& Asciti'sexamination * Ascitisdifferentials

* Portal
* JVP hypertension
& Acute liver tailme, alcoholic hepatitis, circhosis
* Liver span, size
& Heart ansutation points 4 JVP abnormalities (1.4) causes
I cause at distended jup
 You are viewing Maria Nila L~pez·s screen • ,,. , ,••

• OBJEl'TMS
• REFERENCES
• MEDICAi. msTORY
•

• PE PER SYSTEM
• SIJM Y

-·
• • 160 A
a
Participants Chat Share Sc reen Record Reactions
 You are viewing Maria Nila L~pez·s screen . ,.. • 4•i

• TO REVIEW THE
PARTICIPANTS ON MEDICAL
HISTORY AND PHYSICAL
EXAMINATION

• AT THE END OF THE

PRESENTATION THE
PARTICIPANTS SHALL
UNDERSTAND THE CONCEPT
OF MEDICAL HISTORY
TAKING AND PE

-·
• • 160 A
a
Participants Chat Share Sc reen Record Reactions
• HARRISON'S PRINCIPLES OF
INTERNAL MEDICINE , 2QTH EDITION
BY KASPER , FAUCI , HAUSER , ET.
AL

• BATES' GUIDE TO PHYSICAL

EXAMINATION AND HISTORY
TAKING 12TH EDITION BY LYNN S •
BINCKLEY

• DE GOWIN'S DIAGNOSTIC
EXAMINATION : THE COMPLETE \,; / "~
.. Jl _ , .

GUIDE TO ASSESSMENT \ .••

EXAMINATION DIFFERENTIAL
DIAGNOSIS arH EDITION -~
• THE WASHINGTON MANUAL
OF MEDICAL THERAPEUTICS
35TH ED ITION BY ZACHARY
CREES , CASSANDRA FRITZ,
ALONSO HUEDEBRET , ET. AL.

• ROBBINS AND COTRAN :

PATHOLOGIC BASIS OF
DISEA·S ES , 8TH EDITION
• TEXTBOOK OF MEDICAL
PHYSIOLOGY , 11TH EDITION
BY GUYTON AND HALL

• CLINICAL ANATOMY BY
REGIONS , BY RICHARD S
SNELL , grH EDITION

• PRINCIPLES OF ANATOMY
AND PHYSIOLOGY , 15TH
EDITION BY GERARD J
TORTORA , BRYAN
DERRICKSON
 Earpieces
should always
face forward
Tube

• • transmits s-0unds
from chest piece to
ear pieces

• Bell
used for low frequency

Chest piece
some chest pieces
act as both bell and
dlaphragm, with pressure
determining function

Diaphragm
used for high frequency
sounds
DIAPHRAGM OF STETHOSCOPE
• IT IS BETTER FOR PICKING UP Earpieces
, Chestpiece
THE RELATIVELY HIGHPITCHED •
I
Metal tubes •
I
SOUNDS LIKE SOUNDS OF S1
Headset!
AND S2, THE MURMURS OF
I
I
•
i Bell
(with hole}
AORTIC AND MITRAL •

REGURGITATION , AND Diaphragm

PERICARDlAL FRICTION RUBS

BELL OF THE STETHOSCOPE

• THE BELL IS MORE SENSITIVE Flexible
TO THE LOW-PITCHED SOUNDS rubber tubing
LIKE SOUNDS OF S3 AND S4 AND
THE MURMUR OF MITRAL
STENOSIS
COMPONENTS OF AN ADULT
MEDICAL HISTORY
• IDENTIFYING DATA AND THE SOURCE
OF THE HISTORY ( INFORMANT)
• CHIEF QPMPLAINTS - WRITTEN
BASED ON THE PATIENT'S OWN
WORDS
• HISTORY OF PRESENT ILLNESS
• PAST MEDICAL HISTORY
• FAMILY HISTORY
• PERSONAL AND SOCIAL HISTORY
• REVIEW OF SYSTEM
TECHNIQUE'S OF PE
• INSPECTION
• AUSCULTATION
• PALPATION
• PERCUSSION

••

•
SEQUENCE OF PE
• GENERAL SURVEY
NUTRITIONAL STATUS
LEVEL OF CONSCIOUSNESS
AMBULATION
PRESENCE OF CARDIO-PULMONARY
DISTRESS

• VITAL SIGNS
BLOOD PRESSURE
CARDIAC RATE / PULSE RATE
TEMPERATURE
RESPIRATORY RATE
GLASGOW COMA SCALE
(GCS)
• IT IS USED TO OBJECTIVELY
DESCRIBE THE EXTENT OF
IMPAIRED CONSCIOUSNESS IN ALL
TYPES OF ACUTE MEDICAL AND
TRAUMA PATIENTS

• THE SCALE ASSESSES PATIENTS

ACCORDING TO THREE ASPECTS OF
RESPONSIVENESS: EYE-OPENING ,
MOTOR, AND VERBAL RESPONSES
 -
'- ,,
, 'j
A,. •
\'
__,,.
"'
FEATURE RESPONSE SCORE
OPEN SPONTANEOUSLY 4
EYE RESPONSE OPEN TO VERBAL COMMAND 3

OPEN TO PAIN 2

NO EYE OPENING 1

ORIENTED 5
CONFUSED 4
VERBAL RESPONSE INAPPROPRIATE WORDS 3
INCOMPREHENSIBLE SOUNDS 2
NO VERBAL RESPONSE 1
 FEATURE RESPONSE SCORE
OBEYS COMMAND 6
MOTOR RESPONSE MOVES WITH LOCALIZED PAIN 5

FLEXION WITHDRAWAL FROM PAIN 4

ABNORMAL FLEXION ( DECORTICATE) 3

ABNORMAL EXTENSION 2
(DECEREBRATE)
NO RESPONSE 1

BEST RESPONSE 15
Presenter -
CARDIAC RATE/ PULSE RATE RESPIRATORY RATE

BLOOD PRESSURE TEMPERATURE

PULSE RATE / HEART
RATE
• THE RADIAL PULSE IS COMMONLY
USED TO ASSESS THE HEART RATE

• WITH THE PADS OF YOUR INDEX

AND MIDDLE FINGERS , COMPRESS
THE RADIAL ARTERY UNTIL A
MAXIMAL PULSATION IS DETECTED

• NORMAL PULSE RATE / HEART

RATE IS 60 - 100 BEATS / MIN
RESPIRATORY RATE
\;

• OBSERVE THE RATE, PAUSE.

,, .i
RHYTHM , DEPTH , AND
EFFORT OF BREATHING

• TAKE THE RESPIRATORY

FOR ONE (1) MINUTE BY
SUBTLY OBSERVING PATIENT
I

- 60 -
SEC
• NORMAL RESPIRATORY RATE -L
IS 16 - 20 PER MINUTE
 C!::;: 1.r 'leitL/~~.:- -- I
Ii,;
~ri'II ,~
UNDERWEIGHT <1 8.5
NORMAL 18.5- 24.9
OVERWEIGHT 25.0-29.9
OBESITY I 30.0--34.9
II 35.0- 39.9
EXTREME OBESITY Ill ~40

Sou rce: National Institutes of Health and National Heart, Lung, and Blood Institute : Clinical
Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesit y in
Adults: The Evidence Report. NIH Publication 98-4083. June 1998. Ava ilable at
http://www.nhlbi.nih.gov/ guidelines/obesity/ob_gdlns.pdf. Accessed January 21, 2015
POSITION THE CUFF AND ARM
DURING BP TAKING
• Place the arm at heart level ,
• Place the center of the inflatable BP
apparatus over the brachia! artery.
The lower border of the cuff should be
about 2.5 cm above the antecubital
crease. Secure the cuff snugly
• Slightly flex the patient's arm at the
elbow
• Take the blood pressure
 BLOOD PRESSURE CLASSIFICATION FOR ADULTS (JNC 8,
AMERICAN SOCIETY OF HYPERTENSION, JNC 7)

CATEGORY SYSTOLIC DIASTOLIC

NORMAL <120 <80
PREHYPERTENSION 120- 139 80-89
STAGE 1
HYPERTENSION
Ages 18 to 60 140 - 159 90-99
Years Old; OM OR
RENAL Disease
Age 60 Years Old 150 - 159 90-99

STAGE 2 >
- 160 >
- 100
HYPERTENSION
The American Society of Hypertension raises this cutoff to age :2:80 years.
RECORDING OF THE
GENERAL SURVEY
F / D , F / N , Ambulatory ,
Conscious , Coherent, GCS =
15 ( E=4, V=5 , M=6), Not in
any form of Cardio-respiratory
distress
VITAL SIGNS :
BP=110/70 , CR=80/min ,
RR= 20/min, Temp= 36.5 °C \
 Sternal angle &pastotnal noldl
(Angle of Louis)

2nd rib
Snarvt
2 3
2Mcaml
C&'tlage 3
T4
Bocydltmlll 4
5

6 •
6
7

.,ctw
Cctocktdi 7 11
9
;,1,

f I GU R E 8 • 2. . An terior 11bs and intercosul spaces.

You are viewing Maria Nila L~pez·s screen . ,.. • t•i

na
Anterior
axillary
hn0
.__ M1dcla~tcular
ne

Posterior
Anterior ~ - axillary
axillary lina
ne
 You are viewing Maria Nila l~pez's screen . ,.. • t•i

INSPECTION
• DEFORMITIES OR ASYMMETRY IN
CHEST EXPANSION
• ABNORMAL MUSCLE RETRACTION
OF THE INTERCOSTAL SPACES
DURING INSPIRATION , MOST
VISIBLE IN THE LOWER
INTERCOSTAL SPACES.
• IMPAIRED RESPIRATORY
MOVEMENT ON ONE OR BOTH
SIDES OR A UNILATERAL LAG (OR
DELAY) IN MOVEMENT.
 You are viewing Maria Nila L~pez·s screen . ,.. • 4•i

PALPATION
• AS YOU PALPATE THE CHEST,
FOCUS ON AREAS OF
TENDERNESS OR BRUISING,
RESPIRATORY EXPANSION
• IDENTIFY TENDER AREAS. NOTE
ANY PALPABLE CREPITUS,
DEFINED AS A CRACKLING OR
GRINDING SOUND OVER BONES,
JOINTS, OR SKIN, WITH OR
WITHOUT PAIN, DUE TO AIR IN THE
SUBCUTANEOUS TISSUE
• TEST CHEST EXPANSION
 You are viewing Maria Nila Lopez's screen . ,.. • t•i

Q Pws1ionloca:lcn

0 0
( •
I 0 (- - Scapola, luie

0----0 0 0
0 ~- - 0'
o O oo
Ve1te!xi!I llne- --

.,.
0 0
oo oo
'

(l 0 0 (:'

PERCUSS AND AUSCULTATE IN A "LADDER" PATTERN

 You are viewing Maria Nila L~pez·s screen · '.' • 4•i

AUSCULTATION
• LISTEN TO THE CHEST
ANTERIORLY AND LATERALLY AS
THE PATIENT BREATHES WITH
MOUTH OPEN , AND SOMEWHAT
MORE DEEPLY THAN NORMAL

• COMPARE SYMMETRIC AREAS

OF THE LUNGS, USING THE
PATTERN SUGGESTED FO,R
PERCUSSION AND EXTENDING IT
TO ADJACENT AREAS, IF
INDICATED
RECORDING THE PHYSICAL
EXAMINATION-THE CHEST
/THORAX AND LUNGS

CHEST •
• NO LESIONS, .
'
SYMMETRICAL CHEST r
•

EXPANSION , NO RETRACTIONS '

I
I
NOTED, NO RALES NO I

'
WHEEZES NOTED, NO
•
DULLNESS NOTED I
'
 Lung Examination

Patientsitting down & body undressed

upper
·

inspection clues like,

- >

lesions, retractions, asymmetrical expansion,altered respiratory rate, use at excessory muscles

·
Percussion Pulmonary Respiratory Mobility
->

one middle finger Rimly Chest expansion ->

determine
transition from resonance to
patients chest I strike it Hold chestRom lateral sides a create dulness
on
complete expiration & then
->
on on
middle finger at other
with mild skin folds, upon inspiration complete inspiration
hand folds should vanish [Pulmonary Respiratory Mobility Distance -

lung produces resonantsound,

- >

lateletesis, Prmothorax assymetricexpansion]

- >
-

bett both borders]

dull sound - level
below the
at lungs Tactile Fremitus Isound conduction]
Hold lower chest I ask to
say "99"
->

Dullness Tumor, elusions

-

in deep voice: Mild vibrations

Hyperesonance emphysema ->
tactile
↑

Remitus-Premonia,
Pneumothorax ↓ Fremitus-Pleural lesion
Plaal elusion-dullness that
rises on medial
lateral Bronchophony
whisper"61" 4 auscultate
to ·
Ask to

it unilateral dullness: always

- > [lowder whisper means increased sound conduction
other side to contin 9 vice versa)
compare to
->

stepladder pattern in
upper shut
to lateral
I medial in lower chest

Auscultation

listen while deep breaths from mouth

upper airways bronchial breathsounds
-

it heard lower pathological

-

·if pneumoniasuspected ->

auscultate apercuss from
anterior as well areas al
(il heard in other
Lung]

Due to: al
->Due to
passage
air through narrowed
lumen [obstruction]

·
Rhoneli-> same as where but
low pitch
->
caves same as well
obstruction in upper
airway
->
THE DIAPHRAGM OF Earpieces
I
STETHOSCOPE •
I
Metal tubes •
I
•
\
• THE DIAPHRAGM IS BETTER Headset!
I
•
; Bell
FOR PICKING UP THE ,'
• (with hole)
RELATIVELY HIGHPITCHED I'
•
I Diaphragm
SOUNDS OF S1 AND S2, THE I
•
•
MURMURS OF AORTIC AND
,,,'
I

MITRAL REGURGITATION, AND ,.,'

PERICARDIAL FRICTION RUBS. •' I
l
LISTEN THROUGHOUT THE Flexible
PRECORDIUM WITH THE rubber tubing
DIAPHRAGM, PRESSING IT
FIRMLY AGAINST THE CHEST.
PE OF THE HEART ·

• VISUALIZE THE UNDERLYING

STRUCTURES OF THE HEART AS
YOU INSPECT THE ANTERIOR
CHEST. NOTE THAT THE RIGHT
/

VENTRICLE (RV) OCCUPIES MOST

OF THE ANTERIOR CARDIAC
SURFACE. THIS CHAMBER AND THE
PULMONARY ARTERY FORM A Nno~atrty .
WEDGELIKE STRUCTURE BEHIND
AND TO THE LEFT OF THE Aighlventricit3,...
STERNUM
PE OF THE HEART
• THE LEFT VENTRICLE, BEHIND THE
RV AND TO THE LEFT, FORMS THE
LEFT LATERAL MARGIN OF THE
HEART ITS TAPERED INFERIOR TIP
IS OFTEN TERMED THE CARDIAC
APEX
• CARDIAC APEX IS CLINICALLY
IMPORTANT BECAUSE IT
PRODUCES THE APICAL IMPULSE,
IDENTIFIED DURING PALPATION AND
~Yl!fffle
AUSCULTATION OF THE
PRECORDIUM AS THE POINT OF macm

MAXIMAL IMPULSE (PM/)

 You are viewing Maria Nila l~pez·s screen

The p~int of maximal impulse is usually

located in the left anteriOf' chest, in the
mldclavlcula lino, at tho fifth lnte<costal
spac-0. This Is an exce 118tlt place 10
auscul1ate heart sounds and api~I pulSe

•
•I
I
I
I

•
• •
 You are viewing Maria Nila L~pez·s screen . ,.. • 4•i

7
J
10

FI G U R E 8 • > Anterior ribs and lnttn:ostaf ~ -

 You are viewing Maria Nila Lopez's screen . ,.. • t•i

I
••
•
Ar:Gl
(
'

.. w
l l
.-I,
·~
1Ptf0-S1CAIAI.: J
/

I!,• l.• } f

'.,I :i: !g-

• •c u
> I \
I
I
••

-1i~ ·1
E I •·-
•r IJ .... •
\ \

' 0.
 You are viewing Maria Nila L~pez's screen . ,.. • 4•i

"11ldstornal
nne Antonot
axt'llary
111\Q

Midaxillary
line
Mlddavicolar
lme
Postenor
axillaryJ"--..J
tine

Anterlor---
axillaey
lane
 You are viewing Maria Nila L~pez·s screen . ,.. • 4• i

Suprasternal notch

I ,,
Sternal ridge ~y
111 ;:;
("Angle of Louis") ~'l
\i~
;:,::

2"0 lntercostal space , ...

i
••
• ••• '
'
•• •
•
•

4th lntercostal space

i l\ \
-..,
QI ' '
z
>-
,,, 5
IX
ct
ercostal space
-
.J
.1 a::
-
.J
.J
ct X
)C .J
• C[

•••'
•• a: -<
..J
)ll
er
-
•
••
•••
••
•••
0
a: ..,ul -
0
ll'.
•••
• ••• .-z
I.I)

,•
0
• •••
• <II
-r
0

.• er
 You are viewing Maria Nila Lopez's screen . ,.. • t•i

,,
,~
''jl :;;
'I
~·'t.
\"
\J, """
'E::'

, ...
i (&J"
z- .
j \t
\ Scapular
-' !Ille
.,)~ 5 a:
-
• ({
.J

-«
.J
-' ¢
"'
-<
....
)C .J
<r
a: )I(
tr
-
0
u.l
-'
-
0
a:
w
VertobraJ
line

r-
0
Cl) I-
0
z
c:r
 You are viewing Maria Nila L~pez's screen . ,.. • 4•i

Aortic Pulmonic
area area

I 2 I.cl\ n1riun1
•
1

3 rt1c va
Pul11101111J\,'
4
,al\'c
-

5
l{islit a1riu1n
• • ilml \nl

_... Len \Clllricl~

I
Tricuspid Mitral l)lood llo\\
Source: T.E. Di!Yenport,
area
K. lwllg, C.A. Sellelslci, J. Gotdon,
area lhr-0ugh 11 'art
I • ; • • - . • •
 You are viewing Maria Nila L~pez's screen . ,.. • 4•i

Aortic Pulmonic
area area
~{id Cla,·icular

I 2
61 3
4
5
e

I
Tricuspid Mitra!
_ , T,E.
area s.beltlci, l , Gotdo<I-,
K. KIJIIO, C.A.
area
11:.G, W•ID• ~ f t - lo, Pltvllal Tbfflloim, >, ~ B H « I
~ : www.f~locllon.c:orn
COoynoht O Mc.Grlw-tfiV ~tiOCI. 4 riotu _,vecl,
You are viewing Maria Nila L~pez·s screen . ,.. • 4• i

Cardiac auscultation is performed systematically over five locations on

the anterior chest wall. Use the stethoscope's diaphragm, swrtching to
the bell to hear lower pitched sounds.

Second right
Aortic
intercostal space
Valve
(ICS), right
Area
sternal border
Second left
Pulmonic
intercostal space
Valve
(ICS), left sternal
Area
border
Erb's Third left ICS. left
Point sternal border
Tricuspid
Fourth left ICS,
Valve
left sternal border
Area
l\1itral Fifth ICS, left
Valve mid-clavicular
Area line
 You are viewing Maria Nila L~pez·s screen

-- GRADE 1
GRADE DESCRIPTION OF CARDIAC MURMUR
VERY FAINT , HEARD ONLY AFTER EXAMINER HAS "TUNED
INflMAY NOT BE HEARD IN ALL POSITIONS
,

GRADE2 QUIET BUT HEARD IMMEDIATELY AFTER PLACING THE

STETHOSCOPE ON THE CHEST

GRADE3 MODERATELY LOUD

GRADE4 LOUD W ITH PALPABLE THRILL

GRADES VERY LOUD , WITH THRILL , MAY BE HEARD WHEN THE

STETHOSCOPE IS PARTLY OFF THE CHEST

GRADE6 VERY LOUD , WJTH THRILL CAN BE HEARD WITH THE

STEHOSCOPE OFF THE CHEST
 You are viewing Maria Nila L~pez·s screen · '.' • 4• i

• PALPATION HAS REPLACED

PERCUSSION IN THE ESTIMATION OF
CARDIAC SIZE

• WHEN YOU CANNOT FEEL THE

APICAL IMPULSE, PERCUSSION MAY
BE YOUR ONLY OPTION, ALTHOUGH
IT IS NOT ALWAYS RELIABLE

* • UNDER THESE CIRCUMSTANCES,

CARDIAC DULLNESS CAN OCCUPY A
LARGE AREA. STARTING WELL TO
THE LEFT ON THE CHEST, PERCUSS
FROM RESONANCE TOWARD
CARDIAC DULLNESS IN THE 3RD,
4TH, 5TH, AND POSSIBLY 6TH
ON A NORMAL/ UNREMARKABLE PE
OF THE HEART
HEART : ADYNAMIC PRECORDIUM ,
REGULAR RATE , REGULAR RHYTHM ,
PMI ON 5 TH ICS MCL, NO MURMUR ,
NO THRILL
resenter
EXAMPLE OF REPORTING WITH A
PATHOLOGIC FINDINGS
HEART : DYNAMIC PRECORDIUM ,
TACHYCARDIC, IRREGULAR RHYTHM ,
PMI ON 5 TH ICS AAL, (+) GRADE 4/6
DIASTOLIC RUMBLING LOW PITCHED
MURMUR BEST HEARD ON 5 TH ICS
 * Normal Heart sounds

·
Si-atthe start al systolic contraction as ventricles
due toclosure of
->

tricuspid & mitral value

·
32 after systolic contraction iscomplete
-

Due to closure at semilunar

->
values
·

S3-Aproximately 0.is after 32

->
Due to rapid ventricular filling,
pulling a chordal tendinae
·
S4 ->

beones! (always abnormal]

->
Due to still hypertrophic ventricles

* Anscultation

·
Valve stenosis -

Hypertrophy a
preceding (alum/vent]
heartcompartment
·

valve loose (Regurgitation -

dilatation a preading Heartcompartment

Type a Murmur cause Pathology

mid diastolic, lowpitched, Mitral stenosis RhumaticHeartDisease, Infective endocarditis
Rumbling
·

COUD

Pan-systolic murmur, High pitched Mitral Regurgitation

throughoutsystolicperiod

Aortic Stenosis
Ejectionsystolehigh pitchit
·

Early diastolic, soft AorticRegurgitation

 You are viewing Maria Nila Lopez's screen . ,.. • t• i

Right Upper Left Upper

Quadrant (RUQ) Quadrant (LUO)

Right Lower Left Lower

Quadrant (RLQ) Quadrant (LLQ)

Abdominopelvic
·Q uadrants
 You are viewing Maria Nila L~pez·s screen . ,.. • t•i

QUADRANTS OF THE ABDOMEN Abdominal Organs

LIVER l.EFTLoeE
STOMAat!CUT'I
ILUO I
WEN

IOONEY
flJGHTLOBE
GAU.BlAOOEH ouooe.w
IIIGHTUPNR LIFf. BllEOOCT PAtX:REAS
QUADIWff
Kl>NEY P.w-REATIC DUCT
~VEflSE
CClONICUT} OESCENOINO
~SCENOING OOtON
COLON
IIIOtlTLO.td CECIJM SMAU. L'filSTINE
QUADMIT VEIWIFORM
UMBUCUS
APPENOiX
UTERUS RECTW
OVARIES UDEil
ANUS
IALO I ILLQ I
 You are viewing Maria Nila L~pez·s screen . ,.. • t•i

,I

Right Eplgastric Leh

hypochondrium region hypochond m

\
)

) Right left
Umbllkal
lumbar region lumbar

Right Left
Iliac region Hypogasmum IIlac region

. - . ..

QUADRANTS OF
REGIONS OF THE ABDOMEN
THE ABDOMEN
 ' a Lopez
You are viewing Maria N"I ~- =:,.~s screen
--

...... ... •• •••••••• •• • •••

•• _._..

.•
•

Right
•
•...____.
~-=- ·4ett
••
•
•
Eplgastrfc
hypochondriac hypocbondrlac
region region region
• •••
Right f plga.stric Left
hypochondnum region •I
hypochondri\lm ••
Right Lett
lumbar Umbllleal lumbar
region region region
) Right Umblllcal Left
lumbar region lumbar

Right Left
Iliac Hypogastric Jllac
region region region
Right
Hypogastrlum
Leh ·-
iliac region 11lac region
 You are viewing Maria Nila Lopez's screen . ,.. • t•i

ORDER OF PHYSICAL
EXAMINATIONE OF THE
ABDOMEN USING THE
EXAMINATION TECHNIQUE
1. INSPECTION
2. AUSCULTATION
3. PERCUSSION B

4. PALPATION
I
• LIGHT PALPATION
• DEEP PLPATION
 You are viewing Maria Nila L~pez·s screen . ,.. • 4•i

INSPECTION
• OBSERVE THE GENERAL
APPEARANCE OF THE PATIENT-
LYING QUIETLY, WRITHING WITH
DISCOMFORT, OR GRIPPING ONE
SIDE
• TAKE NOTE OF THE CHARACTER
OF THE SKIN IN THE ABDOMEN ,
SCARS , LESIONS , PULSATIONS
OR PERISTALTIC MOVEMENT
• TAKE NOTE OF THE UMBILICUS
AUSCULTATION
• AUSCULTATE THE ABDOMEN
BEFORE PERFORMING Aorla
PERCUSSION OR PALPATION ,
MANEUVERS WHICH MAY ALTER
THE CHARACTERISTICS OF THE
BOWEL SOUNDS
• I - -------- Renal artory

• PLACE THE DIAPHRAGM OF

YOUR STETHOSCOPE GENTLY
ON THE ABDOMEN. LISTEN FOR
-------+- llac artery
BOWEL SOUNDS AND NOTE
THEIR FREQUENCY AND
CHARACTER
- - - - li!moral arte.y
• TAKE NOTE OF BRUIT AND
FR IC TIO N RUB .____..._____,
AUSCULTATE FOR BRUITS
PERCUSSION
• IT HELPS YOU ASSESS THE
AMOUNT AND DISTRIBUTION OF
GAS IN THE ABDOMEN , VISCERA
AND MASSES THAT ARE SOLID
OR FLUID-FILLED, AND THE SIZE
OF THE LIVER AND SPLEEN
P lt" CUSSIO N t.U-
1:t&

• PERCUSS THE ABDOMEN

LIGHTLY IN ALL FOUR
QUADRANTS TO DETERMINE THE
DISTRIBUTl'ON OF TYMPANY AND
DULLNESS
1«1.:it1 ti~ fell an.\ nph1ab.lniMn •lu,.aW!Je I'""'"".,_,
.,b.•\.--c- rr.rt hdt'U\ 1hr: nrubd k, 1 \ f c,,~i r.,;.-nmiers" f II pt-mu f
nr Ilk". "'- !J1"l"I"",
----~
PALPATION
A
LIGHT PALPATION
• GENTLE PALPATION AIDS
DETECTION OF ABDOMINAL
TENDERNESS , MUSCULAR
RESISTANCE, AND SOME I
SUPERFICIAL ORGANS AND
MASSES
• IT ALSO REASSURES AND
RELAXES THE PATIENT
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PALPATION
DEEP PALPATION
• IT IS USUALLY REQUIRED TO
DELINEATE THE LIVER EDGE,
THE KIDNEYS, AND
ABDOMINAL MASSES
• PERFORM THE MANEUVER
IN ALL FOUR QUADRANTS OF
THE ABDOMEN
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EDEMA
PITTING EDEMA
• IT IS A SOFT, BILATERAL
PALPABLE SWELLING FROM
INCREASED INTERSTITIAL FLUID
VOLUME AND RETENTION OF
SALT AND WATER,
DEMONSTRATED BY PITTING
AFTER 1 TO 2 SECONDS OF
THUMB PRESSURE ON THE
ANTERIOR TIBIAE AND FEET
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12mm depression , barely detectable.

1+
j Immediate rebound .
14mm deep pit.
2+
A few seconds to rebound .
6mm deep pit.
3+
[10-12 seconds to rebound .
1 smm: very deep pit.
4+
> 20 seconds to rebound .
-

t+
P\ltlng
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'
"TH·E PURPOSE OF SlethoscoF
Is tho only Jcwcl~ry
A DOCTOR OR ANY that con't be eoffll!d by
money.
HUMAN IN It con lll'lly be earned by
passion and hard work
GENERAL SHOULD -.modk°""llon.,-

NOT SIMPLY TO
DELAY THE DEATH
OF PATIENT, BUT
TO INCREASE THE
PERSON'S
QUALITY OF LIFE "

- PATCH ADAMS
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• A THOROUGH MEDICAL
HISTORY AND PE ARE
IMPOIRTANT TO ARRIVE AT
A DIAGNOSIS

• TECHNIQUES FOR
PHYSICAL EXAMINATION
INCLUDES INSPECTION,
AUSCULTATION ,PALPATION
AND PERCUSSION
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• THE DIAPHRAGM OF THE

STETHOSCOPE IS BETTER FOR
PICKING UP THE RELATIVELY
HIGHPITCHED SOUNDS

• THE BELL OF THE STETHOSCOPE

IS MORE SENSITIVE TO THE LOW-
PITCHED SOUNDS

• ANATOMICAL LANDMARKS GUIDE

THE CLINICIANS IN THE
CONDUCT OF PHYSICAL
EXAMINATION
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