Lymph node examination

Using a gentle circular motion of finger pads, palpate lymph nodes

Beginning with preauricular lymph nodes in front of ear, palpate the 10
groups of lymph nodes in routine order. Many nodes are closely packed,
so you must be systematic and thorough in your examination. Do not
vary sequence or you may miss some small nodes

• Normal nodes feel movable, discrete, soft, and non-tender

• If any nodes are palpable, note location, size, shape, delimitation
(discrete or matted together), mobility, consistency, and tenderness
• If nodes enlarged or tender, check area they drain for source of the
problem; they often relate to inflammation or neoplasm in head
and neck
• Follow up on or refer your findings; an enlarged lymph node,
particularly when you cannot find the source of problem, deserves
prompt attention
• Lymphadenopathy means enlargement of the lymph nodes
(>1cm) from infection, allergy, or neoplasm.

Lung examination, abnormal findings included

Inspection

• Thoracic cage, respirations, skin color, and condition

• Person’s facial expression, and LOC

Palpation

• Confirm symmetric expansion and tactile fremitus.

• Detection of any lumps, masses, or tenderness

Percussion

• Lung fields

Auscultation

• Assess breath sounds, and note any abnormal/adventitious

breath sounds.
Abnormal Respiration Patterns

• Sigh
• Tachypnea
• Bradypnea
• Hyperventilation
• Hypoventilation
• Cheyne-Stokes respiration
• Chronic obstructive breathing

Abnormal adventitious lung sounds

Discontinuous sounds

• Crackles—fine
• Crackles—course
• Atelectatic crackles
• Pleural friction rub

Continuous sounds

• Wheeze—sibilant
• Wheeze—sonorous rhonchi
• Stridor

Murmur pathophysiology (not specific murmurs)

• Blood circulating through normal cardiac chambers and valves

usually makes no noise
• However, some conditions create turbulent blood flow and
collision currents
• These result in a murmur, much like a pile of stones or a sharp
turn in a stream creates a noisy water flow
• A murmur is a gentle, blowing, swooshing sound that can be
heard on chest wall

Conditions resulting in a murmur are as follows:

1. Velocity of blood increases (flow murmur) e.g., in exercise,

thyrotoxicosis)
 2. Viscosity of blood decreases (e.g., in anemia)
3. Structural defects in the valves (a stenotic or narrowed valve, an
incompetent or regurgitant valve) or unusal openings occur in the
chambers (dilated chamber, septal defect)

Why is it important to attempt to palpate all peripheral pulses?

 Any disease in vascular system creates problems with delivery

of oxygen and nutrients to tissues or elimination of waste
products from cellular metabolism
 Arteries supply oxygen and essential nutrients to the tissues
 Ischemia- is a deficient supply of oxygenated arterial blood to
a tissue caused by obstruction of a blood vessel.
 Complete blockage leads to death of the distal tissue.
 Partial blockage creates an insufficient supply, and the ischemia
may be apparent only at exercise when oxygen needs increase.
 PAD- Peripheral artery disease affects non coronary arteries
and usually refers to arteries supplying the limbs. It is usually
caused by atherosclerosis, and less commonly by embolism,
hypercoagulable states, or arterial dissection.

How to document pulse quality and landmarks for peripheral

pulses

o Grade force (amplitude) on a three-point scale

 3+, increased, full, bounding
 2+, normal
 1+, weak
 0, absent

What do the cardiac sounds represent?

First Heart Sound (S1)

“LUB”

 Occurs with closure of AV valves (tricuspid and mitral)

 Caused by turbulence created with the closure of those valves
 signals beginning of systole
 Can hear S1 over all precordium, but loudest at apex
 Second Heart Sound (S2)
“DUB”

Occurs with closure of semilunar valves (pulmonic and aortic)

 Sound caused by the closure of those valves

 signals end of systole
 Although heard over all precordium, S2 loudest at base
 Extra Heart Sounds (S3)
 Normally diastole is silent event
 However, in some conditions, ventricular filling creates
vibrations that can be heard over chest
 In adults, usually abnormal/pathologic
 Fluid volume overload
 But…can also occur in the absence of heart disease
but in thyroid disease, anemia, and pregnancy
 Extra Heart Sounds (S4)
 Occurs at end of diastole, at presystole, when ventricle
resistant to filling
 Atria contract and push blood into noncompliant
ventricle – the sound is ventricular filling
 Can be physiologic in adults with no evidence of CAD
 Can be pathologic in those with heard disease
 Extra Heart Sounds: Murmurs
 Blood circulating through normal cardiac chambers and valves
usually makes no noise
 However, some conditions create turbulent blood flow and
collision currents
 These result in a murmur, much like a pile of stones or a sharp
turn in a stream creates a noisy water flow
 A murmur is a gentle, blowing, swooshing sound that can be
heard on chest wall

Where is the PMI & why would it be misplaced?

Apical Impulse

The point of maximal impulse, known as PMI, is the location at which

the cardiac impulse can be best palpated on the chest wall. Frequently,
this is at the fifth intercostal space at the mid clavicular line. Left
ventricular dilation (volume overload) displaces impulses down and to
left and increases size more than one space. A diameter of ≥ 4cm is likely
a dilated heart. This occurs with heart failure and cardiomyopathy
(hereditary disease of the heart muscle that makes it hard for the heart to
deliver blood to the body)

How would you document findings of edema?

 Firmly depress skin over tibia or medial malleolus for 5

seconds and release
 Normally your finger should leave no indentation,
although a pit commonly is seen if person has been
standing all day or during pregnancy
 If pitting edema is present, grade it on following scale:
• 1+ Mild pitting, slight indentation, no perceptible
swelling
• 2+ Moderate pitting, indentation subsides rapidly
• 3+ Deep pitting, indentation remains, leg looks
swollen
• 4+ Very deep pitting, indentation lasts long time,
leg very swollen

Examination and patient teaching for skin

(read pg. 215) Teach skin self-examination
using ABCDE rule to detect suspicious lesions
• A: asymmetry
• B: border
• C: color
• D: diameter
• E: elevation and enlargement
 Breast exam findings

 Inspection of the Breast

 General appearance
 Note symmetry of size and shape; common to have a
slight asymmetry in size; often left breast is slightly
larger than right.
 Skin
 Normally smooth and of even color
 Note any localized areas of redness, bulging, or
dimpling; also any skin lesions or focal vascular pattern.
 Fine blue vascular network visible during pregnancy;
pale linear striae, or stretch marks, follow pregnancy.
 Normally no edema is present.
 Lymphatic drainage areas
 Observe axillary and supraclavicular regions; note any
bulging, discoloration, or edema.
 Nipple
 Should be symmetric on same plane on both breasts
 Nipples usually protrude, although some are flat and
some are inverted.
 Normal nipple inversion may be unilateral or bilateral
and usually can be pulled out.
 Note any dry scaling, any fissure or ulceration, and
bleeding or other discharge.
 Supernumerary nipple is normal variation.
 An extra nipple along embryonic “milk line” on thorax or
abdomen is congenital finding.
 Usually below breast near midline and has no associated
glandular tissue; looks like a mole, although a close look
reveals a tiny nipple and areola.

Lymphatics

 Breast has extensive lymphatic drainage.

 Four groups of axillary nodes are present

• Central axillary nodes

• Pectoral (anterior)
• Subscapular (posterior)
 • Lateral

 From the central axillary nodes, drainage flows up to

infraclavicular and supraclavicular nodes.

Maneuvers to Screen for Retraction

 Direct woman to change position to check breasts for

skin retraction signs; first ask her to lift arms slowly over
head; both breasts should move up symmetrically.
 Next ask her to push her hands onto her hips and then to
push her two palms together; these maneuvers contract
pectoralis major muscle; slight lifting of both breasts will
occur.
 Ask woman with large pendulous breasts to lean forward
while you support her forearms; note symmetric free-
forward movement of both breasts.
 Inspection and Palpation of the Axillae

Examine axillae while woman is sitting.

 Inspect skin, noting any rash or infection; lift woman’s arm and
support it, so that her muscles are loose and relaxed; use right
hand to palpate left axilla.
 Reach fingers high into axilla; move them firmly down in four
directions.
 Move woman’s arm through range-of-motion to increase
surface area you can reach.
 Usually nodes are not palpable, although you may feel a small,
soft, nontender node in central group.
 Note any enlarged and tender lymph nodes.
 Palpation of the Breasts
 Help woman to a supine position
 Palpation of the breast

• Normally you may feel a firm transverse ridge of compressed tissue in

lower quadrants.
• After palpating over four breast quadrants, palpate nipple; note any
induration or subareolar mass.
• With your thumb and forefinger, gently depress nipple tissue into well
behind areola; tissue should move inward easily.
• If woman reports spontaneous nipple discharge, press areola inward
with your index finger; repeat from a few different directions; note
color and consistency of any discharge.
• If woman mentions a breast lump that she has discovered herself,
examine unaffected breast first to learn a baseline of normal
consistency for this woman.

Proper neuro exam techniques and CN exam / cerebellar function

tests and findings

Cerebellar Function - Coordination and Skilled Movements

  Rapid Alternating Movements (RAM)
 Ask person to pat knees with both hands, lift up, turn
hands over, and pat knees with backs of hands; then ask
person to do this faster
• Normally done with equal turning and quick
rhythmic pace
 Alternatively, ask person to touch thumb to each finger
on same hand, starting with the index finger, then reverse
direction

• Finger-to-nose test: with eyes closed and stretch out arms and touch
tip of their nose with each index finger, alternating hands and
increasing speed
• Normally this is done with accurate and smooth movement
• Heel-to-shin test: ask person in supine position to place heel on
opposite knee and run it down shin to ankle
• Normally person moves heel in straight line down
shin

 Balance Tests
 Gait: observe as person walks 10 to 20 feet, turns, and
returns to starting point; normally person moves with a
sense of freedom; gait is smooth, rhythmic, and
effortless; opposing arm swing is coordinated; person
turns smooth; step length about 15 inches from heel to
heel
 Ask person to walk straight line in heel-to-toe fashion;
this decreases base of support and accentuates any
problem with coordination; normally person can walk
straight and stay balanced
 You may also test for balance by asking person to walk
on toes, then on heels for a few steps
 Romberg test:
 Ask person to stand up with feet together and arms at
sides; when in stable position, ask person to close eyes
and to hold position for about 20 seconds
• Normally person can maintain posture and balance
even with visual orienting information blocked
 Ask person to perform shallow knee bend or hop in
place, first on one leg, then other
 • Demonstrates normal position sense, muscle
strength, and cerebellar function
• Some individuals cannot hop because of aging or
obesity

Throat examination, normal versus abnormal (Read pg. 368)

1+ - Visible

2+- Halfway between tonsillar pillars and uvula

3+- Touching the uvula

4+- Touching one another

• Enlarge your view of posterior pharyngeal wall by depressing tongue

with tongue blade.
– Scan posterior wall for color, exudate, or lesions.
– Notice any breath odor, halitosis.
• Usually due to local cause; poor oral hygiene,
consumption of odoriferous foods, alcohol, smoking, or
dental infection.
– With an acute infection tonsils are bright red and swollen and
may have or large white spots
 – A white membrane covering the tonsils may accompany
infectious mononucleosis, leukemia and diphtheria
– Tonsils are enlarged to 2+, 3+, or 4+ with an acute infection
– A fine tremor of the tongue occurs with hyperthyroidism
– A coarse tremor occurs with cerebral palsy and alcoholism
– Diabetic ketoacidosis has a sweet fruity breath odor; t
– This acetone smell also occurs in children with malnutrition or
dehydration.
– Liver disease- ammonia odor with uremia (musty odor)
– Diphtheria- mouse like smell of the breath
– Dental/respiratory infection- foul, fetid odor
– Alcohol/chemicals ingestion- alcohol odor

Bell versus diaphragm of stethoscope and why

Bell- best for soft, low-pitched sounds such as extra heart sounds or
murmurs.

Diaphragm- best for high-pitched sounds-breath, bowel, and normal

heart sounds.

Dorsal versus ventral

Dorsal means towards the back e.g., the back, buttocks, calves, and the
knuckle side of the hand.

Ventral means towards the front e.g., the chest, abdomen, shins,
palms, and soles.
Structures investigated in abdominal examination and abnormal
versus normal findings
 Inspection of the Abdomen
 Contour
 Your head should be slightly higher than abdomen
 Determine profile from rib margin to pubic bone; contour
describes nutritional state and normally ranges from flat to
rounded
 Symmetry
 Abdomen should be symmetric bilaterally
 Inspection of the Abdomen
 Umbilicus
 Normally it is midline and inverted, with no sign of
discoloration, inflammation, or hernia
 Becomes everted and pushed upward with pregnancy
 Umbilicus is common site for piercings in young women; site
should not be red or crusted
 Skin
 Surface smooth and even, with homogeneous color; good area
to judge pigment because often protected from sun
 Fine venous network may be visible in thin persons
 Good skin turgor reflects healthy nutrition; gently pinch up a
fold of skin; then release to note skin’s immediate return to
original position
 One common pigment change is striae, silvery white, linear,
jagged marks about 1 to 6 cm long- Occur when elastic fibers in
reticular layer of skin are broken after rapid or prolonged
stretching, as in pregnancy or excessive weight gain; recent
striae are pink or blue, then they turn silvery white
 Pigmented nevi (moles), circumscribed brown macular or
papular areas, common on abdomen
 Normally no lesions are present, although you may note well-
healed surgical scars
Abdominal Scars
 If a scar is present, draw its location in person’s record, indicating
length in centimeters.
 Occasionally, a person forgets about an operation while providing the
history; if you note a scar now, ask about it.
 Surgical scar alerts you to possible presence of underlying adhesions
and excess fibrous tissue.
Pulsation or movement
 Normally you may see pulsations from aorta beneath skin in
epigastric area, particularly in thin persons with good muscle
wall relaxation
Hair distribution
 Pattern of pubic hair growth normally has diamond shape in
adult males and an inverted triangle shape in adult females
 Demeanor
 Comfortable person is relaxed quietly on examining table and
has a benign facial expression and slow, even respirations

Auscultation of Bowel and Vascular Sounds

This is done because percussion and palpation can increase peristalsis
(involuntary constriction and relaxation of the muscles of the intestine),
which would give a false interpretation of bowel sounds.
 Use diaphragm end piece because bowel sounds are relatively
high pitched.
 Hold stethoscope lightly against skin; pushing too hard may
stimulate more bowel sounds.
 Begin in RLQ at ileocecal valve area because bowel sounds are
normally always present here.
Bowel Sounds
 Note character and frequency of bowel sounds
 Bowel sounds originate from movement of air and fluid through small
intestine
 Depending on time elapsed since eating, a wide range of normal
sounds can occur
 Bowel sounds are high pitched, gurgling, cascading sounds, occurring
irregularly anywhere from 5 to 30 times per minute; do not bother to
count them
 Judge if they are normal, hypoactive, or hyperactive
 Borborygmus is the sound of hyper peristalsis
 Perfectly “silent abdomen” is uncommon; you must listen for 5
minutes by your watch before deciding bowel sounds are
completely absent
Vascular Sounds
 As you listen to abdomen, note presence of any vascular sounds or
bruits. Use bell of stethoscope.
 Using firmer pressure, check over aorta, renal arteries, iliac, and
femoral arteries, especially in people with hypertension.
 Usually no such sound is present.

Percussion and Tympany

Percuss general tympany
Percuss to assess relative density of abdominal contents, to locate organs,
and to screen for abnormal fluid or masses

General tympany
 First, percuss lightly in all four quadrants to determine
prevailing amount of tympany and dullness
 Move clockwise; tympany should predominate because air in
intestines rises to surface when person is supine
Costovertebral Angle Tenderness
  Indirect fist percussion causes tissues to vibrate instead of producing
a sound
 To assess kidney, place one hand over 12th rib at costovertebral angle
on back
 Thump that hand with ulnar edge of your other fist
 Person normally feels thud but no pain
 Its usual sequence in complete examination is with thoracic
assessment, when person is sitting up and you are standing
behind
Palpate Surface and Deep Areas
Perform palpation
 Judge size, location, and consistency of certain organs and
screen for an abnormal mass or tenderness
 Because most people are naturally inclined to protect
abdomen, you need to use additional measures to enhance
complete muscle relaxation
Light Palpation
 Objective is not to search for organs but to form an overall impression
of skin surface and superficial musculature
 Save examination of any identified tender areas until last
 This method avoids pain and resulting muscle rigidity that would
obscure deep palpation later in examination
 As you circle abdomen, discriminate between voluntary muscle
guarding and involuntary rigidity
 Voluntary guarding occurs when person is cold, tense, or ticklish; it is
bilateral, and you will feel muscles relax slightly during exhalation;
use relaxation measures to try to eliminate this type of guarding
 If rigidity persists, it is probably involuntary
Deep Palpation
 Push down about 5 to 8 cm (2 to 3 inches)
 Moving clockwise, explore entire abdomen
 To overcome resistance of a very large or obese abdomen, use a
bimanual technique
 Place your two hands on top of each other
 Top hand does pushing; bottom hand relaxed and can
concentrate on sense of palpation
 Light and Deep Palpation
 Also remember that some structures are normally palpable
 Mild tenderness normally present when palpating sigmoid colon
 Any other tenderness should be investigated
 If you identify a mass, first distinguish it from a normally palpable
structure or an enlarged organ
 Light and Deep Palpation
 If you identify a mass, then note the following:
Location, Size, Shape, Consistency: soft, firm, hard, Surface:
smooth, nodular, Mobility, including movement with respirations,
Pulsatility And Tenderness.