Chapter 5: Adult Physical Assessment

THE PATIENT HISTORY

GENERAL PRINCIPLES

• The first step in caring for a patient and in soliciting active cooperation is to gather a careful and complete history.
  • In all patient concerns and problems, an accurate history is the foundation on which data collection and the process of assessment are based.
  • The comprehensiveness of the history elicited will depend on the information available in the patient's record and the reliability of the patient.
• Time spent early in the nurse-patient relationship gathering detailed information about what the patient knows, thinks, and feels about the problems will prevent time-consuming errors and misunderstandings later.
• Skill in interviewing will affect both the accuracy of information elicited and the quality of the relationship established with the patient. This point cannot be overemphasized; the reader is encouraged to consult other sources for detailed discussion of techniques of health interviewing.
• The purpose of the interview is to encourage an exchange of information between the patient and the nurse. The patient must feel that his words are understood and that concerns are being heard and dealt with sensitively.

INTERVIEWING TECHNIQUES

• Provide privacy in as quiet a place as possible and see that the patient is comfortable.
• Begin the interview with a courteous greeting and an introduction. Address the patient as Mr., Mrs., or Ms. and shake hands if appropriate. Explain who you are and the reason for your presence.
• Make sure that facial expressions, body movements, and tone of voice are pleasant, unhurried, and nonjudgmental, and that they convey the attitude of a sensitive listener so the patient will feel free to express his thoughts and feelings.
• Avoid reassuring the patient prematurely (before you have adequate information about the problem). This only cuts
  

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  off discussion; the patient may then be unwilling to bring up a problem causing concern.
• At times, a patient gives cues or suggests information, but does not tell enough. It may be necessary to probe for more information to obtain a thorough history; the patient must realize that this is done for his benefit.
• Guide the interview so the necessary information is obtained without cutting off discussion. Controlling a rambling patient is often difficult but, with practice, it can be done without jeopardizing the quality of the information gained.

IDENTIFYING INFORMATION

Purposes

• To eliminate confusion about the patient's identity and obtain the information required for contacting the patient if the need arises
• To provide you with an introduction to the patient and some indication of his habits, lifestyle, and beliefs, which may be explored in greater depth in the personal and social history
• To initiate a relationship based on recognition of the importance of the informant's role in sharing in the care of the patient (when this is the case)

Types of Information Needed

• Date and time
• Patient's name, address, telephone number, race, religion, birth date, and age
• Name of referring practitioner
• Insurance data
• Name of informant—the patient may be the person giving the history; if not, record the name, address, telephone number, and relationship to the patient of the person giving the history
• Accuracy and reliability of informant—this is a judgment based on the consistency of responses to questions and on a comparison of information in the history with your own observations in the physical examination

Method of Collecting Data

• Careful interviewing of the patient or caregiver will provide most of the information.
• The patient's hospital or clinic record may also be a valuable source.
• Repeat information when necessary to verify accuracy (eg, to ensure that there has been no change in address or telephone number).
• Assume a direct and professional manner.
• Explain the reasons why the information is needed to help put the patient at ease.

CHIEF COMPLAINT

Purposes

• To allow the patient to describe his own problems and expectations with little or no direction from the interviewer
• To identify the overriding problem for which the patient is seeking help
  • Adults with chronic conditions often have numerous complaints.
  • If possible, focus on a single problem or concern—the one most important to the patient.
• To identify the patient's feelings about symptoms (The patient may show fear, guilt, or defensiveness in this first statement.)

Types of Information Needed

A brief statement of the patient's primary problem or concern in the patient's own words, including the duration of the complaint. Example: “hacking cough × 3 weeks.”

Method of Collecting Data

• Ask the patient a direct question such as, “For what reason have you come to the hospital?” or “What seems to be bothering your most at this time?”
• Avoid confusing questions such as, “What brings you here?” (“The bus.”) or “Why are you here?” (“That's what I came to find out.”)
• Ask how long the concern or problem has been present; for example, whether it has been hours, days, or weeks. If necessary, establish the time of onset precisely by offering such clues as “Did you feel this way a month (6 months or 2 years) ago?”
• Let the patient speak freely without offering your opinion until he has had an opportunity to identify the problem as clearly as possible.
• Write down what the patient says using quotation marks to identify patient's words.

HISTORY OF PRESENT ILLNESS

Purposes

• To amplify the description of the chief complaint and to clarify its relationship to other symptoms and events
• To complete a symptom analysis by carefully describing a symptom or problem that may be a clue to future diagnosis

Types of Information Needed

• A detailed chronological picture beginning with the time the patient was last well (or, in the case of a problem with an acute onset, the patient's condition just before the onset of the problem) and ending with a description of the patient's current condition.
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• If there is more than one important problem, each is described in a separate, chronologically organized paragraph in the written history of present illness.
• The outline for reporting the present illness will vary with each case.

Method of Collecting Data

• Investigate the chief complaint by eliciting more information through the use of the pneumonic “OLD CARTS”:
  • Onset (setting, circumstances, rapidity, or manner in which it began)
  • Location (exact place where the symptom is felt, radiation pattern)
  • Duration (how long; if intermittent, the frequency and duration of each episode)
  • Character/course (nature or quality of the symptom, such as sharp pain, interference with activity, how it has changed or evolved over time; ask to describe a typical episode)
  • Aggravating/associated factors (medications, rest, activity, diet; associated nausea, fever, and other symptoms)
  • Relieving factors (lying down, having bowel movement)
  • Treatments tried (pharmacologic and nonpharmacologic methods attempted and their outcomes)
  • Severity (the quantity of the symptom; for example, how severe on scale of 1 to 10)
• Alternately, use the pneumonic PQRST: provocative/palliative factors, quality/quantity, region/radiation, severity, timing.
• Obtain OLD CARTS data for all the major problems associated with the present illness, as applicable.
• Clarify the chronology of the illness by asking questions and summarizing the history of present illness for the patient to comment on.
• In the case of acute infections, inquire about possible exposure or an incubation period.
• In both acute and chronic illnesses, note whether the patient has experienced a change in function or activity due to illness.
• Get the patient's subjective appraisal of whether the symptom or problem is getting better or worse.
• Organize the information for recording or presentation.

PAST MEDICAL HISTORY

Purposes

• To determine the background health status of the patient, including present status, recent health conditions, and past health conditions
• To identify any change in the patient's normal pattern of health as well as clues that may aid in diagnosing the present illness
• To serve as a basis for nursing care planning for holistic patient care

Types of Information Needed

• General health and lifestyle patterns—sleeping pattern, diet, stability of weight, usual exercise and activities, use of tobacco, alcohol, illicit drugs
• Acute infectious diseases—measles, mumps, whooping cough, chickenpox, pneumonia, pleurisy, tuberculosis, scarlet fever, acute rheumatic fever, rheumatic heart disease, tonsillitis, hepatitis, polio, sexually transmitted disease (STD), tropical or parasitic diseases, any other acute infectious problem the patient describes
• Immunization—polio, diphtheria, pertussis, tetanus, measles, mumps, rubella, haemophilus influenza type b, hepatitis B, hepatitis A, pneumococcal influenza, varicella, Lyme, and last purified protein derivative or other skin test, abnormal or unusual reactions (give date when possible)
• Operation—indications, diagnosis, dates, hospital, surgeon, complications
• Previous hospitalizations—physician, hospital data (year), diagnosis, treatment
• Injuries—type, treatment, outcome
• Major acute and chronic illnesses (any serious or prolonged illnesses not requiring hospitalization)—dates, symptoms, course, treatment
• Medications—prescription drugs from all providers (including ophthalmologist and dentist); nonprescription drugs including vitamins, supplements, and herbal products; include dosage, length of use, and adherence
• Allergies—environmental allergies, food allergies, drug reactions; give type of reaction (hives, rhinitis, local reaction, angioedema, anaphylaxis)
• Obstetric history (may appear in review of systems)
  • Pregnancies, miscarriages, abortions
  • Describe course of pregnancy, labor, and delivery; date, place of delivery
• Psychiatric history (may appear in review of systems)—treatment by a mental health provider, diagnosis, date, place, medications

Method of Collecting Data

• Begin by explaining the purpose and type of questions you will be asking; for example, “I am now going to ask you some questions about your past health.”
• Explain that these questions are important to obtain an accurate picture of all the events that affected or that did not affect the patient's health in the past.
• Use direct questions; for example, “How would you describe your general health?” and then proceed with more specific queries, such as “Has your weight been stable over the past 5 years?”

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FAMILY HISTORY

Purposes

• To present a picture of the patient's family health, including that of grandparents, parents, brothers, sisters, aunts, and uncles. It also involves the health of close relatives because some diseases show a familial tendency or are hereditary.
• To describe the health of the patient's spouse and children because this may give clues about possible communicable disease problems. It also will be important in determining what sort of condition a family is in and how this affects the patient.

Types of Information Needed

• Age and health status (or age at and cause of death) of maternal and paternal grandparents, parents, siblings
• History, in immediate and close relatives, of heart disease, hypertension, stroke, diabetes, gout, kidney disease or stones, thyroid disease, pulmonary disease, blood problems, cancer (types), epilepsy, mental illness, arthritis, alcoholism, obesity
• Genetic disorders, such as hemophilia or sickle cell disease
• Age and health status of spouse and children

Method of Collecting Data

• Begin with an explanation of what you are asking and why because the patient may not understand the purpose of your questions. For example: “I am going to ask about the health of your immediate family and relatives. It is important to know if there are any conditions that tend to or could occur in your family, or in you as a member of the family.”
• Ask direct questions.
  • Begin with the patient's siblings.
    “Do you have any brothers and sisters?”
    How old are they and what is the state of their health?”
  • List each sibling separately, giving age and state of health.

REVIEW OF SYSTEMS

Purposes

• To obtain detailed information about the current state of the patient and any past symptoms, or lack of symptoms, patient may have experienced related to a particular body system
• May give clues to diagnosis of multisystem disorders or progression of a disorder to other areas

Types of Information Needed

Subjective information about what the patient feels or sees with regard to the major systems of the body.

• Skin—rash, itching, change in pigmentation or texture, sweating, hair growth and distribution, condition of nails, skin care habits, protection from sun
• Skeletal—stiffness of joints, pain, deformity, restriction of motion, swelling, redness, heat (If there are problems, ask the patient to specify any activities of daily life that are difficult or impossible to perform.)
• Head—headaches, dizziness, syncope, head injuries
• Eyes—vision, pain, diplopia, photophobia, blind spots, itching, burning, discharge, recent change in appearance or vision, glaucoma, cataracts, glasses or contact lenses worn, date of last refraction, infection
• Ears—hearing acuity, earache, discharge, tinnitus, vertigo, history of tubes or infection
• Nose—sense of smell, frequency of colds, obstruction, epistaxis, postnasal discharge, sinus pain or therapy, use of nose drops or sprays (type and frequency)
• Teeth—pain; bleeding, swollen or receding gums; recent abscesses, extractions; dentures; dental hygiene practices, last dental examination
• Mouth and tongue—soreness of tongue or buccal mucosa, ulcers, swelling
• Throat—sore throat, tonsillitis, hoarseness, dysphagia
• Neck—pain, stiffness, swelling, enlarged glands or lymph nodes
• Endocrine—goiter, thyroid tenderness, tremors, weakness, tolerance to heat and cold, changes in hat or glove size, changes in skin pigmentation, libido, easy bruising, muscle cramps, polyuria, polydipsia, polyphagia, hormone therapy, unexplained weight change
• Respiratory
  • Pain in the chest and relationship to respirations
  • Dyspnea, wheezing, cough, sputum (character, quantity), hemoptysis
  • Last tuberculin test or chest X-ray and result (indicate where obtained)
  • Exposure to tuberculosis
• Cardiovascular
  • Presence of pain or distress and location (have patient point to location); radiation of pain; precipitating or aggravating causes; alleviating measures; timing and duration
  • Palpitations, dyspnea, orthopnea (note number of pillows required for sleeping), history of heart murmur, edema, cyanosis, claudication, varicose veins
  • Exercise tolerance (determine in relation to patient's regular activities—how much can he do before stopping to rest?)
  • Blood pressure (if known): last electrocardiogram (ECG) and results (indicate where obtained)
• Hematologic—anemia (if so, treatment received), tendency to bruise or bleed, thromboses, thrombophlebitis, any known abnormalities of blood cells
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• Lymph nodes—enlargement, tenderness, suppuration, duration and progress of abnormality
• Gastrointestinal
  • Appetite and digestion, intolerance to certain classes of foods
  • Pain associated with hunger or eating, eructation, regurgitation, heartburn, nausea, vomiting, hematemesis
  • Regularity of bowel movement (describe normal bowel habits and whether they have changed recently); diarrhea, flatulence, stools (color—brown, black, clay; tarry, fresh blood, mucus)
  • Hemorrhoids, jaundice, dark urine, use of laxatives—type, frequency
  • History of ulcer, gallstones, polyps, tumors
  • Previous diagnostic tests—where, when, results
• Genitourinary—dysuria, pain, urgency, frequency, hematuria, nocturia, polydipsia, polyuria, oliguria, edema of the face, hesitancy, dribbling, loss in size or force of stream, passage of stones, stress incontinence, hernias, human immunodeficiency virus status, history of STD
  • Males—puberty onset, sexual activity, use of condoms, libido, sexual dysfunction
  • Females
    • Menses—onset, regularity, duration of flow, dysmenorrhea, last period, intermenstrual bleeding or discharge, dyspareunia
    • Libido, sexual activity, satisfaction with sexual relations
    • Pregnancies (see “Past Medical History,” page 48)
    • Methods of contraception, STD protection
    • Breasts—pain, tenderness, discharge, lumps, mammograms, breast self-examination (techniques and timing with regard to menstrual cycle)
• Neurologic
  • Mental status—history of loss of consciousness; orientation to time, place, person
  • Memory—distant and recent
  • Cognition, or ability of patient to conceptualize (very useful information in determining a health education plan for the patient)
  • Incoordination, weakness, numbness, paresthesia, tremors, muscle cramps
• Psychiatric
  • Patient's description of personality—how patient views self
  • Mood changes, difficulty concentrating, sadness, nervousness, tension, irritability, change in social interaction
  • Obsessive thoughts, compulsions, manic episodes, suicidal or homicidal thoughts
• General constitutional symptoms—fever, chills, night sweats, malaise, fatigability, recent loss or gain of weight

Method of Collecting Data

• Begin by explaining to the patient—“I am going to ask you many questions about your body that will help in understanding your present problem.”
• Ask direct questions about each system, using terms that the patient understands.
• Whenever the patient complains or suggests a symptom, ask the questions outlined under method of collecting data about the present illness (onset, duration).
• Never assume that things are “OK” if the patient fails to mention something.
  • Ask about every aspect of the function of a particular system and be sure to record the patient's responses.
  • Often, the fact that a body system has been free from any symptoms is as important as any symptoms that have been experienced.
• If necessary, memorize a list of questions for each system or use a list when interviewing the patient. Knowing what to ask about each system is based on knowledge of the function of each body system and of the way that normal function manifests itself.

PERSONAL AND SOCIAL HISTORY

Purposes

• To describe the patient's life situation—may have a bearing on the present condition, overall health, or ability to cope
• To develop a plan of care that “fits” the patient. Here the interviewer finds out the many personal and family resources an individual has to aid in coping with the situation—both long-term and short-term
• To identify an opportunity for health promotion activities
• To determine if the patient's occupation is directly or indirectly related to his condition

Types of Information Needed

• Personal status—birth place, education, armed service affiliation, position in the family, education level, satisfaction with life situations (home and job), personal concerns
• Habits and lifestyle patterns
  • Sleeping pattern, number of hours of sleep, difficulty sleeping
  • Exercise, activities, recreation, hobbies
  • Nutrition and eating habits (diet recall for a typical day)
  • Alcohol—frequency, amount, type; CAGE questionnaire for problem drinking:
    • Have you ever thought you should Cut down on your drinking?
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    • Have you ever been Annoyed by criticism of your drinking?
    • Have you ever felt Guilty about your drinking?
    • Do you drink in the morning (ie, an Eye opener)?
  • Caffeine—type and amount per day
  • Illicit drugs (illegal or improperly used prescription or over-the-counter medications)
    • Past and present use
    • Type of drug and route (if I.V., history of needle sharing)
    • Frequency and amount
    • History of treatment, support group, program
  • Tobacco—past and present use, type (cigarettes, cigars, chewing, snuff), pack years
  • Sexual habits (can be part of genitourinary history)—relationships, frequency, satisfaction, number of partners in past year, STD and pregnancy prevention
• Home conditions
  • Marital status, nature of family relationships
  • Economic conditions—source of income; health insurance, Medicare, Medicaid
  • Living arrangements and housing (owning or renting, heating, sewage, pets)
  • Involvement with agencies (name, case worker)
  • History of physical or sexual abuse
• Occupation—past and present employment and working conditions, including exposure to stress and tension, noise, chemicals, pollution
• Religion or faith—its importance in coping and health practices

Method of Collecting Data

• Begin by explaining that you are going to ask questions about the patient's life situation to gain a clearer perspective of the patient's condition and of how you might help.
• Your manner should be matter-of-fact, yet concerned. If you are uncomfortable asking the questions, most likely the patient will sense that and be uneasy answering them.
• A sensitive interviewer can ask most of the questions listed above in an initial interview without alienating the patient. For instance, ask “What has been your education?” instead of “How far have you gone in school?”

ENDING THE HISTORY

When you have completed the history, it is often helpful to say: “Is there anything else you would like to tell me?” or “What additional concerns do you have?” This allows the patient to end the history by saying what is on his or her mind and what concerns the patient most.

PHYSICAL EXAMINATION

GENERAL PRINCIPLES

• A complete or partial physical examination is conducted following a careful comprehensive or problem-related history.
• It is conducted in a quiet, well-lit room with consideration for patient privacy and comfort.

APPROACHING THE PATIENT

• When possible, begin with the patient in a sitting position so both the front and back can be examined.
• Completely expose the part to be examined but drape the rest of the body appropriately.
• Conduct the examination systematically from head to foot so as not to miss observing any system or body part.
• While examining each region, consider the underlying anatomic structures, their function, and possible abnormalities.
• Because the body is bilaterally symmetric for the most part, compare findings on one side with those on the other.
• Explain all procedures to the patient while the examination is being conducted to avoid alarming or worrying the patient and to encourage cooperation.

TECHNIQUES OF EXAMINATION AND ASSESSMENT

Use the following techniques of examination as appropriate for eliciting findings.

Inspection

• Begins with the first encounter with the patient and is the most important of all the techniques.
• Is an organized scrutiny of the patient's behavior and body.
• With knowledge and experience, the examiner can become highly sensitive to visual clues.
• The examiner begins each phase of the examination by inspecting the particular part with the eyes.

Palpation

• Involves touching the region or body part just observed and noting whether these are tender to touch and what the various structures feel like.
• With experience comes the ability to distinguish variations of normal from abnormal.
• Is performed in an organized manner from region to region.

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Percussion

• By setting underlying tissues in motion, percussion helps in determining the density of the underlying tissue and whether it is air-filled, fluid-filled, or solid.
• Audible sounds and palpable vibrations are produced, which can be distinguished by the examiner. The five basic notes produced by percussion can be distinguished by differences in the qualities of sound, pitch, duration, and intensity. (See Table 5-1.)

  TABLE 5-1 Five Basic Notes Produced by Percussion

  RELATIVE INTENSITY RELATIVE PITCH RELATIVE DURATION EXAMPLE LOCATION Flatness Soft High Short Thigh Dullness Medium Medium Medium Liver Resonance Loud Low Long Normal lung Hyperresonance Very loud Lower Longer Emphysematous lung Tymphany Loud * * Gastric air bubble or puffed out cheek * Distinguished mainly by its musical timbre. Adapted from Bickley, L.S. (2004). Bates' guide to physical examination and history taking (8th ed.). Philadelphia: Lippincott Williams & Wilkins.

• The technique for percussion may be described as follows:
  • Hyperextend the middle finger of your left hand, pressing the distal portion and joint firmly against the surface to be percussed.
    • Other fingers touching the surface will damp the sound.
    • Be consistent in the degree of firmness exerted by the hyperextended finger as you move it from area to area or the sound will vary.
  • Cock the right hand at the wrist, flex the middle finger upward, and place the forearm close to the surface to be percussed. The right hand and forearm should be as relaxed as possible.
  • With a quick, sharp, relaxed wrist motion, strike the extended left middle finger with the flexed right middle finger, using the tip of the finger, not the pad. Aim at the end of the extended left middle finger (just behind the nail bed) where the greatest pressure is exerted on the surface to be percussed.
  • Lift the right middle finger rapidly to avoid damping the vibrations.
  • The movement is at the wrist, not at the finger, elbow, or shoulder; the examiner should use the lightest touch capable of producing a clear sound.

Auscultation

• This method uses the stethoscope to augment the sense of hearing.
• The stethoscope must be constructed well and must fit the user. Earpieces should be comfortable, the length of the tubing should be 10 to 15 inches (25 to 38 cm), and the head should have a diaphragm and a bell.
  • The bell is used for low-pitched sounds such as certain heart murmurs.
  • The diaphragm screens out low-pitched sounds and is good for hearing high-frequency sounds such as breath sounds.
  • Extraneous sounds can be produced by clothing, hair, and movement of the head of the stethoscope.

Adult Physical Assessment

EQUIPMENT

• Cotton applicator stick
• Flashlight
• Oto-ophthalmoscope
• Reflex hammer
• Safety pin
• Sphygmomanometer
• Stethoscope
• Thermometer
• Tongue blade
• Tuning fork
• Additional items may include disposable gloves and lubricant for rectal examination and a speculum for examination of female pelvis.

Technique Findings VITAL SIGNS Importance—Many major therapeutic decisions are based on the vital signs; therefore, accuracy is essential. Temperature Routinely, where accuracy is not crucial, an oral temperature will suffice A rectal temperature is the most accurate Unless contraindicated (as in a patient with a severe cardiac arrhythmia), a rectal temperature is often preferred. Temperature—may vary with the time of day. Oral: 98.6° F (37° C) is considered normal May vary from 96.4° to 99.1° F (35.8° to 37.3° C). Rectal: Higher than oral by 0.7° to 0.9° F (0.4° to 0.5° C). Pulse Palpate the radial pulse and count for at least 30 seconds If the pulse is irregular, count for a full minute and note the number of irregular beats per minute Note whether the beat of the pulse against your finger is strong or weak, bounding or thready. Pulse—Normal adult pulse is 60 to 80 beats/minute; regular in rhythm. Elasticity of the arterial walls, blood volume, and mechanical action of the heart muscle are some of the factors that affect strength of the pulse wave, which normally is full and strong. Respiration Count the number of respirations taken in 15 seconds and multiply that by 4 Note rhythm and depth of breathing. Respiration—Normally 16 to 20 respirations per minute. Blood pressure Measure the blood pressure in both arms. Document the patient's position Palpate the systolic pressure before using the stethoscope in order to detect an auscultatory gap.* Apply the cuff firmly; if it is too loose, it will give a falsely high reading Use an appropriate sized cuff: a pediatric cuff for children; a large cuff or a leg cuff for obese people The cuff should be approximately 1 inch (2.5 cm) above the antecubital fossa. Normal blood pressure is <120/80 mm Hg A difference of 5 to 10 mm Hg between arms is common Systolic pressure in lower extremities is usually 10 mm Hg higher than reading in upper extremities. Going from a recumbent to a standing position can cause the systolic pressure to fall 10 to 15 mm Hg and the diastolic pressure to rise slightly (by 5 mm Hg). HEIGHT AND WEIGHT Determine the patient's height and weight. Use a measuring stick or tape rather than asking the patient's height. GENERAL APPEARANCE Begin observation on first contact with the patient (in the waiting room or while the patient is in bed); continue throughout the interview systematically. Inspection Observe for: race, sex, general physical development, nutritional state, mental alertness, affect, evidence of pain, restlessness, body position, clothes, apparent age, hygiene, grooming. Careful observation of the general state of the individual provides many clues about a person's body image, how he behaves, and also some idea of how well or ill he is. SKIN Examination of the skin is correlated with the information obtained in the history and other parts of the physical examination. Examine the skin as you proceed through each body system. Inspection Observe for: skin color, pigmentation, lesions (distribution, type, configuration, size), jaundice, cyanosis, scars, superficial vascularity, hydration, edema, color of mucous membranes, hair distribution, nails. “Normal” varies considerably depending on racial or ethnic background, exposure to sun, complexion, pigmentation tendencies (such as freckles) The skin is normally warm, slightly moist, and smooth and returns quickly to its original shape when picked up between two fingers and released. There is a characteristic hair distribution over the body associated with gender and normal physiologic function. Nails are present and smooth and cared for in some way. Palpation Examine skin for temperature, texture, elasticity, turgor. HEAD Inspection Observe for: symmetry of face, configuration of skull, hair color and distribution, scalp. Normally, the skull and face are symmetric, with distribution of hair varying from person to person. (However, determine by history if there has been any change.) Palpation Examine: hair texture, masses, swelling or tenderness of scalp, configuration of skull. The scalp should be free of flaking, with no signs of nits (small, white louse eggs), lesions, deformities, or tenderness. EYES AND VISION Equipment Ophthalmoscope Snellen chart for visual acuity (see page 559) Anatomic landmarks Globes Palpebral fissures Lid margins Conjunctivae Sclerae Pupils Iris Inspection 1. Globes—for protrusion. 2. Palpebral fissures (longitudinal openings between the eyelids)—for width and symmetry. 2. Palpebral fissures—appear equal in size when the eyes are open. Upper lid—covers a small portion of the iris and cornea. Lower lid—margin is just below the junction of the cornea and sclera (limbus). Ptosis—drooping of eyelids. 3. Lid margins—for scaling, secretions, erythema, position of lashes. 3. Lid margins—are clear; the lacrimal duct openings (puncta) are evident at the nasal ends of the upper and lower lids. Eye lashes—normally are evenly distributed and turn outward. 4. Bulbar and palpebral conjunctivae—for congestion and color. Bulbar conjunctiva—membranous covering of the sclera (contains blood vessels). Palpebral conjunctiva—membranous covering of the inside of the upper and lower lids (contains blood vessels). 4. Bulbar conjunctiva (cover of sclera)—consists of transparent red blood vessels, which may become dilated and produce the characteristic “bloodshot” eye. Palpebral conjunctivae—are pink and clear. Conjunctivitis—inflammation of the conjunctival surfaces. 5. Sclerae and iris—for color. 5. Sclerae—should be white and clear. 6. Pupils—for size, shape, symmetry, reaction to light and accommodation (ability of the lens to adjust to objects at varying distances). 6. Pupils—normally constrict with increasing light and accommodation. Pupils are normally round and can range in size from very small (“pinpoint”) to large (occupying the entire space of the iris). 7. Eye movement—extraocular movements, nystagmus, convergence. (Nystagmus: rapid, lateral, horizontal, or rotary movement of the eye.) (Convergence: ability of the eye to turn in and focus on a very close object.) (See neurologic examination, page 77.) 7. Extraocular movement—movement of the eyes in conjugate fashion. (Six muscles control the movement of the eye.) Eyes normally move in conjugate fashion, except when converging on an object that is moving closer. Nystagmus—may be seen briefly on lateral movement as a result of eye fatigue; however, vertical nystagmus or prolonged nystagmus should be evaluated. Convergence—fails when double vision occurs, usually 4 to 6 inches (10 to 15 cm) from the nose. 8. Gross visual fields—by confrontation. (See neurologic examination, page 77.) 8. Peripheral vision—is full (medially and laterally, superiorly and inferiorly) in both eyes. 9. Visual acuity—check with a Snellen chart (with and without glasses). 9. Normal vision—20/20. Myopia—nearsightedness Hyperopia—farsightedness Palpation 1. Determine the strength of the upper lids by attempting to open closed lids against resistance. 1. The examiner should not be able to open the lids when the patient is squeezing them shut. 2. Palpate globes through closed lids for tenderness and tension. 2. Globes normally are not tender when palpated. Funduscopic examination 1. Red retinal reflex—check the transparency of the anterior and posterior chambers. 1. Red retinal reflex—can be spotted by the examiner while standing 1 foot (30 cm) from the eye. 2. Cornea—check for transparency. 2. Cornea—should be transparent, with the light directed at the pupil. 3. Lens—check for transparency. 3. Lens—should be transparent (retina can be seen). 4. Retina—check for color, pigmentation, hemorrhages, and exudates. 4. Retina—color varies according to the amount of pigment present. There should be no hemorrhages or exudates. 5. Optic disc—check for color, distinction of margins, pigmentation, degree of elevation, cupping. 5. Optic disc—is circular and has a yellowish pink color. Although disc appearance may vary, the margins are normally distinct and regular, with varying amounts of pigment. 6. Macula—check for color. (Lies at a distance of 2 optic disc diameters laterally from the optic disc.) 6. Macula—because it is free of blood vessels, it is lighter in color than the rest of the retina. 7. Blood vessels—check for diameter, arteriovenous (AV) ratio; origin and course; venous-arterial crossings. (Both arteries and veins are present and move outward from the disc nasally and temporally.) 7. Retinal arteries and veins—arteries are approximately 4/5 the size of the veins and lighter in color. Where arteries and veins cross, there is usually no disturbance in the course of either. Pulsations may occur in the vein near the optic disc. Use of the ophthalmoscope 1. Hold the instrument in your right hand and use your right eye to examine the patient's right eye. Reverse the procedure to examine the patient's left eye. This approach allows you to get close to the patient without bumping noses. 2. Hold the instrument so your last two fingers are straight, rather than curved around the handle. You can place these fingers against the patient's cheek to steady the instrument and to avoid hitting the patient with it. 3. Begin the funduscopic examination standing about 1 foot (30 cm) away from, and on the same level as, the patient. The room should be darkened. 4. Turn the dial on the head of the ophthalmoscope to 0 diopters. 5. Turn on the ophthalmoscope light and place the eyepiece up to your eye. If you wear glasses or contact lenses, it is best to wear them during the examination so you do not have to accommodate for your vision by turning the dial on the ophthalmoscope. 6. Aim the light at the pupil of the eye. You should see the red reflex immediately. 6. Absence of the red reflex suggests opacity of the lens (cataract), detached retina, or retinoblastoma (rarely) 7. Slowly move in toward the patient, continuing to look through the eyepiece and keeping the light directed at the pupil, beyond which is the fundus. 8. With the index finger of the hand holding the ophthalmoscope, turn the dial counterclockwise (to the minus diopters) to focus if the patient is nearsighted, or clockwise (toward the plus diopters) to focus if the patient is farsighted. This allows you to focus on the various chambers of the eye. A way to find the eye and pupil is to put your hand on top of the patient's head and your thumb at the outer corner of the eye. If you lose the fundus, you can return to your thumb and get your bearings by moving medially from the thumb nail. 9. Once your hand is resting on the patient's cheek, continue to turn the dial until you can focus on the retina, and the blood vessels and the optic disc appear sharp. 10. Once you are focused on the optic disc, it is possible to follow the blood vessels out from the disc inferiorly and superiorly, medially and laterally. 10. Abnormal findings include hemorrhages, exudates, and papilledema. EARS AND HEARING Equipment Tuning fork Otoscope To examine with otoscope 1. Hold the helix of the ear and gently pull the pinna upward and back toward the occiput to straighten the external canal. 2. Gently insert the lighted otoscope, using an earpiece that is a comfortable size for the patient. 3. Once the otoscope is in place, put your eye up to the eyepiece and examine the external canal. Inspection 1. Pinna—examine for size, shape, color, symmetry, placement on the head, lesions, and masses. 2. External canal—examine with the otoscope for discharge, impacted cerumen, inflammation, masses, or foreign bodies. 2. External canal—is normally clear with perhaps minimal cerumen. 3. Tympanic membrane—examine for color, luster, shape, position, transparency, integrity, and scarring. 3. Tympanic membrane and landmarks. 4. Landmarks—note cone of light, umbo, handle and short process of the malleus, pars flaccida, and pars tensa. Gently move the otoscope to observe the entire drum. (Cerumen may obscure visualization of the drum.) Palpation Pinna—examine for tenderness, consistency of cartilage, swelling. Mechanical tests 1. Test each ear for gross hearing acuity using a whispered word or a watch. Cover the ear not being tested. 1. A person with normal hearing can hear a whispered word from approximately 15 feet (4.5 m) and a watch from 1 foot (30 cm). The patient should hear the sound equally well in both ears; that is, there is no lateralization. 2. Weber test—test for lateralization of vibration. Tap the tuning fork against a hard surface to make it vibrate. Then, place the tuning fork in the center of the scalp near the forehead (A). (Also see Chapter 17). 2. Sound should be heard equally in both ears. 3. Rinne test—compares air and bone conduction. Place the vibrating tuning fork on the mastoid process behind the ear and have the patient tell you when the vibration stops (B). Then quickly hold the buzzing end of the tuning fork near the ear canal and ask if patient can hear it (C). 3. Sound should be heard after vibration can no longer be felt; that is, air conduction is greater than bone conduction. Lateralization and conduction findings are altered by damage to the cranial nerve VIII and damage to the ossicles in the middle ear. NOSE AND SINUSES Equipment Otoscope Nasal speculum Inspection 1. Observe for general deformity. 2. With nasal speculum (otoscope, if speculum is unavailable) examine for: Nasal septum (position and perforation) Discharge (anteriorly and posteriorly) Nasal obstruction and airway patency Mucous membranes for color Turbinates for color and swelling Nasal septum—is normally straight and not perforated. Discharge—none should be present. Airways—are patent. Mucous membranes—are normally pink. Turbinates—three bony projections on each lateral wall of the nasal cavity covered with well-vascularized, mucous-secreting membranes. They warm the air going into the lungs and may become swollen and pale with colds and allergies. Palpation Sinuses (frontal and maxillary)—for tenderness Frontal—direct manual pressure upward toward the wall of the sinus. Avoid pressure on eyes. Maxillary—with thumbs, direct pressure upward over lower edge of maxillary bones. MOUTH Equipment Flashlight Tongue blade Gloves Gauze sponges Inspection 1. Observe lips for color, moisture, pigment, masses, ulcerations, fissures. 2. Use tongue blade and penlight to examine: a. Teeth—number, arrangement, general condition Teeth—an adult normally has 32 teeth. b. Gums—for color, texture, discharge, swelling, or retraction Gums—commonly recede in adults. Bleeding is fairly common and may result from trauma, gingival disease, or systemic problems (less common). c. Buccal mucosa—for discoloration, vesicles, ulcers, masses d. Pharynx—for inflammation, exudate, and masses e. Tongue (protruded)—for size, color, thickness, lesions, moisture, symmetry, deviations from midline, fasciculations Tongue—is normally midline and covered with papillae, which vary in size from the tip of the tongue to the back. (The circumvallate papillae are large and posterior.) f. Salivary glands—for patency Parotid glands Parotid glands—open in the buccal pouch at the level of the upper teeth halfway back. Sublingual and submaxillary glands Sublingual and submaxillary glands—open underneath the tongue. g. Uvula—for symmetry when patient says “ah” h. Tonsils—for size, ulceration, exudates, inflammation Lingual tonsils—can often be seen on the posterior portion of the tongue. i. Breath—for odor Odor of breath—may indicate dental caries. j. Voice—for hoarseness Palpation 1. Examine the oral cavity with a gloved hand for masses and ulceration. Palpate beneath the tongue and laterally explore the floor of the mouth (A) 1. Entire oral cavity should be pink and without ulcers, deep-red color, lesions, palpable masses, or swelling. An indurated mass raises the suspicion of malignancy. 2. Grasp the tongue with a gauze sponge to retract it; inspect the sides and undersurface of the tongue and the floor of the mouth (B). NECK Equipment Stethoscope Inspection 1. Inspect all areas of the neck anteriorly and posteriorly for muscular symmetry, masses, unusual swelling or pulsations, and range of motion. 1. Range of motion—normally, the chin can touch the anterior chest, the head can be extended at least 45 degrees from the vertical position and can be rotated 90 degrees from midline to side. 2. Thyroid—ask the patient to swallow and observe for movement of an enlarged thyroid gland at the suprasternal notch. 2. Thyroid—is not usually visible, except in extremely thin persons. 3. Muscular strength Cervical muscles—have the patient turn his chin forcefully against your hand. Trapezius muscles—exert pressure on the patient's shoulders while he shrugs his shoulders. 3. Strength—see Findings, cranial nerve XI, page 80. Palpation 1. Palpate the 10 areas for cervical lymph nodes as shown here. 1. Cervical nodes—in the adult, the cervical lymph nodes are not normally palpable unless the patient is very thin, in which case the nodes are felt as small, freely movable masses. Tender nodes suggest inflammation; hard, fixed nodes suggest malignancy. 2. Trachea—palpate at the sternal notch. Place one finger along the side of the trachea and note the space between it and the sternomastoid. Compare to the other side. 2. Trachea—should be midline. Spaces measured by fingers should be symmetrical. Tracheal deviation may be caused by neck mass or problems within the chest. 3. Thyroid 3. If the thyroid is palpable, it is normally smooth, without nodules, masses, or irregularities. Stand behind the patient and have him flex the neck slightly to relax the muscles. Place the fingertips of both hands on either side of the trachea just below the cricoid cartilage. Have the patient swallow and feel for any glandular tissue rising under your fingertips. Palpate the area over the trachea for the isthmus and laterally for the right and left lobes. Note any enlargement, nodules, masses, consistency. 4. Carotid arteries 4. A thrill (humming-like vibration) usually indicates arterial narrowing. Palpate the carotids one side at a time. The carotids lie anterolaterally in the neck—avoid palpating the carotid sinuses at the level of the thyroid cartilage just below the angle of the jaw because this may cause slowing of heart rate. Note the symmetry of pulsations, strength, and amplitude. Auscultation 1. Use the diaphragm of the stethoscope to listen for bruits (murmur-like sound) over the carotid arteries. 1. A bruit may indicate arterial narrowing with turbulent blood flow. A cardiac murmur may also be referred to the carotid arteries. LYMPH NODES 1. It is important at some point in the examination to palpate all areas where lymphadenopathy might appear. 1. Lymph nodes are normally nonpalpable or felt as small, nontender, freely moveable masses. 2. Typically, this is done as each region of the body is examined; for example, the cervical nodes are studied when the neck is examined and inguinal nodes are inspected when the abdomen is examined. Inspection Note size, shape, mobility, consistency, tenderness, and inflammation. Palpation 1. Cervical, supraclavicular, and infraclavicular nodes. 1. Supraclavicular and infraclavicular nodes—not normally palpable. Enlargement may indicate a thoracic problem. 2. Axillary nodes (usually done during breast exam). 2. Axillary nodes—normally nonpalpable. Enlargement may occur with a breast or arm problem. Examine the patient while patient is sitting. Place the patient's arm at his side and examine the apex of the patient's axilla. (Use the fingers of your right hand to examine the left axilla and vice versa.) Rotate the examining hand so the fingers can palpate the anterior and posterior axillary fossae pressing against the chest wall. Press against the humerus bone in the axilla to examine the lateral fossa for nodes. Conclude the axillary examination by moving the fingers from the apex of the axilla downward in the midline along the chest wall. 3. Inguinal nodes—are located in the groin and are usually examined when the abdomen is examined. 3. Inguinal nodes—a few may be felt. Enlargement and acute tenderness may indicate a genital or lower extremity problem. 4. Epitrochlear nodes—are palpated just above the medial epicondyle, between the biceps and triceps muscles. 4. Epitrochlear nodes—not normally palpable. Enlargement may indicate an arm or systemic problem. BREASTS (MALE AND FEMALE) Female breast Inspection (With the patient sitting, arms relaxed at sides.) 1. Inspect the areolae and nipples for position, pigmentation, inversion, discharge, crusting, and masses. Extra, or supernumerary, nipples may occur normally, most commonly in the anterior axillary region or just below the normal breasts. 1. The nipples should be at the same level and protrude slightly. An inverted nipple (one that turns inward), if present since puberty, may be normal. A supernumerary nipple usually consists of a nipple and a small areola and may be mistaken for a mole. 2. Examine the breast tissue for size, shape, color, symmetry, surface, contour, skin characteristics, and level of breasts. Note any retraction or dimpling of the skin. 2. Breast size—in the female it is not uncommon to find a difference in the size of the two breasts. Normal asymmetry has usually been present since puberty and is not a recent phenomenon. 3. Ask the patient to elevate her hands over her head; repeat the observation. 3. If there is a mass attached to the pectoral muscles, contracting the muscles will cause retraction of the breast tissue. 4. Have the patient press her hands to her hips; repeat the observation. Palpation (This is best done with the patient in a recumbent position.) 1. The patient with pendulous breasts should be given a pillow to place under the ipsilateral scapula of the breast being palpated so the tissue is distributed more evenly over the chest wall. 2. The arm on the side of the breast being palpated should be raised above the patient's head. 3. Palpate one breast at a time, beginning with the “asymptomatic” breast if the patient complains of symptoms. 3. This allows the examiner to palpate the “normal” breast first and then compare the “symptomatic” breast to it. 4. To palpate, use the palmar aspects of the fingers in a rotating motion, compressing the breast tissue against the chest wall. Don't forget to include the “tail” of the breast tissue, which extends into the axillary region in the upper outer quadrant of the breast. 4. Breast texture—varies according to the amount of subcutaneous tissue present. In young females, tissue is fairly soft and homogeneous; in postmenopausal women, tissue may feel nodular or stringy. Consistency also varies with menstrual cycle, being more nodular and edematous just prior to menstruation. 5. Note skin texture, moisture, temperature, or masses. 5. Masses—If a mass is palpated, its location, size, shape, consistency, mobility, and associated tenderness are reported. 6. Gently squeeze the nipple and note any expressible discharge. 6. Discharge—In the normal nonpregnant or nonlactating female, there is usually no nipple discharge. 7. Repeat the examination on the opposite breast and compare findings. Male Breast Examination of the male breast can be brief but may be important. 1. Observe the nipple and areola for ulceration, nodules, swelling, or discharge. 1. There should be no discharge. 2. Palpate the areola for nodules and tenderness. 2. Enlargement of glandular tissue is gynecomastia, related to hormone imbalance. 3. Palpate axillary lymph nodes (see page 62). THORAX AND LUNGS 1. Methodical inspection of the thorax requires reference to established “landmarks” to locate specific structures and to report significant findings. 2. The same structural landmarks are used in examining both the lung and the heart. 3. It is important to visualize the underlying structures and organs when examining the thorax. Posterior thorax and lungs Begin the examination with the patient seated; examine posterior chest and lungs. Inspection 1. Inspect the spine for mobility and any structural deformity. 2. Observe the symmetry of the posterior chest and the posture and mobility of the thorax on respiration. Note any bulges or retractions of the costal interspaces on respiration or any impairment of respiratory movement. 2. The thorax is normally symmetric; it moves easily and without impairment on respiration. There are no bulges or retractions of the intercostal spaces. 3. Note the anteroposterior diameter in relation to the lateral diameter of the chest. 3. The anteroposterior (AP) diameter of the thorax in relation to the lateral diameter is approximately 1:2. Palpation 1. Palpate the posterior chest with the patient sitting; identify areas of tenderness, masses, inflammation. 2. Palpate the ribs and costal margins for symmetry, mobility, and tenderness and the spine for tenderness and vertebral position. 2. On palpation, there should be no tenderness; chest movement should be symmetric and without lag or impairment. Tenderness may indicate musculoskeletal strain, fracture, or other problems. 3. To assess respiratory expansion, place thumbs at the level of the 10th vertebra. With hands held parallel to the 10th ribs as they grasp the lateral rib cage, ask the patient to inhale deeply. Observe the movement of the thumbs while feeling the range and observe the symmetry of the hands. 4. To elicit vocal and tactile fremitus (palpable vibrations transmitted through the bronchopulmonary system on speaking). Ask the patient to say “99”; palpate and compare symmetric areas of the lungs with the ball of one hand. Begin at the upper lobes and move downward. Note any areas of increased or decreased fremitus. If fremitus is faint, ask the patient to speak louder and in a deeper voice. 4. Posteriorly, fremitus is generally equal throughout the lung fields. It may be increased near the large bronchi due to consolidation of tissue resulting from pneumonia. It may be decreased or absent anteriorly and posteriorly when vocal loudness is decreased, when posture is not erect, or when excessive tissue or underlying structures are present, or in cases of pneumothorax and other pathology. Percussion As with palpation, the posterior chest is optimally percussed with the patient sitting. 1. Percuss symmetric areas, comparing sides. 1. Percussion normally reveals resonance over symmetric areas of the lung. Percussion sound may be altered by poor posture or the presence of excessive tissue. 2. Begin across the top of each shoulder and proceed down between the scapulae and then under the scapulae, both medially and laterally in the axillary lines. 3. Note and localize any abnormal percussion sound. 3. Dullness may indicate mass or consolidation due to pneumonia. 4. For diaphragmatic excursion, percuss by placing the pleximeter (stationary) finger parallel to the approximate level of the diaphragm below the right scapula. (See diagram on next page.) 4. The lower border of the lungs is approximately at the level of the 10th thoracic spinous process on normal respiration. Unilateral abnormality of decreased excursion may indicate pleural effusion, atelectasis, or paralysis of one side of the diaphragm. Ask the patient to inhale deeply and hold his breath; percuss downward to the point of dullness. Mark this point. Let the patient breathe normally and then ask patient to exhale deeply; percuss upward from the mark to the point of resonance. Mark this point and measure between the two marks—normally 2 to 2½ inches (5 to 6 cm). Repeat this procedure on the opposite side of the chest. Auscultation Aids in assessing air flow through the lungs, the presence of fluid or mucus, and the condition of the surrounding pleural space. On auscultation, breath sounds vary according to proximity of the large bronchi. – They are louder and coarser near the large bronchi and over the anterior. – They are softer and much finer (vesicular) at the periphery over the alveolae Breath sounds also vary in duration with inspiration and expiration Sounds may normally decrease in obese individuals. 1. Have the patient sit erect.* 2. With a stethoscope, listen to the lungs as the patient breathes more deeply than normally with his mouth open. (Let the patient pause, as needed, to avoid hyperventilation.) 3. Place the stethoscope in the same areas on the chest wall as those percussed, and listen to a complete inspiration and expiration in each area. 4. Compare symmetric areas methodically from the apex to the lung bases. 5. It should be possible to distinguish three types of normal breath sounds as indicated in the following table. 5. Pathology will alter the normal bronchial, bronchovesicular, and vesicular breath sounds. Adventitious sounds may indicate crackles, wheezes, and rhonchi. Breath Sounds Duration of Inspiration and Expiration Pitch of Expiration Intensity of Expiration Normal Location Vesicular Insp. > Exp. Low Soft Most of lungs Bronchovesicular Insp. = Exp. Medium Medium Near the main stem bronchi (below the clavicles and between the scapulae, especially on the right). Bronchial or tubular Exp. > Insp. High Usually loud Over the trachea Adapted from Bickley, L.S. (2004). Bates' guide to physical examination and history taking (8th ed.). Philadelphia: Lippincott Williams & Wilkins. * Note: If the patient is unable to sit without assistance for examination of the posterior chest and lungs, position him first on one side and then on the other as you examine the lung fields. Anterior thorax and lungs The patient should be recumbent with his arms at his sides and slightly abducted. Inspection 1. Inspect the chest for any structural deformity. 2. Note the width of the costal angle. 2. The angle at the tip of the sternum is determined by the right and left rib margins at the xiphoid process. Normally, the angle is less than 90 degrees. 3. Observe the rate and rhythm of breathing, any bulging or retraction of intercostal spaces on respiration, and use of accessory muscles of respiration (sternocleidomastoid and trapezius on inspiration and abdominal muscles on expiration). 3. There are no bulges or retractions of the intercostal spaces. 4. Note any asymmetry of chest wall movement on respiration. 4. The thorax is normally symmetric and moves easily without impairment on respiration. Palpation 1. To assess expansion, place your hands along the costal margins and note symmetry and degree of expansion as the patient inhales deeply. 2. Palpate for fremitus with the ball of the hand anteriorly and laterally. (Underlying structures [heart, liver] may damp, or decrease, fremitus.) 3. Compare symmetric areas. 4. If necessary, displace the female breast gently. Percussion 1. With patient's arms resting comfortably at his sides, percuss the anterior and lateral chest. Begin just below the clavicles and percuss downward from one interspace to the next, comparing the sound from the interspace on one side with that of the contralateral interspace. 2. Displace the female breast so breast tissue does not damp the vibration. Continue downward, noting the intercostal space where hepatic dullness is percussed on the right and cardiac dullness on the left. 2. A tympanic sound is produced over the gastric air bubble on the left somewhat lower than the point of liver dullness on the right. 3. Note the effect of underlying structures. 3. Percussion over heart will produce a dull sound. The upper border of the liver will be percussed on the right side, producing a dull note. Auscultation Listen to the chest anteriorly and laterally for the distribution of resonance and any abnormal or adventitious sounds. HEART General approach 1. The examiner must visualize the position of the heart under the sternum and the ribs and know certain landmarks for identification of specific structures and significant findings. 2. It is also important to identify those “areas” on the chest wall that will yield the most information initially about the function of the heart and its valves. In locating the intercostal spaces, begin by identifying the angle of Louis, which is felt as a slight ridge approximately 1 inch (2.5 cm) below the sternal notch, where the manubrium and the body of the sternum are joined. The 2nd ribs extend to the right and left of this angle. Once the 2nd rib is located, palpate downward and obliquely away from the sternum to identify the remaining ribs and intercostal spaces. Inspection 1. Inspect the precordium for any bulging, heaving, or thrusting. 1. Normally there are no bulges or heaves; these indicate pathology. 2. Look for the apical impulse in the 5th or 6th intercostal space at or just medial to the midclavicular line. 2. An apical impulse may or may not be observable. 3. Note any other pulsations. Tangential lighting is most helpful in detecting pulsations. 3. There should be no other pulsations. Palpation 1. Use the ball of the hand to detect vibrations, or “thrills,” which may be caused by murmurs. (Use the fingertips or palmar surface to detect pulsations.) 1. There should be no thrills or other pulsations. (Thrills are vibrations caused by turbulence of blood moving through valves that are transmitted through the skin, which feels similar to a purring cat.) 2. Proceed methodically through the examination so no area is omitted. Palpate for thrills and pulsations in each area (aortic, pulmonic, tricuspid, mitral). a. Begin in the aortic area (2nd right intercostal space, close to the sternum) and proceed to the pulmonic area (2nd left intercostal space), and then downward to the apex of the heart. (The mitral area is considered the apex of the heart.) b. In the tricuspid area, use the palm of the hand to detect any heaving or thrusting of the precordium (tricuspid area—5th intercostal space next to the sternum). Ordinarily, no heaving of the ventricle is felt except, possibly, in the pregnant female. c. In the mitral area (5th intercostal space, at or just medial to the midclavicular line) palpate for the apical beat; identify the point of maximal impulse (PMI) and note its size and force. The apical pulse should be felt approximately in the 5th intercostal space, at or just medial to the midclavicular line. In a young, thin person, it is a sharp, quick impulse no larger than the intercostal space. In an older person, the impulse may be less sharp and quick. An apical impulse displaced laterally may indicate left ventricular hypertrophy. Percussion 1. Outline the heart border or area of cardiac dullness. The left border generally does not extend beyond 4, 7, and 10 cm left of the midsternal line in the 4th, 5th, and 6th intercostal spaces, respectively. The right border usually lies under the sternum. 2. Percuss outward from the sternum with the stationary finger parallel to the intercostal space until dullness is no longer heard. Measure the distance from the midsternal line in centimeters. Auscultation 1. Place the stethoscope in the pulmonic or aortic area. 2. Begin by identifying the first (S1) and second (S2) heart sounds. S1 is caused by the closing of the tricuspid and mitral valves. S2 results from the closing of the aortic and pulmonary valves. 2. The two sounds are separated by a short systolic interval; each pair of sounds is separated from the next pair by a longer, diastolic interval. Normally, two sounds are heard—“lub,” “dub.” – In the aortic and pulmonic areas, S2 is usually louder than S1. In this way, each of the paired sounds can be distinguished from the other. – In the tricuspid area, S1 and S2 are of almost equal intensity and, in the mitral area, S1 is often slightly louder than S2. 3. Once the heart sounds are identified, count the rate and note the rhythm as discussed under vital signs. If there is an irregularity, try to determine if there is any pattern to the irregularity in relation to the intervals, heart sounds, or respirations. 3. Normally, the heart sounds are regular, with a rate of 60 to 80 beats/minute (in the adult). In the athlete or jogger, the resting pulse may be between 40 to 60 beats/minute. 4. Once rate and rhythm are determined, listen in each of the four areas and at Erb's point (3rd left interspace, close to the sternum) systematically, first with the diaphragm (detects higher pitched sounds) and then with the bell (detects lower pitched sounds). In each area, listen to S1 and then to S2 for intensity and splitting. 4. An extra “woosh” sound between S1 and S2 indicates systolic murmur; between S2 and S1 indicates a diastolic murmur. Note the area of its greatest intensity (aortic, pulmonic, mitral, tricuspid). An extra sound of short duration usually indicates an S3 or S4 gallop. Occasionally, there may be a splitting of S2 in the pulmonary area. This is normal. Splitting of S2 (two contiguous sounds are heard instead of one) is best heard at the end of inspiration, when right ventricular stroke volume is sufficiently increased to delay closure of the pulmonic valve slightly behind closure of the aortic valve. PERIPHERAL CIRCULATION Jugular veins Evaluation of jugular venous distention is most useful in patients with suspected compromise of cardiac function. Inspection 1. Inspect neck for internal jugular venous pulsations. 1. Jugular venous pulsations can be distinguished from carotid pulsations by the following chart: Internal Jugular Pulsations Carotid Pulsations Rarely palpable Palpable Soft, undulating quality, usually with two or three outward components (a, c, and v waves) A more vigorous thrust with a single outward component Pulsation eliminated by light pressure on the vein just above the sternal end of the clavicle Pulsation not eliminated Level of pulsation barely descends with inspiration Pulsation not affected by inspiration Pulsations vary with position Pulsations are unchanged by position From Bickley, L.S. (2004). Bates' guide to physical examination and history taking (8th ed.). Philadelphia: Lippincott Williams & Wilkins. 2. Note the highest point at which pulsations are seen and measure the vertical line between the point and the sternal angle. With the head raised 30 degrees, the internal jugular venous pulsations should not be visible more than 1 inch (3 cm) above the sternal angle. Increased level of internal jugular pulsations indicates right heart failure. Extremities Inspection 1. Observe skin over extremities for color, hair distribution, pallor, rubor, and swelling. 1. Extremities should be symmetrically even in color, warmth, and moisture, without swelling. Swelling of feet may occur after prolonged standing or sitting, but will disappear readily when extremity is elevated (dependent edema). 2. Inspect for any superficial vessels. Palpation 1. Note the temperature of the skin over extremities, comparing one side to the other. 2. Palpate pulses (radial, femoral, posterior tibial, dorsalis pedis), comparing symmetry from side to side. 2. Absence of peripheral pulses indicates peripheral vascular disease. Palpating pulses. 3. Palpate the skin over the tibia for edema by squeezing the skin between for 30 to 60 seconds. Run the pads of your fingers over the area pressed and note indentation. If indentation is noted, repeat the procedure, moving up the extremity, and note the point at which no more swelling is present. 3. Edema is usually graded from trace to 3+ or 4+ pitting. Trace is a slight indentation that disappears in a short time. Grade 3+ or 4+ is deep pitting that does not disappear readily. At best, these are subjective measurements, which are tried and confirmed through practice and comparison of findings with associates. ABDOMEN General approach 1. Make sure the patient has an empty bladder. 2. The patient should be lying comfortably with his arms at his side. Bending the knees slightly will help to relax the abdominal muscles and make palpation easier. 3. Expose the abdomen fully. Make sure your hands and the stethoscope diaphragm are warm. 4. Be methodical in visualizing the underlying organs as you inspect, auscultate, percuss, and palpate each quadrant or region of the abdomen. Inspection 1. Observe the general contour of the abdomen (flat, protuberant, scaphoid, or concave; local bulges). Also note symmetry, visible peristalsis, aortic pulsations. 1. The abdomen may or may not have any scars and should be flat or slightly rounded in the nonobese person. 2. Check the umbilicus for contour or hernia and the skin for rashes, striae, and scars. Auscultation 1. This is done before percussion and palpation because palpation may alter the character of bowel sounds. 2. Note the frequency and character of bowel sounds (pitch, duration). 2. Anywhere from 5 to 35 bowel sounds per minute. May have familiar sound of “growling.” 3. Listen over the aorta, renal arteries (upper quadrants) and iliac arteries (lower quadrants) for bruits. 3. Bruits indicate arterial narrowing. Percussion 1. Percussion provides a general orientation to the abdomen. 2. Proceed methodically from quadrant to quadrant, noting tympany and dullness. 2. Tympany usually predominates, possibly with scattered areas of dullness due to fluid and feces. 3. In the right upper quadrant (RUQ) in the midclavicular line, percuss the borders of the liver. 3. Percussion of the liver should help guide subsequent palpation. The liver border in the midclavicular line should normally range from 2½ to 4¼ inches (6 to 11 cm). Begin at a point of tympany in the midclavicular line of the right lower quadrant (RLQ) and percuss upward to the point of dullness (the lower liver border); mark the point. Percuss downward from the point of lung resonance above the RUQ to the point of dullness (the upper border of the liver); mark the point. Measure in centimeters the distance between the two marks in the midclavicular line (the liver span). Tympany of the gastric air bubble can be percussed in the left upper quadrant (LUQ) over the anterior lower border of the rib cage. 4. Assess for an enlarged spleen by percussing the lowest interspace of the right anterior axillary line (should be tympanic). Ask the patient to take a deep breath and repeat (should still be tympanic). 4. Change in percussion note to dullness on inspiration indicate an enlarged spleen. Palpation 1. Perform light palpation in an organized manner to detect any muscular resistance (guarding), tenderness, or superficial organs or masses. 1. Tenderness and involuntary guarding indicate peritoneal inflammation. 2. Perform deep palpation to determine location, size, shape, consistency, tenderness, pulsations, and mobility of underlying organs and masses. 2. Rebound tenderness (pain on quick withdrawal of the fingers following palpation) suggests peritoneal irritation, as in acute appendicitis. 3. Move slowly and gently from one quadrant to the next to relax and reassure the patient. 3. Palpate painful areas last. 4. Use two hands if the abdomen is obese or muscular, with one hand on top of the other. The upper hand exerts pressure downward while the lower hand feels the abdomen. Liver 1. Palpate the liver by placing the left hand under the patient's lower right rib cage and the right hand on the abdomen below the level of liver dullness. Press gently inward and upward with your fingertips while the patient takes a deep breath. 1. A normal liver edge may be palpable as a smooth, sharp, regular surface. An enlarged liver will be palpable and may be tender, hard, or irregular. Spleen 1. Place your left hand around and under the patient's left lower rib cage and press your right hand below the left costal margin inward toward the spleen while the patient takes a deep breath. 1. A normal spleen is usually not palpable. Be sure to start low enough so as not to miss the border of an enlarged spleen. Kidney 1. Next palpate for the left and right kidneys. 1. The kidney is usually felt only in persons with very relaxed abdominal muscles (the very young, the aged, and multiparous women). The right kidney is slightly lower than the left. The kidney is felt as a solid, firm, smooth elastic mass. 2. Place the left hand under the patient's back between the rib cage and the iliac crest. 3. Support the patient while you palpate the abdomen with the right palmar surface of the fingers facing the left side of the body. 4. Palpate by bringing the left and right hands together as much as possible slightly below the level of the umbilicus on the right and left. 5. If the kidney is felt, describe its size and shape and note any tenderness. 6. Costal vertebral angle tenderness is palpated with the patient sitting, usually during the examination of the posterior chest. Locate the costal vertebral angle in the flank region and strike firmly with the ulnar surface of your hand. Note any tenderness over the area. 6. There should be no costal vertebral angle tenderness. Aorta 1. Palpate for the aorta with the thumb and index finger. 1. The aorta is soft and pulsatile. 2. Press deeply in the epigastric region (roughly in the midline) and feel with the fingers for pulsations, as well as for the contour of the aorta. Other Findings 1. Palpation of the RLQ may reveal the part of the bowel called the cecum. 1. The cecum will be soft. 2. The sigmoid colon may be palpated in the LLQ. 2. The sigmoid colon is ropelike and vertical and, if filled with feces, may be quite firm. 3. The inguinal and femoral areas should be palpated bilaterally for lymph nodes. 3. Often small inguinal nodes are present; they are nontender, freely movable, and firm. MALE GENITALIA AND HERNIAS This part of the examination, especially for hernias, is best done with the patient standing. (A hernia is the protrusion of a portion of the intestine through an abnormal opening.) 1. Drape the patient's chest and abdomen. 2. Expose the groin and genitalia. Inspection 1. Inspect the pubic hair distribution and the skin of the penis. 2. Retract the foreskin, if present. 2. The foreskin of the penis, if present, should be easily retractable. 3. Observe the glans penis and the urethral meatus. Note any ulcers, masses, or scars. 3. The skin of the glans penis is smooth, without ulceration. 4. Note the location of the urethral meatus and any discharge. 4. The urethral meatus normally is located ventrally on the end of the penis. Normally, there is no discharge from the urethra. 5. Observe the skin of the scrotum for ulcers, masses, redness, or swelling. Note size, contour, and symmetry. Lift the scrotum to inspect the posterior surface. 5. The scrotum descends approximately 1½ inches (4 cm) in the adult; the left side is often larger than the right side. 6. Inspect the inguinal areas and groin for bulges (with and without the patient bearing down, as though having a bowel movement). Palpation Wear gloves. 1. Palpate any lesions, nodules, or masses, noting tenderness, contour, size, and induration. Palpate the shaft of the penis for any induration (firmness in relation to surrounding tissues). 2. Palpate each testis and epididymis separately between the thumb and first two fingers, noting size, shape, consistency, and undue tenderness (pressure on the testis normally produces pain). 2. The testes are usually rubbery and of approximately equal size. The epididymis is located posterolaterally on each testis and is most easily palpable on the superior portion of the testis. 3. Palpate the spermatic cord, including the vas deferens within the cord, from the testis to the inguinal ring. Note any nodules or tenderness. 4. Palpate for inguinal hernias, using the left hand to examine the patient's left side and the right hand to examine the patient's right side. 4. Normally, there is no palpable herniating mass in the inguinal area. Insert the right index finger laterally, invaginating the scrotal sac to the external inguinal ring. If the external ring is large enough, insert the finger along the inguinal canal toward the internal ring and ask the patient to strain down, noting any mass that touches the finger. 5. Palpate the anterior thigh for a herniating mass in the femoral canal. Ask the patient to strain down. (The femoral canal is not palpable; it is a potential opening in the anterior thigh, medial to the femoral artery below the inguinal ligament.) 5. Ordinarily, there is no palpable mass in the femoral area. FEMALE GENITALIA See Procedure Guideline 22-1, page 808. RECTUM Equipment Glove Lubricant Techniques of examination: Male General approach 1. If the patient is ambulatory, have him stand and bend over the edge of the table with his toes pointed inward. 2. It is also possible to examine the anus and rectum with the patient lying on the left side, knees drawn up and buttocks close to the edge of the table. 3. The patient should be draped so only the buttocks are exposed. Inspection Spread the buttocks and inspect the anus, perianal region, and sacral region for inflammation, nodules, scars, lesions, ulcerations, or rashes. Ask the patient to bear down; note any bulges. In males and females, the perianal and sacrococcygeal areas are dry, with varying amounts of hair covering them. Anal and perianal lesions include hemorrhoids, abscesses, skin tags, and sexually transmitted genital lesions. Palpation 1. Palpate any abnormal area noted on inspection. 2. Lubricate the index finger of the gloved hand. Rest the finger over the anus as the patient bears down and, as the sphincter relaxes, insert your finger slowly into the rectum 3. Note sphincter tone, any nodules or masses, or tenderness. 3. The anal canal is approximately 1 inch (2.5 cm) long; it is bordered by the external and internal anal sphincters, which are normally firm and smooth. 4. Insert the finger further and palpate the walls of the rectum laterally and posteriorly while rotating your index finger. Note irregularities, masses, nodules, tenderness. 4. The wall of the rectum in males and females is smooth and moist. 5. Anteriorly, palpate the two lateral lobes of the prostate gland and its median sulcus for irregularities, nodules, swelling, or tenderness. 5. The male prostate gland is approximately 1 inch long, smooth, regular, nonmovable, nontender, and rubbery. 6. If possible, palpate the superior portion of the lateral lobe, where the seminal vesicles are located. Note induration, swelling, or tenderness. 6. The seminal vesicles are generally not palpable unless swollen. 7. Just above the prostate anteriorly, the rectum lies adjacent to the peritoneal cavity. If possible, palpate this region for peritoneal masses and tenderness. 8. Continue to insert the finger as far as possible and have the patient bear down so more of the bowel can be palpated. 9. Gently withdraw your finger. Any fecal material on the glove should be tested for occult blood. 9. There is normally no occult blood in the stools. Techniques of examination: Female General approach 1. The examination is usually performed following the pelvic examination with the patient still in the lithotomy position. 2. If only the rectal examination is done, the patient may be positioned laterally, as for examination of the male. The lateral position permits better visualization of the sacral region. 3. The technique is basically the same for the female as for the male. 4. Anteriorly, the cervix, and perhaps a retroverted uterus, may be felt. 4. Anteriorly, the cervix is round and smooth. MUSCULOSKELETAL SYSTEM General approach 1. Examine the muscles and joints, keeping in mind the structure and functions of each. 2. Observe and palpate joints and muscles for symmetry and examine each joint individually as indicated. 3. The examination is performed with the joints both at rest and in motion, moving through a full range of motion; joints and supporting muscles and tissues are noted. Inspection 1. Inspect the upper and lower extremities for size, symmetry, deformity, and muscle mass. 2. Inspect the joints for range of motion (in degrees), enlargement, redness. 3. Note gait and posture; observe the spine for range of motion, lateral curvature, or any abnormal curvature. 4. Observe the patient for signs of pain during the examination. Palpation 1. Palpate the joints of the upper and lower extremities and the neck and back for tenderness, swelling, warmth, any bony overgrowth or deformity, and range of motion. 2. Hold the palm of your hand over the joint as it moves, or move the joint through the fullest range of motion and note any crepitation (crackling feeling within the joint). 3. Palpate the muscles for size, tone, strength, any contractures, and tenderness. 4. Palpate the spine for bony deformities and crepitation. Gently tap the spine with the ulnar surface of your fist from the cervical to the lumbar region and note any pain or tenderness. NEUROLOGIC SYSTEM Equipment Safety pin Cotton Tuning fork Reflex hammer Flashlight Tongue blade Ophthalmoscope Vision screener Cloves, coffee, or other scented items General information 1. The examination described in this section is a screening neurologic examination. It is performed on individuals without specific neurologic complaints. 2. The examination is performed with the patient in either the sitting or supine position. 3. Much of the neurologic examination can be performed as different regions of the body are being examined. This facilitates the flow of the entire examination. Components of the neurologic examination There are six components of the neurologic examination: Mental status (cerebral function) Cranial nerve function Cerebellar function Motor function Sensory function Deep tendon reflexes (DTRs) The screening neurologic examination involves testing all of these components at least superficially. Learning these components in order will help in organizing the examination and in avoiding the omission of any part. Basic principles 1. Symmetry of function and findings on both sides of the body are important to note. Always compare one side of the body with the other side (for example, compare degree of motor strength of the right biceps with that of the left biceps). 2. Integrating the neurologic examination into the examination of the various body regions is advisable, although the results of the neurologic findings should be recorded together as an entity. Mental status Components of the mental status examination include the following: State of consciousness (alert, somnolent, stuporous, comatose) Memory (short-term, long-term, intermediate) Affect (mood) Ideational content (hallucinations) In a screening examination, mental status is evaluated by observing the patient's affect during the history and the content of what he or she says. 1. While recording the history, ask the patient for identifying information (how to spell his name, where he lives), and ask what the date is. This tests orientation. 1. Normally the individual is alert, knows who he is and where he lives, and can tell you the date. 2. The patient's ability to remember is also evaluated as the history is taken; ask for his past medical history (long-term memory) and dietary habits: “What did you eat for breakfast?” (intermediate memory). 2. The patient remembers recent and past events consistently, and willingly admits forgetting something. Elderly people often have much better long-term memory than recent memory. 3. Cognition and ideational content are evaluated throughout the history by what the patient says and by his articulateness, consistency, and reliability in reporting events. 4. Affect or mood is evaluated by observing the patient's verbal and nonverbal behavior in response to questions asked, sudden noises, and interruptions. For example, does the patient laugh or smile when talking about normally sad events; is he easily startled by unexpected noises? 4. Mood should be appropriate to the content of the conversation. Cranial nerve function First (olfactory) nerve The olfactory nerve is not usually tested unless the patient complains of a disturbance in sense of smell. 1. The airway must be patent. 2. Occlude one nostril; ask the patient to close his eyes and then present various substances to smell (coffee, tobacco). Occlude the other nostril and repeat. 2. The patient should be able to identify common smells such as cinnamon, coffee. Second (optic) nerve Includes tests of visual acuity and of gross visual fields and examination of the optic disc with a funduscope. Visual acuity Visual acuity is tested with the use of a Snellen chart (patient uses glasses if required). 1. Have the patient cover one eye at a time and read the smallest print possible on the chart from a distance of 20 feet (6 m). 1. Normal vision and corrected vision should be 20/20. Visual Fields 1. Have the patient cover his right eye with the right hand. (You cover your left eye with your left hand.) 2. Stand approximately 2 feet (60 cm) from the patient and have him fix his gaze on your nose. 3. Bring two wagging fingers in from the periphery (in a plane equidistant from the patient and you) in all quadrants of the visual field and ask the patient to tell you when he sees your wagging fingers. 3. Assuming your visual fields are grossly normal, the patient and you should see the wagging fingers approximately simultaneously. (The patient's peripheral vision should approximate the examiner's, assuming that it is normal.) Optic Disc The optic disc is visualized as part of the funduscopic examination. (See page 56.) Third (oculomotor), fourth (trochlear), and Sixth (abducens) nerves These nerves are tested together. They control the movements of the extraocular muscles of the eye—the superior and inferior oblique and the medial and lateral rectus muscles. The oculomotor nerve also controls pupillary constriction. 1. Hold your index finger approximately 1 foot (30 cm) from the patient's nose. Ask the patient to hold his head steady. 2. Ask the patient to follow your finger with his eyes. 3. Move your finger to the right as far as the patient's eye moves. Before bringing your finger back to the center, move it up and then down, so that the patient glances up and peripherally and then down and peripherally. 4. Repeat the test, moving your finger to the left. Fifth (trigeminal) nerve The trigeminal nerve controls muscles of mastication and has a sensory component that controls sensations of the face. Motor 1. Have the patient clench teeth while palpating the temporal and masseter muscles of the jaws with both hands. 1. Muscle strength in the face should be present and should be symmetric. Sensory Sensation to light touch. 1. Have the patient close eyes. 1. Sensation should be present and symmetrical. Always demonstrate to the patient how and with what you are testing sensation—to avoid startling the patient and to encourage cooperation. 2. Touch first one side of the patient's face and then the other (forehead, cheek, and chin), asking the patient if the sensation is present and feels the same on both sides. 3. Sensation to pain (pinprick) is tested similarly. Seventh (facial) nerve Motor function is tested by observing facial expression and symmetry of facial movement Ask the patient to frown, close his eyes, and smile. The facial muscles should look symmetric when the patient frowns, closes his eyes, and smiles. Notice particularly the symmetry of the nasolabial folds. Eighth (acoustic) nerve The acoustic nerve has two branches. Cochlear (mediates hearing). (See ear examination, page 57.) Vestibular (helps control equilibrium). Romberg test: Have the patient stand erect with his eyes closed and feet close together. Slight swaying may occur, but the patient should not fall. (Stand close to the patient so you can assist if he begins to fall.) Ninth (glossopharyngeal) and tenth (vagus) nerves These nerves are tested together because they both have a motor portion innervating the pharynx. 1. Ninth: Test the presence of the gag reflex. 1. The gag reflex should be present, and there should be no difficulty in swallowing. 2. Tenth: Ask the patient to say “ah” and observe the movement of the uvula and palate for deviation and asymmetry. 2. The palate and uvula should move symmetrically without deviation. Eleventh (spinal aaccessory) nerve The spinal accessory nerve mediates the sternocleidomastoid and upper portion of the trapezius muscles. 1. Ask the patient to turn his head to the side against resistance while you apply pressure to the jaw. 2. Palpate the sternocleidomastoid muscle on the opposite side. 3. Have the patient shrug his shoulders while you place your hands on his shoulders and apply slight pressure. 3. Neck and shoulder muscle strength should be symmetric. Twelfth (hypoglossal) nerve This nerve innervates muscles of the tongue. It is tested by noting articulation and by having the patient stick out his tongue, noting any deviation or asymmetry. The tongue should be symmetric and should not deviate. Cerebellar function Purpose: to screen for coordination. 1. Observe posture and gait. 2. Ask the patient to walk forward (and then backward) in a straight line. 2. The patient should be able to perform all the tests described with smooth, even movement and without losing balance. 3. To test for muscle coordination in the lower extremities, have the patient run his right heel down his left shin and vice versa. 4. To test coordination in upper extremities, have the patient close his eyes and touch his nose with his index finger (starting position: arms outstretched) first left, then right, in rapid succession. 4. The normal person can do this with rapid, smooth movements without undershooting or overshooting the target. Motor function Tested in conjunction with the skeletal system because any bony deformity will affect motor function. Evaluate muscle mass, tone, strength, and any abnormal movements (tics, fasciculations, twitching). 1. To assess muscle mass, note symmetry between sides of the body and distribution distally and proximally. 1. Muscle mass is usually considered in relation to sex and body build and to use of various muscle groups. 2. Test muscle tone by noting the resistance the muscle offers to movement on passive motion. 2. Generally there is slight resistance to passive movement of muscles as opposed to flaccidity (no resistance) or rigidity (increased muscle tone). 3. Have the patient do deep knee bends; walk on his toes and then his heels; hop on one foot and then the other. 3. Strength will vary from person to person but should be equal bilaterally. 4. Have the patient squeeze your fingers with both hands; compare sides of the body. Also, apply resistance to the patient's outstretched arms and when the patient flexes the wrist and elbow; compare sides. 5. Unusual muscle movements, if present, are noted both when muscle is at rest and when it is moving. 5. Normally, tremors, tics, or fasciculations are not present either at rest or with movement. Sensory function Should test sensitivity to light touch [cotton], pain [pinprick], vibration [tuning fork], and position. Compare both sides of the body. 1. Ask the patient to close eyes. Brush skin with a piece of cotton (on the back of hands, forearms, upper arms, dorsal portion of foot laterally and medially; and along the tibia and thigh laterally and medially). Ask the patient to indicate when he or she feels the cotton and to compare the sensation bilaterally. 1. Patient should feel light touch bilaterally. 2. Use a safety pin; touch the skin as lightly as possible to elicit a sharp sensation. 2. Pain should be felt bilaterally. 3. Test vibration sense by placing a vibrating tuning fork on a bony prominence (wrist, medial and lateral malleoli). Ask the patient to tell you when he no longer feels the vibration. Stop the vibration with your hand. 3. The patient should normally feel no vibration within a very short time. 4. Test position sense by having the patient close his eyes. – Move the patient's digit (finger, great toe) up or down and ask the patient to say in what direction his finger or toe is pointing. – Place your thumb and index finger on either side of the digit being moved so the patient will not sense any pressure from your finger in the direction in which you are moving the digit. 4. Normally the patient can tell you without hesitation in what direction his digit is pointing. Deep tendon reflexes 1. Have the patient relax; provide support for the extremity being tested. 2. Compare reflex amplitude of the same tendons on either side of the body. 2. Amplitude of the reflex may vary for different tendons but is equal bilaterally. Upper extremities Biceps 1. Place your right thumb on the patient's right biceps tendon (located in the antecubital fossa) with the patient's arm slightly flexed. 2. Strike your thumb with the pointed end of the hammer head. Hold the hammer loosely so it pivots in your hand when it is moved with a wrist action. 3. Strike your thumb with the least amount of pressure needed to elicit the reflex. 3. The forearm may move, and your thumb should feel the tendon jerk. Triceps tendon 1. Have the patient hang his or her arm freely while you support it with your non-dominant hand or rest the slightly flexed arm in the patient's lap. 2. With the elbow flexed, strike the tendon directly, using the pointed end of the hammer 2. The forearm should move slightly. NURSINGALERT ALERT If the reflexes are diminished symmetrically, have the patient grasp hands and contract arm muscles to relax the lower extremities, or tap feet on the floor to relax the upper extremities. Brachioradialis tendon 1. Strike the forearm with the hammer about 1 inch (2.5 cm) above the wrist over the radius. 1. The thumb may be observed moving downward. 2. Be sure the forearm is supported and relaxed. Lower extremities Quadriceps reflex 1. Have the patient sit with his legs hanging over the edge of the table or lay down while you support the legs at the knee (slightly bent). 2. Strike the tendon just below the patella. Achilles reflex 1. Support the foot in dorsiflexed position. 2. Tap the Achilles tendon with the hammer. 2. The foot should move downward into your hand. Plantar reflex 1. Stroke the sole of the patient's foot with a flat object such as a tongue blade. 1. Toes normally flex. Dorsiflexion of the great toe and fanning of the other toes is known as a positive Babinski response and indicates a central nervous system problem. * Auscultatory gap: The first sound of blood in the artery is usually followed by continuous sound until nothing is audible with the stethoscope. Occasionally the sound is not continuous and there is a gap after the first sound, after which the sound of blood in the vessel is heard again. If one uses only the auscultatory method and pumps the cuff up until the sound is no longer heard, it is possible, when there is a gap in the sound or when the sound is not continuous, to get a falsely low systolic reading.