History & Physical

Examination
The Format of the Comprehensive Health History
IdentifyingData
Source and Realiability of History
Chief Complaint
History of Present Illness

Medications, Allergies, Tobacco, Alcohol and Drugs

Past History

Childhood Illness
Adult Illness: Medical, Surgical, Ob/Gyn, Physchiatric, health
maintanance.
Family History
Personal & Social History
Review of Systems
Components of the Health History (1)

 Identifiying Data
 Identifiying data-such as age, gender, occupation,

 Source of the history-usualy the patient, but can be family

member, friend, letter of referral, or the medical record

• Chief Complaint(s)
The one or more symptoms or concerns causing the
patients to seek care.
Components of the Health History (2)

 Present Illness
 Amplifies the Chief Complaint, describes how each

symptom developed
 May include medications, allergies, habits of smoking and

alcohol, since these are frequently pertinent to the present

illness
Components of the Health History (3)

 Past History
 Lists childhood illnesses

 Lists adult illnesses with dates for at least four categories:

medical,surgical,obgyn & psychiatric

 Includes health maintenance practices such as:
immunizations, screening tests, lifestyle issues and home
safety
Components of the Health History (4)

 Family History
 Outlines or diagrams age and health, or age and cause of

death, of siblings, parents and grandparents

 Documents presence or absence of spesific illnesses in

family, such as hypertension, coronary artery disease, etc.

Components of the Health History (5)

 Personal and Social History

Describes educational level, family of origin,
current household, personal interests and lifestyle

• Review of Systems
Documents presence or absence of common
symptoms related to each major body system
The Seven Attributes of a Symptom
1. Location. Where is it? Does it radiate?
2. Quality. What is it like?
3. Quantity or severity. How bad is it? (For pain, ask for a rating
on a scale of 1 to 10)
4. Timing. When did (does) it start? How long did (does) it last?
How often did (does) it come?
5. Setting in which it occurs. Include environmental factors,
personal activities, emotional reactions, or other circumstances
that may have contributed to the illness.
6. Remitting or exacerbating factors. Does anything make it
better or worse?
7. Associated manifestations. Have you noticed anything else
that accompanies it?
Review of Systems (1)

 General. Usual weight, recent weight change, any

clothes that fit more tightly or loosely than before,
weakness, fatigue, fever.

 Skin. Rashes, lumps, sores, itching, dryness, color

change, changes in hair or nails.

 Head. Headache, head injury, dizziness.

Review of Systems (2)

 Eyes. Vision, glasses or contact lenses, last examination, pain,

redness, excessive tearing, double vision, blurred vision, spots,
specks, flashing lights, glaucoma, cataracts.

 Ears. Hearing, tinnitus, vertigo, earaches, infection, discharge,

use or nonuse of hearing aids.

 Nose and sinuses. Nasal stuffiness, discharge or itching, hay

fever, nosebleeds, sinus troubles.
Review of Systems (3)

 Throat (or mouth & pharynx). Condition of teeth, gums, bleeding

gums, dentures, if any, and how they fit, last dental examination,
sore tongue, dry mouth, frequent sore throats, hoarseness.

 Neck. Lumps, “swollen glands”, goiter, pain, or stiffness in the

neck.

 Breasts. Lump, pain or dyscomfort, nipple discharge, self

examination practices.
Review of Systems (4)

 Respiratory. Cough, sputum (color, quantity), hemoptysis,

dyspnea, wheezing, pleurisy, last chest x-ray. You may wish to
include asthma, bronhitis, emphysema, pneumonia &
tuberculosis.

 Cardiovascular. Heart trouble, high blood pressure, rheumatic

fever, heart murmurs, chest pain or dyscomfort, palpitations,
dyspnea, orthopnea, paroxysmal nocturnal dyspnea, edema,
past ECG or another heart test result.
Review of Systems (5)
 Gastrointestinal. Trouble swallowing, heartburn, appetite,
nausea, bowel movements, color & size stools, change in bowel
habits, rectal bleeding or black or tarry stools, haemorrhoids,
constipation, diarrhea. Abdominal pain, food intolerance,
excessive bleeding or passing of gas. Jaundice, liver or
gallbladder trouble, hepatitis.

 Urinary. Frequency or urination, polyuria, nocturia, urgency,

burning or pain on urination, hematuria, urinary infections,
kidney stones, incontinence; in males, reduced caliber or force
of the urinary stream, hesistancy, dribbling.
Review of Systems (6)

 Genital. Male: hernias, discharge from or sores on the penis,

testicular pain or masses, history of STD and their treatments.
Sexual, function, birth control methods. Female: regularity,
frequency, and duration of priods; amount of bleeding, bleeding
between periods, last menstrual periods; dysmenorrhea, age of
menapouse, menapousal symptoms and bleeding. Vaginal
discharge, itching, sores, lumps. Number of pregnancies,
number and type of deliveries, number abortion; complication of
pregnancy; birth control methods. Sexual, function, etc.
Review of Systems (7)

 Peripheral Vascular. leg cramps, varicose veins, past clots in

the veins.

 Musculoskeletal. Muscle or join pains, stiffness, arthritis, gout

and backache. If present, describe location of affected joints or
muscles, presence of any swelling, redness, pain, tenderness,
stiffness, weakness, or limitation of motion or activity; include
timing of symptoms (for example, morning or evening), duration
and any history of trauma.
Review of Systems (8)

 Neurologic. Fainting, blackouts, seizures, weakness, paralysis,

numbness or loss sensation, tingling or “pins and needles”,
tremors or other involuntary movements.
 Hematologic. Anemia, easy bruising or bleeding, past transfusion/
or transfusion reactions.
 Endocrine. Thyroid trouble, heat or cold intolerance, excessive
sweating, excessive thrist or hunger, polyuria, change in glove or
shoe size.
 Psychiatric. Nervousness, tension, mood, including depression,
memory change, suicide attemts if relevant.
The Comprehensive Physical Examination (1)

 General Survey. Observe the patient’s general state of health,

height & weight. Note posture, motor activity and gait; personal
hygiene; and any odors of the body or breath. Watch the
patient’s facial expressions and note manner, affect and
reactions to person and things in the environment. Listen to the
patient’s manner of speaking and note the state of awareness or
level of consciousness.
 Vital Signs. Measure height and weight; Blood preassure; pulse
and respiratory rate. If indicated, measure the body temperature.
The Comprehensive Physical Examination (2)
 Skin. Observe the skin of the face and its characteristics,
identify any lesions, noting their location, distribution,
arrangement, type and color. Inspect and palpate the hair and
nails. Study the patient’s hands. Continue your assesment of the
skin as you examine the other body regions.
 Head. Examine the hair, scalp, skull and face.
 Eyes. Check visual acuity and screen the visual fields. Note the
position and alignment of eyes. Observe the eyelids and inspect
the sclera and conjunctiva of each eye. With oblique lighting,
inspect each cornea, iris and lens. Compare the pupils, and test
their reaction to light. Asses the extraocular movements. With an
ophthalmoscope, inspect the ocular fundi.
The Comprehensive Physical Examination (3)

 Ears. Inspect the auricules, canals and drums. Check auditory

acuity. If acuity diminished, check lateralization (Weber test) and
compare air and bone conduction (Rinne test).
 Nose and sinuses. Examine the external nose; using a light
and nasal speculum, inspect the nasal mucosa, septum and
turbinates. Palpate for tenderness of the frontal and maxillary
sinuses.
 Throat (Mouth and pharynx). Inspect the lips, oral mucosa,
gums, teeth, tongue, palate, tonsils and pharynx.
The Comprehensive Physical Examination (4)

 Neck. Inspect and palpate the cervical lymph nodes. Note any
masses or unusual pulsations in the neck. Feel for any deviation
or the trachea. Observe sound and effort of the patient’s
breathing. Inspect and palpate the thyroid gland.
 Back. Inspect and palpate the spine and muscles of the back.
 Posterior Thorax and Lungs. Inspect and palpate the spine
and muscles of the upper back. Inspect, palpate and percuss the
cest. Identify the level of diaphragmatic dullness on each side.
Listen to the breath sounds; identify any adventitious sounds
and if indicated listen to the transmitted voice sounds.
The Comprehensive Physical Examination (5)

 Breasts, Axillae and Epitrochlear Nodes. In a woman, inspect

the breasts with her arm relaxed, then elevated, and then with
her hand pressed on her hips. In either sex, inspect the axillae
and feel for axillary nodes. Feel for epitrochlear nodes.
A Note on the Musculoskeletal System, By this time, you have
made some preliminary observations of the musculoskletal
system. You have inspected the hands, surveyed the upper
back, and at least in women, made a fair estimate of the
shoulder’s range motion. Use these and subsequent
observations to decide whether a full musculoskletal
examination is warranted.
The Comprehensive Physical Examination (6)

If indicated, with the patients still sitting, examine the hands,

arms, shoulders, neck and temporomandibular joints. Inspect
and palpate the joints and check their range of motion.
Palpate the breasts, while at the same time continuing your
inspection.
 Anterior Thorax and Lungs. Inspect, palpate and percuss the
chest. Listen to the breath sounds, any adventitious sounds, and
if indicated transmitted voice sounds.
The Comprehensive Physical Examination (7)

 Cardiovascular System. Observe the jugular venous pulsatitons

and measure the jugular venous preassure in relation to the sternal
angel. Inspect and palpate the carotid pulsations. Listen for carotid
bruits.
Inspect and palpate the precordium. Note the location, diameter,
amplitude and duration of the apical impulse. Listen at the apex and
the lower sternal border with the bell of a stethoscope. Listen at each
auscultatory area with the diaphragm. Listen for the first and second
heart sounds, and for physiologic splitting of the second heart sound.
Listen for any abnormal heart sounds or murmurs.
The Comprehensive Physical Examination (8)

 Abdomen. Inspect, auscultate and percuss the abdomen.

Palpate lightly, then deeply. Asses the liver and spleen by
percussion and then palpation. Try to feel the kidneys, and
palpate the aorta and its pulsation. If you suspect kidney
infection, percuss posteriorly over the costovertebral angels.
 Lower Extremities. Examine the legs, assesing three systems
while the patient is still supine. Each of these three systems can
be further assessed when the patients stands.
The Comprehensive Physical Examination (9)

Examination with the patient supine.

 Peripheral Vascular system. Palpate the femoral pulses and if
indicated, the popliteal pulse. Palpate the inguinal lymph nodes.
Inspect for lower extremity edema, discoloration or ulcers. Palpate for
pitting edema.
 Musculoskeletal System. Note any deformities or enlarged joints. If
indicated, palpate the joints, check their range of motion and perform
any necessary maneuvers.
 Nervous system. Asses lower extremity muscle bulk, tone and
strength; also sensation and reflexes. Observe any abnormal
movements.
The Comprehensive Physical Examination (10)

Examination with the patient standing.

 Peripheral Vascular system. Inspect for varicose veins.
 Musculoskeletal System. Examine the alignment of the spine
and its range of motion, the alignment of the legs, and the feet.
 Genital and Hernias in Men. Examine the penis and scrotal
contents and check for hernias.
 Nervous System. Observe the patient’s gait and ability to walk
heel to toe, walk on the toes, walk on the heels, hop in place and
do shallow knee bends. Do a romberg test and check for
pronator drift.
The Comprehensive Physical Examination (11)

 Nervous System. The complete examination of the nervous

system can also be done at the end of the examination. It
consists of the five segments described below: mental status,
cranial nerves (including funduscopic examination), motor
system, sensory system and reflexes.
Mental Status. If indicated and not done during the interview,
assess the patient’s orientation, mood, thoght process, thought
process, thought content, abnormal perceptions, insight and
judgment, memory and attention, information and vocabulary,
calculating abilities, abstract thinking and cunstructional ability.
The Comprehensive Physical Examination (12)

Cranial Nerves. If not already examined, check sense of smell, strength

of temporal and masseter muscles, corneal reflexes, facial movements,
gag reflex and strength of the trapezia and sternomastoid muscles.
Motor System. Muscle bulk, tone and strength of major muscle groups.
Sensory System. Pain, temperature, light touch, vibration and
discrimination. Compare right with left sides and distal with proximal
areas on the limbs.
Reflexes. Including biceps, triceps, brachioradialis, patellar, Achilles,
deep tendon reflexes; also plantar reflexes or Babinski reflex.
The Comprehensive Physical Examination (13)

 Abdominal Examinations. The rectal and genital examinations

are often performed at the end of the physical examination.
Patient positioning is as indicated.
Rectal Examination in Men. Inspect the sacrococcygeal and
perianal areas. Palpate the anal canal, rectum and prostate. If the
patient cannot stand, examine the genital before doing the rectal
examination.
Genital and Rectal Examination in Women. Examine the
external genitalia, vagina and cervix. Obtain a Pap Smear. Palpate
the uterus and adnexa. Do a rectovaginal and rectal examination.
Preparing for the Physical Examination

 Reflect on your approach to the patient

 Decide on the scope of the examination
 Choose the examination sequence
 Adjust the lighting and the environment
 Make the patient Comfortable
Key to the symbols for the patient’s position
Lying supine, with hips
Lying supine plexed, abducted and
externally rotated and
knee flexed (lithotomy
position)

Lying on the left side Sitting

(left lateral decubitus)

Lying supine, with head of

Sitting, leaning forward
bed raised 30o)

Same, turned partly to Standing

left side
The Physical Examination : Summary Of Suggested Sequence
(1)
 General survey

 Vital signs

 Skin: upper torso, anterior & posterior

 Head & Neck: including tyroid & lymph nodes

 Optional: nervous system (mental status, cranial

nerves, upper extremity motor strength, bulk, tone,

cerebellar function)
 Thorax & lungs

 Breasts

 Musculoskletal as indicated : upper extremities

The Physical Examination : Summary Of Suggested Sequence
(2)

 Cardiovascular, including JVP, carotid upstrokes and

bruits, etc.

 Cardiovascular, for S3 and murmur of mitral stenosis

The Physical Examination : Summary Of Suggested Sequence
(3)

 Cardiovascular, for murmur or aortic insufficiency

 Optional: thorax and lungs- anterior

 Breasts and axillae
 Abdomen
 Peripheral vascular; Optional: skin-lower torso and
extremities.
 Nervous system : lower extremity motor strength,
bulk, tone: sensation; reflexes; Babinski
The Physical Examination : Summary Of Suggested Sequence
(4)

 Musculoskletal, as indicated

 Optional: skin, anterior and posterior

 Optional: nervous system, including gait

 Optional: muskuloskeletal, compherensive

The Physical Examination : Summary Of Suggested Sequence
(5)

 Women: pelvic & rectal examination

 Men: prostate and rectal examination

The General Survey
 Apparent state of health
 Level of consciuousness
 Signs of distress : cardiac or respiratory distress, pain, anxiety or
depression
 Height and build
 Weight
 Skin color and obvious lession
 Dress, grooming, and personal hygine
 Fascial expression
 Odors of the body and breath
 Posture, gait and motor activity
WEIGHT
Causes of weight loss include
malignancy,diabetes mellitus, hyperthyroidism,
chronic infection, depression, diuresis, and
successful dieting
Facial Expression
The stare of hyperthyroidism; the immobile face
of parkinsonism; the flat or sad affect of
depression.
Decreased eye contact may be cultural, or may
suggest anxiety, fear or sadness.
Odors of the Body and Breath
Breath odors of alcohol, acetone (diabetes),
pulmonary infections, uremia, or liver failure
The Vital signs
 Blood pressure
 Heart rate and rhythm
 Respiratory rate and rhythm
 Temperature
Getting Ready to Measure Blood Pressure
 Ideally, ask the patient to avoid smoking, drinking caffeinated
beverages for 30 minutes before the blood pressure is taken and
to rest for at least 5 minutes.
 Check to make sure the examining room is quite and
comfortably warm.
 Make sure the arm selected is free of clothing. There should be
no arteriovenous fistulas for dialysis, scarring from prior brachial
artery cutdowns, or signs of lymphedema.
 Palpate the brachial artery to confirm that it has a viable pulse.
 Position the arm so that the brachial artery, at the antecubital
crease, is at heart level - roughly level with the 4th interspace at
its jnction with the sternum.
 If the patients seated, rest the arm on a table a little above the
patient’s waist; if standing, try to support the patient’s arm at the
midchest level.
BLOOD PRESSURE CLASSIFICATION

JNC 6,1997/ISH-WHO, 2003 JNC 7,2003

Respiratory Rate & Rhythm
 Normal : 14-20 breath/minute with regular
pattern.
 Abnormal :

Bradypneu, Tachypneu
Kussmaul, Chyne Stokes.
Temperature
Normal : 37oC orally
Fever of pyrexia refers to an elevated body temperature.
Hyperpyrexia refers to extreme elevation in temperature. Above
41.10C(1060F), while hypothermia refers to an abnormally low
temperature, below 350C(950F) rectally.

Causes of fever include infection, trauma (such as surgery or crush

injury), malignancy, blood disorders (such as acute hemolytic
anemia), drug reactions, and immune disorders (such as
collagen vascular disease)
Heart Rate & Rhythm (Radial Pulse)
 Normal : 60-100 beats/minute regularly
 Abnormal :

Bradycardia, tachycardia
Irregularity
THE SKIN
Common symptom : hair loss, rash, moles
Examination : inspect and palpate
 Color
 Moisture
 Temperature
 Texture
 Mobility and turgor
 lesions
HEAD & NECK
Common or Concerning Symptoms
 Headache
 Change in vision : hyperlopia, presbyopia, myopia, scotomas
 Double vision, or diplopia
 Hearing loss, erache; tinnitus
 Vertigo
 Nosebleed, or epistaxis
 Sore throat; hoarseness
 Swollen glands
 Goiter
THE HEAD
 The hair
 The scalp
 The skull
 The face
 The skin
The Eyes
 Visual acuity
 Visual fields
 Conjungtive and sclera
 Cornea, lens and pubis
 Extra moleculars
 Fundi including optic disc and cup retina
 Eye lids
THE EARS
 The auricle
 Ear canal and drum
 Auditory acuity
 Air and bone conduction
The Nose and Paranasal Sinuses
 Inspect the anterior and inferior superior surface
of the nose
 Test for nasal obstruction
 Inspect the inside of the nose
THE MOUTH & PHARYNX
 The lips
 The oral mucosa
 The gums and teeth
 The roof of the mouth
 The tongue and the floor of the mouth
 The pharynx
THE NECK
 Lymph nodes
 The trachea and the thyroid gland
 The carotid arteries and jugular vein
 THE THORAX & LUNGS
The common symptoms :
 Chest pain
 Dyspnue
 Wheezing
 Cough
 Blood-streaked sputum (hemoptysis)
All the symptoms comes from :
 The myocardium and pericardium
 The aorta
 The trachea and large bronchus
 The parietal pleura
 The chest wall
 The esophagus
 Extrathoracic structures such as : the neck, gallbladder
and stomact
Examination of the Posterior Chest (1)
Inspection
 Deformities or asymmetry
 Abnormal retraction of the interspaces during inspiration
 Impaired respiratory movement on one or both sides or a
unilateral lag (or delay) in movement

Palpation
 Identify tender area
 Assess any observe abnormalities
 Test chest expansion
 Feel for tactile fremitus
 Palpate and compare asymmetric areas
Examination of the Posterior Chest (2)
Percussion
Pathologic examples :
 Large pleural effesion
 Lobar pneumonia
 Simple chronic bronchitis
 Emphysema, pneumothorax
 Large pneumothorax

Ausculation
 Breath sound (lung sounds) : vesicular, bronchovesicular and
Bronchial
 Adventitious sound : cracles, wheezers and ronchi
Examination of the Anterior Chest
Inspection
 Deformities or asymmetriy
 Abnormal retraction of the lower interspaces during inspiration
 Local lag or impairment in respiratory movement

Palpation
 Identification assessment of chest espansion
 Further assessment of chest pon
 Assessment of tactile fremitus

Percussion
 The heart shape

Auscultation
 Listen to the breath souns
 Identify any adventitious sounds
 Characteristics of Breath Sounds
Duration of sounds Intensity of Pitch of Locations where heard
expiratory expiratory normally
sound sound
Vesicular Inspiratory sounds last Soft Relatively low Over most of both lungs
longer than expiratory ones

Broncho Inspiratory and expiratory Intermediate Intermediate Ofthen in the 1st and 2nd
vesicular sounds are about equal interspaces anteriorly and
between the scapulae

Bronchial Expiratory sounds last longer Loud Relatively high Over the manubrium, if heard
than inspiratory ones at all

Tracheal Inspiratory and expiratory Very loud Relatively high Over the trachea in the neck
sounds are about equal
CARDIOVASCULAR SYSTEM
Common or Concerning Symptoms
 Chest pain
 Palpitations
 Shortness of breath, orthopnea, or paroxysmal
nocturnal dyspnea
 Swelling or edema
THE HEART (1)
Patient Position Examination

Supine, with the head elevated 30o Inspect and palpate the pericordium: the
2nd interspaces; the right ventricle; and
the left ventricle, includingthe apical
impulse (diameter, location, amplitude,
duration)
Left lateral decubitus Palpate the apical impulse if not
previously detected. Listen at the apex
with the bell of stethoscope
Supine, with the head elevated 30o Listen at the tricuspid area with the bell
Listhe at all the auscultatory areas with
the diaphragm
Sitting, leaning forward, after full Listen along the left sternal border and at
exhalation the apex
THE HEART (2)
Inspection and Palpation
Careful inspection of the anterior chest may reveal
the location of the apical impulse or point of
maximal impulse (PMI).

use palpation to confirm the characteristic of he

apical impulse.

Percussion
In most cases, palpation has replaced percussion in
the estimation of cardiac size.
THE HEART (3)
Auscultation
 Listening for heart sounds
 Atributes of heart murmurs
- timing. Systolic murmur falling between S1 and S2
or Diastolic murmur falling between S2 and S1.
- Shape
- Location of maximal intensity
- Radiation or transmission from the point of maximal
intensity
- Intensity
THE HEART (4)
Gradations of Murmurs

Grade Description

Grade 1 Very faint, heard only after listener has “tuned in”; may not be heard in all
positions
Grade 2 Quite, but heard immediately after placing the stethoscope on the chest
Grade 3 Moderately loud
Grade 4 Loud, with palpable thrill
Grade 5 Very loud, with trill, may be heard when stethoscopeis partly off the chest
Grade 6 Very loud, with thrill. May be heard with stethoscope entirely off the chest
ABDOMEN
Common or Concerning Symptoms

Gastrointestinal Disorders Urinary and Renal Disorders

Indigestionor anorexia Suprapubic pain

Nausea, vomiting, or Dysuria, urgency, or frequency
hematemesis Hesitacy, decreased stream in males
Abdominal pain Polyuria or nocturia
Dysphagia and/or odynophagia Urinary incontinence
Change in bowel function Hematuria
Constipation or iarrhea Kidney or flank pain
jaundice Ureteral colic
Techniques of Examination
For a good abdominal examination you need
(1) good light, (2) a relaxed patient, and (3) full
exposure of the abdomen from above the
xiphoid process to the symphysis pubis.
Steps for Enhancing Examination of
the Abdomen
 The patient should have an empty bladder
 Make the patient comfortable in asupine position, with a pillow for the head
and perhaps another under the knees. Slide your hand under the low back to
see if the patient is relaxed and flat on the table.
 Have the patient keep arms at the sides or folded across the chest. Often
patients raise their arms over their heads, but this stretches and tightens the
abdominal wall, making palpation difficult.
 Before you begin palpation, ask the patient to point to any areas of pain and
examine these areas last.
 Warm your hands and stethoscope, and avoid long fingernails.
 Approach slowly and avoid quick unexpected movements. Watch the
patients’ face closely for any signs of pain or discomfort.
 Distract the patient if necessary with conversation or questions. If the aptient
is frightened or ticklish, begin palpation with the patients hand under yours.
After a few moments, slip your hand underneath to palpate directly.
THE ABDOMEN (1)
Inspection
 The skin : scars, striae, dilated veins, rashes and lesions.
 The umbilicus
 The contour of the abdomen : flat, rounded, protuberant
or scaphoid; do the flanks bulge; is the abdomen
symmetric; Are there visible organs or masses.
 Peristalsis
 Pulsations
THE ABDOMEN (2)
Auscultation
Auscultation provides important information about bowel
motility. Listen to the abdomen before performing
percussion or palpation, since these maneuvers may alter
the frequency of bowel sounds.

Auscultation may also reveal bruits, vascular sounds

resembling heart murmurs, barborygmi (stomach growling)
THE ABDOMEN (3)
Percussion
Tympani and dullness

Palpation
Light palpation
Deep palpation
ABDOMEN
Assessment Techniques for :
 Ascites
 Appendicitis
 Acute cholecystitis
 Ventral hernia
 Mass in abdominal wall
Ascites
 Test for shifting dullness
 Test for a fluid wave
 Identifying an organ or a mass in an ascitic
abdomen
Mass in the abdominal wall
To distinquish an abdominal mass from a mass in
the abdominal wall

A mass in the abdominal wall remains palpable; an

intra-abdominal mass is obscured by muscular
contraction
THE LIVER (1)
Percussion
The span of liver dullness in increased when the liver is enlarged.

The span of liver dullness is decreased when the liver is small or

when free air is present below the diaphragm, as from
aperforated hollow viscus.

Liver dullness may be displaced downward by the low diaphragm

of chronic obstructive lung disease. Span, however remains
normal.
THE LIVER (2)
Palpation
Firmness or hardness of the liver, bluntness or rounding of its edge,
and irregularity of its contour sugest an abnormality of the liver.

An obstructed, distended gallbladder may form an oval mass below

the edge of the liver and merging with it. It is dull to percussion.

The edge of an enlarged liver may be missed by starting palpation

too high in the abdomen, as shown below.
The Spleen (1)
Percussion
 Percuss the left lower anterior chest wall between lung
resonance above and costal margin (Traube’s space)
 Check for a splenic percussion sign. Percuss the lowest
interspace in the left anterior axillary line. This area is
usually tympanitic
A change in percussion note from tympany to dullness on inspiration suggests
splenic enlargement. This is a positive splenic percussion sign.
The splenic percussion sign may also be positive when spleen size is normal.
The Spleen (2)
Palpation
 A palpable spleen tip, through not necessarily
abnormal, may indicate splenic enlargement.
The spleen tip below is just palpable deep to the
left costal margin
THE KIDNEYS
Palpation
Kidneys are not usually palpable.
Causes of kidney enlargement include hydronephrosis, cysts
and tumors. Bilateral enlarment suggest polycystic disease

Assessing Kidney Tenderness

Pain with pressure of first percussion seggests
pyelonephritis, but may also have a musculoskeletal cause
The Anus, Rectum and Prostate
Common or Concerning Symptoms
 Change in bowel habits
 Blood in the stool
 Pain with defecation, rectal bleeding, or tenderness
 Anal warts or fissures
 Weak stream of urine
 Burning with urination
The Peripheral Vascular System
Common or Concerning Symptoms
 Pain in the arms or leg
 Intermittent claudication
 Cold, numbness, pallor in the legs, hair loss
 Color change in fingertips or toes in cold weather
 Swelling in calves, legs, or feet
 Swelling with redness or tenderness
Important Areas of Examination
The Arms
 Size, symmetry, skin color
 Radial pulse, brachial pulse
 Epitrochlear lymph nodes

The Legs
 Size, symmetry, skin color
 Femoral pulse and inguinal lymph nodes
 Popliteal, dorsalis pedis and posterior tibial pulses
 Peripheral edema
The Musculoskeletal System
Common or Concerning Symptoms
 Low back pain
 Neck pain
 Monoarticular or polyarticular joint pain
 Inflammatory or infectious joint pain
 Joint pain with systemic features such as fever, chills,
rash, anorexia, weight loss, weakness
 Joit pain with symptoms from other organ systems
Important Areas of Examination for Each of
the Major Joints
 Inspection for joint symmetry, alignment, bony
deformities
 Inspection and palpation of surrounding tissues for skin
changes, nodules, muscle atrophy, crepitus
 Range of motion and maneuvers to rest joint function
and stability, integrity or ligaments, tendons, bursae,
especially if pain or trauma
 Assessment of inflammation or arthritis, especially
swelling, warmth, tenderness, redness
The Nervous System
Common symptoms :
 Change in mood, attention or speech
 Changes in orientation, memory, insight and judgment
 Delirium or dementia
 Headache
 Dizziness or vertigo
 Generalized, proximal or distal weakness
 Numbness, abnormal or loss of sensation
 Loss of consciousness
 Seizures
 Tremors or involuntary movements
 Important Areas of Examination
 Mental status : appearance and behavior, speech and
language, mood, thoughts and perceptions, cognition
 Cranial nerves I through XII
 Motor system : muscle bulk, tone and streght;
coordination, gait and stance
 Sensory system : pain and temperature, position and
vibration, light touch, discrimination
 Deep tendon, abdominal, and plantar reflexes
THANK YOU