H&P Exam II
Spring 2014 OMS I – Exam 2
Respiratory Examination
Anatomy
 Location of findings: vertical axis (verterbral / ICS level) & circumfirential axis
(physical landmarks, midsternal, midclavicular, midaxillary)
 R – horizontal fissure ; R/L – oblique fissure (posterior = major lower lobes @
T3 ; anteroir chest – ICS 1-3 = upper lobe)
 Trachea splits @ sternal angle/T4
 Rib motions: Pump handle (1-3/1-6), Bucket Handle (4-10/6-10), Caliper
(11,12)
History
 Ask for chest DISCOMFORT
 Pain attributes: onset, location, characteristics, aggravating & remitting factors,
treament
 Dyspnea/SOB – categorize by what their ability is w. exertion
 Wheezing = musical respiratory sound
 Cough – dry vs sputum [ace inhibitors assoc. w. chronic cough]
 Hemoptysis – how much, background info  bloody nose, vomitting
Respiratory Examination
Examination
 Posterior chest (seated position) & Anterior Chest (supine position)
 Inspection: visual assessment of rate, rhythm, depth, effort of breathing, patient’s
color, chest shape (COPD—barrel chest), chest deformities (pectus carinatum,
pectus excavatum, scoliosis/kyphoscoliosis)
 Palpation/Percussion
 Percussion: put DIP joint of rigid middle finger on patient (compressing tissue), with
opposite hand strike other finger @ DIP 2-3x
 Tactile fremitus: the transmission of sound from the bronchial tree to the chest wall as
the patient speaks, assessed by the provider palpating w. ulnar side of hand & using
vibratory senstaion
 should be even & symmetric when saying “99” [decreased on L due to heart]
 Consolidation (pneumonia, tumor – within lung) = louder & palpable vibration
 Pleural effusion (outside of lung) = decreated fremitus & decreased vibration
 Don’t percuss over scapula
 Normal: resonant
 Decreased percussion on R for Liver (ICS 5 midclav, 7 midaxil, 9 ICS post) L for heart (ICS 3-5)
 Increased percussion on L for gastric bubble (6th rib superiorly, L costal margin inferiorly & anterior
axillarly line laterally)
 Hard/solid material = flat/dull & extra air = hyperresonant/tympanic
 Diaphragmatic excursion: measure diaphragm location with deep breathe in & out
holding each time
Respiratory Examination
 Auscultation:
 Listen in same place as percuss, 2pt anterorly, 3 pts posteriorly, 1 lateral [on each side]
 Patient breaths through mouth
 Vesicular – soft & low pitched [below 2nd ICS; alveoli air movemnt]
 Bronchial – louder & higher pitched [trachea; large airway passage]
 Bronchovasicular – intermediate intensity & pitch [2nd ICS; transitional area airway
movement]
 Adventitious sounds:
 Crackles: alveoli trouble opening, short high-pitched discontinuous breath sounds, described as explosive
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or popping
Wheezing: musical whistle, narrowed airway, high-pitched, mostly heard during expiration [found in
bronchospasm, asthma, COPD, bronchitis]
Rhonchi: harsh vibratory sound, gelatinous goo in airway, course low-pitched, continous sound of snoringlike quality [found in COPD, bronchitis, bronchospasm, inflammation or tumor/obstruction in larger
airways]
Pleural friction rubs: sound occurring when inflamed visceral & partietal pleura rub together producing a
harsh scratching or crinkling sound [found w. pleurisy, neoplasm, pulmonary infarction]
Stidor: high-pitched sound, often audible without aid of a stethescope that’s generally heard only in
inspiration [ALERT to obstruction or stenosis of large airway; medical emergency]
 Bronchophony: use sound for finding consolidation, “99”
 ↑ loudness: pneumonia & tumor
 Whispered pectoriloquey: whispered “99”, ↑ volume w. consolidation
 Egophony: patient says “eee”, if hear “aaa” = area of consolidation
 Stridor: noisy breathing during inhalation, can be heard grossly (ex: coup)
Respiratory Examination–Book Notes
 Inspection
 Respiratory distress: inability to obtain adequate oxygenation
 Signs: accessory muscle use, intercostal retractions, forward leaning & deep, exaggerated or
labored breathing
 Pursed-lip breathing – sign of COPD
 Tracheal deviation: toward side of atelectasis, away from side of tension
pneumothorax, pleural effusion
 Flail chest: paradoxical movement of the chest wall, retracting inward during
respiration instead of rising as a result of 3+ ribs being fractured at 2 locations each
 AP:lateral ratio: comparison of depth to width of chest wall, should be 1.5-2:1 ratio
 Auscultation
 Always symmetrically move down, do each side before proceeding downward
 Clinical application:
 Pneumonia: dull percussion, increased fremitus [thickened alveolar walls, bigger area
for transmission]
 Pneumothorax: hyperresonant, decreased fremitus [air blocks vibration pathway]
 Pleural effusion: dull percussion, decreased fremitus
Cardiovascular Examinaiton
Basic Physiology
 Juglar venous pulse/waveform
 a wave: small rise in right atrial pressure due to right atrial contraction
 c wave: small rise in small rise in right atrial pressure as the tricuspid valve
closes and bulges toward the right atrium
 v wave: rise in right atrial pressure during ventricular systole, when the
tricuspid valve is (supposedly) closed [atrial filling during ventricular
contraction]
 Large V wave  tricuspid regurgitation
 Absent a wave  lack or inefficiency of atrial contraction (a. fib, dilated RA)
Physical Diagnosis
 Normal heart sounds
S1: closure of AV valves “lub”
S2: closure of SL valves “dub”
Between S1&S2 = systole, diastole ~2x longer than systole
Physiologic splitting of S2: 2 distinct components of S2 (atrial before
pulmonary), best heard during inspiration (not expiration) @3LSB
 S3: in children & young adults
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Cardiovascular Examinaiton
Pathologic Heart Sounds
 Paradoxical split of S2: splitting of S2 heard during expiration, caused by delaying closure of aortic
valve
 Ex: LBBB, outflow obstruction, RV pacemaker, RV ectopic beats
 Fixed splitting of S2: splitting of S2 heard during inspiration AND expiration, hallmark sign of ASD
(assoc. w. midstystolic murmur)
 S3: Tensing of the chordae tendineae and/or sudden limitation of longitudinal ventricular expansion
during early rapid ventricular filling
 Timing: early (to mid) diastole
 Frequency: low (dull “thud”)
 Location: apex -5ICS midclav (L); lower LSB/xyphoid (R)
 Sounds like: Kentucky “ken-tuck-y”
 S4: atrium vigorously contracting against a stiffened ventricle (reduced ventricular compliance)
 Rarely normal [elderly?]
 Timing: late diastole (“presystole”)
 Frequency: low
 Location: apex -5ICS midclav (L); lower LSB/xyphoid (R)
 Sounds like: Tennessee “tenne-see”
 **a. fib has NO S4 sound**
 Quadruple rhythm: all 4 heart sounds (regular heart rate)
 Summation gallop: all 4 heart sounds (tachycardia)
Cardiovascular Examination
Dynamic Auscultation
 Definition: variety of physiological and pharmacological maneuvers, and observing their effects
on auscultatory findings
 Respiration: Inspiration increases venous return to the right side of the heart, increasing
volume and flow in the right side of the heart
 All right-sided pathological auscultatory findings increase in intensity (loudness) during
inspiration except the pulmonic ejection click!
 Postural Changes:
 Squatting to Standing: ↓ venous return/preload , ↓ vascular resistance
 Standing to Squatting: ↑ venous return/preload , ↑ vascular resistance
 Passive elevation of legs while supine: ↑ venous return
 Valsava Maneuver: forceful expiration against closed glottis, ↓ venous return/preload
 Muller Maneuver: opposite Valsava, hiccup motion, ↑ venous return/preload
 Premature Ventricular Contractions: ectopic heart beat that increases
filling (preload), stretch & force of contraction
 Isometric exercise: sustained handgrip for 20-30sec [avoid simultaneous
valsava maneuver] ↑ resistance, pressure, LV volume, HR & CO
 Vasoactive agents:
 Amyl nitrate: inhaled potent vasodilator, 1-30sec ↓ arterial pressure, 30-60sec ↑ HR
& CO
 Phenylephrine: vasoconstrictor, avoid use when CHF or HTN present
Cardiovascular Examination
Murmurs
 Systolic murmur grading system:
1/6: very faint, not usually heard within the first few seconds of listening
2/6: faint, but heard immediately
3/6: easily heard
4/6: easily heard & palpable thrill
5/6: very loud, still heard when only edge of stethoscope is on chest + palpable
thrill
 6/6: way loud, still heard when stethoscope is slightly removed from chest +
palpable thrill
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 Diastolic murmur grading system:
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1/4: very faint, not usually heard within the first few seconds of listening
2/4: faint but heard immediately
3/4: easily heard
4/4: very loud
Cardiovascular Examination
Murmurs
 Types:
 Systolic: begins after or with S1 & ends before S2
 Diastolic: begins after or with S2 & ends before next S1
 Continuous: begins in systole & continues w/out interruption through S2 into all or part of diastole
 Auscultation areas: Aortic (2 ICS RSB), Pulmonary (2 ICS LSB), Tricuspid (5 ICS LSB), Mitral (5
ICS Midclav)
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Sounds not always at anatomical locations, document where you heard it best & rely on timing & quality
 Valvular murmurs:
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Stenosis – from improper opening, causes murmur when valve should be open
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Regurgitation/insufficiency – from improper closing, causes murmur when valve should be closed
Systolic murmur
Diastolic murmur
Aortic
Stenosis
Regurgitation
Pulmonary
Stenosis
Regurgitation
Tricuspid
Regurgitation
Stenosis
Mitral
Regurgitation
Stenosis
Cardiovascular Examination
 Chronic Mitral Regurgitation
 Pansystolic murmur (no change in intensity)
 Best heard at cardiac apex, sometimes radiates to L axilla
 Louder with: isometric handgrip, sudden squatting, vasopressor admin.
 Acute Mitral Regurgitation
 Early systolic, decrescendo murmur
 Mitral Valve Prolapse
 Midsystolic click & late systolic murmur
 Patient positions:
 Supine (control): midsystolic click, late systolic murmur
 Standing: ↓venous return, preload,ventricular volume – click occurs
sooner & murmur lasts longer & often louder [also with Valsava]
 Squatting: click later, shorter murmur & usually softer
Cardiovascular Examination
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Tricuspid Regurgitation
 Pansystolic mumur
 Louder with inspiration (Carvallo’s sign)
 Severe TR triad (rarely seen): carvallo’s sign, pulsatile jugular distension & pulsatile liver
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Ventricular Septal Defect
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Pansystolic murmur
Does NOT get louder with inspiration
Best heard @ lower LSB
Often harsh in quality
Innocent Murmurs
 Don’t radiate, are due to ventricular ejection in “high-flow” states” [pregnancy, youth, fever, anemia, hyperthyroidism]
 Mid-systolic, crescendo-decrescendo murmur
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Aortic Stenosis
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Congenital (bicuspid aortic valve, hallmark = ejection click)
Acquired (RA, senile fibrocalcific)
Crescendo-decrescendo murmur
Radiates to carotids, best heard @ 2ICS RSB
Pulsus parvus & tardus [small, late upstroke] (lub heard, pause then feel weak upstroke in carotid pulse)
Harsh quality, loud
Peaks early = not severe, late might be
Louder after premature beats, murmur is due to pressure gradient
Louder with: squatting & amyl nitrite inhalation [increase gradient]
Softer with: standing, Valsava & isometric handgrip
Cardiovascular Examination
 Hypertrophic Cardiomyopathy (HCM)
 Dynamic (not fixed) obstruction may result from asymmetrical septal
hypertrophy (changed based on ventricular filling)
 Thickened VS causing turbulence & pulls on mitral leaflet, fuller ventricle = softer
murmur
 Dynamic auscultation = key
 Crescendo-decrescendo murmur
 Louder with ↓preload: Valsava, standing from squatting/supine, amyl nitrite
inhalation (nitrate decreases perphieral resistance, more blood can flow out)
 Softer with ↑ peripheral resistance (↓ pressure gradient): isometric handgrip
or squatting
 Pulmonary Stenosis
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Crescendo-decrescendo murmur
Increases with inspiration but doesn’t radiate to carotids
If ejection click present, it’s softer with inspiration
Best heard @ 2LSB
Cardiovascular Examination
 Aortic Insufficiency
 Early diastolic, decrescendo murmur
 High-pitched “blowing” sound, best heard @ 3L/R SB [w. leaning forward &
held exhale]
 Associated murmurs: systemic ejection murmur (↑flow over aortic
valve), Austin Flint murmur (diastolic rumble, best with bell @
apex)
 Associated findings (chronic severe AI)
 Doroziez sign: systolic murmur of femoral a. when compressed
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proximally but diastolic when compressed distally
Wide pulse pressure (diastolic < ½ systolic)
Quincke’s pulse (phasic blanching of nail bed)
Hill sign (popliteal systolic BP exceeds brachial systolic BP >60mmHg)
Corrigan pulse (palpable abrupt upstroke & rapid fall of arterial palsation)
Traube sign (pistole shot sound over femoral a.)
Mueller sign (pulsating uvula)
 Austin Flint Murmur
 “functional mitral stenosis” from AI jet forcing anterior mitral leaflet partially
closed & to flutter
Cardiovascular Examination
 Pulmonary Insufficiency
 Causes: pulmonary HTN w. normal pulmonary valve
(Graham Steell murmur), or valve deformity (congenital or
acquired)
 Graham Steell Murmur
 Early diastolic, decrescendo murmur
 Begins with loud P2 (of S2)
 High pitched, “blowing” sound that gets louder with inspiration
 Best heard between 2nd-4th ICS LSB
 PulmonicValve Deformity Murmur
 Mid-diastolic, crescendo-decrescendo murmur
 Begins after P2
 Low pitched, gets louder during inspiration
 Best heard with bell @ 3-4 ICS LSB
Cardiovascular Examination
 Mitral Stenosis
Almost always a sequela of rheumatic fever
Mid-diastolic murmur (holodiastolic if severe)
Low pitched rumble
Best heard with patient in the left lateral recumbent position, with the bell of
the stethoscope at the cardiac apex
 Associated findings:
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 Opening snap – high pitched, early diastolic
As severity worsens, opening snap goes closer to S2 (↑LA pressure,
getting closer to LV pressure) **boards**
 More calcification get decreased snap intensity
 Loud S1 (higher arterial pressure keeps valves farther apart, then they
slam shut)
 Diminished or absent S1 : long PR interval (more time to approximate,
decreases sound), LV dysfunction, significant AI or MR, HTN
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 MS-like murmurs: austin flint (has no opening snap), carey-coombs (acute RF,
valvulitis), LA myxoma, Tricuspid stenosis
Cardiovascular Examination
 Tricuspid Stenosis
 Same as MS, except: LOUDER with inspiration & best heard at lower
LSB
 Causes: rheumatic heart disease, carcinoid syndrome, anorectic diet
medications
 Continuous Murmurs
 Causes: PDA, cervical venous hum (supra/subclavicular), mammary
souffle (during pregnancy when breasts are enlarged), hepatic venous
hum, AV fistulas (hemodialisis pts), ruptured aneurysm of sinus of
Valsavla
 Must continue through S2
PDA
Cardiovascular Examination
 Signs of Cardiovascular Disease
 Beck’s triad: hyPOtension, JVD (or high central venous pressure) &
muffled/distant heart sounds Dx for peridcardial tamponade
 Exaggerated pulsus paradoxus: exaggeration (greater than 10 mm Hg during
quiet breathing) of the normal decline in systolic arterial pressure during
inspiration
 Fluid around heart prevents RV from expanding in all directions & VS deviates to L
 NOT specific for pericardial tamponade
 Kussmaul sign: Increase in jugular venous pressure (distention) during
inspiration (normally, JVP decreases during inspiration)
 Associated with constrictive pericarditis &others
 Pericardial friction rub: scratchy sound, hallmark of acute pericarditis
(classically triphasic but not differentiable w. tachycardia)
 Best heard w. held exhale
 Virchows triad: vascular injury, venous stasis & hypercoagulability
 Patients at risk for DVT
Cardiovascular Examination – Lab Component
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Eyes (ophthalmic exam) – silver & copper wiring (narrowing &thickening of the retinal ateriolar walls resulting in the central portion appearing as
thin, bright wires) & AV nicking (appearance of retinal venules being pinched off due to compression by overlying arterioles that are hardened with
atherosclerotic plaque)
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Jugular vein:
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Jugular pulsations: visible wave-like fluctuations of blood in the jugular veins that reflect RA functioning
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Jugular venous pressure: visible distention of the jugular vein as a reflection of RA pressure
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Patient lays supine & elevates head 45º &looks slightly L (you’re on R side), identify top of filling (if fills entirely to the angle of the mandible
elevate patient to 60º or higher until top of column is observed (or decreased angle until seen) ; height measured (cm) from sternal
angle & bisecting it with a straight edge laid parallel to the floor at the top of the filling column
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+5cm to bisected number if at 30º or less (sternal angle 5cm above RA) ; +10cm if at 45º or more
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Measurement more accurate using internal jugular
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High – increased RA pressure; Low – dehydration or anemia
Point of Maximal Impulse (PMI) : location of the apex of the heart, tip of the LV, taps against the anteroir chest wall during systole; about 5-6 ICS
midclavicular
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Often not visible
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Displaced inferiorly & L – hypertrophic cardiomyopathy (HTN, AS, R tension pneumothorax), displaced inferiorly & R - COPD
Abdomen:
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Auscultate aorta (halfway between xiphoid & umbilicus & slightly L), iliac arteries (halfway between umbilicus & inguinal canal) & femoral artery (over inguinal
canal)
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For palpation: start laterally & move hands in medially in 1cm increments starting 5cm apart, when pulsatile sides of aorta are encourtered, measure distance
between the 2 sides (normal ~2cm) -- lay hands flat, let hands sink in further with each breath
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Hepatojugular reflex: jugular veins will distend w. deep hepatic palpation
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Peripheral pulses
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Femoral a., popliteal a., posterior tibial a., dorsalis pedis a.
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Brachial a., radial a.
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Strength of pulse: 0 (no palpable pulse) 1 (faint or weak intensity) 2 (easily felt, moderate intensity) 3 (moderately increased intensity) 4 (high intensity, bounding
pulse)
Allen’s Test: compress both ulnar & radial arteries, have patient clench fist, open fist then release one vein ; then repeat with other vein
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Looking for palmar arch integretry for ABG
Abdominal Examination
 Techniques:
stand on R side
must auscultate before palpating/percussing
Patient supine, arms at sides not by head w. emptied bladder
If think something is wrong do a more efficient & gentle exam
Cover lap w. sheet before moving them into supine position (always
assist position change)
 Always inform them what you’re doing
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 Anatomy:
 Boundaries: diaphragm, costal margin, xiphoid, ileum, pubis sympysis
 Abdominal wall composed of 5 pairs of muscles (transverse, internal
oblique, external oblique, rectus & pyramidalis)
Abdominal Examination
Inspection
 Contour: scaphoid (markedly caved, hollow), flat, rounded, distended (state of
inflation), protuberant (thrusting forward in a more solid fashion)
 Symmetry, any masses?, umbilicus
 Skin: lesions, scars (ask for description), striae (normal or worrisome – color) ,
dilated veins, rashes, ecchymoses
 Caput medusa: dilated veins around umbilicus – portal HTN, cirrhosis
 Violaceous striae– Cushing syndrome
 Ecchymoses around umbilicus – Collin’s sign (acute pancreatitis)
 Peristalsis (may indicate bowel obstruction), pulsations, whole patient (are they
moving, in discomfort?, facial expressions)
 Have patient do a sit up-like motion - increases intra-abdominal pressure and may reveal
hernias or rectus diathesis (the separation of rectus abdominis muscles with central linear
bulging)
 4 quadrants (RUQ, LUQ, RLQ, LLQ) & 9 regions (epigastric, umbilical, L/R
hypochondriac, L/R iliac, L/R lumbar/flank, hypogastric/suprapubic)
Abdominal Examination
Auscultation
 Assess all 4 quadrants
 Bowel sounds: created as a result of peristalsis, producing intermittent clicks &
gurgles
 Present, frequency, quality
 Normoactive – 5-34sounds/min
 Hypoactive - not quickly appreciated, auscultation for up to two minutes (Found with ileus,
paralysis of the bowel, and peritonitis)
 Absent - could indicate ischemic or infarcted bowel, where the bowel has died
 Hyperactive - >34/min, Irritation, infection, or inflammation of the bowel; High-pitched, tinkling
sounds reminiscent of a fountain are found with bowel obstruction
 Use diaphragm on bare skin
 Borborygmi: normal (familiar audible rumbling, gurgling sound of air passage through
the fluids of the large bowel)
 Bruits: use bell, check aorta & renal arteries (L2), common illiacs (@bifurcation L4),
femoral arteries
 Liver venous hum: continuous low-grade humming associated with increased
circulation between portal & venous vessels [cirrhosis]
 Friction rub: grating or rasping sounds, indicating inflammation of peritoneum
(peritonitis) or tumor, infection, abscess or splenic infarct
Abdominal Examination
Percussion
 L hand flat against skin w. pressure, R middle fingers hits L middle finger DIP for 2-3
sharp taps
 Assesses: distribution of gas, liver & spleen size, & any masses or anything solid or fluidfilled
 Percuss all 4 quadrants, noting tympany or dullness (enlarged organs or masses)
 Should have dullness on R – Iiver, L – spleen & tympany on L – gastric bubble
 Sound: Air creates drum-like resonance, whereas liquids and solids are dull on percussion
 Resonance is increased in areas where intestinal gas has collected, commonly the gastric air
bubble and over the transverse and descending colon
 Solid organs, masses, stool-filled bowel, and intra-abdominal fluid collections percuss with
dullness
 Liver span: 5ICS midclav. and move downward until reach dullness, then umbilicus &
move upward until dullness reached – measure distance between dullness points
 Normal: 6-12cm
 <6cm indicates cirrhosis, >12cm indicates hepatomegaly, acute hepatitis
Abdominal Examination
Palpation
 Light Palpation FIRST
 Assesses: abdominal tenderness, muscle resistance, superficial organs &
masses, reassures & relaxes patient
 Placing one hand flatly against the abdomen and using the pads of the fingers,
moving in circular motion to feel the skin and subcutaneous tissue for
tenderness or masses
 Watch the patient’s face for grimacing or flinching, signs of pain or discomfort, during
the examination and adjust the technique appropriately
 Decrease voluntary guarding by: techniques to relax patient (bringing knees up), feel
for exhalation muscle relaxation, Ask the patient to mouth breath with jaw dropped
open
 Deep Palpation SECOND
 Top hand applies pressure into the lower one in a rolling motion, kneading the hand
deeply into the abdomen with deliberate screening of each quadrant
 If can’t, document “can’t palpate limited by body habitus”
Abdominal Examination
Palpation
 Liver
 One hand approach: Using one hand, begin palpation in the RLQ, with the
hand placed perpendicular to the MCL
 Roll the hand from the ulnar to the radial aspect, depressing the abdomen
approximately 5 to 10 cm
 After each roll, slide the hand 1 cm cephalad, staying in the MCL, repeating the series
until encountering the liver border or costal margin
 May be palpable just below the costal margin
 Two hand approach: L hand behind patient, parallel to and supporting the
right 11th and 12th rib & pushing anteriorly, R hand on the patient’s right
abdomen lateral to the rectus muscle (fingertips well below lower border of
liver dullness on percussion)
 Feel border upon inspiration
 Hooking technique: Place both hands, side by side, on the right abdomen
below the border of liver dullness, press in with your fingers and up to the
costal margin & instruct patient to take a deep breath
Abdominal Examination
Spleen
 Percussion: percuss the left lower anterior chest wall from the border of cardiac
dullness (at 6th rib anterior axillary line) down to the costal margin [if tympany present,
splenomegaly is unlikely]
 Percussion Sign: Percuss the most inferior interspace on the left anterior axillary line
(Castell’s Point). This is usually tympanic. Ask pt to breath deeply.
 Remains tympanic = negative, splenomegaly less likely
 Switches to dullness = positive, splenomegaly more likely
 Palpation: Line of approach should begin at the umbilicus and move diagonally across the
LUQ to the inferior costal margin
 Placing the L hand behind the L lower ribs and lifting may help to displace the spleen toward the
palpating R hand
 Not normally palpable
 Caution: overly aggressive palpation can cause damage to an enlarged spleen
Kidney
 Kidney catch: by placing one hand behind the costovertebral angle with the other hand
just below the anterior costal margin
 Ask the patient to take a deep breath, with the intent of the diaphragm displacing the
kidney caudad
 At the end of deep inspiration, apply pressure between the hands in an attempt to catch the
kidney & estimate size
Abdominal Examination
Pain
 Before beginning, ask the patient to locate where the pain is most
intense
 Begin palpation with the quadrant diagonally from the area
identified, saving that quadrant for last
 Perform light palpation first, then deep palpation
 Apprehension, the fear that the provider’s palpation of the abdomen
will cause pain, may be encountered
 If the abdomen is profoundly tender, such as with peritonitis, the
patient may exhibit guarding or involuntary movements to stop the
examiner from pressing on the tender area
Abdominal Examination
Clinical Scenarios
 Acute abdomen: refers to a sudden onset of pain, typically within the
prior 24 hours, and is a term often used synonymously with peritonitis
and a ruptured viscous such as appendicitis, gallbladder, ulcer, or
diverticulum
 Rigidity: resulting from exhibition of guarding and severe irritation of
the peritoneum, abdominal muscles are boardlike & may feel hot to the
touch  fetal position can held relax muscles
 Rebound tenderness: to check for irritation of peritoneum, advise the
patient that you must touch their abdomen and that, when you do, you
want him/her to tell you which causes more pain (while pushing down
or lifting off quickly)
 Pain greater with lifting is positive rebound tenderness, suggests
peritonitis
Abdominal Examination
Appendicitis
 Rovsing’s sign: slowly press but firmly down on the LLQ, if RLQ pain worsens =
suspected appendicitis
 Psoas sign: patient flexes hip against resistance, causes iliopsoas muscle to
contract & moves inflamed sheath causing pain if the appendix is in retrocecal
position
 alternative would be to have the patient in the supine position, lying close to the edge
of the examination table, then lowering the leg slowly off the table, stretching the
psoas muscle with passive hip extension, which would again cause pain
 Obturator sign: acute appendititis is suspected when pain is illicited when
patient’s hip & leg are flexed at 90º & internal rotation of hip is performed
[appendix is located at the muscle]
Cholecystitis
 Murphy’s sign: pain in RUQ, depress the abdomen just below the R CM & have
pt take deep breath displacing the gallbladder inferiorly into the provider’s
stationary hand
 Sudden cessation of breath or increased pain suggests cholecystitis
Abdominal Examination
Ascites
 Patient with cirrhosis or heart failure, the abdomen should be assessed for ascites (accumulation of
fluid in the abdominal cavity)
 Fluid Wave: patient’s ulnar aspect of a hand on the midline of the abdomen and depresses 2 to 3 cm,
place one hand laterally on each side of the abdomen, then tap sharply on one side while holding
the other hand firmly on the opposite side
 If ascites is present, the fluid wave moves under the hand in midline and the impulse is felt in your opposite hand
(with adipose will stop midline)
 Shifting Dullness: working from the umbilicus, percuss laterally toward the flanks, moving 2 to 3
cm with each step
 the umbilical area will be resonant with air accumulation superiorly while dullness will be encountered when the
upper level of pooled fluid is reached (mark dullness level)
 Patient now in lateral decubitis (recumbent), Repeat percussion, this time starting at the patient’s superior side and
working toward the table (mark dullness level)
 If free fluid is encountered, the dullness will shift from the first mark to the second—shifting
Hydronephrosis/Pyelonephritis
 Lloyd’s punch: preformed to asses costovertebral angle (CVA)tenderness
 Palpate each CVA for tenderness, first with light and then with deep pressure
 Done too aggressively can illicit pain
 If this is tolerated, one hand is then placed over the CVA and gently thumped with the other fist, using
the hypothenar eminence
 Distention of the kidney capsule or the presence of inflammation will cause the patient to experience
pain and often jump when struck
Ob/Gyn Examination
 Pregnancies
 Gravity: # x pregnant
 Parody: # babies delivered
 # full term, #preterm, #abortions/miscarriages, #live babies
 Nullet (nullparis) : G0 P0
 Multip (multiparis) : multiple pregnancies
 LMP – last menstraul period, when (if long time  potentially pregnancy, premenopausal)
 PAP ≠ Gyne exam
 Annual gynecological exam needed
 No requirement for annual PAP
 PAPS are for looking for cervical dysplasia/precancer screening
 Mammograms
 Categories: 1) unremarkable 2) need discussion, not worrisome 3) needs further eval 4&5) suspicious,
needs biopsy 0) need further testing; more images – its incomplete
 New recommondation: 50y/o every other year ending at 75y/o
 Most insurances cover starting @40y/o & every year
 Hx: if 1st degree should start 10yrs younger than when mother got breast cancer
 BrCA gene testing – 3+ women in family &/or premenopausal
 Gail risk factor – calculating lifetime risk of getting breast cancer
 New law: have dense breast tissue must get letter from radiology stating they have it (if have
heterogenous dense/extremely dense offer MRI)
 Self Breast Exams (SBE) – shouldn’t do it b/c could make her feel guilty if she didn’t find it herself, but
best done right after a period
Ob/Gyn Examination
 HPV vaccine – HPV is a sexually transmitted virus that increases risk of cervical cancer ,
ages 9-26y/o should get it
HPI
 Period description
 Normal: closest 19days from start to start & heaviest can be once/hour for a short period of
time
 Bladder issues
 Intimacy
 Menopausal + intercourse discomfort : atrophy of tissue, pelvic prolapse, vulvar cancer,
contact dermatitis, screen for abuse
 ROS:
 Migraines: perimenopausal, menstral - if w. each cycle can control with birth control but
cannot use estrogen due to increased risk of stroke if have visual changes w. oras, must use
progesterone only
 Blood clots: risk for DVT, no estrogen containing birth control
 CDC recommends annual HIV testing
 DEXA – bone density test for osteoporosis screening
 Start @ 65y/o & every 2 years after
 Also for 2” height loss & previous testing shows ostoporosis, long-term steroid use, breast
cancer & on medications, abnormal heel screen
Ob/Gyn Examination
FHx
 Breast cancer (1st & 2nd degree relatives on same ide)
 Gyne cancer (cervix, uterus, ovaries, vulvar)
 No increased risk w. cervical cancer
 CV disease, thromosis (factor V - >2 persons)
 Most common Hx = cervical dysplasia
 Cervical cancer risk factors: HPV, smoking, early age of intercourse, multiple partners
PE
 If on estrogen BC. Need normal BP
 Height stated & actual height today  if ½” less  DEXA
 BMI is obese  no estrogen containing BC (↑ DVT risk)
 Weight




low (amenorrhea, anovulation)
Rapid gain/loss (thyroid problems)
CV risk
Over time (polycystic ovary disorder, cancer, stress, metabolic issues)
 Breasts – symmetric, no discrete masses, discharge, retractions, dimpling (move hands from hips to
head)
 Move hands in circular motion, look at skin (Paget’s disease – aerolar color change)
 Extremities – no sign of abuse (always point out bruises & ask about them, document findings)
Ob/Gyn Examination
Pelvic Exam
 Always tell them what you’re doing & what to expect
 Do not say something like “looks good”, use normal or unremarkable
 Genitalia – adenopathy, hernia, lesions, hair distribution (↑ w. ↑ testosterone, ↓ w. menopause),
atrophy, inflammation
 Bladder – prolapse (pregnancies, nurses, coughing, heavy lifting)
 Have them bear down & see if bulges occur & on which side of the finger if they do
 Speculum – metal ones should be warmed, touch speculum to leg to check if temper is O.K. first
 Vagina – discharge (white & clumpy=yeast, yellow & fowl smelling=BV, retained tampon)
 Cervix – lesion, friable (raw, irritated tissue that easily bleeds)sign of abuse, pregnancy, cervisits
(chlamydia)
 Cervical motion tenderness: gently move cervix & if she moves = sign of infection
 Uterus – normal size (6-8cm, upside-down pear), state in “weeks size” as if/compared to pregnancy
[enlarged = sign of pregnancy]
 Ovaries – difficult to feel (feeling for enlargement; especially after postmenopause)
 Rectum – vaginal & rectal exam to feel for ovaries, looking for rectal mass, hemorrhoids, rectocele,
sphincter tone (larger baby deliveries may tear sphincter causing decreased tone)
 “Every woman is pregnant until proven otherwise, every pregnancy is ectopic until
proven otherwise”
 There are new ways to dissolve early ectopic pregnancies
Ob/Gyn Examination
PAP
 Looking for cervical dysplasia
 None for historectomy (cervix removed)
 Start @ 21y/o & be done less frequently, end @ 65y/o (less common as age)
 Every 3-5yrs w. HPV testing & negative
 Low risk positive HPV every 3 yrs , high risk HPB depends on patient
 HPV cotesting done on cervix- culture, run on pap collection
 Cervical culture for Chlamydia (up to 25 y/o)
 Done on pap collection or urine sample
 Required if on birth control
 Lab studies:
 Vit D (routinely, osteoporosis screening)
 Lipids (routinely, needs to be normal for estrogen BC)
 STD profile (HIV, need pt approval for release)
 EA/endometrial aspirate (biopsy of uterus lining, checking for uterine cancer, hyperplasia,
fertility eval)
 Wet prep: trichomonas, yeast, BV
 Pessary: goes into vagina & holds things up
 Can erode through
 Needs to be removed periodically & cleaned