Laoag City, Ilocos Norte

BSN NCM 101: HEALTH ASSESSMENT

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Laoag City, Ilocos Norte

MODULE 4

BSN NCM 101: HEALTH ASSESSMENT

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Before going over to the Physical Assessment

topic, let us start first with a game activity that
may help you determine your prior learnings, and
help you open the door to what is new about this
module. Try search hidden words in the letter grid. Words can be arranged forwards,
backwards, horizontally, vertically, or diagonally- and your job is to find them all!
SUBMIT THE ACCOMPLISHED OUTPUT ON CANVAS ASSIGNMENT- HIDDEN
WORDS TAB.

P L E X I M E T E R A
U I A F J E Y R O N S
P T R O I A E A A W I
I E T E R N O S E C D
L A D O O T A E X H E
Q D O D C R A O I J P
X R E R C K O R I E S
S M E A T G S T T X I
O Y O P I U C E O E L
U R A L T E C E E L A
T E I I P H A I U F S
Y T S S I R E A D E R
I M N A N N U L A R O
Y I E T E S T E S O D

Snellen chart Weber test Health Stethoscope Hernia

Aorta Annular Otoscope Physical Exam Vesicular
PERRLA Comedone Hirsutism Pleximeter Red Reflex

Buttocks Dorsalis pedis Percussion Lachman test Ishihara

pupil vitiligo petechiae ANASARCA diaphragm

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Film Clip Analysis:

Please visit this link https://youtu.be/nzzfReCSuRg . Answer the question briefly

but substantially. Submit the accomplished output on CANVAS ASSIGNMENT-
Film Clip Analysis:

Why do you think that physical examination to patient is regarded as a

standard source of clinical information for nurses? (20 points)

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PHYSICAL ASSESSMENT

- Consist of systematically examining the patient for physical evidence of

functional abilities and disabilities or both.
- Is a systematic means of collecting objective assessment data.

Types of Physical Assessment

1. A complete health assessment

2. A problem-focused assessment

Purposes of Physical Assessment:

1. To establish a _____________
2. To identify ________ that place the client at ____ for additional health
problems
3. To detect _________ related to altered function

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SKIN, HAIR, AND NAILS

Assessment of the Skin

In each area, inspect and palpate for the color, moisture, temperature, texture, turgor,
signs of bleeding, ecchymosis, vascularity, and lesions.

1. COLOR

Color Condition Causes Assessment Locations

1.Bluish Increase amount of Heart or lung Nail beds, lips, mouth
(_________) deoxygenated hemoglobin disease, skin
( associated with hypoxia ) Cold environment ( severe cases)
2.Pallor Reduced amount of _________ Face, conjunctiva, nail
oxyhemoglobin beds, palms of hands
Reduced visibility of _________ Skin, nail beds,
______________ resulting from conjunctiva, lips
decreased blood flow
3.Loss of ___________ Congenital or Patchy areas on skin
pigmentation autoimmune over face, hands, arms
condition causing
lack of pigment
4.Yellow- Increased deposit of bilirubin Liver disease, Sclera, mucous
orange in tissues destruction of red membrane, skin
(__________) blood cells
5.Red Increased visibility of Fever, direct Face, area of trauma,
(__________) oxyhemoglobin caused by trauma, blushing, sacrum, shoulders,
dilation or increased blood flow alcohol intake other common sites for
pressure ulcers
6.Tan brown Increased amount of _________ Suntan, Areas exposed to sun
pregnancy face, arms, areolae,
nipples

2. TEXTURE- the character of the skin’s surface and the feel of deeper portions are its
texture.

Normal: Children skin is smooth, soft, even and flexible

Adult palms of the hand and soles of the feet tend to be
thicker.
Older Adults skin becomes wrinkled
3. TURGOR- ability to turn to its normal
Abnormal: Hyperthyroidism—skin feels smoother and softer, like velvet.

Hypothyroidism—skin
BSN NCM 101: HEALTH ASSESSMENTfeels rough, dry, and flaky
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-Is the skin’s elasticity, which can be

diminished by edema or dehydration.

Normal: skins lift easily and snaps back

immediately to its resting position

Abnormal: failure of the skin to resume its

normal contour or shape indicate dehydration.

-a decrease in turgor predisposes the client to

skin breakdown

4. VASCULARITY- the circulation of the skin

affects the appearance of superficial blood
vessels

Petechiae – are pinpoint sized, red or purple spots on the skin caused by small
hemorrhages in the skin layers

5. _______ – areas of the skin become swollen or edematous from a buildup of fluid in the
tissues.

Causes:

1. _______ Trauma
2. Impairment of ___________

Edematous areas should be inspected for location, color and shape.

For the client with dependent edema a caused by poor venous return, typical sites of
edema are the feet, ankles and sacrum.

Edematous skin looks stretched and shiny.

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_________ edema—consider a local or peripheral cause.

Bilateral edema or edema that is generalized over the whole body (___________)—consider
a central problem such as heart failure or kidney failure

6. LESIONS

Common shapes and configurations of lesions

ANNULAR CONFLUENT DISCRETE LINEAR

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GROUPED POLYCYCLIC TARGET

_________ Skin lesions

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___________ skin lesions

ASSESSMENT OF THE NAILS

Stages of Pressure Ulcer

Stages of pressure ulcer

Stage I
Intact skin- appears ____ but ________.
Localized redness in lightly pigmented skin
does not blanch (turn light with fingertip
pressure). Dark skin appears darker but
does not blanch.

StageII
_______________ -skin erosion with loss of
epidermis or also the dermis. Superficial
ulcer looks shallow like an abrasion or
open blister with a red-pink wound bed.

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StageIII
_____________ Pressure ulcer- extending
into the subcutaneous tissue and
resembling a crater. May see
________________ but not muscle, bone, or
tendon.

Stage IV
_______________pressure ulcer- involves
all skin layers and extends into
supporting tissue. Exposes _____, _______,
and ______ may show slough (stringy
matter attached to wound bed) or _______
(black or brown necrotic tissue).

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ASSESSMENT OF THE HAIR

 Occurs during all portions of the examination. Assess the distribution, thickness,
texture, and lubrication of hair. In addition, inspect for infection or infestation of the scalp

 Examine the patient’s hair. Note its quantity, distribution, texture, and pattern of
loss, if any.
 Part the hair in several places and look for scaliness, lumps, nevi, or other lesions.

Hair is normally distributed evenly, is neither excessively dry nor oily, and is pliant or
flexible.

Abnormal Conditions of Hair

AIDS-related Kaposi Sarcoma: Patch stage Toxic Alopecia

Seborrheic Dermatitis

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Pediculosis Capitis (____________)

HIRSUTISM Folliculitis (“razor bumps”)

ASSESSMENT OF THE NAILS

Inspect and palpate for the color, shape, configuration and texture of the nails:

 Check for nail grooming and cleanliness

 Note for nail color and markings
 Observe for the shape of the patients nails
 Palpate to assess texture and consistency, noting whether nail plate is
attached to nail bed.
 Test capillary refill in nail beds by pressing the nail tip briefly and
watching for color change

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NAIL SHAPES AND CONFIGURATIONS

SCABIES Paronychia

Splinter Hemorrhages Beau Line

Onychomycosis Late Clubbing

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Pitting Habit-Tic Dystrophy

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HEAD, EYES, AND EARS

ASSESSMENT OF THE HEAD

 Have the patient sit in a comfortable position

 Face the patient with your head at the same level as the patient’s head
 Observe the general size and contour of the skull. Note any deformities,
depressions, lumps, or tenderness:
Normocephalic
Microcephalic
Macrocephalic

 Place the finger pads on the scalp and palpate all of its surface, beginning in the
frontal area and continuing over the parietal, temporal and occipital areas

 Palpate bilaterally (simultaneously) for the temporal artery by placing the finger
pads immediately in front of the tragus of the ear

 Auscultate for the temporal artery using the bell of

the stethoscope

 Using the pads of the middle and index finger, palpate

for the temporomandibular joint located anterior to the
ears:
 While palpating, ask the patient to open and clench
jaw

Note for the relative smoothness of the

movement as the patient opens and clenches jaw

 Auscultate for the TMJ by placing the bell of the stethoscope

over the joint while letting the patient open and close mouth

Note for any clicking sound made as the patient opens and clenches jaw

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ASSESSMENT OF THE EYES

When assessing the eyes, it is important for the nurse to examine the patient for the following:

 Visual Acuity  Extraocular movements

 Visual Fields  Fundi, including optic disc and cup
 Conjunctiva and sclera  Retina
 Cornea, lens and pupils  Retinal vessels

 Assess for the patient’s visual acuity

Ask the patient to stand or sit facing the visual acuity chart at a distance of 20feet

If the patient normally wears glasses, ask that they be Visual acuity is usually expressed in
removed a fraction (i.e. 20/20, 20/40):
Instruct the patient to cover the left eye with the occluder (𝑑𝑖𝑠𝑡𝑎𝑛𝑐𝑒𝑜𝑓𝑡ℎ𝑒𝑝𝑎𝑡𝑖𝑒𝑛𝑡𝑓𝑟𝑜𝑚𝑐ℎ𝑎𝑟𝑡)
and read as many lines on the chart as possible starting from (𝑑𝑖𝑠𝑡𝑎𝑛𝑐𝑒𝑎𝑡𝑤ℎ𝑖𝑐ℎ𝑎𝑛𝑜𝑟𝑚𝑎𝑙𝑒𝑦𝑒
the top most line 𝑐𝑎𝑛𝑟𝑒𝑎𝑑𝑡ℎ𝑒𝑙𝑖𝑛𝑒𝑜𝑓𝑙𝑒𝑡𝑡𝑒𝑟𝑠)

 Note the number at the end of the last line the patient was able to read

If the patient was not able to read the letters at the top of the chart, move the patient
closer to the chart. Note the distance at which the patient is able to read the top of the
line

Repeat the test, occluding the right eye

VISUAL ACUITY CHARTS

If the patient normally wears glasses, the test should be repeated with the patient
wearing the glasses, and it should be so noted (corrected or uncorrected)

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To test for near vision, have the patient hold a special handheld card (rosen baum card)
14 inches from his/her face and read the letters starting from
the top without moving it Terms associated with color vision
problems:
 Assess for the patient’s color vision:  Achromatopsia
o Have the patient sit comfortably and  Deuteranopia
occlude one eye  Protanopia
o Hold the test plates (ishihara plates) 14
 Tritanopia
inches from the patient’s face and ask the
patient to identify the symbol seen on the plate
o Repeat the test on the other eye
ISHIHARA PLATES

 Assess for the patient’s visual fields(confrontation technique)

Sit or stand approximately 2 to 3 feet opposite the
patient, with your eyes at the same level as that of the
patient

Have the patient cover the right eye with the right hand
or an occlude.

Cover your left eye in the same manner

Have the patient look at your uncovered eye with

his/her uncovered eye Assessing for visual field using
confrontation technique
Hold your freehand at arm’s length equidistant from you and the patient and move it or
a held object such as a pen into your and the patient’s field of vision from nasal, temporal,
superior, inferior and oblique angles
ECTROPION
Ask the patient to say “now” when your hand is seen moving
into the field of vision. Use your own visual fields as the
control of comparison to the patient’s visual field

Repeat the procedure for the other eye

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 Assess for the patient’s external eye and lacrimal

apparatus
Observe patient’s eyelids for drooping, infection, tumors or
other abnormalities

Note the distribution of the eyelashes and eyebrows

Ask the patient to look at your nose ENTROPION

Observe for the blinking of the patient’s eyes

Ask the patient to close eyes and then open them afterwards

Identify the area of the lacrimal gland. Note any swelling or

enlargement of the gland or elevation of the eyelid. Note any
enlargement, swelling, redness, increased tearing, or exudates
in the area of the lacrimal sac at the inner canthus

Compare to the other eye in order to determine whether there

is unilateral or bilateral involvement

Palpate the lacrimal glands:

Palpating for the lacrimal apparatus
Ask the patient to look up

Press on the lower lid close to the medial canthus, just

inside the rim of the bony orbit

 Assess for the patient’s extra ocular muscle

function:
Perform the corneal light reflex

Partially darken the room

Ask the patient to stare straight ahead

Corneal Light Reflex
Through the use of a penlight, shine the light on the bridge of the patient’s nose

Perform the cover-uncover test:

Let the patient stare at the wall behind you

Ask the patient to cover one eye with hand

Ask the patient to uncover the eye

Carefully observe the patient’s eyes for any movement

Assess for the cardinal positions of gaze:

Six Cardinal Positions of Gaze

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While in front of the client, position index finger at 12 inches away from the client’s nose

Ask the client to look at your finger and follow it with his/her gaze as you move it through
the six cardinal positions of gaze

Observe for any involuntary eye movements

 Assess for the anterior segment structures of the patient’s eyes

Inspect the sclera for color, exudates, lesions and foreign bodies

To assess for the cornea:

Shine a penlight directly on the cornea of the patient

Move the light bilaterally and view the cornea from that angle, noting color, discharge
and lesions

Do this for both the patient’s eyes

Inspect the iris for color, nodules and vascularity

To assess for the pupils:

Note the shape and size of the pupils in millimeters’

Move a penlight from the side to the front of one eye allowing the light to shine on the
other eye

Observe the pupillary reaction in that eye (this is the direct light reflex). Note the size of
the pupil receiving light stimulus and the speed of pupillary response to light

Repeat in the other eye

Move the penlight in front of one eye and observe the other eye for pupillary constriction
(this is the consensual light reflex)

Repeat the procedure on the other eye

 Assess for accommodation:

Instruct the patient to shift the gaze to a distant object for about 30 seconds

Instruct the patient to then look at your finger or an object held in your hand about 10cm
from the patient

Note the reaction and size of the pupil

 To assess for the bulbar conjunctiva, separate the lid margins with the
fingers

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 Have the patient look up, down and to the right and
left
 Inspect the surface of the bulbar conjunctiva for color,
redness, swelling, exudates or foreign bodies
 With the thumb, gently pull the lower lid downwards
and inspect the conjunctiva for color, inflammation,
edema, lesions or foreign bodies
 To assess for the palpebral conjunctiva:
 Ask the patient to close his/her eyes
 Place a sterile, cotton tipped applicator about 1cm
above the lid margin
 Gently exert downward pressure on the applicator
while pulling the eyelashes upward to evert the lid
 Inspect the palpebral conjunctiva for redness,
Everting the upper eyelid swelling, exudates or foreign bodies
 When done, gently release the eyelashes and have the
patient blink
 Repeat for the other eye

o Assess for the posterior segment structures of the patient’s eyes:

 Darken the room. Switch on the ophthalmoscope light and
turn the lens disc until you see the large round beam of white light.
Shine the light on the back of your hand to check the type of light,
its desired brightness, and the electrical charge of the
ophthalmoscope.
 Turn the lens disc to the 0 diopter (a diopter is a unit that
measures the power of a lens to converge or diverge light). At this
diopter the lens neither converges nor diverges light. Keep your
finger on the edge of the lens disc so you can turn the disc to focus
the lens when you examine the fundus.
 Remember, hold the ophthalmoscope in your right hand to
examine the patient’s right eye; hold it in your left hand to examine
Using the
ophthalmoscope the patient’s left eye. This keeps you from bumping the patient’s
nose and gives you more mobility and closer range for visualizing
the fundus.

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 Hold the ophthalmoscope firmly braced against the medial

aspect of your bony orbit, with the handle tilted laterally at about a
20° slant from the vertical. Check to make sure you can see clearly
through the aperture. Instruct the patient to look slightly up and
over your shoulder at a point directly ahead on the wall.
 Place yourself about 15 inches away from the patient and at
an angle 15° lateral to the patient’s line of vision. Shine the light
beam on the pupil and look for the orange glow in the pupil—the red
reflex. Note any opacities interrupting the red reflex.
 Now, place the thumb of your other hand across the patient’s
eyebrow (this technique helps keep you steady but is not essential).
Keeping the light beam focused on the red reflex, move in with the
RED REFLEX ophthalmoscope on the 15° angle toward the pupil until you are very
close to it, almost touching the patient’s eyelashes.
 First, locate the optic disc. Look for the round yellowish
orange structure described above. If you do not see it at first, follow
a blood vessel centrally until you do. You can tell which direction is
central by noting the angles at which vessels branch—the vessel size
becomes progressively larger at each junction as you approach the
disc.
 Now, bring the optic disc into sharp focus by
adjusting the lens of your ophthalmoscope. If both
you and the patient have no refractive errors, the
retina should be in focus at 0 diopters. (A diopter is
a unit that measures the power of a lens to
converge or diverge light.) If structures are
blurred, rotate the lens disc until you find the
sharpest focus.
 Inspect the optic disc. Note the following
features:
 The sharpness or clarity of the disc outline.
The nasal portion of the disc margin may be
somewhat blurred, a normal finding.
 The color of the disc, normally yellowish
orange to creamy pink. White or pigmented
crescents may ring the disc, a normal finding.
 The size of the central physiologic cup, if present. It is usually yellowish white. The
horizontal diameter is usually less than half the horizontal diameter of the disc.
 The presence of venous pulsations. In a normal person, pulsations in the retinal
veins as they emerge from the central portion of the disc may or may not be present.
 The comparative symmetry of the eyes and findings in the fundi
 Inspect the retina, including arteries and veins as they extend to the periphery,
arteriovenous crossings, the fovea, and the macula.
 Follow the vessels peripherally in each of four directions, noting their relative sizes
and the character of the arteriovenous crossings. Identify any lesions of the surrounding

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retina and note their size, shape, color, and distribution. As you search the retina, move
your head and instrument as a unit, using the patient’s pupil as an imaginary fulcrum.
 Finally, by directing your light beam laterally or by asking the patient to look
directly into the light, inspect the fovea and surrounding macula. Except in older people,
the tiny bright reflection at the center of the fovea helps to orient you. Shimmering light
reflections in the macular area are common in young people.
 Inspect the anterior structures. Look for opacities in the vitreous or lens by
rotating the lens disc progressively to diopters of around +10 or +12. This technique
allows you to focus on the more anterior structures in the eye.

ASSESSMENT OF THE EARS

 To assess for the external ear:

o Inspect the ears and note the their position, color, size
and shape
o Note any deformities, nodules, inflammation, or
lesions
o Note color, consistency and amount of cerumen
o Palpate the auricle between the thumb and the index
finger, noting any tenderness or lesions. If the patient
has ear pain, assess the unaffected ear first, then
cautiously assess the affected ear
o Using the tips of the index and the middle fingers, External Ear
palpate the mastoid area, noting any tenderness
o Using the tips of the index and the middle fingers,
press inward of the tragus, noting any tenderness
o Hold the auricles in between the thumb and the index finger
and gently pull up and down, noting any tenderness

 To perform auditory screening:

o Perform the voice whisper test:
 Stand 2 feet behind the patient’s field of vision
 Gently occlude and rub the external auditory canal of the non-
tested ear
 Ask the patient to repeat a set of 3 different random numbers
(e.g., 6,1,9) presented to the tested ear
 Exhale completely prior to testing with whispered voice
o With the use of the tuning fork, perform the weber test
 Hold the handle of the tuning fork and strike the tines on the Weber Test
ulnar border of the palm to activate it

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 Place the stem of the fork firmly against the

middle of the patient’s forehead or on the top of
the head at the midline
 Ask the patient if the sound is heard centrally
or toward one side
o With the use of the tuning fork, perform the
rinne test RINNE TEST
 Stand behind or to the side of the patient
 Activate the tuning fork and place its stem
against the patient’s right mastoid process to test bone conduction
 Instruct the patient to indicate if the sound is heard (note the length of time the
patient hears the sound)
 When the patient says the sound has stopped, move the tuning fork, with the tines
facing forward, in front of the right auditory meatus, and ask the patient if the sound
is still heard. Note the length of time the patient hears the sound.
 Repeat the test on the left ear

 Assess for inner ear structures:

o Ask the patient to tip the head away from the ear being assessed
o Select the largest speculum that will comfortably fit the patient
o Hold the otoscope securely in the dominant hand, with the head held downward
and the handle held like a pencil between the thumb and the forefinger
o Rest the back of the dominant hand on the right side of the patient’s head
o Use the ulnar aspect of the free hand to pull the right ear in a manner that will
straighten the ear canal. In adults and in children over three years old, pull the ear
up and back
o Slowly insert the speculum into the canal, looking at the canal as the speculum
passes
o Asses the canal for inflammation, exudates, lesions and foreign bodies
o Continue to insert the speculum into the canal, following the path of the canal until
the tympanic membrane is visualized
o Note for the characteristics of the tympanic membrane

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Nose, Sinuses, Mouth and Throat,

ASSESSMENT OF THE NOSE AND SINUSES

 Inspect the anterior surfaces of the patient’s nose

 Note any asymmetry or deformity of the nose MATERIALS
 Test for nasal patency by pressing on each nasal in turn NEEDED
and asking the patient to breathe in  Otoscope with the
largest ear speculum
 Inspect the inside of the patient’s nose:  Penlight
o Get an otoscope and the largest ear speculum available
o Tilt the patient’s head back a bit and
insert the speculum gently into the vestibule
of each nostril, avoiding contact with the
sensitive nasal septum
o Hold the otoscope handle to one side
to avoid the patient’s chin and improve your
mobility
o By directing the speculum
posteriorly, then upward in small steps,
inspect for the inferior and middle
turbinate’s, the nasal septum, and the Palpating for the Palpating for the
narrow nasal passage between them: frontal sinuses maxillary sinuses

 Nasal mucosa: note its color and any swelling, bleeding, or exudate
 Nasal Septum: note any deviation, inflammation, or perforation of the septum
 Palpate for sinus tenderness:
o Press up on the frontal sinuses from under the bony
brows, avoiding pressure on the eyes
o The press up on the maxillary sinuses
 If tenderness is noted upon palpation of the sinuses,
it may be necessary to perform trans illumination of the
sinuses
o Darken the room thoroughly TRANSILLUMINATION
of the frontal sinuses
o For the frontal sinuses:
 Using a strong, narrow light source, place the light snugly deep under each brow,
close to the nose
 Shield the light with your hand
 Look for a dim red glow as light is transmitted through the air-filled frontal sinus
to the forehead

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o For the maxillary sinuses

 Ask the patient to tilt his or her head back with
mouth opened wide
 Shine the light downward from just below the inner
aspect of each eye
 Look for a dim red glow as light is transmitted
through the air-filled maxillary sinus to the hard palate
Transillumination of the maxillary
sinuses

ASSESSMENT OF THE MOUTH AND THROAT

 If the patient wears dentures, offer a paper towel and ask the patient to
remove them
 Don clean gloves
 Observe the lip color, moisture, swelling, lesions or other signs of inflammation
 Have the patient open his/her mouth:
o Note for the odor of patient’s breath
o Note the color of the gums
o Inspect the gum margins and the
interdental papillae for swelling or ulceration
o Inspect the teeth. Are any of them
missing, discolored, misshapen, or abnormally
positioned? You can check for looseness with your
gloved thumb and index finger.
o Inspect the color and architecture of the
hard palate
o Ask the patient to put out his or her
tongue
 Inspect it for symmetry Palpating for the patient’s tongue
 Note the color and texture of the dorsum of the tongue
 Inspect the sides and undersurface of the tongue and the floor of the mouth
 With your right hand, grasp the tip of the tongue with a square of gauze and gently
pull it to the patient’s left
 Inspect the side of the tongue, and then palpate it with your gloved left hand,
feeling for any induration (hardness)
 Reverse the procedure for the other side.
o Have the patient say “ahh” and press a tongue blade firmly down upon the
midpoint of the arched tongue
 Note for the rise of the soft palate
 Inspect the soft palate, anterior and posterior pillars, uvula, tonsils, and pharynx

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Laoag City, Ilocos Norte

Neck and Shoulders

ASSESSMENT OF THE NECK

 Inspect the neck, noting its symmetry and any masses or scars:
o Look for enlargement of the parotid or submandibular glands and note any visible
lymph nodes.

 To assess for the lymph nodes:

o Have the patient flex head slightly forward.
o Using the pads of your index and middle fingers, palpate for the lymph nodes.
o Note their size, shape, delimitation (discrete or matted together), mobility,
consistency, and any tenderness.

o Palpate the nodes in the following sequence:

 Pre-auricular
 Post-auricular
 Occipital
 Tonsillar
 Sudmandibular
 Submental
 Superficial Cervical
 Posterior Cervical
 Deep Cervical
 Supraclavicular

 Inspect and then palpate the trachea for any deviation from its usual midline
position
o To palpate for the trachea, place your index finger along one side of the trachea
and note for the space between it and the sternomastoid.
o Compare it with the other side.
 Inspect for the patient’s thyroid gland
o Have the patient tilt his/her head backwards.
o Using tangential lighting directed downward from
the tip of the patient’s chin, inspect the region below the
cricoid cartilage for the gland.
o Ask the patient to sip some water and to extend the
neck again and swallow.
o Watch the upward movement of the thyroid gland,
noting its contour and symmetry.
 Palpate for the thyroid gland
o Ask the patient to flex the neck slightly forward to
relax the sternomastoid muscles.

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o Place the fingers of both hands on the patient’s neck so that your index fingers are
just below the cricoid cartilage.
o 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.
o Displace the trachea to the right with the fingers of the left hand; with 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.

ASSESSMENT OF THE SHOULDERS

 Observe for the shoulder and shoulder girdle anteriorly, and inspect the scapulae
and related muscle posteriorly. Note any swelling, deformity, or muscle atrophy or
fasciculations (fine tremors of the muscles).
 Palpate the shoulders and surrounding muscles
o Acromioclavicular joint
 Palpate and compare both joints for swelling or tenderness. Adduct the patient’s
arm across the chest, sometimes called the “crossover test”.
o Subacromial and Subdeltoid Bursae
 Passively extend the shoulder by lifting the elbow posteriorly. This exposes the
bursae anterior to the acromion.
 Palpate carefully over the subacromial and subdeltoid bursae.
o Rotator cuff
 With the patient’s arm hanging at the side, palpate the three “SITS”
muscles that insert on the greater tuberosity of the humerus: suprainfinatus,
infraspinatus and teres minor.
 Passively extend the shoulder by lifting the elbow posteriorly. This
maneuver also moves the rotator cuff out from under the acromion. Palpate the rounded
SITS muscle insertions near the greater tuberosity of the humerus.
 Check the “droop-arm” sign. Ask the patient to fully abduct the arm to shoulder
level (or up to 90 degrees) and lower it slowly.
o Bicipital Groove and Tendon
 Rotate the arm and forearm externally and locate the biceps muscle distally near
the elbow. Track the muscle and its tendon proximally into the bicipital groove along the
anterior aspect of the humerus. As you check for tenderness, rolling the tendon under the
fingertips may be helpful. Finally, hold the patient’s elbow against the body with the
forearm and flexed at a right angle. Ask the patient to supinate the forearm against
resistance.
 Assess for the ROM of the shoulders: flexion, extension, abduction, adduction, and
internal and external rotation.
o Watch a smooth, fluid movement as you stand in front of the patient and ask the
patient to:
 Raise (abduct) the arms to shoulder level with palms facing down (tests pure
glenohumeral motion)

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 Raise the arms to a vertical position above the head with the palms facing each
other (tests scapulothoracic motion for 60 degrees, and combined glenohumeral and
scapulothoracic motion during adduction for the final 30 degrees)
 Place both hands behind the neck, with elbows out to the side (tests external
rotation and abduction)
 Place both hands behind the lumbar region of the back (tests internal rotation and
adduction)

Chest

ASSESSMENT OF THE THORAX AND THE LUNGS

 Perform initial survey of the respiration and the thorax:
Palpation of the posterior thorax
o Observe the rate, rhythm, depth, and effort of breathing
o Assess the patient’s color
o Listen to the patient’s breathing.
 Is there any audible wheezing?
 If so, where does it fall in the respiratory cycle?

o Inspect the neck:

o During inspiration, is there contraction of the
sterno- mastoid or other accessory muscles, or
supraclavicular retraction?
 Is the trachea midline?
o Observe the shape of the chest
 Examine the patient’s posterior chest:
o Palpate the thoracic area for pulsations, masses,
thoracic tenderness and crepitus
 Have the patient cross his/her arms over his/her chest Palpation of the
with hands resting on the opposite shoulder posterior thorax
 Using the pads of the index and middle fingers, palpate Testing for CHEST
the thorax starting from the apex downwards EXPANSION (posterior)
 Note for the location of tenderness, masses, crepitus
o Test for chest expansion:
 Place your thumbs at about the level of the 10th 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 the spine
 Ask the patient to inhale deeply

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 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
o Test for tactile fremitus
 Firmly place the ulnar aspect of the hand/palmar bases
of the fingers/ulnar aspect of a closed fist on the patient’s back
 Ask the patient to repeat the words “ninety-nine” or “one-
one-one”
 Palpate and compare symmetric areas of the lungs Locations for TACTILE FREMITUS
starting from the apex downwards
 Identify and locate any areas of increased, decreased, or
absent fremitus
o Percuss the thorax for any abnormalities:
 Place the patient in an upright, sitting position with a
slight forward tilt
 Have the patient bend the head down and fold the arms in
front at the waist
 Hyperextend the middle finger of your left hand,
known as the pleximeter finger:
 Press its distal interphalangeal joint firmly on the surface
to be percussed Placing the pleximeter
 Avoid surface contact by any other part of the hand, finger for percussion of
the posterior thorax
because this dampens out vibrations
 Note that the thumb, 2nd, 4th, and 5th fingers are not
touching the chest
 Position your right forearm quite close to the surface,
with the hand cocked upward with the middle finger (plexor
finger) should be partially flexed, relaxed, and poised to strike
 With a quick sharp but relaxed wrist motion, strike the
pleximeter finger with the right middle finger, or plexor finger:
 Aim at your distal interphalangeal joint
 Strike with the tip of the plexor finger, not the finger pad
 Withdraw your striking finger quickly to avoid damping Percussion of the posterior thorax
the vibrations you have created
 Percuss one side of the chest and then the other at each
level
o Test for diaphragmatic excursion
 Determine the level of diaphragmatic dullness during
quiet respiration Locations for areas of percussion and
 Ask the client to exhale and hold breath auscultation (posterior thorax)

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 Holding the pleximeter finger above and parallel to

the expected level of dullness, percuss downward in Location and sequence of percussion for
progressive steps until dullness clearly replaces resonance DIAPHRAGMATIC EXCURCION
 Mark this site with a pen
 Ask client to inhale deeply and then hold breath
 Again, percuss downwards until the sound changes
from resonance to dullness
 Now, estimate the extent of diaphragmatic
excursion by determining the distance between the level of
dullness on full expiration and the level of dullness on full
inspiration
o Auscultate the lungs for breath sounds
 Place the patient in an upright position with a
slight forward tilt, head bent down and hands folded in
front of the waist of the patient
 Place the diaphragm of the stethoscope firmly against the patient’s skin in the
right location
 Ask patient to breathe deeply through an open mouth:
 Listen to at least one full breath in each location
 Note for the pitch, intensity, and duration of the expiratory and inspiratory sounds
 Perform this procedure following the location and sequence suggested for
percussion

Intensity
Pitch of Locations
Breath Duration of of
expiratory where heard
Sound sounds expirator
sound normally
y sound
Vesicular Inspiratory
sounds Relatively Over most of
Soft
last longer than low both lungs
expiratory ones.
Often in the
1st and
Inspiratory and
Broncho- 2ndintercostal
expiratory Intermedi Intermedia
vesicular spaces
sounds are ate te
anteriorly and
about equal
between the
scapulae
Bronchial Expiratory
sounds last Relatively Over the
Loud
longer than high manubrium
inspiratory ones
Tracheal Inspiratory and
Over the
expiratory Relatively
Very loud trachea in the
sounds are high
neck
about equal

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 Examine the patient’s anterior chest

o Have the patient lie flat on bed, with arms abducted
o A patient who is having difficulty breathing should be
examined in the sitting position or with the head of the bed
elevated to a comfortable level
o Observe the shape of the patient’s chest and the movement of
the chest wall and note for:
 Deformities or asymmetries
 Abnormal retraction of the lower intercostal spaces during
inspiration Palpation of the anterior thorax
 Local lag or impairment in respiratory movement

o Palpate the anterior chest for pulsations, masses, thoracic

tenderness and crepitus:
 Using the pads of your middle and index fingers, palpate
the anterior chest in a sequential manner

o Test for chest expansion

 Place your thumbs along each costal margin, your hands
along the lateral rib cage
 As you position your hands, slide them medially a bit to Testing for chest expansion
raise loose skin folds between your thumbs (Anterior Chest)
 Ask the patient to inhale deeply
 Observe how far your thumbs diverge as the thorax
expands, and feel for the extent and symmetry of
respiratory movement
o Assess for tactile fremitus
 Firmly place the ulnar aspect of the hand/palmar bases of
the fingers/ulnar aspect of a closed fist on the patient’s
chest Locations for TACTILE FREMITUS
 Ask the patient to repeat the words “ninety-nine” or “one-
one-one”
 Palpate and compare symmetric areas of the lungs
 Identify and locate any areas of increased, decreased, or
absent fremitus

o Percuss the anterior and lateral chest, again comparing

both sides
 The heart normally produces an area of dullness to the left
of the sternum from the 3rd to the 5th intercostal spaces
Locations for areas of percussion and
 Percuss the left lung lateral to it auscultation (anterior thorax)
 In a woman, to enhance percussion, gently displace the
breast with your left hand while percussing with the right
 Identify and locate any area of abnormal percussion note

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o Auscultate the anterior thorax for breath sounds

 Listen to the chest anteriorly and laterally as the patient breathes with mouth open,
somewhat more deeply than normal
 Compare symmetric areas of the lungs, using the pattern suggested for percussion
and extending it to adjacent areas as indicated
 Use the diaphragm of the stethoscope to listen to the breath sounds noting their
intensity and identifying any variations from normal vesicular breathing

ASSESSMENT OF THE BREAST

 Ask the patient to sit upright and
disrobe to the waist
o Inspect the breast and nipples of the
patient in four (4) views:
 Patient’s arms at sides
 Patient’s arms over the head
 Patient’s arms pressed against the
hips
 Patient leaning forward

 Palpate the patient’s breasts for

masses, tenderness, consistency and
nodules
o Ask the patient to lie in a supine
position
o Use the finger pads of the 2nd, 3rd, and 4th fingers, keeping the fingers slightly
flexed in palpating for the breast tissue
o Palpate in small, concentric circles at each examining point, if possible applying
light, medium, and deep pressure
o Examine the lateral portion of the breast
 Roll the drape to the patient’s side to
reveal the breast to be examined
 Ask patient to place her hand on her
forehead but keeping the shoulders
pressed against the bed or examining
table
 Begin palpation in the axilla, moving in
a straight line down to the bra line,
Palpation for the lateral portion of the breast
then move the fingers medially and using vertical strips method
palpate in a vertical strip up the chest
to the clavicle
 Continue in vertical overlapping strips until you reach the nipple, then reposition
the patient to flatten the medial portion of the breast

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o Examine the medial portion of the breast

 ask the patient to lie with her
shoulders flat against the bed or
examining table, placing her hand
at her neck and lifting up her elbow
until it is even with her shoulder
 Palpate in a straight line down
from the nipple to the bra line,
then back to the clavicle,
continuing in vertical overlapping
strips to the mid-sternum
Palpation for the medial portion of the breast
o Palpate each nipple, noting its using vertical strips method
elasticity

OTHER METHODS FOR CLINICAL BREAST EXAMINATION

Pie or Radial Spoke Pattern
 Imagine that the breast is broken into a series
of pie-type slices, with the nipple at the center.
 Start at the nipple, working outwards toward
the periphery of the slice that you're examining. Move
your hands a few centimeters along each time.
 When you are clearly no longer over the breast,
move to the next slice Radial Spoke Pattern

Circular Pattern
 Start palpation at the nipple
 Work along in circular fashion, moving in a
spiral towards the periphery

Circular Pattern

 Examine the lymph nodes draining the

breasts Nodes draining the breast tissues
o The patient should be in a seated position
for both the clavicular and axillary exam to
optimize deep palpation
o Palpation of the Supraclavicular and
Infraclavicular Nodes
 Using firm pressure in small circular
movements, palpate above and below the
clavicle
o Palpation of the axillary nodes:
 To examine the left axilla, ask the patient
to relax with the left arm down

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 Cup together the fingers of your right hand and reach as high as you can toward the
apex of the axilla
 Your fingers should lie directly behind the pectoral
muscles, pointing toward the midclavicle
 Press your fingers in toward the chest wall and
slide them downward, trying to feel the central
nodes against the chest wall
 Proceeding down the mid-axillary chest wall, lift
the tissue with the examining hand and gently
move the pads of the fingers medially and inside
the border of the pectoral muscle and the pectoral Palpation of the central nodes (axilla)
node chain
 Continue by palpating the subscapular nodes. Sweep back up and return to the
axilla with the palm facing laterally, feeling inside the muscle of the posterior
axillary fold
 Check the lateral nodes with the palm of the hand facing the humeral head

central subcapsular nodes

pectoral nodes lateral nodes
nodes

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Laoag City, Ilocos Norte

ASSESSMENT OF THE CARDIOVASCULAR SYSTEM

 As you begin the cardiovascular examination, review the Assessing for jugular
venous pressure
blood pressure and heart rate recorded during the General
Survey and Vital Signs at the start of the physical
examination
 Assess for jugular venous pressure(JVP)
o Position the patient in a supine position with the head of the
bed elevated at 300
o Turn the patient’s head slightly away from the side you are
inspecting
o 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
o Focus on the right internal jugular vein
 Look for pulsations in the suprasternalnotch, between the
attachments of the sternomastoid muscle on the sternum
and clavicle, or just posterior to the sternomastoid
o Identify the highest point of pulsation in the right
internal jugular vein
 Extend a long rectangular object or card horizontally from
this point and a centimetre ruler vertically from the
sternal angle, making an exact right angle
 Measure the vertical distance in centimeters above the Assessing for JVP
sternal angle where the horizontal object crosses the ruler
 This distance measured in centimeters above the sterna angle or the atrium, is the
JVP
 Assess for the carotid pulse
o Position the patient in a supine position with the head of the
bed elevated at 300
o Inspect the neck for carotid pulsations
o Place your left index and middle fingers on the right carotid
artery in the lower third of the neck, press posteriorly, and
feel for pulsations
o Press just inside the medial border of a well-relaxed Palpating for the carotid artery
sternomastoid muscle, roughly at the level of the cricoids cartilage

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o Slowly increase pressure until you feel a

maximal pulsation, then slowly decrease
pressure until you best sense the arterial
pressure and contour
o Try to assess for the following;
 Amplitude of the pulse
 Contour of the pulse wave
 Humming vibrations or thrills
o With the diaphragm of the stethoscope,
auscultate the carotid artery for bruits
 Assess for the heart
o Position the patient in a supine position with the Anatomic locations in cardiac assessment
head of the bed elevated at 300
o Inspect the precordium (the 2ndintercostal spaces;
the right ventricle; and the left ventricle, including
the apical impulse) for pulsations
o Palpate for the apical pulse (point of maximal
impulse) at the left ventricular area
 Use the finger pads of the fingers to palpate for the
Palpating for point of maximal impulse
apical pulse
 When examining a woman, it may be helpful to
displace the left breast upward or laterally as
necessary
 Once you have found the apical impulse, make finer assessments with your
fingertips, and then with one finger
 Note for the location, diameter, amplitude, and duration of the apical impulse
o Assess the right ventricular area
Palpating the right ventricular area
 Place the tips of your curved fingers in the 3rd,
4th, and 5th intercostal spaces and try to feel
the systolic impulse of the right ventricle
 If an impulse is palpable, assess its location,
amplitude, and duration
o Auscultate for heart sounds

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 Listen to the heart with the bell of your stethoscope in the following sequence:
 In the right 2nd intercostal space close to the
sternum;
 Along the left sternal border in each intercostal
space from the 2nd through the 5th;
 At the apex of the heart
 Note for normal heart sounds, presence of
abnormal heart sounds and cardiac murmurs
 Ask the patient to roll partly onto the left side
into the left lateral decubitus position, bringing the
left ventricle close to the chest wall Auscultation of the apical pulse in
left lateral decubitus position
 Listen for the apical pulse through placing the
bell of your stethoscope lightly on the location of the
apical impulse
Anatomic locations of hearts sounds

 Ask the patient to sit up, lean forward, exhale

completely, and stop breathing in expiration
 Listen for heart sounds through placing the diaphragm
of your stethoscope on the chest
o listen along the left sternal border and at the apex,
pausing periodically so the patient may breathe
o Note for normal heart sounds, presence of
abnormal heart sounds and cardiac murmurs

Auscultation of heart soundsin

sitting position

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Abdomen
ASSESSMENT OF THE ABDOMEN
 Make the patient comfortable in a supine position,
with a pillow for the head and perhaps another under the
knees Flat
Abdomen
o 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
Rounded
 Starting from your usual standing position at the Abdomen
right side of the bed, inspect the abdomen
o As you look at the contour of the abdomen and
watch for peristalsis, it is helpful to sit or bend down so
Scaphoid
that you can view the abdomen tangentially Abdomen
o Note for the skin of the abdomen, including the
presence of scars, striae, dilated veins, rashes and other Protuberant
lesions Abdomen
o Note for the contour of the abdomen
Contours of the abdomen
 Is it flat, protuberant, rounded or scaphoid?
 Do the flanks bulge or are there any local bulges?
 Is the abdomen symmetric?
 Are there visible organs or masses?
 Is there visible peristalsis? Locations for auscultation of abdominal
 Are there visible pulsations? bruits
o Inspect the umbilicus for its contour and
location
 Auscultate the abdomen for bowel sounds and
vascular sounds
o Place the diaphragm of your stethoscope
gently on the abdomen of your patient
o Listen for bowel sounds and note for their
frequency
 If bowel sounds appear to be absent, listen for
3 to 5 minutes before concluding that they are gone
o Auscultate for bruit in the epigastrium and in
each upper quadrant, over the iliac arteries and the femoral arteries
 Percuss the abdomen for amount and distribution of gas in the abdomen and as
well as to identify possible masses that are solid or fluid filled
o Percuss the abdomen lightly in all four quadrants to assess the distribution of
tympany and dullness
 Begin percussion in the RLQ moving upward to the RUQ, crossing over to the LUQ
and moving down to the LLQ
 Note any large dull areas that might indicate an underlying mass or enlarged
organ

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 Palpate the abdomen to determine tenderness, muscular resistance, and some

superficialorgans and masses
o Perform light palpation first to detect areas of tenderness and/or muscle guarding
 Keeping your hand and forearm on a horizontal plane, with fingers together and
flat on the abdominal surface, palpate the abdomen with a light, gentle, dipping motion
 Begin palpation in the RLQ moving upward to the RUQ, crossing over to the LUQ
and moving down to the LLQ
o Perform deep palpation of the abdomen
 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
 Assess for the LIVER
o Test for liver span
 Identify the lowerborder of the liver by
percussing starting at a level below the umbilicus,
midclavicular line, moving upward towards the liver
 Note where the sound changes from tympany
to dullness and mark with a pen
 Next, identify the upperborder of liver by
lightly percussing from lung resonance at Course of percussion for
midclavicular line down toward liver liver span
 Note where the sound changes from
resonance to dullness and mark with a pen
 Determine the liver span by measuring in
centimetres the distance between the two points
o Palpate the liver to trace the liver edge both
laterally and medially
 Place your lefthand behind the patient,
parallel to and supporting the right 11th and 12th
ribs and adjacent soft tissues below Palpating for the liver
 Place your righthand on the patient’s right
abdomen lateral to the rectus muscle, with your fingertips well below the lower border of
liver dullness
 Press left hand upward and right hand downward
 Ask the patient to take a deep breath and try to feel the liver edge as it comes down
to meet your fingertips
 If you feel it, lighten the pressure of your palpating
hand slightly so that the liver can slip under your finger
pads and you can feel its anterior surface

 Assess for the spleen

o Start assessment of the spleen through percussion
 In percussing the spleen, two techniques may be
used:
Negative splenic percussion

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 FIRST TECHNIQUE: Percuss the left lower

anterior chest wall, between lung resonance above and
the costal margin (an area termed Traube’s space)
o First percuss along the anterior axillary line
o If percussion note does not change from resonance
to dullness, percuss along the midaxillary line, between
lung resonance above and the costal margin
o As you percuss along the routes, note the lateral
extent of tympany
 Second technique: Check for a splenic percussion
sign
o Percuss the lowest intercos-talspace in the left
anterior axillary line and note for tympany
o Then ask the patient to take a deep breath, and
percuss again
o When spleen size is normal, the percussion note
usually remains tympanic Percussing the spleen (First
o Palpate the SPLEEN sign Technique)
 With your left hand, reach over and
around the patient to support and press forward
the lower left ribcage and adjacent soft tissue
 With your right hand below the left costal
margin, press in toward the spleen
 Begin palpation low enough so that you
are below a possibly enlarged spleen
 Ask the patient to take a deep breath
 Try to feel the tip or edge of the spleen as
it comes down to meet your fingertips
 Note any tenderness, assess the splenic Palpation of the
contour, and measure the distance between the spleen’s lowest point and the spleen while patient
is in supine position
left costal margin
 Repeat with the patient lying on the right side with legs somewhat flexed at hips
and knees
 Assess for the kidneys
o Palpate the left kidney
 Move to the patient’s left side
 Place your right hand behind the patient just below
and parallel to the 12th rib, with your fingertips just reaching
the costovertebral angle
 Lift, trying to displace the kidney anteriorly
 Place your left hand gently in the left upper quadrant,
lateral and parallel to the rectus muscle
 Ask the patient to take a deep breath and at the peak
of inspiration, press your left hand firmly and deeply into the
left upper quadrant, just below the costal margin, and try to “capture” Palpation of the spleen
the kidney between your two hands while patient is in lateral
position

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 Ask the patient to breathe out and then to stop

breathing briefly
 Slowly release the pressure of your left hand,
feeling at the same time for the kidney to slide back into
its expiratory position
 If the kidney is palpable, describe its size,
contour, and any tenderness
o Palpate the right kidney
 To capture the right kidney, return to the
patient’s right side
 Use your left hand to lift from in back, and your right hand to feel deep Palpation of the kidney
in the left upper quadrant
 Proceed as in palpation of the left kidney
o Assess for kidney tenderness
 Pressure from your fingertips through palpation may be enough to elicit
tenderness, but if not, use fist percussion
 Ask the patient to sit upright
 Place the ball of one hand in the costovertebral angle and strike it with the ulnar
surface of your fist
 Use enough force to cause a perceptible but painless jar or thud in a normal person
 To save the patient needless exertion, integrate this assessment with your
examination of the back
 Assess for the bladder
o Palpate for the bladder above the symphysis pubis for consistency and tenderness
o Use percussion to check for dullness and to determine how high the bladder rises
above the symphysis pubis
 Start from the symphysis pubis and percuss upwards
 Assess for the aorta
o Press firmly deep in the upper abdomen, slightly to the left of the midline, and
identify the aortic pulsations
o Measure in centimetres the width at which the pulsations are felt in the fingerpads

Palpation of the aorta

Palpation of the aorta

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Assessment of the Back

Assessment of the back may be integrated during assessment of the posterior chest.
However, it may also be performed separately depending on the overall condition of the
patient. When performed, it usually involves examination of the spine and hips.

ASSESSMENT OF THE SPINE

 Begin by observing the patient’s posture, including the position of the neck and
trunk, when entering the room
o Assess the patient for erect position of the head, smooth, coordinated neck
movement, and ease of gait
 Have the patient stand completely upright, in the patient’s natural standing
position – with feet together and arms hanging at the sides
 Stand at the side of the patient and inspect for cervical, thoracic and lumbar curves
 Stand behind the patient and inspect for the alignment of the spinal column,
alignment of the shoulders, the iliac crests, and the skin creases below the buttocks
 Ask the patient to bend down and reach for the toes
o Observe for the alignment of the spine and shoulders
 Palpate the spinous processes of each vertebra using your thumbs
o Palpate the facet joints that lie between the cervical vertebrae about
l inch lateral to the spinous processes of C2-C7
o Palpate downwards until the sacroiliac joint
 Test for the range of motion of the spine
o To assess for the ROM of the cervical spine:
 Ask the patient to perform flexion of the neck:
 Have the patient to touch his/her chin to the chest
 Ask the patient to perform extension of the neck:
 Have the patient look up at the ceiling
 Ask the patient to perform rotation of the neck:
 Have the patient turn his head side to side, looking directly over the shoulder
 Ask the patient to perform lateral bending of the neck:
 Have the patient tilt the head, touching each ear with the corresponding shoulder
o To assess for the ROM of the rest of the spinal column:
 Ask the patient to perform flexion of the spine:
 Have the patient bend forward to touch the toes
 Note for the smoothness any symmetry of movement, and the range of motion, and
the curve in the lumbar area
 Ask the patient to perform extension of the spine:
 Place your hand on the posterior superior iliac spine, with your fingers pointing
forward the midline, and ask the patient to bend backward as far as possible
 Ask the patient to perform rotation of the spine:
 Stabilize the pelvis by placing one hand on the patient’s hip and the other on the
opposite shoulder
 Then rotate the trunk by pulling the shoulder and then the hip posteriorly
 Repeat these maneuvers for the opposite side

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 Ask the patient to perform lateral bending of the spine

 Again stabilize the pelvis by placing your hand on the patient’s hip
 Ask the patient to lean to both sides as far as possible

ASSESSMENT OF THE HIP

 Inspection of the hip begins with careful observation of the patient’s gait on entering
the room
o Observe for the two phases of gait:
o Observe the gait for the width of the base, the shift of the pelvis , and flexion of the
knee
 Inspect the anterior and posterior surfaces of the hip for any areas of muscle
atrophy or bruising
 Palpate for the surface landmark of the hips
o On the anterior surface locate the iliac crest, the iliac tubercle, and the anterior
superior iliac spine
o On the posterior surface identify the posterior superior iliac spine, the greater
trochanter, the ischial tuberosity, and the sciatic nerve
 Ask the patient to lie in a supine position
 Observe the lumbar portion of the spine for slight lordosis and assess the length of
the legs for symmetry
 Palpate the hips for any abnormalities:
o Ask the patient to place the heel of the leg being examined on the opposite knee
o Palpate along the inguinal ligament, which extends from the anterior superior iliac
spine to the pubic tubercle
o Ask the patient to assume a lateral position with the hip flexed and internally
rotated
o Palpate the trochanteric bursa lying over the greater trochanter
o Then palpate for the ischio gluteal bursa
 Test for the range of motion of the hip
o Have the patient perform flexion of the hip
 With the patient supine, place your hand under the patient’s lumbar spine
 Have the patient turn his head side to side, looking directly over the shoulder
 Ask the patient to perform lateral bending of the neck
 Have the patient tilt the head, touching each ear with the corresponding shoulder
o To assess for the ROM of the rest of the spinal column:
 Ask the patient to perform flexion of the spine:
 Have the patient bend forward to touch the toes
 Note for the smoothness any symmetry of movement, and the range of
motion, and the curve in the lumbar area
 Ask the patient to perform extension of the spine:
 Place your hand on the posterior superior iliac spine, with your fingers
pointing toward the midline, and ask the patient to bend backward as far as possible
 Ask the patient to perform rotation of the spine:
 Stabilize the pelvis by placing one hand on the patient’s hip and the other on the
opposite shoulder

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 Then rotate the trunk by pulling the shoulder and then the hip posteriorly
 Repeat these maneuvers for the opposite side
 Ask the patient to perform lateral bending of the spine
 Again stabilize the pelvis by placing your hand on the patient’s hip
 Ask the patient to lean to both sides as far as possible

Extremities
Assessment of the extremities encompasses examination of the peripheral vascular
system and part of the musculoskeletal system.

ASSESSMENT OF THE UPPER EXTREMITIES

 Inspect both arms from the fingertips to the shoulders and note for
their size, symmetry, and any swelling, venous pattern, color of the skin
and nail beds, the texture of the skin;
 Observe the position of the hands in motion to see if movements are
smooth and natural
 Inspect the palmar and dorsal surfaces of the wrist and hand carefully for
swelling over the joints
 Observe the contours of the palm
 At the wrist, palpate the distal radius and ulna on the lateral and medial surfaces
o Palpate the groove of each wrist joint with your thumbs on the dorsum of the
wrist, your fingers beneath it
o Note any swelling, bogginess, or tenderness
 Palpate the radial pulse with the pads of your fingers on the flexor surface of the
wrist laterally
 Palpate for the anatomic snuffbox
o Have the patient laterally extend his/her thumb away from the hand
o Palpate for the hollowed depression just distal to the radial styloid process formed
by the abductor and extensor muscles of the thumb
 Palpate the eight carpal bones lying distal to the wrist joint, and then each of the
five metacarpals and the proximal, middle, and distal phalanges
 Compress the metacarpophalangeal joints (MCP joint) by squeezing the hand
from each side between the thumb and fingers
o Alternatively, use your thumb to palpate each MCP joint just distal to and on
each side of the knuckle as your index finger feels the head of the metacarpal in
the palm
o Note any swelling, bogginess, or tenderness
 Examine the fingers
o Palpate the medial and lateral aspects of each proximal interphalangeal (PIP)
joint between your thumb and index finger, again checking for swelling,
bogginess, bony enlargement, or tenderness
o Using the same techniques, examine the distal interphalangeal (DIP) joints
 Examine for the range of motion of the wrists and fingers

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 Have the patient perform flexion of the wrist:

 With the patient’s forearm stabilized, place the wrist in extension and place your
fingertips in the patient’s palm
 Ask the patient to flex the wrist against gravity, then against graded resistance
 Have the patient perform extension of the wrist:
 With the patient’s forearm stabilized, place the wrist in flexion and put your hand
on the patient’s dorsal metacarpals
 Ask the patient to extend the wrist against gravity, then against graded resistance
 Have the patient perform ulnar and radial deviation
 With palms down, ask the patient to move the wrists laterally and medially
o To test for the range of motion of the fingers:
 Have the patient perform flexion and extension of the fingers:
 Ask the patient to make a tight fist with each hand, thumb across the knuckles,
and then extend and spread the fingers
 Check for smooth, coordinated movement
 Have the patient perform abduction and adduction of the fingers
 Ask the patient to spread the fingers apart (abduction) and back together
(adduction)
 Check for smooth, coordinated movement
 To assess for the thumb:
 Ask the patient to move the thumb across the palm and touch the base of the 5th
finger to rest flexion and then to move the thumb back across the palm and away from
the fingers to test extension
 Next, ask the patient to place the fingers and thumb in the neutral position with
the lamp up, then have the patient move the thumb anteriorly away from the palm to
assess abduction and back down for adduction
 To test opposition, or movements of the thumb across the palm, ask the patient to
touch the thumb to each of the other fingertips
o Test for capillary refill
 Examine the elbow
o Support the patient’s forearm with your opposite hand so the elbow is flexed to
about 70o
o Identify the medial and lateral epicondyles and the olecranon process of the ulna
 Inspect the contours of the elbow, including the extensor surface of the ulna and
the olecranon process
o Feel for the epitrochlear nodes
 With the patient’s elbow flexed to about 90o and the forearm supported by your
hand, reach around behind the arm and feel in the groove between the biceps and triceps
muscles, about 3cm above the medial epicondyle
 Test for the range of motion of the elbow
o To test flexion and extension, ask the patient to bend and straighten the elbow
o With the patient’s arms at the sides and elbows flexed to minimize shoulder
movement, ask the patient supinate, or turn up the palms, and to pronate, or turn down
the palms
 Remember to test for the other arm

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ASSESSMENT OF THE LOWER EXTREMITIES

 Observe the gait for a smooth, rhythmic flow as the patient as the patient walks
 With the patient in sitting or lying position:
o Check the alignment and contours of the knees
 Look for loss of the normal hollows around the patella
o Observe any atrophy of the quadriceps muscles
o Inspect both legs for their symmetry, venous pattern, signs of venous enlargement,
pigmentation, rashes, scars, or ulcers, color and texture of the skin, the color of the
nail beds, and the distribution of hair on the lower legs, feet, and toes
 Ask the patient to sit on the edge of the examining table with the knees in flexion
o First review the important bony landmarks of the knee:
 Facing the knee, place your thumbs in the soft-tissue depressions on the either side
of the patellar tendon
 On the medial aspect, move your thumb upward and then downward and identify
the medial femoral condyle and the upper margin of the medial tibial plateau
 Trace the patellar tendon distally to the tibial tubercle
 Lateral to the patellar tendon, identify the lateral femoral condyle and the lateral
tibial plateau
 Locate the patella
 Palpate the ligaments, the borders of the menisci, and the bursae of the knee, paying
special attention to any areas of tenderness
 In the patella femoral compartment, palpate the patellar tendon and ask the patient
to extend the leg to make sure the tendon is intact
 Ask the patient to assume a lying position
 Palpate for the peripheral pulses
o For the femoral pulse , press deeply, below the inguinal ligament and about
midway between the anterior superior iliac spine and the symphysis pubis
o For the popliteal pulse:
 The patient’s knee should be somewhat flexed, the leg relaxed
 Place the fingertips of both hands so that they just meet in the midline behind the
knee and press them deeply into the popliteal fossa
o For the dorsalis pedis pulse, feel the dorsum of the foot (not the ankle) just lateral
to the extensor tendon of the great toe
o For the posterior tibial pulse, curve your fingers behind and slightly below the
medial malleolus of the ankle
o Note for the characteristics of pulsations
 Now assess the medial and lateral compartments of the tibio femoral joint
o Flex the patient’s knee to about 90o with the patient’s foot should rest on the
examining table
o Palpate the medial collateral ligament (MCL) between the medial femoral
epicondyle and the femur

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o Then palpate the cordlike lateral collateral ligament (LCL) between the lateral
femoral epicondyle and the fibular head
o Palpate the medial and lateral menisci along the medial and lateral joint lines
 Palpate the pre patellar bursa, and over the anserine bursa on the posteromedial
side of the knee between the medial collateral ligament and the tendons inserting
on the medial tibial and plateau
 Test for the range of motion of the lower extremities
o To test for the ROM of the medial collateral ligament (MCL, perform the abduction
stress test
 With the patient supine and the knee slightly flexed, move the thigh about 30o
laterally to the side of the table
 Place one hand against the lateral knee to stabilize the femur and the other hand
around the medial ankle
 Push medially against the knee and pull laterally at the ankle to open the knee joint
on the medial side (valgus stress)
o To test for the ROM of the lateral collateral ligament (LCL), perform the adduction
stress test
 With the thigh and knee in the same position, change your position so you can place
one hand against the medial surface of the knee and the other around the lateral
ankle
 Push medially against the knee and pull laterally at the ankle to open the knee joint
on the lateral side (varus stress)
o To test for the anterior cruciate ligament (ACL)
 Perform the anterior drawer sign
 With the patient supine, hips flexed and knees flexed to 90o and feet flat on the table,
cup your hands around the knee with the thumbs on the medial and lateral joint
line and the fingers on the medial and lateral insertions of the hamstrings
 Draw the tibia forward and observe if it slides forward (like a drawer) from under
the femur
 Compare the degree of forward movement with flat of the opposite knee
 Perform the lachman test
 Place the knee in 15o of flexion and external rotation
 Grasp the distal femur with one hand and the upper tibia with the other
 With the thumb of the tibial hand on the joint line, simultaneously move the tibia
forward and the femur back
 Estimate the degree of forward excursion
o To test for the Posterior cruciate ligament (PCL), perform the posterior drawer sign
 Position the patient and place your hands in the positions described for the anterior
drawer test
 Push the tibia posteriorly and observe the degree of backward movement in the
femur
o To test for the medial and lateral meniscus, perform the McMurray Test:
 With the patient supine, grasp the heel and flex the knee
 Cup your other hand over the knee joint with fingers and thumb along the medial
and lateral joint line
 From the heel, rotate the lower leg internally and externally

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 Then push on the lateral side to apply a valgus stress on the medial side of
the joint
 At the same time, rotate the leg externally and slowly extend it
 Examine the ankle
o Observe all surfaces of the ankles and feet, noting any deformities, nodules,
or swellings, and any calluses or corns
o With your thumbs, palpate the anterior aspect of each ankle joint, noting any
bogginess, swelling, or tenderness
o Palpate the heel, especially the posterior and inferior calcaneus, and the plantar
fascia for tenderness
o Palpate the metatarsophalangeal joints for tenderness
 Compress the forefoot between the thumb and fingers
 Exert pressure just proximal to the heads of the 1st and 5th metatarsals
o Palpate the heads of the five metatarsals and the grooves between them with your
thumb and index finger
 Place your thumb on the dorsum of the foot and your index finger on the plantar
surface
 Assess for the range of motion of the ankles
o To test for the ROM of the Ankle (Tibiotalar) Joint Dorsiflex and plantar flex the
foot at the ankle
o To test for the ROM of the Subtalar (Talocalcaneal) Joint, stabilize the ankle with
one hand , grasp the heel with the other, and invert and evert the foot
o To test for the ROM of the Transverse Tarsal Joint, stabilize the heel and invert and
evert the forefoot
o To test for the ROM of the Metatarsophalangeal joints, flex the toes in relation to
the feet

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Genitalia

ASSESSMENT OF THE MALE GENITALIA

 Don clean gloves

 Assess for the penis
o Position the patient in supine or standing position depending on the
preference of the patient
o Inspect the skin, prepuce, and the glans
 If prepuce is present, retract it or ask the patient to retract it
 Check the skin around the base of the penis for excoriations
or inflammation
 Compress the glans gently between your index finger above
and your thumb below
o Palpate the penis for any tenderness or induration
 Palpate the shaft of the penis between your thumb and first
two fingers, noting any induration
 Assess for the scrotum and its contents
o Inspect the scrotum for skin and scrotal contours
 Lift up the scrotum so that you can see its posterior surface
o Palpate each testis and epididymis between your thumb and first
two fingers
o Palpate each spermaticcord, including the vas deferens, between
your thumb and fingers from the epididymis to the superficial inguinal ring
 Inspect the inguinal and femoral areas carefully for bulges
 Palpate for any signs of inguinal hernia
o Using in turn your right hand for the patient’s right side and your
left hand for the patient’s left side, invaginate loose scrotal skin with your
index finger
o Start at a point low enough to be sure that your finger will have
enough mobility to reach as far as the internal inguinal ring if this proves
possible
o Follow the spermatic cord upward to above the inguinal ligament
and find the triangular slit like opening of the external inguinal ring
o With your finger located either at the external ring or within the
canal, ask the patient to strain down or cough
 Palpate for a femoral hernia by placing your fingers on the anterior thigh
in the region of the femoral canal
o Ask the patient to strain down again or cough

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ASSESSMENT OF THE FEMALE GENITALIA

 Prepare all the materials needed

 Have the patient lie in a supine position with the head and shoulders
slightly elevated, arms at sides or folded across chest to reduce tightening of
abdominal muscles
 Don gloves
 Drape the patient appropriately and then assist her into the lithotomy
position
o Help her to place first one heel and then the other into the stirrups
o Then ask her to slide all the way down the examining table until her
buttocks extend slightly beyond the edge
 Her thighs should be flexed, abducted, and externally rotated
at the hips
 A pillow should support her head
 Assess for sexual maturity of an adolescent patient
o Note for the character and distribution of pubic hair
 Inspect the patient’s external genitalia
o Seat yourself comfortably and inspect the
mons pubis, labia, and perineum
o Separate the labia and inspect the labia
minora, clitoris, urethral meatus and vaginal opening
or introitus

 Note any inflammation, ulceration,discharge,

swelling, or nodules
o If there is a history or an appearance of labial
swelling, check Bartholin’s glands
 Insert your index finger into the vagina near the
posterior end of the introitus
 Place your thumb outside the posterior part of the
labia majora
 On each side in turn, palpate between your finger and
thumb for swelling or tenderness
 Assess the support of the vaginal walls
o With the labia separated by your middle and
index fingers, ask the patient to strain down
Palpating the bartholin’s
gland

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 Assess the cervix

o Select a speculum of appropriate size and shape, and
lubricate it with warm water
o You can enlarge the vaginal
introitus by lubricating one finger
with water and applying
downward pressure at its lower
margin
o With your other hand (usually
the left), introduce the closed
speculum past your fingers at a
somewhat downward slope
Insertion of vaginal
speculum o To avoid placing pressure on the sensitive urethra: Angle at full
insertion
 When inserting the speculum, hold it at an angle
 And then slide the speculum inward along the posterior wall
of the vagina
o After the speculum has entered the vagina, remove your fingers
from the introitus
o You may wish to switch the speculum to
the right hand to enhance
maneuverability of the speculum
o Rotate the speculum into a horizontal
position, maintaining the pressure posteriorly,
and insert it to its full length
o Open the speculum carefully:
o Rotate and adjust the Entry angle speculum
until it cups the cervix and
brings it into full view
o Position the light until
you can visualize the cervix
well
o Inspect the cervix and
its os
 Note the color
of the cervix, its
position, the
characteristics of its
surface, and any Inspection of the cervix

ulcerations, nodules,
masses, bleeding,or discharge
 Assess the vagina
o Withdraw the speculum slowly while observing the vagina
o As the speculum clears the cervix, release the thumb screw and
maintain the open position of the speculum with your thumb
o Close the speculum as it emerges from the introitus, avoiding both
excessive stretching and pinching of the mucosa

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o During withdrawal inspect the vaginal mucosa, notingits color and

any inflammation, discharge, ulcers, or masses

Perform a bimanual examination of internal genitalia

 Lubricate the index and middle fingers of one of your gloved hands, and
from a standing position insert them into the vagina, again exerting
pressure primarily posteriorly

 Your thumb should be abducted, your ring and little fingers flexed into your
palm

 Pressing inward on the perineum with your flexed fingers causes little if any
discomfort and allows you to position your palpating
fingers correctly

 Note any nodularity or tenderness in the Palpation of the cervix and uterus
vaginal wall, including the region of the urethra
and the bladder anteriorly

 Palpate the cervix, noting its position, shape,

consistency, regularity, mobility, and
tenderness

 Palpate the uterus

Place your other hand on the abdomen about
midway between the umbilicus and the
symphysis pubis
While you elevate the cervix and uterus with your pelvic hand, press your
abdominal hand in and down, trying to grasp the uterus between your two
hands
 Note its size, shape, consistency, and mobility, and identify
any tenderness or masses
 Now slide the fingers of your pelvic hand into the anterior
fornix and palpate the body of the uterus between your hands

Palpate each ovary

Place your abdominal hand on the right lower quadrant, your pelvic hand
in the right lateral fornix
 Place your abdominal hand on the right lower quadrant, your
pelvic hand in the right lateral fornix

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 By moving your hands slightly, slide the adnexal structures

between your fingers, if possible, and note their size, shape,
consistency, mobility, and tenderness
 Repeat the procedure on the other side
 Assess the strength of the pelvic muscles
o Withdraw your two fingers slightly, just clear of the cervix, and
spread them to touch the sides of the vaginal walls
o Ask the patient to squeeze her muscles around them as hard and
long as she can

Anus, Rectum and Prostate

ASSESSMENT OF ANUS, RECTUM AND PROSTATE

 Ask the patient to lie on his left side with his buttocks close to the
edge of the examining table near you.
 Drape the patient appropriately and
adjust the light for the best view Inspecting the sacrococcygeal and perianal area

 Glove your hands and spread the buttocks

apart
 Inspect the sacrococcygeal and perianal
areas for lumps, ulcers, inflammation, rashes, or
excoriations
 Examine the anus and rectum
o Lubricate your gloved index finger,
explain to the patient what you are going to do, and tell him that the
examination may make him feel as if he were moving his bowels but that
he will not do so
o Ask him to strain down
o Inspect the anus, noting
any lesions
o As the patient strains,
place the pad of your lubricated
and gloved index finger over the
anus
o As the sphincter relaxes,
gently insert your fingertip into
the anal canal, in a direction
pointing toward the umbilicus
 Insert your finger
into the rectum as far as possible
 Rotate your hand clockwise to palpate as much of the rectal
surface as possible on the patient’s right side, then counterclockwise
to palpate the surface posteriorly and on the patient’s left side

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 Note any nodules, irregularities, or induration

o Then rotate your hand further counterclockwise so that your finger

can examine the posterior surface of the prostate gland
o Tell the patient that you are going to feel his prostate gland, and
that it may make him want to urinate but he will not do so
o Sweep your finger carefully over the prostate gland, identifying its
lateral lobes and the median sulcus between them
 Note the size, shape, and consistency of the prostate, and
identify any nodules or tenderness
o If possible, extend your finger above the prostate to the region of the
seminal vesicles and the peritoneal cavity
 Note nodules or tenderness
o Gently withdraw your finger, and wipe the patient’s anus or give
him tissues to do it himself

ASSESSMENT OF THE ANUS AND RECTUM IN FEMALES

 Ask the patient to lie on his left side with his buttocks close to the edge of
the examining table near you
 Drape the patient appropriately and adjust the light for the best view
 Glove your hands and spread the buttocks apart
 Inspect the sacrococcygeal and perianal areas for lumps, ulcers,
inflammation, rashes, or excoriations
 Examine the anus and rectum
o Lubricate your gloved index finger, explain to the patient what you
are going to do, and tell him that the examination may make him feel as if
he were moving his bowels but that he will not do so
o Ask her to strain down and inspect the anus, noting any lesions
o As the patient strains, place the pad of your lubricated and gloved
index finger over the anus
o As the sphincter relaxes, gently insert your fingertip into the anal
canal, in a direction pointing toward the umbilicus
 Note for the sphincter tone, any tenderness, induration,
irregularities or nodules
 Insert your finger into the rectum as far as possible
 Rotate your hand clockwise to palpate as much of the rectal
surface as possible on the patient’s right side, then counterclockwise
to palpate the surface posteriorly and on the patient’s left side
 Note any nodules, irregularities, or induration
o Gently withdraw your finger, and wipe the patient’s anus or give
him tissues to do it himself
o Note the color of any fecal matter on your glove, and test it for occult
blood

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QUIZ 6 & 7
TIME TO CHECK WHAT YOU'VE
LEARNED IN THIS MODULE!
FURTHER INSTRUCTION
REGARDING YOUR EXAM WILL BE
ANNOUNCED ON CANVAS
ANNOUNCEMENT TAB AND ON
YOUR GROUP CHAT.

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