Southwestern University – School of medicine (SWU – SM)

PD Clinics (SGD 4) Classical Medical History

Dr. Airiee Arranguez Tello - Preceptor
(Reference: Bate’s Guide to PE and History Taking, 10th Ed)

HISTORY Alcohol: Attempt to quantify as accurately as you can. Use CAGE

questionnaire to screen for alcohol abuse and presence of alcohol dependency.
Informant: (Persons who answers for the patient who can’t talk during the Followed by FAST questionnaire to identify hazardous drinking if suspected.
interview with percentage of reliability given). Example, informant-mother
75% reliability. (This is omitted if the patient herself gives out the data) Smoking: Smoking can either worsen symptoms or increases the risk of
some conditions. Attempt to quantify the habit in ‘pack-years’. (no. of
General Data: Name, age, sex, marital status, occupation, religion, cigarettes smoked per day x number of years)/20. Ask about previous
nationality, present address, no. of times admitted in this hospital, data and smoking if patient call themselves non-smoker or just gave up recently.
time of admission Remember to ask about passive smoking. Do not forget to appear non-
judgemental and resist acting surprised in any way, suggest a number but start
The standard history framework very high (60 a day?) and patient will usually give you a number nearer the
• Presenting complaint (PC) true amount. If you start too low, patient may only admit to half that.
• History of the Present Illness (HPI)
• Past medical history (PMH) Family History: Age, status (alive, dead) of blood relatives and medical
• Drug history (DHx)
problems for any blood relatives (inquiry about cancer, especially breast,
• Allergies/reactions
colon, and prostate; TB, asthma; MI; HTN; thyroid disease; kidney disease;
• Alcohol
• Smoking peptic ulcer disease; diabetes mellitus; bleeding disorders; glaucoma, and
• Family history (FHx) macular degeneration). Can be written out or use family tree.
• Social history (SHx)
• Systematic enquiry Social History: Stressors (financial, significant relationships, work or school,
health) and support (family, friends, significant other, clergy); life-style risk
factors, (alcohol, drugs, tobacco, and caffeine use; diet; and exposure to
Chief complaint: State, in patient’s own words, the current problem. Avoid environmental agents; and sexual practices); patient profile (may include
using medical terms like “dysuria” but instead use “pain on urination” marital status and children; present and past employment; financial support
and insurance; education; religion; hobbies; beliefs; living conditions); for
History of present Illness: Defines the present illness by quality; quantity; veterans, include military service history. Pediatric patients: Include grade in
setting; anatomic location and radiation; time course, including when it began; school, sleep, and play habits.
whether the complaint is progressing, regressing, or steady; of constant or
intermittent frequency; and aggravating, alleviating, and associated factors. Menstrual & Obstetrical History: Menarche, duration, cycle, menstrual
The information should be in chronologic order, including diagnostic tests flow, associated symptoms like dysmenorrhea flow, breast pains, headache,
done prior to admission. Related history, including previous treatment for the etc. Menopause, if still on the reproductive years ask for date of last
problem, risk factors, and pertinent negatives should be included. Any other menstruation, any abnormal vaginal bleeding or discharges. If married ask no.
significant ongoing problems should be included in the HPI in a separate of pregnancies, deliveries and complication like HPN, eclampsia, no. of
section or paragraph. For instance, if a patient with poorly controlled diabetes abortions, procedures like caesarian section, BTL, hysterectomy with the
mellitus comes to the emergency room because of chest pain, the HPI would dates, surgeon, history taking contraceptives or other method used.
first include information regarding the chest pain followed by a detailed
history of the diabetes mellitus. If the diabetes mellitus was well controlled or Systems Review: These are ‘subjective’ complaints of patient you must ask
diet-controlled, the history of the diabetes mellitus is placed in the past and not what you see during PE. The goals are to find the symptoms that the
medical history patient had forgotten about or identifying secondary, unrelated, problems that
can be addressed. Try to ask different signs and symptoms the patient has in
For each symptom, determine: the present and past illness. You can note medical terms like dyspnea,
• The exact nature of the symptom hematuria etc.
• The onset:
o The date it began General Weight loss, weight gain, fatigue, weakness,
o How it began (e.g. suddenly, gradually—over how long?) symptoms: appetite, fever, chills, night sweats
o If long-standing, why is the patient seeking help now? Skins: Rashes, pruritus, bruising, dryness, skin cancer or
• Periodicity and frequency: other lesions.
o Is the symptom constant or intermittent? Hair: Abnormal loss or growth (baldness), premature
o How long does it last each time? graying
o What is the exact manner in which it comes and goes? Nails: Color changes like cyanosis, clubbing or brittleness.
• Change over time: Head: Trauma, headache, tenderness, dizziness, syncope.
o Is it improving or deteriorating? Eyes: Vision, changes in the visual field, glasses, last
• Exacerbating factors: prescription change, photophobia, blurring,
o What makes the symptom worse? diplopia, spots or floaters, inflammation, discharge,
dry eyes, excessive tearing, history of cataracts or
• Relieving factors:
glaucoma.
o What makes the symptom better?
Ears: Hearing changes, tinnitus, pain, discharge, vertigo,
 Associated symptoms.
history of ear infections
The questions to ask about the characteristics of pain can be remembered
Nose: Sinus problems, epistaxis, obstruction, polyps,
with the mnemonic ‘SOCRATES’:
changes in or loss of sense of smell.
Throat: Bleeding gums; dental history (last checkup, etc);
ulcerations or other lesions on tongue, gums, buccal
Past Medical History: History of similar complaint or present problem in the
mucosa.
past like the epigastric pain which is recurrent in peptic ulcer. For each
Neck: Swelling, suppurative lesions (like scrofula)
condition, ask: “When was it diagnosed”, “How was it diagnosed?”, “How has
enlargement of lymph nodes, goiter, stiffness,
it been treated?”. Ask specifically about, Diabetes, Rheumatic fever, limitation of movement.
Jaundice, Hypertension, Angina, Myocardial infarction, stroke or TIA, Breast: Development, lactation, history of trauma, lumps,
Asthma, TB, Epilepsy, Anesthetic problems and Blood transfusions. If pain, discharges from nipple (color), changes of
patient reports having, ask exactly how it was diagnosed, how it has been nipple, gynecomastia, history of surgical procedure
treated. like mastectomy of biopsy result of any.
Resp. system: Respiratory. Chest pain; dyspnea; cough; amount
Drugs history: list all the medications the patient is taking, including the and color of sputum; hemoptysis; history of
does, duration and frequency of each prescription along with any side effects. pneumonia, influenza, pneumococcal vaccinations,
Make a special note of drugs have been started or stopped recently. Also ask or positive PPD.
about compliance/adherence. Patient may not consider some medications to
be ‘drugs’, example inhalers, sleeping pills, oral contraception or herbal Cardiovascular: Chest pain, orthopnea, dyspnea on exertion,
remedies. paroxysmal nocturnal dyspnea, murmurs,
claudication, ankle edema, palpitations
Allergies and reactions: ask if patient is ‘allergic to anything’ explain if they Gastrointestinal: Dysphagia, heartburn, nausea, vomiting,
are unfamiliar with the term. Also ask specifically if they have any ‘reaction’ hematemesis, indigestion, abdominal pain, diarrhea,
to drugs. If any allergy is reported, you should obtain the exact nature of the constipation, melena (hematochezia), hemorrhoids,
event. All true allergies should be clearly recorded in the patient’s case note change in stool shape and color, jaundice, fatty food
and drug chart. intolerance
Genitourinary: Frequency, urgency, hesitancy; dysuria; hematuria;
polyuria; nocturia; incontinence; venereal disease;
discharge; sterility; impotence; polyuria; polydipsia;
change in urinary stream; and sexual history, exact location like right basal lung field).
including frequency of intercourse, number of Auscultation – determine type of breath sounds,
partners, sexual orientation and satisfaction, and whether bronchial, vesicular, presence of abnormal
history of venereal disease. sounds like rales, rhonchi, wheeze, rub (note exact
Endocrine: Polyuria, polydipsia, polyphagia, temperature location).
intolerance, glycosuria, hormone therapy, changes
in hair or skin texture Heart: note anatomical landmarks.
Musculoskeletal: Musculoskeletal. Arthralgias, arthritis, trauma, joint Inspection – symmetry, bulging, location of PMI
swelling, redness, tenderness, limitations in ROM, (normal left 5th IS left MCL) heave, abnormal
back pain, musculoskeletal trauma, gout. pulsation, lesion, bony abnormality.
Peripheral Varicose veins, intermittent claudication, history of Palpation – PMI its location, thrill (location and
vascular: thrombophlebitis timing), pulse rate, tenderness.
Hematology: Anemia, bleeding tendency, easy bruising, Percussion – cardiac dullness (whether within normal
lymphadenopathy. limits or displaced to the left or right.
Neuropsychiatric Syncope; seizures; weakness; coordination Auscultation – heart sounds (distinct or faint)
: problems; alterations in sensations, memory, mood, regularity in rates and rhythm, friction rub, murmur
sleep pattern; emotional disturbances; drug and (TLDIPCTQ)
alcohol problems
Abdomen: inspection – contour, shape, scars (size, size location
-- and state surgical procedure), engorged veins, lesions
like spider nevi etc. visible masses, striae, pulsation,
PHYSICAL EXAMINATION bulging like hernia.
Auscultation – bowel sounds
Key skill (normo/hypo/hyperactive/ absent) metallic sounds,
1. Introduce yourself to the patient bruit, venous hum, fetal heart in pregnant female,
2. Ensure good hand hygiene special maneuvers like puddle sign to rule out ascites.
3. Explain to the patient what you are going to do and ask their permission. Succession splash in obstruction (the last 2 are not
4. Be systematic in your examination routine).
5. Be wary of causing discomfort to the patient. Percussion – lympsny, superior liver dullness, fluid
6. Be systematic in your presentation, giving key clinical findings. wave and shifting dullness (not routinely done), RUQ
7. Give a differential diagnosis and then the most likely diagnosis first percussion CVA tenderness.
Palpation – (always palpable area of pain last) muscle
Suggested structure for clinical examination (mnemonic PIPPAS) Present spasticity, consistency (soft or rigid), crepitation,
yourself, Inspection, Palpation, Percussion, Auscultation, Special tests. tenderness (location, whether on light or deep
palpation) masses (location, sizes, shape, consistency,
End of the Look at the patient, are they well or ill? What makes mobility, tenderness, borders) engorgement of liver,
bed: (Gen. you think this? Are they in pain? If so, does It make spleen, kidney, bladder distension, fetal parts in
survey) them lie still (peritonitis) or writhe about (colic). State pregnant female, aortic pulsation, rebound tenderness,
if patient is in any distress or is assuming an unusual direct tenderness, lump nodes, muscles guarding
position, such as, sitting up leaning forward (position whether voluntary or involuntary.
often seen in patients with acute exacerbation of COPD
or pericarditis). What is the pattern of breathing: Special Maneuvers like Rovsings, Psoas and obturator
labored; rapid; shallow; irregular; distressed? Are they sign in appendicitis you can indicate abnormality or
obese or cachectic? Is their behavior appropriate? Can presence of mass illustration
you detect ay unusual smell? (hepatic fetor, cigarette, Back: Back & spines mobility, curvature vertebral
alcohol). What is the patient mood, stage of tenderness, bony abnormality.
development, race, and sex Extremities: (specify whether upper/lower, left/right), color,
Vital signs: Temperature (note if oral, rectal, axillary), pulse, moisture, clubbing cyanosis, joint swelling or
respirations, blood pressure (may include right arm, deformity, mobility, temperature, equality of pulses,
left arm, lying, sitting, standing), height, weight. Blood edema, varicosity, atrophy, hypertrophy, tenderness of
pressure and heart rate supine and after standing 1 min muscles, abnormal movements, range of motion, signs
should always be included if volume depletion is of inflammation, congenital abnormality.
suspected, such as in GI bleeding, diarrhea, dizziness,
or syncope.
Skin: Rashes, eruptions, scars, tattoos, moles, hair pattern. Neurologic Examination
complexion (describe color & don’t state normal),
texture, turgor (loss/senile/loss/good) pigmentation & Cerebral functions - level of consciousness, appearance & general
location, lesions. behavioral, emotional status, thought content, test for intellectual
performance, ability to recognize object, communicate & to carry out skills.
Lymph nodes: Location (head and neck, supraclavicular, epitrochlear,
axillary, inguinal), size, tenderness, motility, Cerebral functions - determine the gait, test for coordination (Romberg’s
consistency finger to nose, hell to shin, knee pat) posture.
Head, Eyes, Ears, Nose and throat (HEENT)
Head: Size and shape, tenderness, trauma, bruits. Pediatric patients: Motor system
Fontanels, suture lines 1. Test for strength -note any weakness or paralysis
Eyes: Conjunctiva; sclera; lids; position of eyes in orbits; pupil size, UE - test by hand grip
shape, reactivity; extraocular muscle movements; visual acuity LE - test vs. resistance or gravity
(eg, 20/20); visual fields; fundi (disc color, size, margins, cupping,
spontaneous venous pulsations, hemorrhages, exudates, A–V ratio, Record the results.
nicking)
Ears: Hearing test; tenderness, discharge, external canal, tympanic Right Left
membrane (intact, dull or shiny, bulging, motility, fluid or blood, UE 5/5 5/5
injected) LE 5/5 5/5
Nose: Symmetry; palpation over frontal, maxillary, and ethmoid sinuses;
inspection for obstruction, lesions, exudate, inflammation.  Results ranges from 0/5 – 5/5 which is abnormal
Pediatric patients: Nasal flaring, grunting  Test muscle tone for spasticity, rigidity, flaccidity
Throat: Lips, teeth, gums, tongue, pharynx (lesions, erythema, exudate,  Recognize abnormal spontaneous movements like tics, tremors,
tonsillar size, presence of crypts) twitching, chorea, athetosis
Neck: ROM, tenderness, JVD, lymph nodes, thyroid
examination, location of larynx, carotid bruits, HJR. Sensory System
JVD should be reported in relationship to the number 1. Test sense of pain, touch & temperature sensation.
of centimeters above or below the sternal angle, such 2. Test for positions sense (or vibrations).
as 3. Test for discriminatory sensation.
“1 cm above the sternal angle,” rather than “no JVD.” 4. Test for sensory dysfunction.
Breast: Symmetry, dimpling, nipple discharges, mass Test corresponding sides with patients eye closed. Note level of
(location, size, mobility, consistency, tenderness, abnormality you can rap
borders, no.) lymph node (axillary). out of abnormality by illustration with legend.
Chest and Inspection – contour, symmetry, expansion, rate and
lungs: rhythm of breathing, bony abnormalities. Example:
Palpation – tactile or vocal fremitus, whether - normal
equal/increase/decrease and note the location,
tenderness, in chest area/sternum, confirm symmetry. - decrease sensation
///////////
Percussion – changes in resonances, dullness (note
- no sensation of pain c. Knee Jerk
d. Achilles or Ankle jerk
Cranial nerves. 2. Superficial
I.Olfactory - sense of smell on both nostrils if intact. Identification of odor a. Cremasteric male – whether + or –
with patient eye closed. b. Abdominal – whether + or -
II.Optic- test for visual acuity, color vision, confrontation test, 3. Pathological
ophthalmoscopy examination, visual field. a. Ankle clonus + if abnormal L & R
III,IV,VI. – EOM if intact, pupillary rxn, lid lag. b. Babinski + if abnormal L & R
V. Trigeminal- symmetry of face, corneal rxn, ability to open mouth, pain c. Kernigs + if abnormal
sensation of face. d. Brudainski + if abnormal
VII. Facial – ability to wrinkle forehead, smile, frown, raise eyebrows, test for
taste and 2/3 of tongue, chvostek sign. Report result of DTR as follows
VIII. Acoustic – hearing and equilibrium.
IX, X – Symmetry of uvula with phonations, gag reflex, patients “Pulse”, taste Right Left
test post 1/3 of tongue. Biceps ++ ++
XI Accessory – palpable strength of trapezius & sternocleidomastoid muscle Triceps ++ ++
by shoulder shrug if strong or weak & ask patient to move head up and down. Knee ++ ++
XII Hypoglossal – detect deviation of protruded tongue, tremors & strength & Achilles ++ ++
note impaired swallowing. Ankle clonus ++ ++
Babinski + +
Reflexes:
1. DTR – result ranges from 0 - ++++
a. Biceps
b. Triceps
Southwestern University – School of medicine (SWU – SM)
PD Clinics (SGD 4) Must Knows in Physical Examination
Dr. Airiee Arranguez Tello - Preceptor
(Reference: Bate’s Guide to PE and History Taking, 10th Ed)

I. HEAD – A cardinal rule to remember is that when examining any organ or structure which leads to the inside, always begin from the outside, sα

1. EYES. Using Inspection and Palpation,

a. Start with a comparison of both eyes for symmetry, strabismus, also noting for presence of edema (pan-orbital), increase lacrimation, discharge,
swelling, ptosis and exopthalmos
b. Conjunctivae – for color and hemorrhage, and pterygium
c. Sclerae – color, especially yellowish discoloration, hemorrhages
d. Cornea – watch for transparency, scars, opacity and in elderly, arcus senilis
e. Pupils – with the use of penlight, compare size of pupils; follow with papillary light and accommodation reflexes
f. Visual acuity and whether wearing glasses or not

2. EARS
a. Watch for discharges and furuncle in the external auditory canal and characterize
b. See if the tympanic membrane is intact with use of penlight, while holding pinna of the ear outwards and backwards
c. Palpate for tenderness of the mastoid process
d. From the interview, note hearing problem

3. NOSE
a. Watch for the dilation of the alae nasi
b. Any deviation of the nasal septum
c. Discharge – characterize the discharge
d. With penlight, observe the turbinate for color or congestion

4. MOUTH AND THROAT – again use penlight for interior

a. Lips – watch for color, any lesion especially at the angle of the lips; congenital abnormality, cracks or oral ulcers on the under surface, note for
symmetry
b. Any carious or missing teeth or false teeth (dentures)
c. Gums – color, deviation, and degree of smoothness
d. Tonsils – whether enlarged or inflamed (congested)
e. Throat (pharynx) – color and/or congestion

NECK – watch for:

a. Symmetry
b. Deviation of trachea
c. Any swelling or enlargement, central or lateral
d. Palpate the thyroid using any of the 3 maneuvers – if enlarged, with the aid of stethoscope, auscultate for presence of bruit
e. Palpate the cervical lymph nodes, anterior and posterior
f. Ask patient to rotate the neck for rigidity

II. BREAST (FEMALE). With patient sitting down, bare, and with arms on sides or over the head, INSPECT:

1. Symmetry and size

2. Contour & associated dimpling, flattening or inversion of nipple and masses.

3. Appearances of skin esp. color, edema, engorged veins & discharge

4. If the breasts are unusually large or pendulous, make the patient stand and lean forward on a table or chair.

5. If you suspect a mass, make patient, lie down with a small pillow or folded towel under the shoulder of the breast you are palpating. Use the back of your fingers in a
rotary motion to compress the breast gently against the chest wall. Do NOT FORGET to palpate the axilla for possible enlarged lymph node.

III. CHEST & LUNGS. Position of patient is sitting down with bare back and with both arms folded over each other and with examiner at the back of the patient.

1. Inspection

a. watch for symmetry in contour

b. symmetry of expansion with normal breathing

2. Palpation

a. Confirm the degree of expansion which you saw on inspection by putting the palms of your hand on patient’s sides at the bases of the lungs.

b. Elicit vocal or tactile fremitus.

3. Percussion: Percuss both lungs beginning from the suprascapular area of one side to the opposite side and coming down to the bases in step ladder fashion avoiding
the bones (Scapulae and Vertebrae).

4. Ausculation: Using the same points as Percussion, auscultate both lungs from left to right starting at the apex and stay on the interscapular areas. Listen for breath
sounds, rales wheezes and friction rub.

IV. HEART: With patient on dorsal recumbent position and examiner on the right side.

1. Inspection: Watch for

a. Symmetry of anterior chest wall

b. Bulging of the precordium
c. PMI

d. Engorgement of neck veins

2. Palpation
a. Confirm by touch, the location of PMI
b. Feel for a thrill with the palm over precordium
c. Also palpate for a heave which is a forward thrust of the precordium.

3. Percussion: This outlines the cardiac borders – start from lateral (along the anterior axillary line) 2 nd intercostal space going medial, then follow with the
rest of the interspace up to the 5th ICS.

4. Auscultation: Auscultate only over the clinical valvular areas (APMT) and listen for:

a) Heart sounds, including heart rate

b) Murmurs

c) Arrhythmias or abdominal rhythm of heart rate.

V. ABDOMEN:

Here the order of P.E varies. Position of patient is dorsal recumbent, preferably with the thighs flexed, which is correct position for palpation of the
abdomen. Expose abdominal wall from xiphoid process up to pubic symphysis. Examiner is on right side of patient.

1. Inspection: Watch for:

a. Symmetry
b. Shape which includes distention or enlargement
c. Engorged blood vessels
d. Umbilicus
e. Striae
f. Skin lesion, rashers or pigmentation
g. Peristalsis
h. Abnormal pulsation

2. Auscultation: Note for:

a. Bowel sounds (Borborygmi)
b. Fetal heart beat in pregnancy
c. Hyper-peristalsis

3. Percussion: done over

a. Abdominal wall in all quadrants
b. Liver- normal liver dullness extends from 7 to 10 intercostal space, right side.
c. In case of Ascites, elicit shifting dullness (the most diagnostic sign)
d. In kidney inflammation, elicit kidney punch over the lumbar areas at the back.

4. Palpation: this is the best method to diagnose abdominal conditions.

a. Palpate the liver and spleen in all patients – this is Routine
b. A special palpatory technique in case of ascites in Fluid Wave.
c. Note for tenderness, especially Rebound tenderness of Acute Appendicitis.

VI. RECTAL EXAM: Patient in either Sims position & Dorsal Lithotomy position.

Preparation of Examiner:

1. Explain to patient purpose and the procedure

2. Gloved fingers with Lubricant
3. Insert index finger – and observe for:
a. Tightness of rectal sphincter
b. Presence of external and internal hemorrhoids
c. Palpate for Prostate Gland on removal of finger – observe for presence or absence of stools and character (bloody or back)
Southwestern University – School of medicine (SWU – SM)
PD Clinics (SGD 4) Respiratory System Physical Examination
Dr. Airiee Arranguez Tello - Preceptor
(Reference: Bate’s Guide to PE and History Taking, 10th Ed)

GENERAL PRINCIPLES OF CHEST/LUNGS EXAMINATION

> Patients should be disrobe up to the waist for better evaluation of the anterior and chest wall. For men, arrange the patient's gown so that you can see the chest fully.
For women, cover the anterior chest when you examine the back. For the anterior examination, drape the gown over each half of the chest as you examine the other
half.

> Proceed in an orderly fashion: inspect, palpate, percuss, and auscultate.

> Always compare the findings in the right side of the chest to the left side when doing the physical assessment.

> Be systemic in doing the examination, may either start from the lung apex going to base or vice versa. > If possible, examine the posterior chest with the patient
sitting, arms folded across the anterior chest and the hands resting on the opposite shoulder. This position moves both scapulae partly out of the way and increase the
access to the lung fields.

> For the anterior chest wall, you may examine the patient sitting up with arms at the side or preferable on supine position especially in women. Supine position allows
the breast to be moved and are less likely to interfere with the examination of the chest.

> If the patient is unable to sit up by himself/herself for the examination, the patient maybe assisted in sitting up. Or patient maybe rolled to either the right or left
lateral decubitus position to gain access to the posterior chest wall.

INITIAL SURVEY OF RESPIRATION AND THE THORAX

> Observe the rate, rhythm, depth and effort of breathing.

> A healthy resting adult breathes quietly and regularly about 14 to 20 times a minute, quiet breathing and regular in rhythm with minimal effort.

> Dyspneic patients breathe rapidly, often laboring to draw breaths even at rest.

> Sleep apnea patients have episodes of stalled breathing (apnea) in between regular cycle.

> Always inspect the patient for any signs of respiratory difficulty

a. Assess the patient's color for cyanosis

b. Listen to the patient's breathing - wheezing, stridor c. Inspect the neck - note for contraction of the accessory muscles of respiration, namely the sternomastoid and
scalene muscles, or supraclavicular retraction. Is the trachea midline?

A. INSPECTION - Note the following:

1. Shape of the chest- any deformities or asymmetry of the chest

2. Abnormal retractions of the intercostal space during inspiration. ICS retractions are most apparent in the lower interspaces.

3. Note for prominence of accessory muscles of respiration Note: Presence of 2 & 3 signifies respiratory distress

> Other signs of respiratory distress- flaring of ala nasae, pursed lip breathing 4. Any asymmetry/lag/delay on the unilateral chest wall during respiration

> Unilaterally/lag/delay in chest movement suggests significant lung parenchymal disease or pleural disease.

B. PALPATION – Note the following:

1. Identify tender areas on the chest wall – focus on areas of tenderness and abnormalities in the overlying skin, respiratory expansion, and fremitus.

2. Test for chest expansion/symmetry.

► Place your thumbs at about the level of the 10 th ribs, with your fingers loosely grasping and parallel to the lateral rib cage. As you position your
hands, slide them medially just enough to raise a loose fold of skin on each side between your thumb and spine.

► 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.

► A symmetric convergence/divergence of the thumbs during respiration – indicates a delay of chest expansion brought about by pulmonary fibrosis,
pleural effusion, lobar pneumonia, pleural pain with associated splinting and unilateral bronchial obstruction.

3. Assessment for tactile fremitus.

► Fremitus are palpable vibration transmitted through the lungs when a person speaks.

► Use either the ulnar surface of your hands or the ball of your hands (bony part of the palm at the base of the fingers.)
► Place both hands on both sides of the anterior/posterior chest wall (same level or ICS)

► Ask patient to verbalize “ninety-nine” or “one, two, three” and note if tactile fremitus palpated is equal on both hands,

► Start from the apex and move down repeating the procedure until you have compared both lungs in the anterior and posterior chest wall.

► Normal lungs should have equal and symmetrical tactile fremitus on both sides.

► Any condition that obstructs the transmission of breath sounds from the airways to the chest wall will result in diminished tactile fremitus (pleural
effusion, pneumothorax, obstructed bronchus – COPD, thick chest wall.)

► Lobar consolidation will result in increased tactile fremitus.

Posterior aspect Anterior aspect

C. PERCUSSION

 Percussion sets the chest wall and underlying tissues into motion, producing audible sound and palpable vibration.
 Helps determine whether the underlying tissue are air-filled, fluid or sail.

Technique: right handed examiner

 Hyperextend the middle finger of your hand (pleximeter finger). Press the distal interphalageal joint firmly on the surface of the chest to be
percussed. To avoid dumping the vibrations, it is best to avoid contact of the chest by any other part of the hand.
 Position of the right forearm close to the proximeter finger, with the wrist partially extended, the right middle finger partially flexed and
relaxed.
 Strike the distal interphalangeal of the pleximeter finger with the right middle finger using a brisk, sharp but relaxed flexion at the right wrist
joint.
 Use the tip of the right middle finger and not the pads.
 Withdraw the striking finger quickly to avoid damping the vibration it created.
 Start from the apex, moving and comparing the percussion sound elicited with both sides of the anterior and posterior chest.
 Normal percussion sound of a healthy lung is resonant.
 Once the lungs/pleura is filled with fluid, blood, fibrosis or mass – it becomes dull on percussion.
 A hyperinflated lung due to airway obstruction will result in hyperresonance.

D. AUSCULTATION

 May use either the bell or the diaphragm of the stethoscope

 Air flowing through the bronchi will produce characteristic breath sounds which can be picked up by auscultating the anterior and posterior chest wall.
 With your stethoscope touching your chest wall, ask the patient to take deep inhalations and exhale preferably through the open mouth.
 Using locations similar to those recommended for percussion, always compare symmetrical areas of the lungs from apex down to the lower chest.
 Listen to at least one full breath (inspiration & expiration) in each location and note for

1. Breath sounds characteristics

 intensity (decreases in obesity, thick muscular chest wall or failure to take deep inhalation)
 pitch (low pitch in vesicular breath sounds vs high pitch in bronchial breath sounds)
 duration of inspiratory or expiratory sounds
 location of vesicular and bronchial breath sounds
2. Added or adventitious breath sounds
 Crackles
 Wheezes
 Rubs
 Rales
 Amphoric breath sounds, etc.
3. Note what adventitious sounds you hear.
4. Where in the respiratory cycle you hear the added sounds (inspiratory phase, expiratory phase or in both phases)

If there are abnormalities (diminished) in tactile fremitus, percussion or auscultation, check for alterations in the spoken and whispered voice sounds

a.) Egophony- Greek word for “Voice of the Goat”

- With your stethoscope on the chest wall, ask the patient to say “ee” as you move the stet from one part to another. Listen in symmetrical areas of
the lungs, noting the intensity and clarity of the sounds. You will hear a muffled long E. Normally it is muffled. When “ee” is heard as “ay”, an
E-to-A change (egophony) is present as in lobar consolidation from pneumonia. The quality sounds nasal.

b.) Bronchophony – Louder, clearer voice sounds are called bronchophony.

- Ask the patient to say “ninety-nine”. Normally the sounds transmitted through the chest wall are muffled and indistinct, as it is being filtered
through the lung parenchyma. In the presence of an airless lung tissue (consolidation in pneumonia), voice sounds appear louder and clearer than
usual because the higher pitched components are better transmitted.

c.) Whispered Pectoriloquy – ask the patient to whisper “ninety-nine” or “one, two, three”. The whispered voice is normally heard faintly and indistinctly, if at
all. Louder, clearer whispered sounds are called whispered pectoriloquy.

Southwestern University – School of medicine (SWU – SM)

PD Clinics (SGD 4) Cardiovascular System Examination
Dr. Airiee Arranguez Tello - Preceptor
(Reference: Bate’s Guide to PE and History Taking, 11th Ed)

A. Cardiovascular Examination of the Neck

A.1 Jugular Venous Pressure and Pulses
-reflects pressure in the right atrium, or central venous pressure
-best assessed from pulsations in the right internal jugular vein
-the jugular veins and pulsations are difficult to see in children under 12 years of age, so it is not useful in
evaluating cardiovascular system in this age group

STEPS FOR ASSESSING THE JVP

1. Make the patient comfortable. Raise the head slightly on a pillow to relax the sternomastoid muscles.
2. Raise the head of the bed or examining table to about 30 degrees. Turn the patient’s head slightly away from
the side you are inspecting.
3. Use tangential lighting and examine both sides of the neck. Identify the external jugular vein on each side,
then find the internal jugular venous pulsations.
4. If necessary, raise or lower the head of the bed until you can see the oscillation point or meniscus of the
internal jugular venous pulsations in the lower half of the neck.
5. Focus on the right internal jugular vein. Look for pulsations in the suprasternal notch, between the
attachments of the sternomastoid muscle on the sternum and clavicle, or just posterior to the
sternomastoid.
6. Identify the highest point of pulsation in the right jugular vein. Extend a long rectangular object or card
horizontally from this point and a centimeter ruler vertically from the sternal angle, making an exact right
angle. Measure the vertical distance in centimeters above the sternal angle where the horizontal object
crosses the ruler and add to this distance 4 cm, the distance from the sternal angle to the center of the
right atrium. The sum is the JVP.

Note: If unable to see pulsations in the internal jugulars, use external jugulars and look for the point above
which the external jugular veins appear to collapse.

-Sternal angle of Lewis is roughly 5cm above R atrium

-Normal JVP reading is less than or equal to 3cm
A.2 Hepatojugular/Abdominojugular Reflux -Increased pressure suggest right-sided congestive
-done to check a rise in jugular venous pressure in suspected congestive heart failure or, less commonly, constrictive
heart failure pericarditis, tricuspid stenosis, or superior vena cava
- Position patient on the bed so that the highest level of pulsation is readily obstruction
seen in the lower half of the neck -In patients with obstructive lung disease, venous
- Place the palm of the hand on the center of the abdomen and slowly press pressure may appear elevated on expiration only.
inward, extending firm and sustained This finding does not indicate congestive heart
pressure for 30-60 seconds. failure.
- Watch for sustained increase in JVP which is >3 cm rise for at least q5
secs after resumption of spontaneous
respiration
- A transient rise in JVP is otherwise normal.
- Increase JVP (>3cm) can be seen in right-sided heart failure, constrictive
pericarditis, tricuspid stenosis and
superior vena caval obstruction.
- Increase in JVP (>3cm) only during expiration but veins are collapsed on
inspiration is seen in Obstructive lung
disease

A.3 Carotid Pulse

1. Palpation
- The patient should be lying down with the head of bed elevated to about 30 degrees.
- When feeling for the carotid artery, first inspect the neck for carotid pulsation.
These may be visible jus medial to
the sternomastoid muscle.
- Then place your index and middle fingers (or left thumb) on the right carotid artery
in the lower third of the
neck, press posteriorly, and feel for pulsations.
- For the left carotid artery, use your right fingers or thumb.
- Never press both carotids at the same time. This may decrease blood flow to the
brain and induce syncope.
- Slowly increase pressure until you feel a maximal pulsation; then slowly decrease
pressure until you best sense
the arterial pressure and contour. Aim to assess:
● The amplitude of the pulse. This correlates reasonably well with the pulse pressure.
● The contour of the pulse wave, namely the speed of the upstroke, the duration of its summit, and the speed
of the downstroke. The normal upstroke is brisk. It is smooth, rapid, and follows S1 almost immediately. The
summit is smooth, rounded, and roughly midsystolic. The downstroke is less abrupt than the upstroke.
● Any variations in amplitude
● The timing of the carotid upstroke in relation to S1 and S2. Note that the normal carotid upstroke follows
S1 and precedes S2.

2. Thrills and Bruits

- During palpation, humming vibrations, or thrills, like the throat vibrations in a cat when it purrs, may be
detected.
- If you feel a thrill, listen over both the carotid arteries for a bruit, a murmur-like sound arising from turbulent
arterial blood flow. Ask the patient to stop breathing for a few seconds, then listen with the diaphragm of the
stethoscope

B. Examination of the Extremities

B. 1 Inspection -redness, swelling (thrombophlebitis)
- Edema, varicose veins venous/arterial ulcers (differentiate)
- Clubbing, cyanosis, pallor
- Trophic changes of peripheral arterial insufficiency
- Shiny skin, hair loss
B.2 Palpation -calf pain tenderness (venous thrombosis)
-Temperature of extremity (cold extremity in peripheral arterial insufficiency)
-Pulsations in peripheral pulse (weak in arterial occlusion or hypotension)

C. Anterior Chest Examination

Sequence of the cardiac examination
Patient Position Examination Accentuated findings
nd
Supine, with the head elevated 30⁰ Inspect and palpate the precordium; the 2 right and left
interspaces; the right ventricle; and the left ventricle, including the
apical impulse (diameter, location, amplitude, duration)

Left lateral decubitus Palpate the apical impulse, if not previously detected. Listen at the Low-pitched extra sounds such as an S₃,
apex with the bell of the stethoscope. opening snap, diastolic number of mitral
stenosis

Supine, with the head elevated 30⁰ Listen at the 2nd right and left interspaces, along the left sternal
border across to the apex with the diaphragm.

Sitting, leaning forward, after full Listen at the right sternal border for tricuspid murmurs and sounds Soft decrescendo diastolic murmur of aortic
exhalation with the bell. insufficiency

C.1. Inspection - patient in supine position with head of bed elevated at 30⁰
- Note for gross chest deformities (pectus excavatum? Carinatum? Bulging or prominences over
the precordium?)
- Pulsations – the only normal pulsation seen in the chest is the apex beat
- Epigastric pulsation may be visible (from abnormal aorta in thin patients)
- Hypertrophied RV/ overactive RV can also give epigastric pulsation

Apex beat of PMI:

- Location: 5th L-ICS, 7-9 cm from MSL
- Size: less than 2cm in diameter
- Can be normally invisible

C.2 Palpation – supine with head of the bed elevated at 30 degrees.

1. Apex Beat – try supine position first, if not palpable may do partial left lateral decubitus position or ask the pt to fully exhale and hold breath while
palpating.
- Search first the palmar surfaces of several fingers, once you have found the apex beat use the
fingertips for finer assessment and then with one finger.
-Conditions that will result in undetectable apical impulse:
Obesity, very muscular chest wall and emphysema.

Apex beat characteristics:

a. Location–at the 5th ICS, 7-9 cm from MCL (medial to MCL)
- if located lateral to the MCL, suggest cardiac enlargement or displacement.
b. Diameter–1.2 cm (>2cm > LV enlargement)
c. Amplitude–small in amplitude is seen in hyperkinetic states (hyperthyroidism), LV pressure overload
(aortic stenosis) or LV volume overload (mitral regurgitation)
d. Duration - auscultate at the same time palpating for the apex beat.
- normal duration is brief and occupies the first 2/3 of systole; does not reach the S2.
- a sustained contraction that reaches the S2>LV

2. Right Ventricular Heave Lift – place the tips of your curved fingers at the left sternal border in the 3 rd , 4th, 5th ICS. Hold them flat or obliquely on the body
surface
- Normally, a brief systolic tap of low amplitude and duration is felt which represents systolic
impulse of RV.
- RV impulse with increase amplitude and duration occurs in RV pressure overload (pulmonic
stenosis or pulmonary HTN)

3. Thrills – most often accompany loud, harsh or rumbling murmurs (AS, PDA, VSD, MS)
- use the base of the fingers or ulnar side of the hand
- Apical thrills – best felt with the pt lying on left side and on breathhold
- Aortic and pulmonic thrills – best felt on held expiration and pt leaning forward

C.3 Percussion– purpose, to delineate the right and left cardiac borders.

LCBD: delineate the left cardiac border by percussing the 3rd, 4th, 5th starting over the resonant areas near the axilla going medially. Mark the skin
where change from resonant to dullness occurs. Does not exceed 4cm (3rdICS) 7cm (4th ICS) and 9cm (5th ICS) from MSL.

RCBD: percuss the 3rd, 4th, 5th R ICS (normally there should be no dullness beyond the right edge of the sternum from 3 rd – 5th ICS and should be reported as
such).

C.4 Auscultation
Auscultatory areas/locations:
2nd R- ICS –Aortic valve
2nd L-ICS - Pulmonic valve
Left sternal border from 2nd to 5th ICS – Tricuspid valve
Apex (5th L-ICS, 7-9cm from MSL) – Mitral valve

Note: Locations are not suitable for each heart valve sound. Murmurs of more than 1 origin may occur in a given area.
a.) Sequence: either start to auscultate from the base of the heart to the apex or vice versa.
b.) Use of stethoscope: use the diaphragm of the stethoscope to listen for high pitched sounds like S1, S2, murmurs of aortic regurgitation (AR) or mitral
regurgitation (MR) and pericardial friction rubs. The bell of the stethoscope is more sensitive to low-pitched sounds like S3, S4 and mitral murmurs.
c.) Patient position: auscultate with patient in supine position
1.) Left lateral decubitus position – brings the left ventricle close to chest wall
- Accentuates left-sided S3, S4 mitral murmurs
2.) Ask the pt. to sit up, lean forward exhale completely and hold the breath
- This accentuates murmur or aortic regurgitation (AR)
d.) Heart sounds
1.) S1 - louder than S2 at the apex
- due to the closure of mitral valve (mainly) and tricuspid valve
- may split into two sounds but not always detected since the louder mitral valve may mask the softer tricuspid valve
- auscultate for split S1 at left lower sternal border
- splitting of S1 does not vary with respiration

2.) S2 - louder than S1 at the base of the heart: 2nd R & L ICS
- due to the closure of aortic and pulmonic valves (A2+P2)
- during expiration – A2 and P2 fused to produce a single S2
- during inspiration – A2 and P2 separate slightly – S2 splits into two audible components
- auscultate for split S2 at 2nd or 3rd L-ICS near sternum
> Ask the pt. to breathe quietly, and slightly more deeply than normal
- does S2 split into its 2 components, as it normally does? If not,
> Ask the pt to (1) breathe more deeply, or (2) sit up
> Listen again
 Width of split- How wide is the split? Normal: quite narrow
 Timing of split – When in the respiratory cycle do you hear the split?
Normal: heard late in inspiration
 Does the split disappear as it should, during exhalation?
> if not, listen again with pt sitting up
 Intensity of A2 &P2 – Compare the intensity of 2 components: A2 is usually louder

3.) Extra Heart Sounds during systole – ejection sounds, systolic clicks of mitral valve prolapse
4.) Extra Heart Sounds during diastole – S2, S4, opening snap
 S3 – due to rapid ventricular filling as blood flows early in diastole from LA to LV
 S4 – due to increased left ventricular and diastolic stiffness which decreases compliance
 Opening snap – due to opening of stenotic mitral valve

Heart murmurs
- has longer duration compared to heart sounds
-systolic murmurs may indicate heart disease but often occur in a normal heart; occur in between S1 and S2
- diastolic murmurs usually indicate heart disease
- diastolic murmurs occur in between S1 and S2

Murmurs if heard are characterized according to:

1. Intensity – 6 point scale for grading murmur intensity
Grade 1 – very faint, heard only after the clinician has really “tuned in”
Grade 2 – quiet but heard immediately upon placing stet to chest wall
Grade 3 – moderately loud
Grade 4 – loud
Grade 5 – very loud, heard with stet partly off the chest wall
Grade 6 – heard with stet entirely off the chest wall
2. Timing – systolic in between S1 and S2
- diastolic if in between S2 and S1
- systolic murmur – midsystolic murmurs (AS or PS) or pansystolic/holosystolic murmur (regurgitant flow across an AV valve- MR, TR, VSD)
- diastolic murmur – early diastolic murmur (regurgitant flow across incompetent AV or PV, middiastolic and late diastolic murmur/presystolic (due to turbulent
flow across AV valve-MS)
3. Quality – blowing, harsh rumbling or musical
4. Pitch – high, medium or low pitch
5. Location – which ICS is the murmur heard
6. Radiation - transmission from the point of maximal intensity
- determined by the intensity of murmur and direction of blood flow
Ex. Murmur of AS often radiates to the neck (direction of arterial flow)
7. Effect of Respiration – murmurs from right side of the heart tend to change more with respiration than do left-sided murmurs
Ex. A harsh, medium pitched, grade 3/6 midsystolic murmur at the 2nd R ICS with radiation to the neck, no variation with respiration

 SPECIAL TECHNIQUES
Maneuvers to Identify Systolic Murmurs

Effects on Systolic Sounds and Murmurs

Maneuver Cardiovascular Effect Mitral Valve Prolapse Hypertrophic Aortic Stenosis

Cardiomyopathy
Squatting; Increased left ventricular prolapse of mitral outflow obstruction blood ejected into aorta
Valsalva: volume from venous valve
Release Phase return to heart
Increased vascular tone: intensity of murmur intensity of murmur
arterial blood pressure; Delay of click and
peripheral vascular murmur shortens
resistance
Standing; Decreased left ventricular prolapse of mitral outflow obstruction blood volume ejected
Valsalva: volume from venous valve into aorta
Strain Phase return to the heart
Decreased vascular tone: intensity of murmur intensity of murmur
arterial blood pressure Click moves earlier in
systole and murmur
lengthens

Southwestern University – School of medicine (SWU – SM)

PD Clinics (SGD 4) Skin, Head, Face and Neck Exam
Dr. Airiee Arranguez Tello - Preceptor
(Reference: Bate’s Guide to PE and History Taking, 10th Ed)

A. Skin

I. Inspection
1.) Color:
a.) Central cyanosis – lips, buccal mucosa, tongue (lung disease, congenital heart disease, palmar edema, abnormal hemoglobin)
b.) Peripheral cyanosis – nails and skin in the extremities (cold exposure, anxiety, and venous obstruction)
c.) yellowish discoloration sec to pt’s carotene (palms, soles, face)
d.) jaundice (liver disease, hemolysis) – sclera, skin, lips, hard palate, under the tongue.
2.) Lesions:
a.) Note the anatomic location & distribution (localized/generalized)
- Psoriasis usually affects the elbows and knees
- Acne usually affects the face, upper chest and back
b.) Note the grouping or arrangement of the lesions (linear, clustered, annular, dermatomal); ex. - vesicles in unilateral dermatomal pattern is typical of
Herpes zoster.
c.) Note the type of lesions:
- Fluid filled lesions < 0.5cm- vesicle; >0.5 cm is bulla; pustule if pus
- Flat lesions < 1cm- patch
- palpable elevated solid mass – papule <0.5 cm plaque if >2 cm – nodule 0.5 to 1-2 cm diameter and firmer lesion, tumor if >2cm

Note: Evaluating Bedbound patients > look for pressure sores at the back or hips
- Occurs when sustained pressure compression obliteration arteriolar & capillary blood flow to the skin

II. Palpation

1.) Moisture- dryness, sweating, oiliness (dryness in hypothyroidism, oiliness in acne)

2.) Texture- roughness or smoothness (roughness in hypothyroidism)
3.) Temperature- use the back of the hand to determine temperature
- Generalized warmth in fever, hyperthyroidism
-Coolness in hypothyroidism
- Local warmth in inflammation or cellulitis
4.) Mobility and turgor- lift and fold of skin and note the ease with which it is moved (mobility) & the speed with its return into place (turgor).
- Decrease in mobility in edema or sclerodema: decrease turgor in dehydration
B. Nails & Hair
I. Inspection & palpation of the fingernails & toenails- color, shape and lesion
- normal angle of the fingernail and nail base is 160
- clubbing of fingernails > angle exceeds 180
- spoon nails (koilonychia)- concave curves (seen in iron deficiency anemia)

II. Inspection and palpation of hair- note quantity, distribution and texture
- Alopecia- refers to hair loss (can be patchy, diffuse of total)

Note: read the tables on basic types of skin lesions, vascular & pupuric lesions of the skin, skin turgor, pressure ulcers, benign or malignant nevi, skin color, nail
findings

C. Head and Face

I. Inspection and palpation
1. Hair- note quantity, distribution, pattern of loss, dandruff etc.
- Fine hair in hypothyroidism, coarse hair in hyperthyroidism
2. Scalp- look for scaliness, lumps, etc.
- Redness & scaling in sebhorrheic dermatitis, psoriasis
3. Skull- general size and contour, note any deformities, tumors and tenderness ( enlarged skull- hyrocephalus)
4. Face- facial expression, involuntary movements, asymmetry,skin lesions, pigmentation (Acne, hirutism, etc.)
D. Neck
I. Inspection: note any symmetry, masses, scar, pulsation, venous distention, tracheal deviation, thyroid gland visibility
- a horizontal neck scar may indicate past thyroid surgery
- ask pt. To swallow water and watch as all the 3 structures (thyroid cartilage, cricoids and thyroid gland) rise upon swallowing

II. Palpation: Lymph nodes, trachea, thyroid gland, hyoid bone, thyroid cartilage, R/L carotid arteries/pulsation

a. Lymph node pulsation

- use the pads of 2nd and 3rd fingers to palpate the different lymph nodes with a gentle rotary motion moving the skin over the underlying tissues in
each area.
- Start at the preauricular nodes (in front of the ears), posterior auricular (behind the ear), occipital (base of the skull), tonsillar (angle of the
mandible), submandibular (below the mandible), submental (below the chin), superficial cervical, posterior cervical and supraclavicular above the
clavicle.
- Tender lymph nodes suggest inflammation
- Hard and fixed lymph node suggest malignancy
- Enlarged supraclavicular nodes especially on the left suggest possible metastasis of thoracic or abdominal malignancy

b. palpate for tracheal deviation- place your finger along the right side of trachea and note the space between it and the sternocleidomastoid
muscle. Do the same maneuver along the left side of the trachea and compare both sides it is symmetrical.
c. Palpating the Thyroid Gland:

--STEPS FOR PALPATING THE THYROID GLAND--

1. ask the patient to flex the neck slightly forward to relax the sternomastoid muscles.
2. Place the fingers of both hands on the patient’s neck that your index finger are just below the cricoid cartilage
3. Ask the patient to sip and swallow water as before. Feel for the thyroid isthmus rising up under your finger pads. It is often but not always palpable.
4. Displace the trachea to the right with fingers of the left hand, the right hand fingers, palpate laterally for the right lobe of the thyroid in the space between the
displaced trachea and the relaxed sternomastoid. Find the lateral margin. In similar fashion, examine the left lobe.
5. The lobes are somewhat harder to feel than the isthmus, so practice is needed. The anterior surface of a lateral lobe is approximately the size of the distal phalanx of
the thumb and feels somewhat rubbery.

- Note the size, shape and consistency of the gland and identify and nodules or tenderness.
- If the thyroid gland is enlarged listen over the lateral lobe with a stethoscope to detect bruit, a sound similar to a cardiac murmur but on noncardiac origin.

Southwestern University – School of medicine (SWU – SM)

PD Clinics (SGD 4) Physical Examination of the Abdomen
Dr. Airiee Arranguez Tello - Preceptor
(Reference: Bate’s Guide to PE and History Taking, 10th Ed)
TECHNIQUES OF EXAMINATION
 For a skilled abdominal examination, you need good light and a relaxed and well-draped patient
 Expose the abdomen from just above the xiphoid process to the symphysis pubis
 The groin should be visible while the genitalia should remain draped
 The abdominal muscles should be relaxed to enhance all aspects of the examination, but aspects of the examination, but especially palpation

Tips for Enhancing Examination of the Abdomen

 Check that the patient has an empty bladder.

 Make the patient comfortable in the supine position with a pillow under the head and perhaps another under the knees. Slide your hand under the low back to
see if the patient is relaxed and lying flat on the table.
 Ask the patient to keep the arms at the sides or folded across the chest. If the arms are above the head, the abdominal wall stretches and tightens, making
palpation difficult. Move the gown to below the nipple line, and the drape to the level of the symphysis pubis.
 Before you begin palpation, ask the patient to point to any areas of pain so you can examine these areas last.
 Warm your hands and stethoscope. To warm your hands, rub them together or place them under hot water. You can also palpate through the patient’s gown
to absorb warmth from the patient’s body before exposing the abdomen.
 Approach the patient calmly and avoid quick, unexpected movements. Watch the patient’s face for any signs of pain or discomfort. Make sure you avoid
fingernails.
 Distract the patient if necessary with conversation or questions. If the patient is frightened or ticklish, begin palpation with the patient’s hand under yours.
After a few moments, slip your hand underneath to palpate directly.

Proceed in the following sequence – inspection, auscultation, percussion & palpation.

A. INSPECTION- Note the following from the side of the bed:

1. Skin – a.) Scars (note their location)

b.) striae – stretch marks are usually silver striae; pink purple striae are seen in Cushing’s syndrome
c.) Dilated veins – significant dilated veins seen in hepatic cirrhosis or inferior vena cava obstruction
d.) Rashes/lesions
2. Umbilicus – contour any signs of inflammation or hernia
3. Contour of abdomen – flat, protuberant, rounded or scaphoid (concave or hallowed), presence for bulging flanks (ascitis), local bulges (suprapubic bulge of
distended bladder or pregnant uterus)
4. Symmetry – asymmetry seen in organomegaly or mass
5. Masses
6. Peristalsis – may be visible normally in very thin individuals
- observe for several minutes if you suspect bowel obstruction (increase peristaltic waves of intestinal obstruction)
7. Pulsations – normal aortic pulsation may be visible in the epigastric area
- increased pulsation suggestive of aortic aneurysm or increased pulse pressure.

B. AUSCULTATION – useful in assessing bowel motility, presence of bruits or vascular sounds resembling heart mumurs, over the oarta or other arteries in
the abdomen
- Auscultate the abdomen before performing percussion or palpation because these maneuvers may alter the frequency of bowel sounds

1. Bowel Sounds
- Listen for bowel sounds in one spot of the abdomen using the diaphragm of the Stethoscope, note their frequency and character
- Normal bowel sounds – consist of clicks and gurgles, occurring at an estimated frequency of 5 to 34 per minute
- Increased bowel sound – borborygmi – prolonged gurgles of hyperperistalsis – the familiar “stomach growling”, as in diarrhea or early intestinal obstruction
- Decreased/absent BS – paralytic ileus, peritonitis
- Before deciding that bowel sounds are absent, sit down and listen for 2 min or even longer

2. Bruit: Vascular sounds resembling heart murmur

- Listen in the epigastrium and both right & left upper abdominal quadrants
- A hepatic bruit suggest carcinoma of the liver or alcoholic hepatitis
- Arterial bruits with both systolic and diastolic components suggest partial occlusion of the Aorta or large arteries
- Partial occlusion of a renal artery may explain hypertension.

3. Venous Hum: Very rare and located in the epigastrium and umbilical areas
- it is a soft humming noise with both systolic and diastolic components
- indicates increase collateral circulation between the portal vein and hepatic veins (hepatic cirrhosis)

4. Friction rub – grating sounds with respiratory variation; they are rare
- indicate inflammation of the peritoneal surface of an organ, as in liver cancer,
chlamydial or gonococcal perihepatitis, recent liver biopsy, or splenic infarct
- when a systolic bruit accompanies a hepatic friction rub, suspect carcinoma of the liver

C. PERCUSSION – for assessing the amount and distribution of gas in the abdomen and to identify possible masses that are solid or fluid-filled. It’s use in
estimating the size of the liver and spleen

Technique – percuss the abdomen lightly in all four quadrants to assess the distribution of tympany and dullness. Tympany usually predominates because of
gas in the gastrointestinal tract, but scattered areas of dullness from liquid and feces are also typical.

1. Percussion and determination of liver size/span:

- Measure the vertical span of liver dullness in the right midclavicular line.
- Use a light to moderate percussion stroke, because examiners with a heavier stroke underestimate liver size
- Along the right MCL, starting at the level below the umbilicus, lightly percuss upward towards the liver. Note at which level in the abdomen that tympany
on percussion becomes dullness. This represents the lower border of the liver in the midclavicular line
- To identify the upper border of liver dullness at MCL, lightly percuss from lung resonance down towards the liver and note the level in the abdomen where
resonance is replaced by dullness on percussion
- Determine the liver span in centimeters by measuring the vertical span or height of the liver dullness (measure distance between the upper border & lower
border of liver dullness)
- Normal liver span is 6-12 cm in right midclavicular line or 4-8 cm in the midsternal line
- Liver span dullness is normally greater in men and tall individuals. It is increased if liver is enlarged and decreased if liver is small.
- Liver dullness may be displaced downward in COPD but the span remains normal.
- The presence of free air under the diaphragm from a perforated bowel may falsely decreased the liver span dullness.

2. Percussion of Spleen
- Normal spleen lies in the curve of the diaphragm just posterior to the midaxillary line.
- When a spleen enlarges (splenomegaly), it does so anteriorly, downward and medially replacing the tympany of stomach & colon with dullness of solid
organ.
Two techniques may help to detect splenomegaly, an enlarged spleen:

a. PERCUSSION IN THE TRAUBE’S SPACE

- Percuss the left lower anterior chest wall between lung resonance above and the costal margin, an area termed Traube’s space. Percuss going
lateral to the anterior axillary line and midaxillary line
- If tympany is prominent, especially laterally, splenomegaly is not likely is not likely
- If percussion dullness is present, especially above the midaxillary line, palpation correctly detects presence or absence of splenomegaly more
than 80% of the time.

*Dullness in the Traube’s space = Splenomegaly

b.
- Percuss the lowest intercostal space at the left midaxillary line. If spleen size in normal, it will remain tympanitic.
- A change in percussion sound from tympany to dullness during deep breathing suggest splenic enlargement (positive splenic percussion sign)

D. PALPATION – Light palpation & deep palpation

1. Light Palpation - Helpful in identifying muscular resistance, abdominal tenderness, and some superficial organs and masses.

Technique:

 Keeping your hand and forearm on a horizontal flame, with fingers together and flat on the abdominal surface, palpate the abdomen with a
light, gentle, dipping motion.
When moving your hand from place to place, raise it just off the skin. Moving smoothly, feel in all quadrants.
 Note any organs, masses, area of tenderness or increase resistance.
 Resistance can be voluntary resistance (in a ticklish patient where rectus abdominis muscle is contracted) or involuntary spasm which suggest
peritoneal irritation/inflammation.

2. Deep palpation – to delineate abdominal masses

Technique:

 Again using the palmar surfaces of your fingers, feel in all four quadrants. Identify any masses and note their location, size, shape,
consistency, tenderness, pulsations, and any mobility with respiration or with the examining hand. Correlate your palpate findings with their
percussion notes.
 For obese or muscular patients, palpate using two hands, one on top of the other.

- Abdominal masses may be categorized in several ways:

1. Physiologic (pregnant uterus)
2. Inflammatory (diverticulitis uterus)
3. Vascular ( an abdominal aortic aneurysm)
4. Neoplastic ( carcinoma of the colon)
5. Obstructive ( a distended bladder or dilated loop of bowel)

A. Assessment of peritoneal irritation:

Technique:
 Direct tenderness – to elicit and localize abdominal pain/tenderness secondary to peritoneal irritation, ask patient to cough before palpation
and note if coughing will produce abdominal pain (location). Then palpate gently with one hand/few fingers to the tender area. Pain elicited
by coughing and palpation may signify peritoneal irritation/peritonitis.
 Indirect/rebound tenderness – press your fingers firmly and slowly. Then quickly withdraw them. If the act of withdrawal of your
hand/fingers also causes pain, then you have elicited rebound tenderness – peritonitis.

Caution: old age may blunt the manifestation or peritoneal inflammation, resulting in diminished or absent direct/indirect tenderness or muscle guarding.

B. Liver palpation:

Technique:
1. Bimanual palpation:
 place your left hand behind the patient supporting the right 11th & 12th ribs at the back .
 place your right hand on the pt’s right abdomen lateral to the rectus muscles with fingertips below the right subcoastal area.
 Press your left hand forward at the same time pressing your right hand deep into the abdomen to palpate for the liver edge.
 Normal liver egde is soft, sharp, and regular, with a smooth surface. The normal liver may be slightly tender.
 On inspiration, the liver is palpable about 3 cm below the right coastal margin in the midclavicular line.

EXAMPLES OF ABNORMALITIES
- Firmness or hardness of the liver,
bluntness or rounding of its edge, and
irregularity of its contour suggest an
abnormality of the liver.
BIM - An obstructed, distended gallbladder AN
UAL
PALPATION may form an oval mass below the edge
of the liver and merge with it. It is dull
2. “ Hooking Technique” of liver palpation to percussion.
 Stand at the right side of pt’s chest
 Place both hands in side by side on the right abdomen below the border of
the liver dullness.
 Press in with your fingers toward the costal margin.
 Then ask pt to take a deep breath.
 The liver edge is palpable with the finger pads of both hands.

C. Spleen palpation:

Technique:
 Place your left hand behind the patient at the level of the 11th 12th left posterior ribs.
 Put your right hand below the left subcostal margin and press in toward the spleen at the same time lifting your left hand behind forward.
 Try tonpalpate the splenic edge.
 Repeat the maneuver with the patient taking a deep breath.
 Try to feel the tip or edge of the spleen as it comes down to meet your fingertips.

- Splenomegaly is eight times more likely

when the spleen is palpable.
- Causes include portal hypertension,
hematologic malignancies. HIV infection,
and splenic infarct or hematoma. The
spleen tip below is just palpable deep to
the left costal.

D. Kidney Palpation:
1) Right kidney palpation
 Palce your left hand nehind pt just below the 12th rib with the fingertips reaching the costovertebral angle.
 Lift your left hand and try to displsce the kidneys anteriorly. At the same time, place your right hand in the right upper quadrant, lateral & parallel to
the rectus muscle.
 Ask pt to take a deep inspiration and press your right hand firmly and deeply into the upper quadrant just below the costal margin.
 Try to palpate the kidneys and describe its size, contour and tenderness it is palpable.
2) Left kidney palpation
 Position yourself to that patient’s left side and use your right hand to lift the kidney from the back and your left hand to press deep into the left upper
quadrant.
 Similar to palpating the right kidney, ask patient to take a deep inspiration and try to palpate the left kidney.
Note: a normal right or left kidney is rarely palpable except in thin relaxed patients where the normal right kidney may sometimes be palpable.

3) Kidney Tenderness : Fist percussion technique

 Place the ball of one hand in each of the costovertebral angle at thye back and strike it with the surface at your fist.
 Use sufficient force to cause a perceptible painless jar or thud in a normal person.
 Normal response to fist percussion is no pain or tenderness elicited.
 Pain with fist percussion at the costovertebral angle suggest kidney infection, however, is can also be seen in musculoskeletal pathology.
Examples of Abnormalities:

E. Bladder Palpation
 The bladder normally cannot be examined unless it is distended above the symphysis pubis.
 On palpation, the dome of the distended bladder feels smooth and round.
 Check for tenderness.
 Use percussion to check for dullness and to determine how high the bladder rises above the symphysis pubis
 Abnormalities: bladder distention from outlet obstruction due to urethral stricture, prostatic hyperplasia; also from medications and neurologic disorders
such as stroke, multiple sclerosis; Suprapubic tenderness in bladder infection.

F. Palpation of the aorta

 Press firmly deep in the upper abdomen, slightly to the left of the midline, and identify the aortic pulsations.
 In people older than age 50, assess the width of the aorta by pressing deeply in the upper abdomen with one hand on each side of the aorta.
 In this group, a normal aorta is not more than 3.0 cm wide (average, 2.5 cm). This measurement does not include the thickness of the abdominal wall.
 The ease of feeling aortic pulsations varies greatly with the thickness of the abdominal wall and with the anteroposterior diameter of the abdomen.

Examples of Abnormalities
- A periumblical or upper abdominal mass with
expansile pulsations that is 3 cm or more wide
suggests an AAA.
- Screening by palpation followed by ultrasound
decreases mortality, especially in male smokers 65
years or older.
- Pain may signal rupture. Rupture is 15 times more
likely in AAAs <4 cm than in smaller aneurysms.

G. Special Maneuvers:
I. Assess for possible ascites – a protuberant abdomen with bulging slanks suggest the possibility of ascites. Because ascetic fluid characteristically sinks with
gravity, whereas gas-filled loops of bowel float to the top, percussion gives a dull note in dependent areas of the abdomen.

1 a) Test for shifting dullness

 pt on supine position, map the border between areas of tympany and dullness by percussing from the center of the abdomen then outward in several
directions from the central area of tympany.
 Then ask pt to turn to one side again. Noting the borders between tympany and dullness again
 If no ascites, the borders stay constant between supine and lateral decubitus position.
 If with ascites, dullness shifts to the more dependent side while tympany shifts to the top.
b) Test for fluid wave
 Have the patient or another assistant press the edges of both hands firmly down the midline of the
abdomen. This will help stop the transmission of a wave through the fat.
 While you tap one flank sharply with your fingertips, feel on the opposite flank of an impulse
transmitted through the fluid.
 Unfortunately, this sign is often negative until ascites is obvious, and it is sometimes positive in
people without ascites.
 An easily palpable impulse suggests ascites.

c) Identifying an Organ or a Mass in an Ascitic Abdomen

 Try to ballotte the organ or mass, exemplified here by an enlarged liver. Straighten and stiffen the
fingers of one hand together, place them on the abdominal surface, and make a brief jabbing
movement directly toward the anticipated structure.
 This quick movement often displaces the fluid so that your fingertips can briefly touch the surface
of the structure through the abdominal wall.

II.) Assess for possible Appendicitis

 Ask the patient to point to where the pain began and where is it now. Ask the patient to cough.
Determine whether and where pain results.
 The pain of appendicitis classically begins near the umbilicus, the shifts to the right lower quadrant,
where coughing increases it.
 Localized tenderness anywhere in the right lower quadrant, even in the right flank, may indicate appendicitis

Special maneuvers to assess for acute appendicitis

1. Perform a rectal examination and, in women, a pelvic examination.
- These maneuvers may not help you to discriminate between a normal and an inflamed appendix, but they may help to identify an inflamed appendix
atypically located within the pelvic cavity. They may also suggest other causes of the abdominal pain.
2. Check the tender area for rebound tenderness.
(If other signs are typically positive, you can save the patient unnecessary pain by omitting this test.)

3. Rovsing’s sign (referred rebound tenderness) – palpate deeply in the left lower quadrant and quickly withdraw your fingers. Pain in the right lower quadrant
during a left sided pressure suggest appendicitis
(positive Rovsing’s sign)

4. Psoas sign – Place your hand just above the patient’s right knee and ask the patient to raise that thigh against your hand. Alternatively, ask the patient to turn onto
the left side. Then extend the patient’s right leg at the hip. Flexion of the leg at the hip makes the psoas muscle contract; extension stretches it.

5. Obturator sign - flex the patient’s right thigh at the hip, with the knee bent, and rotate the leg internally at the hip. This maneuver stretches the internal obturator
muscle.

6. Test for cutaneous hyperesthesia

- At a series of points down the abdominal wall, gently pick up a fold of skin between your thumb and index finger, without pinching it. This maneuver should
not normally be painful.
- Localized pain with this maneuver, in all or part of the right lower quadrant, may accompany appendicitis.

III. Assessing possible acute cholecytitis

 Murphy’s Sign
- when right upper quadrant pain and tenderness suggest acute cholecytitis, look for Murphy’s sign. 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 muscle intersects with the costal margin. Alternatively, if the liver is enlarged, hook your
thumb or fingers under the liver edge at a comparable point below. Ask the patient to take a deep breath. Watch the patient’s breathing and note the degree of
tenderness.

- A sharp increase in tenderness with a sudden stop in inspiratory effort constitutes a positive Murphy’s sign of acute cholecyctitis. Hepatic tenderness may also
increase with this maneuver but is usually less well localized.

IV. Assessing Ventral Hernias

- Ventral hernias are hernias in the abdominal wall exclusive of groin hernias. If your suspect but do not see an umbilical or incisional hernia, ask the patient to
raise both head and shoulders off the table
- The bulge of a hernia will usually appear with this action

V. Mass in the Abdominal Wall

 Distinguishing an Abdominal Mass from a Mass in the Abdominal Wall
An occasional mass is in the abdominal wall rather than inside the abdominal cavity. Ask the patient either to raise the head and shoulders or to strain down,
thus tightening the abdominal muscles. Feel for the mass again.
- A mass in the abdominal wall remains palpable; an intra-abdominal mass is obscured by muscular contraction.

EXAMPLE of recording the Physical Examination-The Abdomen

“Abdomen is protuberant with active bowel sounds. It is soft and non-tender; no palpable masses or
hepatosplenomegaly. Liver span is 7 cm in the right midclavicular line; edge is smooth and palpable 1 cm below the
right costal margin. Spleen and kidneys not felt. No costovertebral angle (CVA) tenderness.”

OR

“Abdomen is flat. No bowel sounds heard. It is firm and board like, with increase tenderness, guarding, and rebound
in the right midquadrant. Liver percusses to 7 cm in the midclavicular line; edge not felt. Spleen and kidneys not felt.
No palpable masses. No CVA tenderness.”
-------NOTHING FOLLOWS-------