TAKING HEALTH HISTORY &

NURSING ASSESSMENT

For 2nd year nursing students

By Usman N.(MSc in AHN)
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 Taking Health History
Health history: can be defined as the
systematic collection of subjective and objective
data that is used for determining a client‘s
functional health pattern status for the purpose of
nursing diagnosis.

It is also a chronological and detailed health

record of a client.

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 Purposes of history taking
To elicit information regarding all of the variables
that may affect the client‘s health experience and
status.
Guides on which body parts or systems to focus
during physical examination.
To establish a trusting relationship between the nurse
and the patient/client.
Helps to develops understanding about the
patient/client.
Serves as a background material related to the
development of the present symptoms
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 Phases of history taking
History taking has three basic phases:
• Introductory phase:
– The Nurses introduces self and explains the purposes
of the interview to the patient.
– An explanation of note taking, confidentiality, and
type of questions to be asked should be given.
– Comfort, privacy and confidentiality are provided.

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• Working phase:
– This is the actual data collection phase.
– The Nurses facilitates the patient‘s comments about
major biographical data, reason for seeking health
care, and functional health pattern responses.
• Summary and closure phase:
– The Nurses summarizes information obtained from
the patient during the working phase and validates
problems and goals with the patient.
– Possible plans to resolve the problems are identified
and discussed with the patient.

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 Techniques of effective history
taking
• Great the patient according to the norm and
culture then call according to his/her title and
name, and give undivided attention.
• Keep comfort and privacy-watch for indications
of discomfort such as poor positioning, evidence
of pain, or anxiety or signs of the need to urinate.
• Never be in a hurry(act quickly) even when you
are in a limited time.
• Design questions appropriately: avoid leading
questions, begin with general questions.
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• Facilitation: you can use posture, actions, or
words that encourages the patient to say more.
• Reflection: This is the repetition of the patient‘s
words to encourage him/her to give you more
details.
• Clarification: when the patient‘s words are
ambiguous or associations are not clear, you must
ask for clarifications.
• Empathetic response: this is the recognition of
feelings such as embarrassment, shame suffering
and responding to patients in a way that shows
understanding and acceptance.
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 Ethical considerations in Health Assessment
When you collect data from the patient, you should
take the following points in to consideration:
 The patient has a full right to know why you are
collecting the information
The individual patient/ client is fully informed
about the process of data collection and the
decision of the patient is freely made.

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Following the interview, the nurse selectively
records information that is pertinent to the health
status of the patient.
When data collection is completed and the data
recorded, the written record is maintained in a
secure place and made available only to those
health professionals directly involved in the care
of the patient

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 Approach of health assessment in nursing

1. Gordon’s Functional Health Patterns:

• Marjorie Gordon (1987) proposed functional
health patterns as a guide for establishing a
comprehensive nursing data base.
• These 11 categories make possible a
systematic and standardized approach to data
collection, and enable the nurse to determine
the following aspects of health and human
function:

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Categories :
» Health perception-health management pattern.
» Nutritional-metabolic pattern
» Elimination pattern
» Activity-exercise pattern
» Sleep-rest pattern
» Cognitive-perceptual pattern
» Self-perception-concept pattern
» Role-relationship pattern
» Sexuality-reproductive pattern
» Coping-stress tolerance pattern
» Value-belief pattern
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Health Perception and Health Management Pattern:
Data collection is focused on the person's perceived level of
health and well-being, and on practices for maintaining health.
• What is your opinion about health?
• Are you immunized against the target diseases?
• Last immunization?
• Do you have any allergy? If yes then type of allergy.
• Any surgery in past? What type of surgery?
• Last physical examination & for what purpose.
• Are you using any medicine recently?
• Do you know about these medicines?

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Nutrition and Metabolism Pattern:
Assessment is focused on the pattern of food and fluid
consumption relative to metabolic need.
• Ask about their skin, scalp and nails?
• What is your diet menu?
• Any food restriction regarding disease point of view?
• Any food restriction regarding religious point of view?
• Any food like or dislike?
• Any food allergy?

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Elimination Pattern:
Data collection is focused on excretory patterns (bowel,
bladder, skin).
• Excretory problems such as incontinence, constipation,
diarrhea, and urinary retention.
Urine:
• Color of urine, amount, frequency, odor and any discharge.
• Any urinary problem, dysurea, Anurea, Oligourea, ,
polyuria.
Defecation:
• Are you using any laxative? If yes which?
• Any problem during passing defecation?

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Activity and Exercise Pattern:
Assessment is focused on the activities of daily living
requiring energy expenditure, including self-care activities,
exercise, leisure activities respiratory and cardiac system.
• Do you have any breathing problem?
• In which apnea, hypoxia, hypoxemia, hypercapnia.
• Do you have cough? (Productive or non productive)
• Any changes in heart beat during exercise?
• Do you feel pale during exercise?
• What type of exercise you do or any problem during
exercise?

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Cognition and Perception Pattern:
Assessment is focused on the ability to thinking,
decision making, and problem solving.
• Orientation about time place and person.
• Any difficulty in sentence making?
• Loss of memory.

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Sleep and Rest Pattern:
Assessment is focused on the person's sleep, rest, and
relaxation practices.
Dysfunctional sleep patterns, fatigue, and responses to
sleep deprivation may be identified.
• Sleeping hour?
• Are you using nap (evening type sleeping).
• What do you feel after waking? (Fresh, headache,
drowsy).
• Are you using any medication for sleeping?
• Do you have any exercise or walking at night?

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Self-Perception and Self-Concept Pattern:
Assessment is focused on the person's attitudes
toward self, including identity, body image, and
sense of self-worth.
• What is your self perception about yourself?
• Are you satisfied with your self body image?
• Do you like grooming?

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Roles and Relationships Pattern:
Assessment is focused on the person's roles in the
family and relationships with others.
• What is your role in family?
• If you are in hospital then who will perform your
responsibilities?
• All the family members are cooperative with you?
• Who is decision maker in your family?

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Sexuality and Reproduction Pattern:
Assessment is focused on the person's satisfaction or
dissatisfaction with sexuality patterns and
reproductive functions.
• When you first notice changes in your menarche
(first menses is called menarche)
• Do you have any sexual problem? (loss of libido)
• Active sex (direct sex with male and female)
Passive sex (sex without male and female partner)
• Reproductive: Infertility

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Coping and Stress Tolerance Pattern:
Assessment is focused on the person's perception of stress and on his
or her coping strategies Support systems are evaluated, and symptoms
of stress are noted.
• If you have stress then what is your coping mechanism towards
stress?
Crying, angry, violence, (what is your opinion regarding that)
Values and Belief Pattern:
Assessment is focused on the person's values and beliefs (including
spiritual beliefs).
• What is your religion?
• Do you offer prayer?

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Approach of health assessment in nursing

2.Body System Model

The Body systems model (also called the medical
model or review of systems) focuses on the
client‘s major anatomic systems.
The framework allows nurses to collect data
about past and present condition of each organ or
body system and to examine thoroughly all body
systems for actual and potential problems.

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 Structure of the Health History
Systems approach
• A typical comprehensive adult history should
include the following contents:
1. Date – The date of assessment is always
important, and in rapidly changing conditions the
time should also be added.
2. Identifying data- Name , age, sex , race,
ethnicity, birthplace, occupation, etc
3. Source of referral, if any, and the purpose of it.

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5. Source of history- may include the patient
him/herself, a relative, a friend, the patient‘s
medical record or a referral letter.
• Documenting source of history has the following
purposes:
– It helps to assess the value and possible bias of the
information.
– Under some circumstances it is also helpful to
comment on the probable reliability of the source of
data.

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6. Chief complaint- This is the starting point of
the main part of the history.
• It can be defined as one or more symptoms or
other concerns for which the patient is seeking
care or advice.
• It should be recorded in patient‘s own words.

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7. History of present illness: it is the amplification
of the chief complaint.
• The history of the present illness usually
identifies major disease mechanisms and may
even establish the diagnosis when symptoms are
precise.
• In the history of present illness, the nurse
organizes the data obtained form the primary or
secondary source.

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• History of present illness should include:
A full, clear, chronological account of how
each of the symptoms developed and what
events were related to them.
How the patient thinks and feels about the
illness, what concerns have led to seeking
attention, and how the illness has affected the
patient‘s life and functions.
Significant negatives ( the absence of certain
symptoms that will aid in differential diagnosis

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A narrative including :
– The onset of the problem.
– The setting in which it developed.
– Its manifestations.
– Any treatments and results.
– The condition of the patient just before this
illness.
– How the patient was brought or how he had
come to the interviewer.

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The principal symptoms should be described in
terms of:
• Location – pinpoint the body systems or organs
involved. Where is it? Does it radiate?
• Quality- What is it like? Usually a person will
equate a symptom with an analogy: by stating it is
―like some thing. For example, ―my chest pain feels
like a knife is being thrust in my chest.‖
• Quantity/Severity - the clinician needs to quantify
the symptom according to the level of intensity, how
it affects activities of daily living, frequency,
volume, number and size, or extent of the symptom.
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• Timing (onset, duration and frequency) - the
nurse need to consider the symptom in relation to
time.
• When did it start? How long did it last? How
often did it come?
• The setting in which they occur- this is the
description of where and what the person was
doing when the symptom occurred.

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• Aggravating or relieving factors-Does any thing
make it better or worse? Identify what worsens
(aggravates)or relives (alleviates) the symptom.
For example, does the chest pain change with
exercise, emotional upset, or rest etc.
• Associated manifestations- Assess associated
factors or symptoms. Some disorders produce
symptoms in more than one body parts. For
example, a person with congestive heart failure
may have swollen ankles and abdomen and may
experience shortness of breath.

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8. History of past illness- This explores prior
illnesses, injuries, child hood illness, operations,
hospitalizations and medical interventions.
9. Current medications:
– Home remedies.
– None prescription drugs (vitamins/mineral
supplements).
– Medicines borrowed from family.
– Recreational drugs- type, dose, duration.
– Diet – Usual favorite diet, restrictions, if any, and
problems with it.

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10. Family history – Family health history is a
past medical history of relatives.
The following are areas to be included in the
family health history.
o Present health status of parents and siblings:
Ask the patient about the age and health status of
the mother, father, and each of the siblings, or
the age at death and cause.

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o Medical problems: Ask the person about family
history of disorders that may be influenced by
heredity or contact.
• Also ask about family allergies, deformities, or
serious illnesses.
• You may include the following: diabetes, heart
disease, renal disease, cancer, tuberculosis, stroke,
gout arthritis, mental illness, alcoholism, seizures,
obesity, hypertension, and others.
o Similar illness or symptom in the family: is any
one in the family experiencing an illness or
symptoms similar to the person‘s present illness?

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11. The Psychosocial history- This helps to identify
some contributory factors in the patient‘s illness
and to evaluate the patient‘s sources of support,
reactions to illness, coping mechanisms, strengths
and concerns.
• The psychosocial history often includes:
Home situation and significant other.
Daily life.
Important experience: schooling, military service,
job history.
Financial situation, marriage and retirement.
Religious beliefs relevant to perception of health,
illness and treatment
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 12. Review of systems (functional
inquiry)
• It is a detailed account of signs and symptoms
referable to each system of the body.
• The major purpose of functional inquiry (systems
review) is to unearth symptoms of which the
patient has not complained spontaneously and
which he/she may feel are not relevant to the
presenting complaint.

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• Functional inquiry has the following advantages:
It gives a clear understanding of the history of the
present illness.
It is a double check of the history of the present
illness.
It helps to group signs and symptoms that need to
be considered with the present complaint in order
to arrive at a plausible diagnosis.
NB: The absence of signs or symptoms is as
important as their presence.

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• The systems review should be recorded as follows
General – Usual weight, recent weight, changes,
weakness, fatigue, fever.
Head- headache, head injury
Eyes- vision, glasses, contact lenses, pain,
changes in color, tearing, double vision, blurring
of vision, spots, flashing of lights, glaucoma, and
cataracts.

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 Ears- Hearing, tinnitus, vertigo, earaches, discharge.
If hearing is decreased, use of hearing aids.
 Nose and sinuses- frequent colds, nasal stuffiness,
discharge or itching, bleeding.
 Mouth and throat – conditions of teeth and gums,
bleeding gums, sore tongue, dry mouth, frequent sore
throat, hoarseness.
 Endocrine- heat or cold intolerance, excessive
sweating, diabetes (diagnosed), excessive thirst or
hunger, polyuria.
Neck – Lumps, swollen glands, goiter, pain or stiffness
in the neck.
Breasts- Lumps, pain or discomfort, nipple discharge.
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Respiratory- cough, sputum (color, quantity,
odor), hemoptysis, wheezing, asthma, bronchitis,
emphysema, pneumonia, tuberculosis, pleurisy,
chest pain, shortness of breath, cyanosis.
Cardiovascular-, edema, rheumatic fever, leg
cramps, varicose veins. Dyspnea, palpitation,
orthopnea (number of pillows required),
paroxysmal nocturnal- dyspnea, chest pain,
syncope, stridor, hypertension
Gastrointestinal tract- Appetite, nausea,
vomiting, dysphagia, heart burn, abdominal pain,
hemorrhoids, hepatitis.
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• Genito-urinary tract- flank pain, frequency,
dysuria, urgency, hesitancy, haematuria, pyuria,
incontinence, STIs, menstrual history (menarche,
interval between periods, duration and amount of
flow, intermenstrual bleeding or discharge post
coital bleeding), menopause, postmenopausal
symptoms.

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Musculoskeletal – Muscle or joint pain, stiffness,
arthritis, backache.
Neurologic – Fainting, seizures, weakness,
paralysis, numbness or loss of sensation, tingling,
involuntary movement (tremors, tics,
fasciculation), poor memory, lack of orientation.
Skin – Rashes, lumps, sores, itching, dryness,
color change, changes in hair or nails

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 Physical Assessment
Is an organized systemic process of collecting
objective data based upon a health history and
head-to-toe or general systems examination.

 Is the first step in the nursing process.

It provides the foundation for the nursing care

plan in which your observations play an integral
part in the assessment, intervention, and
evaluation phases.

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The purposes for a physical assessment
1. To obtain baseline physical and mental data on
the patient.
2. To supplement, confirm, or question data
obtained in the nursing history.
3. To obtain data that will help the nurse establish
nursing diagnoses and plan patient care.
4. To evaluate the appropriateness of the nursing
interventions in resolving the patient's identified
pathophysiology problems.
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 Physical assessment
• It is always advisable to follow the points below while
examining the patient:
 Examination should take place with good lighting and in a quite
environment
 It is advisable to examine a supine patient from the patient‘s
right side
 By words or gesture, be as clear as possible in your instructions
 If possible try to demonstrate the patient what to do rather than
giving verbal instructions alone.
 Keep the patient informed as you proceed with your examination
 While examining the patient, it is help full to move ―from Head
to Toe.‖
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 Techniques of physical examination
 Four basic methods are used to systematically
guide the uses of senses of sight, touch and
hearing in physical assessment.
 They are:
- Inspection
- Palpation
- Percussion
- Auscultation.

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 1. Inspection
It is a concentrated watching or looking
Always comes first
Compare right and left side of the body
It requires good lightening, adequate exposure
and occasional use of certain instruments
(othoscope, ophthalmoscope and pen light) to
enlarge your view
Looking (observation with out doing any
thing)
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 Inspection….
All observations must be conducted with
adequate lighting.
Expose body parts being observed while keeping
the rest properly draped
Always look before touching.
Provide a warm room for examination.
Observe for color, size, location, texture,
symmetry, odors, and sounds.
Compare right and left side

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 2. Palpation
The process of examining part of the body by
careful feeling with hands and finger tip

Always be slow and systematic

Warm your hands before anything

Palpation is used to assess the roughness,

smoothness, hardness, softness, moistness,
dryness, motility, and a nodule or mass
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 Palpation …
Different parts of the hands are best suited for
assessing different factors:
Finger tips: best for fine tactile discrimination,
such as skin texture, swelling pulsatility and
determining presence of lumps.
A grasping action of the fingers: to detect the
position, shape and consistency of an organ or
mass.

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 Palpation …
The dorsa (backs) of hands and fingers: best
for determining temperature because the skin
here is thinner than on the palms.

Base of the fingers (metacarpophalengeal

joints) or ulnar surface of hand: to detect
vibration, to feel thrills and fremitus

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 Palpation …
Palpation may be light, deep, or bimanual.

Light palpation:- is the safest and least

uncomfortable, involving exerting gentle
pressure with the finger tip of your dominant
hand, moving them in a circular motion and
depress the skin surface approximately 1-2cm

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 Light Palpation

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 Palpation …
Deep palpation:- which is done after light
palpation is used to detect abdominal masses.

oThe technique is similar to light palpation

except that the fingers are held at a greater
angle to the body surface and the skin is
depressed about 4-5 cm.

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 Palpation …

oA variation of this technique involves placing

the finger tips of one hand over the finger tips
of the palpating hand. The top hand should
press and guide the hand to detect underlying
masses

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 Palpation …

Bimanual palpation:- involves using both

hands to trap a structure between them.

oThis technique can be used to evaluate the

spleen, Kidney and uterus.

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 Bimanual palpation
liver and spleen

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Light palpation precedes deep palpation.
Tender areas are palpated last through light
palpation, in order not to aggravate pain and
interfere with further gathering of pertinent data.
Bimanual palpation used to assess organs deep in
the abdomen by using two hands, one on each side
of body part or organs being felt.

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 3.Percussion
To tap a portion of the body to elicit
tenderness or sounds that varies with the
density of underlying structures.
There are two basic types of percussion:
-Direct and indirect.
In the direct technique, the body is lightly
tapped directly with the fingers or hand. This
technique is used usually to elicit tenderness
or pain.
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 Direct Percussion

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 Percussion …

Blunt percussion
oHit with the ulnar surface of your fist against
body surface.

oCauses the tissue to vibrate instead of

producing sound for tenderness

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The indirect method is done bimanually. This
technique is used to elicit one of the following
sounds over the chest or abdomen, flatness(muscle,
bone),dullness(liver, spleen),resonant(normal
lung),hyper-resonant(lung with emphysema)and
tympanic(puffed-out cheek, air in bowel).
These are arranged from the most dense to the least
dense underlying body structure.
 The technique used in this type of percussion, press
middle finger of the hand firmly on body part.
Keep other fingers off body part, strike the on the
body part with middle finger of the dominant hand.
Flex wrist quickly (not fore arm).

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 Indirect percussion

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 Auscultation
The skill of listening to body sounds created in
the lungs, heart, blood vessel, and abdominal
viscera by the help of a stethoscope.
It is usually the last technique used during the
examination.
Choose a stethoscope with two-end pieces: a
diaphragm and a bell

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 Auscultation …
Stethoscope: an instrument useful for
auscultation which has two ends:
Bell : best for the soft, low pitched sounds
such as extra heart sounds or murmurs.
Diaphragm : is used mostly, because its flat
edge is best for high pitched sounds: breath,
bowel and normal heart sounds.

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 Auscultation
Usually involves listening for various breath,
heart, and bowel sounds using a stethoscope.
The diaphragm best transmits high-pitched
sounds (i.e. normal heart sounds, breath
sounds, bowel sounds, friction rubs and
crepitus, by pressing it firmly on body part.
The bell usually used to detect low-pitched
sounds (i.e. bruits of stenotic arteries, heart
murmurs, and venous hums.

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 Remember
o Always inspect, palpate, percuss, and then
auscultate, except in the abdominal examination.
o Auscultate bowel sounds and percuss the
abdomen prior to palpation to avoid alterations in
bowel sounds.
o Use each technique to compare symmetrical sides
of the body and organs.

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 Physical Examination:
Components of physical examination
Steps
General appearance (G/A)
Vital sign
HEENT (head , eye, ear, nose and throat)
Lympho glandular system (LGS)
Respiratory system (RS)

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Cardio vascular system (CVS)

Gastro intestinal system (GIT)

Genito urinary system (GUT)

Intugmentary system (IS)

Muscular skeletal system (MS)

Nervous system (NS)

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 General appearance (G/A)
Observe the general state of health of the patient carefully.
Check the patient.
– Is breathing – fast, slow, painful etc distressed or not
– Sign of dehydration – sunken eye ball, dry-lip
– Level of consciousness
• Is s/he confused or alert
• Is s/he answering well or not
– Posture, dressing, personal hygiene, facial
expression.

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Result will be
 well looking – if there is no relevant finding
 Acutely sick looking (with distress, in pain, and highly
fatigue).
 Chronic sick looking
 Emaciated patient
 Weak patient
 Conscious or unconscious
 Calm or irritated

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 Measuring Vital signs
Vital signs /cardinal signs; are a group of data that reflects
interrelated physiological systems of the body. It is an
indication that an individual is still alive.

The 1st four are valuable indicators of the internal function

of the body
- 1. Pulse (PR)
2. Respiration (RR)
3. Blood pressure (BP)
4. Temperature (To)
5. Weight (wt.)
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Why vital sign is needed?
The purpose includes;
• To identify cardinal symptoms (changes of body).
• To establish baseline data for diagnosis.
• To aid in planning intervention.
• To evaluate the pt’s response to wards the procedure.
• For growth monitoring.
• As a base line data for comparing with future
measurement.
• Far correct administration of drug dose & type.
• To detect malnutrition.
 PULSE RATE (PR)
• Pulse is a pressure wave of blood caused by the alternating
contraction & expansion of elastic arteries due to contraction of left
ventricles. It is the peripheral feeling of the heart beat.

• Pulse rate is the number of each contraction or the

number of heart beat per one minute.
• It is classified as central (heart) & peripheral pulse
(peripheral artery)
Normal pulse rate distribution with age per minute
 Age Normal range Average
New born 120-160 140
1-12 months 80-140 120
12 month-2 yrs 80-130 110
2yrs -6yr 75-120 100
6yrs-12hrs 75-110 95
Adolescence 60-100 80
Adult 60-100 72
1. Normal factors that increase heart rate
includes; Age, Exercise, Excessive, eating,
Stimulants (drugs), Emotional conditions such as
fear, angry, anxiety
2. Normal factors that decrease heart rate
include; Athlete, Rest, Sleep.
3. Abnormal factors that increase heart rate
includes;Pain, Fever, Hypovolemia, Infection, &
Anemia.
4. Abnormal factors that decrease heart rate
include; Digitalization, Increase intra cranial
pressure, Conduction problem of heart.
Pulse deficit is the difference between apical & peripheral pulse
rate. It requires two people to measure pulse deficit.
Observations to be made during taking pulse rate are
• Pulse force /tension/; this reflects the strength of the stroke
volume and Expressed as; full /bounding (strong) or
weak/thready (diminished).
• Rhythm /regularity; this reflects the time interval between
beats & expressed as; Arrhythmia /irregular/ or Regular
/rhythmic/
• Rate of pulse
• Pulse volume; expressed as small volume or large volume
• High pulse rate is called tachycardia.
Low pulse rate is called – bradycarida

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Site for pulse assessment/measurement are:
• Radial
– The most common site
– The thumb side of the inner aspect of the wrist
• Carotid
– Medial border of the sternomastoid muscle (in
the lower half of the neck)
• Brachial
– Between the groove of the biceps and triceps
muscle in the inner aspect of the upper arm.
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 Radial pulse

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Brachial pulse

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Apical pulse is felt between 4th and 5th ribs in
left side
Femoral
– Palpated in the anterior medial aspect of the
thigh
Popleteal
– Palpate behind the knee in the lateral aspect of
the popleteal fossa.
Pedal
– Palpate on the dorsal aspect of the foot
Posterior tibia
– Located behind the malleoles of inner ankle

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 Equipment to measure pulse rate
(1) Watch.
(2) If apical (heart) and radial (wrist) beats are to
be counted, compared, and recorded, a
stethoscope is needed.

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 Procedure
• Handle necessary materials.
• Ask patient cooperation.
• Have patient at rest, sitting or lying. Rest arms
across the chest or on bed.
• Place the first three fingers, slightly over the artery.
Do not apply too much pressure. Do not use thumb
to feel pulse. And count as follows; Count for 1/2
minute and multiply by two or Count for a quarter
minute and multiply by four. Record the pulse for
full minute if rhythm assessment is needed.
• Note rate, regularity, skipped beats and force.
 RESPIRATORY RATE (RR)
• Respiration is a process of gas exchange between organism & its
environment
 Types of respiration
• Internal respiration: - occurs in the cellular level.
• External respiration: - between lung & external environment.
• Respiration depends on four distinct events.
• These are; ventilation, external respiration, gas transportation &
cellular respiration.
 Respiratory rate (RR); is a number of breaths per minute. One breath
is one cycle of expiration & inspiration.
Factors affecting respiratory measurement
• Hemorrhage.
• Activities like speaking, laughing, crying.
• Temperature.
• Environmental conditions.
• Drug such as atropine morphine etc.
 Respiratory rates
 Adult = 12 -20 breaths /minutes

 1 – 4 years = <40 breath /minutes

 2 – 11 month = < 50 breath /minute

 < 2 month =< 60 breath /minutes

 Tachypnea= greater than the normal range
 Bradypnea = less than the normal range

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 Abnormally fast respiratory rate is called tachypnea
Abnormally slow respiratory rate is called
bradypnea
The absence of respiration for 10 second or above is
called apnea.
Rhythm
Show the regularity of the pattern of inspiration and
expiration
Normally expiration is twice as long as inspiration
Best time to count respiration is while you are feeling the
pulse.

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 Respiration…….
Depth :-Assessed by observing the movement of the chest
wall
Quality:- Respiration is usually automatic, quite and
effortless
Abnormality
Dyspnea = difficulty of breathing
– Dyspnea after exercise = exertional dyspnea
Strider :- is a harsh inspiratory sound that occur during
inspiration
Wheezing is a high pitched musical sound usually heard on
expiration

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N.B:- Do not tell the pt as you count RR.
- Take RR after obtaining radial pulse while taking
the attention of pt.
- Take before talking to in infants & children’s.
Equipment
(1) Watch with second hand or pulse meter.
(2) Paper and pencil.
Procedure
(1) Place the fingers on the wrist.
(2) Count the rise and fall of the chest or upper abdomen
for ½ minute (repeat).
(3) Do not let patient know that his respiration is being
counted as he will consciously alter it. You may look
away and only feel the respiration movements while
counting.
 Blood pressure
 Definition - A pressure of blood exerted on the
wall of the arteries
Normally measured and expressed as the ratio
of systolic pressure over the diastolic pressure
and is stated in millimeter mercury (MmHg)
Normal adult Bp range
Systolic – 90 - 120 mmhg
Diastolic– 60 - 90 mmhg
Always measure the Bp on the same hand for
the same pt.
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Positions of the patients to take blood pressure
• Comfortable position:- either lying down with the arm
resting on the bed or sitting with the arm supported on
the table at heart – level
Affecting factors
 Age
= (Increase) B/P
 Anxiety
 Fear
 Exercise
 Medication (anti hypertensive decrease B/P)
 Bleeding

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 Blood Pressure Classification
(Adults)*
Category Systolic (mm Hg) Diastolic (mm Hg)

Hypertension
Stage 3 (severe) ≥180 ≥110
Stage 2 (moderate) 160–179 100–109

Stage 1 (mild) 140–159 90–99

High Normal 130–139 85–89

Normal <130 <85

Optimal <120 <80

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 Body Temperature
Definition: - The amount of the count of body
temperature measured at a site
Always remember to check
– Time and position
– The functionality of thermometer
Always shake the thermometer until the mercury is
below 350C point before measuring

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Body Temperature…….
Sites
– There are three sites

1. Oral temperature

The mouth of the pt under the tongue

The lips closed (not the teeth)

Leave it there for 3 minutes

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 Body Temperature…..
2. Rectal temperature
 The anus of the patient
 Patient must lying down, on the sides
 Leave it there for 3 minuets
 The most accurate and reliable site for temperature
measurement
3. Axillary's temperature
 The armpit of the patient

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 Body Temperature ……
Contra indications
Rectal To for Patient with diarrhea, patient
under go rectal surgery, and disease of rectal
Oral To for unconscious patient, seizure
disorder, irrational patient.
Remember Axillary’s To is the least accurate
and least reliable of all the site.

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 Body Temperature…..

Normally value = 36.1oC – 37.2 oC

Febrile patient > 37.2 oC

Hyper pyrexia > 41.6 oC

Hypothermia < 35 oC

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 Inspection & palpation
Head Assessment:
• Hair - Note its quantity, distribution, texture, and
pattern of loss if any.
• Inspect for the presence of nits and tiny white
granules that adhere to hairs (dandruff).
E.g. Fine hair in hyperthyroidism; coarse hair in
hypothyroidism.
 Scalp- Look for scaliness, lumps or other lesions.
 Redness and scaling in seborrheic dermatitis,
psoriasis etc
 Skull -Inspect and palpate skull for size, shape, and
consistency, the presence of any deformity, lumps or
tenderness.
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 Inspection & palpation cont‘d
 Size: Normal-varies, abnormal- very small, very
large.
 Shape: Normal-Symmetrical and round, abnormal-
asymmetrical.
 Consistency:
 Normal - Hard and smooth
 Abnormal-soft areas, masses.
Enlarged skull in hydrocephalus, Paget‘s disease of
bone. Tenderness after trauma.

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Face-Inspect and palpate the patient's facial
expression and facial features.
Normally
Note symmetry of facial movements. Ask the client to
elevate the eyebrows, frown, close the eyes tightly,
smile and show teeth.
Abnormal
Asymmetry , involuntary movement, edema and
masses.
E.g. - Dull, puffy faces in myxedema (severe
hypothyroidism).
 Edematous and pale face in nephritic syndrome.
 Moon face with red checks in Cushing's syndrome.
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1/29/2024 104
Pathology: Peripheral CN 7 (Bell‘s) Palsy
– Patient can‘t close Left eye, wrinkle Right forehead or
raise Right corner mouth

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Bell’s Palsies 105
Skin- Inspect the skin, noting its color,
pigmentation, texture thickness, hair distribution
and any lesions.
E.g. Acne in many adolescents. Hirsutism
(excessive facial hair) in some women.

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 Anatomy and physiology of the eye

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 Accessory Structures of the Eye
Eyelids: Meets at medial and lateral canthus
Eyelashes
 Ciliary glands – modified sweat glands between the
eyelashes

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 Objective Data
Important areas of examination

Visual acuity
Visual fields
Conjunctiva and sclera
Cornea, pupils, and lens
Extra ocular movement
Retinal vessels etc

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 Inspect the Eyes
Inspect External Ocular Structures
Eyebrows
Move symmetrically
Assess for scaling or lesions
Eyelids/eyelashes
Eyelids meet together
Eyelashes should be evenly distributed
Ptosis – drooping of upper lid
Skin without redness, discharge or lesions
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 cont’d
Check visual acuity and screen the visual fields.
Note the position and alignment of the eyes.
Observe eyelids, sclera & conjunctiva of each eye.
With oblique lighting, inspect each cornea, iris, &
lens.
Compare pupils, & test their reactions to light.
Assess the extra ocular movements.
With ophthalmoscope, inspect the ocular fundi.

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 Con‘t
Eyeballs
Exophthalmos (protruding eyes)
Enophthalmos (sunken eyes)
Conjunctiva and sclera
Conjunctiva - normal color – pink over
lower lids, white over sclera
Sclera – white
Assess drainage, swelling, redness,
symmetry, lesions
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 Conjunctiva
• Evert the upper lids and inspect the palpebral
conjunctiva. The surface of the palpebral
conjunctiva is normally pink.
• There are normally many small blood vessels
visible on the bulbar conjunctiva. Redness can
result from serious eye diseases.
• The bulbar conjunctiva can be observed by
separating the lids and having the client look
down and to both sides.
• The palpebral conjunctiva of anemic clients
generally appears very pale.
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• An erythematous and swollen palpebral
conjunctiva (conjunctivitis), the vessels become
engorged, and there is redness, swelling, and pain.
• Serious diseases, such as iritis, keratitis, and
glaucoma, can also cause redness and require
prompt evaluation and treatment by an
ophthalmologist.

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 Sclera
• Observe the sclera. Normally, the sclera is white.
• In hepatitis, the sclera may become a bright
yellow; in obstructive jaundice, greenish yellow;
and in pernicious anemia, lemon yellow.
• Cyanosis and pallor also may be detected by
careful observation of the sclera.

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 Cornea
• Note the surface and clearness of the cornea. The
cornea is normally smooth and transparent.
• The corneal reflex should be tested late in the
examination of the eye by touching a wisp of cotton to
the center of the cornea and observing for rapid lid
closure.
• Test both eyes; they should have equal reaction.
• Any ulceration or opacity is abnormal.
• Absence of the corneal reflex due to lack of corneal
sensitivity indicates injury of the sensory component
of the 5th cranial (Trigeminal) nerve.
• Failure of lid closure may be due to injury of the
motor component of the 7th cranial (facial) nerve.
1/29/2024 117
 Pupils
• Note whether the pupils are PERRLA (pupils equal,
round, react to light and accommodation).
• Inequality in pupil size is called anisocoria. Unequal
pupils are always considered abnormal and in need
of further investigation.
• To test for direct pupillary reaction, stand on one
side of the client and focus a penlight on the pupil.
The normal papillary reaction is constriction.
• To test for consensual reaction to light, perform the
same procedure but observe the opposite pupil; it
should also constrict, even though no direct light is
focused on it.
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• Perform these tests on both eyes.
• When the optic nerve is diseased, the affected
eye will have no direct reaction to light, although
it will react consensually if the unaffected eye is
stimulated.
• When the affected eye is stimulated, however, the
unaffected eye will not react consensually.
• Accommodation is the phenomenon where by
the pupils dilates to bring in more light when
looking at a distant object. As the eyes focus on a
near object, the pupils should narrow.
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BASIC EXAMINATION OF THE EYE

TESTING THE VISION

Visual acuity

Visual field

Color vision

Ophthalmoscopy Examination

120
 1. Visual acuity Test
• Measured with snellen‘s test chart.
• In snellen chart, there are series of letters with different
size where the smaller is visible from 6 meters and the
largest from 60 meters
• Visual acuity = d/D , where
• d= First number (numerator) is distance from chart
• D= Second number is distance at which a normal eye
could have read that line
• Always position the patient at 6 meters from the chart.

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Cont..
Measured with a Snellen chart
showing letters, ‗E‘ chart or pictures for patient who
cannot read.
Steps
Patient should sit/stand at 6 meters from the chart
Start with the right eye by closing the left eye with
palm of the hand.
Use commonly ‗E‘ chart and ask the patient to show
the direction of the ‗E‘ (right, left, up or down) and
then record the last line that the patient sees.
Repeat for the left eye.

122
 Con‘t…..
Visual acuity is expressed as two numbers (e.g., 6/60):
The human finger is about the same size as the top letter
on the chart

If vision is below 1/60, use the patient to detect motion of

hand in front of the eye; ‗hand motion‘ (HM)

If the patient can‘t see HM, the final test is to shine a light
into his eye
If he can perceive light – LP
If he can‘t perceive light – NPL 123
Visual Acuity…
Interpretation of V/A eg 6/60 6=distance of p‘t from
snellen chart ,60=ability of normal person to see from snell.
.chart

The WHO classification of Visual impairment & blindness:

Values Labels

6/6 -6/18 Normal

<6/18 -6/60 Visual impairment

<6/60 - 3/60 Severe Visual impairment
<3/60 - NLP Blindness 124
124
 6/60

6/40

6/30

6/20

6/15

6/10
6/7.5
6/6

125 125
 2. Visual Fields
• A crude estimate of the peripheral fields of vision
can be obtained by a technique called gross
confrontation.
• Using this procedure, you are comparing your
own field of vision with the client‘s. Not always
performed routinely, it needs to be performed
with a client suspected of having a visual
problem, on the older adult who is at higher risk
for glaucoma, and on the client with neurologic
symptoms.
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Stand face to face with the client, about 2 feet
apart, with your eyes level with the client‘s.
Have the client focus on your eyes.
Have the client cover one eye, and you cover your
opposite eye.
Move your wiggling fingers or an object midway
between you and the client in eight axes from the
periphery.
The horizontal field of vision is smaller because
of interference by the eyebrow, nose, and
cheekbone.
1/29/2024 127
• The field of vision is about 60 degrees medially
and about 70 degrees downward. The lateral field
of vision is 90 degrees; thus, with normal visual
field range, both you and the client will
immediately see your fingers.

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 VF test

 Normally, a person sees both sets of fingers at the same

time. If so, fields are usually normal

1/29/2024 129
Further Testing
If you find a defect, try to
establish its boundaries
Test one eye at a time

1/29/2024 130
 3. Color vision

Done by using a chart called ’Ishihara chart‘.

Simple macular test is to ask the patient for red
and green color perception.

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132 132
 Ophthalmoscopy Examination
At first, using the ophthalmoscope may seem
awkward, and it may be difficult to visualize the
fundus. With patience and practice of proper
technique, the fundus will come into view, and
you will be able to assess important structures
such as the optic disc and the retinal vessels.
Remove your glasses unless you have marked
nearsightedness or severe astigmatism. (However,
if the patient‘s refractive errors make it difficult to
focus on the fundi, it may be easier to keep your
glasses on.)

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1/29/2024 134
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 Position and Alignment of the Eyes
Stand in front of the patient and survey the eyes for
position and alignment with each other.

• Inward or outward deviation of the eyes;

abnormal protrusion may indicate:

 Graves‘ disease
 Ocular tumors

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 Eyelids
Note the position of the lids in relation to the
eyeballs
Inspect for the following:
Width of the palpebral fissures
Edema of the lids
Color of the lids (e.g. redness)
Lesions
Condition and direction of the eyelashes
Adequacy with which the eyelids close

1/29/2024 137
 Abnormalities of eyelids

1/29/2024 138
 Conjunctiva and Sclera
 Ask the patient to look up as you depress both lower lids
with your thumbs, exposing the sclera and conjunctiva.
 Inspect the sclera and palpebral conjunctiva for color, &
note vascular pattern against white scleral background.
 Look for any nodules or swelling.

1/29/2024 139
Normal sclera
 inspect the palpebral conjunctiva
1/29/2024 140
 Abnormalities

1/29/2024 141
 Pupillary Reactions
Pupillary size changes in response to light and to
the effort of focusing on a near object
The Light Reaction--A light beam shining onto one
retina causes pupillary constriction in both:
That eye (direct reaction)
The opposite eye (consensual reaction)
The Near Reaction--When a person shifts gaze
from a far object to a near one, the pupils
constrict.
The response to both light and object is mediated
by the oculomotor nerve
1/29/2024 142
 Ophthalmoscopic Examination

Absence of a red reflex

suggests:
An opacity of the lens
(cataract) or possibly
of the vitreous
Less commonly, a
detached retina
Occular tumor

1/29/2024 143
 The Ear
Houses two senses
Hearing
Equilibrium (balance)

Anatomy of the Ear

The ear is divided into three areas
Outer ear: pinna & external auditary canal
(involved in hearing only)
Middle ear
Inner ear
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 Anatomy of the Ear

1/29/2024 145
The Middle Ear or Tympanic Cavity
Air-filled cavity within the temporal bone
Only involved in the sense of hearing
Normal tympanic membrane

Air filled

1/29/2024 146
 Assessment of the ear
• Inspect the auricles, canals, and drums.
• Check auditory acuity.
• Hearing Loss/hearing aids, earaches, infections,
drainage/discharge, itching, Tinnitus (ringing in
the ears), dizziness, vertigo

• Ears should be equal size

• Microtia: ears smaller than 4 cm vertically
• Macrotia: – ears larger than 10 cm vertically

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1/29/2024 148
• tympanic membrane
• Note any redness, swelling, discharge,
foreign bodies
• The tympanic membrane, or eardrum 
translucent with a pearly gray color.
–Ear drum should be flat and intact
Inspection with otoscope for:
• Proper positioning
• External canal
• color, position, bony landmarks
1/29/2024 149
 Move Pinna and push on tragus

1/29/2024 150
 The auricles
Inspect each auricle and surrounding tissues for
deformities, skin lesions, and lumps.
Move the auricles up and down, press the tragus
just behind the ears firmly.
Movement of the auricles and pressing the tragus
is painful in acute otitis externa (inflammation of
the ear canal), but not in otitis media
(inflammation of the middle ear).
Tenderness behind the ear may be present in otitis
media while pain and tenderness behind the ears
may suggest mastoiditis.
1/29/2024 151
 Ear canal and drum
Inspect the ear canal for any discharge, foreign
body, redness, lesions or swelling.
Use the largest and most comfortable ear speculum
by pulling the auricle upward, backward, and
slightly away from the head to help your
observation.
 Inspect the eardrum for color and contour.
Red bulging drum suggests purulent otitis media.

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 Auditory acuity test
Occlude one ear to test one ear at a time.
Exhale fully and whisper words with two
accented syllables such as ―Buna-bet‖, baseball,
nine-four, by standing one or two feet a way
(don‘t allow patient to read your lips).
If hearing is diminished, try to distinguish
between conductive and sensory neural hearing
loss.

1/29/2024 153
 Air and Bone Conduction
1. Test for lateralization (Weber test)
 Prepare a quite room and a tuning fork.
 Place the base of a lightly vibrating tuning fork
firmly on top of the patient‘s head or mid for head
or teeth.
 Ask the patient through which ear he hears better.
 Normally the sound is heard in the mid line or
equally in both ears.
 In unilateral conductive hearing loss, the sound
is heard better in the affected ear. This is because
the obstruction obliterates the room noise, thus
enabling bone conduction.
1/29/2024 154
 If a sensory neural hearing loss exists, however,
the sound lateralizes to the better hearing ear.
(There fore the Weber test is useful in cases of
unilateral hearing loss).
 Common causes of conductive hearing loss
include: acute otitis media, perforation of the
eardrum, and obstruction by earwax.

1/29/2024 155
 Comparing Air conduction and Bone
conduction (Rinne test)
Place a lightly vibrating tuning fork on the mastoid
bone with its base, behind the ear and level with the
canal.
 Immediately when the patient can no longer hear the
sound, quickly place the “u” of the fork near the canal
and ascertain whether the sound can be heard again.
Normally the sound is heard longer through air than
through bone (AC > BC).
In conductive hearing loss, sound is heard through bone
longer than through air.
In sensory neural hearing loss, sound is heard longer
through air.

1/29/2024 156
1/29/2024 157
 Otoscopy Basics
• Make sure patient seated comfortably & ask not to
move
•Place tip of speculum in external canal under direct
vision
•Gently pull back on top of ear
• Advance otoscope slowly as look through window
•Avoid fast, excessive movement . Stop if painful

1/29/2024 158
 Assessment of the nose
Inspect and palpate the nose for:
 Symmetry
 Deformity, inflammation
 Patency of each nostril
Nasal flaring
 Use nasal speculum and note:
Mucosa color
Discharge (amount, color, and consistency)
Septum (deviation, perforation, bleeding)

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Observe the Nose and sinuses for:
Discharge, sneezing, Stiffness, Allergies,
Frequent colds, Obstructions, Trauma, Epistaxis,
itching.
External structure: deviation in shape, size,
color, and the presence of nasal discharge,
masses.
Septum: Tilt the head back and while pushing up
the tip slightly, examine the nares for redness,
discharge, or foreign bodies.

1/29/2024 160
1/29/2024 161
 Palpate for sinus tenderness
Local tenderness, together with symptoms such as
pain, fever, and nasal discharge, suggests acute
sinusitis involving the frontal or maxillary sinuses

Palpate for tenderness of the frontal and maxillary sinuses

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 Normal Findings:
1. Nose in the midline
2. No Discharges.
3. No flaring alae nasi.
4. Both nares are patent.
5. No bone and cartilage deviation noted on
palpation.
6. No tenderness noted on palpation.
7. Nasal septum in the mid line and not perforated.
8. The nasal mucosa is pinkish to red in color.
(Increased redness turbinate are typical of
allergy).
1/29/2024 163
 Mouth and Pharynx
Techniques - Inspection and palpation.
o If suspicious ulcers or nodules are observed,
palpate the lesion, noting especially any
thickening of tissue that might suggest
malignancy.
• Lips  observe their color and moisture and note
any lumps, ulcers, cracking.
– Normal- Pink, moist, smooth, with no lesions.
– Abnormal  Dry, cracked, cyanosis, pallor, lesions of
Herpes simplex, chancre of syphilis, carcinoma of the
lip.

1/29/2024 164
 Oral mucosa:
• Inspect the oral mucosa for color, ulcers, white
patches and nodules, consistency.
• Normal
• color – pink,
• Consistency - smooth moist, without lesions.
• Abnormal
• Color - pale, cyanotic, or reddened mucosa.
• Consistency - dry mucosa, ulcer bleeding or
white patches present.
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1/29/2024 166
 Gums
• Inspect and palpate, by retracting lips for:
• color
– Normal – pink,
– abnormal - pale, redness (in gingivitis),
• Consistency
– normal - moist, clearly defined margin.
– Abnormal - dry, edema, ulcer bleeding, tenderness
(Swollen interdentally papillae in gingivitis).

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 Gingival hypertrophy

1/29/2024 168
 Teeth
• Inspect and palpate for (number, condition, color).
• Number (are any of them missing)
• normal – 32,
• abnormal - missing teeth,
• Position/condition (misshapen or abnormally positioned).
• Normal- Stable fixation, smooth surface and edge,
• Abnormal - Loose or broken teeth, jagged edges, dental
carries.
• Color (discolored),
• normal- white and shiny,
• abnormal - darkened, brown discoloration.

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 Tongue
• Inspect a protrude tongue for: Symmetry, texture,
movement, color.
• Symmetry and texture:
– Normal - moist, papillae present, symmetrical appearance,
midline fissure present.
– Abnormal - dry; nodules, ulcers; papillae or fissure ;
asymmetrical.
• Movement:
– Normal – Smooth,
– abnormal - Jerky or unilateral movement (Asymmetric
protrusion suggest a lesion of cranial nerve XII (hypoglossal
nerve).
• Color:
– Normal – Pink,
– abnormal - Pale
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 Turning the tongue with gauze

1/29/2024 171
 Pharynx
Now, with the patient‘s mouth open but the
tongue not protruded, ask the patient to say ah.
This action may let you see the pharynx well.
If not, press a tongue blade firmly down upon the
midpoint of the arched tongue—far enough back
to get good visualization of the pharynx but not so
far that you cause gagging.
Simultaneously, ask for an ah. Note the rise of the
soft palate—a test of Cranial Nerve X (the vagal
nerve).

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Inspect the soft palate, uvula, tonsils, and
pharynx.
Note their color and symmetry and look for
exudate, swelling, ulceration, or tonsillar
enlargement.
 If possible, palpate any suspicious area for
induration or tenderness.
Normal -tonsils present (unless surgically
removed) and without exudates, uvula at midline.
Abnormal - enlarged tonsils; with exudates;
asymmetrical, uvula devotes from midline;
edema, ulcers, lesions.
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In Cranial Nerve X paralysis, the soft palate fails to
rise and the uvula deviates to the opposite side.

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 Uvula: Ask person to say aahh
»Soft palate & uvula rise in the
midline
Throat: Inspect for lesions
Tonsils
–Acute infection
–White membrane covering tonsils 
leukemia, diphtheria
–Enlargement; Acute infection
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 Uvula

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 Selected Pathology of Oropharynx
L CN 9 palsy L CN 12 palsy
uvula pulled to R tongue deviates L

L peri-tonsilar abscess uvula pushed to R

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 Examination of neck
Inspect the Neck
• Symmetry – head position midline
• Head tilt in muscular spasm
• Test strength of cervical muscles
• Abnormal pulsations
• Trachea in midline
• Enlargement of thyroid
• Enlargement of lymph and salivary glands
• Range of motion/ROM
• pain, or stiffness in the neck.
• Note pain, abnormal movement, limited ROM due to
arthritis or inflammation of neck muscles
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 Neck assessment
• Inspect the neck for symmetry, movement, and the
presence of any masses or scar.
• Appearance – symmetrical, (Normal - centered head
position).
• Movement:
– Normal - Smooth, controlled movement- Flexion (-450),
Extension (-550) Lateral abduction (=400), Rotation
(=700).
– Abnormal- Rigid, jerky movement, pain on movement.
• Assess muscle strength by asking the client to turn
the head against the resistance of your hand.

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 Lymph nodes
• Palpate lymph nodes and note, their size, Shape,
delimitation (discrete or matted together), mobility,
consistency and tenderness.
• Small, mobile, discrete, non tender nodes are frequently
found in normal people.
• Consistency: normal– Soft, abnormal - hard, firm,
• Tenderness: Normal - non tender, abnormal - verbalizes
pain on palpation.
• Tender nodes suggest inflammation
• Hard or fixed nodes suggest malignancy
• Distinguish between regional and generalized
lymphadenopathy.
• Roll a node in two directions; up and down and side to
side not to mistake muscles or /and artery for lymph node.

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 Feel in sequence for the following nodes:
1.Preauricular—in front of the ear
2. Posterior auricular—superficial to the mastoid
process
3. Occipital—at the base of the skull posteriorly
4. Tonsillar—at the angle of the mandible
5. Submandibular—midway between the angle
and the tip of the mandible.

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6.Submental—in the midline a few centimeters
behind the tip of the mandible.
7.Superficial cervical—superficial to the
sternomastoid
8. Posterior cervical—along the anterior edge of
the trapezius
9. Deep cervical chain—deep to the sternomastoid
and often inaccessible to examination. Hook your
thumb and fingers around either side of the
sternomastoid muscle to find them.
10.Supraclavicular—deep in the angle formed by
the clavicle and the sternomastoid .
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 Using the pads of the 2nd and 3rd
fingers, palpate the preauricular nodes
with a gentle rotary motion.

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 Lymph nodes
Note:
• Size and shape
• Delimitation
• Mobility
• Consistency – hard or soft
• Tenderness (with acute infection)
• Exact location
• Freely moveable, adherent to deeper structures,
or matted together
• Presence of surrounding inflammation
• Texture

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 Palpation of lymph nodes

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Characterized large lymph nodes
– Site – location of the LN
– Number – Involved LN s.
– Size – In CM - < 1cm or > 2cm
– Consistency
• Fluctuant - pyogenic inflammation
• Firm – chronic inflammation
• Rubbery – Lymphoma
• Hard – metastasis neoplasm
– Tenderness – Suggests infection
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 Trachea and thyroid gland
To orient yourself to the neck, identify the,
cricoid cartilage, the thyroid and the trachea
below them.
Inspect - The trachea for any deviation from its
usual mid line position.
Place your finger along side of the trachea and
note the space between it and the sternomastoid).
Compare it with the other side. The spaces should
be symmetrical.

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• Inspect the thyroid gland at the region below the
cricoids cartilage when a head back a bit.
• Masses in the neck may push the trachea to one
side.
• Tracheal deviation may also signify important
problems in the thorax, such as a mediastinal
mass, atelectasis, or a large pneumothorax

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 Thyroid assessment
Note Size, shape, consistence of the gland and identify any nodules.

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• Ask the patient to sip some water and to extend
the neck and swallow. Watch for upward
movement of the thyroid gland, noting its contour
and symmetry. The thyroid cartilage, the cricoid
cartilage, and the thyroid gland all rise with
swallowing and then fall to their resting
positions.
• Stand behind client and place the fingers of both
hands on the patient's neck so that your index
fingers are just below the cricoid cartilage
(Adjust the patient's neck extensor to avoid
tightened neck muscles that might interfere with
your palpation).
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• Ask the patient to sip and swallow water, feel for any
glandular tissue rising under your finger pads.
• Palpate thyroid for:
• Position- normal – midline, abnormal - deviate from
the midline.
• Characteristics, landmarks: normal - smooth, firm,
non tender. Abnormal - enlarged lobes, irregular
consistency, tender on palpation.
• The lower border of this large thyroid gland is outlined
by tangential lighting.
• Goiter is a general term for an enlarged thyroid gland.

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 Anatomy of the Female Breast:
Introduction
• Each breast lies on the superior aspect of the chest wall. In
women the breasts are the organs of lactation, whereas in men
the breasts are normally functionless and undeveloped
• Each breast consists of 12–20 conical lobes. The base of each
lobe is in close proximity to the ribs. The apex, which contains
the major excretory duct of the lobe, is deep to the areola and
nipple
• Approximately 80–85% of the normal breast is adipose tissue.
The breast tissues are joined to the overlying skin and
subcutaneous tissue by fibrous strands

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 Four Quadrants of the Breast

• Upper outer (superolateral) quadrant

• Upper inner (superomedial) quadrant
• Lower outer (inferolateral) quadrant
• Lower inner (inferomedial) quadrant

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 4 Quadrants of the Breast

Findings can be localized as the time on the face of a clock (e.g.,

3 o‘clock) and the distance in centimeters from the nipple.
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 Examination of the Breast

• Introduce yourself to the patient

• Ask Permission to perform the examination
• Assure privacy
• ask for chaperone to be present
• Explain what you want to do
• Expose the patient adequately
• Position the patient correctly
• If sores visible wear gloves.

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History: Common breast complaints are:
lump in the breast
 breast pain
 nipple discharge and
 ulceration

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 Con‘t
• Discharge; bleeding.
• Tenderness;
(inflammatory, eg abscess).
• Location: quadrants,
proximity to nipple
unilateral vs. bilateral
• Timing: spread of masses.
midcycle tenderness
• Currently breast feeding;
(mastitis

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 Con‘t
• Age: Different breast pathologies tend to occur in different age
groups. E.g. A breast lump in a teenager is most likely to be a
fibro adenoma, where as in elderly women it‘s likely to be
cancer.
• Breast lump: This is the commonest breast complaint. Ask
about:
 duration
 any accompanying nipple discharged
 multiply
 how it was first noticed
 change in size \relation to menses: explanation

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 Con‘t
• Breast pain: It is mostly of functional and inflammatory origin. Ask
about:
 site, which quadrant
 severity
 associated swelling, lump, discharge
 relation to menses (cyclic or non cyclic)
 pregnancy, lactation
• Nipple discharge: Ask about:
 color (bloody, serous, purulent, milky, etc)
 spontaneous Vs non-Spontaneous
 unilateral Vs bilateral
 relation to menstrual cycle
 associated breast lump
 drug intake E.g. Oral contraceptives

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 Con‘t
• Ask for any risk factor for cancer
 family history of breast cancer, 1st degree relation
 age at menarche (<12 years)
 age at menopause (>55 years)
 nulliparity
 history of contra lateral breast cancer
• Ask for symptoms of metastatic disease (if cancer is
suspected)
 bone pain or swelling
 cough, dyspnea, hemoptysis
 jaundice
 neurological abnormalities
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 Physical Examination
General principles
• Should be done in a private place with good illumination
• Is more informative if done just after the end of menses
• patient should be in a semi sitting position
• expose the whole of the upper half of the body
• always start from the normal breast
• examine systematically, quadrant by quadrant

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 Physical Examination of breast
Types
1. self breast examination
2. clinical breast examination

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 Clinical breast examination

• The clinical breast examination is an important component of

women‘s health care: it enhances detection of breast cancers
• An adequate inspection requires full exposure of the chest, but
later in the examination you may find it helpful to cover one
breast while you are palpating the other. Because breasts tend
to swell and become more nodular before menses as a result of
increasing estrogen stimulation,
• The best time for examination is 5 to 7 days after the onset of
menstruation

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 Inspection:
• Stand in front of the patient. Look at the:
size of breast
symmetry and contour of breast
nipple & areola for absence, symmetry, retraction,
discharge
skin for retraction, discoloration, and ulceration
• Repeat the inspection with
arms at sides,
arms over head,
arms pressed against hips,
and leaning forward
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 Con‘t

Arms Over Head

Arms at Sides

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 Con‘t

HANDS PRESSED AGAINST HIPS LEANING FORWARD

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 PALPATION
• palpate with the palmar surface of your fingers
• roll the breast tissue between the chest wall and your hand
• palpate the whole breast quadrant by quadrant
• check for
 skin temperature
 consistency of breast, nodularity
 tenderness
 nipple discharge (expression)
 mass

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 Con‘t

• Pattern of examination during palpation

1. circular pattern
2. vertical strip pattern is currently the best validated
technique for detecting breast masses.
3. others like parallel lines , wedge pattern

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 Wedge

Parallel
lines

Concentric lines

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 Nodules

Assess and describe the characteristics of any nodule:

• Location—by quadrant or clock, with centimeters from the
nipple
• Size—in centimeters
• Shape—round or cystic, disc like, or irregular in contour
• Consistency—soft, firm, or hard
• Delimitation—well circumscribed or not
• Tenderness
• Mobility—in relation to the skin, pectoral fascia, and chest
wall. Gently move the breast near the mass and watch for
dimpling

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 Breast self examination

• Breast Self-Examination should be practiced once a

month. If you menstruate, do it two or three days after the
end of your period, when your breasts are least likely to
be tender or swollen.
• If you are not menstruating, due to: location, menopause,
surgical menopause, amenorrhea, or other causes, choose
a day such as the first of the month, and perform a breast
self examination each month on that day.

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 Steps of a Breast Self-Exam

• Step 1 Begin by looking at your breasts in the mirror with your

shoulders straight and your arms on your hips
Here's what you should look for:
 Breasts that are their usual size, shape, and color.
 Breasts that are evenly shaped without visible distortion or swelling.
 If you see any of the following changes, bring them to your doctor's
attention:
 dimpling, puckering, or bulging of the skin
 A nipple that has changed position or an inverted nipple
(pushed inward instead of sticking out)redness, soreness, rash,
or swelling.

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 Step 2: Now, raise your arms and look for the
same changes

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 Con‘t

• Step 3: While you're at the mirror, look for any signs of fluid
coming out of one or both nipples (this could be a watery,
milky, or yellow fluid or blood).
• Step 4: Next, feel your breasts while lying down, using your
right hand to feel your left breast and then your left hand to
feel your right breast. Use a firm, smooth touch with the first
few finger pads of your hand, keeping the fingers flat and
together. Use a circular motion, about the size of a quarter.
• Step 5: Finally, feel your breasts while you are standing or
sitting. Many women find that the easiest way to feel their
breasts is when their skin is wet and slippery, so they like to do
this step in the shower. Cover your entire breast, using the
same hand movements described in Step

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 Con‘t

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 Palpation technique for Axillary‘s LNS
 To examine the left axilla, ask
the patient to relax with the left
arm down.
 Hold the left arm with your left
arm and put your right index
finger in the axilla as high as
possible.
 Press your finger in towards the
chest wall and slide them down
ward, trying to feel the central
nodes of the chest wall.
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Palpation technique for Axillary’s LNS………..

One or more soft, small (< 1cm), non –tender

Lymph Nodes are frequently felt.
Enlarged axillary nodes are most commonly due
to infection of the hands or arm to recent
immunization
Nodules > 1cm and firm hard, matted, together,
fixed to the skin or underlying skin –malignancy.

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Examination of thorax and the lungs
Chest exam landmarks
Anterior
Sternal angle
• Around 5 cm down in the
sternum, there is a notch,
follow the line horizontally
and the rib you get is the 2nd
rib
• Remember the ribs and
their arrangements
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Land marks Posterior
• The inferior angle of the scapula
usually lies at the level of the 7th
rib or interspaces.
• The Apex of each lung rises 2-4
cm above the inner third of the
clavicle.
• The lower border of the lung
crosses the 6th rib at the mid
clavicular line (MCL) and the 8th
rib at MCL (Anterior) and it is
about the level of the 10th thoracic
spinous process.
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• The respiratory system consists of the lungs,
the branching airways, the gaseous exchange
membrane, the rib cages and the respiratory
muscle.
Locating Findings on the Chest
• Describe abnormalities of the chest in two
dimensions: along the vertical axis and
around the circumference of the chest.

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 Locating vertically
Number ribs and interspaces accurately.
Anteriorly, the sternal angle (Angle of Louis),
the horizontal bony ridge that joins the
manibrium to the body, is the best guide.
Moving laterally from the Angle of Louis, you
find the adjacent second rib and costal cartilage.
Now you can walk down the inter spaces using
your two fingers. An inter space is named by the
rib above it.

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Posteriorly, the twelfth rib gives an other possible
starting point for counting the ribs and inter
spaces. This is especially useful in locating
findings on the lower posterior chest and also
helps when the anterior approach is unsatisfactory.
The inferior angle of the scapula lies at the level of
the seventh rib or interspaces.

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The spinous process of the seventh cervical
vertebrae (When a person flexes his neck for
ward, the most prominent process is usually that
of the seventh cervical vertebrae, and when two
processes appear equally prominent, they are of
the seventh cervical and the first thoracic
vertebrae) helps to locate findings posteriorly.

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 Locating Findings Around The
Circumference of The Chest
• The mid sternal and vertebral lines precise;
others are estimated. These lines drop vertically
in the middle of the sternum and the vertebral
column respectively.
• The mid clavicular lines –drop vertically from
the mid point of the clavicle

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• The anterior and posterior axillary lines- drop
vertically from the anterior and posterior axillary
folds (the muscle masses that border the axilla).
• The mid axillary lines- drop from the apexes of
the axilla.
• The scapular lines – drop from the inferior angles
of the scapulas

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 Lobes of the lung

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 Lobes of the lung ……

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 Locations on the Chest
Be familiar with general anatomic terms used to
locate chest findings, such as:
– Supraclavicular—above the clavicles
-Infraclavicular—below the clavicles
-Interscapular—between the scapulae
-Infrascapular—below the scapula

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 The trachea and major bronchi
Breath sounds over the trachea and bronchi have
a different quality than breath sounds over the
lung parenchyma.
Be sure you know the location of these structures.
The trachea bifurcates into its main stem bronchi
at the levels of the sternal angle anteriorly and the
T4 spinous process posteriorly.

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 Common or Concerning Symptoms
Of Respiratory System
o Chest Pain: Complaints of chest pain or chest
discomfort raise the specter of heart disease, but
often arise from structures in the thorax and lung
as well. To assess this symptom, you must pursue
a dual investigation of both thoracic and cardiac
causes.

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 Sources of chest pain are listed below
• The myocardium-Angina pectoris, myocardial
infarction
• The pericardium-Pericarditis
• The aorta-Dissecting aortic aneurysm
• The trachea and large bronchi-Bronchitis
• The parietal pleura-Pericarditis, pneumonia
• The chest wall, including the musculoskeletal
system and skin-Costochondritis, herpes zoster
• The esophagus-Reflux esophagitis, esophageal
spasm
• Extrathoracic structures such as the neck,
gallbladder, and stomach -Cervical arthritis,
biliary colic, gastritis
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 Dyspnea
• Is a non painful but uncomfortable awareness of
breathing that is inappropriate to the level of
exertion. This serious symptom warrants a full
explanation and assessment, since dyspnea
commonly results from cardiac or pulmonary
disease.
• Ask ―Have you had any difficulty of breathing?‖
Find out when the symptom occurs, at rest or with
exercise.

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Wheezes:
• are musical respiratory sounds that may be audible
both to the patient and to others.
• Wheezing suggests partial airway obstruction from
secretions, tissue inflammation, or a foreign body.
Cough:
• is a common symptom that ranges in significance
from trivial to ominous.
• Cough is a reflex response to stimuli that irritate
receptors in the larynx, trachea, or large bronchi.
• These stimuli include mucus, pus, and blood, as well
as external agents such as dusts, foreign bodies, or
even extremely hot or cold air.
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• Other causes include inflammation of the
respiratory mucosa and pressure or tension in the
air passages from a tumor or enlarged
peribronchial lymph nodes. Although cough
typically signals a problem in the respiratory tract,
it may also be cardiovascular in origin.
• For complaints of cough, a thorough assessment is
needed.
Ask whether the cough is dry or produces sputum.
Ask the patient to describe the volume of any
sputum and its color, odor, and consistency.
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Cough is an important symptom of left-sided
heart failure.
Dry cough in pneumonia; productive cough in
bronchitis, viral or bacterial pneumonia
Foul-smelling sputum in anaerobic lung abscess;
tenacious sputum in cystic fibrosis
Large volumes of purulent sputum in
bronchiectasis or lung abscess

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 Hemoptysis
• is the coughing up of blood from the lungs.
• For patients reporting hemoptysis, assess the
volume of blood produced as well as the other
sputum attributes; ask about the related setting
and activity and any associated symptoms.
• Before using the term ―hemoptysis,‖ try to
confirm the source of the bleeding by both history
and physical examination.
• Blood or blood-streaked material may originate in
the mouth, pharynx, or gastrointestinal tract and is
easily mislabeled.
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• When vomited, it probably originates in the
gastrointestinal tract. Occasionally, however,
blood from the nasopharynx or the
gastrointestinal tract is aspirated and then
coughed out.
• Blood originating in the stomach is usually
darker than blood from the respiratory tract and
may be mixed with food particles.

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 General guidelines
Expose the chest fully
Proceed in an orderly fashion: inspection, palpation,
percussion, and finally auscultation
Compare one side with the other- with side-to-side
comparison.
Examine the posterior thorax and lungs while the
patient is still in a sitting position. The patient‘s arms
should be folded across the chest with hands resting,
if possible on the opposite shoulder as this position
moves the scapula apart and increases your access to
the lung fields.
Relate all other findings in the thorax with findings
such as shape of the fingernails and position of the
trachea or cyanosis
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 Inspection
1.Inspect the shape of the chest.
In the normal adult the thorax is wider than it is
deep (the lateral diameter is about half of the
anterio-posterior diameter).
Inspect the chest for its symmetry and any
deformities.

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 Pigeon chest:
• In a pigeon chest, the
sternum is displaced
anteriorly, increasing the
anterio-posterior diameter.
• The costal cartilages
adjacent to the sternum are
depressed.
• Shows scurvy (Vitamin C
deficiency)

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 Funnel chest (Pectures excavatum)

• Characterized by a
depression in the
lower portion of the
sternum
• Compression of the
heart and great
vessels may cause
murmurs.

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 A barrel chest has an increased anterio-
posterior diameter. This shape is normal
during infancy, and often accompanies
normal aging and chronic obstructive
diseases.
 A flail chest is unstable chest resulting
when multiple ribs are fractured. Because
descent of the diaphragm decreases intra
thoracic pressure on inspiration, the injured
area caves inward; on expiration, it moves
outward (paradoxical respiration).
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In thoracic kyphoscoliosis, abnormal spinal
curvatures and vertebral rotation deform the
chest. Distortion of the underlying lungs
may make interpretation of lung findings
very difficult.
Kyphosis-posterior curvature of the spine
Lordosis- Anterior curvature of the spine
Scoliosis-Lateral curvature of the spine

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 2. Inspect respiratory pattern (rate,
depth, rhythm, effort)
• Normal respiration is 12-20 times per
minute each phase taking about 4-6
seconds, almost regular, and quite and
spontaneous.
• On quite respiration, the chest expands
1-2 inches in adults.

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• Conditions such as restrictive lung diseases,
pleuritic chest pain, and elevated diaphragm
produce rapid shallow breathing often called
tachypnea.
• Rapid and deep breathing (hyperpnea, hyper
ventilation) may be caused by exercise, anxiety,
or metabolic acidosis among other causes. If the
hyperventilated patient is comatose, consider
infarction, hypoxia, or hypoglycemia affecting the
pons.

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• Kussmaul breathing is deep breathing due to
metabolic acidosis. It may be fast, normal or slow
in rate.
• Bradypnea (slow breathing) may be caused by
diabetic coma, drugs or increased intracranial
pressure

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• Cheyne-stokes breathing, periods of deep
breathing alternate with periods of no breathing,
may be normal in children and aging people
during sleep. It may also have other sever causes
such as heart failure, uremia, drug induced
respiratory depression, or brain damage (typically
on both sides of the cerebral hemispheres or
diencephalon).
• Brain damage at the medulary level causes ataxic
breathing (breathing characterized by
unpredictable irregularity).
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• In obstructive breathing, expiration is prolonged
(longer than 6 seconds) because narrowed
airways increase resistance to airflow.
• Causes include asthma, chronic bronchitis and
emphysema. Contraction of the sternomastoid
muscle or supraclavicular retractions during
inspiration at rest signal sever difficulty in
breathing.
• Intercostal and sub costal retractions suggest
pulmonary stiffness whereas intercostal bulges
during exhalation indicate emphysema.
• Number of pillows used, if any

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 3.Observe for cyanosis
• (blue discoloration of the skin, nail beds or mucous
membrane when there is at least 5 gm % free Hgb in
the blood)
• Cyanosis signals hypoxia. Clubbing of the nails in
chronic obstructive pulmonary disease (COPD) or
congenital heart disease.
• Listen to the patient‘s breathing. Is there any audible
wheezing? If so, where does it fall in the respiratory
cycle?
• Audible stridor, a high-pitched wheeze, is an
ominous sign of airway obstruction in the larynx or
trachea.

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 4. Movement of the Chest
One has to inspect whether both sides of the
chest is moving symmetrically or not. Causes of
asymmetrical chest expansion are:
o Pleural effusion
o Pneumothorax
o Extensive consolidation
o Atelectasis
o Pulmonary Fibrosis

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 Palpation
Palpation has the following uses:
1.Identification of tender areas: palpate any area
where pain has been reported or lesions are
evident.
2.Assessment of observed abnormalities example
masses
3. Test chest expansion. Place your thumbs at
about the level of the 10th ribs, with your fingers
loosely grasping and parallel to the lateral rib
cage.
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• As you position your hands, slide them medially
just enough to raise a loose fold of skin on each
side between your thumb and the spine. Ask the
patient to inhale deeply. Watch the distance
between your thumbs as they move apart during
inspiration, and feel for the range and symmetry
of the rib cage as it expands and contracts.
• Causes of unilateral decrease or delay in chest
expansion include chronic fibrotic disease of the
underlying lung or pleura, pleural effusion, lobar
pneumonia, pleural pain with associated splinting,
and unilateral bronchial obstruction.

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 Cont…

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4. Feel for tactile fremitus (the palpable vibrations
transmitted through the broncho- pulmonary tree
to the chest wall when the patient speaks):
 Ask the patient to repeat words ‗99‘ or ‗one-one-
one‘ and with the ball of your hand (the bony part
of the palm at the base of the fingers) or the ulnar
surface of your hand, palpate and compare
symmetrical areas of the lung.
• If fremitus is faint, ask the patient to speak more
loudly or in a deeper voice.

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Identify any areas of increased, decreased or
absent fremitus and locate them.
Fremitus is typically more prominent in the
interscapular area than in the lower lung fields,
and is often more prominent on the right side
than on the left.
It disappears below the diaphragm.

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Fremitus is decreased or absent when the voice
is soft, the transmissions of the vibrations from
the larynx to the surface of the chest wall is
impended as in obstructed bronchus, chronic
obstructive diseases, separation of the pleural
surfaces by fluid (pleural effusion), air
(pneumothorax), fibrosis (pleural thickening),
infiltrating tumor or when there is very thick
chest wall.
On the contrary, fremitus is increased when
transmission is increased as through the
consolidated lung of lobar pneumonia.

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 Reason
any mass
Tenderness
Tracheal deviation
Total chest expansion
Tactile fremitus
Trachea – displacement
Put your fingers along the side of trachea and feel
the space between the trachea and sterno mastoid
muscle and compare the two sides. They should be
symmetrical
Trachea deviates away from air or fluid filled lungs
and towards the collapsed lung
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 Percussion
Percussion of the thorax has three main purposes:
To determine whether the underlying tissues are
air filled, fluid filled or solid.
To estimate diaphragmatic excursion
To identify level of diaphragmatic dullness

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Techniques:
• Hyper extend the middle finger of your left hand
(pleximeter finger) and press its distal
iterphalangeal joint on the surface to be percussed
(avoid surface contact by any other part of the
hand as it dumps the vibrations).
• Position your right forearm quite close to the
surface with the hand cocked up ward and, with a
quick, sharp, but relaxed wrist motion strike the
pleximetre finger with the tip of right middle
finger.
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• You should always use the lightest percussion that
produces a clear note; a thick chest wall requires
heavier percussion than a thin one.
• Remember to keep your technique constant in
comparing two areas.
Interpretation of percussion findings is based on the
following five percussion notes:
– Flat- this is a type of note we get by percussing
over the thigh;
pathological examples massive pleural effusion,
tumor, etc.
– Dull: a type of note similar to the one detected
over normal liver.
Pathological examples lobar pneumonia,
pleural effusion, hemothorax, etc.
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 – Resonance: this is the percussion note of normal
lung tissue though it can‘t rule out lung
abnormalities. Pathological example, chronic
bronchitis.
– Hyper resonance: this note is detected when there
is larger amount of air contained under the surface
to be percussed as in emphysema and bronchial
asthma (in which case it is generalized) or
pneumothorax (in which case it is localized).
– Tympani: this note can be learned by percussing
over a puffed out cheek or over most areas of the
stomach. Pathological example, large
pneumothorax.
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Percussion

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 Percussion

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 Identifying The Level Of Diaphragmatic
Dullness
Starting above the expected level of
dullness, percuss down ward until dullness
replaces resonance during quiet respiration.
Check the level of this change near the middle of
the hemi thorax and also more laterally. An
abnormally high level may suggest pleural
effusion, or high diaphragm as from atelectasis or
diaphragmatic paralysis.

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 Estimating Diaphragmatic
Excursion
o Ask the patient to exhale fully and keep.
o Percuss the posterior chest down from area of
resonance to area of dullness and mark.
o Then ask the patient to breath in deep and hold,
continue percussing down until resonance changes to
dullness and mark.
o Measure the vertical distance between the two
points.
o Do the same for the other side.
o Normally it should be 5-6 cm, with the possibility of
the right side to be 2cm higher than the left side.
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 Auscultation
It is the most important examining technique for
assessing airflow through the broncho-tracheal tree.
Instruct the patient to breath deeply through an open
mouth.
Using the diaphragm of the stethoscope, auscultate
areas suggested by percussion and compare
symmetrical areas.
You should auscultate between the ribs not at the
ribs. In children, the interspaces are small and there
fore you better use the bell of your stethoscope
pressed tightly.

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Auscultation has the following three
main purposes:
–To identify whether the breath sounds are
decreased, absent or abnormally located
–To identify the presence of added
(adventitious) sounds
–To identify extent of transmission of voice
sounds

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 The Normal Breath Sounds
1. Vesicular breath: Sound that is characterized by:
– Inspiratory sounds lasting longer than expiratory
ones
– Soft and low pitched
– No pause between expiration and inspiration
– Heard through inspiration and one–third of expiration
– Normally heard over most of both lungs

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 2. Bronchial Breath
sound that is characterized by:
 Loud and relatively high pitched
Expiratory sounds lasting longer than inspiratory
ones
 Short silent period between inspiration and
expiration
The normal location is over the manubrium if heard
at all

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 3.Broncho-Vesicular Breath
sounds are characterized by:
Intermediate in intensity and pitch
 Inspiratory and expiratory sounds are about
equal in duration
A silent gap between inspiration and expiration
may or may not be present
Normally it can be heard in the first and
second interspaces anteriorly and between the
scapulas posteriorly.

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If bronchial or broncho-vesicular sounds are heard in
locations distant from those listed, suspect that air filled
lung has been replaced by fluid filled or solid lung
tissue.

Breath sounds may be decreased when airflow is

decreased (example obstructive lung disease or
muscular weakness) or when the transmission of
sound is poor (example in pleural effusion,
pneumothorax, or emphysema).

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 Added Sounds
These are sounds that are superimposed on the
usual breath sounds. The common ones are
described here.
Crackles/rales/crepitation:
discontinuous/intermittent, nonmusical sounds of
brief-like dots in time that may be fine (soft and
brief) or coarse (louder and not quit so brief).
• Due to the presence of fluid in the alveoli.
stethoscope rubbing over hairy skin.

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Crackles are caused by air babbles flowing through
lightly closed airways during respiration.
They also result from a series of tiny explosions
when small airways, deflated during expiration
(Example interstitial lung disease, early congestive
heart failure, pneumonia).
If you hear crackles, note whether fine or coarse,
their timing in the respiratory cycle, location on the
chest wall, persistence of their pattern from breath
to breath and any change after coughing or
changing position.

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Wheezes: relatively high-pitched, continuous, musical
sounds which are longer than crackles and like
dashes in time. Wheezes are often audible through
mouth or chest wall.
It occurs when air flows through bronchi that are
narrowed to the point of closure.
Generalized wheezes are commonly caused by
asthma, chronic bronchitis and congestive heart
failure.
A persistent localized wheeze suggests a partial
obstruction of a bronchus, as by a tumor or foreign
body.
It may be inspiratory, expiratory or both.
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Stridor: Is entirely or predominantly inspiratory. It
indicates a partial obstruction of the larynx or
trachea and is a medical emergency.
Rhonchi :are continuous sounds with snoring quality;
it suggests secretions in the larger airways. due to
partial abstracted bronchi.
Pleural friction rub: Are discrete granting sounds that
appear continuous because they are numerous.
Pleural friction rub are usually confined to a small
area of chest wall and typically heard in both phases
of the respiration.
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 Transmitted voice sounds
If you hear abnormally located broncho-vesicular
breath sounds or bronchial breath sounds,
continue on to assess transmitted voice sounds.
This can be done in the following ways.
 Ask the patient to say ‗99‘,‘ arba-arat‘ or ‗afurtemi-
afur‘ as applicable and auscultate over the auscultatory
areas with your stethoscope.
o Normally the sounds transmitted through the chest
wall are muffled and indistinct.
o Louder clearer voice sounds heard through the
stethoscope (bronchophony) suggest that air-filled
lung has become airless.
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 Ask the patient to say ‗ee‘. Normally, you hear a
muffled long ―E‖ sound. When ―ee‖ is heard as
―ay,‖ an E-to-A change (egophony)is present, as
in lobar consolidation from pneumonia. The
quality sounds nasal. it suggests that the lung has
been changed to airless.
 Ask the patient to whisper ‗99‘ or one-two-three‘
and auscultate. The whispered voice is normally
heard faintly and indistinctly. Louder clearer
whispered sounds (whispered pectoriloquy)
suggest airless lung.

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 Examination of cardiovascular system
• Right ventricle occupies most of the anterior
cardiac surface. This chamber and the pulmonary
artery form a wedge like structure behind and to the
left of the sternum.
• The left ventricle, behind the right ventricle and to
the left, forms the left lateral margin of the heart.
• Its tapered inferior tip is often termed the cardiac
―apex.‖ It is clinically important because it
produces the apical impulse/PMI.
• This impulse locates the left border of the heart and
is usually found in the 5th interspace 7-9 cm lateral
to the mid sternal line.
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 Common or Concerning Symptoms
Chest pain or discomfort is one of the most important
symptoms you will assess as a clinician. As you listen
to the patient‘s story, you must always keep serious
adverse events in mind, such as angina pectoris,
myocardial infarction, or even a dissecting aortic
aneurysm.
 Your initial questions should be broad . . . ―Do you
have any pain or discomfort in your chest?‖ Ask the
patient to point to the pain and to describe all of its
attributes.
 After listening closely to the patient‘s description,
move on to more specific questions such as ―Is the
pain related to exertion?‖ and ―What kinds of
activities bring on the pain?‖
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Also ―How intense is the pain, on a scale of 1 to
10?‖ . . . ―Does it radiate into the neck, shoulder,
back, or down your arm?‖ . . . ―Are there any
associated symptoms like shortness of breath,
sweating, palpitations, or nausea?‖ . . . ―Does it
ever wake you up at night?‖ ―What do you do to
make it better?‖
Exertional chest pain with radiation to the left
side of the neck and down the left arm in angina
pectoris; sharp pain radiating into the back or into
the neck in aortic dissection.

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 Palpitations are an unpleasant awareness of the
heartbeat. When reporting these sensations, patients
use various terms such as skipping, racing, fluttering,
pounding, or stopping of the heart.
 Palpitations may result from an irregular heartbeat,
from rapid acceleration or slowing of the heart, or from
increased forcefulness of cardiac contraction. Such
perceptions, however, also depend on the sensitivities
of patients to their own body sensations.
 Palpitations do not necessarily mean heart disease. In
contrast, the most serious dysrrhythmias, such as
ventricular tachycardia, often do not produce
palpitations.

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• You may ask directly about palpitations, but if
the patient does not understand your question,
reword it. ―Are you ever aware of your heartbeat?
What is it like?‖ Ask the patient to tap out the
rhythm with a hand or finger. Was it fast or slow?
Regular or irregular? How long did it last? If
there was an episode of rapid heartbeats, did they
start and stop suddenly or gradually?

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Paroxysmal nocturnal dyspnea, or PND,
describes episodes of sudden dyspnea and
orthopnea that awaken the patient from sleep,
usually 1 or 2 hours after going to bed, prompting
the patient to sit up, stand up, or go to a window
for air.
There may be associated wheezing and coughing.
PND suggests left ventricular heart failure or
mitral stenosis and may be mimicked by
nocturnal asthma attacks.

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Edema refers to the accumulation of excessive fluid in
the interstitial tissue spaces and appears as swelling.
 Questions about edema are typically included in the
cardiac history, but edema has many other causes,
both local and general.
 Focus your questions on the location, timing, and
setting of the swelling, and on associated symptoms.
―Have you had any swelling anywhere? Where? . . .
Anywhere else? When does it occur? Is it worse in the
morning or at night? Do your shoes get tight?‖
 Continue with ―Are the rings tight on your fingers?
Are your eyelids puffy or swollen in the morning?
Have you had to let out your belt?‖ Also, ―Have your
clothes gotten too tight around the middle?

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 Dependent edema appears in the lowest body parts
(the feet and lower legs) when sitting or the sacrum
when bedridden. Causes may be cardiac (congestive
heart failure), nutritional (hypoalbuminemia),or
positional.
Orthopnea: Shortness of breath that occurs during
recumbent position. It is gauged by the number of
pillows that are used to relief the symptom.
Orthopnea suggests left ventricular heart failure or
mitral stenosis; it may also accompany obstructive
lung disease.
Cough : which usually occurs at night(Nocturnal)
Syncope: a sudden episode of fainting related to
Hemodynamic derangement
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 General Considerations in
Cardiovascular Examination
The patient must be properly undressed above the
waist
The examination room must be quiet to perform
adequate auscultation
Observing the patient for general signs of
Cardiovascular disease
 Breathing Pattern
 Cyanosis
 Finger clubbing
 Edema
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 Cardiovascular Examination
include examination should
A comprehensive cardiovascular
include the assessment of:
o Appearance
o Arterial pulse
o Blood pressure
o The hands
o The jugular vein distention
o The heart
o The PMI and any heaves, lifts, or thrills
o The first and second heart sounds, S1 and S2
o Presence or absence of extra heart sounds such as S3
or S4
o Presence or absence of any cardiac murmurs.
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 Jugular Venous Pressure (JVP)
Estimating the JVP is one of the most important and
frequently used skills of physical examination. At
first it will seem difficult, but with practice and
supervision you will find that the JVP provides
valuable information about the patient‘s volume
status and cardiac function.
The JVP reflects pressure in the right atrium, or
central venous pressure, and is best assessed from
pulsations in the right internal jugular vein.
Note, however, that the jugular veins and pulsations
are difficult to see in children younger than 12 years
of age, so they are not useful for evaluating the
cardiovascular system in this age group.
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 Steps for assessing the jugular venous
pressure (JVP)
 Make the patient comfortable. Raise the head slightly
on a pillow to relax the sternomastoid muscles.
 Raise the head of the bed or examining table to
about 30°. Turn the patient‘s head slightly away from
the side you are inspecting.
 Use tangential lighting and examine both sides of the
neck. Identify the external jugular vein on each side,
then find the internal jugular venous pulsations.
 If necessary, raise or lower the head of the bed until
you can see the oscillation point or meniscus of the
internal jugular venous pulsations in the lower half of
the neck.

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Focus on the right internal jugular vein. Look for
pulsations in the suprasternal notch, between the
attachments of the sternomastoid muscle on the
sternum and clavicle, or just posterior to the
sternomastoid.
Distinguish the internal jugular vein from carotid
artery pulsations. There are four methods to do
this:
1. Internal jugular veins are rarely palpable but the
carotid artery pulsations are palpable.

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2.Internal jugular pulsations are eliminated by light
pressure on the vein just above the sternal end of
the clavicle, but this pressure cannot eliminate
carotid artery pulsations.
3. Level of internal jugular vein pulsations change
with position, dropping as the patient becomes
more up right, but position change does not
change level of carotid artery pulsations.
4. Level of pulsation in internal jugular veins drop
with inspiration, but not in carotid artery.

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Identify the highest point of pulsation in the right
internal jugular vein.
Extend a long rectangular object or card
horizontally from this point and a centimeter ruler
vertically from the sternal angle, making an exact
right angle.
Measure the vertical distance in centimeters
above the sternal angle where the horizontal
object crosses the ruler.
This distance, measured in centimeters above the
sternal angle or the atrium, is the JVP.
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NB: Identify the highest point of pulsations in the
internal jugular vein and with a centimeter ruler
measure the vertical distance between this point
and the sternal angle. Normally this distance is
less than three cm.
 Increased pressure (> 3-4 cm) when it is
bilateral suggests right-sided heart failure or less
commonly tricuspid stenosis, superior venacava
obstruction or rarely constrictive pericarditis.
In patients with obstructive lung diseases, venous
pressure may appear elevated on expiration only.
The veins collapse during expiration showing,
therefore, this does not show congestive heart
failure.
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 Pericardium examination
Inspection
 Activity of the precordium ( Quit, Active or
Hyperactive)
Precordial Buldging or any chest deformity:
Show - cardiomegally
Location of the apical impulse
Any shift from the normal position
- Shows – mediastinal shift.
 Any Visible Veins or Scars
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 Point of maximal pulse
 The point where there is maximum palpable heart
beat can be detected.
Apical impulse
 The point where there is maximum heart beat is
heard.
 The two points are always located in the left 5th
intercostals space in mid clavicular line(MCL).

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Site of apical pulse 5th intercostals MCL

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 Palpation
• Point of maximum pulse (PMI)
 Normally at the 5th ICS at the left mid clavicular line (MCL)
 Shift – enlargement of the left ventricle because of the left
ventricular failure.
 More space – Normally PMI took one space (intercostals
space)
Abnormally, it may prolonged
1) Trill – palpable murmur
2) Heave (Precordial lift)- parasternal and/or Apical
– If the apical impulse is broad and forceful

3) Palpable heart Sounds

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 Auscultation
Auscultate the heart to listen heart sounds

• Site

• Aortic area – 2nd ICS to right of sternum

• Pulmonary area – 2nd ICS to the left of the sternum

• Tricuspid area – 4th and 5th ICS to the left of the

sternum (Right ventricle)

• Mitral (apical ) area - 5th ICS to the left of the sternum

(Lt Ventricle)
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Always remember
There are two heart sounds
S1 – best heard at the apex of the heart
(Mitral)
S2 – best heard at the base of the heart
Sometimes in children
Other sound called gallop
S3 – gallop – rapid filling of the ventricle
S4 – gallop – rare – created while the atria
contracts and the ventricle resist to be filled.
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Murmur
• Sound created by the turbulent blood flow (as blood passes
through narrowed valve)
• Characterized based on – intensity, pitch, timing, shape,
radiation, and quality.
Timing: First decide if you are hearing a systolic murmur,
falling between S1and S2, or a diastolic murmur, falling
between S2 and S1.
• Murmurs that coincide with the carotid upstroke are
systolic.
• Systolic murmurs are usually mid systolic or pan systolic
• Diastolic murmurs usually indicate valvular heart disease.
• Systolic murmurs may indicate valvular disease, but often
occur when the heart is entirely normal.
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• A mid systolic murmur begins after S1 and stops
before S2. Brief gaps are audible between the
murmur and the heart sounds. Listen carefully
for the gap just before S2. It is heard more
easily and, if present, usually confirms the
murmur as mid systolic, not pan systolic.
• A pan systolic (holosystolic) murmur starts with
S1 and stops at S2, without a gap between
murmur and heart sounds.
• A late systolic murmur usually starts in mid- or
late systole and persists up to S2.
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 Examination of Abdomen
Anatomy of abdomen

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• For descriptive purposes, the abdomen is often
divided by imaginary lines crossing at the
umbilicus, forming the right upper, right lower,
left upper, and left lower quadrants.
• Another system divides the abdomen into nine
sections. Terms for three of them are commonly
used: epigastric, umbilical, and hypogastric, or
suprapubic.

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• For a good abdominal examination you need
(1) good light,
(2) a relaxed patient, and
(3) full exposure of the abdomen from above the
xiphoid process to the symphysis pubis.
• Make the patient comfortable in a supine position
• Have the patient keep arms at the sides or folded
across the chest
• Before you begin palpation, ask the child to point to
any areas of pain and examine these areas last.
• Warm your hands and stethoscope, and avoid long
fingernails
• Watch the child’s face closely for any signs of pain
or discomfort.
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Symptoms of gastrointestinal disease
Dysphagia:
• Dysphagia can be defined as difficulty or
discomfort in swallowing
Odynophagia:
• This is a condition where pain felt during
swallowing secondary to either
Mucosal inflammation
Reflux esophagitis
Esophageal candidiasis
Mucosal abnormality
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Nausea and vomiting
• Nausea: denotes the feeling of an imminent
desire to vomit, usually referred to the throat or
epigastrium.
• Vomiting (emesis): refers to the forceful oral
expulsion of gastric contents.
• Hematemesis: Is the vomiting of blood –pure or
altered.

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Regurgitation:
• Refers to the expulsion of food in the absence
of nausea and without the abdominal, and
diaphragmatic muscular contraction associated
with vomiting
Indigestion (Dyspepsia):
• A common complaint that generally refers to
distress associated with eating.
Abdominal Pain
• Visceral pain, Parietal pain, Referred pain

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 Inspection
Look for
(+) Protuberance (small bulging)
- Thin abdominal wall
- Lumbar lordosis
(+) Marked protuberance (distention)
- Gas, fluid, feaces
- Rickets
- Intestinal obstruction
(+) Localized bulging
- Marked hepato –spleeno megally
- distended urinary bladder
- Hernia, etc
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=> Generally
- Abdomen – distended – bulged out wards
- Full – normal
- Scaphoidal – depressed inward
• Skin
– Scars- location
– Steriae – (stretch marks)
– Rashes
– Lesions

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Umbilicus – averted, inverted, flat
Any sign of inflammation
Movement – Abdominal movement during
respiration
Peristalsis – Peristaltic movement
Pulsation – any visible pulsation
Hernia – site – epigastric – inguinal or umbilical

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 Auscultation
Place your diaphragm gently on the abdomen and
hear for bowel sounds and note their frequency and
character.
Normal sound – consists of clicks and gurgles – 5 to
34 per minute frequency
Bowel sound could be
Norm active
Hyperactive – Intestinal obstruction – Diarrhea
Hypoactive – Paralytic illus – peritonitis
Auscultation may also reveal bruits, vascular sounds
resembling heart murmurs, over the aorta or other
arteries in the abdomen, which suggest vascular
occlusive disease.
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 Palpation
Two ways used – Light Palpation and deep
palpation
Light Palpation: Feeling the abdomen gently is
especially helpful in identifying abdominal
tenderness, muscular resistance, and some
superficial organs and masses.

• Technique – keep your hand and forearm on a

horizontal plane, with fingers together and flat
on the abdominal surfaces
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Rebound tenderness
- Press your fingers in firmly and slowly,
and then quickly withdraw them.
- Watch and listen to the patient for signs of
pain.
- It results from the rapid movement of an
inflamed peritoneum.

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 Deep Palpation
- Usually required to delineate abdominal masses.
- use the palmar surfaces of fingers, feel in all
four quadrants.
• Identify any masses and note their location, size,
shape, consistency, tenderness, pulsations, and
any mobility with respiration or with the
examining hand.

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Liver
Palpation
Ask the patient to take breath, and palpate
starting from lower, right quadrant and push up
while the patient breathe in air
Mark the area
Normally Liver is enlarged 6 cm below the
costal margin at the right mid clavicular line

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 Deep palpation

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 Liver palpation

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 Spleen
• When a spleen enlarges, it expands anteriorly,
downward, and medially
• It then becomes palpable below the costal margin
• With your left hand, reach over and around the patient to
support and press forward the lower left rib cage and
adjacent soft tissue. With your right hand below the left
costal margin, press in toward the spleen
• Ask the patient to take a deep breath.
• Try to feel the tip or edge of the spleen as it comes down
to meet your fingertips.
• Note any tenderness, assess the splenic contour, and
measure the distance between the spleen’s lowest point
and the left costal margin
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 Bimanual palpation

• By using two hands, from the upper and lower surfaces

of the body.
Percussion
• Normally tympani predominate on percussion of the
abdomen
Abnormality
• Shifting dullness
• You start to Purcus from the upper parts of
abdomen downwards and allocate the borders you
ask the patient to turn to side and purcused the
boarders again
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 Palpation of the Kidney
• Palpation of the Left Kidney.
- Move to the patient‘s left side.
- Place your right hand behind the patient just below
and parallel to the 12th rib, with your fingertips just
reaching the costovertebral angle. Lift, trying to
displace the kidney anteriorly.
- Place your left hand gently in the left upper
quadrant, lateral and parallel to the rectus muscle.
Ask the patient to take a deep breath.
- At the peak of inspiration, press your left hand
firmly and deeply into the left upper quadrant, just
below the costal margin, and try to ―capture‖ the
kidney between your two hands.
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 Right kidney
• Use your left hand to lift from in back, and your
right hand to feel deep in the right upper
quadrant

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 Assessing Kidney Tenderness.
• Pressure from your fingertips may be enough
to elicit tenderness, but if not, use fist
percussion.
• Place the ball of one hand in the costovertebral
angle and strike it with the ulnar surface of
your fist.
• Use enough force to cause a perceptible but
painless jar or thud in a normal person.

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 Percussion
• helps to assess the amount and distribution of gas in the
abdomen
• to identify possible masses that are solid or fluid filled.
• Its use in estimating the size of the liver and spleen
• Percuss the abdomen lightly in all four quadrants to
assess the distribution of tympany and dullness
• Shifting dullness: - purcus and map the borders of
tympani and dullness, as the patient to turn on one side,
purcus and mark the borders again.

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Vertical span of liver dullness
• Measure the vertical span of liver dullness in the
right midclavicular line.
• Starting at a level below the umbilicus (in an area of
tympany, not dullness), lightly percuss upward
toward the liver
• identify the upper border of liver dullness in the
midclavicular line.
• Lightly percuss from lung resonance down toward
liver dullness.
• measure in centimeters the distance between your
two points
• Normally 6-12cm in right mid clavicular
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 Test for shifting dullness-
- After mapping the borders of tympany and
dullness, ask the patient to turn onto one side.
Percuss and mark the borders again.
- In a person without ascites, the borders between
tympany and dullness usually stay relatively
constant.
- In ascites => dullness shifts to tympani

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 Test for a fluid wave/ fluid thrill
- Ask the patient or an assistant to press the edges
of both hands firmly down the midline of the
abdomen.
- You put your hands on the two sides of the
abdomen
- This pressure helps to stop the transmission of a
wave through fat.
- While you tap one flank sharply with your
fingertips, feel on the opposite flank for an
impulse transmitted through the fluid.
• An easily palpable impulse suggests ascites
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 Digital examinassions (PR)
Per rectal examinassions
• Wear your glove and lubricate your examining finger
explain the patient what you are going to do and
gently insert your finger (index for adults and little
for pediatric pt) into anal canal.
• Rotate your finger further clock wise so that you can
examine the posterior surface of the prostate gland
for enlargement
• Feel -Tenderness
• Mass
• Modules
• Irregularity
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 Digital examinassions (PR) ….

If sphincter is tight pause Rectal cancer

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 Genito- urinary system (GUS)

Inspection
External genitals
Female
Inspect the vulva, mons pubis and perineum inspect
any inflammation ulceration, discharge swelling or
nodules

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 Female genitalia

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Palpation
With the labia separated by your middle and index
finger inspect Bartholine‘s gland for swelling,
tenderness
Speculum examination
Insert speculum
Hold the speculum closed and insert it by making a
slight diagonal to the vaginal left. And push it up by
rotating to the handler become down wards and
finally open it.

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Inspect
for the cervix – ulceration ,bleeding, mass,
discharge
When you pull it out gently pull it around two
centimeters and dose the speculum and rotate
it gust opposite of the insertion

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 Inserting speculum

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 Inserting speculum
Normal cervix Cervical polyp

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 Abnormal cervix

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 The Penis
Inspection:
Inspect the penis, including:
■The skin
■The prepuce(foreskin). If it is present, retract it or ask
the patient to retract it. This step is essential for the
detection of many chancres and carcinomas
■The glans: Look for any ulcers, scars, nodules, or
signs of inflammation.
Check the skin around the base of the penis for
excoriations or inflammation.
• location of the urethral meatus.

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Phimosis: is a tight prepuce that cannot be retracted
over the glans.
Paraphimosis: is a tight prepuce that, once
retracted, cannot be returned.
Balanitis(inflammation of the glans);
Hypospadiasis a congenital, ventral displacement of
the meatus on the penis .

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 Palpation
• Palpate any abnormality of the penis, noting any
tenderness or induration.
• Palpate the shaft of the penis between your
thumb and first two fingers, noting any
induration.
• Induration along the ventral surface of the penis
suggests a urethral stricture or possibly a
carcinoma.

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 The Scrotum
Inspection:
Inspect the scrotum, including:
■The skin.
■The scrotal contours. Note any swelling, lumps, or
veins.
• A poorly developed scrotum on one or both sides
suggests cryptorchidism(an undescended testicle).
• Common scrotal swellings include indirect inguinal
hernias, hydroceles, and scrotal edema.
• Tender, painful scrotal swelling in acute epididymitis,
acute orchitis, or strangulated inguinal hernia.
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 Palpation
• Palpate each testis and epididymis between your
thumb and first two fingers.
• Note size, shape, consistency, and tenderness;
feel for any nodules.

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 Palpation

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 Per vaginal examination (PV)
This examination is done by using your index
and middle finger
Insert and see
Cervical motion tenderness pain elicited by
moving the cervix shows cervical infection
/inflammation
Palpate any mass see for size, firmness,
tenderness

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 Musculoskeletal examination
• The musculoskeletal system includes the muscles,
bones, joints, and soft tissue structures such as
tendons and ligaments.
GENERAL PRINCIPLES :
Examination of the musculoskeletal system:
includes
• Inspection
• Palpation
• Asses range of motion

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 General observations (inspection)
Gait
• Posture
• Mobility
• Deformity
• Independence: use of wheelchair or walking aids
• Muscle wasting
• Long bones
Palpation of the extremities should be done
 to determine areas of tenderness,
 swelling,
 and increased or decreased temperature.
• Any one or all of these findings may be noted at sites of
fracture, bone or joint disease, infection, and sprain.
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 Determining the range of motion
• Flexion, extension, abduction, adduction,
supination, pronation, eversion, and inversion
should be demonstrated within the normal
anatomical limits of the particular joint.
• Variation from normal between paired joints and
extremities also should be noted

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 THE BONES
• The examination of the bones should always be directed by information
obtained from the history.
• Inspection
• Palpation
 FRACTURES
• Examination of suspected fracture
• Fractures: clinical features
Closed
Compound (open)
Features
• Haemorrhage
• Deformity
• Pain
• Crepitus
• Restricted movement

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 Examination of individual joints
 All motion should be measured in degrees from a
neutral or zero position, which must be defined
whenever possible, and compared with the
opposite side.

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 THE SPINE
GENERAL EXAMINATION OF THE VERTEBRAL
COLUMN
Inspection ;
• Examine the patient both in standing and in sitting in
the erect posture.
• If there is an abnormality, note which vertebrae are
involved and at what level any vertebral projection
is most prominent.
Palpation ;
• The major landmarks are the spinous processes of
C7 (the vertebra prominens) and the last rib,
which articulates with the twelfth thoracic vertebra

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 THE CERVICAL SPINE
• Rotation
• Flexion
• Extension
• Lateral bending
THE THORACIC AND LUMBAR SPINE
• Flexion
• Extension
• Lateral bending
• Thoracic rotation

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THE ELBOW
• The neutral position is with the forearm in extension.
The following movements should be tested
Flexion
Hyperextension
THE WRIST
• The neutral position is with the hand in line with the
forearm, and palm down. The following movements
should be tested
• extension
• flexion
• Lateral deviation
• medial deviation.

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THE HIP
• The neutral position is with the hip in
extension and the patella pointing forwards.
• Look for scars and wasting of the gluteal and
the thigh muscles.
• The following movements should be tested
• Flexion: measured with knee bent.
• Abduction: measured from a line that forms an
angle of 90° with a line joining the anterior
superior iliac spines
• Adduction (measured in the same manner)
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THE KNEE
• The neutral position is complete extension.
Observe any valgus (lateral angulation of the tibia)
or varus (medial angulation) deformity on the couch
and on standing. Look for muscle wasting.
• Check the apparent height of the patella and watch
to see if it deviates to one side in flexion or
extension of the knee. Feel for tenderness at the joint
margins, not forgetting the patellofemoral joint.
• Measure the girth of the thigh muscles 10cm above
the upper pole of the patella.
• The movements of the knee are flexion and extension
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THE ANKLE and FOOT
• The neutral position is with the outer border of
the foot at an angle of 90° with the leg, and
midway between inversion and eversion. Observe
the patient from behind in the standing position.
With any long-standing ankle disorder there will be
a loss of calf muscle bulk.
• The following movements should be tested
Dorsiflexion: test with the knee in flexion and
extension to exclude tight calf muscles
• Plantar flexion: place a finger on the head of the
talus to be sure that it is moving

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 Integumentary system
• Inspect
• Color :- depends on the presence of melanine,
carotene – factors :- life style, light exposure, and
diet
– Pallor :- temporary – shock, hemorrhage, anemia,
vasoconstriction persistence
– Redness – fever , inflammation , flushing, sunburn
– Cyanosis – central – on the lips, oral mucosa tongue
– Peripheral = nail, hand, feet
=> Shows absence or shortage of oxygen
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 Inspect……..
• Caroteenemia
• Yellowish discoloration over the palm but not the
conjunctiva
Pigmentation
• Hypo pigmentation – scar, vitilgo (symmetrical white or
pale macules)
• Hyper pigmentation –chloasma (symmetrical brown
patches on the face
• Moisture – dryness/moisten, Sweating

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 Jaundice
• Jaundice makes the skin diffusely
yellow.
• The colour of jaundice is seen most
easily and reliably in the sclera.
• Sclera, lips, dorsum of tongue and skin
may be yellowed in color

• It may also be visible in mucous

membranes.
• Happen because of excess bilirubin
(a bile pigment) in the blood
• Causes include liver disease and
hemolysis of red blood cell

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 Cyanosis
• Cyanosis is the some what
bluish color that is visible in
these toe nails and toes.
• Impaired venous return in the
leg caused this example of
peripheral cyanosis.
• Cyanosis, especially when
slight, may be hard to
distinguish from normal skin
color

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• Lesions
• see the location, distribution, symmetry,
arrangements
• Palpate the skin for
• Texture
• Moisture
• Tenderness
• Temperature edema
• Cryptation
• Mobility (lifting up)
• Turger (return of skin)

Basic types of skin lesion

Primary lesion
• A raise from normal skin
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 Macules – circumscribed, flat, discoloration
Small flat spot, up to 1.0 cm
Examples: freckle, petechia

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 Papule :- Up to 1.0 cm.
Example: an elevated nevus

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Nodules:- 5-20 mm – raised, circumscribed lesion
e.g wart
Marble-like lesion larger than 0.5 cm, often deeper
and firmer than a papule

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 Tumor -> 20mm e.g lipoma, slightly thicker and deeper

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 Plague:- flat circumscribed, elevated , 5mm , usually
coalesce of papule e.g psoriasis

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 Patch :- circumscribed, flat, discoloration of
>5mm e.g Vitilgo

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 Wheal:- localized skin edema, transient, irregular, peripheral,
erythematic, flat e.g urticaria

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 Pustule:- pus containing lesions (vesicles)
e.g Impetigo

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 Bullae:- Large blisters, >5mm e.g pempling

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 Vesicle:- Circumscribed, superficial elevated of fluid
containing skin <5mm e.g herpes simplex

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Secondary lesion
rise from primary lesion
Erosion :- Loss of epidermis , vascular rupture

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 Fissure :- linear crackled e.g T. pedis

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 Scale : - thin flake of exfoliated epidermis e.g
psoria

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 Scar :- abnormal healing process , fibrous tissue

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 Lichenification :- thick , rash skin e.g
chromic eczema

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 Excoriation :- abrasion, scratch marks

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 ulcer :- loss of epidermis and partial or
total dermis

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 The Nerves System

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 Anatomy and Physiology of Central
Nervous System

• The Nervous System includes Cental Nervous System And The

Periphereal Nervous System.

• The Central Nervous System consists of the brain and the spinal cord.

• The Peripheral Nervous System consists of the 12 pairs of cranial nerves

and the spinal and peripheral nerves.

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 Central Nervous System
The Brain
• The brain has four regions: the cerebrum, the diencephalon(the thalamus and the
hypothalamus), the brainstem, and the cerebellum.

• The brain is a vast network of interconnecting neurons(nerve cells). These consist

of cell bodies and their axons.

*Axons – are single long fibers that conduct impulses to other parts of the nervous
system.

• Brain tissue may be gray or white:

-Gray matter consists of aggregations of neuronal cell bodies.

-White matter consists of neuronal axons that are coated with myelin.

• Deep in the Brain there are additional clusters of grey matters,these includes Basal
Ganglia which affect movement and the diencephalon.

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• The Diencephalon consists Thalamus and Hypothalamus.

- Thalamus processes sensory impulses and relays them to the cerebral cortex.

- Hypothalamus -Maintains homeostasis and regulates temperature, heart rate

and blood pressure.

-Affects the endocrine system and governs emotional

behaviors such as anger and sexual drive.

• The brainstem ,which connects the upper part of the brain with the spinal cord, consist three
sections, the midbrain, the pons, and the medulla.

• The cerebellum ,which lies at the base of the brain, coordinates all movements and helps maintain
the body upright in space.

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 Spinal Cord
• The spinal cord is a cylindrical mass of nerve tissue encased within the
bony vertebral column, extending from the medulla to the first or second
lumbar vertebra.
• The spinal cord is divided into five segments: cervical (C1–8), thoracic (T1–12), lumbar (L1–5),
sacral (S1–5), and coccygeal.
• It‘s functions include:
-contains important motor and sensory nerve pathways that exit and enter the cord via anterior and
posterior nerve roots and spinal and peripheral nerves.
-mediates reflex activity of the deep tendon (or spinal nerve) reflexes.

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 Peripheral Nervous System
• Consists the Cranial nerves and the peripheral nerves:

THE CRANIAL NERVES

• Twelve pairs of special nerves called cranial nervesemerge from within the skull or
cranium.

THE PERIPHERAL NERVES

• Thirty-one pairs of nerves attach to the spinal cord: 8 cervical, 12 thoracic, 5 lumbar, 5
sacral, and 1 coccygeal.

• Each nerve has an anterior (ventral) root contain-ing motor fibers, and a posterior (dorsal)
root containing sensory fibers.

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 Physical Examination
 Important Areas of Examination
• Mental status: appearance and behavior, speech and language, mood,
thoughts and perceptions, cognition
• Cranial Nerves: I through XII
• Motor system: muscle bulk, tone, and strength; coordination, gait, and stance
• Sensory system: pain and temperature, position and vibration, light touch,
discrimination
• The Reflex

• Meningeal irritation signs

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 Mental Status
 Components of the mental status examination include:

• Appearance and behavior

• Speech and language

• Mood

• Thoughts and perceptions

• Cognitive function, including memory, attention, information and vo-

cabulary, calculations, and abstract thinking and constructional ability.

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 Con‘t…
 Appearance and behaviour:-

• Level of consiousness : Is the patient awake and alert?

:Does the patient seem to understand your questions and respond

appropriate and reasonably quickly?

• Posture and Motor Behavior :Does the patient lie in bed, or

prefer to walk about?

:Note body posture and the patient‘s ability to relax.

:Observe the pace, range, and character of movements.

:Do they seem to be under voluntary control? Are certain

parts immobile?
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 Con‘t…
• Dress, Grooming, and Personal Hygiene
• Facial Expression
• Manner, Affect, and Relationship to
Persons and Things

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 Con‘t…
 Speech And Language
note the characteristics of the patient‘s speech, including the following:
• Quantity :Is the Patient talkative or relatively silent.
• Rate : Is speech fast or slow.
• Loudness : Is speech loud or soft?
• Articulation of Words : Are the words spoken clearly and distinctly? Is there
a nasal quality to the speech?
• Fluency :This involves the rate, flow, and melody of speech and the con-tent
and use of words.

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• Mood : The appropriateness of the patient‘s mood or affect is
noted
 E.g. If the patient smiles while experiencing excruciating chest
pain, this is considered as inappropriate mood.
:Disorders in affect may be manifested as depression or
mania.
• Thought and perception : Observe the patient for logic and
coherence.
:Any unusual aspects of thought, illusions or delusions,
perseveration and
insight.

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• Cognitive function : Orientation to time, place, and person.
 Assess the three aspects to memory, which usually becomes obvious during
the interview.
1. Immediate recall by saying a series of numbers and having the patient repeat
them.
2. Recent memory by asking the patient torecall something after 5 minutes has
elapsed.
3. Remote memory refers to events in the distant past.
 The patient‘s attention is assessed by simple calculations such as serial
sevens : Subtracting 7 from 100 and keep on subtracting 7 from the result or
serial 3 i.e. subtracting 3 from 20 and keep on subtracting

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 Level of consciousness
• Glasgow coma scale :- this method is based on the
eye opening , best motor responses and verbal
responses of the patient to different stimuli.
• The value in this scale range from 3(the deepest
comma) to 15 (the full alertness

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 Con‘t….
Eye opening Best motor responses Verbal responses

Spontaneously = 4 Obeys command = 6 Oriented = 5

To speech =3 Localizes pain = 5 Confused conversation =4

To pain =2 Withdraws to pain = 4 Inappropriate words = 3

No response at all = 1 Abnormal flexion to pain = 3 Incomprehensible sound = 2

Extends to pain = 2 No response = 1

No response = 1

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 Interpretation

• Individual elements as well as the sum of the score are

important. Hence, the score is expressed in the form "GCS 9 =
E2 V4 M3 at 07:35".
• Generally, brain injury is classified as:
Severe, with GCS ≤ 8
Moderate, GCS 9 - 12
Minor, GCS ≥ 13.

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 Assessment of Cranial
Nerves
The Cranial Nerves are:
I: Olfactory - Smell
II: Optic - Visual acuity, visual fields, and ocular fundi
II-III : Pupillary reaction
III-IV-VI: extraoculars
V: Trigeminal :Corneal reflexes, facial sensation, and jaw
movements
VII: Facial
VIII: Vestibulocochlear - Hearing
IX-X: Glossopharyngeal, Vagus - Swallowing and rise of the palate,
gag reflex
V-VII-X-XII : Voice & Speech
XI: Accessory - Shoulder and neck movements
XII: Hypoglossal - Tongue symmetry and position

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 CN I: Olfactory
• Usually not tested.
• Observe for rash, deformity of nose or
discharge (CSF).
• Test each nostril with essence bottles of coffee,
peppermint.

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 CN II: Optic

• Test each eye separately on eye chart/ card using an eye cover.

• Examine visual fields by confrontation , keep examiner's head

level with patient's head.

• If poor visual acuity, map fields using fingers and a quadrant-

covering card.

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CN III, IV, VI: Oculomotor,
Trochlear, Abducens
• Look at pupils: shape, relative size, ptosis.
• Shine light in from the side to gauge pupil's light reaction.
• Assess both direct and consensual responses.
• Assess afferent pupillary defect by moving light in arc from
pupil to pupil.
• "Follow finger with eyes without moving head": test the 6
cardinal points in an H pattern.
• Look for failure of movement, nystagmus [pause to check it
during upward/ lateral gaze].
• Convergence by moving finger towards bridge of pt's nose.

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 CN V: Trigeminal
• Corneal reflex: patient looks up and away.
• Touch cotton wool to other side.
• Look for blink in both eyes, ask if can sense it.
• Repeat other side
• Facial sensation: sterile sharp item on forehead, cheek, jaw.
• Repeat with dull object. Ask to report sharp or dull.
• If abnormal, then temperature (heated/ water-cooled tuning
fork), light touch (cotton).
• Motor: pt opens mouth, clenches teeth
• Palpate temporal, masseter muscles as they clench.

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 CN VII: Facial
• Inspect facial droop or asymmetry.
• Facial expression muscles: pt looks up and
forehead.
• Pt shuts eyes tightly: compare each side.
• Pt grins: compare nasolabial grooves
• Also: frown, show teeth, puff out cheeks

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CN VIII: Vestibulocochlear
• Rub one hand's fingers with noise on one side, other hand noiselessly.
• Ask pt. which ear they hear you rubbing.
• Repeat with louder intensity, watching for abnormality.
• Weber's test: Lateralization
 512/ 1024 Hz vibrating fork on top of patients head/ forehead.
 "Where do you hear sound coming from?"
 Normal reply is midline.
• Rinne's test: Air vs. Bone Conduction
 512/ 1024 Hz vibrating fork on mastoid behind ear. Ask when stop hearing it.
 When stop hearing it, move to the patients ear so can hear it.
 Normal: air conduction [ear] better than bone conduction [mastoid].

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 CN IX, X:
Glossopharyngeal, Vagus
• Voice: hoarse or nasal.
• Pt. swallows, coughs
• Examine palate for uvular displacement.
• Pt says "Ah": symmetrical soft palate
movement.
• Gag reflex [sensory IX, motor X]:
 Stimulate back of throat each side.
 Normal to gag each time.

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 CN XI: Accessory
• From behind, examine for trapezius
atrophy, asymmetry.
• Pt. shrugs shoulders (trapezius).
• Pt. turns head against resistance:
watch, palpate SCM on opposite
side.

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 CN XII: Hypoglossal
• Listen to articulation.
• Inspect tongue in mouth for
wasting, fasciculation.
• Protrude tongue: unilateral deviates
to affected side.

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 Motor System
• Includes
Body position
Presence of involuntary body
movements
Characteristics of muscles
Coordination of movements

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 Motor examination

• Muscle status
• Muscle tone
• Muscle power
• Tendon reflexes
• Gait & coordination

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• Body Position
 Look at the patient‘s resting and standing posture:
 Hemiplegia : flexed upper limb, extended lower limb
 wrist drop : radial nerve palsy

• Involuntary Movements
 Tremor are relatively rhythmic oscillatory movements.Includes;
 Parkinson‘s :coarse rhythmical tremor at rest, lessens on
movement
 Essential tremor :tremor present on action; look at out-stretched
hands
 Chorea :abrupt, involuntary repetitive semi-purposeful
movement
 Athetosis :slow, continuous writhing movement of limb

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• Muscle Tone
 When a normal muscle with an intact nerve supply is relaxed
voluntarily, it maintains a slight residual tension known as
muscle tone.
 Ask the patient to relax his arm and then you flex and extend his
wrist or elbow.Move through a wide arc moderately slowly, at
irregular intervals to prevent patient cooperation.
 Ask the patient to let the limb go loose, lift it up and move at
knee joint(hip and ankle if required).

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 Con‘t…
• Hypertonia(increased tone):
 pyramidal:more obvious in flexion of upper limbs and extension of lower limbs. Occasionally ‗clasp
knife‘, i.e. diminution of tone during movement
 extrapyramidal: uniform ‗lead pipe‘ rigidity. If associated with tremor the movement feels like a ‗cog
wheel‘
 hysterical:increases with increased movement

• Hypotonia(decreased tone):
 lower motor neuron lesion
 recentupper motor neuron lesion
 cerebellar lesion
 unconsciousness

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Motor system…….

• Generalized hypotonic
• Malnutrition

• Down syndrome

• Rickets

• Muscle dystrophies

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Motor system……

• Localized hypnotic

• Tetanus

• Upper motor lesion

• Power /strength

• Ask the patient to make a particular movement

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 Muscle Strength
• Muscle strength is graded on a 0 to 5 scale:
 0: No muscular contraction detected
 1: A barely detectable flicker or trace of contraction
 2: Active movement of the body part with gravity eliminated
 3: Active movement against gravity
 4: Active movement against gravity and some resistance
 5: Active movement against full resistance without evident
fatigue. This is normal muscle strength.

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 Power /strength…………

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 Power /strength…………

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 Power /strength…………

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 Sensory System
• Superficial sensation (peripheral sensation)
:pain, temp, light touch
• Cortical sensation:- Higher-order aspects of
sensation, or cortical sensation
• Deep sensation (joint movement, position &
vibration sensation)

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 Con‘t…
• peripheral sensation
 Pain and temperature sensation tests (spinothalamic)
- Pain sensation is tested with a sterilized pin.
-Temperature tested by using hot and cold test tubes .
 Position and vibration sensation tests (posterior column)
- Position sense is tested by asking the patient to close eyes, and the examiner moves
the patient‘s finger or toe up or down while the patient interprets the action.
- Vibratory test needs a tuning fork which is placed over bony prominences such as the
wrist, elbow, medial malleoli or patellae.

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 Con‘t…
• Cortical sensation : also referred to as central or
discriminativesensation.
1. Sterognosis -identify objects by touching while the eyes are closed
2. Graphstesia -identify numbers or letterswritten on the skin surface
with eyes closed
3. Two point differentiation -identify two closely approximated stimuli
as separate.
4. Point localization - Briefly touch a point on the patient‘s skin. Then
ask the patient to open both eyes and point to the place touched

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Sensation……

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 Sensation………

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 Sensation………..

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 Reflex
• Reflexes are usually graded on a 0 to 4+ scale:
 4+ Very brisk, hyperactive, with clonus(rhythmic oscillations between
flexion and extension)
 3+ Brisker than average; possibly but not necessarily indicative of disease
 2+ Average; normal
 1+ Somewhat diminished; low normal
 0 No response

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 Con‘t…
• The Common Reflexes are :
1. The Biceps Reflex (C5, C6).
2. The Triceps Reflex (C6, C7).
3. The Supinator or Brachio-radialis Reflex (C5, C6).
4. The Knee Reflex (L2, L3, L4).
5. The Ankle Reflex (primarily S1).
6. The Plantar Response (L5, S1).

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 Reflex …………

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 6. Signs of Meningeal irritation

• Neck stiffness
–Ask to flex his neck and touch his
sternum with his chin or mentum
results in pain at the back so pt an able
to do so.

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Kerning’s sign

• Kerning’s sign
– On the supine
position flex the hip
and knee and try to
extend the knee
passively results in
pain to the spinal
cord.

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Brudgneski’s sign

– On supine position flex the neck of the

patient passively to decrease to pain at the
back the patient flax his knee and hip.

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 Brudgneski’s sign…..

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