Case 1 - For Candidate
Mrs. Felty has been having
increasing problems moving the
joints in her hands and wrists.
1) Take a psychosocial history.
2) Examine her hands and wrists.
Case 1 - For Assessor/Patient
Question for Candidate
Mrs. Felty has been having increasing pain and stiffness in her hands and wrists.
1) Take a psychosocial history.
2) Examine her hands and wrists.
History
Name: Mrs. Annette Felty
Psychosocial History
Age: 50
 Smoking: nil
Presenting Complaint
 Alcohol: 1-2 glasses on wine on the
 6 weeks ago - first noticed some
weekend
swelling in BOTH your wrists and the
 Recreational Drugs: nil
MCP joint of your thumb.
 Occupation: Suit Tailor - working
 Wrists also feel stiff and are difficult
frequently with very small needles,
to move until you 'warm them up'
buttons etc. The stiffness is a real
which usually takes 45-60 mins.
concern as you have just taken out a
 In the last month you have also been
loan to start your own tailoring
having a dull aching pain in both your
business.
wrists (Was 1/10 before but recently
 Husband runs his own plumbing
3 or 4/10 severity).
business - works long hours.
 Pain, stiffness and swelling are all
 Home: Live with husband only. Two
worst in the morning.
daughters (20 and 25 y.o) both
 Pain improves slightly with Panadol
moved out and live far away.
and after moving the joints for a
 Love to knit and sew at home - joint
morning.
problems have stopped you recently.
 No joint locking/giving way or other
systemic symptoms.
Main Concern:
Past Medical History
 Your main concern is that you may
 Childhood asthma
have rheumatoid arthritis like your
 One previous hospital admission for a
grandmother and scared that you will
fractured radius during early 20s.
have deformed hands like her and it
Medications and Allergies
will "ruin your life".
 Nil prescription medications.
 Allergic to eggs.
Family History
 Grandmother with rheumatoid
arthritis. Poorly controlled, severely
deformed hands and wrists at end of
her life.
 Your mother and your children at still
all alive and well.
 Father died last year (age 78) from
stroke.
Case 1 - For Assessor/Patient
Question for Candidate
Mrs. Felty has been having increasing pain and stiffness in her hands and wrists.
1) Take a full psychosocial history.
2) Examine her hands and wrists.
History
Name: Mrs. Annette Felty
Psychosocial History
Age: 50
 Smoking: nil
Presenting Complaint
 Alcohol: 1-2 glasses on wine on the
 6 weeks ago - first noticed some
weekend
swelling in BOTH your wrists and the
 Recreational Drugs: nil
MCP joint of your thumb.
 Occupation: Suit Tailor - working
 Wrists also feel stiff and are difficult
frequently with very small needles,
to move until you 'warm them up'
buttons etc. The stiffness is a real
which usually takes 45-60 mins.
concern as you have just taken out a
 In the last month you have also been
loan to start your own tailoring
having a dull aching pain in both your
business.
wrists (Was 1/10 before but recently
 Husband runs his own plumbing
3 or 4/10 severity).
business - works long hours.
 Functional status: unable to sew and
 Home: Live with husband only. Two
knit anymore
daughters (20 and 25 y.o) both
 Pain, stiffness and swelling are all
moved out and live far away.
worst in the morning.
 Love to knit and sew at home - joint
 Pain improves slightly with Panadol
problems have stopped you recently.
and after moving the joints for a
morning.
Main Concern:
 No joint locking/giving way or other
 Your main concern is that you may
systemic symptoms.
have rheumatoid arthritis like your
Past Medical History
grandmother and scared that you will
 Childhood asthma
have deformed hands like her and it
will "ruin your life".
 One previous hospital admission for a
fractured radius during early 20s.
Medications and Allergies
 Nil prescription medications.
 Allergic to eggs.
Family History
 Grandmother with rheumatoid
arthritis. Poorly controlled, severely
deformed hands and wrists at end of
her life.
 Your mother and your children at still
all alive and well.
 Father died last year (age 78) from
stroke.
Examination of the Hands and Wrists
o
o
Position/Exposure
 Make sure that any jewellery or watches are removed.
 Patient should be exposed beyond the elbows and forearms on a pillow.
Inspection
 Look on the dorsal surface and then palmar surface for:
 MCP positioning and alignment (knuckles)
 Muscle wasting
o Easily seen at hypothenar and thenar eminences - can ask patient to turn hands
onto palmar side and extend fingers.
 Swellings and deformities
 Scars (e.g. carpal tunnel release on wrist)
 Skin colour changes and nail abnormalities
 Asymmetry testing:
 Praying position - normal is ~90°
 Inverted pray position - normal is ~90°
 Look at the dorsum of the patients arms at the elbow
 Fleshy nodules may be present in RA
 Psoriatic lesions
o
Palpation and Movement
 Wrist
 Palpate bimanually
 Flex and extend passively
 Look for radial/ulnar deviation.
 MCPs
 Squeeze MCP joints from the side
 Palpate each joint individually for tenderness etc
 Assess passive movements of flexion and extension as you go
 PIPs/DIPs
 Palpate and move IP joints passively
o
Functional Assessment

Grip Strength - get patient to squeeze two of your fingers in each hand
 Pincer Grip - thumb and index finger - try to force apart
 Opposition Strength - thumb and little finger - try to force apart
 Practical Test - undo a button/write with a pen
Viva Questions:


Can you tell me the normal range of movements of each hand and wrist joint?
o Wrists
 Flexion/Extension - 75°; Radial/Ulnar Deviation - 20°
o MCPs
 Flexion - 90°; Extension - 30°; Adduction/Abduction - 25°
o PIPs - Flexion - 120°; DIPs - Flexion - 90°
Do you think Mrs. Felty's history is more consistent with rheumatoid arthritis or osteoarthritis? What clinical
features would you expect to find in the hands of someone with RA vs OA?
RA
OA
 Soft, boggy swellings of the wrists, MCPs and
 Hard, bony swelling of the PIPs, DIPs and 1st
PIPs, with sparing of DIPs
CMC
 Boutonniere's and Swan Neck Deformity
 Heberden's nodes (DIP)
 Z deformity of the thumb
 Bouchard's nodes (PIP)
 MCP ulnar deviation and palmar subluxation
 Osteophytes
Case 2 - For Candidate
DJ is applying for a job at Coles but must go
through a check-up first.
1) Perform a checkup of DJ
2) Examine the oral cavity
3) Examine the lymph nodes of his head and
neck, and state the appropriate landmarks.
Case 2 - For Patient
Question for Candidate
DJ is applying for a job at coles but must go through a check-up first.
1) Perform a checkup of DJ
2) Examine the lymph nodes of his head and neck
History
Name: Mr DJ Ly
Age: 22
Psychosocial History
 Smoking: nil
 Alcohol: 1-2 glasses of wine 3 nights a
NOTE TO PATIENT: don’t tell student about depression or
week and sometimes you have a bit
suicide attempt unless specifically asked about it.
more. If specifically asked what a “bit
However please repeat how desperately you need this
more” means, say 2 bottles of wine but
job.
that’s only happened twice.
 Been drinking since you started dating
Main Concern:
your girlfriend 4 years ago.
 You’re out of money and your girlfriend is about to
 Recreational Drugs: nil
leave you for a guy named Vu. You REALLY need
 Occupation: Unemployed so you really
this job. You’ve been depressed and have tried
need this job!
taking your life twice in the past by trying to drink
 Home: Lives with girlfriend who is a plain
too much alcohol.
clothes model and looks down on you for
 Keep emphasizing how desperately you need this
having no job
job.
 Sexual History: nil - never had sex.
Presenting Complaint
 Travel History: nil
 You have no presenting complaint
 Feels unsupported emotionally and
 If asked “Why have you come to see me?”, explain
financially
that you need to get this checkout chick job at
 Diet: normal
Coles, so you have to get a general check up done. Depression History (only say if specifically
 If asked open question about what’s wrong, just
asked)
say you feel fully healthy (e.g. “Have you noticed
 Only admit to feeling depressed, if
any changes to your health recently?” “Nope, I feel
specifically asked if you’ve been feeling
fine”)
“sad or depressed”
 Student should begin a systems review and start
 For the last 4 years, you’ve been feeling
asking you associated symptoms. Deny all of them,
sad, feeling guilty, you’ve lost interest in
except trouble concentrating if specifically asked.
your hobbies and have trouble
Just say a little bit of trouble concentrating but
concentrating
you’ve had that for ages.
Suicide History (only say if specifically asked)
Past Medical History
 You believe life isn’t worth going on
 Had the flu a week ago but you think you’re all
with/world would be better off without
better now
you
 No surgical history
 Have thought about taking your own life
 Only when specifically asked if you’ve been to
 You would do it by drinking yourself to
hospital before, say you have twice for drinking a
death.
little bit too much.
 You have access to a lot of wine at home
Medications and Allergies
 Have tried taking your own life twice by
 Nil prescription medications.
drinking yourself to death with alcohol
 Taking multivitamins for general health.
and that’s why you’ve been to hospital
 Allergic to penicillin; causes generalized rash
twice
Family History
 If asked how can they can help you, say:
 Mum has Hypertension, Diabetes type 1 and
by passing you on this checkup
Hypercholesterolaemia.
Case 2 - For Assessor
Question for Candidate
DJ is applying for a job at coles but must go through a check-up first.
1) Perform a checkup of DJ
2) Examine the lymph nodes of his head and neck
History
Name: Mr DJ Ly
Age: 22

NOTE TO PATIENT: don’t tell student about
depression or suicide attempt unless specifically
asked about it. However please repeat how
desperately you need this job.
INTRODUCTORY QUESTIONS
 Introduction
 Informed consent
 Ask if patient is comfortable (sitting, want
to close curtains, etc.)
Main Concern:
 Pt out of money and girlfriend is about to
leave him for a guy named Vu. Pt REALLY
needs this job. Has been depressed and
has tried taking his life twice in the past
by trying to drink too much alcohol.
Presenting Complaint
 Asks last time patient felt fully well
 Performs full system Review


Neuro
o Headache or pain anywhere?
o Changes in vision or hearing?
o Changes in taste or smell?
o Weakness, numbness or clumsiness?
o Blackouts, fits, faints dizziness?
o Vomiting or drowsy or nausea?
o Memory or concentration?
o Bladder or bowel problems?
Cardiac
o Chest pain or discomfort?
o Pain in legs or anywhere else?
o Ever aware of your own heart
thumping?
o Cold sweats?
o Swelling in ankles?
o Trouble breathing?


Respiratory
o Trouble breathing?
o Wheeze or cough?
o Chest discomfort or any pain
elsewhere?
o Fever, chills, sore muscles or joints?
o Runny or blocked nose?
o Trouble speaking or swallowing?
Gastro
o Any weight loss or changes to eating
habits?
o Vomiting, fever, fatigue?
o Trouble swallowing or reflux?
o Pain or bloating?
o Changes to bowel habits?
o Changes to urinary habits?
o Discharges or itchiness from genitals?
Musculoskeletal
o Any swelling or pain?
o Any joint locking up or giving way
suddenly?
o Any trouble moving?
Past Medical History
 Had the flu a week ago. Now recovered.
 Must specifically ask about past surgeries
or procedures: No surgical history
 Specifically ask if been to hospital before.
Pt says twice for drinking a little bit too
much.
 Points for asking how much pt drank
Medications and Allergies
 Nil prescription medications.
 Taking multivitamins for general health
(must remember to ask about over-thecounter medications and why they are
taking it)
 Allergic to penicillin – generalized rash.
MUST ask what type of allergic reaction
they get!
Family History
 Mum has Hypertension, Diabetes type 1
and Hypercholesterolaemia.
Psychosocial History
Suicide History (don’t give student hints to do
 Does some sort of a disclaimer e.g. “These this. Only tell them to do this, if they want to
are just some questions we ask everyone start the examination)
to get a better picture of what’s going on”
 Do you ever feel sad or depressed?
 Smoking: nil
 Do you ever feel like life isn’t worth going
on with?
 Alcohol: 1-2 glasses of wine 3 nights a
week and sometimes has a bit more.
 Have you ever thought about taking your
own life?
 Must specifically ask what a “bit more”

How would you take your own life?
means: pt says 2 bottles of wine but that’s
only happened twice.
 Do you have the resources/means to do
 Been drinking since dating girlfriend 4
that?
years ago.
 Have you ever attempted to take your
 Recreational Drugs: nil
life?
 Occupation: Unemployed
 Is there anything I can do for you at the
moment?
 Home: Lives with girlfriend who is a plain
clothes model and looks down on DJ for
having no job
 Sexual History: nil - never had sex.
 Travel History: nil
 Must ask about feeling supported
emotional AND THEN ask about feeling
supported financially: Feels unsupported
emotionally and financially
 Diet: normal
Depression History (don’t give student hints to
do this. Only tell them to do this, if they want to
start the examination)
 Have you been feeling sad or even
depressed?
 How long for? (more than 2 weeks is
suspicious)
 Do you find you wake very early in the
morning?
 Has your appetite been poor recently?
 Have you lost weight recently?
 How do you feel about the future?
 Have you had trouble concentrating
on things?
 Have you had guilty thoughts?
 Have you lost interest in things you
usually enjoy?
Question for Candidate
1. How do the head and neck lymph nodes drain? Which drains most of the region? Detail its
drainage. (Bloody $5 to the kid who can smash all this out without any help.)
2. What forms Waldeyer’s Ring?
3. Name the muscles that form the Palatine Arches? What are they innervated by?
Answers
1. Occipital and post-auricular drain to superficial cervical then deep cervical. Everything else (i.e.
pre-auricular, submandibular and submental) drain directly into deep cervical. All the lymph
nodes eventually drain into the deep cervical lymph nodes.
These nodes then drain into the left and right jugular trunks. The right jugular trunk then joins
the thoracic duct. The thoracic duct then has the left subclavian trunk also join it; the left
bronchiomediastinal trunk sometimes also joins it.
The right jugular trunk then joins the right lymphatic duct. The right subclavian trunk also then
joins the right lymphatic duct; the right bronchiomediastinal may also join.
The right lymphatic duct and thoracic duct both empty in the junction of their respective
internal jugular vein and subclavian veins, forming the brachiocephalic vein. Left and right
brachiocephalic veins join to form the superior vena cava and empties into the right atrium.
2. Pharangeal tonsils, Palantine tonsils, Tubal tonsils and Lingual tonsils
3. Anterior one is known as the palatoglossal arch, which is formed by the palatoglossus. The
posterior one is known as the palatopharyngeal arch and is formed by the Palatopharyngeus.
Both muscles are innervated by the Vagus Nerve.
Between these two arches is the palatine tonsil.
Examination of the Oral cavity and Cervical Lymph Nodes
Throat Examination

General Inspection
o Observe the:
 Lips, buccal mucosa, gums, palate and teeth - note any signs of
inflammation such as erythema or swelling.
 Inspect the tongue in mouth and then poked out and then touched to roof
of mouth (to inspect floor or tongue).
o Ask patient to say "Ahh" and inspect oropharynx and uvula.
 Use a tongue depressor, if necessary, to obtain a better view of the pharynx.
It is important that the depressor does not cause the patient to gag.
o Inspect tonsils: size, shape, colour, discharge.

Palpation
o Full oral cavity examination should include palpation of the tongue for lumps
(wearing gloves) as well as palpation of the salivary glands and cervical lymph nodes.
The tonsils are part of the lymphatic system and should be examined when conducting
a systematic examination of the lymphatic system. The examination of the oral cavity
includes more than looking at the tonsils but the focus here is on examining the tonsils.
Lymph Node Examination

Position and Exposure
o Patient should be sitting upright, both sides of neck are examined at same time.
o Neck must be fully exposed including supraclavicular fossa - ideally shirts should be
removed (bra for women can be left on but straps should be moved).

General Inspection
o Observe for:
 Swelling
 Asymmetry
 Scars
o Ask about any tenderness present before proceeding with palpation.

Palpation (see images below)
o Use alcohol rub and warm hands.
o A total of 8 lymph node regions should be palpated here:
 Submental
 Posterior to the inferior edge of the mental protuberance of the mandible
and between the anterior bellies of both digastric muscle



Submandibular
 Inferior to the body of the mandible
Pre-auricular
 Just anterior to the tragus
Post-auricular (mastoid)
 on the mastoid insertion of the Sternocleidomastoid muscle and inferior to
the Auricularis posterior.
Post-auricular node




Occipital
 Near the insertion of the trapezius to the skull
 Resting on the insertion of the Semispinalis capitis (if you want to sound
like a precise pro)
Posterior Cervical triangle
 Formed by clavicle, trapezius (ant.) and sternocleidomastoid (post.)
 Palpate down to scalene node behind scalene insertion at clavicle.
Anterior Cervical triangle (deep & superficial Cervical Lymph nodes)
 Formed by mandible, SCM (ant.) and the midline.
 Palpation here is for both superficial and deep anterior cervical chain nodes
- deep nodes difficult to feel even when enlarged as they are deep to SCM,
closely located to and around the neurovascular bundles.
Supraclavicular fossae
 Ask patient to shrug their shoulders and feel behind the clavicle.
Case 3 - For Candidate
Mr. Clark is concerned about the recent
changes in his urinary habits.
1) Take a full medical history and address
his concerns.
2) Perform an abdominal examination.
Case 3 - For Patient/Assessor
Question for Candidate
Mr. Clark is concerned about the recent changes in his urinary habits.
1) Take a full medical history and address his concerns.
2) Perform an abdominal examination.
History
Name: Mr. Maxwell Clark
Age: 32
Occupation: Taxi Driver
Medications and Allergies
 Regular medication for diabetes and but
 No allergies or non-prescription drugs.
Presenting Complaint
 Burning sensation when peeing - began 3
days ago.
 Burning has become more and more painful
since then.
 Since yesterday, you have also been
experiencing some pain "low down on my
bell" (suprapubic).
 When prompted you have also been
experiencing:
o That you need to pull over in your
taxi while working to pee more
often (frequency).
o Been getting up a night more often
to pee, never used to.
o You don't get any warning, and just
suddenly feel like you need to go.
Awkward when you have a
customer in your taxi.
 No fever, renal angle pain, or other urethral
discharge.
Travel History
 Nil
Sexual history
 Married and committed to monogamous
relationship. No engagement with sex
workers, IVDU etc. Confident that wife is
clean as a whistle too.
 Don't use contraception or condoms - wife is
pregnant.
Family History
 Brother with prostate cancer
 Father died of IHD in his 50s
 Mother died of ovarian cancer.
Past Medical History
 Previously had 2 UTIs - only needed
antibiotics once. The other time, you just
drank a lot of water and it went away.
 Type II Diabetes Mellitus
 Both are managed well by regular
medication that you can’t remember
Psychosocial History
 Live with wife in a small one-bedroom
apartment on third floor of a building.
 Alcohol - 2 beers a day usually, sometimes a
few more on weekends (since 18 if pushed).
 Smoked 5 cigarettes a day in youth (from 18
to 25 if pushed).
 Nil recreational drugs.
 Taxi driver - work 10 shifts a week, long
periods of time with no sleep and no break
(not even to go to the toilet, "simply gotta
tough it out").
 No children, but wife is currently pregnant still in first trimester.
Main Concern
 Your main concern is that your illness will
prevent you from working the long hours
you have been currently.
 This concerns you because you are already
"on the ropes" financially and can't afford to
stop working.
Examination of the Abdomen

Position and Exposure
o Ask patient if he/she is comfortable to lie flat, with head on pillow, arms resting by sides →
assists in relaxation of abdominal muscles.
o Expose the abdomen from lower chest to pubic symphysis, inguinal ligament and iliac crest.
Legs should be covered.

General Inspection
o Wasting (malignancy, alcoholic cirrhosis), pallor and jaundice (skin and scleral icterus →HCC
damage or biliary obstruction causing hyperbilirubinaemia).
o Make an obvious attempt to look around the immediate environment for any salient
features (oxygen bottles, walkers etc).
o Other symptoms: leukonychia (hypoalbuminaemia), clubbing, palmar erythema, bruising,
scratch marks (pruritus), spider naevi, gynecomastia →chronic liver disease.
o E.g. "On general inspection there does not appear to be any wasting, pallor..."

Inspection of Abdomen
o Look from above:
 Localised Swelling (enlargement of abdominal or pelvic organ, hernia)
 General Distension (fat, fluid (ascites), flatus (gaseous distension from bowel
obstruction), faeces, 'filthy' tumour)
 Scars (laparascopic, nephrectomy, transplanted kidney or other).
 Other: caput Medusae, striae.
o Look from abdominal level
 Repeat from abdominal level and ask patient to take slow deep breaths through
their mouth and watch for asymmetrical movement indicating presence of a mass.
o E.g. "On closer inspection of the abdomen there does not appear to be..."

Systemic Palpation of Abdomen
o Wash and warm hands first
o Examine from the patient’s right side when possible.
o Ask the patient if any part of their abdomen is painful and examine this part last.
o Systematic light palpation of the abdominal quadrants for tenderness
 Ask the patient if anywhere is tender when you press it.
 Look at the patient's face to look for any response rather than at your hand.
 MCP movements only and forefinger lateral surface for organs and masses.
o Systematic deep palpation of the abdominal quadrants for:
 Masses and/or enlarged organs (spleno, hepato, organo)

Palpation and Percussion of Liver
Palpation
o
o
o
o
Begin in right lower quadrant/iliac fossa with hand parallel to right costal margin and
lateral to lateral margin of rectus abdominis.
Ask patient to breathe deeply and adjust hand during expiration to be ready during next
inspiration. (Not too much pressure or lifting movement from liver is missed).
Move up ~2cm if liver is not palpated and repeat until costal margin is reached.
If liver is palpated, move along edge to xiphisternum until no longer palpable.
o
If not palpated, repeat process more laterally to detect Reidel's lobe.
 This is an extended, tongue-like right lobe of the liver.
Percussion
o Hand orientation and starting position same as palpation. Percuss softly in MCL.
o Confirm sound change from resonant to dull with patient deep respiration.
o Note of location of liver edge.
o
o
o

Percuss upper border beginning in 3rd IC space and percuss firmly down MCL.
Confirm sound change with patient respiration.
Measure liver span in MCL
 A normal liver span is 8-12cm (>13cm is abnormal)
Palpation and Percussion of Spleen
Palpation
o
o
o
o
Left hand posterolaterally over left lower ribs and right hand beginning in below umbilicus
in midlineTO and orientated obliquely towards axilla.
Ask patient to breathe deeply and adjust hand during expiration to be ready during next
inspiration. Hand moves upwards and laterally towards left hand.
If spleen not palpated, patient rolls onto their right (towards examiner) and place left arm
across upper chest if required - palpate again under costal margin.
Spleen usually needs to be enlarged 1.5-2 times normal size to be palpated.
Percussion
Percussion for lower spleen pole in Traub's space (9th ICS anterior to anterior axillary line) →
this should be resonant normally.


Palpation of Kidneys
o With patient still rolled over, place right hand in left renal angle (made by 12th rib and
lateral margin of vertebral column).
o Return patient to supine so they are resting on your right hand
o Left hand placed anteriorly lining up with right hand (below costal margin and lateral to
rectus abdominis).
o As patient inspires deeply, flex at MCP of posterior hand and push in with top hand.
o Repeat on other side with hands swapped.
General Percussion
o Performed to determine whether abdominal distension is due to gas or fluid (ascites). Ensure
the patient is lying flat.
o Percuss for flank dullness starting from midline and moving laterally to the left flank. Fingers
should be parallel to rectus abdominis.
o Dullness should not be detected until lateral abdominal wall.
o If detected before lateral abdominal wall → test for shifting dullness.
 Note where dullness was detected early and roll patient onto right side.
 Wait 30 seconds
 Percuss at original point of dullness which should be resonant to confirm shifting
dullness.
 Percuss further laterally to confirm shifting dullness and percuss medially to
determine extent of shifting dullness.
The absence of flank dullness is reliable sign for excluding ascites and hence not necessary to test for shifting
dullness if there is no flank dullness. In contrast, flank dullness alone is not reliable enough to conclude ascites
and therefore must test of shifting dullness.

Auscultation
o Warm the diaphragm of the stethoscope before auscultating.
o Listen for bowel sounds:
 Due to peristalsis and can be heard anywhere in abdomen.
 Place stethoscope diaphragm below umbilicus and listen for at least 30 seconds
before concluding that bowel sounds are absent.
 Report as absent or present.
o Listen for arterial (aortic) bruits:
 Stethoscope diaphragm in midline 1cm above umbilicus to listen to AA.
o Listen for renal bruits:
 2.5cm lateral to site listened to for aortic bruit on either side.
Viva Questions




Given this man's history are there any other aspects of examination you would like
to perform?
o Urinalysis (then ask: what results will you be looking for? Leukocytes, nitrates,
red blood cells, etc.)
o Midstream urine (then what?) then send to lab for culture, staining and
microscopy
Can you describe the surface anatomy markings of the liver?
o Liver upper border - horizontal line across 5th ribs
o Liver lower border - oblique line from lowest point of right costal margin
across to the left 5th rib in the midclavicular line.
What is the normal liver span?
o 8-12 cm in the MCL (>13 is considered hepatomegaly)
Where do the kidneys normally lie?
o Located retroperionteally
o Lie in renal angle made from 12th rib and lateral margin of vertebral column
o Kidneys extend from T12 to L2 with the right kidney slightly lower than the
left kidney.