Clinical log

1

Physical Examination:

Adapted from:

 Rathe, R. (1999). University of Florida. Retrieved: http://medinfo.ufl.edu/year1/bcs/clist/index.html

 Jarvis, C. (2008). Student Laboratory Manual for Physical Examination & Health Assessment (5th ed.). St. Louis: Saunders Elsevier.

 D’Amico, D. & Barbarito, C. (2012). Health & Physical Assessment in Nursing. Pearson Education

 Dillon, P.M. (2006). Nursing Health Assessment: Student Applications. Philadelphia: F.A. Davis Company.

 Darlene Ellchuk, D. (2005) College of Licensed Practical Nurses of BC

Cephalo-caudal assessment is under complete physical examination, which includes the entire body of the

client. This type of assessment is an effective way in gathering the most number of objective cues from the

client which will lead to a comprehensive nursing health assessment.

Inspection

Look at colour, size, location, movement, texture, symmetry, odours and sounds.

Palpation

 Touching patient with different parts of the hands using varying degree of pressure.

 Feel for:  vibration or pulsation  rigidity or spasticity  crepitation  presence of lumps or masses  presence of tenderness or pain

 Fingertips – best for fine tactile discrimination, skin texture, swelling, pulsation, and determining presence of lumps

 A grasping action of the fingers and thumb – to detect the position, shape and consistency or an organ or mass

 The dorsa (backs) of hands and fingers – best for determining temperature because the skin here is thinner than on palms

 Base of fingers (metacarpophalangeal joints) or ulnar surface of the hand – best for vibration

** tender areas are palpated last.

Light palpation:

 use this technique to feel surface abnormalities

 depress the skin 1 to 2cm with your finger pads, using the lightest touch possible

 assess for texture, tenderness, temperature, moisture, elasticity, pulsations, superficial organs, and masses.

Deep palpation: (single hand / bimanual)

 use this technique to feel internal organs and masses for size, shape, tenderness, symmetry and mobility

 depress the surface 3 to 4cm with firm, deep pressure

2

Percussion

 Is tapping against the person’s body with short, sharp strokes to assess underlying structures

 The strokes yield a palpable vibration and a characteristic sound that assist locating organ borders, identify organ shape and position, and determine if an organ is solid or filled with fluid or gas.

 Method: direct, indirect, fist / blunt

Auscultation

 Stethoscope is used: bell for low pitch sounds (cardiac sounds), diaphragm for high pitch sounds (bowel, breath, normal cardiac)

 Note four characteristics of sounds:  Frequency/pitch: number of vibrations per second  Loudness: soft, medium, loud  Quality: types; gurgling, blowing  Duration: short, medium, long

 Method: direct, indirect

Starting the physical examination

I. General survey II. Measurement

III. Vital Signs IV. Head-to-toe physical examination or body system physical examination

I. General Survey

Physical appearance

Age – appears as stated

Gender

Level of consciousness – Glasgow Coma Scale

Skin colour

Facial features

Body structure

Stature (height in upright position)

Nutrition

Symmetry

Posture

Body built, contour

Any physical deformity

Mobility

Gait (a particular way or manner of moving on foot) Range of motion

Involuntary movement

3

Behaviour manner of behaving or

conducting oneself

Mental status: orientation, mood & affect, memory, cognition (Mood is more of a constant/’ever-present’ or sustained emotion (everyday feeling). Affect is a state of

feeling when it is observable, for example, euphoria, anger, sadness. Mood and affect can be likened to

climate and weather. Affect is to mood as weather is to climate.)

Speech

Facial expression

Dress

Personal hygiene

Example: testing mental status

Orientation: ask about person, place, and time.

(evaluate for speech: articulation, pattern, content, native language)

1. Ask the patient to spell his name, name his children, or recite his address.

Does the patient know who he is?

Does the patient know who the others are?

2. Ask the patient to tell you where he is.

Asked to name the hospital, city, state, and so on.

3. Ask the patient to tell you the year, month, and time-of-day (mid-morning, late

afternoon, and so forth). Do not ask for the date. This is a poor indication of

orientation. Most people cannot tell you the exact date when questioned.

Evaluate affect or mood - observe patient's verbal and nonverbal behavioural

responses for appropriateness.

For example:

 Does the patient laugh when talking about serious or sad subjects?

 Is the patient easily startled by loud noises?

 Does the patient respond to stimuli in a normal manner?

 Does the patient display excessive anger, fear, confusion, and so forth?

Evaluate long and short term memory by asking questions:

1. Discussing past events or questioning the patient about his medical history will test his ability for remote recall long-term memory

2. Questions about daily events will test recent recall short- term memory). For example, ask the patient what he ate for breakfast that morning.

3. Evaluate cognition is tested by asking the patient to perform calculations. Ask the patient to count backward from 100 by 5s.

Measurement  Height

 Weight

 (+ visual test – far distance and near distance acuity & gross peripheral visual field, colour vision test)

 (+ BMI)

Ishihara Coloured Plates

Vital signs  5 cardinal signs

4

Physical

examination  Head-to-toe approach

 Body system approach

Physical examination:

Integumentary Skin, hair and nails

Skin:

Inspection:

 Colour  Vascularity:

o petechiae - hematoma less than 2 mm in diameter o purpura - hematoma of 3 mm to 1 cm in diameter o ecchymoses or eccymosis - hematoma of greater than 1 cm in

diameter

 Lesions:  Colour  Elevation: flat, raised or pendunculated  Shape:

o Discoid – Round or oval. o Annular – Circular with central clearing. o Target (bull’s eye) – Annular with central internal activity.

 Pattern: o Discrete – individual lesions. Are separate and distinct. o Grouped – lesions are clustered together.

 Confluent – lesions merge so that discrete lesions are not visible or palpable.

 Dermatoral – lesions form a line or an arch and follow a dermatome. o Size (in centimeters): use a ruler to measure.

 Location & distribution: o Generalised – distributed all over the body. o Regionalised – limited to one area of the body. o Localised – sharply limited to a specific areas. o Scattered – dispersed either densely or widely. o Exposed areas – limited to areas exposed to the air or sun.

 Type: o Pustule – a small, pus-filled lesion (called follicular pustule if it

contains a hair).

o Cyst – a closed sac in or under the skin that contains fluid or semisolid material.

o Nodule – a raised lesion detectable by touch that’s usually 1 cm or more in diameter.

o Wheal – a raised, reddish area that’s commonly itchy and lasts 24 hours or less.

o Fissure – a painful crack like lesion of the skin that extends at least into the dermis.

o Macule – a small, discolored spot or patch on the skin. o Vesicle – a small, fluid-filled blister that’s usually 1 cm or less

in diameter.

o Papule – a solid, raised lesion that’s usually less than 1 cm in diameter.

 Exudates: Note its colour and/or odour  Suspected melanoma:  A – asymmetrical lesion  B – border - irregular  C – colour  D – diameter (> 6mm)  E – elevated / enlarging lesion

5

Palpation

Skin:

 Temperature

 Moisture

 Texture (Thickness & oedema - feet, ankles, and sacral areas) o 1 + mild pitting, slight indentation, no perceptible swelling of the leg. o 2 + moderate pitting, indentation subsides rapidly. o 3 + deep pitting, indentation remains for a short time, leg looks swollen. o 4 + very deep pitting, indentation lasts a long time, leg is very swollen.

 Mobility & turgor • Surface characteristics and tenderness of lesions

• Pulsations and blanching of vascular lesions

Hair:

• Texture

• Scalp tenderness, masses, and mobility

Nails:

• Texture

• Capillary refill

Head, Eyes, Ears, Nose, and Throat (HEENT)

6

Equipment needed:

 Latex Gloves

 A Snellen Eye Chart or Pocket Vision Card

 Cotton Tipped Applicators

 Tongue Blades

 An ophthalmoscope (advance)

 An otoscope (advance)

Sites Examination Notes

Head, Face, and

Neck

Head, Face, and Neck

Symptoms

Headaches

• Lesions on mouth or lips

• Swelling of head or neck area

• Difficulty chewing or

swallowing

• Fatigue

• Nasal discharge or postnasal

drip

 Hoarseness or voice change

7

Sites Examination Notes

Head, Face, and

Neck

Scalp & hair

1. Instruct the client 2. Observe cleanliness 3. Observe hair colour 4. Assess texture of hair 5. Observe amount and

distribution of hair throughout

the scalp

6. Inspect scalp for lesion

proceed to nails

7. Instruct the client 8. Assess for hygiene 9. Inspect nails for an even, pink

undertone

10. Assess capillary refill 11. Inspect and palpate the nails

for shape and contour

12. Palpate the nails to determine their thickness, regularity and

attachment to nail bed

Inspection

Head:

• Size

• Shape

• Symmetry

• Position

Face:

• Facial expression

• Signs of distress

• Symmetry of facial features

(palpebral fissures and

nasolabial folds)

• Abnormal movements

• Lesions

• Hair distribution

Nose:

• Position

• Deformities

• Septal deviation

• Discharge

• Flaring

Nasal mucosa, septum, and

turbinates:

 Colour

• Intactness

• Lesions

• Oedema

• Discharge

• Foreign objects

8

Sites Examination Notes

Head, Face, and

Neck

Frontal and maxillary sinuses:

• Oedema

• “Dark circles” under eyes

 Percuss for tenderness

Lips:

• Colour

• Condition

• Lesions

• Breath odour

• (Pursed-lip breathing)

Oral mucosa:

• Colour

• Condition

 Lesions

Gingivae:

• Colour

• Condition

• Retraction

• Hypertrophy

• Oedema

• Bleeding

• Lesions

Teeth:

• Number

• Colour

• Condition

• Missing or loose teeth

Tongue:

• Colour

• Texture

• Position

• Mobility

• Involuntary movements

• Lesions

Oropharynx, hard/soft palate,

tonsils, and uvula:

• Colour

• Condition

• Intactness of palates

• Lesions

• Enlargement of tonsils

• Drainage

• Exudates

• Oedema

• Symmetrical rise of uvula - CN X

• Swallow reflex - CN X

9

Sites Examination Notes

Head, Face, and

Neck

Neck:

 Inspect for skin colour, shape &

symmetry

 Test ROM of neck

 Observe carotid arteries &

*jugular veins (*see CVS)

 Palpate trachea @ midline

 Inspect thyroid gland

 Palpate thyroid gland from

behind the client

OR ALTERNATE

 Palpate thyroid gland from the

front in front of client

 Auscultate the carotid arteries –

bell of stethoscope (client to

hold breath)

 (Auscultate the thyroid gland

for bruit) – bell of stethoscope

(client to hold breath)

 Palpate the lymph nodes of

head & neck

If lymph nodes palpable, note:

o Size o Shape o Symmetry o Consistency o Mobility o Tenderness

Ears Ear Symptoms

• Hearing loss

• Vertigo

• Tinnitus

• Discharge (otorrhoea)

• Ache (otalgia)

Inspection:

External ear:

• Symmetry

• Colour

 Integrity

• Lesions

Palpation

External ear:

 Tenderness (palpate tragus and

 mastoid)

 Swelling

 Lesions

Otoscopic exam: (advance)

External ear canal:

• Colour

• Drainage

• Patency

• Oedema

• Lesions

• Foreign objects

10

Sites Examination Notes

Ears Tympanic Membrane:

• Intactness of TM

• Colour

• Lesions

• Mobility of TM

Hearing Tests

Gross hearing:

• Whispered voice (cover site of

ear not tested when performing

& vice versa)

To conduct the following only

when hearing is compromised:

• Weber: test for lateralisation

• Rinne: compare bone

conduction to air conduction

Balance Romberg test: CN VII

• Test with eyes open then eyes

closed

Weber test

Rinne test

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Eyes

12

Sites Examination Notes

Eyes Eye Symptoms

• Vision loss

• Tearing

• Eye pain

• Changes in eye appearance

• Blurred vision

• Dry eyes

• Double vision

• Drainage

Test visual acuity:

• Far vision: Snellen’s Chart @ 6m

• Near vision: Newsprint @ 12in

(Rosenbaum test) Inability to see objects at close range is call hyperopia. Presbyopia is the inability

to accommodate for near vision is

common in person over 45yrs of age.

Test colour vision: (male)

• Ishihara colour plates

Test gross peripheral visual

field by confrontation: (2 feet)

• Peripheral vision: Superior,

inferior, nasal and temporal

fields

Eyes – additional information on testing peripheral visual field.

Visual field range

13

Sites Examination Notes

Eyes

Inspection:

Eyelashes:

• Symmetry

• Distribution

Eyelids:

• Colour

• Lesions

• Oedema

• Lid lag

• Symmetry of palpebral fissures

14

Sites Examination Notes

Eyes

Conjunctiva (palpebral and

bulbar):

• Colour

• Moisture

• Lesions

• Foreign bodies

Sclera:

• Colour

• Moisture

• Lesions or tears

Cornea: (inspect by shining a

penlight from the side across

the cornea)

• Clarity

• Lesions

• Abrasions

• Test corneal reflex – CN X

Anterior chamber:

• Clarity

• Bulging of iris

• Blood

Iris:

• Colour

• Size

• Shape

• Symmetry

Lacrimal ducts:

• Colour

• Oedema

• Excessive tearing

• Drainage

Pupils:

 Size

 Shape

 Equality

15

Sites Examination Notes

Eyes Pupils:

 Reaction to light (direct and

consensual) – CN III

 Test accommodation (focus far

then focus near at pen point

about 5 inches away – pupils

constrict when focus near)

Extraocular Muscles (EOM)

CN III, IV, VI

• Corneal light reflex test ocular

alignment (1 foot away): -

• 6 cardinal fields of vision

 Test convergence: patient

fixate on an object as it is

moved slowly towards a point

right between the patient's eyes

Palpation

Lacrimal apparatus (glands and

ducts):

• Tenderness

• Excessive tearing or discharge

Respiratory

Anterior thorax

16

Posterior thorax

Lateral

17

Equipment needed:

 Examination gown and drape

 Examination gloves

 Examination light

 Stethoscope

 Metric ruler

 Tissues

 Face mask

18

Sites Examination Notes

Posterior thorax

Inspection of posterior thorax:

 skin colour

 structure (vertebra midline,

scoliosis, kyphosis)

 symmetry

 respiration (rate, rhythm,

depth)

Palpation of posterior thorax:

 tenderness

 masses

 crepitus

 ribs

respiratory expansion

(excursion)

site at posterior lateral of chest

@ T9 to T10 level

 tactile fremitus: (verbalise 99)

Percussion:

Respiratory Symptoms

• Cough

• Dyspnoea

• Chest pain

• Related symptoms (oedema and fatigue)

How to perform a percussion:

 Firmly rest the first joint of the middle finger of one hand on the patient's chest, but don't let the rest of the hand touch the chest

 Keep the fingers of the other hand flexed and the wrist loose

 With the tip of the middle finger of the flexed hand, strike the first joint of the middle finger of the hand that is on the patient's chest. Have the motion come

from the wrist.

 Withdraw the striking finger immediately to avoid damping the vibration.

 Strike once or twice, then move your hands symmetrically to another part of the chest.

Percussion Notes and Their Meaning

Flat or

Dull

Pleural Effusion or Lobar

Pneumonia

Normal Healthy Lung or Bronchitis

Hyperres onant

Emphysema or Pneumothorax

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Sites Examination Notes

Posterior thorax

Anterior thorax

Auscultation of posterior

thorax:

Breath sounds are decreased

when normal lung is displaced by

air (emphysema or

pneumothorax) or fluid (pleural

effusion).

Breath sounds shift from

vesicular to bronchial when there

is fluid in the lung itself

(pneumonia). Extra sounds that

originate in the lungs and

airways are referred to as

"adventitious" and are abnormal.

Inspection of anterior thorax:

 skin colour

 structure:

(barrel chest, pectus

excavatum, pectus carinatum –

pigeon chest, sternal recession)

anterior-posterior chest ratio =

2:1

 symmetry

 respiration (rate, rhythm,

depth)

 usage of accessory muscles

Palpation of anterior thorax:

 tenderness

 masses

 crepitus

 sternum, ribs

 respiratory expansion

(excursion) – N= 3 to 5cm

 tactile fremitus

Adventitious (Extra) Lung Sounds

Crackles These are high pitched, discontinuous sounds similar to the sound produced by rubbing your hair between your

fingers. (Also known as Rales)

Wheezes

These are generally high pitched and "musical" in quality. @ expiration.

Stridor is an inspiratory wheeze associated with upper

airway obstruction (croup).

Rhonchi These often have a "snoring" or "gurgling" quality. Any extra sound that is not a crackle or a wheeze is probably a

rhonchi.

20

Sites Examination Notes

Anterior thorax

Percussion:

Auscultation:

Chest - cardiovascular

Landmark for precordium examination

Sternal angle or Angle of Louis: junction of the manubrium and the body of the sternum

21

Sites Examination Notes

Chest –

cardiovascular

Central

Cardiovascular Symptoms

• Chest pain

• Dyspnoea

• Cough

• Oedema

• Syncope

• Palpitations

• Fatigue

• Extremity changes

Inspection:

Neck Vessels:

• Identify carotid arteries and

jugular veins

• Differentiate carotid pulsations

from venous

• Measure JVP @ position of 45 o

(normal – reading not > 4cm)

Precordium: note pulsations at:

• Apex

• Left lateral sternal border

 Base left and right

• Xiphoid

Palpation

Neck vessels (carotids):

• Palpate carotid one at a time

• Rate

• Rhythm

• Strength

• Contour

• Symmetry

• Elasticity

• Thrills (vibration)

Neck vessels (jugular veins):

• Check direction of fill

• Check abdominojugular

(hepatojugular) reflux

Precordium:

• Apex

• Left lateral sternal border

• Base left

• Base right

• Xiphoid or epigastric area

Note:

• Thrills

• Lifts / Heaves

Percussion: (limited value)!!

Precordium: - to identify cardiac

borders

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Cardiovascular – additional information on auscultation

Additional heart sounds

The third heart sound (S3), also known as the "ventricular gallop", occurs just after S2 when the mitral valve opens allowing passive filling of the left ventricle. The S3 sound is actually produced by the large amount of blood striking a very compliant left ventricle. S

3 ~ ‘Kentucky’

The fourth heart sound (S4), also known as the "atrial gallop", occurs just before S1 when the atria contract to force blood into the LV. If the LV is non-compliant and atrial contraction forces blood through the AV valves, an S4 is produced by the blood striking the LV. S

4 ~ ‘Tennessee’

Auscultation landmarks:

 Angle of Louis – about 5 cm (2”) below sternal notch  Intercostal spaces – is below each rib

 Aortic area – right 2

nd

intercostal space right sternal border

 Pulmonic area - left 2

nd

intercostal space left sternal border

 Erb’s point – left 3

rd

intercostal space left sternal border

 Tricuspid area – left 4

th

intercostal space left sternal border

 PMI - 5

th

intercostal space at mid clavicular line

 Epigastric area - @ tip of sternum

• Aortic area – S2 is louder than S1 • Pulmonic area – S2 is louder than S1 • Erb’s point –S1 and S2 are heard equally • Tricuspid area – S1 is louder than S2 • Apex (Point of Maximum Impulse)– S1 is louder than S2

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Sites Examination Notes

Chest –

cardiovascular

Central

Auscultation

Carotids:

• Use bell of stethoscope

• Have client hold breath

• Listen for bruits

Precordium:

 Landmark for:

- Aortic - Pulmonic - Erb’s point - Tricuspid - Mitral

 S1

 S2

 S3 - advance

 S4 - advance

Locating PMI and count apical

pulse:

 Locate the point of maximal

impulse (PMI), by palpating

the angle of Louis

 Place index finger just to the

left of the patient’s sternum

and palpate the second

intercostal space

 Place middle finger in the third

intercostal space, and continue

palpating downward until the

PMI is located at the fifth

intercostal space

 Move index finger laterally

along the fifth intercostal space

to the midclavicular line

(MCL)

 Warm the stethoscope in the

palm of hand and place the

diaphragm of the stethoscope

firmly over PMI

 Count the rate for 1 minute –

note rate, rhythm and intensity

of pulse

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Sites Examination Notes

Peripheral-

Vascular/

Lymphatic

Peripheral-

Vascular/Lymphatic

Symptoms

• Swelling

• Limb pain

• Changes in sensation

• Fatigue

Inspection

Upper extremities:

• Colour

• Oedema (Grade +1 to +4)

• Erythema

• Lesions

• Capillary refill

Abdomen:

• Pulsations of arteries:

- Abdominal aorta - Renal - Iliac

Lower Extremities:

• Colour

• Condition of skin

• Hair distribution

• Varicosities

• Oedema

• Erythema

• Lesions

Palpation:

Skin temperature (upper &

lower extremities)

Abdomen: for thrill

- Abdominal aorta - Renal - Iliac

(+ auscultation for bruit)

Capillary refill

Pulses:

• Brachial

• Radial

• Ulnar

• Femoral

• Popliteal

• Posterior tibialis

• Dorsalis pedis

Note:

• Rate

• Rhythm

• Equality

• Strength (+1 to +4)

1+ 2+ 3+ 4+

2mm 4mm 6mm 8mm

25

Sites Examination Notes

Peripheral-

Vascular/

Lymphatic

Palpation:

Lymph Nodes:

• Axillary

• Epitrochlear

• Inguinal

Blood pressure:

• Both arms

• Supine, sitting, standing

• Auscultatory gap

• Orthostatic drop

• Pulse pressure

Breast

Sitting position: inspection and

palpation for lymph nodes

Supine - palpation

Arms up clasped tight and arms at side pressed @ hips - brings out dimpling

and retraction because fibrous strands of cancer attach to both skin and the

facia overlying the pectoral muscle

A: Cervical nodes on neck

B: Supraclavicular nodes just above

collarbone

C: Infraclavicular nodes just behind

collarbone

D: Axillary nodes in armpit

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Sites Examination Notes

Breasts

Breast Symptoms

• Lump or mass

• Pain or tenderness

• Nipple discharge

Inspection

Positions:

• Sitting, arms at side

• Sitting, hands over head –

clasped and tensed, move to left

and right

• Sitting, hands on hips or hands

pressed together

• Leaning forward

Note:

Breasts:

• Size

• Shape

• Symmetry

• Colour

• Visible masses

• Lesions

• Oedema

• Venous pattern

• Dimpling/retraction

Nipple and areola:

• Colour

• Shape

• Symmetry

• Direction of nipple: retracted,

inversion/eversion

• Discharge

• Masses

• Lesions

• Supernumerary nipples

Leaning forward:

pendulous breast may reveal asymmetry of the breast or

nipple not otherwise visible

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Sites Examination Notes

Breasts

Inspection:

Axilla:

• Colour

• Lesions

• Masses

• Hair distribution

Palpation

Technique:

• Light, medium and deep

palpation

Vertical strip, pie wedge, or

circular method

Breasts:

• Texture

• Consistency

• Tenderness

• Masses

Nipple and areola:

• Elasticity

• Discharge

• Tenderness

Lymph nodes:

• Anterior cervical

• Supraclavicular

• Infraclavicular

• Axilla

• Epitrochlear

Note:

o Size o Shape o Symmetry o Consistency o Mobility o Borders o Tenderness

Suspected malignancy:

A – Asymmetrical lesion.

B – Border irregular.

C – Colour of lesion varies with

shades

D – Diameter greater than 6 mm.

E – Elevated or enlarging lesion.

Procedure:

1. Have the patient lie supine on the exam table. (Provide a flat pillow if needed)

2. Ask the patient to remove the gown to expose one breast first and place her hand behind her head on that

side.

3. Begin to palpate at junction of clavicle and sternum using the pads of the index, middle, and ring fingers. If

open sores or discharge are visible, wear gloves.

4. Press breast tissue against the chest wall in small circular motions.

Use:

light pressure for superficial breast tissue

medium pressure for intermediate layer, and

deep pressure for tissue close to chest wall

5. Palpate the breast in overlapping vertical strips. Continue until you have covered the entire breast

including the axillary "tail."(also known as tail of

Spencer - x)

6. Palpate around the areola and the depression under the nipple. Press the nipple gently between thumb and

index finger and make note of any discharge.

7. Lower the patient's arm and palpate for axillary lymph nodes. (epitrochlear nodes if necessarily)

8. Have the patient replace the gown and repeat on the other side.

9. Reassure the patient, discuss the results of the exam. 10. Document findings in health assessment form:

• contour of breast

• location of the lump

• size of the lump

• discharge findings

Note: if patient complains about feeling a / some lumps on a

breast, always starts the examination on the unaffected

breast first.

A: Light Pressure for

superficial breast tissue

B: Medium Pressure for

intermediate layer

C: Deep Pressure for tissue

close to chest wall

 Note for any tenderness

X

28

Abdomen

Landmarks:

 Xiphoid process

 Umbilicus

 Costal margin

 Iliac crests

 Pubic bone

29

Referred cutaneous pain areas

30

4 quadrants method of examination

Sequencing:

 Inspection of the abdomen

 Auscultation of the abdomen

 Percussion of the abdomen

 Percussion of the liver

 Percussion of the spleen

 Palpation of the abdomen

 Palpation of the liver

 Palpation of the spleen

 Palpation of the aorta

 Palpation for rebound tenderness

 Percussion for ascites

 Testing for psoas sign or obturator sign

 Testing for Murphy’s sign (advance)

Equipment needed:

o Examination gown and drape o Examination gloves o Examination light o Stethoscope o Skin marker o Metric ruler o Tissues o Tape measure

Sites Examination Notes

Abdomen

(+urinary)

Abdominal Symptoms

• Elimination pattern (frequency,

colour, and consistency of

stool)

• Abdominal pain or tenderness

• Nausea and vomiting

• Weight changes

• Appetite

31

Sites Examination Notes

Abdomen

(+urinary)

Inspection

Abdomen:

• Size

• Shape

• Symmetry

• Condition of skin

• Colour

• Lesions, scars, striae

• Superficial veins

• Hair distribution

• Hernias

Movements:

• Respiratory

• Pulsations

• Peristalsis

Umbilicus:

• Position

• Contour

• Colour

• Herniation

• Discharge

Auscultation

Abdomen:

• Bowel sounds (normal,

hypo/hyper-active, absent)

• Friction rubs

• Arteries (abdominal aorta,

renal, iliac, femoral arteries

for bruits

Percussion

• Abdomen:

• Note areas of tympany,

dullness, or tenderness

• Liver (downward from the chest in the right midclavicular line until you detect

the top edge of liver dullness) • Spleen (lowest costal interspace in the left anterior axillary line) • Fist/blunt percussion for organ

Tenderness (11 th

to 12 th

ribs of

costovertebral angle)

32

Sites Examination Notes

Abdomen

(+urinary)

Palpation

Technique:

• Light

• Deep / = bimanual

Abdomen – all four quadrants

Abdomen:

Light:

• Surface characteristics

• Tenderness

• Muscular resistance*

• Turgor

Deep:

• Organs

• Masses

Organs: ask the patient to take a deep breath. • Liver

• Spleen

Aorta: (upper abdomen to the left of midline below the xiphoid process)

• Size

• Pulsation A well-defined, pulsatile mass, greater

than 3 cm across, suggests an aortic

aneurysm.

Bladder

Additional tests:

• Rebound tenderness This is a test for peritoneal irritation:

1. Press slowly and deeply on the

abdomen with your hand (90 o ) on the

area of no pain or discomfort.

2. Then quickly release hand site.

3. If it hurts more when release, the patient has rebound tenderness =

Blumberg’s sign

**If this is tested on LIF and client experience pain at McBurney’s point (1

to 2 in or 2.5 to 5cm above the anteriorsuperior iliac spine, on a line

between the ileum and the umbilicus) it

is suggestive of peritoneal irritation in appendicitis = Rovsing’s sign.

General Palpation

1. Begin with light palpation. At this point you are mostly looking for areas of tenderness. The most sensitive indicator of tenderness is the

patient's facial expression (so watch the patient's face, not your

hands). Voluntary or involuntary guarding may also be present.

2. Proceed to deep palpation after surveying the abdomen lightly. Try to identify abdominal masses or areas of deep tenderness.

*: ‘rigidity’ vs ‘voluntary guarding’ in abdominal palpation

Rigidity:

is a constant board-like hardness of the muscles; is a protective

mechanism accompanying acute inflammation of the peritoneum; it may

be unilateral and the same area usually becomes painful with increase

intraabdominal pressure eg. by attempting to sit up

Voluntary guarding:

occurs when a person is cold, tense or ticklish. It is bilateral and muscles

usually relax slightly

Palpating liver Palpating spleen

Aorta

33

Sites Examination Notes

Abdomen

(+urinary)

Additional tests:

Psoas Sign This is a test for appendicitis.

1. Place your hand above the patient's right knee.

2. Ask the patient to flex the right

hip against resistance. 3. Increased abdominal pain

indicates a positive psoas sign.

Obturator Sign

This is a test for appendicitis.

1. Raise the patient's right leg with the knee flexed.

2. Rotate the leg internally at the

hip. 3. Increased abdominal pain

indicates a positive obturator

sign.

Test for Murphy’s sign While palpating the liver, asks the client

to take a deep breath, as the diaphragm descends it pushes the liver and the

gallbladder toward your hand – in normal case, there is no pain felt.

Positive sign occurs in client with

cholecystitis

Inguinal lymph nodes:

• Inguinal nodes

Note:

o Size o Shape o Symmetry o Consistency o Mobility o Borders o Tenderness

Psoas test

34

Musculoskeletal:

!!!! Very much linked to neurological examination, especially on motor movements and muscles bulk

& strength

 Skeletal body frame

 Head

 Neck Upper extremities:

 Shoulder

 Elbow

 Wrist

 Fingers Lower extremities:

 Hips

 Knees

 Ankles

 Feet

Sequence of examination:

1. Inspection 2. Palpation 3. ROM 4. Muscles strength

Sites Examination Notes

Musculoskeletal

in general

Motor-Musculoskeletal

symptoms

• Pain

• Weakness

• Deformity

• AL limitations

• Balance and coordination

problems

Inspection:

Posture:

• Position of head

• Body alignment

• Position of knees

Spinal curves:

• Normal curves for adult

(cervical, thoracic, lumbar,

sacral, kyphosis, scoliosis,

lordosis)

Gait: (will be tested in neuro

examination)

• Base of support

35

Sites Examination Notes

Upper

extremities

Inspection:

Upper extremities

 shoulders

 arms (elbows and wrists)

 hands (palms and fingers)

 inspect both sides  proximal to distal  any involuntary movement  any deformities  any change in muscles bulk

(also a component in neuro

examination)

 flaccid or spastic / rigid  skin texture  skin integrity

Palpation:

for pulses & circulation:

 brachial

 radial

 ulnar

 capillary refill

Palpate for temperature and

moisture

Range of motion (ROM): Neck:

 flexion

 extension

 left rotation

 right rotation

Shoulders:

 abduction

 adduction

 flexion

 extension

 internal rotation

 external rotation

 circumduction

Elbows:

 Flexion

 Extension

 Supination

 Pronation

Wrists:

 Flexion

 Extension

 Radial flexion

 Ulnar flexion

Fingers:

 Flexion

 Extension

 Hyperextension

36

Sites Examination Notes

Upper

extremities

Muscle strength Shoulders:

 Cranial nerve XII – shrug

shoulders against resistance of

hands

Elbows and wrists tested

together:

 Elbows and wrists flexed –

push against examiner’s flexed

elbows and wrists

Fingers:

 patient to squeeze and release

examiner ‘s index and middle

fingers tightly

 patient try to pulling away the

fingers from examiner’s grasp

NORMAL muscle grade

strength is on a scale from 0 to

5 “out of five”

Pronator Drift:

A test for delicate upper

extremity weakness:

Have patient stand, close their

eyes & extend both hands, palm

up. Tap both extended are

lightly.

e.g. If R arm slightly weak, it

will pronate & “drift” down

ward.

Lower

extremities

Inspection

Hips:

 symmetry

 deformities

Knees:

 symmetry

 alignment

 deformities

Shin & calf:

 symmetry

 colour

 hair

 muscle bulk

Ankles and feet:

 symmetry

 alignment

 deformities

 colour

Right calf atrophy

Grading Motor Strength

Grade Description

0/5 No muscle movement

1/5 Visible muscle movement, but no movement at the joint

2/5 Movement at the joint, but not against gravity

3/5 Movement against gravity, but not against added resistance

4/5 Movement against resistance, but less than normal

5/5 Normal strength: movement against gravity and resistance well

37

Sites Examination Notes

Lower

extremities

Palpation Hips for:

 stability

 tenderness

Knees for:

 tenderness

 warmth

Ankles and feet for:

 tenderness

 warmth

Palpation for pulses and

circulation

 popliteal

 posterior tibial

 dorsalis pedis

 capillary refill

Range of motion (ROM):

Hips

 flexion with knee up to chest

and back to knee flexed

 adduction

 abduction

 inward rotation

 outward rotation

 hip hyperextension

Knees:

 extension

 flexion

Ankles and feet:

 dorsiflexion

 plantar flexion

 inversion

 eversion

 toe flexion

 toe extension

38

Sites Examination Notes

Lower

extremities

Muscle strength

Test strength by having the

patient move against your

resistance and always compare

one side to the other.

Hips:

1. flexion at the hip—place

your hand on the patient’s

thigh and ask the patient to

raise the leg against your hand

2. adduction at the hips—place

your hands firmly on the bed

between the patient’s knees.

Ask the patient to bring both

legs together

3. abduction at the hips—place

your hands firmly on the bed

outside the patient’s knees.

Ask the patient to spread both

legs against your hands

4. extension at the hips—have

the patient push the posterior

thigh down against your hand

Knees:

1. extension at the knee— support the knee in flexion

and ask the patient to

straighten the leg against your

hand

2. flexion at the knee—place the

patient’s leg so that the knee

is flexed with the foot resting

on the bed. Tell the patient to

keep the foot down as you try

to straighten the leg

Ankles and feet:

Test plantar flexion at the

ankle—ask the patient to push

down the foot against your hand

NORMAL muscle grade

strength is on a scale from 0 to

5 “out of five”

39

Neurological system:

Neurologic examination follows a standardised pattern. Experience may tailor the full examination and

result in focusing more on the most pertinent signs and symptoms. In addition often certain abnormalities

should be reexamined over and over again to assure the abnormality.

 Consciousness and Evaluation of Cognition:

 Level of consciousness is measured with the Glasgow Coma Scale

 Cognitive function can be tested with various validated tool, eg: Mini mental status examination (MMSE)

40

Sites Examination Notes

Neurological

system

Cranial nerves

1. Olfactory (CN I) – usually not tested

2. Optic (CN II) – gross peripheral visual fields, visual

acuity near & distance, colour

plates

(refer eyes examination)

3. Oculomotor (CN III) – pupillary constriction and the

EOM

4. Trochlear (CN IV) – EOM 5. Trigeminal (CN V): a. while palpating the temporal and

masseter muscles in turn, ask the

patient to clench her teeth

b. check the forehead, cheeks and jaw on each side for pain and light

touch

c. check the corneal reflex with a wisp of cotton

6. Abducens (CN VI) – EOM 7. Facial (CN VII): a. ask the patient to raise both

eyebrows

b. frown c. close both eyes tightly d. show both upper and lower teeth e. smile f. puff out both cheeks

8. Acoustic (CN VIII): – assess gross hearing, Weber & Rinne test, assess balance

Romberg test

9. Glossopharyngeal (CN IX) –

tested together with CN X

10. Vagus (CN X): • Ability to swallow and cough

• Gag reflex

• soft palate elevation and

symmetrical rise of uvula @ ‘ah’

11. Spinal Accessory (CN XI): a. Ask the patient to shrug both

shoulders against your hands

b. Ask the patient to turn her head to

each side against your hand

12. Hypoglossal (CN XII)

a. Ask the patient to protrude her tongue

b. Ask the patient to push the tongue

against the inside of each cheek

** V,VII,X,XII - Voice and speech

Neurological Symptoms

• Headaches • Dizziness

• Seizures

• Loss of consciousness

• Change in sensation

• Change in mobility

• Dysphagia (difficulty swallowing)

 • Dysphasia (difficulty in speaking)

41

Sites Examination Notes

Neurological

system:

Motor system

Sensory

!! Testing does not solely

examine cerebellum –i.e. also

requires strength, motor function,

joint movement, etc =

neuromuscular.

Musculoskeletal = muscle bulk

tone, strength also applies in

neuro exam.

Sensory:

Assess the Spinothalmic Tract

(to test ability to sense pain,

temperature, and light touch)

Test with eyes closed

 Light touch sensitivity –

cotton wisp

1. Shoulders 2. Inner and outer aspects

of the forearms

3. Thumbs and little fingers

4. Front of both thighs 5. Medial and lateral

aspect of both calves

6. Little toes

 Sharp vs dull for pain sensation: @ sites:

1. Shoulders 2. Inner and outer aspects of

the forearms

3. Thumbs and little fingers 4. Front of both thighs 5. Medial and lateral aspect

of both calves

6. Little toes

 Temperature (additional to

pain sensation test) =

proceed only if pain test is

normal

42

Sites Examination Notes

Neurological

system: Sensory

Deep tendon

Reflexes &

superficial

reflexes

Sensory

Assess Posterior Column Tract

(may identify lesions of the

sensory cortex or vertebral

column)

Test with eyes closed

 Position sense:

(proprioception)

(test digits position with eyes

closed)

Tactile discrimination:

 Stereognosia:

identify objects with eyes

closed

OR

 Graphesthesia:

identify number or letter

written on palm with eyes

closed

 Vibration test

 Two point discrimination

Superficial Reflexes

The following reflexes are

considered normal in adults.

Upper Abdominal:

Ipsilateral contraction of

abdominal muscles on the

stroked side.

Lower Abdominal:

Ipsilateral contraction of

abdominal muscles on the

stroked side.

Plantar response:

Stroke the lateral aspect of the

sole of each foot with the end of

a reflex hammer or key.

Note movement of the toes –

normal: toes down (plantar

flexion) Extension of the big toe with fanning

of the other toes is abnormal. This is

referred to as a positive Babinski.

Deep tendon reflexes

43

Sites Examination Notes

Cerebellar

function:

coordination,

skilled

movements and

balance

Coordination:

A. Point-to-point movements

test

Finger-to-finger:

Place your finger in space in

front of patient, have patient

move index finger between

his/her nose & your finger tip

OR

Finger-to-nose:

Patient to touch tip of nose

alternating one at a time with left

index finger (forefinger) then

right index finger, first with eyes

open then with eyes closed.

B. Rapid Alternating Hand

Movement:

1. Ask the patient to strike one

hand on the thigh, raise the

hand, turn it over, and then

strike it back down as fast as

possible.

2. Ask the patient to tap the distal

thumb with the tip of the

index finger as fast as

possible.

OR

Rapid Alternating Finger

Movement:

Have patient alternately touch

tips of each finger against thumb

of same hand

C. Heel-to-shin:

Have patient run heel of 1 foot

up & down opposite shin and

repeat on the other side

For all test: Normal movement

is both smooth& accurate.

Skilled movements:

Gait:

Walk heel to toe in a straight line

- forwards and backwards.

Assess: abnormalities such as

stiff posture, staggering, wide

base of support, lack of arm

swing, unequal steps, dragging or

slapping of foot, and presence of

ataxia.

44

Female Genitourinary

Sites Examination Notes

Cerebellar

function:

coordination,

skilled

movements and

balance

Balance:

Romberg’s Test

With eyes closed, have the

patient stand with feet together

and arms extended to the

front, palms up. Your patient

should be able to maintain their

balance (10 secs). Stay next to

the patient when they are

performing this test in particular,

so if they begin to fall,

you can catch them. Balance

should be maintained.

Sites Examination Notes

Female

Genitourinary

Female Genitourinary

Symptoms

• Vaginal discharge

• Pain

• Lumps/masses

• Dysmenorrhoea

• Amenorrhoea

• Urinary symptoms

Inspection

External genitalia:

• Labia majora

• Labia minora

• Clitoris

• Urethra

• Vaginal orifice

• Skene’s glands

• Bartholin’s glands

• Perineum

Note:

• Colour

• Hair distribution

• Condition of the skin

• Swelling

• Lesions

• Polyps

• Discharge

• Odour

• Prolapse

• Pubic pediculosis

45

Sites Examination Notes

Female

Genitourinary

Inspection:

Rectal Area:

• Condition of skin

• Inflammation

• Rashes

• Excoriation

• Rectal prolapse

• Haemorrhoids

• Polyps

• Lesions

• Fissures

• Bleeding

• Discharge

Pelvic Exam with Speculum X

Cervix:

• Colour

• Lesions

• Discharge

• Bleeding

• Position

• Size

• Shape and symmetry

• Shape and patency of os

Vaginal walls:

• Colour

• Lesions

• Discharge

Obtain specimens

Palpation

Skene’s and Bartholin’s glands:

• Masses

• Swelling

• Discharge

• Tenderness

Vaginal walls:

• Texture

• Swelling

• Lesions

• Tenderness

Perineum:

• Tone

• Texture

Cervix:

• Size

• Shape

• Consistency

• Position

• Mobility

• Tenderness

46

Male Genitourinary

Sites Examination Notes

Female

Genitourinary

Palpation:

Uterus:

• Size

• Shape

• Symmetry

• Position

• Masses

• Tenderness

Ovaries:

• Size

• Shape

• Symmetry

• Tenderness

Anus and Rectum:

• Sphincter tone

• Pain/tenderness

• Nodules/polyps

• Lesions/masses

• Haemorrhoids

• Bleeding

• Test for occult blood

Sites Examination Notes

Male

Genitourinary

Male Genitourinary Symptoms

• Pain

• Lesions

• Discharge

• Swelling

• Urinary symptoms

• Erectile dysfunction

Inspection

Penis:

• Condition and colour of skin

• Lesions

• Discharge

• Size r/t physical and

developmental age

• Position of urinary meatus

• Foreskin:

Circumcised/uncircumcised

Scrotum:

• Colour

• Hair distribution

• Lesions

• Swelling

• Size and position

• Pubic pediculosis

47

Sites Examination Notes

Male

Genitourinary

Transilluminate:

• Fluid

• Mass

Inguinal area:

• Condition of skin

• Bulges

• Enlarged lymph nodes

Rectal Area:

• Condition of skin

• Inflammation

• Rashes

• Excoriation

• Rectal prolapse

• Haemorrhoids

• Polyps

• Lesions

• Fissures

• Bleeding

• Discharge

Palpation

Penis:

• Consistency

• Tenderness

• Induration

• Masses or nodules

Scrotum, testes, epididymis:

• Size

• Shape consistency

• Mobility

• Masses or nodules

• Tenderness

Inguinal area:

• Inguinal or femoral hernias

• Lymph nodes, horizontal and

vertical, enlargement and

tenderness

Anus and Rectum:

• Sphincter tone

• Pain/tenderness

• Nodules/polyps

• Lesions/masses

• Haemorrhoids

• Bleeding

• Test for occult blood

Prostate:

• Size

• Shape

• Symmetry

• Mobility

• Consistency

• Nodules

• Tenderness

48

Take over shift Head to Toe Assessment Checklist – compulsory checking

Vital Signs

Time

 T

 P

 R

 B/P (Manual/Electronic)

 Location

 Body Position

Upper Extremities

 Skin Colour

 Skin Temperature

 Turgor(Chest)

 Radial Pulses

 Capillary refill

 Handgrip

 Movement

 ROM

Oxygen

 Oximetry

 Liters/Minute

 Room Air

 Nasal Cannula

 Mask

Lower Extremities

 Skin Colour

 Skin Temperature

 Pedal Pulses

 Capillary refill

 Movement

 ROM

IV

 Solution

 Rate

 Site

 Redness

 Irritation

 Oedema

CVS

 Apical Pulse

 Rate

 Regular

 Regular Irregularity

 Irregular Irregularity

Pain

 Location

 Duration

 Scale (1 – 10)

 Intervention

 Evaluation (within 30 minutes)

Respiratory

 Breath Sounds

 Anterior/Posterior

 L Upper

 Middle

 Lower

 Inspiratory/Expiratory

Mental Status

 Alert

 Person

 Place

 Time

Eyes

Pupils

Left Right

P

E

R

R

L

A

Mucous Membranes

Moist

Pink

Abdomen

Soft

Round

Non Tender

LUQ RUQ

LLQ RLQ

Dressing

Location

Clean

Dry

Intact

Drainage

Colour

Amount

Odour

Consistency

Elimination

 Voiding freely

 Continent/incontinent

 Foley

 Patent

 Colour

 Clarity

 Bowel Movement

 Continent/incontinent

 Color

 Consistency

 Amount

Miscellaneous

Pt in bed

Low position

Side rails up

Call light within reach

Special equipment