THE HEAD AND NECK

MODULE 8
 COMMON OR CONCERNING SYMPTOMS
OF THE HEAD
• HEADACHE
• HEAD INJURY
• HEAD OR NECK SURGERY
• TRAUMATIC BRAIN INJURY
 HEADACHE
• A HEADACHE IS PAIN OR DISCOMFORT IN THE HEAD, FACE,
OR NECK. HEADACHES CAN FEEL LIKE PRESSURE,
THROBBING, OR A CONSTANT ACHE. THEY CAN VARY IN
INTENSITY, LOCATION, AND FREQUENCY.
• THE OLDCART OR PQRST METHODS CAN BE USED IN
ORDER TO OBTAIN THE HEALTH HISTORY OF THE PATIENT’S
HEADACHE.
 HISTORY INTERVIEW (OLDCART)
• ONSET: WHEN DID YOU FIRST NOTICE THE HEADACHE?
• LOCATION: WHERE DO YOU FEEL THE HEADACHE? CAN YOU POINT TO
THE AREA(S)?
• DURATION: HOW LONG HAS THIS BEEN GOING ON? DID THE
HEADACHE BEGIN SUDDENLY (IN A FEW MINUTES OR LESS THAN AN
HOUR) OR GRADUALLY (OVER A FEW HOURS OR DAYS)? IS IT
TEMPORARY OR CONSTANT? WHEN DOES THE PAIN BEGIN (MORNING,
EVENING)? DOES IT WAKE YOU AT NIGHT? HOW LONG DO THE
HEADACHES LAST? ARE THEY RECURRING? IS THERE A PATTERN?
• CHARACTERISTIC SYMPTOMS: DESCRIBE WHAT IT FEELS LIKE
(THROBBING, HAMMERING, SQUEEZING). DESCRIBE THE PAIN ON
A SCALE OF 1 TO 10 WITH 1 BEING MINIMAL PAIN AND 10
BEING THE WORST PAIN YOU EVER FELT.
• RELIEVING FACTORS: WHAT HAVE YOU TRIED TO MAKE THE
HEADACHE GO AWAY? (E.G. SLEEP? DARK ROOM? COOL
COMPRESSES? RELAXATION TECHNIQUES?) WHAT HAS WORKED
THE BEST? WHAT HAS NOT WORKED AT ALL? DOES ANYTHING
MAKE IT WORSE? HOW HAVE THE HEADACHES AFFECTED YOUR
DAILY LIFE AND ACTIVITIES?
•
• TREATMENT: HAS ANYONE TREATED YOU FOR HEADACHES
IN THE PAST? (E.G. PHYSICIAN, NURSE PRACTITIONER, OR
MASSAGE THERAPIST). HAVE YOU USED ANY MEDICATION?
IF YES, THEN THE NAME OF THE MEDICATION, DOSAGE,
AND AFFECT?
 TRAUMATIC BRAIN INJURY (TBI)
• IS A BLOW TO THE HEAD OR A PIERCING HEAD INJURY THAT
INTERFERES WITH THE FUNCTION OF THE BRAIN NOT ALL
INJURIES TO THE HEAD RESULT IN A TBI, AND THOSE THAT
OCCUR IN SPAN FROM MILD TO SEVERE.
• A TRAUMATIC BRAIN INJURY (TBI) REFERS TO A BRAIN INJURY
THAT IS CAUSED BY AN OUTSIDE FORCE. TBI CAN BE CAUSED BY
A FORCEFUL BUMP, BLOW, OR JOLT TO THE HEAD OR BODY, OR
FROM AN OBJECT ENTERING THE BRAIN. NOT ALL BLOWS OR
JOLTS TO THE HEAD RESULT IN TBI.
 COMMON OR CONCERNING
SYMPTOMS OF THE NECK
• SWOLLEN LYMPH NODES OR NECK LUMPS
• ENLARGED THYROID GLAND
• HOARSENESS
PHYSICAL ASSESSMENT
 THE HAIR
• NOTE ITS QUANTITY, DISTRIBUTION, TEXTURE, AND
PATTERN OF LOSS, IF ANY. YOU MAY SEE LOOSE
FLAKES OF DANDRUFF.
 THE SCALP
• PART THE HAIR IN SEVERAL PLACES AND LOOK FOR
SCALINESS, LUMPS, NEVI, OR OTHER LESIONS.
 THE SKULL
• OBSERVE THE GENERAL SIZE AND CONTOUR OF THE
SKULL. NOTE ANY DEFORMITIES, DEPRESSIONS, LUMPS, OR
TENDERNESS.
• LEARN TO RECOGNIZE THE IRREGULARITIES IN A NORMAL
SKULL, SUCH AS THOSE NEAR THE SUTURE LINES BETWEEN
THE PARIETAL AND OCCIPITAL BONES.
 THE FACE
• NOTE THE PATIENT’S FACIAL, EXPRESSION AND CONTOURS.
OBSERVE FOR ASYMMETRY, INVOLUNTARY MOVEMENTS,
EDEMA, AND MASSES.
 THE SKIN
• OBSERVE THE SKIN, NOTING ITS COLOR, PIGMENTATION,
TEXTURE, THICKNESS, HAIR DISTRIBUTION, AND ANY
LESIONS.
 THE NECK
• OBSERVE THE SKIN, NOTING ITS COLOR, PIGMENTATION,
TEXTURE, THICKNESS, HAIR DISTRIBUTION, AND ANY
LESIONS. INSPECT THE NECK, NOTING ITS SYMMETRY AND
ANY MASSES OR SCARS.
• LOOK FOR ENLARGEMENT OF THE PAROTID OR
SUBMANDIBULAR GLANDS, AND NOTE ANY VISIBLE LYMPH
NODES.
 THE LYMPH NODES
• PALPATE THE LYMPH NODES. USING THE PADS OF YOUR
INDEX AND MIDDLE FINGERS, MOVE THE SKIN OVER THE
UNDERLYING TISSUES IN EACH AREA IN A CIRCULAR
MOTION. THE PATIENT SHOULD BE RELAXED, WITH NECK
FLEXED SLIGHTLY FORWARD AND, IF NEEDED, SLIGHTLY
TOWARD THE SIDE BEING EXAMINED.
 THE TRACHEA AND THE THYROID
GLAND
• INSPECT THE TRACHEA FOR ANY DEVIATION FROM ITS
USUAL MIDLINE POSITION. THEN FEEL FOR ANY DEVIATION.
 INSPECT THE NECK FOR THE
THYROID GLAND
• THE THYROID GLAND IS A BUTTERFLY-SHAPED
ENDOCRINE GLAND IN THE NECK THAT PRODUCES
HORMONES THAT REGULATE METABOLISM,
GROWTH, AND DEVELOPMENT.
THE EYES
MODULE 9
 CHANGES IN VISION:

HYPEROPIA
• FARSIGHTEDNESS (HYPEROPIA) IS A COMMON
VISION CONDITION IN WHICH YOU CAN SEE
DISTANT OBJECTS CLEARLY, BUT OBJECTS NEARBY
MAY BE BLURRY
PRESBYOPIA
• IS WHEN YOUR EYES GRADUALLY LOSE THE ABILITY
TO SEE THINGS CLEARLY UP CLOSE. IT IS A NORMAL
PART OF AGING. IN FACT, THE TERM “PRESBYOPIA”
COMES FROM A GREEK WORD WHICH MEANS “OLD
EYE”. YOU MAY START TO NOTICE PRESBYOPIA
SHORTLY AFTER AGE 40.
MYOPIA
• MYOPIA IS THE MEDICAL NAME FOR NEARSIGHTEDNESS,
WHICH MEANS THAT YOU CAN SEE OBJECTS THAT ARE NEAR
CLEARLY BUT HAVE DIFFICULTY SEEING OBJECTS THAT ARE
FARTHER AWAY
SCOTOMAS
• IS AN AREA OF PARTIAL ALTERATION IN FIELD OF VISION
CONSISTING OF A PARTIALLY DIMINISHED OR ENTIRELY
DEGENERATED VISUAL ACUITY THAT IS SURROUNDED BY A
FIELD OF NORMAL–OR RELATIVELY WELL-PRESERVED– VISION.
DIPLOPIA
• DOUBLE VISION, WHICH IS ALSO CALLED DIPLOPIA,
CAUSES PEOPLE TO SEE TWO OF THE SAME IMAGE—
WHETHER HORIZONTAL, VERTICAL OR DIAGONAL—
INSTEAD OF ONE.
STRABISMUS
• IS WHEN YOUR EYES ARE NOT LINED UP PROPERLY AND
THEY POINT IN DIFFERENT DIRECTIONS
 PHYSICAL
EXAMINATION
 EQUIPMENT FOR EXAMINATION

• SNELLEN CHART OR “E” CARD

ROSENBAUM, NEAR-VISION CARD
OPHTHALMOSCOPE
 VISUAL ACUITY
• THIS IS EXPRESSED AS TWO NUMBERS (E.G., 20/30):
THE NUMERATOR INDICATES THE DISTANCE OF THE
PATIENT FROM THE CHART AND THIS NUMBER
SHOULD ALWAYS BE 20 UNLESS THE PATIENT
MOVED CLOSER TO SEE, AND THE DENOMINATOR IS
THE DISTANCE AT WHICH A NORMAL EYE CAN READ
THE LINE OF LETTERS.
 NEAR VISION
• TESTING NEAR VISION WITH A SPECIAL HAND-HELD CARD, THE
ROSENBAUM CHART, HELPS IDENTIFY THE NEED FOR READING
GLASSES OR BIFOCALS IN PATIENTS OLDER THAN 45 YEARS.
THIS CARD CAN BE UTILIZED TO TEST VISUAL ACUITY AT THE BED
SIDE. HELD 14 INCHES FROM THE PATIENT’S EYES, THE CARD
SIMULATES A SNELLEN CHART. HOWEVER, PATIENTS MAY
CHOOSE THEIR OWN DISTANCE.
 EXTERNAL EYE EXAMINATION
• POSITION AND ALIGNMENT OF THE EYES. STAND IN FRONT
OF THE PATIENT AND SURVEY THE EYES FOR POSITION AND
ALIGNMENT. IF ONE OR BOTH EYES SEEM TO PROTRUDE,
ASSESS THEM FROM ABOVE.
• EYEBROWS. INSPECT THE EYEBROWS, NOTING THEIR
QUANTITY AND DISTRIBUTION AND ANY SCALINESS OF THE
UNDERLYING SKIN.
• EYELIDS NOTE THE POSITION OF THE LIDS IN RELATION TO
THE EYEBALLS.
 INTERNAL EYE EXAMINATION
• CORNEA AND LENS. WITH OBLIQUE LIGHTING, INSPECT THE CORNEA
OF EACH EYE FOR OPACITIES AND NOTE ANY OPACITY IN THE LENS
THAT MAY BE VISIBLE THROUGH THE PUPIL.
• IRIS. AT THE SAME TIME, INSPECT EACH IRIS. THE MARKINGS SHOULD BE
CLEARLY DEFINED. WITH YOUR LIGHT SHINING DIRECTLY FROM THE
TEMPORAL SIDE, LOOK FOR A CRESCENTIC SHADOW ON THE MEDIAL
SIDE OF THE IRIS. BECAUSE THE IRIS IS NORMALLY FAIRLY FLAT AND
FORMS A RELATIVELY OPEN ANGLE WITH THE CORNEA, THIS LIGHTING
CASTS NO SHADOW.
• PUPILS. INSPECT THE SIZE, SHAPE, AND SYMMETRY OF THE
PUPILS. IF THE PUPILS ARE LARGE (5 MM), SMALL (<3 MM), OR
UNEQUAL, MEASURE THEM. A PUPIL GUIDE WITH BLACK CIRCLES
OF VARYING SIZES FACILITATES MEASUREMENT. TEST THE
PUPILLARY REACTION TO LIGHT. ASK THE PATIENT TO LOOK
INTO THE DISTANCE, AND SHINE A BRIGHT LIGHT OBLIQUELY
INTO EACH PUPIL IN TURN.
 OPHTHALMIC EXAMINATION
• THE NURSE WOULD EXAMINE THE PATIENT’S EYES WITHOUT
DILATING THE PUPILS. THE VIEW IS THEREFORE LIMITED TO
THE POSTERIOR STRUCTURES OF THE RETINA.
• TO SEE MORE PERIPHERAL STRUCTURES, TO EVALUATE THE
MACULA WELL, OR TO INVESTIGATE UNEXPLAINED VISUAL
LOSS, OPHTHALMOLOGISTS DILATE THE PUPILS WITH
MYDRIATIC DROPS UNLESS THIS IS CONTRAINDICATED.
 EXTRAOCULAR MUSCLES
• THE NORMAL CONJUGATE MOVEMENTS OF THE
EYES IN EACH DIRECTION, OR ANY DEVIATION FROM
NORMAL
 NASOLACRIMAL DUCT
OBSTRUCTION
• THIS TEST HELPS IDENTIFY THE CAUSE OF EXCESSIVE TEARING.
ASK THE PATIENT TO LOOK UP.
• PRESS ON THE LOWER LID CLOSE TO THE MEDIAL CANTHUS, JUST
INSIDE THE RIM OF THE BONY ORBIT — THIS COMPRESSES THE
• LACRIMAL SAC. LOOK FOR FLUID REGURGITATED OUT OF
PUNCTA INTO THE EYE. AVOID THIS TEST IF AREA IS INFLAMED
AND TENDER.
 VARIATIONS AND
ABNORMALITIES OF THE EYELIDS
OPACITIES OF THE CORNEA AND LENS
EARS, NOSE, MOUTH, AND
THROAT
MODULE 10
 COMMON OR CONCERNING SYMPTOMS OF THE
EARS:
• HEARING LOSS
• EARACHE
• DISCHARGE
• TINNITUS
• VERTIGO
 HEARING LOSS
CONDUCTIVE LOSS
• WHICH RESULTS FROM PROBLEMS IN THE EXTERNAL OR
MIDDLE EAR
SENSORINEURAL LOSS
• FROM PROBLEMS IN THE INNER EAR, THE COCHLEAR NERVE,
OR ITS CENTRAL CONNECTIONS IN THE BRAIN
• PEOPLE WITH SENSORINEURAL LOSS HAVE
PARTICULAR TROUBLE UNDERSTANDING SPEECH,
OFTEN COMPLAINING THAT OTHERS MUMBLE;
NOISY ENVIRONMENTS MAKE HEARING WORSE. IN
CONDUCTIVE LOSS, NOISY ENVIRONMENTS MAY
HELP.
• MEDICATIONS THAT AFFECT HEARING INCLUDE
AMINOGLYCOSIDES, ASPIRIN, NONSTEROIDAL ANTI-
INFLAMMATORY DRUGS (NSAIDS), QUININE, FUROSEMIDE,
AND OTHERS.
• SYMPTOMS ASSOCIATED WITH HEARING LOSS, SUCH AS
EARACHE OR VERTIGO; HELP YOU TO ASSESS LIKELY
CAUSES.
 EARACHE
• COMPLAINTS OF EARACHE, OR PAIN IN THE EAR, ARE ESPECIALLY
COMMON. ASK ABOUT ASSOCIATED FEVER, SORE THROAT,
COUGH, AND CONCURRENT UPPER RESPIRATORY INFECTION.
• PAIN SUGGESTS A PROBLEM IN THE EXTERNAL EAR, SUCH AS
OTITIS EXTERNA, OR, IF ASSOCIATED WITH SYMPTOMS OF
RESPIRATORY INFECTION, IN THE INNER EAR, AS IN OTITIS [Link]
MAY ALSO BE REFERRED FROM OTHER STRUCTURES IN THE MOUTH,
THROAT, OR NECK.
 DISCHARGE

• ASK ABOUT DISCHARGE FROM THE EAR, ESPECIALLY IF

ASSOCIATED WITH EARACHE OR TRAUMA.
• UNUSUALLY SOFT WAX, DEBRIS FROM INFLAMMATION
OR RASH IN THE EAR CANAL, OR DISCHARGE THROUGH
A PERFORATED EARDRUM MAY BE SECONDARY TO
ACUTE OR CHRONIC OTITIS MEDIA.
 TINNITUS
•TINNITUS IS A PERCEIVED SOUND THAT HAS NO
EXTERNAL STIMULUS AND COMMONLY IS HEARD
AS MUSICAL RINGING OR A RUSHING OR
ROARING NOISE.
•TINNITUS IS A COMMON SYMPTOM, INCREASING
IN FREQUENCY WITH AGE. WHEN ASSOCIATED
WITH HEARING LOSS AND VERTIGO, IT SUGGESTS
MÉNIÈRE’S DISEASE.
 VERTIGO
• VERTIGO REFERS TO THE PERCEPTION THAT THE PATIENT
OR THE ENVIRONMENT IS ROTATING OR SPINNING.
THESE SENSATIONS POINT PRIMARILY TO A PROBLEM IN
THE LABYRINTHS OF THE INNER EAR, PERIPHERAL LESIONS
OF CRANIAL NERVE (CN) VIII, OR LESIONS IN ITS CENTRAL
PATHWAYS OR NUCLEI IN THE BRAIN.
 PAST HISTORY (EAR)
• CONGENITAL HEARING LOSS
• REMOVAL OF CERUMEN
• EAR SURGERY
• TRAUMA OR INJURY TO YOUR EAR(S)
• INFECTION
• EXPOSURE TO HAZARDOUS NOISE LEVELS (WORK, HOME, WAR)
• HISTORY OF SYPHILIS, RUBELLA, MENINGITIS
 FAMILY HISTORY
• HEARING LOSS
• OTITIS MEDIA
• ALLERGIES
• SMOKING OR EXPOSURE TO CIGARETTE SMOKE
 COMMON OR CONCERNING SYMPTOMS
OF THE NOSE AND SINUSES
RHINORRHEA
• THIS REFERS TO DRAINAGE FROM THE NOSE AND IS
OFTEN ASSOCIATED WITH NASAL CONGESTION, A
SENSE OF STUFFINESS OR OBSTRUCTION.
• CAUSES INCLUDE VIRAL INFECTIONS, ALLERGIC
RHINITIS (“HAY FEVER”), AND VASOMOTOR
RHINITIS.
• RELATION TO SEASONS OR ENVIRONMENTAL
CONTACTS SUGGESTS ALLERGY.
CONGESTION
•THE SYMPTOMS USUALLY APPEAR AFTER AN UPPER
RESPIRATORY INFECTION. TOGETHER THESE
SUGGEST ACUTE BACTERIAL SINUSITIS. SENSITIVITY
AND SPECIFICITY ARE HIGHEST FOR SYMPTOMS
APPEARING AFTER A URI (90% AND 80%).
EPISTAXIS
•EPISTAXIS MEANS BLEEDING FROM THE NOSE.
•LOCAL CAUSES OF EPISTAXIS INCLUDE TRAUMA
(ESPECIALLY NOSE PICKING), INFLAMMATION,
DRYING AND CRUSTING OF THE NASAL
MUCOSA, TUMORS, AND FOREIGN BODIES.
CHANGE IN SENSE OF SMELL
ASK THE PATIENT FOR THE FOLLOWING:
•TRIGGER
• ILLNESS PRIOR TO THE SYMPTOM
• ANY INJURY TO THE NOSE AND HEAD
• IF THE SYMPTOM IS CONSTANT OR INTERMITTENT
 PAST HISTORY
• SINUS INFECTIONS
• UPPER RESPIRATORY INFECTIONS
• ALLERGIES
•TRAUMA OR INJURY
• NASAL OR SINUS SURGERY
• POLYPS
• DENTAL HISTORY
 FAMILY HISTORY
• ALLERGIES
• ASTHMA
•CANCER OF THE NOSE OR SINUS
 COMMON OR CONCERNING SYMPTOMS OF THE
MOUTH AND THROAT
• SORE THROAT
• HOARSENESS
• LESIONS
• SORE TONGUE
• BLEEDING GUMS
• TOOTHACHE
• DYSPHAGIA
 SORE THROAT
•SORE THROAT IS A FREQUENT COMPLAINT,
USUALLY ASSOCIATED WITH ACUTE UPPER
RESPIRATORY SYMPTOMS.
 HOARSENESS
• HOARSENESS REFERS TO AN ALTERED QUALITY OF THE VOICE,
OFTEN DESCRIBED AS HUSKY, ROUGH, OR HARSH. THE PITCH MAY
BE LOWER THAN BEFORE. HOARSENESS USUALLY ARISES FROM
INFLAMMATION OR INFECTION OF THE LARYNX BUT MAY ALSO
DEVELOP AS EXTRA LARYNGEAL LESIONS PRESS ON THE
LARYNGEAL NERVES.
• CHECK FOR OVERUSE OF THE VOICE, ALLERGY, SMOKING OR
OTHER INHALED IRRITANTS, AND ANY ASSOCIATED SYMPTOMS.
 BLEEDING FROM GUM
• BLEEDING FROM THE GUMS IS A COMMON
SYMPTOM, ESPECIALLY WHEN BRUSHING TEETH. IT
CAN ALSO BE CAUSED BY GINGIVITIS.
• ASK WHAT TYPE OF TOOTHBRUSH IS USED? HARD OR
SOFT? ASK ABOUT LOCAL LESIONS AND ANY
TENDENCY TO BLEED OR BRUISE ELSEWHERE.
 DYSPHAGIA
• THE PATIENT HAS DIFFICULTY OF SWALLOWING,
WHETHER IT IS FOOD OR FLUIDS.
 PAST HISTORY
• SORE THROAT
• LOSS OF VOICE
• DENTAL, MOUTH, OR THROAT SURGERY
• TRAUMA OR INJURY TO TEETH, MOUTH, OR THROAT
• HISTORY OF INFECTIONS
• ORAL CANCER
• SEXUALLY TRANSMITTED DISEASE
 FAMILY HISTORY
• ALLERGIES
• SMOKING OR EXPOSURE TO CIGARETTE
SMOKE
• STROKE
•TUBERCULOSIS
THE RESPIRATORY
SYSTEM
MODULE 11
 COMMON OR CONCERNING
SYMPTOMS OF THE RESPIRATORY
SYSTEM
•DYSPNEA
•COUGH
•CHEST PAIN
 DYSPNEA
•IT IS AIR HUNGER, A NON-PAINFUL BUT
UNCOMFORTABLE AWARENESS OF BREATHING THAT
IS INAPPROPRIATE TO THE LEVEL OF EXERTION,
COMMONLY TERMED SHORTNESS OF BREATH.
•THIS IS A SERIOUS SYMPTOM THAT WARRANTS A FULL
EXPLANATION AND ASSESSMENT. IT CAN RESULT
FROM PULMONARY OR CARDIAC DISEASE.
 COUGH
• THIS IS TYPICALLY A REFLEX RESPONSE TO STIMULI THAT IRRITATE
RECEPTORS IN THE LARYNX, TRACHEA, OR LARGE BRONCHI. THESE
STIMULI INCLUDE MUCUS, PUS, BLOOD, DUST, FOREIGN BODIES,
AND EVEN EXTREMELY HOT OR COLD AIR.
• MUCOID SPUTUM IS TRANSLUCENT, WHITE OR GREY; PURULENT
SPUTUM IS YELLOWISH OR GREENISH.
FOUL-SMELLING SPUTUM IN ANAEROBIC LUNG
ABSCESS; TENACIOUS SPUTUM IN CYSTIC FIBROSIS.
LARGE VOLUMES OF PURULENT SPUTUM IN
BRONCHIECTASIS OR LUNG ABSCESS.

• AN ACUTE COUGH LASTS < 3 WEEKS, SUBACUTE 3

TO 8 WEEKS, AND CHRONIC > 8 WEEKS.
 CHEST PAIN

• THIS MAY BE CAUSED BY CARDIAC, RESPIRATORY,

GASTROINTESTINAL, OR MUSCULOSKELETAL ETIOLOGIES.
LUNG TISSUE ITSELF HAS NO PAIN FIBERS.
• PAIN IN LUNG CONDITIONS, SUCH AS PNEUMONIA OR
PULMONARY INFARCTION, USUALLY ARISES FROM
INFLAMMATION OF THE ADJACENT PARIETAL PLEURA.
 SOURCES OF CHEST PAIN ARE:
• TRACHEA AND LARGE BRONCHI DUE TO BRONCHITIS
• PARIETAL PLEURA DUE TO PERICARDITIS, PNEUMONIA
• CHEST WALL, INCLUDING THE MUSCULOSKELETAL SYSTEM
AND SKIN DUE TO COSTOCHONDRITIS, HERPES ZOSTER
• MYOCARDIUM DUE TO ANGINA PECTORIS OR MYOCARDIAL
INFARCTION
• PERICARDIUM DUE TO PERICARDITIS
• AORTA DUE TO DISSECTING AORTIC ANEURYSM
• ESOPHAGUS DUE TO REFLUX ESOPHAGITIS OR
ESOPHAGEAL SPASM
• EXTRA THORACIC STRUCTURES: NECK, GALLBLADDER,
AND STOMACH DUE TO CERVICAL ARTHRITIS, BILIARY
COLIC, GASTRITIS
• ANXIETY (THE MECHANISM OF PAIN REMAINS OBSCURE)
PHYSICAL EXAMINATION
 PERCUSSION

•HEALTHY LUNGS ARE RESONANT.

•WHILE THE PATIENT KEEPS BOTH ARMS
CROSSED IN FRONT OF THE CHEST, PERCUSS
THE THORAX IN SYMMETRIC LOCATIONS
FROM THE APEX TO THE BASE.
• DULLNESS REPLACES RESONANCE WHEN FLUID OR
SOLID TISSUE REPLACES AIR- CONTAINING LUNG OR
OCCUPIES THE PLEURAL SPACE
• BENEATH YOUR PER- CUSSING FINGERS. EXAMPLES
INCLUDE LOBAR PNEUMONIA, IN WHICH THE PLEURAL
ACCUMULATIONS OF SEROUS FLUID (PLEURAL EFFU-
SION), BLOOD (HEMOTHORAX), PUS (EMPYEMA),
FIBROUS TISSUE, OR TUMOR.
• GENERALIZED HYPERRESONANCE MAY BE HEARD
OVER THE HYPERINFLATED LUNGS OF COPD OR
ASTHMA, BUT IS NOT A RELIABLE
• SIGNIFICANT UNILATERAL HYPERRESONANCE
SUGGESTS A LARGE PNEUMOTHORAX OR POSSIBLY
A LARGE AIR-FILLED BULLA IN THE LUNG
 BREATH SOUNDS: NORMAL BREATH SOUNDS
VESICULAR
• SOFT AND LOW PITCHED. THEY ARE HEARD THROUGH
INSPIRATION, CONTINUE WITHOUT PAUSE THROUGH EXPIRATION,
AND THEN FADE AWAY ABOUT ONE THIRD OF THE WAY
THROUGH EXPIRATION.
BRONCHOVESICULAR
• WITH INSPIRATORY AND EXPIRATORY SOUNDS ABOUT EQUAL IN
LENGTH, AT TIMES SEPARATED BY A SILENT INTERVAL
BRONCHIAL
• LOUDER AND HIGHER IN PITCH, WITH A SHORT SILENCE
BETWEEN INSPIRATORY AND EXPIRATORY SOUNDS.
EXPIRATORY SOUNDS LAST LONGER THAN INSPIRATORY
SOUNDS.
 ADVENTITIOUS BREATH SOUNDS

• DETECTION OF ADVENTITIOUS SOUNDS LIKE CRACKLES

(SOMETIMES CALLED RALES), WHEEZES, AND RHONCHI—IS
AN IMPORTANT PART OF YOUR EXAMINATION, OFTEN
LEADING TO DIAGNOSIS OF CARDIAC AND PULMONARY
CONDITIONS
 CRACKLES
•THESE ARE INTERMITTENT, NON-MUSICAL,
BRIEF CRACKLING SOUNDS (COLLAPSED OR
FLUID-FILLED ALVEOLI POPPING OPEN)
 WHEEZES
•SUGGEST NARROWED AIRWAYS, AS IN
ASTHMA, COPD, OR BRONCHITIS.
•THESE ARE HIGH PITCHED SOUNDS HEARD
FIRST UPON EXHALATION.
 RHONCHI
•SUGGEST SECRETIONS IN LARGE AIRWAYS.
THIS IS A LOW-PITCHED, SNORING,
RATTLING SOUNDS THAT OCCUR
PRIMARILY DURING EXHALATION
 STRIDOR
•LOUD, HIGH PITCHED CROWING SOUND
THAT IS HEARD UPON INHALATION.
DEFORMITIES OF THE CHEST AND THORAX
THE CARDIOVASCULAR
SYSTEM
MODULE 12-14
 THE CARDIOVASCULAR SYSTEM
• THIS IS MADE UP OF THE HEART AND BLOOD VESSELS.
• THE MAIN FUNCTIONS OF THIS SYSTEM ARE DELIVERING
OXYGEN AND NUTRIENTS TO THE CELLS OF THE BODY,
REMOVING WASTE PRODUCTS, AND MAINTAINING PERFUSION
TO THE ORGANS AND TISSUES.
• THE HEART IS THE PUMP THAT DRIVES CIRCULATION OF THE
BLOOD AND BLOOD VESSELS ARE PATHWAYS TO AND FROM
THE TISSUES.
THE HEART AND GREAT VESSELS
RELATION OF AUSCULTATORY FINDINGS TO THE
CHEST WALL
THE CONDUCTION SYSTEM
 THE HEART AS A PUMP
• THE LEFT AND RIGHT VENTRICLES PUMP BLOOD
INTO THE SYSTEMIC AND PULMONARY ARTERIAL
TREES, RESPECTIVELY.
• CARDIAC OUTPUT, THE VOLUME OF BLOOD
EJECTED FROM EACH VENTRICLE DURING 1 MINUTE,
IS THE PRODUCT OF HEART RATE AND
• STROKE VOLUME (THE VOLUME OF BLOOD
EJECTED WITH EACH HEARTBEAT) DEPENDS IN
TURN ON PRELOAD, MYOCARDIAL
 MYOCARDIAL CONTRACTILITY
•REFERS TO THE ABILITY OF THE CARDIAC MUSCLE,
WHEN GIVEN A LOAD, TO CONTRACT OR SHORTEN.
CONTRACTILITY INCREASES WHEN STIMULATED BY
THE SYMPATHETIC NERVOUS SYSTEM AND DECREASES
WHEN BLOOD FLOW OR OXYGEN DELIVERY TO THE
MYOCARDIUM IS IMPAIRED.
COMPONENTS OF THE
CARDIOVASCULAR
EXAMINATION
 PREPARATION OF THE PATIENT:
•THE PATIENT SHOULD BE COMFORTABLE AND CALM
AS ANXIETY MAY ELEVATE THE BLOOD PRESSURE OR
CHANGE THE HEART RATE OR RHYTHM.
•REVIEW THE EXAMINATION PROCEDURE WITH THE
PATIENT BEFORE PUTTING ON THE EXAMINATION
GOWN. EXPLAIN WHY VISUALIZATION OF THE
ANTERIOR CHEST IS IMPORTANT FOR DATA
GATHERING.
•THE EXAMINATION GOWN HAS THE OPENING IN THE
FRONT, WHICH ENABLES THE NURSE TO OPEN THE
GOWN ONLY AS NECESSARY
•DURING THE EXAMINATION ASSIST THE PATIENT ONTO
THE EXAMINATION TABLE, IF NECESSARY, AND
IMMEDIATELY DRAPE WITH A SHEET. PERFORM THE
EXAMINATION FROM THE PATIENT’S RIGHT SIDE.
 EQUIPMENT NEEDED FOR
EXAMINATION
• STETHOSCOPE WITH A BELL AND DIAPHRAGM
• SPHYGMOMANOMETER
• TWO 15-CM RULERS
• WATCH WITH SECOND HAND
• EXAMINATION LIGHT FOR TANGENTIAL LIGHTING
 FACE
• AS YOU ARE TAKING THE PATIENT’S HISTORY INSPECT THE
FACE, NOTING ITS COLOR AND THE PRESENCE OF ANY
ORBITAL EDEMA.
• LOOK FOR SIGNS OF ANXIETY. PALLOR OR CYANOSIS
MAY INDICATE POOR PERFUSION OF OXYGEN AND
ORBITAL EDEMA MAY INDICATE HEART FAILURE. ANXIETY
OCCURS DURING HEART ATTACKS.
 GREAT VESSELS OF THE NECK

•THE CAROTID ARTERY PULSE PROVIDES VALUABLE

INFORMATION ABOUT CARDIAC FUNCTION AND
IS ESPECIALLY USEFUL FOR DETECTING STENOSIS
OR INSUFFICIENCY OF THE AORTIC VALVE.
 THE AMPLITUDE AND CONTOUR
• TO ASSESS AMPLITUDE AND CONTOUR OF THE CAROTID PULSE, THE PATIENT SHOULD BE
LYING DOWN WITH THE HEAD OF THE BED
• ELEVATED TO ABOUT 30°.
• FIRST INSPECT THE NECK FOR CAROTID PULSATIONS. THESE MAY BE VISIBLE JUST MEDIAL TO
THE STERNOCLEIDOMASTOID MUSCLES.
•THEN PLACE YOUR INDEX AND MIDDLE FINGERS
ON THE RIGHT CAROTID ARTERY IN THE LOWER
THIRD OF THE NECK, PRESS
•POSTERIORLY, AND FEEL FOR PULSATIONS.
• A TORTUOUS AND KINKED CAROTID ARTERY
MAY PRODUCE A UNILATERAL PULSATILE BULGE.
• CAUSES OF DECREASED PULSATIONS INCLUDE
DECREASED STROKE VOLUME AND LOCAL FACTORS IN
THE ARTERY SUCH AS ATHEROSCLEROTIC NARROWING
OR OCCLUSION.
• PRESS JUST INSIDE THE MEDIAL BORDER OF A WELL-
RELAXED STERNOCLEIDOMASTOID MUSCLE, ROUGHLY
AT THE LEVEL OF THE CRICOID CARTILAGE.
•AVOID PRESSING ON THE CAROTID SINUS, WHICH
LIES AT THE LEVEL OF THE TOP OF THE THYROID
CARTILAGE.
•FOR THE LEFT CAROTID ARTERY, USE YOUR RIGHT
FINGERS. NEVER PRESS BOTH CAROTIDS AT THE
SAME TIME. THIS MAY DECREASE BLOOD FLOW TO
THE BRAIN AND INDUCE SYNCOPE.
•SLOWLY INCREASE PRESSURE UNTIL THE
MAXIMAL PULSATION IS FELT, AND THEN
SLOWLY DECREASE PRESSURE UNTIL YOU BEST
SENSE THE ARTERIAL PRESSURE AND CONTOUR.
 THE AMPLITUDE OF THE PULSE
•THIS CORRELATES REASONABLY WELL WITH THE
PULSE PRESSURE.
•SMALL, THREADY, OR WEAK PULSE IN
CARDIOGENIC SHOCK; BOUNDING PULSE IN
AORTIC INSUFFICIENCY
 THRILLS AND BRUITS
•DURING PALPATION OF THE CAROTID ARTERY,
HUMMING VIBRATIONS, OR THRILLS, THAT FEEL LIKE
THE THROAT OF A PURRING CAT MAY BE DETECTED.
ROUTINELY, BUT ESPECIALLY IN THE PRESENCE OF A
THRILL, LISTEN OVER BOTH CAROTID ARTERIES WITH
THE BELL OF THE STETHOSCOPE FOR A BRUIT, A
MURMUR-LIKE SOUND OF VASCULAR RATHER THAN
CARDIAC ORIGIN.
 THE BRACHIAL ARTERY
•USE THE INDEX AND MIDDLE FINGERS TO FEEL FOR
THE PULSE JUST MEDIAL TO THE BICEPS TENDON.
THE PATIENT’S ARM SHOULD REST WITH THE ELBOW
EXTENDED, PALM UP. WITH YOUR FREE HAND, YOU
MAY NEED TO FLEX THE ELBOW TO A VARYING
DEGREE TO GET OPTIMAL MUSCULAR RELAXATION.
 SEQUENCE OF CARDIAC
EXAMINATION
INSPECTION
•CAREFULLY INSPECT THE ANTERIOR CHEST FOR THE
LOCATION OF THE APICAL IMPULSE OR POINT OF
MAXIMAL IMPULSE OR HEAVES OVER THE
PRECORDIUM, WHICH INDICATE INCREASED
VENTRICULAR MOVEMENT.
PALPATION
•CHECK FOR THRILLS, FORMED BY THE TURBULENCE OF
UNDERLYING MURMURS, BY PRESSING THE BALL OF
YOUR HAND FIRMLY ON THE CHEST. IF SUBSEQUENT
AUSCULTATION REVEALS A LOUD MURMUR, GO BACK
TO THAT AREA AND CHECK FOR THRILLS AGAIN.
•THRILLS MAY ACCOMPANY LOUD, HARSH, OR
RUMBLING MURMURS AS IN AORTIC STENOSIS,
PATENT DUCTUS ARTERIOSUS, VENTRICULAR
SEPTAL DEFECT, AND, LESS COMMONLY, MITRAL
STENOSIS. THEY ARE PALPATED MORE EASILY IN
PATIENT POSITIONS THAT ACCENTUATE THE
MURMUR.
PERCUSSION
•THIS IS RARELY USED TODAY TO ESTIMATE CARDIAC
SIZE. X-RAYS, ECG, AND ECHOCARDIOGRAPHY
PROVIDE ACCURATE MEASUREMENT. PALPATION OF
THE APICAL IMPULSE CAN PROVIDE A ROUGH SIZE
ESTIMATE.
AUSCULTATION
•THE DIAPHRAGM. THE DIAPHRAGM IS BETTER FOR
PICKING UP THE RELATIVELY HIGH-PITCHED SOUNDS
OF S1 AND S2, THE MURMURS OF AORTIC AND
MITRAL REGURGITATION, AND PERICARDIAL
FRICTION RUBS. LISTEN THROUGHOUT THE
PRECORDIUM WITH THE DIAPHRAGM, PRESSING IT
FIRMLY AGAINST THE CHEST.
•THE BELL. THE BELL IS MORE SENSITIVE TO THE LOW-
PITCHED SOUNDS OF S3 AND S4 AND THE MURMUR
OF MITRAL STENOSIS.
•APPLY THE BELL LIGHTLY, WITH JUST ENOUGH
PRESSURE TO PRODUCE AN AIR SEAL WITH ITS
FULL RIM. USE THE BELL AT THE APEX, AND THEN
MOVE MEDIALLY ALONG THE LOWER STERNAL
BORDER. RESTING THE HEEL OF YOUR HAND ON
THE CHEST LIKE A FULCRUM MAY HELP YOU TO
MAINTAIN LIGHT PRESSURE.
 HEART MURMURS:
MIDSYSTOLIC MURMUR
•BEGINS AFTER S1 AND STOPS BEFORE S2. BRIEF GAPS
ARE AUDIBLE BETWEEN THE MURMUR ANDTHE HEART
SOUNDS. LISTEN CAREFULLY FOR THEGAP JUST
BEFORE S2. IT IS HEARD MORE EASILYAND, IF PRESENT,
USUALLY CONFIRMS THE MURMUR AS MIDSYSTOLIC,
NOT PANSYSTOLIC
PANSYSTOLIC MURMUR
•STARTS WITH S1 AND STOPS AT S2, WITHOUT AGAP
BETWEEN MURMUR AND HEART SOUNDS
LATE SYSTOLIC MURMUR
•USUALLY STARTS IN MID- OR LATE SYSTOLE AND
PERSISTS UP TO S2
EARLY DIASTOLIC MURMUR
•STARTS IMMEDIATELY AFTER S2, WITHOUT A
DISCERNIBLE GAP, AND THEN USUALLY FADES
INTO SILENCE BEFORE THE NEXT S1
MID-DIASTOLIC MURMUR
•STARTS A SHORT TIME AFTER S2. IT MAY FADE
AWAY, AS ILLUSTRATED, OR MERGE INTO A LATE
DIASTOLIC MURMUR
LATE DIASTOLIC (PRESYSTOLIC) MURMUR
•STARTS LATE IN DIASTOLE AND TYPICALLY
CONTINUES UP TO S1
 INTENSITY OF HEART MURMUR
•THIS IS USUALLY GRADED ON A 6-POINT SCALE AND
EXPRESSED AS A FRACTION.
• THE NUMERATOR DESCRIBES THE INTENSITY OF THE
MURMUR WHEREVER IT IS LOUDEST; THE
DENOMINATOR INDICATES THE SCALEYOU ARE USING.
INTENSITY IS INFLUENCED BY THE THICKNESS OF THE
CHEST WALL AND THE PRESENCE OF INTERVENING
TISSUE.
 THE PERIPHERAL
VASCULAR SYSTEM AND
LYMPHATIC SYSTEM
MODULE 15
 COMMON OR CONCERNING SYMPTOMS
OF THE PERIPHERAL VASCULAR SYSTEM &
LYMPHATIC SYSTEM
• PAIN IN THE ARMS OR LEGS
• INTERMITTENT CLAUDICATION
• COLD, NUMBNESS, OR PALLOR IN THE LEGS; HAIR LOSS
• SWELLING IN THE CALVES, LEGS, OR FEET
• SWELLING WITH REDNESS AND TENDERNESS
• DO YOU HAVE PAIN OR CRAMPING IN YOUR LEG
DURING WALKING OR EXERTION?
• IS IT RELIEVED BY REST WITHIN 10 MINUTES?
IF PRESENT, IDENTIFY THE LOCATION AND THE DISTANCE
THE PATIENT WALKS BEFORE SYMPTOMS OCCUR.
• DO YOU HAVE COLDNESS, NUMBNESS, OR PALLOR IN
THE LEGS OR FEET?
• DO YOU HAVE HAIR ON YOUR SHINS?
• DO YOU HAVE ACHING OR PAIN AT REST IN THE
LOWER LEG OR FOOT?
• IS PAIN ALLEVIATED BY ELEVATING THE LEGS?
• DO YOU HAVE FATIGUE OR ACHING IN THE LOWER
LEGS WITH PROLONGED STANDING?
DO YOU HAVE SWELLING OF THE FEET OR LEGS?
• EDEMA, VARICOSE VEINS, AND ACHING IN THE
LEGS ARE SYMPTOMS OF VENOUS STASIS.
IF PRESENT, IDENTIFY:
• LOCATION
•TIME OF DAY IT IS PRESENT
• WHETHER IT IS BILATERAL OR UNILATERAL
DO YOU HAVE ANY VARICOSE VEINS?
•WHERE ARE THEY LOCATED?
• HOW LONG HAVE YOU HAD THEM?
• DO YOU HAVE ANY DISCOMFORT FROM THEM?
 DO YOU HAVE ANY WOUNDS OF THE LEGS OR FEET
THAT WILL NOT HEAL OR HEAL VERY SLOWLY?
• ULCERS MAY BE OF VENOUS OR ARTERIAL ORIGIN.
• WHERE IS THE WOUND LOCATED?
•HOW LONG HAVE YOU HAD THE WOUND?
• WHAT PRECIPITATED THE WOUND (E.G., AN INJURY)?
DO YOUR FINGERTIPS OR TOES CHANGE COLOR IN
COLD WEATHER?
• MAY BE CAUSED BY RAYNAUD DISEASE: THE SMALL
ARTERIES SPASM IN RESPONSE TO COLD.
HAVE YOU EXPERIENCED ERECTILE DYSFUNCTION?
• POOR BLOOD SUPPLY TO THE PENILE ARTERIES CAN
CAUSE ERECTILE DYSFUNCTION.
DO YOU HAVE ABDOMINAL PAIN AFTER MEALS?
• DOES IT PREVENT YOU FROM EATING?
• ATHEROSCLEROSIS OF THE MESENTERIC OR CELIAC
ARTERIES CAN CAUSE INTESTINAL ISCHEMIA,
PRODUCING ABDOMINAL
•PAIN AND “FOOD FEAR,” WHERE THE PATIENT IS
FEARFUL OF EATING.
DO YOU HAVE TENDER OR SWOLLEN LYMPH
NODES (GLANDS)?
• SWOLLEN NODES MAY INDICATE AN
INFECTION OR TUMOR.
PAST HISTORY
RISK FACTORS
FAMILY HISTORY
IMPORTANT AREAS OF
EXAMINATION
 ARMS
INSPECTION: INSPECT BOTH ARMS FROM THE
FINGERTIPS TO THE SHOULDERS.
1. THEIR SIZE, SYMMETRY, SWELLING, AND ANY LESIONS
• LYMPHEDEMA OF THE ARM AND HAND MAY FOLLOW AXILLARY
NODE DISSECTION AND RADIATION THERAPY.
2. THE VENOUS PATTERN
• PROMINENT VEINS IN AN EDEMATOUS ARM SUGGEST VENOUS
OBSTRUCTION
3. THE COLOR OF THE SKIN AND NAIL BEDS AND THE TEXTURE OF
THE SKIN

PALPATION:
• 1. PALPATE THE TEMPERATURE OF THE ARMS AND HANDS
SIMULTANEOUSLY WITH THE BACKS OF YOUR FINGERS. COMPARE
THE TEMPERATURE OF THE ARMS SIMULTANEOUSLY.
• IN RAYNAUD DISEASE, WRIST PULSES ARE TYPICALLY
NORMAL, BUT SPASM OF MORE DISTAL ARTERIES CAUSES
EPISODES OF SHARPLY DEMARCATED PALLOR OF THE
FINGERS
2. PALPATE THE RADIAL PULSE WITH THE PADS OF YOUR
FINGERS ON THE FLEXOR SURFACE OF THE WRIST LATERALLY.
PARTIALLY FLEXING THE PATIENT’S WRIST MAY HELP YOU FEEL
THIS PULSE. COMPARE THE PULSES IN BOTH ARMS. PULSES MAY
BE PALPATED SIMULTANEOUSLY TO FACILITATE COMPARISON.
 LEGS
• THE PATIENT SHOULD BE LYING DOWN AND DRAPED SO
THAT THE EXTERNAL GENITALIA ARE COVERED AND THE
LEGS FULLY EXPOSED. A GOOD EXAMINATION IS
IMPOSSIBLE THROUGH STOCKINGS OR SOCKS
• INSPECTION:INSPECT BOTH LEGS FROM THE GROIN AND
BUTTOCKS TO THE FEET.
• 1. THEIR SIZE, SYMMETRY, AND EDEMA. MEASURE LEG
CIRCUMFERENCES IN CENTIMETERS IF DISCREPANCY IS
SUSPECTED.
• 2. THE VENOUS PATTERN AND ANY VENOUS ENLARGEMENT
OR VARICOSITIES
• 3. PIGMENTATION, RASHES, SCARS, OR ULCERS
4. THE COLOR AND TEXTURE OF THE SKIN AND THE COLOR
OF THE NAIL BEDS
5. THE DISTRIBUTION OF HAIR ON THE LOWER LEGS, FEET,
AND TOES.
6. LOOK FOR BROWNISH AREAS (OR INCREASED
PIGMENTATION ON DARK-SKINNED CLIENTS) NEAR THE
ANKLES.
• THE BROWN DISCOLORATION IS CAUSED BY
HEMOSIDERIN RELEASED FROM THE RED BLOOD CELLS
THAT SEEP INTO THE SKIN WITH EDEMA AND BREAK
DOWN.
• 7. NOTE THE LOCATION, SIZE, AND DEPTH OF ANY
ULCERS IN THE SKIN. ARE THE EDGES OF THE
WOUND WELL DEMARCATED? IS THERE BLEEDING?
PALPATION
1. PALPATE THE TEMPERATURE OF BOTH LEGS AND FEET
SIMULTANEOUSLY WITH THE BACKS OF YOUR HANDS.
COMPARE THE
• TEMPERATURE OF THE LEGS. BILATERAL COOLNESS IS
MOST OFTEN CAUSED BY A COLD ENVIRONMENT OR
ANXIETY. COLDNESS, ESPECIALLY WHEN UNILATERAL OR
ASSOCIATED WITH OTHER SIGNS, SUGGESTS ARTERIAL
INSUFFICIENCY FROM INADEQUATE ARTERIAL
CIRCULATION.
2. PALPATE FOR EDEMA. COMPARE ONE FOOT AND LEG
WITH THE OTHER, NOTING THEIR RELATIVE SIZE AND THE
PROMINENCE OF
• VEINS, TENDONS, AND BONES. EDEMA CAUSES SWELLING
THAT MAY OBSCURE THE VEINS, TENDONS, AND BONY
PROMINENCES.
• PALPATE FOR PITTING EDEMA. PRESS FIRMLY BUT GENTLY
WITH YOUR THUMB FOR AT LEAST 5 SECONDS (1) OVER
THE DORSUM OF EACH FOOT, (2) BEHIND EACH MEDIAL
MALLEOLUS, AND (3) OVER THE SHINS. LOOK FOR
PITTING—A DEPRESSION CAUSED BY PRESSURE FROM
YOUR THUMB. NORMALLY THERE IS NONE.
 PALPATE THE PULSES TO ASSESS THE
ARTERIAL CIRCULATION
.
•FEMORAL PULSE.
•POPLITEAL PULSE.
•DORSALIS PEDIS PULSE.
•POSTERIOR TIBIAL PULSE.
THE GASTROINTESTINAL
AND RENAL SYSTEMS
MODULE 16
THE FOUR QUADRANTS OF THE
ABDOMEN
 THE RIGHT UPPER QUADRANT:
• IN THE RIGHT UPPER QUADRANT, THE SOFT CONSISTENCY
OF THE LIVER MAKES IT DIFFICULT TO FEEL THROUGH THE
ABDOMINAL WALL.
• THE LOWER MARGIN OF THE LIVER, THE LIVER EDGE, IS
OFTEN PALPABLE AT THE RIGHT COSTAL MARGIN.
• THE GALLBLADDER, WHICH RESTS AGAINST THE INFERIOR
SURFACE OF THE LIVER, AND THE MORE DEEPLY LYING
DUODENUM ARE GENERALLY NOT PALPABLE.
• AT A DEEPER LEVEL, THE LOWER POLE OF THE RIGHT KIDNEY
MAY BE FELT, ESPECIALLY IN THIN PEOPLE WITH RELAXED
ABDOMINAL MUSCLES. MOVING MEDIALLY, THE EXAMINER
ENCOUNTERS THE RIB CAGE, WHICH PROTECTS THE
STOMACH; THE XIPHOID PROCESS LIES IN THE MIDLINE.
• THE ABDOMINAL AORTA OFTEN HAS VISIBLE PULSATIONS
AND IS USUALLY PALPABLE IN THE UPPER ABDOMEN.
 THE LEFT UPPER QUADRANT:
• IN THE LEFT UPPER QUADRANT, THE SPLEEN IS LATERAL TO
AND BEHIND THE STOMACH, JUST ABOVE THE LEFT KIDNEY
IN THE LEFT MID AXILLARY LINE. ITS UPPER MARGIN RESTS
AGAINST THE DOME OF THE DIAPHRAGM.
• THE 9TH, 10TH, AND 11TH RIBS PROTECT MOST OF THE
SPLEEN. THE TIP OF THE SPLEEN MAY BE PALPABLE BELOW
THE LEFT COSTAL
• MARGIN IN A SMALL PERCENTAGE OF ADULTS.
• THE PANCREAS IN HEALTHY PEOPLE ESCAPES DETECTION.
 THE LEFT LOWER QUADRANT
• IN THE LEFT LOWER QUADRANT, THE FIRM, NARROW,
TUBULAR SIGMOID COLON IS OFTEN FELT AND
PORTIONS OF THE TRANSVERSE AND DESCENDING
COLON MAY ALSO BE PALPABLE.
 THE RIGHT LOWER QUADRANT
• IN THE LOWER MIDLINE THE BLADDER MAY BE
PALPATED. IN THE RIGHT LOWER QUADRANT ARE
BOWEL LOOPS AND THE APPENDIX AT THE TAIL OF
THE CECUM NEAR THE JUNCTION OF THE SMALL
AND LARGE INTESTINES. IN HEALTHY PEOPLE, THERE
WILL BE NO PALPABLE FINDINGS.
 THE URINARY BLADDER
• A DISTENDED BLADDER MAY BE PALPABLE ABOVE THE
SYMPHYSIS PUBIS. THE BLADDER ACCOMMODATES ROUGHLY
300 ML OF URINE FILTERED BY THE KIDNEYS INTO THE RENAL
PELVIS AND THE URETERS. BLADDER EXPANSION STIMULATES
CONTRACTION OF BLADDER SMOOTH MUSCLE, THE
DETRUSOR MUSCLE, AT RELATIVELY LOW PRESSURES.
• RISING PRESSURE IN THE BLADDER TRIGGERS THE
CONSCIOUS URGE TO VOID.
 THE KIDNEYS
• THE KIDNEYS ARE POSTERIOR ORGANS. THE RIBS
PROTECT THEIR UPPER PORTIONS.
• THE COSTOVERTEBRAL ANGLE—THE ANGLE FORMED BY
THE LOWER BORDER OF THE 12TH RIB AND THE
TRANSVERSE PROCESSES OF THE UPPER LUMBAR
VERTEBRAE—DEFINES THE REGION TO ASSESS FOR
KIDNEY TENDERNESS (FLANK AREA).
THE HEALTH HISTORY
PATTERNS AND MECHANISMS OF
ABDOMINAL PAIN
•VISCERAL PAIN
•PARIETAL PAIN
•REFERRED PAIN
HISTORY OF ABDOMINAL PAIN OR
DISCOMFORT
• ONSET: FIRST DETERMINE THE TIMING OF THE PAIN.
IS IT ACUTE OR CHRONIC?
• LOCATION: THEN ASK THE PATIENT TO POINT TO
THE PAIN.
• DURATION: HOW LONG DOES IT LAST?
• CHARACTERISTIC SYMPTOMS: ASK PATIENTS TO DESCRIBE
THE PAIN IN THEIR OWN WORDS.
• ASSOCIATED MANIFESTATIONS: ASK THE PATIENT IF HE OR
SHE IS EXPERIENCING ANY OTHER SYMPTOMS
• RELIEVING FACTORS: AS YOU PROBE FACTORS THAT
AGGRAVATE OR RELIEVE THE PAIN
• TREATMENT: DETERMINE WHAT REMEDIES THE PATIENT HAS
TRIED AND THE RESULTS OF EACH.
THANK YOU FOR
LISTENING!