Vital Signs

Equipment Needed
O A Stethoscope
O A Blood Pressure CuII
O A Watch Displaying Seconds
O A Thermometer
eneral Considerations
O The patient should not have had alcohol, tobacco, caIIeine, or perIormed vigorous
exercise within 30 minutes oI the exam.
O deally the patient should be sitting with Ieet on the Iloor and their back supported.
The examination room should be quiet and the patient comIortable.
O istory oI hypertension, slow or rapid pulse, and current medications should always
be obtained.
%emperature
Temperature can be measured is several diIIerent ways:
O ral with a glass, paper, or electronic thermometer (normal 98.6F/37C) |1|
O illary with a glass or electronic thermometer (normal 97.6F/36.3C)
O #ectal or "core" with a glass or electronic thermometer (normal 99.6F/37.7C)
O ural (the ear) with an electronic thermometer (normal 99.6F/37.7C)
OI these, axillary is the least and rectal is the most accurate.
#espiration
1. Best done immediately aIter taking the patient's pulse. Do not announce that you are
measuring respirations. |p129, p237| |2|
2. Without letting go oI the patients wrist begin to observe the patient's breathing. s it
normal or labored?
3. Count breaths Ior 15 seconds and multiply this number by 4 to yield the breaths per
minute.
4. n adults, normal resting respiratory rate is between 14-20 breaths/minute. Rapid
respiration is called tachypnea.
!ulse
1. Sit or stand Iacing your patient.
2. Grasp the patient's wrist with your Iree (non-watch bearing) hand (patient's right with
your right or patient's leIt with your leIt). There is no reason Ior the patient's arm to be
in an awkward position, iust imagine you're shaking hands.
3. Compress the radial artery with your index and middle Iingers.
4. Note whether the pulse is regular or irregular:
4 #egular - evenly spaced beats, may vary slightly with respiration
4 #egularly Irregular - regular pattern overall with "skipped" beats
4 Irregularly Irregular - chaotic, no real pattern, very diIIicult to measure rate
accurately
5. Count the pulse Ior 15 seconds and multiply by 4.
6. Count Ior a Iull minute iI the pulse is irregular.
7. Record the rate and rhythm.
Interpretation
O A normal adult heart rate is between 60 and 100 beats per minute.
O A pulse greater than 100 beats/minute is deIined to be tachycardia. Pulse less than 60
beats/minute is deIined to be bradycardia. Tachycardia and bradycardia are not
necessarily abnormal. Athletes tend to be bradycardic at rest (superior conditioning).
Tachycardia is a normal response to stress or exercise.
lood !ressure
1. Position the patient's arm so the anticubital Iold is level with the heart. Support the
patient's arm with your arm or a bedside table.
2. Center the bladder oI the cuII over the brachial artery approximately 2 cm above the
anticubital Iold. !roper cuff size is essential to obtain an accurate reading. Be sure
the index line Ialls between the size marks when you apply the cuII. Position the
patient's arm so it is slightly Ilexed at the elbow.
3. Palpate the radial pulse and inIlate the cuII until the pulse disappears. This is a rough
estimate oI the systolic pressure
4. Place the stetescope over the brachial artery.
5. nIlate the cuII to 30 mmg above the estimated systolic pressure.
6. Release the pressure slowly, no greater than 5 mmg per second.
7. The level at which you consistantly hear beats is the systolic pressure
8. Continue to lower the pressure until the sounds muIIle and disappear. This is the
diastolic pressure
9. Record the blood pressure as systolic over diastolic ("120/70" Ior example).
Interpretation
O igher blood pressures are normal during exertion or other stress. Systolic blood
pressures below 80 may be a sign oI serious illness or shock.
O Blood pressure should be taken in both arms on the Iirst encounter. I there is more
than 10 mmg diIIerence between the two arms, use the arm with the higher reading
Ior subsequent measurements.
O t is Irequently helpIul to retake the blood pressure near the end oI the visit. Earlier
pressures may be higher due to the "white coat" eIIect.
O Always recheck "unexpected" blood pressures yourselI.

lood !ressure Classification in dults
Category Systolic Diastolic
Normal 140 90
solated Systolic ypertension ~140 90
Mild ypertension 140-159 90-99
Moderate ypertension 160-179 100-109
Severe ypertension 180-209 110-119
Crisis ypertension ~210 ~120
O n children, pulse and blood pressure vary with the age. The Iollowing table should
serve as a rough guide:
;erage !ulse and lood !ressure in Normal Children
ge Birth 6mo 1yr 2yr 6yr 8yr 10yr
!ulse 140 130 115 110 103 100 95
Systolic ! 70 90 90 92 95 100 105

Eamination of the Head and Neck
Equipment Needed
O An Otoscope
O Tongue Blades
O Cotton Tipped Applicators
O atex Gloves
eneral Considerations
The head and neck exam is not a single, Iixed sequence. DiIIerent portions are included
depending on the examiner and the situation.
Head
1. ook Ior scars, lumps, rashes, hair loss, or other lesions.
2. ook Ior Iacial asymmetry, involuntary movements, or edema.
3. Palpate to identiIy any areas oI tenderness or deIormity.
Ears
1. nspect the auricles and move them around gently. Ask the patient iI this is painIul.
2. Palpate the mastoid process Ior tenderness or deIormity.
3. old the otoscope with your thumb and Iingers so that the ulnar aspect oI your hand
makes contact with the patient.
4. Pull the ear upwards and backwards to straighten the canal.
5. nsert the otoscope to a point iust beyond the protective hairs in the ear canal. Use the
largest speculum that will Iit comIortably.
6. nspect the ear canal and middle ear structures noting any redness, drainage, or
deIormity.
7. nsuIIlate the ear and watch Ior movement oI the tympanic membrane.
8. Repeat Ior the other ear.
Nose
t is oIten convenient to examine the nose immediately aIter the ears using the same
speculum.
1. Tilt the patient's head back slightly. Ask them to hold their breath Ior the next Iew
seconds.
2. nsert the otoscope into the nostril, avoiding contact with the septum.
3. nspect the visible nasal structures and note any swelling, redness, drainage, or
deIormity.
4. Repeat Ior the other side.
%hroat
t is oIten convenient to examine the throat using the otoscope with the speculum removed.
1. Ask the patient to open their mouth.
2. Using a wooden tongue blade and a good light source, inspect the inside oI the
patients mouth including the buccal Iolds and under the tougue. Note any ulcers,
white patches (leucoplakia), or other lesions.
3. I abnormalities are discovered, use a gloved Iinger to palpate the anterior structures
and Iloor oI the mouth.
4. nspect the posterior oropharynx by depressing the tongue and asking the patient to
say "Ah." Note any tonsilar enlargement, redness, or discharge.
Neck
1. nspect the neck Ior asymmetry, scars, or other lesions.
2. Palpate the neck to detect areas oI tenderness, deIormity, or masses.
3. The musculoskeletal exam oI the neck is covered elsewhere...
ymph Nodes
1. Systematically palpate with the pads oI your index and middle Iingers Ior the various
lymph node groups.
1. Preauricular - n Iront oI the ear
2. Postauricular - Behind the ear
3. Occipital - At the base oI the skull
4. Tonsillar - At the angle oI the iaw
5. Submandibular - Under the iaw on the side
6. Submental - Under the iaw in the midline
7. SuperIicial (Anterior) Cervical - Over and in Iront oI the sternomastoid muscle
8. Supraclavicular - n the angle oI the sternomastoid and the clavicle
2. The deep cer;ical chain oI lymph nodes lies below the sternomastoid and cannot be
palpated without getting underneath the muscle:
1. nIorm the patient that this procedure will cause some discomIort.
2. ook your Iingers under the anterior edge oI the sternomastoid muscle.
3. Ask the patient to bend their neck toward the side you are examining.
4. Move the muscle backward and palpate Ior the deep nodes underneath.
3. Note the size and location oI any palpable nodes and whether they were soIt or hard,
non-tender or tender, and mobile or Iixed.
%hyroid land
1. nspect the neck looking Ior the thyroid gland. Note
whether it is visible and symmetrical. A visibly
enlarged thyroid gland is called a goiter.
2. Move to a position behind the patient.
3. dentiIy the cricoid cartilage with the Iingers oI
both hands.
4. Move downward two or three tracheal rings while
palpating Ior the isthmus.
5. Move laterally Irom the midline while palpating Ior
the lobes oI the thyroid.
6. Note the size, symmetry, and position oI the lobes, as well as the presence oI any
nodules. The normal gland is oIten not palpable.
Special %ests
Facial %enderness
1. Ask the patient to tell you iI these maneuvers causes excessive discomIort or pain.
2. Press upward under both eyebrows with your thumbs.
3. Press upward under both maxilla with your thumbs.
4. Excessive discomIort on one side or signiIicant pain suggests sinusitis.
Sinus %ransillumination
1. Darken the room as much as possible.
2. Place a bright otoscope or other point light source on the maxilla.
3. Ask the patient to open their mouth and look Ior an orange glow on the hard palate.
4. A decreased or absent glow suggests that the sinus is Iilled with something other than
air.
%emporomandibular 1oint
1. Place the tips oI your index Iingers directly in Iront oI the tragus oI each ear.
2. Ask the patient to open and close their mouth.
3. Note any decreased range oI motion, tenderness, or swelling.

Eamination of the Chest and ungs
Equipment Needed
O A SLeLhoscope
O A eak llow MeLer
eneral Considerations
O @he paLlenL must be properlv undressed and aowned for Lhls examlnaLlon
O deallv Lhe paLlenL should be slLLlna on Lhe end of an exam Lable
O @he examlnaLlon room must be quleL Lo perform adequaLe percusslon and ausculLaLlon
O bserve Lhe paLlenL for aeneral slans of resplraLorv dlsease (flnaer clubblna cvanosls alr
hunaer eLc)
O @rv Lo vlsuallze Lhe underlvlna anaLomv as vou examlne Lhe paLlenL
Inspection
bserve Lhe raLe rhvLhm depLh and efforL of breaLhlna noLe wheLher Lhe explraLorv phase
ls prolonaed 2
2 LlsLen for obvlous abnormal sounds wlLh breaLhlna such as wheezes
3 bserve for reLracLlons and use of accessorv muscles (sLernomasLolds abdomlnals)
4 bserve Lhe chesL for asvmmeLrv deformlLv or lncreased anLerlorposLerlor (A) dlameLer
3
3 Conflrm LhaL Lhe Lrachea ls near Lhe mldllne? 4
!alpation
denLlfv anv areas of Lenderness or deformlLv bv palpaLlna Lhe rlbs and sLernum p238
p248
2 Assess expanslon and svmmeLrv of Lhe chesL bv placlna vour hands on Lhe paLlenLs back
Lhumbs LoaeLher aL Lhe mldllne and ask Lhem Lo breaLh deeplv
3 Check for LacLlle fremlLus ++ 3
1uctlle Fremltux
Ask Lhe paLlenL Lo sav nlneLvnlne several Llmes ln a normal volce ++
2 alpaLe uslna Lhe ball of vour hand
3 ?ou should feel Lhe vlbraLlons LransmlLLed Lhrouah Lhe alrwavs Lo Lhe luna
4 ncreased LacLlle fremlLus suaaesLs consolldaLlon of Lhe underlvlna luna Llssues 8
!ercussion
!roper %echnique
vperexLend Lhe mlddle flnaer of one hand and place
Lhe dlsLal lnLerphalanaeal [olnL f|rm|y aaalnsL Lhe paLlenLs
chesL
2 JlLh Lhe end (noL Lhe pad) of Lhe opposlLe mlddle
flnaer use a qulck fllck of Lhe wrlsL Lo sLrlke flrsL flnaer
3 CaLeaorlze whaL vou hear as normal dull or
hvperresonanL
4 racLlce vour Lechnlque unLll vou can conslsLanLlv
produce a normal percusslon noLe on vour (presumablv normal) parLner before vou work
wlLh paLlenLs

!osterior Chest
ercuss from slde Lo slde and Lop Lo boLLom uslna Lhe paLLern shown
ln Lhe lllusLraLlon mlL Lhe areas covered bv Lhe scapulae
2 Compare one slde Lo Lhe oLher looklna for asvmmeLrv
3 noLe Lhe locaLlon and quallLv of Lhe percusslon sounds vou hear
4 llnd Lhe level of Lhe dlaphraamaLlc dullness on boLh sldes
luphruqmutlc Fxcurxlon
3 llnd Lhe level of Lhe dlaphraamaLlc dullness on boLh sldes
6 Ask Lhe paLlenL Lo lnsplre deeplv
7 @he level of dullness (dlaphraamaLlc excurslon) should ao down 33cm symmetr|ca||y 6 ++

nterior Chest
ercuss from slde Lo slde and Lop Lo boLLom uslna Lhe paLLern shown
ln Lhe lllusLraLlon
2 Compare one slde Lo Lhe oLher looklna for asvmmeLrv
3 noLe Lhe locaLlon and quallLv of Lhe percusslon sounds vou hear
Interpretation
9ercuss|on Notes and 1he|r Mean|ng
llaL or uull leural Lffuslon or Lobar neumonla
normal ealLhv Luna or 8ronchlLls
vperresonanL Lmphvsema or neumoLhorax
uscultation
Use the diaphragm oI the stethoscope to auscultate breath sounds.
!osterior Chest
AusculLaLe from slde Lo slde and Lop Lo boLLom uslna Lhe paLLern shown ln Lhe lllusLraLlon
mlL Lhe areas covered bv Lhe scapulae
2 Compare one slde Lo Lhe oLher looklna for asvmmeLrv
3 noLe Lhe locaLlon and quallLv of Lhe sounds vou hear
nterior Chest
AusculLaLe from slde Lo slde and Lop Lo boLLom uslna Lhe paLLern shown ln Lhe lllusLraLlon
2 Compare one slde Lo Lhe oLher looklna for asvmmeLrv
3 noLe Lhe locaLlon and quallLv of Lhe sounds vou hear
Interpretation
Breath sounds are produced by turbulent air Ilow. They are categorized by the size oI the
airways that transmit them to the chest wall (and your stethoscope). The general rule is, the
larger the airway, the louder and higher pitched the sound. Vesicular breath sounds are low
pitched and normally heard over most lung Iields. Tracheal breath sounds are heard over the
trachea. Bronchovesicular and bronchial sounds are heard in between. nspiration is normally
longer than expiration ( ~ E). |2|
Breath sounds are decreased when normal lung is displaced by air (emphysema or
pneumothorax) or Iluid (pleural eIIusion). Breath sounds shift from ;esicular to bronchial
when there is is Iluid in the lung itselI (pneumonia). Extra sounds that originate in the lungs
and airways are reIerred to as "adventitious" and are always abnormal (but not always
signiIicant). (See Table)
dvent|t|ous (Lxtra) Lung 5ounds
Crack|es
@hese are hlah plLched dlsconLlnuous sounds slmllar Lo Lhe sound produced bv
rubblna vour halr beLween vour flnaers (Also known as ka|es)
Wheezes
@hese are aenerallv hlah plLched and muslcal ln quallLv 5tr|dor ls an lnsplraLorv
wheeze assoclaLed wlLh upper alrwav obsLrucLlon (croup)
khonch|
@hese ofLen have a snorlna or aurallna quallLv Anv exLra sound LhaL ls noL a
crackle or a wheeze ls probablv a rhonchl


Cardio;ascular Eamination
Equipment Needed
O A uoubleeaded uoubleLumen SLeLhoscope
O A 8lood ressure Cuff
O A Moveable LlahL Source or en LlahL
eneral Considerations
O @he paLlenL must be properlv undressed and ln a aown for Lhls examlnaLlon
O @he examlnaLlon room must be quleL Lo perform adequaLe ausculLaLlon
O bserve Lhe paLlenL for aeneral slans of cardlovascular dlsease (flnaer clubblna cvanosls
edema eLc)
rterial !ulses
#ate and #hythm
Compress Lhe radlal arLerv wlLh vour lndex and mlddle flnaers
2 noLe wheLher Lhe pulse ls reaular or lrreaular
3 CounL Lhe pulse for 3 seconds and mulLlplv bv 4
4 CounL for a full mlnuLe lf Lhe pulse ls lrreaular 2
3 8ecord Lhe raLe and rhvLhm
9u|se C|ass|f|cat|on |n du|ts (t kest)
Norma| 8radycard|a 1achycard|a
60 Lo 00 bpm less Lhan 60 bpm more Lhan 00
kegu|ar kegu|ar|y Irregu|ar Irregu|ar|y Irregu|ar
Lvenlv spaced beaLs mav varv
sllahLlv wlLh resplraLlon
8eaular paLLern overall
wlLh sklpped beaLs
ChaoLlc no real paLLern verv dlfflculL
Lo measure raLe accuraLelv 2
|See below Ior children.|
mplitude and Contour
bserve for caroLld pulsaLlons
2 lace vour flnaers behlnd Lhe paLlenLs neck and compress Lhe caroLld arLerv on one slde
wlLh vour Lhumb at or be|ow Lhe level of Lhe crlcold carLllaae ress flrmlv buL noL Lo Lhe
polnL of dlscomforL 3
3 Assess Lhe followlna
4 @he ampllLude of Lhe pulse
4 @he conLour of Lhe pulse wave
4 IarlaLlons ln ampllLude from beaL Lo beaL or wlLh resplraLlon
4 8epeaL on Lhe opposlLe slde
uscultation for ruits
I the patient is late middle aged or older, you should auscultate Ior bruits. A bruit is oIten,
but not always, a sign oI arterial narrowing and risk oI a stroke. |4|
lace Lhe be|| of Lhe sLeLhoscope over each caroLld arLerv ln Lurn ?ou mav use Lhe
dlaphraam lf Lhe paLlenLs neck ls hlahlv conLoured
2 Ask Lhe paLlenL Lo sLop breaLhlna momenLarllv
3 LlsLen for a blowlna or rushlna sounda brulL uo noL be confused bv hearL sounds or
murmurs LransmlLLed from Lhe chesL
lood !ressure
The patient should not have eaten, smoked, taken caIIeine, or engaged in vigorous exercise
within the last 30 minutes. The room should be quiet and the patient comIortable.
oslLlon Lhe paLlenLs arm so Lhe anLlcublLal fold ls level wlLh Lhe hearL
2 CenLer Lhe bladder of Lhe cuff over Lhe brachlal arLerv approxlmaLelv 2 cm above Lhe
anLlcublLal fold 9roper cuff s|ze |s essent|a| Lo obLaln an accuraLe readlna 8e sure Lhe lndex
llne falls beLween Lhe slze marks when vou applv Lhe cuff oslLlon Lhe paLlenLs arm so lL ls
sllahLlv flexed aL Lhe elbow
3 alpaLe Lhe radlal pulse and lnflaLe Lhe cuff unLll Lhe pulse dlsappears @hls ls a rouah
esLlmaLe of Lhe svsLollc pressure 6
4 lace Lhe sLeLescope over Lhe brachlal arLerv 3
3 nflaLe Lhe cuff 20 Lo 30 mma above Lhe esLlmaLed svsLollc pressure
6 8elease Lhe pressure slowlv no areaLer Lhan 3 mma per second
7 @he level aL whlch vou conslsLanLlv hear beaLs ls Lhe svsLollc pressure 7
8 ConLlnue Lo lower Lhe pressure unLll Lhe sounds muffle and dlsappear @hls ls Lhe dlasLollc
pressure 8
9 8ecord Lhe blood pressure as svsLollc over dlasLollc (20/70)
08lood pressure should be Laken ln boLh arms on Lhe flrsL encounLer 9
nterpretutlon
8|ood 9ressure C|ass|f|cat|on |n du|ts
Category 5ysto||c D|asto||c
normal 30 83
lah normal 3039 8389
Mlld vperLenslon 4039 9099
ModeraLe vperLenslon 6079 0009
Severe vperLenslon 80209 09
Crlsls vperLenslon 20 20
n children, pulse and blood pressure vary with the age. The Iollowing table should serve as a
rough guide:
verage 9u|se and 8|ood 9ressure |n Norma| Ch||dren
ge 8lrLh 6mo vr 2vr 6vr 8vr 0vr
9u|se 40 30 3 0 03 00 93
5ysto||c 89 70 90 90 92 93 00 03
1ugular Venous !ressure
oslLlon Lhe paLlenL suplne wlLh Lhe head of Lhe Lable elevaLed 30 dearees ++
2 use LanaenLlal slde llahLlna Lo observe for venous pulsaLlons ln Lhe neck
3 Look for a rapld double (someLlmes Lrlple) wave wlLh each hearL beaL use
llahL pressure [usL above Lhe sLernal end of Lhe clavlcle Lo ellmlnaLe Lhe
pulsaLlons and rule ouL a caroLld orlaln
4 Ad[usL Lhe anale of Lable elevaLlon Lo brlna ouL Lhe venous pulsaLlon

3 denLlfv Lhe hlahesL polnL of pulsaLlon uslna a horlzonLal llne from Lhls polnL measure
verLlcallv from Lhe sLernal anale 0
6 @hls measuremenL should be less Lhan 4 cm ln a normal healLhv adulL
!recordial Mo;ement
oslLlon Lhe paLlenL suplne wlLh Lhe head of Lhe Lable sllahLlv elevaLed
2 Alwavs examlne from Lhe paLlenLs rlahL slde
3 nspecL for precordlal movemenL @anaenLlal llahLlna wlll make movemenLs more vlslble
4 alpaLe for precordlal acLlvlLv ln aeneral ?ou mav feel exLras such as Lhrllls or exaaaeraLed
venLrlcular lmpulses
3 alpaLe for Lhe polnL of maxlmal lmpulse (M or aplcal pulse) L ls normallv locaLed ln Lhe
4Lh or 3Lh lnLercosLal space [usL medlal Lo Lhe mldclavlcular llne and ls less Lhan Lhe slze of a
quarLer
6 noLe Lhe locaLlon slze and quallLv of Lhe lmpulse
uscultation
oslLlon Lhe paLlenL suplne wlLh Lhe head of
Lhe Lable sllahLlv elevaLed
2 Alwavs examlne from Lhe paLlenLs rlahL slde
A quleL room ls essenLlal
3 LlsLen wlLh Lhe dlaphraam aL Lhe rlahL 2nd
lnLerspace near Lhe sLernum (aorLlc area)
4 LlsLen wlLh Lhe dlaphraam aL Lhe lefL 2nd
lnLerspace near Lhe sLernum (pulmonlc
area)
3 LlsLen wlLh Lhe dlaphraam aL Lhe lefL 3rd
4Lh and 3Lh lnLerspaces near Lhe sLernum
(Lrlcuspld area)
6 LlsLen wlLh Lhe dlaphraam aL Lhe apex (M)
(mlLral area)
7 LlsLen wlLh Lhe be|| aL Lhe apex
8 LlsLen wlLh Lhe be|| aL Lhe lefL 4Lh and 3Lh lnLerspace near Lhe sLernum ++
9 ave Lhe paLlenL roll on Lhelr lefL slde ++
4 LlsLen wlLh Lhe be|| aL Lhe apex
4 @hls poslLlon brlnas ouL S3 and mlLral murmurs
0ave Lhe paLlenL slL up lean forward and hold Lhelr breaLh ln exhalaLlon ++
4 LlsLen wlLh Lhe dlaphraam aL Lhe lefL 3rd and 4Lh lnLerspace near Lhe sLernum
4 @hls poslLlon brlnas ouL aorLlc murmurs
8ecord S S2 (S3) (S4) as well as Lhe arade and conflauraLlon of anv murmurs (Lwo over
slx or 2/6 pansvsLollc or crescendo)
Interpretation
Murmurs and Lxtra 5ounds

5ysto||c L[ect|on

Innocent/9hys|o|og|c
ort|c/9u|mon|c 5tenos|s

9ansysto||c

M|tra|/1r|cusp kegurg|tat|on

5ysto||c C||ck
Late 5ysto||c

M|tra| Va|ve 9ro|apse


Lar|y D|asto||c

ort|c kegurg|tat|on

M|d D|asto||c

M|tra|/1r|cusp 5tenos|s
Cpen|ng 5nap
D|asto||c kumb|e

M|tra| 5tenos|s

L[ect|on 5ound

ort|c Va|ve D|sease

53

Norma| |n Ch||dren
neart Ia||ure
54

9hys|o|og|c
Var|ous D|seases

Murmur Grades
Grade Vo|ume 1hr|||
/6 verv falnL onlv heard wlLh opLlmal condlLlons no
2/6 loud enouah Lo be obvlous no
3/6 louder Lhan arade 2 no
4/6 louder Lhan arade 3 ves
3/6 heard wlLh Lhe sLeLhoscope parLlallv off Lhe chesL ves
6/6 heard wlLh Lhe sLeLhoscope compleLelv off Lhe chesL ves

Eamination of the bdomen
Equipment Needed
O A SLeLhoscope
eneral Considerations
O @he paLlenL should have an empty b|adder
O @he paLlenL should be lvlna suplne on Lhe exam Lable and
approprlaLelv draped
O @he examlnaLlon room must be quleL Lo perform adequaLe
ausculLaLlon and percusslon
O Watch the pat|ents face for slans of dlscomforL durlna Lhe
examlnaLlon
O use Lhe approprlaLe Lermlnoloav Lo locaLe vour flndlnas
4 8lahL upper CuadranL (8uC)
4 8lahL Lower CuadranL (8LC)
4 LefL upper CuadranL (LuC)
4 LefL Lower CuadranL (LLC)
4 Mldllne
LplaasLrlc
erlumblllcal
Suprapublc
O ulsorders ln Lhe chesL wlll ofLen manlfesL wlLh abdomlnal svmpLoms L ls alwavs wlse Lo
examlne Lhe chesL when evaluaLlna an abdomlnal complalnL
O Conslder Lhe lnaulnal/recLal examlnaLlon ln males Conslder Lhe pelvlc/recLal examlnaLlon ln
females
Inspection
Look for scars sLrlae hernlas vascular chanaes leslons or rashes
2 Look for movemenL assoclaLed wlLh perlsLalsls or pulsaLlons
3 noLe Lhe abdomlnal conLour s lL flaL scaphold or proLuberanL?
uscultation
lace Lhe dlaphraam of vour sLeLhoscope llahLlv on Lhe
abdomen 2
2 LlsLen for bowel sounds Are Lhev normal lncreased decreased
or absenL?
3 LlsLen for brulLs over Lhe renal arLerles lllac arLerles and aorLa
!ercussion
ercuss ln all four quadranLs uslna proper Lechnlque
2 CaLeaorlze whaL vou hear as LvmpanlLlc or dull @vmpanv ls normallv presenL over mosL of
Lhe abdomen ln Lhe suplne poslLlon unusual dullness mav be a clue Lo an underlvlna
abdomlnal mass

i;er Span
ercuss downward from Lhe chesL ln Lhe r|ght m|dc|av|cu|ar
||ne unLll vou deLecL Lhe Lop edae of llver dullness
2 ercuss upward from Lhe abdomen ln Lhe same llne unLll vou
deLecL Lhe boLLom edae of llver dullness
3 Measure Lhe llver span beLween Lhese Lwo polnLs @hls
measuremenL should be 62 cm ln a normal adulL

Splenic Dullness
ercuss Lhe lowesL cosLal lnLerspace ln Lhe |eft anter|or ax|||ary ||ne
@hls area ls normallv LvmpanlLlc
2 Ask Lhe paLlenL Lo Lake a deep breaLh and percuss Lhls area aaaln uullness ln Lhls area ls a
slan of splenlc enlaraemenL
!alpation
eneral !alpation
8ealn wlLh ||ght pa|pat|on AL Lhls polnL vou are mosLlv looklna for areas of Lenderness @he
mosL senslLlve lndlcaLor of Lenderness ls Lhe paLlenLs faclal expresslon (so waLch Lhe
paLlenLs face noL vour hands) IolunLarv or lnvolunLarv auardlna mav also be presenL
2 roceed Lo deep pa|pat|on afLer survevlna Lhe abdomen llahLlv @rv Lo ldenLlfv abdomlnal
masses or areas of deep Lenderness
!alpation of the i;er
tunJurJ MethoJ
lace vour flnaers [usL below Lhe rlahL cosLal maraln and press flrmlv
2 Ask Lhe paLlenL Lo Lake a deep breaLh
3 ?ou mav feel Lhe edae of Lhe llver press aaalnsL vour flnaers r lL mav sllde
under vour hand as Lhe paLlenL exhales A normal llver ls not Lender

lternute MethoJ
This method is useIul when the patient is obese or when the examiner is
small compared to the patient.
SLand bv Lhe paLlenLs chesL
2 ook vour flnaers [usL below Lhe cosLal maraln and press flrmlv
3 Ask Lhe paLlenL Lo Lake a deep breaLh
4 ?ou mav feel Lhe edae of Lhe llver press aaalnsL vour flnaers
!alpation of the orta
ress down deeplv ln Lhe mldllne above Lhe umblllcus ++
2 @he aorLlc pulsaLlon ls easllv felL on mosL lndlvlduals
3 A well deflned pulsaLlle mass areaLer Lhan 3 cm across suaaesLs an aorLlc aneurvsm
!alpation of the Spleen
use vour lefL hand Lo llfL Lhe lower rlb caae and flank ++
2 ress down [usL below Lhe lefL cosLal maraln wlLh vour rlahL hand
3 Ask Lhe paLlenL Lo Lake a deep breaLh
4 @he spleen ls not normallv palpable on mosL lndlvlduals
Special %ests
#ebound %enderness
This is a test Ior peritoneal irritation.
Jarn Lhe paLlenL whaL vou are abouL Lo do
2 ress deeplv on Lhe abdomen wlLh vour hand
3 AfLer a momenL qulcklv release pressure
4 f lL hurLs more when vou release Lhe paLlenL has rebound Lenderness 4
Costo;ertebral %enderness
CVA tenderness is oIten associated with renal disease.
Jarn Lhe paLlenL whaL vou are abouL Lo do
2 ave Lhe paLlenL slL up on Lhe exam Lable
3 use Lhe heel of vour closed flsL Lo sLrlke Lhe paLlenL flrmlv over Lhe cosLoverLebral anales
4 Compare Lhe lefL and rlahL sldes
Shifting Dullness
This is a test Ior peritoneal Iluid (ascites).
ercuss Lhe paLlenLs abdomen Lo ouLllne areas of dullness and Lvmpanv
2 ave Lhe paLlenL roll awav from vou
3 ercuss and aaaln ouLllne areas of dullness and Lvmpanv f Lhe dullness has shlfLed Lo areas
of prlor Lvmpanv Lhe paLlenL mav have excess perlLoneal fluld 3
!soas Sign
This is a test Ior appendicitis.
lace vour hand above Lhe paLlenLs rlahL knee
2 Ask Lhe paLlenL Lo flex Lhe rlahL hlp aaalnsL reslsLance
3 ncreased abdomlnal paln lndlcaLes a poslLlve psoas slan
bturator Sign
This is a test Ior appendicitis.
8alse Lhe paLlenLs rlahL lea wlLh Lhe knee flexed
2 8oLaLe Lhe lea lnLernallv aL Lhe hlp
3 ncreased abdomlnal paln lndlcaLes a poslLlve obLuraLor slan
Eamination of the Etremities and ack
Equipment Needed
O none

eneral Considerations
O @he paLlenL should be undressed and aowned as needed for Lhls examlnaLlon
O Some porLlons of Lhe examlnaLlon mav noL be approprlaLe dependlna on Lhe cllnlcal
slLuaLlon (performlna ranae of moLlon on a fracLured lea for example)
O @he musculoskeleLal exam ls all abouL anatomy @hlnk of Lhe underlvlna anaLomv as vou
obLaln Lhe hlsLorv and examlne Lhe paLlenL
O Jhen Laklna a hlsLorv for an acuLe problem alwavs lnqulre abouL Lhe mechan|sm of |n[ury
loss of funcLlon onseL of swelllna ( 24 hours) and lnlLlal LreaLmenL
O Jhen Laklna a hlsLorv for a chronlc problem alwavs lnqulre abouL pasL ln[urles pasL
LreaLmenLs effecL on funcLlon and currenL svmpLoms
O @he cardlnal slans of musculoskeleLal dlsease are paln redness (ervLhema) swelllna
lncreased warmLh deformlLv and loss of funcLlon
O |ways beg|n w|th |nspect|on pa|pat|on and range of mot|on reaardless of Lhe realon vou
are examlnlna Speclallzed LesLs are ofLen omlLLed unless a speclflc abnormallLv ls suspecLed
A compleLe evaluaLlon wlll lnclude a focused neuroloalc exam of Lhe effecLed area
#egional Considerations
O 8emember LhaL Lhe c|av|c|e ls parL of Lhe shoulder 8e sure Lo lnclude lL ln vour examlnaLlon
O @he pate||a ls much easler Lo examlne lf Lhe lea ls exLended and relaxed
O 8e sure Lo palpaLe over Lhe sp|nous process of each verLebrae
O L ls alwavs helpful Lo observe Lhe paLlenL stand|ng and wa|k|ng
O Alwavs conslder referred pa|n from Lhe neck or chesL Lo Lhe shoulder from Lhe back or
pelvls Lo Lhe hlp and from Lhe hlp Lo Lhe knee
O aln wlLh or llmlLaLlon of rotat|on ls ofLen Lhe flrsL slan of hlp dlsease
O ulaanosLlc hlnLs based on |ocat|on of paln
8ack 5|de Iront
5hou|der 9a|n Muscle Spasm 8urslLls or 8oLaLor Cuff Clenohumeral !olnL
n|p 9a|n SclaLlca 8urslLls lp !olnL
Inspection
Look for scars rashes or oLher leslons
2 Look for asvmmeLrv deformlLv or aLrophv
3 Alwavs compare wlLh Lhe oLher slde
!alpation
Lxamlne each ma[or [olnL and muscle aroup ln Lurn
2 denLlfv anv areas of Lenderness 2
3 denLlfv anv areas of deformlLv
4 Alwavs compare wlLh Lhe oLher slde
#ange of Motion
Start by asking the patient to move through an active range oI motion (ioints moved by
patient). Proceed to passive range oI motion (ioints moved by examiner) iI active range oI
motion is abnormal.
cti;e
Ask Lhe paLlenL Lo move each [olnL Lhrouah a full ranae of moLlon
2 noLe Lhe dearee and Lvpe (paln weakness eLc) of anv llmlLaLlons
3 noLe anv lncreased ranae of moLlon or lnsLablllLv
4 Alwavs compare wlLh Lhe oLher slde
3 roceed Lo passlve ranae of moLlon lf abnormallLles are found
!assi;e
Ask Lhe paLlenL Lo relax and allow vou Lo supporL Lhe exLremlLv Lo be examlned ++ 3
2 CenLlv move each [olnL Lhrouah lLs full ranae of moLlon
3 noLe Lhe dearee and Lvpe (paln or mechanlcal) of anv llmlLaLlon 4
4 f lncreased ranae of moLlon ls deLecLed perform speclal LesLs for lnsLablllLv as approprlaLe
3 Alwavs compare wlLh Lhe oLher slde
Specific 1oints
O llnaers flexlon/exLenslon abducLlon/adducLlon
O @humb flexlon/exLenslon abducLlon/adducLlon opposlLlon
O JrlsL flexlon/exLenslon radlal/ulnar devlaLlon
O lorearm pronaLlon/suplnaLlon (funcLlon of 8@ elbow and wrlsL)
O Llbow flexlon/exLenslon
O Shoulder flexlon/exLenslon lnLernal/exLernal roLaLlon abducLlon/adducLlon (2/3
alenohumeral [olnL /3 scapuloLhoraclc) 3
O lp flexlon/exLenslon abducLlon/adducLlon lnLernal/exLernal roLaLlon
O nee flexlon/exLenslon
O Ankle flexlon (planLarflexlon)/exLenslon (dorslflexlon)
O looL lnverslon/everslon
O @oes flexlon/exLenslon
O Splne flexlon/exLenslon rlahL/lefL bendlna rlahL/lefL roLaLlon p466 p477
Vascular
!ulses
Check Lhe radlal pulses on boLh sldes f Lhe radlal pulse ls absenL or weak check Lhe brachlal
pulses
2 Check Lhe posLerlor Llblal and dorsalls pedls pulses on boLh sldes f Lhese pulses are absenL
or weak check Lhe popllLeal and femoral pulses
Capillary #efill
ress down flrmlv on Lhe paLlenLs flnaer or Loe nall so lL blanches ++
2 8elease Lhe pressure and observe how lona lL Lakes Lhe nall bed Lo plnk up
3 Caplllarv reflll Llmes areaLer Lhan 2 Lo 3 seconds suaaesL perlpheral vascular dlsease arLerlal
blockaae hearL fallure or shock
Edema. Cyanosis. and Clubbing
Check for Lhe presence of edema (swelllna) of Lhe feeL and lower leas
2 Check for Lhe presence of cvanosls (blue color) of Lhe feeL or hands
3 Check for Lhe presence of clubblna of Lhe flnaers
ymphatics
Check for Lhe presence of eplLrochlear lvmph nodes ++
2 Check for Lhe presence of axlllarv lvmph nodes ++
3 Check for Lhe presence of lnaulnal lvmph nodes ++
Special %ests
Upper Etremities
nuffbox 1enJernexx (cupholJ)
denLlfv Lhe anaLomlc snuffbox beLween Lhe exLensor polllcls
lonaus and brevls (exLendlna Lhe Lhumb makes Lhese sLrucLures
more promlnenL) ++
2 ress flrmlv sLralahL down wlLh vour lndex flnaer or Lhumb
3 Anv Lenderness ln Lhls area ls hlahlv suaaesLlve of scaphold
fracLure 6
rop rm 1ext (Rotutor Cuff)
SLarL wlLh Lhe paLlenLs arm abducLed 90 dearees ++
2 Ask Lhe paLlenL Lo s|ow|y lower Lhe arm
3 f Lhe roLaLor cuff (especlallv Lhe suprasplnaLus) ls Lorn Lhe paLlenL wlll be unable Lo lower
Lhe arm slowlv and smooLhlv
mplnqement lqn (Rotutor Cuff)
SLarL wlLh Lhe paLlenLs arm relaxed and Lhe shoulder ln neuLral roLaLlon ++
2 AbducL Lhe arm Lo 90 dearees
3 SlanlflcanL shoulder paln as Lhe arm ls ralsed suaaesLs an lmplnaemenL of Lhe roLaLor cuff
aaalnsL Lhe acromlon
Flexor lqltorum uperflclullx 1ext
old Lhe flnaers ln exLenslon excepL Lhe flnaer belna LesLed ++
2 Ask Lhe paLlenL Lo flex Lhe flnaer aL Lhe proxlmal lnLerphalanaeal
[olnL
3 f Lhe paLlenL cannoL flex Lhe flnaer Lhe flexor dlalLorum superflclalls Lendon ls cuL or non
funcLlonal
Flexor lqltorum ProfunJux 1ext
old Lhe meLacarpophalanaeal and proxlmal
lnLerphalanaeal [olnLs of Lhe flnaer belna LesLed ln exLenslon
++
2 Ask Lhe paLlenL Lo flex Lhe flnaer aL Lhe dlsLal
lnLerphalanaeal [olnL
3 f Lhe paLlenL cannoL flex Lhe flnaer Lhe flexor
dlalLorum profundus Lendon ls cuL or nonfuncLlonal

uxculur unJ Neuroloqlc 1extx
Allen Test (Rauial0lnai Aiteiies)
Ask Lhe paLlenL Lo make a LlahL flsL ++
2 Compress boLh Lhe ulnar and radlal arLerles Lo sLop blood flowlna Lo Lhe hand
3 Ask Lhe paLlenL Lo open Lhe hand
4 8elease pressure on Lhe ulnar slde @he hand should plnk up ln a few seconds unless Lhe
ulnar arLerv ls occluded
3 8epeaL Lhe process for Lhe radlal arLerv as lndlcaLed
alens Test (Neuian Neive)
Ask Lhe paLlenL Lo press Lhe backs of Lhe hands LoaeLher wlLh Lhe
wrlsLs fullv flexed (backward pravlna) ++
2 ave Lhe paLlenL hold Lhls poslLlon for 60 seconds and Lhen commenL
on how Lhe hands feel
3 aln Llnallna or oLher abnormal sensaLlons ln Lhe Lhumb lndex or
mlddle flnaers sLronalv suaaesL carpal Lunnel svndrome
Tinels Sign (Neuian Neive)
use vour mlddle flnaer or a reflex hammer Lo Lap over Lhe carpal Lunnel ++
2 aln Llnallna or elecLrlc sensaLlons sLronalv suaaesL carpal Lunnel svndrome
ower Etremities
Colluterul Ilqument 1extlnq
@he paLlenL should be suplne wlLh Lhe leas resLlna on Lhe exam Lable ++
2 old Lhe lea Lo be examlned ln 2030 dearees of flexlon 7
3 lace one hand laLerallv [usL below Lhe knee Crasp Lhe lea near Lhe ankle wlLh vour oLher
hand
4 CenLlv push wlLh boLh hands ln opposlLe dlrecLlons Lo sLress Lhe knee
3 f Lhe knee [olnL opens up medlallv Lhe medlal collaLeral llaamenL mav be Lorn
6 8everse vour hands and repeaL Lhe sLress
7 f Lhe knee [olnL opens up laLerallv Lhe laLeral collaLeral llaamenL mav be Lorn
Iuchmun 1ext (Cruclute Ilqumentx)
Ask Lhe paLlenL Lo lle suplne on Lhe exam Lable 8 ++
2 Crasp Lhe Lhlah wlLh one hand and Lhe upper Llbla wlLh Lhe oLher old Lhe knee ln abouL 3
dearees of flexlon
3 Ask Lhe paLlenL Lo relax and aenLlv pull forward on Lhe Llbla
4 @he normal knee has a dlsLlncL end polnL f Lhe Llbla moves ouL from under Lhe femur Lhe
anLerlor cruclaLe llaamenL mav be Lorn
3 8epeaL Lhe LesL uslna posLerlor sLress
6 @he normal knee has a dlsLlncL end polnL f Lhe Llbla moves back under Lhe femur Lhe
posLerlor cruclaLe llaamenL mav be Lorn
nterlor/Poxterlor ruwer 1ext (Cruclute Ilqumentx)
Ask Lhe paLlenL Lo lle suplne on Lhe exam Lable wlLh knees flexed Lo 90 dearees and feeL flaL
on Lhe Lable 9 ++
2 SlL on or oLherwlse sLablllze Lhe fooL of Lhe lea belna examlned
3 Crasp Lhe lea [usL below Lhe knee wlLh boLh hands and pull forward
4 f Lhe Llbla moves ouL from under Lhe femur Lhe anLerlor cruclaLe llaamenL mav be Lorn
3 JlLhouL chanalna Lhe poslLlon of vour hands push Lhe lea backward
6 f Lhe Llbla moves back under Lhe femur Lhe posLerlor cruclaLe llaamenL mav be Lorn
ullotuble Putellu (Mujor Knee Fffuxlon)
Ask Lhe paLlenL Lo lle suplne on Lhe exam Lable wlLh lea muscles relaxed ++
2 ress Lhe paLella downward and qulcklv release lL
3 f Lhe paLella vlslblv rebounds a larae knee effuslon (excess fluld ln Lhe knee) ls presenL
Mllklnq the Knee (Mlnor Knee Fffuxlon)
Ask Lhe paLlenL Lo lle suplne on Lhe exam Lable wlLh lea muscles
relaxed ++
2 Compress Lhe suprapaLellar pouch wlLh vour Lhumb palm and
lndex flnaer
3 Mllk downward and laLerallv so LhaL anv excess fluld collecLs on
Lhe medlal slde
4 @ap aenLlv over Lhe collecLed fluld and observe Lhe effecL on Lhe
laLeral slde or balloL Lhe paLella as ouLllned above
3 A fullness on Lhe laLeral slde lndlcaLes LhaL a small knee effuslon ls presenL
ack
trulqht Ieq Rulxlnq (I5/ Nerve Rootx)
Ask Lhe paLlenL Lo lle suplne on Lhe exam Lable wlLh knees sLralahL ++
2 Crasp Lhe lea near Lhe heel and ralse Lhe lea slowlv Lowards Lhe celllna
3 aln ln an L3 or S dlsLrlbuLlon suaaesLs nerve rooL compresslon or Lenslon (radlcular paln)
4 uorslflex Lhe fooL whlle malnLalnlna Lhe ralsed poslLlon of Lhe lea
3 ncreased paln sLrenaLhens Lhe llkellhood of a nerve rooL problem
6 8epeaL Lhe process wlLh Lhe opposlLe lea
7 ncreased paln on Lhe oppos|te slde lndlcaLes LhaL a nerve rooL problem ls almosL cerLaln
FFR 1ext (Hlpx/ucrollluc jolntx)
FABER stands Ior Flexion, duction, and External #otation oI the hip. This test is used to
distinguish hip or sacroiliac ioint pathology Irom spine problems. |10|
Ask Lhe paLlenL Lo lle suplne on Lhe exam Lable
2 lace Lhe fooL of Lhe effecLed slde on Lhe opposlLe knee (Lhls flexes abducLs and exLernallv
roLaLes Lhe hlp)
3 aln ln Lhe aroln area lndlcaLes a problem wlLh Lhe hlp and noL Lhe splne
4 ress down aenLlv buL flrmlv on Lhe flexed knee and Lhe opposlLe anLerlor superlor lllac
cresL
3 aln ln Lhe sacrolllac area lndlcaLes a problem wlLh Lhe sacrolllac [olnLs