclavicular line
6. Measure in centimeters the distance between your two
pointsthe vertical span of liver dullness.
EXAMPLES OF ABNORMALITIES
Dullness of a right pleural effusion or consolidated lung, if
adjacent to liver dullness, may falsely increase the estimate of
liver size.
Gas in the colon may produce tympany in the right upper
quadrant, obscure liver dullness, and falsely decrease the
estimate of liver size.
Only about half of livers with an edge below the right costal
margin are palpable, but when the edge is palpable, the likelihood
of hepatomegaly roughly doubles.
PALPATION OF LIVER EDGE
1. Place your right hand on the right abdomen lateral to the
rectus muscle, with your fingertips well below the lower
border of liver dullness.
2. Ask the patient to take a deep breath.
3. Try to feel the liver edge with your fingertips.
4. Lighten the pressure of your palpating hand slightly so that
the liver can slip under your finger pads and feel its anterior
surface.
5. Note any tenderness.
normal liver edge: soft, sharp, and regular, with a smooth
surface, may be slightly tender.
EXAMPLES OF ABNORMALITIES
Firmness or hardness of the liver, bluntness or rounding of its
edge, and irregularity of its contour an abnormality liver.
On inspiration, the liver is palpable about 3 cm below the right
costal margin in the midclavicular line.
An obstructed, distended gallbladder may form an oval mass
below the edge of the liver and merge with it. It is dull to
percussion.
hooking technique may be helpful in obese
1. Stand to the right of the patient's chest.
2. Place both hands, side by
side, on the right abdomen
below the border of liver dullness.
3. Press in with your fingers and up toward the costal margin.
4. Ask the patient to take a deep breath.
5. Liver edge shown below is palpable with the fingerpads of both
hands.
26
HOOKING TECHNIQUE

PALPATION OF THE SPLEEN

Assessing tenderness of a nonpalpable liver With your left hand, reach over and around the patient to
Place your left hand flat on the lower right rib cage support and press forward the lower left rib cage and
Gently strike your hand with the ulnar surface of your right adjacent soft tissue.
fist. With your right hand below the left costal margin, press in
Ask the patient to compare the sensation with that toward the spleen. Ask the patient to take a deep breath.
produced by a similar strike on the left side.
Tenderness over the liver suggests inflammation
Hepatitis
Congestion, as in heart failure
ASSESSMENT OF SPLEEN
THE SPLEEN
Enlarge spleen
-anteriorly, downward, and medially
-palpable below the costal margin.
PERCUSSION cannot confirm splenic enlargement but raise
your suspicions of it.
PALPATION: confirm the enlargement, but often misses
large spleens that do not descend below the costal margin.
Tenderness, splenic contour, and distance between the
spleens lowest points and the left costal margin.
Palpable tip of the spleen low, flat diaphragm as in COPD,
and a deep inspiratory descent of the diaphragm.

PERCUSSION OF THE SPLEEN

Percuss the Traubes space (left lower anterior chest wall
between lung resonance above and the costal margin)
POSITIVE TRAUBES SIGN OR (+) Dullness on percussion
Splenomegaly
Fluids or solids in the stomach or colon

27
SPLEEN

ASSESSMENT OF KIDNEYS
PALPATION OF LEFT KIDNEY

- Pressure from your fingertips may be enough to elicit tenderness, but

if not, use fist percussion.
- Use enough force to cause a perceptible but painless jar or thud in a
normal person.

ASSESSMENT OF URINARY BLADDER

URINARY BLADDER

Try to feel for the left kidney by a method similar to feeling for the
spleen.
left hand: reach over and around the patient to lift
the left loin
right hand: feel deep in the left upper quadrant.

PALPATION OF THE RIGHT KIDNEY

n.b.
Bladder distention from outlet obstruction due to urethral stricture,
prostatic hyperplasia; also from medications and neurologic disorders
such as stroke, multiple sclerosis.

ASSESSMENT OF ABDOMINAL AORTA

Use your left hand to lift from in back, and your right hand to feel
deep in the left upper quadrant. Proceed as before.
- Liver edge, if palpable, tends to be sharper and to extend farther
medially and laterally. It cannot be captured.
The lower pole of the kidney is rounded.
- A normal kidney may be palpable, especially in thin, well-relaxed
women. +/- tenderness. The patient is usually aware of a capture and
release.

PERCUSSION OF THE KIDNEYS

1. Identify the costovertebral angle and place the ball of one
hand.
2. Strike it with the ulnar surface of your fist. n.b. Normal aorta: < 3 cm wide.
3. Look for tenderness when examining the abdomen and at An apparent enlargement of the aorta indicates assessment by
each costovertebral angle. ultrasound.
pain on percussion or (+) Goldflam sign suggest PYELONEPHRITIS

28
PALPATION OF ABDOMINAL AORTA FLUID WAVE TEST

Risk factors for abdominal aortic aneurysm (AAA) are age 65 years or
older, history of smoking, male gender, and a first-degree relative with
a history of AAA repair.39, 40
Pressing your hands down the midline creates pressure, which
SPECIAL TECHNIQUES helps to stop the transmission of a wave through fat.
A. Ascites Unfortunately, this sign is often negative until ascites is obvious,
B. Appendicitis and it is sometimes positive in people without ascites.
C. Acute cholecystitis An early palpable impulse suggests ascites A positive fluid
D. Ventral hernia wave, shifting dullness, and peripheral edema
E. Mass in the abdominal wall
IDENTIFYING AN ORGAN OR A MASS IN AN ASCITIC ABDOMEN
TEST FOR SHIFTING DULLNESS

This quick movement often displaces the fluid so that your fingertips
-ascitic fluid sinks with gravity can briefly touch the surface of the structure through the abdominal
-gas-filled loops of bowel float to the top, percussion gives a dull note wall.
in dependent areas of the abdomen.
ASSESSING POSSIBLE APPENDICITIS
1. Ask the patient to point where the pain began and where it
is now.
2. Ask the patient to cough. Determine whether and where
pain results.
3. Search carefully for an area of local tenderness.
4. Feel for muscular rigidity.
5. Perform a rectal examination and, in women, a pelvic
examination.

Additional techniques in assessing appendicitis

1. Check the tender area for rebound tenderness.
Ascites vs. tympany: 2. Check for Rovsings sign and for referred rebound
-ascitic fluid sinks with gravity tenderness. Press deeply and evenly in the left lower
-gas-filled loops of bowel float to the top, percussion gives a dull note quadrant. Then quickly withdraw your fingers.
in dependent areas of the abdomen. 3. Look for a Psoas sign.
In ascites dullness shifts to the more dependent side, whereas In a) Place your hand just above the patients right knee and
tympany shifts to the top. ask the patient to raise that thigh against your hand.
OR
b) Ask the patient to turn onto the left side. Then extend
the patients right leg at the hip.
Flexion of the leg at the hip makes the psoas muscle contract;
extension stretches it.
4. Look for an obturator sign. Flex the patients right thigh at the
hip with the knee bent, and rotate the leg internally at the
hip.
5. Test for cutaneous hyperesthesia. At a series of points down
the abdominal wall, gently pick a fold of skin between your
thumb and index finger, without pinching it.
o Obturator sign stretches the internal oblique muscle.
o Test for cutaneous hyperesthesia This maneuver
should not normally be painful.

29
ASSESSING POSSIBLE ACUTE CHOLCYSTITIS
1. When right upper quadrant and tenderness suggest acute
cholcystitis, look for Murphys sign.
2. Hook your left thumb or the fingers of your right hand under
the costal margin at the point where the lateral border of the
rectus intersects with the costal margin.
3. Alternatively, if the liver is enlarged, hook your thumb or
fingers under the liver edge at a comparable point below.
4. Ask the patient to take a deep breath. Watch the patients
breathing and note the degree of tenderness.
ASSESSING VENTRAL HERNIAS
1. If you suspect but do not see an umbilical or incisional
hernia, ask the patient to raise both head and shoulders off
the table. (+) bulge
*Ventral hernias are hernias in the abdominal wall exclusive of groin
hernias.
- The bulge of a hernia will usually appear with this action.
- The cause of intestinal obstruction or peritonitis may be missed
by overlooking a strangulated femoral hernia.
MASS IN THE ABDOMINAL WALL
Distinguishing an abdominal mass from a mass in the abdominal wall:
1. Ask the patient either to raise the head and shoulders or to
strain down, thus tightening the abdominal muscles.
2. Feel for the mass again.
An occasional mass is in the abdominal wall rather than inside the
abdominal cavity.
n.b. A mass in the abdominal wall remains palpable; an
intraabdominal mass is obscured by muscular contraction.
30