O: OBJECTIVE:

Vitals: when report only say values

ED: T (oral, axillary +1 , rectal-1) to get core temp. BP, HR, R O2 sat at RA
Current (flow sheet): Tmax & ins and outs (under flow sheets):

PE:
1. GENERAL:
WD-well developed, WN-well nourished,
Age: (young/middle-aged/elderly),
Race [Caucasian-white/black/Asian], Sex.
NAD (no apparent distress)
(mildly) Obese (pts build, height, wt-BMI)
(Grooming/Apparent state of health): Diaphoretic, bed elevated ~45degrees)
A/O x2,3,4 (non-verbal/level of consciousness-obtunded)
(Signs: Anxious/Depressed/Pain/Cardiac or respiratory distress)
Ex: WD/WN Asian male; NAD, mildly obese, middle-aged, A&Ox4, diaphoretic, bed elevated ~45degrees

2. SKIN: .No scars, rashes, bruises with intact skin .

*surgical scars, rashes, ecchymosis (bruises), tattoos, warm/cold, xerotic (dry)/wet, intact skin.
*peeling = desquamation

3. HEAD: Normocephalic atraumatic

4. Eyes: PERRLA (Pupils equal round reactive to light & accommodation), EOMI (extraocular movement
intact),
Conjunctiva pallor/injection/icterus: No conjunctiva pallor, injection, or scleral icterus
Fundal papilledema/hemorrhage. +light reflex

5. Ears: Normal shape and symmetry

Tenderness, discharge, external canal appearance, tympanic membrane inflammation, gross auditory acuity

6. NOSE: Normal shape and symmetry, tenderness, discharge, frontal/maxillary tenderness

7. THROAT/MOUTH: No tonsillar erythema, mucosa inflammation or pallor

Hygiene, dentures
Mucosa inflammation/pallor/erythema/exudate, tonsil enlargement

8. NECK: masses, ROM, spinal/tracheal deviation (ET tube in place), thyroid size/masses, JVD (from sternal
angle and degree of bed), Carotid bruit, lymphadenopathy

Supple; normal ROM, no JVD, carotid bruit, or lymphadenopathy, No hepato-jugular reflex

9. BREAST: masses, tenderness (important to check if pt comes in with bone pain bc breast cancers like mets to
bone) (-deferred)

10. HEART: RRR (Regular rate and rhythm. Normal S1, S2. No S3, murmurs or rubs/gallops Pericardial
movements, parasternal heave, PMaxI location)

IE: Afib = Irregularly irregular rhythm w/irreg. ratio. Normal rate, S1, S2. No S3
Abn: Normal S1+S2; irregular rhythm, tachycardic rate, no murmurs
 11. LUNGS: Clear and resonant to auscultation and percussion B/L
Rhonchi/wheezes/crackles-rails in what lung fields (upper/lower). Were they heard not lung lobe (radiology
term), vocal fremitis, whispered pectoriloquy

No W/R;
Crackles on RLL
Cheyne-stokes?

12. ABDOMEN: soft; NT/ND; normalactivve/pitch +BS; tympanic on percussion in all 4 quadrants, no
abdominal bruits
Shape (Round/flat/distended)
Bowel sounds (pitch and activity-borborygmi)
Consistency: Soft/hard/firm
Tenderness: Severity and location
Percussion, distention, masses, guarding or rebound tenderness
Spleen size, Liver span (N: 6-12cm), shifting dullness, CVA tenderness, grey tuners or Cullens sign,
Non-tender, non-distended

13. GU/RECTAL: (If pt has Catheter mention here cc per 24 hours

(deferred)

14. MSK: muscle atrophy, weakens, joint ROM, instability, erythema, swelling, tenderness

15. Extremities: Clubbing, cyanosis or edema

Ex: No C/C, mild edema

16. VASCULAR: pulses in carotid, radial, posterior tibial, dorsalis pedis bilaterally 2+ bilaterally
Capillary refill <5sec
Ex: 2+ pulses in carotid, radial, & dorsal pedis B/L

17. NEURO: CN2-12 Grossly intact

CN2-3: light reflex
CN3,4,6: H-test
CN5: Facial sensation
CN7: facial muscles (smile, wrinkle forehead)
CN8: auditory
CN9: gag
CN10: Uvula midline
CN11: Shoulder shrug Strength Intact (= good), Turn head against resistance
CN12: Tongue movements

18. Reflexes: - Draw stick man

19. Babinski: yes/no
20. Clonus: yes/no
21. Gait: waddle, wide step, shuffle
22. Cerebellum: diadochokinesis (alternating hands), finger to nose, heel to shin
23. MMSE: /30

24. Glasgow comma scale: /15

Q: 6 neuro components: CN, Sensory, Motor, Cerebellum/Gait, Reflexes, MSE

1). GENERAL SURVEY of the patient
Inspect:
Observe general appearance of the patient: AGE, RACE, SEX, Dress, Grooming and personal hygiene.
Pts build, height and weight (BMI), Apparent State of Health and the level of consciousness, any signs of
anxiety or depression, pain or any cardiac or respiratory distress.
Notice the body odors and the breath (fetor) for any indication of abnormalities.
Examine the skin for color, moisture, skin turgor, mobility and temperature with the back of your hand.
Examine the head size, shape, lumps, bumps and hair color, texture and distribution.
Examine the eyes for pallor, jaundice, and strabismus.
Examine the lips for pallor, peripheral cyanosis, oral cavity mucosa, gums, tongue (glossitis and central
cyanosis) and teeth.
Examine the hands and nails for clubbing, capillary refill, peripheral cyanosis, splinter hemorrhages, tremor
and palmar erythema
Examine the lower extremities for peripheral edema (pitting/non-pitting), varicose veins, trophic changes,
ulcers and perfusion.
*Intro:
Wash hands.
Hello, my name is ___. I'm a second year medical student and you are?
May I call you Mr./Mrs. ___?
Thank you, Mr/Mrs. ___. Now, before we begin, I just want to let you know that everything that happens in this room will be
kept confidential between me and my colleagues (indicate people in room) unless you pose a threat to yourself or to others. Is
that alright?
Thank you. Now for this examination, I will be touching you in various parts of your body. It should not cause pain or
discomfort, but if it does, please let me know. I have already washed my hands.
Begin: At foot of bed with patient sitting.
Mr./Mrs. ___ is an (Afro-Caribbean) (middle-aged) male/female of (average/small/large) build and (acceptable/low/high)
BMI. He/she is conscious and alert, well-groomed, does not look anxious or depressed, shows no signs of respiratory or
cardiac distress, does not appear to be using any accessory muscles for breathing, does not look to be in pain, and has no fetor
or body odor.
Head:
Mr./Mrs. ___, may I have permission to touch your head? I will be feeling for symmetry and for any bumps or tenderness.
Please let me know if this causes you any discomfort.
Feel both sides of head for symmetry, bumps, and watch for tenderness.
Skull is symmetrical with no bumps or tenderness. Mr./Mrs. ___'s (black) hair is distributed evenly around the head with an
appropriate color and texture for his/her age and race.
Check forehead temperature with the back of your hand.
Mr./Mrs. ___ is afebrile.
Ears:
Ears are symmetrical (and pierced) with no signs of discharge.
Eyes:
Now I will be touching your eyelids. Will you please look down for me?
Pull upper eyelid up and look at conjunctiva.
Will you look up for me please?
Pull lower eyelid down and look at conjunctiva.
Conjunctiva is pink and moist. White if anemia.
Sclera is anicteric/white. Yellow if Jaundice.
There are no signs of strabismus and no unusual discharge. If eye(s) are deviated, there's strabismus.
Nose:
The bridge of his/her nose isn't collapsed or abnormally flat. There are no signs of discharge.
Mouth:
Mouth is pink and moist. Blue = peripheral cyanosis
No signs of cheilosis (cracked lip ends).
Will you please smile for me? Mr./Mrs. ___ has all his/her teeth. Gums are pink, moist, and are not bleeding.
Will you please open your mouth for me? There is no fetor. No signs of cavities. No mouth ulcers.
Will you please stick out your tongue? Tongue is pink and moist without excessive swelling or discoloration. No signs of
glossitis.
 Will you please lift your tongue for me? The underside of the tongue is pink which indicates no central cyanosis. If
completely blue = central cyanosis
Neck:
I will now be touching your neck.
Feel for enlarged lymph nodes, bumps, or masses.
There are no enlarged lymph nodes, bumps, or masses. No signs of tenderness.
Arms:
Will you please hold out your arms for me?
Have patient hold their arms straight out with their palms facing down.
No signs of fine tremor. Now will you please extend your hands like this?
Motion to keep their arms extended, but with their palms facing you. Look for red palms.
No signs of flapping tremor or palmar erythema. Do you mind holding the nail(beds) of your middle fingers together like
this?
Have patient make a heart with their fingers and look for a diamond-shaped space between their nail beds.
There are no signs of clubbing. Is it alright if I look at your nails?
Have them hold out their hands and look at their nails for small, red capillaries.
No splinter hemorrhages visible.
Press a nail on each hand and count to two.
Capillary refill is under two seconds.
Look at wrists.
No signs of edema at the wrist. May I lightly pinch your skin?
Pinch skin.
Skin is of appropriate moisture and turgor for his/her age. There are no signs of bruises, bleeding, or discoloration.
Legs:
Now I will be looking at and lightly pressing on your legs and feet. Please let me know if you feel any discomfort or pain.
Press on dorsum of foot and look at patient's face. Quickly check for pitting, then look back up at patient's face and press on
medial malleolus. Check for pitting again, then looking back up at patient's face, work your way up their shins with your
thumbs. Watch for wincing.
No edema, pitting or non-pitting, present. There were no signs of tenderness.
Look at legs, foot, and bottom of feet.
No varicose veins present, no foot ulcers or trophic changes.
Do capillary refill check of big toes.
Capillary refill for toes under two seconds. Indicates adequate perfusion.
Stand up and thank the patient.
Thank you very much and that concludes the general survey.

Learning issues:
What are the causes of Jaundice, Anemia, Clubbing, and Edema?
Jaundice: liver disease or RBC hemolysis
Anemia: decreased hemoglobin
Clubbing: hypoxia, pulmonary hypertension, lung cancer, heart disease
Edema: increased hydrostatic pressure of veins which leads to poor reabsorption
What are the differences between peripheral and central cyanosis and what causes them?
Central cyanosis: circulatory or ventilatory problem that leads to poor blood oxygenation. It can be
caused by hypoventilation, congestive heart failure, lung disease, high altitude, and hypothermia
Peripheral cyanosis: seen in extremities due to inadequate circulation. Can be caused by all causes of
central cyanosis, as well as cold exposure, Raynaud's, vasoconstriction, and arterial occlusion.
2). Examine the peripheral circulation
Palpate the radial pulse, the brachial pulse, the femoral pulse, the popliteal pulse, the posterior tibial pulse and
the dorsalis pedis pulse on both sides.
Check for radio-femoral delay.
Examine the carotid by auscultating for any bruits and palpate the carotid pulse one side at a time, and
describe the character of the carotid pulse (and the contour and amplitude of the carotid pulse as monophasic
and brisk upstroke, when it is normal).
Examine for the presence of varicose veins, any foot ulcers, and trophic changes.
*Intro:
Wash hands.
Hello, my name is ___. I'm a second year medical student and you are?
May I call you Mr./Mrs. ___?
Thank you, Mr/Mrs. ___. Now, before we begin, I just want to let you know that everything that happens in this room will be
kept confidential between me and my colleagues (indicate people in room) unless you pose a threat to yourself or to others. Is
that alright?
Thank you. Now for this examination, I will be feeling for your pulse in various parts of your body. It should not cause pain
or discomfort, but if it does, please let me know. I have already washed my hands.
Radial:
I'll be measuring your radial pulse. Will you please hold out both hands for me?
Feel both radial pulses.
Bilateral radial pulse is symmetrical in rate, rhythm, and volume. Rhythm is regular, volume is full, and character is non-
bounding. Abnormal character = bounding or thready.
Now I will be measuring the pulse rate in one hand.
Take one hand and measure radial pulse for a full minute.
Pulse is ___ beats per minute.
Brachial:
Now, I'll be feeling for your brachial pulse in both arms. Will you please bend both arms for me?
Pressing your fingers medially to the biceps tendon (OUTSIDE and slightly above the pit of the elbow), feel for the brachial
pulse in both arms simultaneously.
Brachial pulse is symmetrical, rhythm is regular and volume is full.
Carotid:
Will you please lay down for me?
PULL OUT FOOT TABLE.
Now I will be touching your neck and listening to it with a stethoscope. Please let me know if this causes you any
discomfort.
Feel for the carotid pulse between the trachea and the SCM (NOT HIGH) on the neck on each side..
The carotid pulse is monophasic with a brisk upstroke and regular rhythm.
I'm going to place the stethescope on your neck. Please let me know if this causes you any discomfort.
Place bell on each carotid artery.
No bruits present on either carotid artery.
Femoral: Stand on the patient's right side (left side of table).
I will now be feeling for your femoral pulse. Please let me know if you feel any pain or discomfort while I do so.
Press on each inguinal ligament (leg-hip crease) right where the pubic hair begins to feel for femoral pulse.
Thank you. Femoral pulses are symmetrical with a regular rhythm and full volume. Now, I'd like to check both your femoral
and radial pulse. Will you please give me your right hand?
Check the right radial pulse and the right femoral pulse at the same time.
May I please have your other hand?
Do the other side.
There is no radio-femoral delay on either side of the body. If there was a delay = coarctation of aorta
Popliteal:
Will you please bend your knees for me? I will be feeling for your popliteal pulse. Please let me know if it causes you any
discomfort.
Wrap your fingers of both hands around the back of one knee and push in on the lateral side of the popliteal fossa. You should
be able to feel it on the middle finger of the lateral hand. Popliteal pulse may not be palpable. If not, say it's not, but say what
you would expect.
Popliteal pulse is palpable, has a regular rhythm and full volume.
Do on other leg.
Popliteal pulse is palpable, has a regular rhythm and full volume.
Posterior tibial:
I will be feeling for a pulse pulse on the insides of your ankles. Please let me know if it causes you any pain.
Simultaneously feel for the posterior tibial pulse behind and inferior to the medial malleolus on both ankles.
Posterior tibial pulse is symmetrical, has a regular rhythm, and full volume.
Dorsalis pedis:
I will now be feeling the top of your feet. Please let me know if you experience any discomfort.
Find the dorsalis pedis pulse half-way down the foot between the tendons of the first and second foot. Sometimes it's a bit
higher. (It is also occasionally, congenitally not present.)
Dorsalis pedis is palpable and symmetrical in regular rhythm and full volume.
Legs/feet:
Examine the foot, top and bottom.
There is no presence of varicose veins, no foot ulcers, and no trophic changes.
Thank you very much. That concludes the examination of the peripheral circulation.

Learning issues:
What is the significance of Radio-femoral delay?
a delay suggests coarctation of the aorta
What are trophic changes?
they are changes in the size of arms or legs, indicating an obstruction in the circulation resulting in atrophy
(atrophied muscle = smaller); also changes in hair distribution, presence of ulcers...
What is the mechanism of development of varicose veins?
when venous valves don't work, blood pools in the veins, causing them to dilate and become visible.
(Common in superficial leg veins that are subject to high pressure when standing.)
What are the signs of arterial occlusion/obstruction in the peripheries?
bruits are signs of arterial occlusion
reduced blood flow can also cause peripheral cyanosis.
asymmetric pulses are also an indication of atherosclerosis or embolism
3). Perform a detailed examination of the Radial Pulse
Examine both radial pulses and compare the volume and timing. Check for Radio- radial delay and then
palpate one Radial pulse and describe rate, rhythm, volume, tone and character.
Check for radio-femoral delay.
Examine for the presence of collapsing (water-hammer) pulse and explain the significance.
Examine to demonstrate the effect of both phases of respiration on radial pulse rate and volume.
*Intro:
Wash hands.
Hello, my name is ___. I'm a second year medical student and you are?
May I call you Mr./Mrs. ___?
Thank you, Mr/Mrs. ___. Now, before we begin, I just want to let you know that everything that happens in this room will be
kept confidential between me and my colleagues (indicate people in room) unless you pose a threat to yourself or to others. Is
that alright?
Thank you. Now for this examination, I will be feeling for your pulse and asking you to do various tasks. They should not
cause pain or discomfort, but if it does, please let me know. I have already washed my hands.
Will you please give me both your wrists?
Examine both radial pulses.
Radial pulse is symmetrical, has a regular rhythm and full volume.
Visibly press down on both pulses.
No calcifications are felt. Now do you think you can lie down for me? I will be touching you low on your stomach to feel
for your femoral pulse. Please let me know if this causes you any discomfort.
Expose the patient's femoral artery and palpate with the radial artery.
There was no radiofemoral delay. Will you please sit back up for me?
Make sure you can feel the radial pulse.
Now I'm going to quickly lift your right arm.
Keeping your hand on their radial pulse, quickly lift their wrist above their head.
I felt a slight decrease in the amplitude. If the patient had aortic regurgitation, then I would expect to feel a sharp rise in the
amplitude then a sharp drop. Water-hammer
Will you please take a deep breath?
On inspiration, the pulse increased and with expiration, there's a decrease in pulse.
Thank you very much. That concludes the radial pulse examination.
Learning issues:
What is the significance of radio-radial delay?
signifies presence of an obstruction downstream from the branching of the left subclavian artery
What is the significance of Radio-femoral delay?
obstruction upstream from branching of left subclavian artery
Explain what irregularly irregular pulse is and what causes it?
no pattern or consistency between pulses; associated with atrial fibrillation
Explain the causes of small and weak pulse, large bounding pulse, bisferiens pulse, pulsus alternans, bigeminal pulse
and paradoxical pulse.
small and weak pulse: decreased pulse pressure, hypovolemia, aortic stenosis, increased peripheral
resistance and CHF
large and bounding: increased pulse pressure, decreased peripheral resistance (fever, anemia,
hyperthyroidism, aortic regurg, patent ductus arteriosus)
bisferiens pulse: increased arterial pressure with double systolic peak due to aortic regurgitation
pulsus alternans: amplitude alternates between beats due to left ventricular failure, usually S3 is also
heard.
bigeminal pulse: premature contraction of the ventricles causes two beats to occur right after each
other
paradoxical pulse: inspiration causes an increase in heart rate rate and DECREASE in volume (COPD,
cardiac tamponade, pericarditis)
What will be the effect of both phases of respiration on both rate and volume of radial pulse.
inspiration increases rate and volume of radial pulse
expiration decreases rate and volume of radial pulse
4). Examine the JVP
With patient supine, elevate the head of patient to about 30-45 and ask the patient to turn the neck away to
the left and inspect the neck and the Right Internal jugular vein.
Observe the symmetry of Internal Jugular Vein on both sides of the neck.
Describe the mechanism of production and character of the Internal Jugular Vein wave forms (a & v waves,
x & y troughs).
Compare the Jugular venous pulse with the Carotid pulse and describe at least 4 differences between them.
Measure the JVP with reference to the sternal angle
Estimate the right atrial pressure
Examine for hepatojugular reflux.
*Intro:
Wash hands.
Hello, my name is ___. I'm a second year medical student and you are?
May I call you Mr./Mrs. ___?
Thank you, Mr/Mrs. ___. Now, before we begin, I just want to let you know that everything that happens in this room will be
kept confidential between me and my colleagues (indicate people in room) unless you pose a threat to yourself or to others. Is
that alright?
Thank you. Now for this examination, I will be touching and measuring your neck. It should not cause pain or discomfort,
but if it does, please let me know. I have already washed my hands.
Left side:
Raise the bench to 45 degrees.
Will you please lie down for me and turn your head toward[s me?
Shine the penlight upwards so shadows are cast across neck. JVP is located low between the two heads of the
sternocleidomastoid (lateral on the neck).
I am going to press on your neck.
The JVP is biphasic and disappears with light palpation.
The first visible wave is the A wave which represents the atrial contraction. It is followed by the X-trough which is atrial
relaxation and the V wave which represents ventricular contraction. The Y-trough represents the opening of the tricuspid
valve/ventricular filling..
Right side:
Now will you please turn your head away from me?
The location of the right JVP is symmetrical in location with that on the left. It is biphasic.
May I touch your neck? It also disappears with light palpation as expected.
Will you please take a breath for me?
JVP descends with inspiration. negative Kussmaul neck sign
Now I'm going to measure your JVP.
Find highest point of JVP and use a ruler to make a parallel line to the floor. With another ruler, measure the vertical distance
from the sternal angle to the other ruler and add 5cm
JVP is measured to be __cm..
Now, will you please sit up for me?
Location of JVP changed with position. Normal = goes down the more vertically the patient is sitting
Now I'm going to press on your stomach. Please let me know if this causes you any pain.
Press on liver and watch JVP go up for a short while and go back down.
JVP temporarily rose with with pressure to the liver. negative hepatojugular reflux
Learning issues:
Explain the significance of hepatojugular reflux.
Explain Kussmauls neck sign.
it tests the heart's capacity to compensate for an increase in venous return (Starling's law)
with inspiration, the JVP should increase then descend
a positive Kussmaul sign is when the JVP doesn't descend due to right-sided heart failure or cardiac
tamponade
What are the causes of different types of wave form (a & v) abnormalities?
prominent a wave = tricuspid stenosis
no a wave = atrial fibrillation
prominent v wave = tricuspid regurgitation
5). Measure the Blood pressure
Enquire about previous BP measurements and previous history of Hypertension and use of any medication.
Make sure the patient is relaxed for at least 10 minutes and has not consumed alcoholic drinks, coffee and
soda.
Check the cuff size, both width and length, compared with the arm circumference and explain what is the
correct size.
Measure SBP by palpatory method and deflate the cuff completely after that.
Inflate cuff to about 30 mm of Hg above SBP (recorded earlier by palpatory method)
and deflate slowly while listening for the korotkoff sounds (appearance, muffling and disappearance).
BP should be recorded at least twice in the same arm and the average measurement taken.
BP should be recorded in both arms.
BP should be recorded in both supine (or sitting) and standing positions in the same arm.
Give BP reading rounded to the nearest 2 mm.
*Intro:
Wash hands.
Hello, my name is ___. I'm a second year medical student and you are?
May I call you Mr./Mrs. ___?
Thank you, Mr/Mrs. ___. Now, before we begin, I just want to let you know that everything that happens in this room will be
kept confidential between me and my colleagues (indicate people in room) unless you pose a threat to yourself or to others. Is
that alright?
Thank you. Now for this examination, I will be checking your blood pressure. It should not cause pain or discomfort, but if
it does, please let me know. I have already washed my hands.
Questions:
Have you ever had your blood pressure taken before? (What was the last reading?)
Have you ever been diagnosed with hypertension or Diabetes?
Do you take any medications that may affect your blood pressure?
Have you had any caffeine recently?
Have you exercised recently?
Do you smoke?
Thank you, now I will be taking your blood pressure. Do you prefer an arm?
Measure:
width of BP cuff should be 40% of upper arm circumference
length of BP bladder should be 80% of upper arm circumference lose overestimates BP
Mr./Mrs. __ may I please look at both your arms?
Check for scars, lesions, bruises, or changes in size and also check for both brachial pulses.
There are no scars, lesions, bruises or trophic changes in either arm. Brachial pulse is bilaterally palpable.
Auscultatory gap:
Wrap BP cuff ~2cm above pit of elbow. Place the stethescope under the cuff. Now, inflate the cuff while feeling for the radial
pulse to disappear.
Radial pulse disappeared at __, so I will pump the cuff to __ + 30.
Deflate the cuff and take the blood pressure. Give the blood pressure in EVEN NUMBERS.
Blood pressure was measured to be __/__. If time permitted, I would wait two minutes before retaking the blood pressure.
DO NOT DEFLATE OR REMOVE THE CUFF. Just make sure the BP returns to 0. Then take the blood pressure on the
same arm.
Blood pressure was measured to be __/__. The average of the two blood pressures are __/__.
If time permitted, I would take the blood pressure again on the same arm with Mr./Mrs.___ standing and supine, as well as in
the other arm standing, sitting, and supine.
Thank you very much. This concludes the blood pressure examination.
Learning issues:
Explain what an auscultatory gap is?
silent interval that may be present between systolic and diastolic and may cause an underestimation of
systolic or overestimation of diastolic
Explain why BP should be recorded in both arms?
to make sure there is no obstruction
Explain why BP should be recorded in different positions ( what is orthostatic hypotension?)
to check for orthostatic/postural hypotension (confirmed by a drop of >20mmHg in systolic or >10mmHg
drop in diastolic with standing)
What is the JNC VII classification of Hypertension?
Normal: below 120/80
Prehypertensive: 120-139/80-89
Stage 1: 140-159/90-99
Stage 2: 160/100
Hypertensive: >139/>89
Note: Systolic changes every 20, Diastolic changes every 10
6). Examination of the Heart excluding auscultation (precordial examination)
Inspect the supine patient, who is adequately exposed and appropriately draped, from the foot end of the bed.
Inspect the shape, symmetry of precordium, apical impulse and scars.
Inspect from the patients right side closely for the apical impulse.
Palpate the precordium in all the 4 areas (mitral, tricuspid, aortic and pulmonary) for thrills and palpable
impulses (palpable heart sounds).
Palpate the apical impulse (location midclavicular 5th intercostal space, size - 2cm, amplitude - strong,
duration- short and character - brisk/tapping).
Roll the patient into the left lateral decubitus position and palpate the mitral area, if the apical impulse is not
palpable in the supine position.
Palpate the parasternal area for any heave and explain the significance of it.
*Intro:
Wash hands.
Hello, my name is ___. I'm a second year medical student and you are?
May I call you Mr./Mrs. ___?
Thank you, Mr/Mrs. ___. Now, before we begin, I just want to let you know that everything that happens in this room will be
kept confidential between me and my colleagues (indicate people in room) unless you pose a threat to yourself or to others. Is
that alright?
Thank you. Now for this examination, I will be touching various areas of your chest. It should not cause pain or discomfort,
but if it does, please let me know. I have already washed my hands.
Will you please lie down?
From the foot of the bed:
The chest is symmetrical. There seems to be no pectus carinatum or pectus excavatum. There are no visible scars or
lesions.
From the side of the bed:
The apical impulse is not visible.
Palpation:
I will now be touching your chest. Please let me know if you feel any discomfort.
Use ball of hand to palpate the four areas (APT M) for thrills and palpable heart sounds
Heart sounds are palpable. No thrills are present.
With the fingertips palpate the M region.
Apical impulse is in the fifth intercostal space in the midclavicular line. Is less than 2 cm, has a short duration (between S1
and S2), is brisk.and is not weak or hyperdynamic.
If I couldn't feel it, I'd have the patient roll into a left lateral decubitus position, have him exhale fully and hold it for a few
seconds, then feel for it in the same location.
Parasternal heave:
Make a thumbs up and put the bottom of the fist on the left sternal edge.
Will you please breathe deeply? If there's a heave, the right side of the chest will lift up higher than the left side.
Parasternal heave was negative.
Thank you very much. That concludes this examination.
Learning issues:
Define a thrill.
fine, palpable rushing vibration or a harsh, rumbling murmur (aortic stenosis, patent ductus arteriosus, VSD)
Describe the findings on inspection and palpation found in left ventricular hypertrophy.
apical impulse diameter would be >3cm in the left lateral decubitus position or there would be a sustained
impulse duration.
Describe the findings on inspection and palpation found in right ventricular hypertrophy.
there would be parasternal heave
7). Auscultate the Heart
With the patient in the supine position, who is adequately exposed and appropriately draped, listen with the
stethoscope while timing with the carotid pulse, in all 4 areas (mitral, tricuspid, pulmonary and aortic) using
the diaphragm first and then the bell and describe the heart sounds (S1, S2, S3 and S4).
Describe the splitting of the S2 in the pulmonary area while noticing the respiratory
movements
Roll the patient into the left lateral decubitus position and auscultate with the bell at the apex with the
patients breath held at the end of expiration and describe the heart sounds.
Listen at the aortic area and the 3rd left parasternal border with the patient sitting up and leaning forwards and
the patients breath held at the end of expiration.
*Intro:
Wash hands.
Hello, my name is ___. I'm a second year medical student and you are?
May I call you Mr./Mrs. ___?
Thank you, Mr/Mrs. ___. Now, before we begin, I just want to let you know that everything that happens in this room will be
kept confidential between me and my colleagues (indicate people in room) unless you pose a threat to yourself or to others. Is
that alright?
Thank you. Now for this examination, I will be touching and listening to various areas of your chest. It should not cause
pain or discomfort, but if it does, please let me know. I have already washed my hands.
Auscultation:
Will you please lie down?
Stand on patient's right (left side of table)
Will you please turn to yourhead to your left?
Place your hand on the carotid artery and KEEP IT THERE THE ENTIRE TIME.
I will now listen to your heart sounds. I am warming up the stethescope. Please let me know if this causes you any
discomfort.
Warm the diaphragm and listen to the four areas (APT M) for the heart sounds.
A = S1, which is the closing of the atrioventricular valves, is synchronous with the carotid pulse. S2 is louder and shorter
than S1 and is a higher pitch. S2 is the sound of the closing of the semilunar valves.
P = S2 is louder and shorter than S1 and is a higher pitch.
Will you please inhale for me?
There is an expected physiological splitting of the S2 heart sound with inspiration.
T = S1 is louder and longer than S2 and is a lower pitch.
M = S1 is louder and longer than S2 and is a lower pitch.
No abnormal heart sounds (S3, S4) were heard throughout the examination
Now using the bell, listen to all same heart sounds, repeating No murmurs are heard.
Will you please roll over on your left side?
Place your bell on their M region.
Now exhale and hold it.
I hear no signs of mitral stenosis.
Now will you please sit up?
Place the diaphragm on the A region.
Will you please lean forward, exhale and hold it?
Move the diaphragm to the A region and then one rib-space below the P region.
Okay you can breathe again. No aortic regurgitation heard.
Thank you very much. That concludes this examination.
Learning issues:
Explain the mechanism of physiological splitting of S2.
the aortic valve closes faster than the pulmonic valve, but it can especially be heard during inspiration when
there's lower intrathoracic pressure causing more blood to flow into the heart. The increase in venous return
makes the right ventricle take longer to empty, leading to an additional delay in the closure of the pulmonic
valve.
Explain the mechanism of S1, S2, S3 and S4.
S1 = closing of atrioventricular valves (mitral and tricuspid valves)
S2 = closing of semilunar valves (aortic and pulmonic valves); split heard better in skinny people, athletes,
and kids
S3 = gallop right after S2 rapid filling of ventricles (Swoosh); normal in children and thin people;
otherwise indicative of left ventricular failure
 S4 = heard right before S1; PATHOLOGICAL echo of the blood bouncing off stiffened ventricle (esp left);
indicative of MI and decreased vessel compliance
Describe the typical murmurs of Mitral stenosis, Mitral regurgitation, Aortic stenosis and Aortic regurgitation.
Aortic stenosis = narrowing of aortic valve = LOW pitch; systolic
Mitral stenosis = narrowing of mitral valve = low pitch; diastolic
Mitral regurgitation = HIGH pitch, systolic, heard after S1
Aortic regurgitation = high pitch, diastolic, heard after S2
Explain how you can differentiate pericardial friction rub from a pleural friction rub.
if you ask the patient to hold their breath and the rub is still heard, then it's a pericardial friction rub
8). Examination of the respiratory system excluding auscultation
With the patient in the sitting position and adequately exposed and appropriately draped, inspect the patient as
you walk all around the patient and describe the shape, symmetry, movements of thorax and tracheal position.
Describe any inspiratory retraction, flail chest, or use of accessory muscles.
Describe the rate, rhythm, depth and effort of breathing and any respiratory distress.
Confirm the tracheal position by palpation.
Palpate for Tenderness.
Palpate the chest starting with the posterior thorax (including both apices and infra axillary areas), with the
patients hands crossed in front and on the opposite shoulder: measure chest diameter, chest expansion, any
tenderness and tactile vocal fremitus.
Percussion of chest: with the patients hands crossed in front and on the opposite shoulders, percuss the
posterior thorax (including both apices and infra axillary areas) and describe the normal percussion note and
any abnormal note, if present.
Now repeat the entire above mentioned exam on the anterior thorax either in sitting or in supine position with
the patients hands at the sides.
If the patient is a female, ask the patient to push the breast gently away (up, down or to a side) to facilitate
your examination.
*Intro:
Wash hands.
Hello, my name is ___. I'm a second year medical student and you are?
May I call you Mr./Mrs. ___?
Thank you, Mr/Mrs. ___. Now, before we begin, I just want to let you know that everything that happens in this room will be
kept confidential between me and my colleagues (indicate people in room) unless you pose a threat to yourself or to others. Is
that alright?
Thank you. Now for this examination, I will be touching various areas of your body. It should not cause pain or discomfort,
but if it does, please let me know. I have already washed my hands.
Inspection:
The patient doesn't seem to be in any respiratory distress. He isn't using any accessory respiratory muscles. No audible
wheezing or stridor. Virchow's (left supraclavicular node) node doesn't seem enlarged.
Go behind the patient.
The patient does not present with any scoliosis or kyphosis.
Return to the front of the patient.
Now will you please place your hand over your chest?
Pretend to take the radial pulse, but count the respiratory rate for a full minute.
Respiratory rate is ___ breaths per minute which is within normal range. Breathing is unlabored, of average depth and
requires minimal effort. 14-20 = normal
Now will you please lie down? According to a few instructors, patient does NOT have to lie down. Make sure you go
around to the side of the sitting patient and mention that there's no signs of barrel chest.
From foot of bed: The chest is flat, symmetrical with breathing. There's no pectus excavatum or pectus carinatum. No signs
of inspiratory retraction or flail chest.
Will you please sit back up for me?
Palpation:
Now I'll be touching your body. Please let me know if this causes any discomfort.
Stand in front of the patient and check the trachea with your middle finger in the jugular notch and the index and ring fingers
on each side of the trachea. Stroke the trachea with the middle finger.
Trachea is midline.
Measure the side of the body with one palm and the back with two palms.
AP diameter is 2 to 1 indicating an elliptical-shaped chest.
Now I'll be touching your back. Please let me know if you feel any tenderness. Do you think you can turn your head
towards me?
Palpate above the clavicles one at a time.
Will you please cross your arms for me?
Now palpate 8 spots down the back and 2 on each side.
No signs of tenderness.
Now I'll be touching the same areas and every time you feel me touch your skin, will you please say 99?
Place both hands (pinky-side down) above clavicles, then have the patient cross their arms and do the same 12 spots.
Hand placement:
\ / over and parallel with clavicles
| | between scapula
 | |
_ _ below scapula
__
then __ x2 on each side under arms
Tactile vocal fremitus is within normal limits and symmetrical.
Now I'll be squeezing a small area of your back. Please let me know if you experience any discomfort.
Place your hands on the back and squeeze the area under the scapula together.
Please inhale.
Watch your thumbs spread apart.
Chest expansion is symmetrical.
Percussion:
Now I'll be tapping the same spots as earlier. Please let me know if you feel any pain.
Percuss the 14 spots without forgetting to have the patient cross his arms.
It was resonant throughout all lung fields.
If I had time, I'd repeat everything I've done on the back on the chest with their arms at their sides. Thank you very much,
that concludes the respiratory exam without auscultation
Learning issues:
Describe abnormal patterns of breathing (Biots, Cheyne-stokes and Kussmauls breathing).
Biots: ataxic breathing, shallow or deep breaths with periods of apnea; respiratory depression at medulla
Cheyne-stokes: rhythmic waxing and waning in rate and depth with periods of apnea; cardiac or neurological
disorders
Kussmaul: hyperpnea (rapid and deep breaths) due to metabolic acidosis
What is flail chest?
Flail chest: multiple rip fractures cause paradoxical movements; chest wall moves IN with INspiration
What does accessory muscle usage denote?
Respiratory distress; they're using their scalenes and SCMs to aid in forced inspiration and expiration.
9). Auscultate the Lungs.
With the patient in the sitting position and adequately exposed and appropriately draped auscultate both lung
apices with bell and describe the character of breath sounds
Auscultate with the diaphragm of the stethescope, the posterior thorax (including both infra-axillary areas)
with patients hands crossed over his/her opposite shoulders and describe the character of breath sounds.
Auscultate the anterior thorax with patients hands at his/her sides and describe the character of breath
sounds.
Describe the character of normal breath sounds.
Describe whether any adventitious sounds like crackles, rhonchi or wheezes are present or absent.
Examine for the presence of any transmitted voice sounds (Bronchopony, egophony, whispered pectoriloquy).
*Intro:
Wash hands.
Hello, my name is ___. I'm a second year medical student and you are?
May I call you Mr./Mrs. ___?
Thank you, Mr/Mrs. ___. Now, before we begin, I just want to let you know that everything that happens in this room will be
kept confidential between me and my colleagues (indicate people in room) unless you pose a threat to yourself or to others. Is
that alright?
Thank you. Now for this examination, I will be touching and listening to various areas of your body. It should not cause
pain or discomfort, but if it does, please let me know. I have already washed my hands.
I'm going to be listening to your breathing. I'm warming the stethescope for you. Please let me know if you feel any
discomfort.
Stand behind the patient.
Warm diaphragm and bell. Use bell to listen to the apex above the clavicles for two breath cycles.
Now will you please cross your arms?
With the diaphragm listen to other 12 regions for two breath cycles each.
Vesicular breath sounds were heard throughout all lung fields. There were no adventitious breath sounds (no wheezing or
rales).
Now when the stethescope touches you, please say 99.
Use the diaphragm for all 14 spots with arms crossed.
Bronchophony was absent.
Now when the stethescope touches you, please say ee.
Eegophony was absent.
Now when the stethescope touches you, please whisper 123.
Whisper pectriloquy was absent.
If I had time, I'd do the exact same examinations on the chest. Thank you very much. That concludes the examination.
Learning issues:
Describe abnormal breath sounds (bronchial and broncho-vesicular breath sounds etc).
Bronchial breath sounds: heard over manubrium and lobar pneumonia; expiration > inspiration, high
pitch and loud
Broncho-vesicular breath sounds: heard over 1st and 2nd intercostal spaces and interscapular space
(right under clavicles); inspiration > expiration; medium pitch and medium intensity
Vesicular sounds: heard in most of lung; inspiration > expiration, low pitch and soft (quiet)
Tracheal sounds: heard over trachea; inspiration = expiration; high pitch and very loud
What disease causes transmitted voice sounds?
fibrosis, consolidation (pneumothorax, pneumonia)
Describe the adventitious sounds (crackles, wheezes etc)
crackles/rales = discontinuous, nonmusical, and brief; pneumonia, fibrosis, early congestive heart failure, or
bronchitis
wheezes = continuous, musical, prolonged, with hissing or shrill quality; narrowed airways, COPD, or
bronchitis
Describe pleural friction rub and explain how it can be differentiated from pericardial friction rub.
pleural friction rub = inflamed and roughened pleural surface grating against each other; creaking sounds;
disappears when breath is held

10). Perform a general abdominal examination

Inspect the patient in the supine position with the patient exposed and draped adequately, from the foot end of
 the bed for shape, symmetry, contour, and movement with breathing.
Then come to the right side of the patient and inspect the abdomen for scars, straie, position of umbilicus,
visible peristalsis, pulsations and distended veins
Observe for the presence of any herniation and ask the patient to cough to see if a hernia becomes evident.
Auscultate the abdomen in all 4 quadrants for bowel sounds.
Auscultate for bruits over the renal arteries and friction rubs over the liver and spleen.
Percuss the abdomen in all 9 regions and describe the normal tympanic note or any abnormal note, if present.
Palpate the abdomen in all 9 regions by using the technique for light palpation while watching the patients
face and describe the normal findings on palpation (consistency, tenderness, guarding, rigidity, and any
superficial palpable masses).
Repeat by deep palpation in all the 9 regions while timing the palpation to patients breathing pattern and
watching the patients face for any tenderness and describe any palpable organs and masses.
Demonstrate the technique of rebound tenderness.
*Intro:
Wash hands.
Hello, my name is ___. I'm a second year medical student and you are?
May I call you Mr./Mrs. ___?
Thank you, Mr/Mrs. ___. Now, before we begin, I just want to let you know that everything that happens in this room will be
kept confidential between me and my colleagues (indicate people in room) unless you pose a threat to yourself or to others. Is
that alright?
Thank you. Now for this examination, I will be touching various areas of your body. It should not cause pain or discomfort,
but if it does, please let me know. I have already washed my hands.
CCHUBSSSFPP:
foot of bed - Contour, Caput medusae, Herniae, Umbilicus, Breathing, Striae, Scars, Symmetry, Flanks;
at side - Peristalsis, Pulsations
At foot of bed with the patient lying down:
Contour is flat. No visible caput medusae. Will you please turn your head to the side and cough for me?
No hernia seen Umbilicus is inverted and midline. Breathing is non-labored. No signs of striae, scars. Abdomen is
symmetrical with breathing. Flanks are not protruded.
At the right side of the patient (left of bed):
No visible peristalsis. Abdominal aortic pulsation can be lightly seen (it can also not be seen and be normal).
Auscultation:
I will now be listening to your stomach. I'm warming up the stethescope. Please let me know if you feel any discomfort.
Auscultate the abdomen in all four quadrants for bowel sounds.
Normal bowel sounds were present in all four quadrants.
Use the diaphragm over the liver and the spleen to listen for friction rubs.
No friction rubs heard over the liver and spleen.
Use bell to listen for bruits over liver and spleen.
No bruits present over liver and spleen.
Use the bell to auscultate for bruits over the abdominal aorta (below the xiphoid process), the renal arteries (right below the
costal margins near the midline), the iliac arteries (right below the naval on both sides).
No bruits heard in the abdominal aorta, renal arteries, and iliac arteries.
Percussion:
Now I'm going to be tapping on your stomach. Please let me know if you feel uncomfortable.
Percuss the abdomen in all nine regions of the abdomen.
Percussion was tympanic throughout the abdomen.
Now I will be pressing on your stomach. Please let me know if you feel uncomfortable.
Palpation:
With one hand, palpate all nine regions of her abdomen, while watching the patient's face.
Throughout the exam, Mr./Mrs.__ did not guard and showed no signs of tenderness. His/her abdomen was not rigid and had
no (superficial) palpable masses.
Now I'll be pressing a little bit harder. Please let me know if you feel any discomfort.
Palpate with both hands, timing the palpation to the patient's breathing and watching the patient's face for any tenderness.
There were no palpable organs or masses.
Now I'm going to press on your stomach. Please let me know if you feel any pain when I press down or let go.
Press down on any region on the stomach, hold it for a second, then suddenly release. If there's pain upon removal of pressure
peritonitis
Did you feel any pain?
There was no rebound tenderness. Thank you. That concludes this exam.
Learning issues:
How do you describe normal bowel sounds?
bowel sounds are made by the movement of food through the intestines; sounds like bubbles/water pipes
What are the causes of absent bowel sounds and increased bowel sounds (hyperperistalsis)?
absent bowel sounds = ileus = lack of activity; could be a mechanical bowel obstruction (tumor)
decreased bowel sounds = not eaten in a while, during sleep
increased bowel sounds: just eaten or if there's diarrhea
What is the cause of visible peristalsis?
newborns or very thin individuals
intestinal obstruction, the peristaltic wave will temporary increase its force to try and squeeze the contents
past the obstruction resulting in visible peristalsis
11). Examination of the liver
With the patient sitting up and adequately exposed and draped adequately, perform general survey to find out
if there is jaundice, palmar erythema, fetor hepaticus and asterixis (flapping tremor).
With the patient in the supine position, you stand at the foot end of the bed and inspect the abdomen for shape
and contour and then move to the right side of patient to examine the position and shape of umbilicus,
peristalsis, distended veins, scars and straie.
Auscultate for any friction rub and/or bruit over the liver
Percuss to determine liver span starting in the midclavicular line from the right 2nd intercostal space for upper
border and from the right mid inguinal point for the lower border and measure the liver span and compare
with the normal range of liver span.
Palpate the abdomen starting in right iliac fossa and going to the right costal margin as the patient is breathing
in and out, while timing the palpation to patients breathing pattern and watching the patients face for any
evidence of tenderness.
Describe the liver edge, surface, consistency, any nodularity and tenderness, if palpable.
Demonstrate how to perform hooking method.
Demonstrate how to elicit Murphys sign.
*Intro:
Wash hands.
Hello, my name is ___. I'm a second year medical student and you are?
May I call you Mr./Mrs. ___?
Thank you, Mr/Mrs. ___. Now, before we begin, I just want to let you know that everything that happens in this room will be
kept confidential between me and my colleagues (indicate people in room) unless you pose a threat to yourself or to others. Is
that alright?
Thank you. Now for this examination, I will be touching various areas of your body. It should not cause pain or discomfort,
but if it does, please let me know. I have already washed my hands.
Will you please look into my eyes? Sclera are white.
There's no fetor hepaticus.
Will you please hold out your hands with your palms facing me?
No flapping tremor and no signs of palmar erythema.
Will you please lie down for me?
CCHUBSSSFPP:
foot of bed - Contour, Caput medusae, Herniae, Umbilicus, Breathing, Striae, Scars, Symmetry, Flanks;
at side - Peristalsis, Pulsations
At foot of bed with the patient lying down:
Contour is flat. No visible caput medusae. Will you please turn your head to the side and cough for me?
No hernia seen Umbilicus is inverted and midline. Breathing is non-labored. No signs of striae, scars. Abdomen is
symmetrical with breathing. Flanks are not protruded.
At the right side of the patient (left of bed):
No visible peristalsis. Abdominal aortic pulsation can be lightly seen (it can also not be seen and be normal).
Auscultation:
I will now be listening to your stomach. I'm warming up the stethescope. Please let me know if you feel any discomfort.
Auscultate the liver with the diaphragm for for friction rub and with the bell for a bruit.
Friction rub and bruit was not audible. (Should do and say these separately)
Percussion:
Now I'm going to tap on your stomach. Please let me know if you feel any discomfort.
Percuss up from the right iliac fossa to dullness. Mark the point.
Percuss down from halfway up the chest to dullness.
Liver span is within 6-12cm.
Now I'm going to touch your stomach. Please let me know if you feel any discomfort.
Palpation:
Palpate the abdomen starting in the right iliac fossa to the right costal margin as the patient is breathing in and out, timing the
palpation to the patient's breathing pattern and watching the patient's face for any evidence of tenderness.
If liver edge was palpable, then the liver edge should be sharp, non-tender, and have no nodules.
Now I'm going be wrapping my fingers under your ribs. Please let me know if you feel any discomfort.
Have the patient exhale, hook fingers under ribs, ask patient to inhale and try to feel for the liver.
If liver was palpable, its edge should be sharp, smooth, and have no nodules.
Now I'm going to press on your stomach. Please let me know if it hurts.
Press on the liver.
Breathe in please.
 No guarding was present meaning a negative Murphy's sign.
Thank you very much. That concludes the end of this exam.

Learning issues:
What are the most common causes of Liver enlargement?
hepatitic C
cancer
Explain the significance of a friction rub or bruit heard over the liver.
friction rub: liver metastasis or primary hepatoma or liver infarction, partial artery obstruction
bruit: with systolic and diastolic components suggests renal artery stenosis because of hypertension
Explain the significance of a positive Murphys sign.
sharp increase in tenderness with a sudden stop in respiratory effort is positive and indicative of acute
cholecystitis
12). Examination of the spleen.
Inspect the abdomen with the patient in the supine position and adequately exposed and draped adequately,
from the foot of the bed for shape, contour and from the right side of patient for umbilicus, peristalsis,
distended veins, scars and straie.
Auscultate for any friction rub or bruit over the spleen.
Percuss the abdomen starting in right iliac fossa and reaching the left costal margin and up to the left
midaxillary line and describe the percussion note.
Percuss the abdomen in the Traubs space towards the left midaxillary line and elicit splenic percussion sign.
Palpate the abdomen starting in right iliac fossa while timing the palpation to patients breathing pattern and
reaching the left costal margin while watching the patients face for tenderness.
Roll the patient over to the right lateral decubitus position and palpate for the spleen starting at least at the
umbilicus and reaching the left costal margin
Describe if the Spleen is palpable or not.
*Intro:
Wash hands.
Hello, my name is ___. I'm a second year medical student and you are?
May I call you Mr./Mrs. ___?
Thank you, Mr/Mrs. ___. Now, before we begin, I just want to let you know that everything that happens in this room will be
kept confidential between me and my colleagues (indicate people in room) unless you pose a threat to yourself or to others. Is
that alright?
Thank you. Now for this examination, I will be touching various areas of your body. It should not cause pain or discomfort,
but if it does, please let me know. I have already washed my hands.
CCHUBSSSFPP:
foot of bed - Contour, Caput medusae, Herniae, Umbilicus, Breathing, Striae, Scars, Symmetry, Flanks;
at side - Peristalsis, Pulsations
At foot of bed with the patient lying down:
Contour is flat. No visible caput medusae. Will you please turn your head to the side and cough for me?
No hernia seen Umbilicus is inverted and midline. Breathing is non-labored. No signs of striae, scars. Abdomen is
symmetrical with breathing. Flanks are not protruded.
At the right side of the patient (left of bed):
No visible peristalsis. Abdominal aortic pulsation can be lightly seen (it can also not be seen and be normal).
Auscultation:
I will now be listening to your stomach area. I'm warming up the stethescope. Please let me know if you feel any
discomfort.
Using the diaphragm, listen for a friction rub over the spleen.
No friction rub heard over the spleen.
Using the bell, listen for a bruit over the spleen.
No bruit heard over the spleen.
Percussion:
Now I'll be tapping on your stomach. Please let me know if it causes you any discomfort.
Starting from the right iliac fossa, diagonally percuss the abdomen to the left costal margin and up to the left midaxillary line.
Abdominal sounds were tympanic throughout the abdomen and flank.
Keeping your stethescope below the left costal margin ask: Now will you please inhale for me?
Traub's space remained tympanic, which is not indicative of splenomegaly which would sound dull.
Palpation:
Now I'll be pressing on your stomach area. Please let me know if this causes you any pain.
With one hand behind the spleen, starting in the right iliac fossa moving diagonally to the left costal margin, use the other
hand to push down to feel for spleen with patient's inhalation and move up during exhalation, WHILE WATCHING FACE
FOR TENDERNESS.
Spleen was not palpable. No tenderness was observed. Now will you please roll over on your RIGHT side for me?
With one hand behind the location of the spleen, use the other hand to palpate for the spleen starting from the umbilicus up to
the left costal margin.
Spleen was not palpable. No tenderness was observed. Thank you very much. That concludes this examination.
Learning issues:
What are the most common causes of Splenic enlargement?
sickle cell anemia, hemolysis
Explain the significance of a friction rub heard over the spleen.
It would suggest splenic enlargement.
Describe the features of splenic enlargement.
The spleen moves inferior and medially and would be palpable.
How will you differentiate at the bedside Splenic enlargement from left kidney enlargement?
Spleen moves down and medially. Percussion would be dull.
Kidney isn't palpable. It's retroperitoneal and it would be tympanic.
13). Examination for the presence of Ascites
With the patient in the supine position and adequately exposed and appropriately draped, inspect the abdomen
from the foot of the bed for shape, contour, and from right side of patient for everted umbilicus, distended
veins, scars and distention and fullness of flanks.
Auscultate for bowel sounds in at least 4 areas of the abdomen.
Percuss the abdomen starting from the umbilicus towards each flank and describe the percussion note.
Demonstrate how to examine for shifting dullness on both sides and explain the significance if it was present
Demonstrate how to examine for fluid wave and explain the significance if it was present.
*Intro:
Wash hands.
Hello, my name is ___. I'm a second year medical student and you are?
May I call you Mr./Mrs. ___?
Thank you, Mr/Mrs. ___. Now, before we begin, I just want to let you know that everything that happens in this room will be
kept confidential between me and my colleagues (indicate people in room) unless you pose a threat to yourself or to others. Is
that alright?
Thank you. Now for this examination, I will be touching various areas of your body. It should not cause pain or discomfort,
but if it does, please let me know. I have already washed my hands.
CCHUBSSSFPP:
foot of bed - Contour, Caput medusae, Herniae, Umbilicus, Breathing, Striae, Scars, Symmetry, Flanks;
at side - Peristalsis, Pulsations
At foot of bed with the patient lying down:
Contour is flat. No visible caput medusae. Will you please turn your head to the side and cough for me?
No hernia seen Umbilicus is inverted and midline. Breathing is non-labored. No signs of striae, scars. Abdomen is
symmetrical with breathing. Flanks are not protruded.
At the right side of the patient (left of bed):
No visible peristalsis. Abdominal aortic pulsation can be lightly seen (it can also not be seen and be normal).
Auscultation:
I will now be listening to your stomach. I'm warming up the stethescope. Please let me know if you feel any discomfort.
Auscultate for bowel sounds in all four quadrants.
Normal bowel sounds were heard throughout all four quadrants. Now I'll be tapping on your stomach. Please let me know if
this causes you any discomfort.
Percussion:
Percuss the abdomen from the umbilicus, up towards each flank in the shape of a half-smiley face on each side.
Abdomen and flanks were tympanic throughout the exam. If I reached a point of dullness, I would have the patient turn onto
his/her side and percuss again after waiting a few seconds. If the sound remained dull, it may be due to a mass. Then I'd
percuss back down towards the umbilicus until I heard the new point of dullness, which would be where the fluid shifted to.
Now do you mind please holding your hands, pinky side down, over your stomach? Thank you. I'll be lightly tapping each
side of you.
With one hand on one flank, tap the other flank to feel for a ripple. Then do it with the other hand.
Fluid transmission was negative. If it was present, it would suggest ascites. Thank you very much. That concludes this
examination.
Learning issues:
What are the most common causes of ascitis?
portal hypertension
sodium retention via SIADH
What are the causes of distended veins over the abdomen?
obstruction because of clotting or thrombus OR liver cirrhosis, portal hypertension
What is caput medusa?
distended abdomnial veins caused by severe portal hypertension
What are spider neavi?
A small clump of blood vessels (angioma) suggestive of liver cirrhosis
How can you differentiate the dullness in the flanks due to intra-abdominal mass and fluid?
If it's fluid, dullness becomes tympanic when rolling onto a side
If it's a mass, it'll remain dull.
14). Examination of the kidneys
With the patient in the sitting position and adequately exposed and appropriately draped, perform general
inspection for signs of renal disease e.g.: pallor, wasting, a-v shunts, uremic fetor and pedal edema
With the patient in the supine position and adequately exposed and appropriately draped, inspect the abdomen
from the foot end of the bed for shape, contour and from right side of patient for scars, umbilical position and
shape, peristalsis, distended veins and straie.
Auscultate for presence of renal artery bruit.
Percuss and describe the percussion note in both the flanks/lumbar region.
Palpate the kidneys on both sides by both ballottement and capture technique as the patient is breathing in and
out, while watching the patients face for any tenderness.
With the patient sitting up, demonstrate how to elicit costo-vertebral-angle tenderness in the appropriate site.
*Intro:
Wash hands.
Hello, my name is ___. I'm a second year medical student and you are?
May I call you Mr./Mrs. ___?
Thank you, Mr/Mrs. ___. Now, before we begin, I just want to let you know that everything that happens in this room will be
kept confidential between me and my colleagues (indicate people in room) unless you pose a threat to yourself or to others. Is
that alright?
Thank you. Now for this examination, I will be touching various areas of your body. It should not cause pain or discomfort,
but if it does, please let me know. I have already washed my hands.
Mr./Mrs. ___ is not pale, not wasting. I don't see an a-v shunt. S/he has no uremic fetor. Is it alright if I touch your legs?
Check for edema and pitting on dorsum of foot, medial malleolus, and up shins while looking at face.
No signs of non-pitting or pitting pedal edema.
Now will you please lie down for me?
CCHUBSSSFPP:
foot of bed - Contour, Caput medusae, Herniae, Umbilicus, Breathing, Striae, Scars, Symmetry, Flanks;
at side - Peristalsis, Pulsations
At foot of bed with the patient lying down:
Contour is flat. No visible caput medusae. Will you please turn your head to the side and cough for me?
No hernia seen Umbilicus is inverted and midline. Breathing is non-labored. No signs of striae, scars. Abdomen is
symmetrical with breathing. Flanks are not protruded.
At the right side of the patient (left of bed):
No visible peristalsis. Abdominal aortic pulsation can be lightly seen (it can also not be seen and be normal).
Auscultation:
I will now be listening to your stomach. I'm warming up the stethescope. Please let me know if you feel any discomfort.
With the BELL auscultate for renal artery bruit (NOT over the kidneys).
No renal artery bruits heard.
Percussion:
Now I'll be tapping on your stomach region. Please let me know if you feel any discomfort.
Percuss from the umbilicus to the midaxillary lines.
Abdominal sounds were tympanic throughout the abdomen. I will now attempt to feel for the kidneys.
Sandwich the patient's side with your hands.
Mr./Mrs. ___, do you think you can breathe in and hold for me? Please let me know if this causes you any pain.
Try to bounce the kidney with either hand onto the other hand.
Ballottement test was negative. Thank you, you can breathe now.
Standing on the same side of the bed, check the other kidney.
Ballottement test was negative. Thank you, you can exhale now. I'll now be doing a similar test. Do you think you can
breathe in for me?
Try to capture/sandwich the kidney between your hands.
Capture technique was negative.
Do the same for the other side.
Capture test was negative.
Will you please sit up?
I'm going to tap on your back. Please let me know if it hurts. Will you please turn your head towards me?
Tap the back on your hand on the patient's back at about 1/3 up from the elbow on both sides.
Murphy's punch was negative. Thank you very much. That concludes the end of this exam.
Learning issues:
Describe features of kidney enlargement.
kidney moves inferiorly and would be palpable in ballottement and capture.
What are the common causes of kidney enlargement?
masses, lumps, cysts, or polycystic disease
What is the significance of a bruit heard over the renal artery?
renal artery bruit signifies renal artery stenosis
*bruit = obstruction
How can you differentiate at the bedside Splenic enlargement from left kidney enlargement?
spleen moves downwards and medially; percussion would be dull
kidney isn't palpable and would remain tympanic