General Appearance:

1. _________________________________________________________
2. _________________________________________________________
3. _________________________________________________________
4. _________________________________________________________
5. _________________________________________________________
6. _________________________________________________________
7. _________________________________________________________
8. _________________________________________________________
9. _________________________________________________________

Alert pts. _________________________________________________________

Anxious patients:_________________________________________________________

Cyanosis in the lips, tongue, and oral mucosa signals __________. Pallor and sweating
(_______________) are common in ___________________________.

Jaundice is the result of ____________________________.

Breath odors can reveal ___________________, ________________, _______________,

_______________.

Patients often prefer sitting upright ________________________ and leaning forward with arms braced
in _________________________.

Watch for very short stature in ____________, and ____________; long limbs in _______________; and
height loss in ____________-and _________________.

There is generalized fat distribution in _________________ and truncal fat with relatively thin limbs in
__________________ and _________________.

If patient’s BMI is ____________, measure the patient's waist circumference at

__________________________.

Why?____________________________________________________________________

Other tests to consider:

1.

2.

a)

b)
Vital Signs:

Radial pulse:

Using the pads of your _____ and ____________ palpate the pulse along the groove on the on the
anterior surface of the _________________ until a maximal pulsation is detected. Assess for the
following features:

1.

30 sec when _________________ and 60 secs when_________________

2.

3.

Respiratory Rate and Rhythm:

While holding the patient’s wrist OR with the patient’s arm folded across the chest, watch the patient’s
chest (or abdomen if the patient is female) Observe the rate for ______ sec. Assess for :

1.

2.

3.

Prolonged expiration is common in __________________________.

Blood Pressure

Ensure the patient’s arm is unrestricted, and arm is supported at _____________ (such as on a table or
by suspending the arm)

Locate the _______________ by palpation prior to placing BP cuff.

Center the cuff over the brachial artery with the lower border of the cuff is ________ above the
_____________

Ensure the cuff fits appropriately.

Cuff bladder width: _____ of upper arm circumference

Cuff bladder length: _____ of upper arm circumference

Slightly flex the patient’s arm at the elbow.

Estimate systolic pressure by palpation:

Palpate the _________________ while inflating cuff until the initial pulse disappears.

Then slowly deflate the cuff until _______________ and note the reading on the pressure gauge.

Deflate the cuff completely.

Re-inflate the cuff to about ___________________ the initial reading (___________ pressure) and place
the ________________ of your stethoscope over the _______________. Slowly deflate the cuff while
listening for the ____________________ at a rate of 2–3 mm Hg/sec.

Note the level when you hear the sounds of at least _________________. This is the _______________.
Continue to deflate until the sounds become ____________________. The disappearance point is the
best estimate of the ____________________.

Read both the systolic and diastolic levels to the nearest ____mmHg.

If the brachial artery is below heart level, the blood pressure reading will be ___________ ; if the
brachial artery is above heart level, the reading will be ___________.

A _______ cuff or a bladder that balloons outside the cuff leads to falsely ________ readings.

If the cuff is too _________ (___________), the blood pressure will read ________; if the cuff is too
_______ (_______), the blood pressure will read _________ on a small arm and _______ on a large arm.

An unrecognized __________________ may lead to serious ___________________ of systolic pressure

(150 instead of 200 in the example below) or _______________ of diastolic pressure.

Orthostatic Blood Pressure:

If indicated and/or the patient reports ___________________. Causes of orthostatic hypotension

include ______, ___________________, ________________, and ____________________. Orthostatic
change is defined as _________________ in systolic BP, _______________ in diastolic BP.

Measure the blood pressure with the patient in two positions: _____________ and ____________.

Have the patient lie down resting for _____________.

Measure blood pressure.

Have the patient stand.

Repeat blood pressure after standing _______________________.

Measure Temperature

Shake the thermometer to bring the mercury to ___________

Place the thermometer using one of the following locations:

_______: Place the thermometer under the patient’s tongue and instruct the patient to close their lips.
Read after _______________

_______: Place the thermometer in the patient’s axilla with the bulb pointing towards the apex of the
axilla. Instruct the patient to bring their arms towards chest wall to hold the thermometer in place. Read
after ____________
_________: Lubricate the thermometer and insert it _______ (about ___________) into the patient’s
rectum with the patient lying on his side with their _______. Read after ________

__________: Aim the infrared thermometer gun at the optimal body part of the targeted person
( __________, ________, _________) which you want to measure and then pull the trigger to view the
accurate temperature reading on the digital display within ________.

CVS:

Hands:

1.

2.

Radial pulse:

1.

2.

Blood pressure:

Carotid Pulse:

1.

2.

3.

Jugular venous pulse:

1.

2.

Face, mouth eyes:

1.

2.

3.

4.

5.

6.

7.

Precordium:
1.

2.

Auscultation:

Back:

1.

2.

Back:

1.

2.

Abdomen:

1.

2.

3.

4.

Tendon Xanthomas:

1.

Femoral pulses:

1.

2.

Legs:

1.

2.

1. Inspect for Carotid pulsations bilaterally:

Inspect the neck for carotid pulsations, often visible just ___________________________.

2.Ausculate for possible carotid bruits:

Ask the patient to stop breathing for ____________. Use the ______________ of your stethoscope to
auscultate both carotid arteries for any _________.

3.Palpate the carotid pulse:

Use ______________ to palpate carotid over ________ of the neck. (The fingers should be positioned
between the _______ and the _______ border of the _________________ muscle at the level of the
_________ cartilage.)

Examine each side separately. Never palpate both carotid arteries at the same time. This may decrease
blood flow to the brain and induce __________

The presence of carotid bruits suggests ______________________ that may cause _______.

Causes of decreased pulsations include decreased ____________ from ________ or _______ and
_________ ________ ___________ or _____________.

Comment on the ____________ and _________________, namely the speed of the upstroke, the
duration of its summit, and the speed of the downstroke.

The normal upstroke is ________; it is smooth, rapid, and follows _____ almost immediately. The
summit is smooth, rounded, roughly __________. The downstroke is less abrupt than the upstroke.

Evaluation of the Jugular venous pulse:

Ask patient to turn head slightly away to the _______ and use __________ lighting to inspect JVP on the
______ side of the neck

Observe the _____________ and the ____________ of the jugular venous pulsations.

The JVP is best assessed from _________ in the ___________________, which is directly in line with the
_______________ and _____________.

Measure Jugular Venous Pressure:

Focus on the _______________________.

Look for pulsations in the _________________, between the attachments of the ______________ on
the sternum and clavicle, or just ______________________.

Identify the highest point of pulsation in the ________________.

Place a ruler vertically on the ____________________; then another straight edge object is placed at
right angles to the ruler to mark the level of the JVP. Measure the point of intersection on the ruler

To determine central venous pressure, add_________ H2O to the estimated JVP.

JVP measured at __________ above the sternal angle, or ___________________ in total distance above
the _______________, is considered elevated above normal.

Hepato-Jugular Reflux:

Performed if suspected ________________, _____________ due to other __________________,

_____________________, ______________, and ____________________
With the patient ___________ at a ___ elevation, apply gentle firm pressure over the
_____________________ for at least ________

Repeat the JVP. An increase in JVP ______ is a positive test

In Normal subjects the jugular venous pressure may transiently rise and then return to normal or
decrease within __________.

Inspection of Precordium:

Inspect the precordium (__________ chest wall) for

a. __________, ___________ or ______________

b. _________________________.

A _______________________scar usually indicates previous valve replacement or coronary artery

bypass surgery. _____________________are seen after pacemaker or defibrillator implantation, and the
bulge of the device may be obvious.

Palpate the Point of Maximal Impulse (PMI):

With the patient ________, palpate over the _____________ line in the ____________________ with an
open palm to location the apical impulse. If you do not feel the impulse, ask the patient to turn in the
_______________________ position

Once found, localize the apical impulse with __________

Using your ___________, identify the exact site of the PMI by ______________________________ from
the sternal angle.

Note its location (______________ and anatomical line - _______________).

Lateral displacement toward the ______________ from _____________________ is seen in

_________________, ___________________, and ___________________________; and also in
________________________ and ___________________.

Palpate for heaves (right ventricular heave)

With the patient ____________, press the ___________ border of the hand parallel to the
____________________. If you feel rhythmically lifts, this indicates _______________________ or
_______________, most often accompanying ___________________________.

Palpate for thrills:

With the patient ____________, palpate using the ______________ of your hand

Palpate the chest in the areas for auscultation of the heart. If a ___________ sensation is felt, this
indicates a ___________________ and the area should be auscultated.

Auscultation of the precordium:

Determine S1 and S2. The carotid pulse must be checked ____________________ at the beginning of
auscultation to identify the ___________ and ______________ heart sounds. It is also crucial for
determining ____________ vs. ____________ events (sounds, murmurs).

The timing of the carotid upstroke in relation to S1 and S2. Note that the normal carotid upstroke
follows S1 and precedes S2. This relationship is very helpful in correctly identifying S1 and S2.

Auscultate with the ________________ for S1 and S2 at the following areas with the patient
___________

___________ (R. 2nd interspace)

______________ (L. 2nd interspace)

_________________ (L. 4th interspace)

__________________ (apex or 5th interspace around _______________)

Screen for Mitral Stenosis murmur

Place the _______ of your stethoscope over the __________ while the patient is ___________. Keep
your stethoscope at this point. Ask the patient to exhale completely and stop breathing after expiration.
Then ask the patient to roll onto the left side (__________________) and listen for any murmurs

This position accentuates a left-sided _____ and _____ and __________ murmurs, especially
____________________. Otherwise, you may miss these important findings.

Screen for Aortic Regurgitation murmur

Ask the patient to sit up, lean forward, exhale completely and stop breathing after expiration.

Use the ______________ auscultate along the ____________________ ( ____________ Left ICS).

You may easily miss the ___________________________ of aortic regurgitation unless you listen at this
position.

Identifying Heart Murmurs:

Heart murmurs are produced by _______________________ across an abnormal valve, septal defect or
outflow obstruction. ‘Innocent’ murmurs are caused _________________________________________
and occur when stroke volume is ________________, as in pregnant women, athletes with resting
bradycardia or patients with fever

If a Murmur is detected, describe completely:

Time the murmur (by checking the _________________)?

Is it systolic: you hear the turbulence __________ the pulse?

Is it diastolic: you hear the turbulence __________ the pulse?

Locate where on the precordium the murmur is loudest

Location:

At the base (___________ or ____________)

Along with the sternal border

At the Tricuspid area

At the apex (____________)?

Does it radiate?

Determine the shape of the murmur

1.

2.

3.

4.

Grade the intensity of the murmur from __________ and determine its _______ and _________.

Quality

1.

2.

3.

4.

Conduct any necessary maneuvers, such as having the patient _____________ and __________ or turn
to the ____________ position or ____________________

Identify associated features such as the quality of S1 and S2, the presence of ____________ such as
_____, ______, or an _______________, or the presence of additional murmurs.

PVS:
Assess the Temperature

Use the ____________________ and compare both sides.

Palpate the following Upper extremity pulses bilaterally:

Radial Pulse: With the pads of your ___________________ of the ______________ hand, palpate over
the ___________ aspect of the wrist.

Brachial Pulse: Flex the patient’s elbow and palpate the artery just _________ to the ______________ at
the antecubital crease OR in the groove between the _________ and _________ muscles
Assess Capillary refill:

Press down on nail so it blanches, then let go and note the time it takes to “pink up. Should be done on
at least one nail on each limb. Normal is _______________.

Allen Test:

Assess Patency of the Radial and Ulnar arteries

Ask the patient to make a _____________ with one hand then compress both ________ and
___________ arteries firmly with your _________

Ask the patient to open the hand. The palm should be __________

Release the thumb compressing the ____________ to test the patency of the ______________. There
should be return of color in ________________.

Repeat the assessment to test the patency of the radial artery

Arterial occlusive disease is much less common in the _______ than in the _________. Absent or
diminished pulses at the wrist occur in ____________________ and in ____________, or
thromboangiitis obliterans.

Persisting pallor indicates _______________________ or its distal branches.

Lower limb examination for arterial and venous system

Inspection: from the groin and buttocks to the feet

Assess _______, ______________, and note any ___________

Note color of _____ and ____________

Note the distribution of ____ on the _________, _________ and _______

Inspect the leg for _____________

Note any _______________, ____________, _________, or _________ (Include toes and soles of feet.)

Special Test for Suspected deep vein thrombosis:

Calf Circumference

Palpate the _____________________ and measure ______ below

From this point, measure the calf circumference and note the measurement

Repeat on the other limb

Normal result is a difference in calf circumference of ______. Calf asymmetry _______ increases the LR
for ______ to >2.26 Also consider _________________, __________ (posterior knee), and ___________.
Homan’s Test

With the patient _______ and the knee ___________, passively __________ the foot at the ankle. If the
patient experiences ______________ in the calf region, the test is positive for _____________________.

Palpation

Note Temperature of legs and feet

Use backs of fingers and compare bilaterally

Asymmetric coolness of the feet has a positive LR of >6 for ___________

Acute arterial occlusion from _______________ or _______________ causes _______________ or

____________-. The limb distal to the occlusion becomes ________, _______, and ____________.

Palpate the following Lower extremity pulses bilaterally:

Femoral Pulse: Press deeply, below the ______________ and about midway between the
_________________________and the _________________.

Popliteal Pulse: With the knee flex, place the fingertips of both hands in the _______________________
and press firmly into the ____________________.

Posterior Tibial Pulse: Palpate behind and slightly below the __________________ of the ankle.

Dorsalis Pedis: Palpate the dorsum of the foot lateral to the ______________________________.

Amplitude of pulses

0=

1=

2=

3=

4=

Assess capillary refill

Press down on nail so it blanches, then let go and observe the time it takes to turn pink).

Buerger’s test:

Assessment of chronic arterial insufficiency of lower extremities.

With patient lying _______, Raise and support both legs to ________º for up to _______________.
Watch for pallor with emptying of the ____________________

Then ask the patient to sit up and dangle feet over the edge of the bed.
Note return of pinkness in ______________ and filling of veins of feet and ankles in _____________. In
darker skinned patients inspect the __________________

Clinical Examination of the respiratory system:

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

Techniques of Examination

For best results, examine the posterior thorax and lungs while the patient is _________, and the anterior
thorax and lungs with the patient __________. Be considerate when draping the patient's gown. For
men, arrange the gown so that you can see the full chest. For women, cover the anterior chest when
you examine the back; for the anterior examination, drape the gown over each half of the chest as you
examine the other half. Begin with _________, then _________, _________, and __________. Try to
visualize the underlying lobes and compare the right lung field with the left, carefully noting any
asymmetries.

With the patient sitting, examine the _____________________. The patient's arms should be folded
across the chest with hands resting, if possible, on the opposite shoulders. This position swings the
scapulae laterally and ________________________. Then ask the patient to lie down

With the patient supine, examine the __________________. For women, this position allows the breasts
to be gently displaced. Some clinicians examine both the posterior and anterior chest with the patient
sitting, which is also satisfactory.

Assess for Signs of Respiratory Distress

Observe the _______, ____________, ___________ and __________________.

Inspect _________ and ________________________ for ___________ or __________ and fingers for
clubbing.

Observe for audible sounds of breathing

Inspect for use of _____________________, _________________ or ___________________________

Observe for “Barrel Chest”

Normally, the chest is ________ than it is deep, that is, 1:2 ratio. Measure the __________________
diameter in relation to the lateral diameter if you suspect ______________ in patients with __________
lung disease (COPD).

Examination of the Posterior Thorax: Inspection

Stand __________ the patient in the ____________ and then at the side. Note the following:

The _______________ of the chest and chest movements

_______, __________, __________, ____________ or Deformities

Abnormal muscle retraction of the ________________.

Palpation

Identify any chest wall __________________

Palpate the ________________ chest using one or both hands for _______________ and ____________

Test for chest expansion:

Place your hands on costal margin at the level of the __________ with thumbs pointed ___________
and ________________ to each other while grasping a small fold of skin in between them.

Ask the patient to inhale deeply. Watch the ____________________________ as they move apart
during inspiration.Note symmetry.

Perform _______________________

The patient should be seated upright with arms crossed

Place the __________ surface of your dominant hand only in the ___________________
(____________) and ask the patient to repeat the words "____________."

Start at ___________ to the scapular border and compare with the opposite side. Move downward in a
ladder like pattern to compare the symmetric areas of the lungs until the level of the _____________

Ensure to compare symmetric areas of the lung and omit areas over the scapula

Unilateral decrease or delay in chest expansion occurs in ____________________ of the underlying lung
or __________, ______________, _________________, _________________ with associated splinting,
unilateral bronchial obstruction, and paralysis of the hemidiaphragm.
Fremitus is decreased or absent when the voice is _____________________ or when the transmission of
vibrations from ______________ to the __________________ is impeded by a thick chest wall, an
obstructed bronchus, COPD, or pleural effusion, fibrosis, air (pneumothorax), or an infiltrating tumor.

Percussion

Demonstrate proper percussion technique

The middle finger is _____________________ with the ____________________ joint pressed on the
skin surface. Avoid surface contact by any other part of the hand.

Use the tip of the _______________ finger of the striking hand to hit the DIP joint with a brisk but
relaxed wrist motion

Withdraw the striking finger immediately to avoid ______________ vibrations.

Dullness replaces _______________ when fluid or solid tissue replaces air containing lung or occupies
the pleural space beneath your percussing fingers. Examples include: lobar pneumonia, and pleural
accumulations of serous fluid (______________), blood (______________),or pus (________________) .

Generalized _________________ is common over the hyperinflated lungs of ________ or _________

General percussion:

The patient should be upright with _________________

Place the _______________ digit in the intercostal space (_____________)

Percuss one side of the chest and then the other at each level in a _______________ using the proper
percussion technique.

Omit areas over the ________________ - the thickness of muscle and bone alters the percussion notes
over the lungs.

Start at _______ medial to the scapular border to the level of _______________.

Assess for Diaphragmatic Excursion:

Diaphragmatic excursion should be performed on the ____________________ in a patient with

suspected ________________________, large __________________ or _________________________:
Ask the patient to take a deep breath in fully and hold (_____________).

On one side of the posterior thorax, percuss from below the scapula in the ___________________ until
the level of ________________ is identified. Note this point with a mark that can be removed / use the
patient’s finger

Then ask the patient to breathe out fully and hold (_______________).

On the same side, percuss from below _________________ in the ________________ line until the level
of _______________ is identified again. Note this point with a mark that can be removed / use the
patient’s finger
Measure difference between the two points (Normal _____________)

Repeat on the other side for comparison.

Auscultation

The patient should be upright with arms crossed

Ask patient to breathe deeply in and out through an ______________.

Auscultate the _________________ using the _____________ of the stethoscope.

Always place the stethoscope directly on the skin. Clothing alters the characteristics of the breath
sounds and can introduce friction and added sounds.

Start at the top and move along the ______________________ to the level of ________ using the ladder
like pattern and comparing symmetric areas.

Listen to the ___________, ____________, and _____________ of expiratory and inspiratory sound
Identify the breath sounds (vesicular or bronchial)

Identify any adventitious sounds such as ______________ (or crepitations, rales), _____________
( wheezing) or _______________________.

Breath sounds may be decreased when air flow is _______________ (as in obstructive lung disease or
respiratory muscle weakness) or when the transmission of sound is poor (as in pleural effusion,
pneumothorax, or COPD)

The crackles of heart failure are usually best heard in the _______________________ lung fields.

Clearing of crackles, wheezes, or rhonchi after coughing or position change suggests

_______________________, seen in _______________ or ________________.

Examination of the Anterior Thorax :Inspection

Patient should be________________/ __________(for females) with arms at the side. Observe for the
following:

The ________ of the chest and ___________________

Deformities or asymmetry of chest

Abnormal ______________________ of the intercostal spaces

Abnormal retraction occurs in severe _________, _____________, or ____________________________.

Palpation

Palpate for tracheal deviation

Place your finger along one side of the trachea and note the space between it and the
________________. Compare it with the other side. The spaces should be symmetric.

Identify any chest wall tenderness

Palpate the anterior chest using one or both hands for ______________ and _____________.

NB: If female standardized patient, do not assess tenderness over the breasts

Test for chest expansion:

Place hands along the _______________ with thumbs pointed ____________ and paralleled to each
other while grasping a small fold of skin in between them.

Ask the patient to inhale deeply. Watch the distance between your thumbs as they move apart during
inspiration. Note symmetry.

Perform tactile fremitus:

Place the ____________ surface of your dominant hand in the intercostal space (horizontally) and ask
the patient to repeat the words “________________.”

Start at the ____________ (__________________) and move downward. Compare symmetric areas of
the lung in a ladder-like a pattern.

Assess the lateral chest in the ______________________ at the level of __________________________.

NB: If female standardized patient, assess tactile fremitus over areas “1-3” as above. If the breast tissue
is obstructing area “3” – ask the patient to move the breast outward. Then ask the patient to elevate her
breast and assess area “4” and “5” directly below the breast. Do not examine over the breasts

General Percussion

Place the _______________ digit in the intercostal space (horizontally)

Percuss the _____________________, using a ladder-like a pattern, percuss both sides starting
_______________________, moving down to the level of ________________ along the
____________________.

Assess the ____________________in the ______________________ at the level of _________________

NB: If female standardized patient, assess percussion over areas “1-3” as above. If the breast tissue is
obstructing area “3” – ask the patient to move the breast outward. Then ask the patient to elevate her
breast and assess area “4” and “5” directly below the breast. Do not examine over the breasts

Dullness represents __________________ from inflammation or secretions. Because pleural fluid usually
sinks to the lowest part of the pleural space (posteriorly in a supine patient), only a very large effusion
can be detected ______________________. The hyperresonance of COPD may obscure dullness over
the heart.

Auscultation:

Ask the patient to take deep breaths in and out through an ______________________.

Listen to breath sounds on the _____________________ using the _________________ of the

stethoscope comparing sides in a “ladder pattern” starting at the apex (________________________)
and moving down to the level of ________________ along the __________________, skipping the
breast.
Listen to breath sounds on the lateral chest wall between the anterior and posterior axillary line at the
level of _____________________________

Listen to the __________, ________________, and __________________________

Identify the breath sounds (vesicular or bronchial) any adventitious sounds such as crackles (or
crepitations), rhonchi ( wheezing) or friction rub.

NB: If female standardized patient, auscultate over areas “1-3” as above. If the breast tissue is
obstructing area “3” – ask the patient to move the breast outward. Then ask the patient to elevate her
breast and assess area “4” and “5” directly below the breast. Do not examine over the breasts.

Assess for Consolidation:

Perform all voice transmission tests to assess suspected _________________ (signs of _____________):
Bronchophony: Ask the patient to say “ninety-nine (normal volume). Normally, the sounds are
_________________ and ____________ . ______________ volume of sounds over the affected area of
the lungs is indicative of consolidation.

Egophony. Ask the patient to say “eee”. Usually, “___” is heard. If the sound is more like an “_____,” this
is associated with consolidation.

Whispered Pectoriloquy. Ask the patient to whisper “ninety-nine” or “one-two-three.”(low volume).

Normally, the sounds are ______________________. _______________ volume of sounds over the
affected area of the lungs is indicative of consolidation.

Note: These can be performed on the anterior and/or posterior chest. Should also be done
symmetrically to identify any abnormalities.

HEENT:

Inspection

Skull:

Observe from the front, side and behind for the _____________ and _______________. Note any
______________ and ____________________.

Hair and the scalp:

Note its _____________, _____________, __________, and _________________

Part the hair in several areas and inspect the _____________. Look for scales, lumps, nevi or other
lesions.

An enlarged skull may signify ______________ or _____________ of bone. Palpable tenderness or bony
step-offs may be present after ____________________. Fine hair is seen in _________________, coarse
hair in _________________________. Tiny white ovoid granules that adhere to hairs may be
__________ (lice eggs). Look for redness and scaling that may indicate _________________ or _______.
Acne is common in ___________________. Hirsutism (excessive facial hair) may appear in some women
with ____________________.

Face:

Observe during rest and conversation for _________________ and ____________, any involuntary
movements or _____________, ______________, and __________________

Skin:

Observe for the ___________, _____________, _______________, and __________________________

Palpation

Palpate the skull for any ____________, ________, __________ or __________

Palpate the __________________________ bilaterally and report _____________\

Neck Examination: Inspection

Stand in front the patient. Look for any ___________, _____________, ______________

Observe the patient ____________. Ask the patient to sip some water and to extend the neck again and
swallow.

Inspect the _________ for any deviation from its midline position.

Palpation:

Assess for Lymphadenopathy: With the pads of your ________________ together in a circular
movement, palpate the following lymph nodes

Occipital: at the base of the skull ________________

Posterior Auricular: behind the __________, superficial to the _____________________

Preauricular node: in front of the ______________

Tonsillar: at the angle of the ___________________

Submandibular: midway between the ___________ and the ________________.

Submental: under the tip of the ________________

Cervical Nodes :

Superficial Cervical: above the _________________

Posterior cervical: along the anterior edge of the ____________________

Deep cervical chain: hook your thumb and fingers around either side of the _______________________
Supraclavicular: in the angle formed by the _____________ and the _______________. You may use a
_____________________________ approach.
Lymphatic drainage patterns are helpful when assessing possible ___________________________: For
suspected malignant or inflammatory lesions, look for enlargement of the neighboring regional lymph
nodes; when a node is enlarged or tender, look for a source in its nearby drainage area.

Enlargement of a supraclavicular node, especially on the left, suggests possible metastasis from a
_____________ or an ___________________ malignancy

Assess for Tracheal deviation:

Place your finger along one side of the ______________ and note the space between it and the
sternocleidomastoid. Compare it with the other side. The spaces should be symmetric.

Masses in the neck may cause tracheal deviation to one side, raising suspicion of conditions in the
thorax such as a ______________________, ____________________, or a ________________________

Assess the Thyroid gland:

Stand behind the seated patient o Place your ________________ of both hands just below the
________________

Ask patient to take a sip of water and hold it in their mouth. Ask the patient to swallow the water while
palpating the ____________________.

Next, displace the trachea to the right with the fingers of the ________ hand; with the right hand
palpate laterally for the right lobe of the thyroid between the displaced trachea and the
sternocleidomastoid muscle (SCM) while the patient swallows.

Displace the trachea to the left with the fingers of the ___________ hand; with the left hand palpate
laterally for the left lobe of the thyroid between the displaced trachea and the SCM while the patient
swallows.

Note the __________, ________________ and _________________ of the gland.

Auscultation:

If the thyroid is enlarged, auscultate for __________. A bruit may be a sign of ___________________ or
__________________________.

Eye Examination:

Position and Alignment of the Eyes

Stand in front of the patient and survey the eyes for ___________ and _______________. If one or both
eyes seem to ____________________, assess them from above

Abnormalities include __________________ (inward deviation) or __________________ (outward

deviation) of the eyes and also abnormal protrusion in ________________ or _______________.

Eyebrows:
Inspect the eyebrows, noting their ______________, ______________________, and any
__________________ of the underlying skin. Scaliness occurs in __________________, lateral
sparseness in ___________________.

Eyelids:

Note the position of the lids in relation to the eyeballs. Inspect for the following:

1.

2.

3.

4.

5.

Inspect each lacrimal apparatus for ________________ or ________________/_____________

___________ is a drooping of the upper lid. Causes include _________________, damage to the
________________ nerve (CN III), and damage to the ____________________ (Horner syndrome).
Upslanting palpebral fissures are noted in _______________________. Red inflamed lid margins occur in
__________________, often with crusting.

Conjunctivae and sclerae:

Ask the patient to ________________ as you depress both lower lids with your thumbs.

Ask patient to look _____________ and _________________ to expose the visible sclera.

Note the ______________, _________________, ________________, _______________, ___________

Cornea, lens, and Iris

Use oblique lighting pointing directly ______________ to the iris inspect for opacities. At the same time
assess the iris.

Pupils

Assess the pupils for _______ and _________

In a dim light, inspect the size, shape, and symmetry of both pupils.

Measure the pupils with a card showing black circles of varying sizes, shown below, and test the light
reaction.

Note if the pupils are large (__________), small (_________) or ______________

Assess pupillary light reaction (direct and consensual reaction).

Ask the patient to fix his/her eyes on a ______________________________________.

Bring a bright penlight from the side to shine on the pupil.

Look for constriction of that pupil ( ________________ )

Repeat and look for constriction of the opposite pupil ( _________________).

_______________ refers to constriction of the pupils, ________________ to dilation. Compare benign

________________ with Horner syndrome, oculomotor nerve paralysis, and tonic pupil.

Near Reaction (Accommodation convergence reflex):

Hold your finger or a pencil _________from the patient’s eyes, and ask him/her to look at the pencil,
then into the distance, and back to the pencil.

Watch for _______________ with near effort and convergence of the eyes. The third component of the
near reaction, accommodation of the lens that brings the near object into focus, is not visible.

Testing the near reaction is helpful in diagnosing _______________ and _______________

Extraocular movements (EOM):

Hold your finger vertically at least ___________ away from the patient and ask him to follow it with
his/her eyes, without moving the head.

Move your finger steadily to one side, then up and down, then to the other and repeat, describing the
letter ________ in the air.

Note any conjugate __________ or ___________. Pause during each gaze position to detect
_________________. Then, test convergence by asking patient to follow your finger as you bring it to
your nose

__________ (trochlear nerve) damage, due to head trauma, congenital causes, or central lesions, causes
dysfunction of the _____________________, leading to __________________ (double vision).

Convergence is poor in ________________________.

Bedside Tests For Visual Acuity (OD, OS, then OU):

With correction if needed.

Ask patient if he/she wears corrective lenses and to put them on if so. Use Rosenbaum chart at ______.
Mini Snellen’s Chart at ______ .Large Snellen’s Chart ______

Ask patient to cover one eye at a time and read the smallest print line possible, and then test both eyes
at the same time. • Record the visual acuity designated at the side of this line, along with use of glasses,
if any.

Visual acuity is expressed as two numbers (e.g., 20/30): the first indicates the
________________________, and the second, ______________________________________________.

Vision of 20/200 means that at 20 feet the patient can read print that a person with normal vision could
read at 200 feet. The larger the second number, the _____________ the vision. “20/40 corrected”
means the patient could read the 20/40 line with glasses (a correction).
Visual Fields Visual fields by Confrontation:

Position yourself directly in front of patient so face is level with that of patient, approximately
______________ feet away.

Instruct the patient to cover one eye with the palm of hand and look directly into the examiners
_______________ eye. Examiner closes or covers his/her other eye.

Test each quadrant separately with the index finger(target). Hold the target _____________ between
you and the patient.

Start ___________________ and move the target along the _______________ towards the center of
vision until the patient detects it.

Repeat for the other quadrants.

Compare your visual field with the patient’s.

Causes of __________________________ include glaucoma, optic neuropathy, optic neuritis, and

glioma. ______________________________ include stroke and chiasmal tumors.

OU=

OD=

OS=

Examination With The Ophthalmoscope ( Fundoscopy):

Set the ophthalmoscope at correct setting:

Aperture/Filter Dial: ______________

Focusing Wheel (Lens)

Turn the lens disc to the _______ diopter. (A diopter is a unit that measures the power of a lens to
converge or diverge light.) At this diopter, the lens neither converges nor diverges light.

Keep your finger _____________________________________ so that you can turn the disc to focus the
lens when you examine the fundus.

Hold the ophthalmoscope in your ____________ hand and use your __________ eye to examine the
patient’s right eye. Repeat for the left eye with your left hand and your left eye.

Place your free hand on the patient’s forehead and gently retract the eyelid against the _____________
Ask the patient to fixate on a _______________________ and try not to move the eyes.

Shine the beam of light into the patient’s eye from approximately ___________ and about ___________
lateral to patient’s line of vision.

Note the orange glow in pupil, red reflex from retina, and opacities interrupting red reflex.

Now continue advancing the fundoscope until you are touching the hand resting on the patients
forehead.
Examine the ______________, _____________________, __________________,
_________________and ___________________. Identify any lesions of the surrounding retina and note
their size, shape, color, and distribution. As you search the retina, move your head and instrument as a
unit, using the patient's pupil as an imaginary ______________.

Inspect the optic disc: Note __________, ___________________, ___________________,

___________________, and any ___________________.

Inspect the retina: distinguish arteries from veins; arteriovenous junctions; and note any lesions, masses,
hemorrhages, or exudates

Inspect the fovea and macula by asking the patient to look _____________________. Note any
exudates, hemorrhages, cysts.

Repeat steps 7-8 for left eye

Ear Examination:

Observe each auricle (pinna) and surrounding tissue. Ensure you look _____________ and
_____________________ by pulling the auricle forward. Note for

1.

2.

3.

4.

5.

6.

7.

Use an otoscope with the largest ear speculum that the canal will accommodate

Position the patient’s head tilted to the _____________________ side o Pull auricle upward, outward
and back to straighten the canal

Hold otoscope correctly between thumb and index finger using your fifth digit to brace the patient’s face
- protects the patient from injury. Remember, _____________________. _____________________.

Insert the speculum gently into the ear canal directing it down and forward and through the hairs, if any
o Inspect the Ear canal for:

1.

2.

3.

4.
5.

Inspect the Tympanic membranes for:

1.

2.

3.

4.

Palpation

Assess for Tenderness “_________________”

Pull auricle / pinna up and down

Press firmly on the ________________

Press behind the ear over the ___________________________

Movement of the auricle and tragus (the “tug test”) is painful in _____________________________
(inflammation of the ear canal), but not in _______________________ (inflammation of the middle
ear). Tenderness behind the ear occurs in ___________________________.

Testing Auditory Acuity—Whispered Voice Test:

Stand ______________ behind/at the side of the seated patient

Ask the patient to occlude the _______________________ ear with their finger

Exhale a full breath before whispering to ensure a quiet voice

Whisper a _____________________________________, such as 3-U-1. Use a different number/letter

combination for the other ear and ask patient to repeat the word. You may cover your mouth while
whispering to avoid lip reading.

Normal: Patient repeats initial sequence correctly.

Abnormal: ______________ of the six possible numbers and letters are incorrect.

Testing for Conductive Versus Neurosensory Hearing Loss

To conduct these tests, make sure the room is quiet, and use a tuning fork of __________ Hz.

Weber Test:

Place the vibrating tuning fork (512 Hz) at the _______________________________________________

Ask the patient in which ear the sound is best heard or if it is equal.

Rinne Test:

Hold the vibrating tuning fork on the ________________________ until the patient cannot hear the
sound. When the patient can no longer hear the sound, quickly place the tuning fork close to the ear and
ask if the patient hears the vibration. Here, the “U” of the fork should face forward, which maximizes
sound transmission for the patient. Repeat the test in the other ear.

Hearing disorders of the _______________________ cause conductive hearing loss. ________________

causes include cerumen impaction, infection (otitis externa), trauma, squamous cell carcinoma, and
benign bony growths such as exostoses or osteomas. ___________________________ include otitis
media, congenital conditions, cholesteatomas and otosclerosis, tumors, and perforation of the tympanic
membrane.

Nose Examination: Inspection

Observe the external nose and note the _______, _______________, any ___________________,
______________, or ___________________

Observe the nasal vestibule

Tilt the patient’s head back

Apply gentle pressure on the tip of the nose with your thumb to ________________________

Use a penlight and observe the vestibule for ________________, ___________________________ and
_________________________.

Palpation:

Assess for Tenderness

Press your fingers and thumb together to gently palpate the exterior of the nose starting below the
_______________________ and moving inferiorly to the ___________

Assess for Patency

Instruct the patient to occlude one nostril with their finger

Ask patient to breathe in through _________________

Examine internal nose using ______________________

Hold the otoscope between the first two fingers (i.e., the index and ring fingers) of your dominant hand,
and support it using your thumb (of the same hand; the technique for holding the otoscope is similar to
how you would hold a pen for writing).

Tilt the patient’s head back and raise the tip of her nose for visual inspection with your nondominant
hand.

Insert nasal speculum without touching the septum up and backward Note the following:

Mucosa: color, swelling, bleeding, exudate, ulcers, polyps

Septum: look midline at the septum for any deviations, inflammation or perforations.

In _____________________, the mucosa is reddened and swollen; in _______________________, it

may be pale, bluish, or red. ________________________ are pale saclike growths of inflamed tissue that
can obstruct the air passage or sinuses, seen in allergic rhinitis, aspirin sensitivity, asthma, chronic sinus
infections, and cystic fibrosis.

Examination of the Paranasal Sinuses: Palpation

Palpate the Sinuses:

Frontal sinuses: Press upwards under the _______________________________ avoiding pressure on

the eyes. Note any tenderness

Maxillary sinuses: Press upwards on the maxillary sinus located below the _______________________
on the _____________________________________. Note any tenderness

Local tenderness, together with symptoms such as __________________, _______________________,

purulent nasal discharge, nasal obstructions, and smell disorder, especially when present for
_____________ , suggest ___________________________________ involving the frontal or maxillary
sinuses.

Transillumination of the Sinuses:

Place light source upward under the _______________________to illuminate _________________

sinus.

Place light source at the junction of the ____________________________________ then point

downward; ask the patient to open their mouth and look at the roof of the mouth for illumination.

Oral Cavity and Pharynx Examination:

Inspection:

Lips: Observe the outer lips for ________, ________, ________, ________and ________Watch for
central cyanosis or pallor from ________

Oral Cavity: Look into the patient’s mouth with a penlight and a tongue blade. Note the following:

Buccal mucosa: color, areas of pigmentation, ulcers, white patches, nodules

Tongue:

Ask patient to stick out tongue and then move it to one side and then the other side to look. Note the
________, ________, ________________ (i.e., white raised lesion(s) and any abnormalities

Gums and teeth:

Use a light and tongue blade to inspect the ________, ________, ________or ________________.
Identify any ________________, ________________________________________________

Hard and soft palate:

Inspect ________and architecture of the hard palate using the penlight. Ask the patient to say “Ahhh’
and note the movement of the soft palpate and uvula.
Pharynx: ________, ________, ________, ________________ (Use a light and tongue blade to inspect.)
Tonsils: ________, ________, ________, ________, ________ (Use a light and tongue blade to inspect)

Palpation:

Tongue and floor of mouth:

With gloves on, use a piece of gauze to hold the tip of the tongue and extend the tongue outward and
lateral

Visualize the ___________ and ____________________ of the tongue for abnormalities

Palpate base of mouth and sides of tongue for ___________________

Gums/teeth:

Use gloves and palpate over upper and lower gums and teeth for _________________ and
_________________________.

Abdomen:

Tips for Examining the Abdomen:

Make the patient comfortable in the _______________ position, with a pillow under the head and
perhaps under the knees.

Ask the patient to keep the arms at the sides. When the arms are above the head, the abdominal wall
stretches and tightens, which hinders palpation.

Draping the patient: Place the drape or sheet at the level of the ____________________, then expose
the abdomen by raising the patient's gown to just below the _______________ above the
________________________. The groin should be visible, but the genitalia should remain covered. The
abdominal muscles should be relaxed to enhance all aspects of the examination, especially palpation.
Before you begin, ask the patient to point to any areas of pain so that you can examine these areas
_________.

Approach the patient calmly and avoid quick, unexpected movements. Avoid having long fingernails that
can scratch or scrape the patient's skin.

Position yourself at the patient's _____________ side and proceed in a systematic fashion with
inspection, percussion, and palpation. Mentally visualize each organ in the region you are examining.
Watch the patient's face for any signs of pain or discomfort.

Inspection:

Observe the patient from the ___________________ then stand on the _______________ side of the
patient inspecting the abdomen for:

__________________ and _____________: flat, protuberant, rounded, scaphoid (concave), bulges or

localized swelling

__________________: Discoloration, scars, striae, rashes, lesions, dilated veins, or ecchymosis.

________________________: contour and location and any inflammation or bulges.

Abnormal movements: ______________ or ________________________

Hernias: ask the patient to turn his/her head to the side and ______________. A bulge or swelling may
indicate a hernia.

Pink–purple striae are a hallmark of ____________________________.

Dilated veins suggest _________________________ from cirrhosis (caput medusae) or inferior vena
cava obstruction.

_____________________ suggests a hernia, an enlarged organ, or a mass.

_______________________

_____________________________ of the abdominal wall is seen in intraperitoneal or retroperitoneal

hemorrhage.

_______________ the abdomen before performing percussion or palpation, maneuvers that may alter
the characteristics of the bowel sounds.

Auscultate for Bowel sounds: Using the _______________________ of your stethoscope, note
_________________ and ______________________. Auscultating in the _______________ is sufficient.
Normal bowel sounds of peristalsis occur approximately every _____________________ and have a
low-pitched gurgle-like sound.

f bowel sounds are present and normal, there is no need to listen to other quadrants.

If diminished or absent, listen in each quadrant.

Frequency __________ is considered to arise from hypoactive bowel sounds and of __________ from
hyperactive bowel sounds

Because bowel sounds are widely transmitted through the abdomen, listening in one area, such as the
____________, is usually sufficient.

Listen for bruits:

Using the __________________ of your stethoscope.

____________: 5cm (2 inches) above the umbilicus

____________________: 5cm (2inches) above the umbilicus then 2.5cm (1 inch) to the right of that
point

___________________________: 5cm (2inches) above the umbilicus then 2.5cm (1 inch) to the left of
that point.

_____________________________________: (listen ~2 inches from the umbilicus on a line to the

femoral pulse)
______________________________________:(midway between the anterior superior iliac crest and
the symphysis).

If an abdominal pulsatile mass is seen on physical examination suggestive of an _________, auscultation

over the mass may identify the presence of turbulent flow (__________) within the aorta

Demonstrate Proper Percussion technique: The middle finger is _________________ with the distal
interphalangeal joint [DIP] pressed on the skin surface. The middle finger of the ___________ strikes the
DIP joint in a brisk but relaxed wrist motion.

Percuss generally in all _________ regions to determine the distribution of tympany and dullness. Note
any tenderness.

Percuss the abdomen lightly in all _________________ quadrants to determine the distribution of
tympany and dullness.

________________ usually predominates because of gas in the GI tract, but scattered areas of dullness
from fluid and feces are also common.

_________ areas characterize an intrauterine pregnancy, an ovarian tumor, a distended bladder, large
volume ascites, or a large liver or spleen.

_________________ in both flanks prompts further assessment for ascites

Palpation:

Light Palpation

Perform light palpation in all _______ regions. This should be superficial, and any area of reported pain
should be assessed _______. Use one hand in a ___________ plane with fingers together and slide the
hand to the next location.

Identify any area of _________, ________, __________ or __________________.

________________ aids detection of abdominal tenderness, muscular resistance, and some superficial
organs and masses.

Identify any superficial organs, masses or hernias and any area of tenderness or increased resistance to
palpation. If resistance is present, try to distinguish __________________________ from
______________________________or rigidity.

Deep Palpation:

Perform deep palpation in all _______ regions. Place your dominant hand on the abdomen and place
your nondominant hand on _______ then press down deeply (____________). It is not sufficient to
palpate one area in each quadrant.

Identify and describe palpable masses regarding their: _____________, ___________, ______________,
__________________ (cystic, soft, firm, solid), _________________, _________________ and
____________________.

Rebound Tenderness for peritonitis:

Press down slowly in tenderness, then withdraw your hand quickly.

The maneuver is positive if withdrawal produces _________

Signs of Peritonitis

Guarding is a ____________ contraction of the abdominal wall, often accompanied by a grimace that
may diminish when the patient is distracted.

__________ is an involuntary reflex contraction of the abdominal wall from peritoneal inflammation
that persists over several examinations.

______________________ refers to pain expressed by the patient after the examiner presses down on
an area of tenderness and suddenly removes the hand. To assess rebound tenderness, ask the patient,
“_____________________________________________?” Press down with your fingers firmly and
slowly, then withdraw your hand quickly. The maneuver is positive if _________________________
________________. Percuss gently to check for percussion tenderness.

Percussion:

Measure the Liver span:

Percuss from the ________ in the __________________________ up towards the liver. Note the change
from _________________________ and mark this point – Lower liver border.

Next, percuss at the nipple line or below the breast in the adult female in the ________________ line
downwards and note the change from ___________________________. Mark this point – Upper liver
border.

Measure the difference between the two points.

Palpation

Place your left hand ________________ between the _____________________ and the ____________,
gently pushing _______________.

Place the fingertips of the right hand in the _________ parallel and lateral to the ____________ muscle
in the ___________________ line.

Ask patient to take a deep breath during the exam. You may feel the liver edge descend during
inspiration.

Move upwards and press inward depressing the abdomen during expiration. Ask the patient to take a
deep breath and feel for the liver edge.

Place your hand well below where you would expect the lower border of the liver, which you previously
percussed. Starting palpation too close to the ___________________________ risks missing the lower
edge of an enlarged liver that extends into the RLQ.

When palpable, the normal liver edge is soft, distinct in outline, and with a smooth surface. If you feel
the edge, slightly lighten the pressure of your palpating hand so that the liver can slip under your
fingerpads and you can feel its __________________. Note any tenderness (the normal liver may be
slightly tender).

Firmness or hardness of the liver, bluntness or rounding of its edge, and surface irregularity are
suspicious for ________________________.

Spleen: Percussion

Percuss at the ____________________ at the lowest interspace. Note any ________________. Then ask
patient to take a deep breath while continuing to percuss and note any changes. When the spleen size is
normal, the percussion note is _________________. If there is splenomegaly, the note is ____________.

Palpation:

Reach over, place the __________________ behind the patient’s ___________________, __________,
and ____________________ and push upward. Using right hand, start palpation in the _____________
and palpate in an ___________________ towards the spleen. Ask patient to take a deep breath and try
to feel for the spleen edge on _______________________.

If the spleen is still not palpable, ask the patient to turn on __________________ and repeat the
palpation technique.

Causes of ______________ include portal hypertension, hematologic malignancies, HIV infection,

infiltrative diseases like amyloidosis, and splenic infarct or hematoma.

Kidneys: Palpation (ballottement)

Place your _______________ behind the patient, just below and ________________________________
and push upwards to displace the ______________________. With your left hand lateral and parallel to
the _____________________, ask the patient to breathe in deeply and press firmly downward in the
__________ along the __________________ line trying to capture the kidney.

Place your left hand behind the patient, just below and parallel to the _________ and push upwards to
displace the right kidney anteriorly. With your right hand lateral and parallel to the _________________,
ask the patient to breathe in deeply and press firmly downward in the _________ along the
_______________________ line trying to capture the kidney.

The kidneys are ______________________ and usually not palpable unless markedly enlarged.

Costovertebral Angle (CVA) tenderness for infection around the kidney (e.g. perinephric abscess,
pyelonephritis):

Assess percussion tenderness over the CVA:

In patients suspected to have ________________ or ___________________, CVA tenderness can be

elicited due to inflammation of the ___________________________.

Place the palm of one hand along ___________________.

Then make a fist with the other hand and strike the hand already on the CVA with the _____________
surface of your fist.
Use enough force to cause a perceptible but painless jar or thud on the area.

Pain with pressure or fist percussion supports ______________________ if associated with fever and
dysuria but may also be musculoskeletal.

Assessment techniques for Ascites:

Shifting dullness:

With the patient supine, percuss in a ____________ line from the midline of the abdomen down to the
patient’s right side until you note a change from ___________________________. Mark this point

Ask the patient to turn into the _______________________________. Repeat the percussion, starting
from the umbilicus, and make a second mark on the skin when the tympanic sound changes to dull.

This can be repeated from several points along the midline.

The borders of tympani and dullness should be the same in healthy individuals. If ascites is present, the
fluid drains to the dependent, lower side. The dullness “shifts” to the more _______________ position,
and, therefore, the “level of dullness” rises.

A protuberant abdomen with bulging flanks is suspicious for _________________, the most common
complication of ____________________. Because ascitic fluid characteristically sinks with gravity,
whereas gas filled loops of bowel rise, dullness appears in the _________________ areas of the
abdomen.

Ascites reflects the increased _________________________ in cirrhosis (the most common cause of
ascites), heart failure, constrictive pericarditis, or inferior vena cava or hepatic vein obstruction. It may
signal decreased ___________________________ in nephrotic syndrome, malnutrition, or ovarian
cancer.

Fluid wave:

Ask the patient or an assistant to press the _____________ surface of their hand down the midline.
Indenting the abdominal wall stops transmission of an impulse by the skin and subcutaneous adipose
tissue.

Tap one side of the abdomen while feeling for the wave to hit the opposite hand on the opposite side.

Assessment techniques for Appendicitis

McBurney Point Tenderness: Assess for tenderness in the point that lies ______________ from the
___________________________________ to the umbilicus.

Rovsing sign: Press deeply in the _____________ then quickly withdraw your fingers. Rovsing sign is
positive when pressure on the patient’s left lower quadrant causes _____________________________
______________________

Psoas sign: Pain during resisted ___________________ or _____________________________ is positive

There are two techniques.
1. Place your hand just above the patient’s right knee and ask the patient to raise that thigh against your
hand.

2. Ask the patient to turn onto the left side. Then extend the patient’s right leg at the hip.

Obturator sign: Flex the patient’s right thigh at the hip, with the knee bent and rotate the leg _________
at the hip. Pain with ____________________________ and ___________________________ is positive.

Appendicitis is twice as likely in the presence of ______________________, Rovsing sign (indirect

tenderness), and the psoas sign; it is ________________________________ if there is McBurney point
tenderness (McBurney sign).

You must perform all 4 tests if suspect appendicitis.

Localized tenderness anywhere in the _________, even in the right flank, suggests appendicitis.

Pain in the ____________ during left-sided pressure is a positive Rovsing sign.

Increased abdominal pain on either technique is a positive _________________, suggesting irritation of

the right psoas muscle by an inflamed ___________________________.

_____________________ is a positive obturator sign, from irritation of the ________________________

muscle by an inflamed appendix located in the pelvis.

Assessment techniques for Cholecystitis (Murphy sign):

Deeply palpate the __________ at the location of the patient's pain.

Ask the patient to take a deep breath, which forces the liver and gallbladder down toward the examining
fingers. Note any sharp pain that stops inspiration.

_______________________________________________________________from palpation of the

gallbladder on examination is a positive Murphy sign.

A digital rectal examination is indicated as part of a full physical examination and is often incorporated in
a focused urologic, gynecologic, gastrointestinal, and neurologic examination. Disease processes that
may be investigated with a digital rectal examination include, but are not limited to, the following:

1.

2.

3.

4.

5.

6.

7.

8.
9.

10.

11.

An examination may also confirm proper _____________________________ and facilitate placement of

rectal tubes and suppository medication. According to the American Urological Association (AUA), a
digital rectal examination may be indicated for _______________________. This is only after discussing
and determining the risks and benefits of screening with the patient using the process of shared
decision-making.