for tenderness, crepitation, masses, and abnormal pulsations. Palpate for any signs of vibrations or thrills. Percuss the chest for signs of resonance, hyperresonance, tympany, dullness, and flatness. Use a stethoscope to auscultate for abnormal breath sounds such as rales, rhonchi, and wheezing. Listen for abnormal voice sounds.
Cardiovascular SystemPlace the patient in a supine position. Palpate the chest wall in the area of the left midclavicular line to detect thrills, rate, rhythm, and precardial heave. Auscultate the heart for abnormal sounds such as friction rubs and heart murmurs.
Gastrointestinal SystemInspection, auscultation, percussion, and palpation are of significant value in examining the gastrointestinal system. Most of the information gathered from the examination will be from palpation. Always perform palpation last because some findings of auscultation can be markedly altered by manipulation of the abdomen. Place the patient in a supine position with the head slightly elevated. Visually inspect the exposed skin from the sternum to the pubis. Observe for symmetry, masses, and general nutritional state. Note the presence of scars, stretch marks, blemishes, a visible hernia, or abdominal distension. Auscultate to detect any abnormal peristalsis sounds, friction rubs, and bruits (e.g., a splashing or blowing sound). Percuss the abdominal area to detect the presence of tumors, fluid, distension, and enlargement of the underlying organs. Palpation of the abdominal walls is the most important of all the steps and the most difficult to perform. First, make sure your hands are warm. Start to palpate by placing your hand in an area where there is no pain and gently move your hand over the entire abdomen. Note any enlargements or masses and any pain produced. When examining the abdomen, you should be alert for any sign of a hernia. There are three types of abdominal hernias: ventralsoft masses that protrude into the abdominal wall anteriorly; inguinala protrusion of peritoneum through the abdominal wall in the inguinal area; and femoral-located on the anterior surface of the thigh just below the inguinal ligament. The last part of the examination is the rectal. This part of the examination is crucial and should be performed in every case involving the gastrointestinal tract. The perianal area should be inspected for lesions and external hemorrhoids. Also palpate the anal canal for tumors, polyps, masses, and tenderness. The prostate should be palpated for size, shape, and consistency. After withdrawing the gloved hand from the rectum, check the character of any stool that may be on the glove, and perform a guaiac test.
Genitourinary SystemInspect the lower abdomen and flank area for any signs of tenderness if kidney involvement is suspected. Whenever possible, do a microscopic examination of the urine. Examine the genitalia for signs of discharge, ulcers, growths, phimosis, paraphimosis, condylomata (venereal warts), cysts, lipomas or any masses (any testicular mass must be considered as cancerous until proven otherwise), and areas of tenderness and swelling (as in epididymitis). If not already performed, a rectal examination is essential. If renal calculi are suspected, screen all urine for signs of sandy grit, pus, blood.
ExtremitiesCompare upper extremities for symmetry, muscular development, deformity, evidence of nail biting, redness, warmth, tenderness, and crepitation. Examine the joints for range of motion, areas of tenderness, swelling, and discoloration. Inspect and palpate all lymph nodes in the upper extremities. Examine the legs for symmetry, edema, muscular development, abnormalities in blood vessels, and dermatological diseases. Apply passive and active range of motion techniques and check for tenderness, swelling, discoloration, and deformity in joints. Inspect and palpate all inguinal and femoral nodes. Examine the feet for changes in coloration or temperature-indicators of impaired circulation.
Central Nervous System ChecksThe following are the five testing categories in a neurological assessment:
Mental Status and SpeechNote the patients dress, grooming and personal habits, expressions, manner, mood, speech, and level of consciousness.
Cranial NervesTest the olfactory and optic nerves by having the patient identify smells, testing visual acuity and mobility of the eyes, assessing the hearing, and observing for facial weakness or tics.
MusclesTest for muscle tone, coordination, involuntary movements, and atrophy.