Post on 14-Apr-2018
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o Abdomen and femoral arteries, before palpation
or percussion
o Bowel sounds start RLQ then to RUQ, LUQ,
LLQ—irregular, gurgling and high-pitched. 5-
30X/min
Hyperactive—loud, high pitched
Hypoactive—slow and sluggish—bowel
obstruction
Absent bowel sound---paralytic ileus
o ***Use BELL***Vascular sounds start with
aortic directly under xiphoid process mid chest
down a tad & left then to right for renal arteries
down more left and right more for iliac arteries
down & left to right for femoral arteries.
o Listening for –should be no
Bruit – pulsatile and blowing
Friction rub—rough grating sound –organs
rubbing together
• Palpate
o Abdomen systematically
• Percussion
o Abdomen systematically, including percussion
of organs
Start in RLQ & percuss thru all remaining
quadrants
Normal sounds over abdomen--- Tympany, a
loud hollow sound
Dullness heard of liver & spleen
Dullness in LLQ=presence of stool in colon
ask about last BM
o Percuss for liver dullness—Right side
Define the lower edge of liver
dullness in the mid-clavicular
line, starting at a level below the
umbilicus
Define the upper edge of liver
dullness in MCL, starting in the
area of lung resonance
Gently displace a woman’s
breast as necessary
Measure in centimeters with a
ruler the vertical span of liver
dullness in the MCL
o Percuss for splenic dullness—Left side
relax
Percuss along the L lower chest
wall between the lung resonance
above and the costal margin
moving laterally
Ask the patient to take a deep
breath and percuss again in this
area
Dull sound=splenomegaly
o
• Musculoskeletal system and extremities
• Assess
o ROM All extremities
o Strength all extremities Gross
• Palpate
o Skin temp & edema
o Pulsesbilateral radial, femoral, popliteal,
posterior tibal, and dorsalis pedis
• Spine and gait
• Inspect
• Spine contour, position, motion
o Inspect scapulae, spine, back and hips as the
patient bends forward, backward and from side to
side
o Should have full ROM, easy flexibility and signs
of scoliosis or varicosities
o Detects musculoskeletal abnormalities• Observe
o Barefoot gait
o Heel walk, toe walk, and heel to toe walk
Look straight ahead and not at floor
Should have steady gait, good balance and no
signs of muscle weakness or pain while walking
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Checks cerebellum and motor system &
vertebral disk problems
• Neurological system
• Assess
• Deep tendon reflexes
• Biceps
o Pt arm slightly flexed w/ palm up a little; myhand around elbow w/ thumb pressing in on bicep
tendon, briskly tap my thumb w/ pointed side of
reflex hammer or stethoscope.
• Triceps
• Patellar
• Achilles
• Brachoradialis
• Pathological reflex
• Babinski or clonus
• Neurosensory loss, face and all four extremities
• Cerebellar function using upper and lower
extremities
• Finger-nose
o Test coordination and equilibrium. “aka” pass
point test
o Pt. in sitting position
o Eyes openExtend both arms straight out then
touch tip of nose w/ right and then left index finger
then return to extended position.
o Eyes closedRepeat above
• Rapid, Alternating movements
o Alternate movements of both palms from down
to up from slower to faster pace.
o Motor neuron weakness
• Proprioception
o Romberg
Patient stand straight up w/ feet together and
arms at sides with eyes open
Stand next to pt. prevent fall—observe for
swaying
Have pt. close both eyes w/o changing position
Should have steady stance with minimal
weaving
Assess coordination and equilibrium (cranial
nerve 8)
Possible disease of posterior columns of spinal
cord
o Position sense in lower extremities bilaterally
Posterior thorax
1) The patient should be sitting with the posterior
thorax exposed.
2) The doctor assumes a midline position behind the
patient
3) Inspect the cervical, thoracic and upper lumbar spine
(you will check for ROM of the thoracic and lumbar
spine towards the end of the complete physical when
the patient is standing up)
4) Palpate the spinous processes of each vertebra for
tenderness with your thumb or by thumping with theulnar surface of your fist (Bates p 503)
5) Assess for costovertebral tenderness
a) Place the ball of one hand in the costovertebral
angle and strike it with the ulnar surface of your
fist (Bates p 344)
6) Inspect the shape and movement of the chest wall
a) Place your thumbs at the level of the 10th ribs
with your fingers loosely grasping the rib cage
and gently slide them medially.
b) Ask the patient to inhale deeply and observe
whether your thumbs move apart symmetrically
Posterior thorax – lung exam
1) Examination techniques MUST be performed on
bare skin
2) Palpate for tactile fremitus
a) Use either the ball of your palm or the ulnar
surface of your hand for palpation
b) Ask the patient to repeat the words “ninety-nine”
c) You may palpate one side at a time or use both
hands simultaneously to compare sidesd) Palpate in four locations on both sides of the
chest and compare (Bates p 223)
3) Percuss
a) Ask the patient to keep both arms crossed in
front of the chest
b) Press the DIP joint of the left middle finger
firmly against the chest wall, avoiding contact
with other fingers (Bates p 223)
c) Strike this DIP joint with the tip of the right
middle finger, swinging from the wrist
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d) Percuss in seven areas on each side (Bates p
225)
4) Auscultate for breath sounds
a) Instruct the patient to breathe deeply through an
open mouth
b) Listen with the diaphragm of the stethoscope in
the same seven areas in which you percussed
Anterior thorax—lung exam1) Examination techniques MUST be performed on
bare skin
2) The patient may be either sitting or supine. The
drape should be adjusted to allow exposure of the
area being examined
3) Inspect the shape of the patient’s chest and
movement of the chest wall (NB when moving from
the post chest when you have completed
auscultating, it is acceptable to auscultate the ant
chest before inspection or palpation)
4) Palpate for tactile fremitus
a) Use the ball of the palm or ulnar surface of thehand to palpate in 3 areas on each side of the
anterior chest (Bates p 231)
5) Percuss the anterior and lateral chest, comparing
sides, in 6 areas on each side (Bates p 231)
a) Displace a woman breast with your left hand or
ask her to move her breast for you
6) Auscultate the anterior chest, comparing sides in the
6 areas on each side where you percussed.
EXTENDED EXAM TECHNIQUES FOR THE
THORAX AND LUNGS1) Percussion for diaphragmatic excursion (Bates, p
226)
a) Determine the level of diaphragmatic dullness
during quiet respiration
b) Have the patient take in a deep breath and hold it
and again determine the level of dullness
c) Have the patient exhale completely and hold it
and determine the level of dullness
d) Measure the distance between the levels of
dullness at maximal exhalation and maximal
inhalation
2) Egophonya) Ask the patient to say “ee” while auscultating
over the lung
3) Whispered pectoriloquy
a) Ask the patient to whisper “one-two-three” or
“ninety-nine” while listening over the lung
Axillae – examination of the axillae can be performed at
the present juncture. It is sometimes performed at the
end of the exam, or as part of a breast exam in a female
1) Inspect the skin of each axilla (Bates, pp 310-311)
2) Palpation L axilla
a) Ask the patient to relax with the L arm down
b) Support the L wrist or hand with your left hand
c) Cup together the fingers of your right hand and
reach as high as you can toward the apex of the
axilla
d) Press your fingers toward the chest wall and
slide down to feel potential LN
e) To palpate for lateral group of LN, feel along theupper humerus
3) Palpation R axilla – reverse your hands and follow
the steps above
Cardiovascular
1) The patient should be supine with the upper body
raised by elevated the table to about 30°. The drape
should be arranged to expose the precordium.
EXAM TECHNIQUES MUST BE PERFORMED
ON BARE SKIN.
2) The examiner should stand tat the patient’s right side
3) Inspect the precordiuma) look for apical impulse
b) look for any other movements
4) Palpate for precordium
a) Use the palmar surfaces of several fingers to
locate the PMI—can switch to one fingertip
when located
i) Displace a woman’s breast upward or
laterally, or ask her to do this for you
ii) Note location of PMI, amplitude and
duration
b) Palpate for the RV impulse along the lower leftsternal border
5) Auscultation of the heart
a) Listen to the heart with the diaphragm of your
stethoscope in the R 2nd ICS, L 2nd ICS, L 3rd or
4th ICS, and the lower left sternal border (5th
ICS) and at the apex (may also start at the apex
and proceed to the base of the heart)
b) Listen to the heart with the bell of your
stethoscope in the same five listening areas
6) Inspect the neck for jugular venous pulsations
a) Turn the patient’s head slightly away from the
side you are inspecting (Bates p 267)b) Raise or lower the bed until you identify the
pulsations
c) Identify the highest point of pulsation
i) Measure the vertical distance of this point
above the sternal angle
7) Inspect the neck for carotid pulsations
8) Palpate the carotid pulsation
a) Place your left index and middle fingers (or
thumb) on the right carotid artery
i) Note amplitude and contour of the pulse
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wave
ii) Never palpate both carotids simultaneously
b) Use your right fingers or thumb to palpate the
left carotid artery
9) Auscultate the carotid arteries for bruits with the bell
of the stethoscope
a) Ask the patient to take a deep breath and hold it
to eliminate breath sounds
EXTENDED EXAM TECHNIQUES FOR THE
CARDIOVASCULAR EXAM
1) Steps for assessing the JVP (Bates, p 267)
2) Use of left lateral decubitus position to enhance
apical sounds (Bates, p 271)
3) Use of sitting position to enhance the murmur of AI
4) Timing of S3 and S4 (Bates, p 280)
5) Attributes of classical heart murmurs of SEM, AS,
AI, MR, MS (Bates, p 281 and Tables)
Abdomen
1) The patient should be in a supine position with armsat side or folded across the chest
2) The drapes should be arranged to expose the
abdomen from above the xyphoid process to the
symphysis pubis.
3) Approach the patient from his right side
4) Inspect the abdomen
5) Auscultate the abdomen as the next step in the exam
after inspection
a) Place the diaphragm of the stethoscope gently on
the abdomen
b) Listen for bowel soundsi) Listening in one spot is sufficient
c) Listen for an aortic bruit on the midline just
above the naval
6) Percuss the abdomen lightly in four quadrants and in
the suprapubic and epigastric areas
Percuss for liver dullness
Define the lower edge of liver dullness in the mid-
clavicular line, starting at a level below the
umbilicus
Define the upper edge of liver dullness in MCL,
starting in the area of lung resonance
Gently displace a woman’s breast as necessaryMeasure in centimeters with a ruler the vertical span
of liver dullness in the MCL
Percuss for splenic dullness
Percuss along the L lower chest wall between the
lung resonance above and the costal margin moving
laterally (Bates p 341)
Ask the patient to take a deep breath and percuss
again in this area
7) Palpate the abdomen lightly in four quadrants
a) Use a gentle, light dipping motion (Bates p 335)
8) Palpate the abdomen deeply in all four quadrants
a) Use a firmer dipping motion
9) Palpate for the liver edge
a) Place your R hand on the right abdomen lateral
to the rectus muscle, beginning more than 3
fingerbreadths below the costal margin
b) Ask the patient to take in a deep breath
c) Palpate upwards trying to feel the descending
liver edge, using a rocking motioni) May also use the “hooking technique”
described in Bates p 340
10) Palpate for a spleen tip
a) Reach over and around the patient with your left
hand to support and press forward the lower left
rib cage
b) Press inward towards the spleen with your right
hand, beginning at least 3 finger breadths below
the L costal margin
c) Ask the patient to take in deep breaths, trying to
feel the spleen tip as it comes down to meet your
fingertips.11) Palpates for aorta by pressing deeply with one hand
on each side of the aorta (Bates, p 344)
12) Palpate for the superficial inguinal lymph nodes
(Bates, p 452)
13) Palpate for both femoral artery pulses
a) Press deeply below the inguinal ligament (Bates,
p 452)
EXTENDED EXAMINATION TECHNIQUES FOR
THE ABDOMEN
1) Palpation for the kidneysa) Left Kidney (Bates, p 343)
i) Move to the patient’s left side
ii) Place your R hand behind the patient, just
below and parallel to the 12 th rib with your
fingertips reaching the costovertebral angle,
and lift, trying to displace the kidney
anteriorly
iii) Place your L hand in the LUQ, lateral and
parallel to the rectus muscle
iv) Ask the patient to take a deep breath
v) At the peak of inspiration, press your left
hand firmly and deeply into the LUQ justbelow the costal margin and try to capture
the kidney between your two hands
vi) Ask the patient to breathe out and then hold
it, while you release the pressure of your L
hand, allowing the kidney to slide back into
its expiratory position
b) Right kidney
i) Move to the patient’s right side
ii) Switch the positions of your hands and
proceed as above
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2) Assess for possible ascites (Bates, p 345-347)
a) Test for shifting dullness
i) With the patient supine, map the borders of
tympany and dullness, by percussing
outward from the central area of tympany
ii) Ask the patient to turn onto one side and
percuss and mark the borders of dullness
one more
b) Test for a fluid wavei) Ask the patient or an assistant to press the
edges of both hands firmly down the midline
of the belly
ii) Tap one flank sharply with your fingertips
and feel on the opposite flank for an impulse
transmitted through the fluid
c) Balottement of organs in ascitic fluid
i) Make a brief jabbing movement with the
fingers of one hand into the protuberant
abdomen towards the anticipated organ
3) Psoas sign (Bates, p 348)
a) Place your hand just above the patient’s rightknee and ask the patient to raise that thigh
against your hand
4) Obturator sign (Bates, p 348)
a) Flex the patient’s right thigh at the hip, with the
knee bent, and rotate the leg internally at the hip
Upper extremity—MSK and Partial Neurological
(these maneuvers must be repeated on both upper
extremities
1) Inspect the hands, including each finger, its skin and
joints, and nailsa) Palpate any abnormal joints
2) Inspect the wrist
3) Palpate the distal radius and snuff box; palpate the
distal ulna
4) Palpate the radial pulse on the flexor surface of the
wrist, laterally
a) Compare the pulses in both arms
5) Check ROM of the fingers
a) Ask the patient to make a tight fist with each
hand
b) Extend and spread the fingers
c) Ask the patient to spread the fingers apart andback together
d) Ask the patient to move the thumb across the
palm and touch the base of the 5th finger, and
then back across the palm and away from the
fingers
e) Have the patient touch the thumb to each of the
other fingertips
6) Check ROM of the wrist (Bates p 499)
a) Flexion
b) Extension
c) Ulnar and radial deviation
7) Check ROM of the elbow (Bates p 497)
a) Flexion and extension: ask the patient to bend
and straighten the elbow
b) Pronation and supination: with arms at his side,
and elbows flexed, ask the patient to turn the
palms up and then down
8) Palpate for epitrochlear lymph nodes (Bates p 451)
a) Flex the elbow to 90°b) Palpate in the groove between the biceps and
triceps
9) Inspect the shoulder (Bates, p 492)
10) Palpate the shoulder (Bates, p 493)
a) Locate the acromion process and the
acromioclavicular joint
b) Locate the greater tubercle of the humerus
c) Locate the coracoid process of the scapula
11) Check ROM of the shoulder (Bates, p 493)
a) Watch for smooth, fluid movement as you stand
in front of the patient and ask:
i) Raise the arms to shoulder level (abduct)with palms facing down
ii) Raise the arms to a vertical position above
the head with the palms facing each other
iii) Place both hands behind the neck with
elbows out to the side (external rotation and
abduction)
iv) Place both hends behind the small of the
back (internal rotation and adduction)
12) Test Muscle strength in the upper extremity (Bates
pp 574-575). You must compare sides
a) Test grip—ask the patient to squeeze two of your fingers as hard as possible and not let them
go
b) Test finger abduction—position the patient’s
hand with palms down and fingers spread. Try
to force the fingers together
c) Test opposition of the thumb—the patient
should try to touch the little finger with the
thumb against your resistance
d) Test extension of the wrist by asking the patient
to make a fist and resist you pulling it down
e) Test flexion and extension of the elbow by
having the patient pull and push against yourhand
EXTENDED EXAM OF JOINTS OF THE UPPER
EXTREMITY
1) Shoulder (Bates, Table 15-4, page 526-527)
a) Acromioclavicular joint (Bates, p 494)
i) Palpate and compare both joints for swelling
or tenderness
ii) Adduct the patient’s arm across the chest
b) Rotator cuff (Bates, p 494)
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i) With the patient’s arm at the side, palpate
the three “SITS” muscles that insert of the
greater tuberosity of the humerus
ii) Passively extend the shoulder by lifting the
elbow posteriorly
iii) Once again palpate the SITS muscle
insertions
iv) Check the “drop arm” sign by asking the
patient to fully abduct the arm to shoulderlevel and lower it slowly
c) Bicipital tendonitis (Bates, p 495)
i) Rotate the arm and forearm externally and
locate the biceps muscle distally near the
elbow
ii) Track the muscle and its tendon proximally
into the bicipital groove along the anterior
aspect of the humerus
iii) Check for tendon tenderness
d) Glenohumeral joint
i) Inspect the shoulder from above
ii) Palpate the capsule and synovial membranebeneath the ant and post acromion
2) Elbow (Bates, p 496 and Table 15-5, p 528)
a) Lateral epicondylitis (tennis elbow)
i) Pain and tenderness at the lat epicondyle and
possibly in the extensor muscles close to it
ii) Pain increases when the patient tries to
extend the wrist against resistance
b) Medial epicondylitis (pitcher’s, golfer’s or Little
League elbow)
i) Tenderness at the medial epicondyle
ii) Wrist flexion against resistance increases thepain
c) Ulnar neuropathy at elbow
3) Wrist (Bates, p 497)
a) Carpal tunnel syndrome
i) Pain and numbness on the ventral surface of
the first three digits, especially at night, due
to median nerve compression in the carpal
tunnel
ii) Weakness of abduction of the thumb
iii) Tinel’s sign – percuss lightly over the course
of the median nerve in the carpal tunnel
4) Fingers (Bates, Table 15-6, p 530-531)a) Trigger finger
b) Felon
c) Paronychia
d) Flexor tendon sheath
e) Ganglion
Lower extremity—MSK and Partial Neurological
(these maneuvers must be repeated on both lower
extremities
1) The patient may be sitting or lying down and draped
so that the external genitalia are covered with the
legs fully exposed during the exam
2) Inspect both feet and ankle—compare sides
3) Palpate the feet and ankles (Bates, p 517)
a) Assess for pedal edema—press firmly with your
thumb over the dorsum of the foot, behind each
medial malleolus and over the shins (Bates, p
455)
b) Palpate the anterior aspect of each ankle jointc) Palpate the heel, especially the post and inf
calcaneus
d) Palpate the MTP joints
e) Palpate the heads of the five metatarsals
4) Palpate for the peripheral pulses of the legs
a) Dorsalis pedis—feel the dorsum of the foot just
lateral to the extensor tendon of the great toe
b) Posterior tibial—feel below the medial
malleolus of the ankle
5) Check ROM of the ankle (Bates, p 518)
a) Dorsiflex and plantar flex the foot at the ankle
b) Invert and evert the footc) Flex the toes
6) Inspect the knee for alignment and contours
7) Palpate the knee with the knee in flexion (Bates, p
511-513)
a) Identify the medial femoral condyle and the
medial tibial plateau
b) Identify the tibial tubercle
c) Identify the lateral femoral condyle and lateral
tibial plateau
d) Identify the patellar tendon and ask the patient to
extend the lege) Palpate the medial collateral and lateral
collateral ligaments and menisci
f) Feel for swelling above and to the sides of the
patella
g) Check the prepatellar, anserine and popliteal
bursae (Bates p 513)
8) Check ROM of the knee (Bates p 515)
a) Ask the patient to flex and extend the knee while
sitting (or by asking the patient from a standing
position to squat and then stand up again
b) Check internal and external rotation by asking
the patient to rotate the foot medially andlaterally
9) Inspect the hip by observing the patient’s gait at
some time during the exam (Bates p 506)
10) Palpate the surface landmarks of the hip
a) Anterior surface: locate the iliac crest, iliac
tubercle and anterior superior iliac spine
b) Posterior surface: locate the posterior superior
iliac spine, the greater trochanter and the ischial
tuberosity
11) Check ROM of the hip (Bates, p 509-510)
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a) Flexion—with the patient supine, ask him to
bend each knee in turn up to the chest and pull it
firmly against the abdomen
b) Abduction—grasp the ankle and abduct the
extended leg until you feel the iliac spine move
c) Adduction—hold one ankle and move the leg
medially across the body and over the opposite
extremity
d) Rotation—flex the leg to 90°
at hip and knee;stabilize the thigh with one hand, grasp the ankle
with the other and swing the lower leg, medially
and laterally
12) Check muscle strength in the LE (Bates, p 576-578)
a) Test flexion at the hip—place your hand on the
patient’s thigh and asking the patient to raise the
leg against your hand
b) Test adduction at the hips—place your hands
firmly on the bed between the patient’s knees.
Ask the patient to bring both legs together
c) Test 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
d) Test extension at the hips—have the patient push
the posterior thigh down against your hand
e) Test extension at the knee—support the knee in
flexion and ask the patient to straighten the leg
against your hand
f) Test 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 legg) Test dorsiflexion and plantar flexion at the ankle
—ask the patient to pull down and push down
against your hand
EXTENDED EXAM OF JOINTS OF THE LOWER
EXTREMITY
1) Knee
a) Prepatellar bursitis (housemaid’s knee) –
swelling over the patella is suggestive
b) Patellar tendonitis – tenderness over the patellar
tendon
c) Chondormalacia – pain with patellar movementduring quadriceps contraction is suggestive
d) Pes anserine bursitis – swelling postero-medial
to the tibial tubercle (usually from running)
e) Abduction Stress Test for the MCL (Bates, p
515)
f) Adduction Stress Test for the LCL (Bates, p
515)
g) Anterior Drawer Sign for the ACL (Bates, p
515)
h) Lachman Test (Bates, p 516)
i) Posterior Drawer sign (Bates, p 516)
Neurological – some parts of the neurological exam
have been woven into exam of the head and neck and
extremities (i.e. Cranial Nerve exam and motor testing).
The remaining components of the neurological exam are
covered here
1) Mental Status Exam
a) Level of alertnessb) Language function (fluency, comprehension,
repetition and naming)
c) Memory (short-term and long-term
d) Calculation
e) Visuospatial processing
f) Abstract reasoning
2) Motor function
a) Gait – see below
b) Coordination
i) Fine finger movements
ii) Rapid alternating movements and point-to-
point – described below undercerebellar/coordination
c) Involuntary movements
d) Pronator drift (Bates, p 582)
e) Tone – resistance to passive manipulation
f) Bulk
g) Strength – incorporated into regional exams of
LE and UE
3) Reflexes (Bates, p 588-591)
a) Biceps reflex (C5, C6) — with patient’s arm
partially flexed at the elbow and palm down,
place your thumb or finger firmly on the bicepstendon and strike with reflex hammer
b) Triceps reflex (C6, C7) – flex the patient’s arm
at the elbow with palm towards the body and
pull it across the chest. Strike the triceps tendon
above the elbow
c) Brachioradialis (C5, C6) –The patient’s hand
should rest on the abdomen or the lap with the
forearm partly pronated. Strike the radius about
1-2 inches above the wrist
d) Knee (Patellar) reflex (L2, L3, L4) – patient may
be either sitting or supine with knee flexed. Tap
the patellar tendon just below the patellae) Ankle (Achilles) reflex (S1) – dorsiflex the foot
at the ankle and strike the Achilles tendon
f) Plantar (Babinski) response (L5, S1) – with a
key or the tip of the shaft of a reflex hammer,
stroke the lateral aspect of the sole from the heel
to the ball of the foot, curving medially across
the ball
4) Sensory (Bates, p 583-584)
a) Pain – Create a sharp from a broken tongue
blade
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i) Compare symmetrical areas on the two sides
of the body, including arms, legs and trunk
ii) Compare the distal with the proximal areas
of the extremities
iii) Vary the pace of your testing and
occasionally substitute the blunt end for the
point, while asking “Is this sharp or dull?”
or “Does this feel the same as this?”
b) Light touch – using a fine wisp of cotton, touchthe skin lightly, avoiding pressure
i) Ask the patient to respond whenever a touch
is felt.
ii) Compare one area with another
c) Vibration – Use a low-pitched tuning fork (128
Hz)
i) Set the fork vibrating and place it firmly
over a DIP of a finger and of the great toe
ii) Ask what the patient feels
iii) If vibration sense is impaired, move to more
proximal bony prominences
d) Joint position sensei) Grasp the patient’s big toe, holding it by its
sides and pull it away from the other toes so
as to avoid friction.
ii) Demonstrate “up” and “down”
iii) With patient’s eyes closed ask him to
identify up and down movements
iv) Compare sides
v) Move more proximally if joint position is
impaired
vi) Test JPS in the UE by moving a finger joint
e) Proprioception (Bates, p 585)5) Cerebellar/Coordination (Bates, p 578-580)
a) Rapid alternating movements
i) UE – Show patient how to strike one hand
on the thigh, first with the palm, then with
the back of the hand. Have the patient repeat
these alternating movements as rapidly as
possible. Repeat with opposite hand
(1) OR Show the patient how to tap the
distal joint of the thumb with the tip of
the index finger as rapidly as possible.
Have the patient perform the action.
Check the opposite hand
ii) LE – ask the patient to tap your hand as
quickly as possible with the ball of each foot
in turn
b) Point-to-point movements
i) UE – ask the patient to touch your indexfinger and then his nose alternately several
times. Move your finger about.
ii) LE – Ask the patient to place one heel on the
opposite knee and then run it down the shin
to the big toe. Repeat on the other side
6) Gait
a) Ask the patient to walk across the room, then
turn and come back
b) Walk heel-to-toe in a straight line
c) Walk on toes then on heels
7) Romberg Test
a) The patient should first stand with feet togetherand eyes open and then close both eyes for 20-
30 secs without support
Back
1) ROM (Bates, p 505)
a) Flexion – with patient standing, ask him to bend
forward to touch the toes
b) Extension – place your hand on the posterior
superior iliac spine and with your fingers
pointing towards the midline, ask the patient to
bend backward as far as possiblec) Lateral bending – ask the patient to lean to both
sides as far as possible
NOTE THAT BREAST, GENITAL AND RECTAL
EXAMS HAVE NOT BEEN INCLUDED IN THIS
CHECKLIST
Nursing Assessment in Tabular Form
ASSESSMENT FINDINGS
Integumentary
• Skin When skin is pinched it goes to previous state immediately (2
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seconds).With fair complexion.With dry skin
• HairEvenly distributed hair.With short, black and shiny hair.With
presence of pediculosis Capitis.
• Nails
Smooth and has intact epidermisWith short and clean
fingernails and toenails. Convex and with good
capillary refill time of 2 seconds.
SkullRounded, normocephalic and symmetrical, smooth and has
uniform consistency.Absence of nodules or masses.
FaceSymmetrical facial movement, palpebral fissures equal in
size, symmetric nasolabial folds.
Eyes and Vision
• EyebrowsHair evenly distributed with skin intact.Eyebrows are
symmetrically aligned and have equal movement.
• Eyelashes Equally distributed and curled slightly outward.
• EyelidsSkin intact with no discharges and no discoloration.Lids close
symmetrically and blinks involuntary.
• Bulbar conjunctiva Transparent with capillaries slightly visible
• Palpebral Conjunctiva Shiny, smooth, pink
• Sclera Appears white.
• Lacrimal gland, Lacrimal sac,
Nasolacrimal duct
No edema or tenderness over the lacrimal gland and no
tearing.
Cornea
• Clarity and texture
Transparent, smooth and shiny upon inspection by the use of
a penlight which is held in an oblique angle of the eye and
moving the light slowly across the eye.Has brown eyes.
• Corneal sensitivityBlinks when the cornea is touched through a cotton wisp from
the back of the client.
Pupils
Black, equal in size with consensual and direct reaction,pupils equally rounded and reactive to light and
accommodation, pupils constrict when looking at near
objects, dilates at far objects, converge when object is moved
toward the nose at four inches distance and by using penlight.
Visual Fields
When looking straight ahead, the client can see objects at the
periphery which is done by having the client sit directly
facing the student nurse at a distance of 2-3 feet. The right
eye is covered with a card and asked to look directly at the
student nurse’s nose. Hold penlight in the periphery and ask
the client when the moving object is spotted.
Visual Acuity
Ableto identify letter/read in the newsprints at a distance of
fourteen inches. She was able to read the newsprint at a
distance of 8 inches.
Ear and Hearing
• Auricles
Color of the auricles is same as facial skin, symmetrical,
auricle is aligned with the outer canthus of the eye, mobile,
firm, non-tender, and pinna recoils after it is being folded.
• External Ear Canal Without impacted cerumen.
• Hearing Acuity Test Voice sound audible.
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• Watch Tick Test
Able to hear ticking on right ear at a distance of one inch and
was able to hear the ticking on the left ear at the same
distance
Nose and sinuses
• External NoseSymmetric and straight, no flaring, uniform in color, air
moves freely as the clients breathes through the nares.
• Nasal CavityMucosa is pink, no lesions and nasal septum intact and in
middle with no tenderness.Mouth and Oropharynx Symmetrical, pale lips, brown gums and able to purse lips.
• Teeth With dental caries and decayed lower molars
• Tongue and floor of the mouthCentral position, pink but with whitish coating which is
normal, with veins prominent in the floor of the mouth.
• Tongue movementMoves when asked to move without difficulty and without
tenderness upon palpation.
Uvula Positioned midline of soft palate.
Gag ReflexPresent which is elicited through the use of a tongue
depressor.
Neck Positioned at the midline without tenderness and flexeseasily. No masses palpated.
Head movementCoordinated, smooth movement with no discomfort, head
laterally flexes, head laterally rotates and hyperextends.
Muscle strength With equal strength
Lymph Nodes Non-palpable, non tender
• Thyroid GlandNot visible on inspection, glands ascend but not visible in
female during swallowing and visible in males.
Thorax and lungs
Posterior thorax Chest symmetrical
• Spinal alignment Spine vertically aligned, spinal column is straight, left andright shoulders and hips are at the same height.
Breath Sounds With normal breath sounds without dyspnea.
• Anterior Thorax Quiet, rhythmic and effortless respiration
AbdomenUnblemished skin, uniform in color, symmetric contour,
undistended.
Abdominal movements Symmetrical movements cause by respirations.
• Auscultation of bowel sounds With audible sounds of 23 bowel sounds/minute.
Upper Extremities Without scars and lesions on both extremities.
Lower Extremities With minimal scars on lower extremities
Muscles
Equal in size both sides of the body, smooth coordinated
movements, 100% of normal full movement against gravity
and full resistance.
Bones and Joints No deformities or swelling, joints move smoothly.
Mental Status
Language Can express oneself by speech or sign.
Orientation Oriented to a person, place, date or time.
Attention spanAble to concentrate as evidence by answering the questions
appropriately.
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Level of ConsciousnessA total of 15 points indicative of complete orientation and
alertness. E4V5M6
Motor Function
Gross Motor and Balance
• Walking gaitHas upright posture and steady gait with opposing arm swing
unaided and maintaining balance.
Standing on one foot with eyes closed Maintained stance for at least five (5) seconds.
Heel toe walking Maintains a heel toe walking along a straight line
Toe or heel walking Able to walk several steps in toes/heels.
Fine motor test for Upper Extremities
Finger to nose test Repeatedly and rhythmically touches the nose.
Alternating supination and pronation of
hands on kneesCan alternately supinate and pronate hands at rapid pace.
Finger to nose and to the nurse’s finger Perform with coordinating and rapidity.
Fingers to fingers Perform with accuracy and rapidity.
Fingers to thumb Rapidly touches each finger to thumb with each hand.
Fine motor test for the Lower Extremities
Pain sensationAble to discriminate between sharp and dull sensation when
touched with needle and cotton.
Thorax and Lungs
• Lungs / Chest:
o The spine is vertically aligned. The right
and left shoulders and hips are of the
same height.
• The chest wall is intact with no tenderness and
masses. There’s a full and symmetric expansion
and the thumbs separate 2-3 cm during deep
inspiration when assessing for the respiratory
excursion. The client manifested quiet, rhythmic
and effortless respirations.
• Heart: There were no visible pulsations on the
aortic and pulmonic areas. There is no presence
of heaves or lifts.
o The jugular veins are not visible.
o When nails pressed between the fingers
(Blanch Test), the nails return to usual
color in less than 4 seconds.
• Abdomen: The abdomen of the client has an
unblemished skin and is uniform in color. The
abdomen has a symmetric contour. There were
symmetric movements caused associated with
client’s respiration.
NECK
The neck is inspected for position symmetry and obvious
lumps visibility of the thyroid gland and Jugular Venous
Distension.
Normal Findings:
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1. The neck is straight.
2. No visible mass or lumps.
3. Symmetrical
4. No jugular venous distension (suggestive of
cardiac congestion).
The neck is palpated just above the suprasternal note
using the thumb and the index finger.
The neck is palpated just above the suprasternal noteusing the thumb and the index finger.
Normal Findings:
1. The trachea is palpable.
2. It is positioned in the line and straight.
Lymph nodes are palpated using palmar tips of
the fingers via systemic circular movements.
Describe lymph nodes in termsof size, regularity,
consistency, tenderness and fixation to surrounding
tissues.
Normal Findings:1. May not be palpable. Maybe normally palpable
in thin clients.
2. Non tender if palpable.
3. Firm with smooth rounded surface.
4. Slightly movable.
5. About less than 1 cm in size.
6. The thyroid is initially observed by standing in
front of the client and asking the client to swallow.
Palpation of the thyroid can be done either by
posterior or anterior approach.
A. Posterior Approach:
1. Let the client sit on a chair while the examiner
stands behind him.
2. In examining the isthmus of the thyroid, locate
the cricoid cartilage and directly below that is the
isthmus.
3. Ask the client to swallow while feeling for any
enlargement of the thyroid isthmus.
4. To facilitate examination of each lobe, the
client is asked to turn his head slightly toward the
side to be examined to displace the
sternocleidomastoid, while the other hand of the
examiner pushes the thyroid cartilage towards the
side of the thyroid lobe to be examined.
5. Ask the patient to swallow as the procedure is
being done.
6. The examiner may also palate for thyroid
enlargement by placing the thumb deep to and
behind the sternocleidomastoid muscle, while the
index and middle fingers are placed deep to and in
front of the muscle.
7. Then the procedure is repeated on the other side.
A. Anterior approach:
1. The examiner stands in front of the client and
with the palmar surface of the middle and index
fingers palpates below the cricoid cartilage.
2. Ask the client to swallow while palpation isbeing done.
3. In palpating the lobes of the thyroid, similar
procedure is done as in posterior approach. The
client is asked to turn his head slightly to one side
and then the other of the lobe to be examined.
4. Again the examiner displaces the
thyroid cartilage towards the side of the lobe to be
examined.
5. Again, the examiner palpates the area and hooks
thumb and fingers around thesternocleidomastoidmuscle.
Normal Findings:
1. Normally the thyroid is non palpable.
2. Isthmus maybe visible in a thin neck.
3. No nodules are palpable.
Auscultation of the Thyroid is necessary when there is
thyroid enlargement. The examiner may hear bruits, as a
result of increased and turbulence in blood flow in an
enlarged thyroid.
Check the Range of Movement of the neck.
Lung borders
In the anterior thorax, the apices of the lungs extend for
approximately 3 – 4 cm above the clavicles. The inferior
borders of the lungs cross the sixth rib at the
midclavigular line.
In the posterior thorax, the apices extend of T10 on
expiration to the spinous process of T12 on inspiration.
In the Lateral Thorax, the lungs extend from the apex of
the axilla to the 8 th rib of the midaxillary line.
Lung Fissures
The right oblique (diagonal) fissure extend from the area
of the spinous process of the 3 rdthoracic vertebra,
laterally and downward unit it crosses the 5 th rib at the
midaxillary line. It then continues ant medially to end at
the 6th rib at the midclavicular line.
The right horizontally fissure extends from the 5th rib
slightly posterior to the right midaxillary line and runs
horizontally to thee area of the 4 th rib at the right sternal
border.
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The left oblique (diagonal) fissure extend from the
spinous process of the 3rd thoracic vertebra laterally and
downward to the left mid axillary line at the 5th rib and
continues anteriorly and medially until it terminates at
the 6th rib in the midclavicular line.
Borders of the Diaphragm.
Anteriorly, on expiration, the right dome of the
diaphragm is located at the level of the 5th
rib at themidclavicular line and he left dome is at the level of the
6th rib. Posteriorly, on expiration, the diaphragm is at the
level of the spinous process of T10; laterally it is at the
8th rib at the midaxillary line. On inspiration the
diaphragm moves approximately 1.5 cm downward.
Inspection of the Thorax
For adequate inspection of the thorax, the client should
be sitting upright without support and uncovered to the
waist.
The examiner should observe:A.
1. Shape of the thorax and its symmetry.
2. Thoracic configuration.
3. Retractions at the ICS on inspiration.
(suprasternal, costal, substernal)
4. Bulging structures at the ICS during
expiration.
5. position of the spine.
6. pattern of respiration.
Normal Findings:
The shape of the thorax in a normal adult is
elliptical; the anteroposterior diameter is less than
the transverse diameter at approximately a ratio of
1:2.
Moves symmetrically on breathing with no
obvious masses.
No fail chest which is suggestive of rib fracture.
No chest retractions must be noted as this may
suggest difficulty in breathing.
No bulging at the ICS must be noted as this may
obstruction on expiration, abnormal masses, or
cardiomegaly.
The spine should be straight, with slightly
curvature in the thoracic area.
There should be no scoliosis, kyphosis, or
lordosis.
Breathing maybe diaphragmatically of costally.
Expiration is usually longer the inspiration.
Palpation of the Thorax
1. General palpation – The examiner should
specifically palpate any areas of abnormality. The
temperature and turgor of the skin should be
assessed. Palpate for lumps, masses and areas of
tenderness.
2. Palpate for thoracic expansion or lung excursion
A. Anteriorly, the examiner’s hands are placed
over the anterolateral chest with the thumbsextended along the costal margin, pointing
to the xyphoid process. Posteriorly, the
thumbs are placed at the level of the 10th rib
and the palms are placed on the
posterolateral chest.
B. Instruct the client to exhale first, then to
inhale deeply.
C. The examiner the amount of thoracic
expansion during quiet and deep inspiration
and observe for divergence of the thumbs onexpiration.
D. Normally, symmetry of respiration between
the left and right hemithoraces should be felt
as the thumbs are separated are separated
approximately 3 – 5 cm (1 – 2 inches)
during deep inspiration.
1. Palpate for the tactile fremitus.
A. Place the palm or the ulnar aspect of the
hands bilaterally symmetrical on the chest
wall starting from the top, then at then
medial thoracic wall, and at the anterolateral
B. Each time the hands move down, ask the
client to say ninety-nine.
C. Repeat the procedure at the posterior thoracic
wall.
D. Normally, tactile fremitus should be
bilaterally symmetrical. Most intense in the
2ndICS at the sternal border, near the area of
bronchial bifurcation. Low pitched voices of
males are more readily palpated than higher
pitched voices of females.
E. Basic abnormalities like increased tactile
fremitus maybe suggestive of consolidation;
decreased tactile fremitus may be suggestive
of obstructions, thickening of pleura, or
collapse of lungs.
Percussion of the Thorax
Anterior thorax:
A. Patient maybe placed on a supine position.
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B. Percuss systematically at about 5 cm intervals
from the upper to lower chest, moving left to right to
left. (Percuss over the ICS, avoiding the ribs. Use
indirect percussion starting at the apices of the lungs.
C. The examiner notes the sound produced during
each percussion.
Whispered Pectorioquy – Ask the client top whisper “1-
2-3” Over normal lung tissue it would almost beindistinguishable, over consolidated lung it would
be loud and clear.
Inspection of the Heart
The chest wall and epigastrum is inspected while the
client is in supine position. Observe for pulsation and
heaves or lifts
Normal Findings:
1. Pulsation of the apical impulse maybe visible.
(this can give us some indication of the cardiac size).
2. There should be no lift or heaves.
Palpation of the Heart
The entire precordium is palpated methodically using the
palms and the fingers, beginning at the apex, moving to
the left sternal border, and then to the base of the heart.
Normal Findings:
1. No, palpable pulsation over the aortic, pulmonic,
and mitral valves.
2. Apical pulsation can be felt on palpation.
3. There should be no noted abnormal heaves, and
thrills felt over the apex.
Percussion of the Heart
The technique of percussion is of limited value in
cardiac assessment. It can be used to determine borders
of cardiac dullness.
Auscultation of the Heart
Anatomic areas for auscultation of the heart:
Aortic valve – Right 2nd ICS sternal border.
Pulmonic Valve – Left 2nd ICS sternal border.
Tricuspid Valve – – Left 5 th ICS sternal border.
Mitral Valve – Left 5th ICS midclavicular line
Positioning the client for auscultation:
If the heart sounds are faint or undetectable, try
listening to them with the patient seated and learning
forward, or lying on his left side, which brings the
heart closer to the surface of the chest.
Having the client seated and learning forward s
best suited for hearing high-pitched sounds related to
semilunar valves problem.
The left lateral recumbent position is best suited
low-pitched sounds, such as mitral valve problems
and extra heart sounds.
Auscultating the heart
A.
1. Auscultate the heart in all anatomic
areas aortic, pulmonic, tricuspid and mitral
2. Listen for the S1 and S2 sounds (S1closure of AV valves; S2 closure of semilunar
valve). S1 sound is best heard over the mitral
valve; S2 is best heard over the aortric valve.
3. Listen for abnormal heart sounds e.g.
S3, S4, and Murmurs.
4. Count heart rate at the apical pulse for
one full minute.
Normal Findings:
1. S1 & S2 can be heard at all anatomic site.
2. No abnormal heart sounds is heard (e.g.Murmurs, S3 & S4).
3. Cardiac rate ranges from 60 – 100 bpm.
Inspection of the Breast
There are 4 major sitting position of the client used for
clinical breast examination. Every client should be
examined in each position.
1. The client is seated with her arms on her side.
2. The client is seated with her arms abducted over
the head.
3. The client is seated and is pushing her hands into
her hips, simultaneously eliciting contraction of the
pectoral muscles.
4. The client is seated and is learning over while
the examiner assists in supporting and balancing her.
While the client is performing these maneuvers,
the breasts are carefully observed for symmetry,
bulging, retraction, and fixation.
An abnormality may not be apparent in the
breasts at rest a mass may cause the breasts, through
invasion of the suspensory ligaments, to fix,
preventing them from upward movement
in position 2 and 4.
Position 3 specifically assists in eliciting
dimpling if a mass has infiltrated and shortened
suspensory ligaments.
Normal Findings:
1. The overlying the breast should be even.
2. May or may not be completely symmetrical at
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rest.
3. The areola is rounded or oval, with same color,
(Color va,ies form light pink to dark brown
depending on race).
4. Nipples are rounded, everted, same size and
equal in color.
5. No “orange peel” skin is noted which is present
in edema.6. The veins maybe visible but not engorge and
prominent.
7. No obvious mass noted.
8. Not fixated and moves bilaterally when hands
are abducted over the head, or is learning forward.
9. No retractions or dimpling.
Palpation of the Breast
Palpate the breast along imaginary concentric
circles, following a clockwise rotary motion, from
the periphery to the center going to the nipples. Besure that the breast is adequately surveyed. Breast
examination is best done 1 week post menses.
Each areolar areas are carefully palpated to
determine the presence of underlying masses.
Each nipple is gently compressed to assess for
the presence of masses or discharge.
Normal Findings:
No lumps or masses are palpable.
No tenderness upon palpation.
No discharges from the nipples.
NOTE: The male breasts are observed by adapting the
techniques used for female clients. However, the various
sitting position used for woman is unnecessary.
abdomen
In abdominal assessment, be sure that the client has
emptied the bladder for comfort. Place the client in a
supine position with the knees slightly flexed torelax abdominal muscles.
Inspection of the abdomen
Inspect for skin integrity (Pigmentation, lesions,
striae, scars, veins, and umbilicus).
Contour (flat, rounded, scapold)
Distension
Respiratory movement.
Visible peristalsis.
Pulsations
Normal Findings:
Skin color is uniform, no lesions.
Some clients may have striae or scar.
No venous engorgement.
Contour may be flat, rounded or scapoid
Thin clients may have visible peristalsis.
Aortic pulsation maybe visible on thin clients.
Auscultation of the Abdomen This method precedes percussion because bowel
motility, and thus bowel sounds, may be increased
by palpation or percussion.
The stethoscope and the hands should be
warmed; if they are cold, they may initiate
contraction of the abdominal muscles.
Light pressure on the stethoscope is sufficient to
detect bowel sounds and bruits. Intestinal sounds are
relatively high-pitched, the bell may be used in
exploring arterial murmurs and venous hum.Peristaltic sounds
These sounds are produced by the movements of air and
fluids through the gastrointestinal tract. Peristalsis can
provide diagnostic clues relevant to the motility of
bowel.
Listening to the bowel sounds (borborygmi) can be
facilitated by following these steps:
1. Divide the abdomen in four
quadrants.
2. Listen over all auscultation sites,
starting at the right lower quadrants,
following the cross pattern of the
imaginary lines in creating the
abdominal quadrants. This direction
ensures that we follow the direction
of bowel movement.
3. Peristaltic sounds are quite irregular.
Thus it is recommended that the
examiner listen for at least 5
minutes, especially at the
periumbilical area, before
concluding that no bowel sounds are
present.
4. The normal bowel sounds are high-
pitched, gurgling noises that occur
approximately every 5 – 15 seconds
It is suggested that the number of
bowel sound may be as low as 3 to
as high as 20 per minute, or roughly
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one bowel sound for each breath
sound.
Percussion of the abdomen
Abdominal percussion is aimed at detecting
fluid in the peritoneum (ascites), gaseous distension,
and masses, and in assessing solid structures within
the abdomen.
The direction of abdominal percussion followsthe auscultation site at each abdominal guardant.
The entire abdomen should be percussed lightly
or a general picture of the areas of tympany and
dullness.
Tympany will predominate because of the
presence of gas in the small and large bowel. Solid
masses will percuss as dull, such as liver in the RUQ,
spleen at the 6th or 9th rib just posterior to or at the
mid axillary line on the left side.
Percussion in the abdomen can also be used inassessing the liver span and size of the spleen.
Percussion of the liver
The palms of the left hand is placed over the region of
liver dullness.
1. The area is strucked lightly with a fisted right
hand.
2. Normally tenderness should not be elicited by
this method.
3. Tenderness elicited by this method is usually a
result of hepatitis or cholecystitis.
Renal Percussion
1. Can be done by either indirect or direct method.
2. Percussion is done over the costovertebral
junction.
3. Tenderness elicited by such method suggests
renal inflammation.
Palpation of the Abdomen
Light palpation
It is a gentle exploration performed while the
client is in supine position. With the examiner’s
hands parallel to the floor.
The fingers depress the abdominal wall, at each
quadrant, by approximately 1 cm without digging,
but gently palpating with slow circular motion.
This method is used for eliciting slight
tenderness, large masses, and muscles, and muscle
guarding.
Tensing of abdominal musculature may occur because
of:
1. The examiner’s hands are too cold or are pressed
to vigorously or deep into the abdomen.
2. The client is ticklish or guards involuntarily.
3. Presence of subjacent pathologic condition.
Normal Findings:
1. No tenderness noted.
2. With smooth and consistent tension.
3. No muscles guarding.Deep Palpation
It is the indentation of the abdomen performed
by pressing the distal half of the palmar surfaces of
the fingers into the abdominal wall.
The abdominal wall may slide back and forth
while the fingers move back and forth over the organ
being examined.
Deeper structures, like the liver, and retro
peritoneal organs, like the kidneys, or masses may be
felt with this method. In the absence of disease, pressure produced by
deep palpation may produce tenderness over the
cecum, the sigmoid colon, and the aorta.
Liver palpation:
There are two types of bi manual palpation
recommended for palpation of the liver. The first one is
the superimposition of the right hand over the left hand.
1. Ask the patient to take 3 normal breaths.
2. Then ask the client to breath deeply and hold.
This would push the liver down to facilitate
palpation.
3. Press hand deeply over the RUQ
The second methods:
1. The examiner’s left hand is placed beneath the
client at the level of the right 11th and 12thribs.
2. Place the examiner’s right hands parallel to the
costal margin or the RUQ.
3. An upward pressure is placed beneath the client
to push the liver towards the examining right hand,
while the right hand is pressing into the abdominal
wall.
4. Ask the client to breath deeply.
5. As the client inspires, the liver maybe felt to slip
beneath the examining fingers.
Normal Findings:
The liver usually can not be palpated in a normal
adult. However, in extremely thin but otherwise well
individuals, it may be felt a the costal margins.
When the normal liver margin is palpated, it
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must be smooth, regular in contour, firm and non-
tender.
Has equal contraction and even.
Can perform complete range of motion.
No crepitus must be noted on joints.
Can counter act gravity and resistance on ROM.