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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.
1
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
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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.
Tinea Versicolor
- Hypopigmented, slightly scaly macules on the trunk, neck, and
upper arms (short-sleeved shirt distribution).
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.
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
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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
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Ex. Cat scratches
Vascular Lesions
Spider Angioma
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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
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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
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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
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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
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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 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.
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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.
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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.
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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
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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.
The right lung is thus divided into upper, middle, and lower lobes.
The left lung has only two lobes, upper and lower.
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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.
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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.
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about 5 cm or 6 cm. This estimate does not correlate well,
however, with radiologic assessment of diaphragmatic movement.
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.
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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
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.
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Percuss the left lung lateral to it.
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
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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
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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.
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
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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).
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HOOKING TECHNIQUE
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SPLEEN
ASSESSMENT OF KIDNEYS
PALPATION OF LEFT KIDNEY
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.
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.
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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.
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ASSESSING POSSIBLE ACUTE CHOLCYSTITIS
1. When right upper quadrant and tenderness suggest acute *Ventral hernias are hernias in the abdominal wall exclusive of groin
cholcystitis, look for Murphys sign. hernias.
2. Hook your left thumb or the fingers of your right hand under - The bulge of a hernia will usually appear with this action.
the costal margin at the point where the lateral border of the - The cause of intestinal obstruction or peritonitis may be missed
rectus intersects with the costal margin. by overlooking a strangulated femoral hernia.
3. Alternatively, if the liver is enlarged, hook your thumb or
fingers under the liver edge at a comparable point below. MASS IN THE ABDOMINAL WALL
4. Ask the patient to take a deep breath. Watch the patients Distinguishing an abdominal mass from a mass in the abdominal wall:
breathing and note the degree of tenderness. 1. Ask the patient either to raise the head and shoulders or to
strain down, thus tightening the abdominal muscles.
ASSESSING VENTRAL HERNIAS 2. Feel for the mass again.
1. If you suspect but do not see an umbilical or incisional An occasional mass is in the abdominal wall rather than inside the
hernia, ask the patient to raise both head and shoulders off abdominal cavity.
the table. (+) bulge n.b. A mass in the abdominal wall remains palpable; an
intraabdominal mass is obscured by muscular contraction.
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