Professional Documents
Culture Documents
1. Introduce yourself to patient, usually last name and title and have a little conversation to relax the patient
and to judge mental state.
2. Wash hands before starting examination
Preferably, this should be done in view of the patient.
3. Patient is seated in a chair
4. Palpate radial (wrist) Pulses for at least 30 seconds and record
The examiner places the pad of his index, middle and ring fingers over the radial artery. If properly done, the
examiner should be able to feel the artery pulsating under the examiner’s fingertips. The radial pulse may be
measured for 30 seconds, then the pulse perminute can be found by multiplying by two. Attention should also
be paid to the rhythm. The examiner should not use his thumb to palpate any pulse.
5. Palpate both radial (wrist) pulses simultaneously for symmetry for at least 30 seconds
6. Measure respiratory rate for 30 seconds and record
The examiner unobtrusively measures patient’s respiratory rate. This may be accomplished by the examiner
leaving his hands on the patient’s wrists for another 30 seconds after measuring the radial pulses so the patient
does not realize that the examiner is watching him breathe. The depth and rhythm should also be noticed. The
respiratory rate can also be measured during the back exam.
7. Measure blood pressure on right arm
Blood pressure may be measured with the patient in a sitting or lying position. In each position, the artery in
which the blood pressure is to be measured should be at the level of the heart (at the level of the fourth
intercostal space in the sitting position; at the level of the middle axillary line in the lying position). The
patient’s arm should be resting on a smooth table or supported by the examiner, and slightly flexed at the
elbow.
8. Place cuff in correct location 2-3 cm above the antecubital crease
The examiner secures the blood pressure cuff snugly over the upper, arm so that one finger can be admitted
under the cuff. The cuff should be positioned 2 ~ 3 cm above the antecubital crease or elbow joint. Put the
middle of the cuff over the brachial artery.
9. Palpate brachial artery
The examiner can locate the brachial artery which lies slightly medial to the tendon of the biceps muscle in the
antecubital fossa. The mercury column on the manometer dial should be properly calibrated with the pointer at
“0” before the cuff is inflated (i. e. , all the air should be pressed out of the cuff before it is inflated).
The stethoscope is placed firmly over the brachial artery. The examiners inflates the cuff slowly but steadily.
Until the brachial artery pulse disappears. Then he continues to inflate cuff 2.6 ~4.0kPa (20~30 mmHg higher,
generally to about 21.3kPa (160mmHg)).
10. Measure blood pressure over brachial artery twice and record the lower reading
Deflate the cuff slowly at the rate of about 0.26kPa (2mmHg) Per second. The number where the examiner
hears the first pulse sound is the systolic pressure. The pulse sound will waken and then disappear. The number
where the pulse sound disappears is the diastolic pressure. If the difference between weakening of the sound
and its disappearance is 2.6kPa (20mmHg) or greater, the examiner should record these two numbers. The cuff
must be completely emptied with the pointer at “0” before it is reinflated. The same procedure may be followed
for a second measurement of B. P. in the same or opposite arm. The lower pressure is recorded as the patient’s
blood pressure. After finishing the measurement, the examiner deflates and rolls up the cuff, leans the
manometer over a little so the mercury column disappears, closes the mercury column switch, puts the balloon
in order, and closes the manometer.
D. BACK
99. Expose the back correctly
Have the patient undress except for his underwear. With the patient seated, the examiner stands behind the patient
and carefully inspects the spine for any postural abnormalities, configuration and symmetry of chest, and
landmarks of posterior thorax (midspinal line, scapula line, costovertebral angle)
100. Palpate spinous processes one by one (check for scoliosis and tenderness)
With the index and middle fingers, the examiner presses on the patient’s spinous processes from top to bottom
rapidly. The skin shows a red line which should be straight. Normally, no tenderness exists.
101. Test for percussion pain of spinal column one by one (or by indirect method)
For the direct method, the examiner uses a reflex hammer or finger and directly percusses every spinous process.
This method is used mainly for the examination of the lumbar and thoracic vertebeae. Normal individuals have no
percussion pain. For the indirect method, the examiner places his left hand on the top of the patient’s head and
makes a partial fist with his right hand and percusses the left hand with the hypothenar eminence. The examiner
should note the patient’s expression, especially if it is painful.
102. Test CVA for kidney tenderness by pressure and indirect fist percussion
First, the examiner places both thumbs on both Costovertebral Angles and presses. If there is no pain, then the
examiner uses his first to strike gently just below the costovertebral angle on both sides. If there is no pain, then
the examiner should strike with moderate force. This also can be done by indirect first percussion over the
examiners hand placed on the C. V. A. Pay attention to the reaction of the patient.
103. Palpate thoracic expansion and symmetry
Confirm expansion and symmetry of respiratory movement by putting both hands gently on the patient’s rib cage
from behind with fingers between the ribs, thumbs vertical and parallel to the spinal column, at the 10 th costal
level, and have patient breath in and out. The thumbs and fingers are placed as in the figure. Estimate the
movement of the chest and check the resistance of the shest wall at the same time. The examiner notes divergence
of his thumbs and the symmetry of the pump handle effect of both his forearms.
104. Have patient cross arms in front and touch opposite shoulder
Examine the back of the patient’s lungs by asking the patient to bend slightly forward and have both hands touch
the opposite shoulder to expose the interscapular area as widely as possible.
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105. percuss posterior lung fields
To percuss, place the palmar surface of the distal interphalangeal joint of the midfinger of the left hand on the
chest and keep the other fingers of the left hand off the chest wall. The midfinger tip of the right hand strikes over
the distal interphalangeal joint on the chest wall. The strike should be sharp, occur repeatedly, with the movement
coming from the wrist. Each point should be percussed two or three times.
106. Percuss posterior lung fields comparatively and symmetrically
Percuss posterior lung fields comparatively and symmetrically from top to bottom and from lateral to medial.
When percussing interscapular area, middle finger should be parallel to spine, below the scapulae area, middle
finger should be parallel to ribs. Pay attention to the sound and the feeling on the left midfinger.
107. Measure diaphragmatic excursion
Percuss for bottom of lung during normal breathing and then ask patient to take a deep breath and hold it. Percuss
to the lower border of the posterior lung fields. Ask patient to exhale completely. Percuss to the lower border of
the posterior lung fields again, Note the difference between the two points, which should be 6~8cm
108. Instruct the patient to breathe a little deeply with mouth open slightly
109. Auscultate posterior lung fields (see 110)
110. Auscultate comparatively and symmetrically
Auscultate the lungs in the same order as percussed. Pay attention to the change of intensity and nature of the
breath sounds. Differentiate normal breath sounds from abnormal including the presence of bronchial and
bronchovesicular breath sounds that are heard in any area of the lungs that normally have vesicular breath sounds.
Also note increased, decreased, or absent breath sounds, At each point listen to at least one or two full breath
cycles. Use the diaphragmatic chest piece and place it between ribs with moderate pressure.
111. Vocal audible resonance
The examiner asks the patient to whisper “one”, “two”, “three” while examiner auscultates lung fields. Compare
both sides of lung fields
bilaterally and symmetrically.
G. HEART
133. Screening test for elevated venous pressure.
Place patient in semirecumbent position with head elevated to 15~30 degrees.
Observe neck and note distension of external jugular vein. Ask patient to change to a sitting position. In a normal
patient, the distension of the vein will disappear. The distension level should be limited in lower two thirds of the
distance between super clavicle and jaw at supine position.
134. Observe precordium (view tangentially).
Observe precordium with the patient supine. The character and location of any visible cardiac impulses should be
noted. For example: the location, range and intensity of apical impulse should be observed. Normally the PMI can
be located at the 5th left ICS,. 5~1cm medial to the midclavicular line. The area of the pulse will be 2 ~2.5cm in
diameter. In some normal patients this may not be found. Minor precordial movements can be amplified by
observing during expiratory apnea. Tangential lighting may be necessary to see these movements.
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135. Palpate apical area with palm and fingertips.
Palpation serves to confirm the findings detected during inspection and may reveal pulsatile movements or thrills
or friction rubs suggesting specific cardiac disease. Palpate apical (mitral) area with two steps. First, use palm to
palpate apical impulse, and then use one or two finger tips to further localize the impulse. The palm is especially
useful in detecting thrills; fingertips are more helpful in detecting and analyzing pulsations. When you feel the
apical pulse, this indicates the beginning of systole. The apical impulse can be used to distinguish the first and
second heart sounds and to time thrills and murmurs. The apical impulse is always more powerful with the patient
on his left side, which usually displaces the apex 2 ~ 3 cm to the left and brings it closer to the chest wall. For
purposes of auscultation and analysis of the configuration of the apical impulse, this is a useful maneuver, but
assessment as to location and duration of the apical impulse should be made with the patient supine.
136. Palpate precordial area with palm.
Palpate the precordium including the : lower half of the sternum, the 3rd, 4th, and 5th ICS at the left sternal
border, 2nd ICS at the left sternal border, 2nd ICS at the right sternal border, epigastrium and right lower
parasternal border. Examine for pulsation, thrill, pericardial friction rub.
137. Percuss relative dullness of the heart.
Percuss the relative dullness of the heart at the left 5th ICS and record the margin of dullness.
Generally, percussion starts on the left side of the chest, 2 ~ 3cm outside of the apical impulse, and moves
medially until cardiac dullness is perceived in the 5th or possibly the 4th interspace.
If you cannot palpate the apical impulse, you can percuss from 1 ~ 2cm outside of the mid clavicular line in the
5th or 4th ICS and move medially until cardiac dullness is appreciated. Usually, the left border of relative dullness
of the heart in the 5th ICS is located 1 ~2 cm medial to the MCL in normal persons. As more detailed knowledge
of normal and abnormal precordial movements has been accumulated, palpation has largely replaced percussion in
cardiac examination. When one cannot feel the apical impulse, percussion may suggest where to search for it.
Occasionally percussion may be your only tool. For example, a large pericardial effusion may make the impulse
undetectable. Under these circumstances. Cardiac dullness often occupies a large area. Starting well to the left on
the chest, percuss from resonance toward cardiac dullness in the 3rd, 4th, 5th and possibly the 6th interspaces, and
note the change with the patient’s position from reclining to sitting.
Auscultate with diaphragm
Use diaphragmatic head first to auscultate the chest wall using firm pressure. The diaphragm is best for listening
to high frequency sounds. Five reference points are used for localization of sounds on the surface of the chest. The
examiner should follow the following sequence for auscultation:Pulmonic area→Aortic area→2nd Aortic
area→Mitral area→Tricuspid area. One should auscultate for heart rate rythym, heart sounds, murmurs, and
friction rub, Listen at each area for 15 seconds to 1 min. Identify the first and second sounds. Pay attention to the
changes of intensity, nature, splitting of heart sounds, and extra heart sounds. To detect a murmur, pay attention to
the timing, location, duration, quality, radiation, intensity, pitch, and relationship with position of the body,
respiration, exercise, etc. The sounds of greatest importance are the S1 and S2 sounds which divide the cardiac
cycle into systole and diastole. Place the diaphragm onto the pulmonary area. Normally there are two sounds: S1
and S2. Normally, S1 is lower pitched and is softer and longer than S2. With normal rhythm, the interval between
S1 and S2 is shorter than between S2 and the next S1. Sometimes it may be difficult to identify S1 and S2
especially with an abnormal S1 and/or S2. In this case, three techniques may be of value; the apex impulse,
carotid pulses, and the “inch by inch” move. See details of these techniques in Organ System Manual.
138. Pulmonary area (second left ICS).
139. Aortic area (second right ICS).
140. Second aortic area (third and fourth left ICS).
141. Mitral area (Apical area).
142. Tricuspid area (fourth, fifth left ICS, LSB).
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Auscultate with bell
Use bell-type head to auscultate the chest wall using light pressure without leaving a mark. Otherwise, low
frequency sounds may be missed.
143. Pulmonary area
144. Aortic area
145. Second aortic area
146. Mitral area (Apical area)
147. Tricuspid area
H. ABDOMEN
148. Expose abdomen
Both breasts of women should be covered. Expose abdomen completely from just below breasts to just above
pubis.
149. Place pillow under head, bend knees, arms at side, have patient breathe normally. A suitable pillow
should be placed beneath the head. Ask patient to bend his knees, put arms at sides, relax abdominal muscles,
breathe normally.
150. Observe abdomen.
Visualize the abdomen divided into 4 quadrants by a pair of imaginary lines drawn perpendicular to each other
through the umbilicus.
Look at abdominal contour and symmetry. Observe the skin of abdomen, hair, striae (vertical stretch marks which
result from expansion and contraction of abdominal wall such as with pregnancy), scars, location and shape of
umbilicus.
Check respiratory movement as mentioned before. Observe abdominal contour and peristalsis wave tangentially.
Observe abdominal veins. Observe groin area for hernia.
151. Auscultate for bowel sounds. Place stethoscope in area of umbilicus Auscultate bowel sounds with
diaphragmatic head for at least one minute. If there are no bowel sounds, listen until you hear them or for at least
five minutes. Pay attention to the frequency, pitch and intensity.
152. Percuss abdomen
Using indirect percussion, percuss the abdominal four quadrants, from LLQ counterclockwise, and get general
information about the percussion sound (tympany or dullness) of abdomen.
153. Percuss liver span
Percussion should be done with the patient breathing normally through right midclavicular line downward from
resonance in lung field (usually 2 ~ 3 ICS) to dullness and upward from tympany in abdominal field (usually
umbilicus level) to dullness. Estimate or measure from upper to lower dullness for liver span. It is normally about
9~11 cm in midclavicular line.
154. Watch patient’s face and response as you palpate abdomen
When examining abdomen, intermittently pay attention to the patient’s face and withdrawal response which
indicate discomfort and pain.
155. Palpate superficially
Examination is begun with a gentle maneuver. Use the palm of hand, put the four fingers together, with arm
relaxed, press with fingers about 1 cm deep. Palapte all areas of the abdomen counter-clockwise from LLQ. Look
for tenderness or resistance of abdominal muscles and/or enlargement of organs.
156. Palpate deeply
Using right hand , palpate more deeply to find the deep lesions in the abdomen. In some cases, the examiner
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should use both hands. (left fingertips on right DIP joints) to palpate more deeply. Use a forward and backward
circular motion. The order of palpation is the same as for superficial palpation. Screen for tenderness, masses, etc.
157. Palpate liver at midclavicular with monomanual method.
In the midclavicular line, press down firmly and ask the patient to inhale deeply and allow the liver to move down
to meet your fingertips. If you feel the liver, describe the edge (sharp or round and tender or not, hard or soft) and
repeat the process laterally and medially to define the contour. For a mass within the liver, describe the same
characteristics as above and listen for a murmur over the mass. Normally, the liver cannot be felt more than 1 cm
below the costal margin. But failure to feel the liver, does not mean that it is normal.
158. Palpate liver at midclavicular line with bimanual method
Right upper quadrant
With patient lying comfortably on his back, put your left hand on the top of lower rib cage or posteriorly beneath
the right lower rib cage to restrict the movement and thereby encourage abdominal breathing. Place right hand on
the abdominal wall a few centimeters below the lower border of liver dullness. Use the same maneuver as
monomanual method (Figure 2-30).
159. Palpate liver at midsternal line
Palpate superiorly from umbilicus along midsternal line to attempt to locate the medial inferior liver edge, using
the monomanual method.
160. Palpate spleen with bimanual method.
For palpation of spleen, put the left hand behind left rib cage, from about 7th to 10th rib, and press towards
umbilicus. Right hand palpates the spleen starting from umbilical level or below the dullness. The maneuver is the
same as that for the liver but more subtle because the spleen is more mobile and deeper.
161. Palpate spleen with patient rolled toward his right side.
If the spleen is not palpated, have the patient roll on his right side and palpate again.
162. Palpate kidneys with bimanual method.
For palpation of left kidney, put left hand below left rib cage, at the costospinal angle and lift up. Right hand
palpates deeply from umbilicus level in the left midclavicular line and moves progressively upward following
each period of breath. Palpate both kidneys respectively.
163. Test for pain or light touch on abdominal wall.
Ask patient to close his eyes and to respond whenever he feels his skin touched and /or pricked. The examiner
performs this in upper, middle, and lower parts of the abdomen bilaterally and symmetrically.
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