1. Symmetry, contour, skin discoloration, scars (size & location), rashes, abnormal vascular patterns, umbilical position, bulges, guarding or visible peristalsis.
2. With any visible masses or herniations, have the patient raise his/her head & cough.
3. Using the diaphragm of the stethoscope, listen for bowel sounds in each quadrant. THIS MUST BE DONE BEFORE ANY OTHER PROCEDURE!
4. Listen for bruits with the bell of the stethoscope over the abdominal aorta, renal, common iliac & femoral arteries.
Abdominal aorta – just superior to the umbilicus
Renal – few cm superior to the umbilicus on the lateral side of the rectus abdominis muscle
Iliac – just medial to mid-way point of ASIS & umbilicus
Femoral – just inferior to the inguinal ligament approx. 1⁄2 of the distance from ASIS to pubes.
5. Listen for bruits (bell), venous hums (diaphragm) & friction rubs (bell) over the liver & spleen. For the liver, listen 2-6 cm above the subcostal margin from the mid-sternal line to the AAL. The spleen is located along the 9th, 10th, & 11th ribs roughly from the left mid-scapular line to the MAL. Listen in the PAL at the level of the 10th (lowest palpable) ICS.
6. Percuss the abdomen from the subcostal margin to the pelvis in the midsternal, midclavicular & anterior axillary lines.
7. Percuss the margins of the liver in the midclavicular line, noting its span. Percuss toward the margins. Normal span = 6-12 cm in MCL.
8. Percuss for splenic enlargement in several areas beginning in areas of lung resonance. In the lowest intercostal space in the anterior axillary line on the left, percuss while the patient slowly inspires fully. Note any change in the percussive note from tympanic to dull, indicating splenic enlargement.
9. Begin palpation gently & superficially in the area farthest away from the location of pain. In the absence of pain, begin at the RUQ & proceed clockwise. Cover all 4 quadrants, noting tenderness, guarding or masses.
10. Palpate deeper by using your free hand to push the palpating hand into the tissues. Again palpate all 4 quadrants PLUS the aortic pulse superior to the umbilicus.
11. Attempt to palpate the kidneys & spleen. Both are usually only palpable in thin people. NEVER palpate a spleen that is possibly friable (easily ruptured).
12. If a mass is discovered, determine its general location. While palpating the mass, have the patient bear down (contract the abdominal muscles). If the mass becomes more prominent, it is located in the wall (intramural). If the mass disappears, it is located within the abdominal cavity (intraabdominal).
13. Locate the edge of the liver. Place both hands on the subcostal margin; curl fingers under. Every time the patient exhales, move your fingers under the right subcostal margin. Feel for an enlarged liver sliding under your fingers as it descends.
14. Check for rebound tenderness by gently & slowly applying deep pressure in an area far away from the location of pain. Without warning, quickly release the pressure. Pain will localize over the area of peritoneal irritation.
15. Check for the presence of ascites. Have the patient in the quadruped position. Steadily “flick” the flank while auscultating in the midline with the diaphragm of the stethoscope. In the normal patient, the percussive note is auscultated “loud & clear”. A patient with ascitic fluid will exhibit a muffling of the auscultated percussive note that becomes “loud & clear” as the stethoscope is moved toward the opposite flank, past the margins of the puddle of ascitic fluid. This finding during auscultatory percussion of the abdomen is called a positive puddle sign. (Normally, you would have had the patient lying prone for 5 minutes prior to performing this technique.) This method detects very small amounts of ascitic fluid.
16. With the patient seated, percuss the left & right costovertebral angles for kidney tenderness.
17. Manual muscle testing (MMT) of psoas (iliopsoas test) & engaging obturator (obturator test) for abdominal tenderness.
18. Cutaneous hyperesthesia is tested by picking up a fold of skin between thumb & index finger at a series of points down the abdominal wall. Normally, this maneuver should not be painful.
1. Seat the patient comfortably in a chair with a back, legs uncrossed & palms facing up; arm selected is free of clothing.
2. The arm is resting at the level of the 4th intercostal space (level of the heart) & not tensed.
3. Choose the appropriate sized cuff by checking indicator marks on the cuff.
4. Position the artery indicator of the deflated cuff over the brachial artery (medial to the biceps tendon); tubing should rest on the outside of the arm.
5. The lower border of the cuff should is placed about 2.5 cm above the antecubital crease.
6. The cuff is secured snugly.
7. The patient’s arm is supported and positioned so that it is slightly flexed at the elbow.
8. The systolic pressure is determined by palpation, to determine how high to raise the cuff pressure. While feeling the radial artery with the fingers of one hand, the cuff is rapidly inflated to 30 mm HG above the level where the radial pulse disappears.
9. Insert the stethoscope earpieces, angled forward to fit snugly.
10. The diaphragm* of the stethoscope is placed over the brachial artery (just medial to the biceps tendon), taking care to lightly press, but to make an air seal with its full rim.
11. The cuff pressure is reduced at a 3-5mmHg/sec rate.
12. The pressure at which the first sound is heard is identified as the systolic pressure. (The systolic level is read & recorded to the nearest 2 mm Hg.)
13. The cuff pressure reduced & the point at which the sounds disappear is identified as the diastolic pressure.
14. Auscultation is continued for another 10 to 20 mm Hg drop to make sure diastolic has been identified. (The diastolic level is read & recorded to the nearest 2 mm Hg.)
15. The cuff is then rapidly deflated to zero.
16. Slow or repetitive inflations of the cuff are avoided.
17. Accurate data is obtained/recorded.
18. Demonstrates knowledge of standard hypertension definitions: Normal (desirable): <120/<80
Hypertension Stage 1: 140-159/90-99
Hypertension Stage 2: ≥160/≥100
19. Demonstrates knowledge on hypertension (HTN) urgency and emergency.
Urgency HTN: Urgency >220/>120 without evidence of organ damage (i.e., normal funduscopic exam)
Emergency: Malignant hypertension >220/>120 with evidence of organ damage (i.e., abnormal funduscopic exam) or accelerated HTN (recent significant increase over baseline)
1. General appearance/hands/nails
2. With the patient supine (gown open to the front), observe for chest asymmetry, deformity, scars and precordial impulses. Attempt to identify the apical impulse.
3. With the patient supine, palpate for the PMI (Point of Maximum Intensity) as well as thrills, lifts or heaves.
The Levine grading scale is a numeric scoring system to characterize the intensity or the loudness of a heart murmur. The grading gives a number to the intensity from 1 to 6:
- The murmur is only audible on listening carefully for some time.
- The murmur is faint but immediately audible on placing the stethoscope on the chest.
- A loud murmur readily audible but with no palpable thrill.
- A loud murmur with a palpable thrill.
- A loud murmur with a palpable thrill. The murmur is so loud that it is audible with only the rim of the stethoscope touching the chest.
- A loud murmur with a palpable thrill. The murmur is audible with the stethoscope not touching the chest but lifted just off it.
The Levine scaling system persists as the gold standard for grading heart murmur intensity. It provides accuracy, consistency, and interrater agreement which are essential for diagnostic purposes, particularly to distinguish innocent from pathological murmurs. Louder murmurs (grade ≥3) are more likely believed to represent cardiac pathology.
4. With the patient supine (ideally), determine the lateral border of the heart by percussing lateral-to-medial in the 3rd, 4th & 5th ICS on the left side, working from resonance to dullness.
5. With the patient in the seated position (female suitably draped), the patient is instructed to breathe normally. Apply the diaphragm of the stethoscope over all valve locations (APETM). Repeat in the reverse direction with the bell.
6. Mitral valve enhancement in left lateral decubitus position.
7. Aortic evaluation with seated patient leaning forward
8. Jugular Venous Pressure (JVP)
1. Auricles for position, size, symmetry, nodules or skin lesions.
2. External ear canal for discharge, swelling or erythema.
3 & 4. Ear canal & eardrum using an otoscope w/ largest speculum ear will accommodate.
5. Movement of the auricle & tragus (“tug test”) in cases of ear pain, discharge or inflammation.
CN VIII assessment (hearing)
6. Auditory Acuity
- Weber Test If acuity is decreased, perform the Weber test. Place base of a lightly vibrating 512 Hz tuning fork firmly on top of the patient’s head. Ask patient where the sound is heard. Sound is normally heard equally in both ears. Sound will lateralize to the “bad” ear in conductive hearing loss; sound will lateralize to the “good” ear in sensorineural loss.
- Rinne Test To compare bone & air conduction, perform the Rinne test. Place the base of a lightly vibrating 512 Hz tuning fork on one mastoid process. When the patient no longer hears sound, quickly place the fork near the EAM. Normally, the vibration is heard longer through air than through bone (AC>BC). BC > AC = conductive loss.
- Schwabach Test To compare the patient’s bone conduction to your own, perform the Schwabach test. Place the superior portion of a lightly vibrating 512 Hz tuning fork 2 inches in front of patient’s EAM. When patient no longer hears sound, quickly place the fork 2 inches in front of your own EAM. Normally, the vibration will be heard at approximately the same intensity for both the examiner & the patient. If the patient hears longer than the doctor, conductive loss is suspect. If the normal doctor hears longer than the patient, sensorineural loss is suspect. Longer duration = conductive; shorter duration = sensorineural (s=s).
- Otoscopic exam is also part of CN VIII assessment. See above “inspection” section.
1. Alignment & symmetry of eyes, eyelids & eyebrows
2. Eyelashes should be curved outward & equally distributed.
3. Inflammation, crusting, edema or masses
4. Conjunctivas & sclera
5. Lacrimal system
6. Sclera & conjunctiva
7. Cornea & lens
CN VII (facial expression) – portion which affects eye
8. Ask patient to close & open eyes slowly; eyelids should move symmetrically & close completely.
CN II (vision)
Have patient stand 20 feet away from Snellen Chart & cover one eye (without pressure). Ask patient to read smallest line of print possible (glasses or contact lenses should be worn). Record visual acuity at side of line. Test the other eye.
Using a pocket chart (Rosenbaum), have the patient hold the chart at the focal length that is best for them (~14 inches). Have them recite the line with the smallest letters that they can read and record the acuity. > 50% of a line read correctly is what is considered passing. DOT standard = at least 20/40 in either corrected or uncorrected eye (& must be able to distinguish between red, yellow and green).
10-11. Pupil Evaluation (PERRLA)
P = pupils; E = equal; R = round; R + L = react to light (direct & consensual); A = accommodation (to near distance)
12. Eye Alignment & Muscle Balance: Corneal Light Reflection Test
13 – 15. Funduscopic Exam
Set ophthalmoscope (Panoptic) by focusing on print 15 feet away. Keep your thumb on the focus wheel. Tell patient to gaze straight ahead at a specific distant point. Use your dominant eye to examine either eye. Place one hand on patient’s forehead to stabilize Shine light beam on patient’s pupil, starting 6 inches away and beginning 15 degrees to the temporal side of the patient. Locate a red reflex (reflection), noting any opacities interrupting the reflex, or the optic disc itself.
Move in toward the patient until the optic disc is seen or by following a blood vessel centrally until you do. Observe for:
- Sharpness or clarity of the disc outline;
- Color of the disc (normally yellowish orange to creamy pink);
- Size of the central physiologic cup (< 50% of the horizontal diameter of the disc) and
- Comparative symmetry of the eyes in respect to findings of the fundi. Also,
- Pigmented crescent(s) (which ring the disc) is/are present in some & is/are normal finding(s).
CN III, IV, VI (extraocular muscles)
16. Visual Fields
Use your moving fingers as a stimulus to check the 3 lateral (temporal) fields. Compare each field with its contralateral counterpart (superolateral, lateral & inferolateral). Bring your wiggling fingers into patient’s field of vision & have the patient indicate by raising their index finger when they first see the moving stimulus. Do both sides at the same time to save time & for direct comparison. Normal: at least 70 degrees of horizontal field in each eye; at least 20 degrees of visual field both above and below the horizontal axis in each eye
17-18. Eye Alignment & Muscle Balance: Cover/Uncover & Cross Cover/Uncover Tests
Cover/uncover test is utilized when testing for strabismus (tropias). Patient fixates on a penlight or other interesting target. While patient covers one eye, examiner observes movement of uncovered eye. Patient covers other eye and test is repeated.
19-20. H-Pattern of Gaze & Lid Lag Assessment
Tell patient to follow your finger while moving it through the 6 cardinal fields of gaze. Eye movements should be symmetrical & conjugate. To detect nystagmus, pause during upward & lateral gazes. Look for lid lag as patient’s eyes move from up-to-down (this suggests hyperthyroidism).
Head and face
1. Shape of the skull & size of the head in proportion to the body. Position of head in relation to neck.
2. Condition & distribution of scalp hair. Note any facial hair. Scalp scaling, nits & scars.
3. Face shape, color & skin condition, noting any skin lesions, scars, masses, edema & unusual pigmentation.
4. Shape & symmetry of eyebrows, eyes, nose & mouth
5a. Scalp & skull for masses and tenderness
5b. Parotid gland
6a. Maxillary sinuses
Press up (with thumbs) on the maxillary sinuses. Pain may suggest sinusitis (See Percussion section – must palpate & percuss for credit)
6b. Frontal sinuses
Press up (with thumbs) on the frontal sinuses, avoiding pressure on the eyes. Pain may suggest sinusitis. (See Percussion section – must palpate & percuss for credit)
7. Temporal artery
8. Orbital artery
6a. Maxillary sinuses
6b. Frontal sinuses
9. CN V assessment (sensory & motor to the jaw)
10. CN VII assessment (motor to the face)
1. Color & skin condition, noting any skin lesions, scars, masses, edema, unusual pigmentation
2. Tracheal deviation
3. Thyroid gland, with extension of neck & tangential lighting (i.e., penlight)
4. Thyroid gland, with swallowing
5. Tracheal deviation
Use 3 fingers, palpate it with middle finger and use 2 fingers in supratracheal notch in relation to SCM muscles; trachea should be able to be palpated symmetrically in the concavity formed.
6. Thyroid gland
7. Lymph nodes
b. Posterior auricular
g. Superficial cervical
h. Posterior cervical
(i. Deep cervical chain-inaccessible)
9. Carotid artery
Auscultate with the bell for bruits.
10. CN XI assessment (SCM & upper trapezius strength)
Nose (sinuses), mouth, and oropharynx
1. Nose externally for symmetry & deformity.
2. Nasal vestibule, including nasal mucosa, septum & turbinates, using a (short, wide) speculum (of the otoscope).
3. Lips, noting color & moisture, and note any lumps, ulcers, cracking or scaliness.
4. Dorsum of tongue for size & texture; sides & undersurface of tongue (with gloved hand and paper towel) for nodules or ulcerations.
5. Inspect buccal (i.e., cheek) mucosa for appropriate pigmentation, ulcers, nodules & bite marks.
6. Inspect gums for color & swelling.
7. Teeth for color & surface.
8. Frenulum length (as patient lifts up tongue).
9. Saliva amount & consistency.
10. Floor of mouth, intraoral salivary glands & duct openings.
11. Hard palate for color & form.
12. Pharynx by depressing tongue with tongue blade. As patient says “ahhh”, observe anterior & posterior pillars & observe tonsils of fossae for redness or exudates; rise of soft palate & uvula should be symmetrical.
13. Test for nasal patency/obstruction (patient occludes one ala nasi while attempting to inhale through the opposite one).
14. Maxillary sinuses
15. Frontal sinuses
16. Maxillary sinuses
17. Frontal sinuses
18. CN XII assessment (patient protrudes tongue)
19. CN IX & X assessment (gag reflex)
20. Assess for halitosis.
Peripheral vascular – lower extremity
Systematic Inspection of the Lower Extremity in the Supine Position
1. Full inspection of lower extremity from toes to inguinal ligament in the supine patient (with loose shorts rolled away or loin cloth), include the bottom of the feet & between toes.
2. Pulse assessment (accurate locations & techniques)
a. Dorsalis Pedis
b. Posterior Tibial
Non-Pulse Arterial Assessment
- Skin & nail color
- Trophic assessment of the skin & the appendages of the skin
- Skin temperature (backs of the hand touching the patient in symmetrical areas)
- Nail (toe) compression test
- Femoral auscultation (light pressure with the bell)
- 8. Inspect for chronic venous stasis (ankle pigmentation or ulcers)
- 9. Inspect / test for pitting edema
Press thumb firmly but gently behind medial malleolus, dorsum of foot, over the shins or obvious area of edema for at least 5 seconds. Look for pitting (a depression caused by pressure from your thumb). Normally, there is none. Classically, the severity of edema is graded on a 4-point scale:
1+ Mild pitting, slight indentation, no perceptible swelling of the leg 2+ Moderate pitting, indentation subsides rapidly 3+ Deep pitting, indentation remains for a short time, leg looks swollen 4+ Very deep pitting, indentation lasts a long time, leg is very swollen
10. Palpate for skin thickening of the ankle areas
11. Inspect / palpate for varicosities with patient standing
12. Perform the Venous Tap Test.
Patient stands for this technique. Examiner palpates the long saphenous vein at the level of the medial knee with one hand. Examiner taps over saphenofemoral junction (medial thigh, just below the inguinal ligament – 4 cm lateral to & 4 cm inferior to pubes) with the other hand. Examiner feels for palpably transmitted impulse (positive test). Palpable impulse indicates valve incompetence along the long saphenous vein.
13. Observe for swelling or redness.
14. Palpate for heat, tenderness or cords.
15. Gently palpate in the posterior middle calf for tenderness.
16. Homan’s sign
Inguinal Region, Lymph & Hernia Assessment
17. Femoral pulse assessment
18. With cough:
a. Femoral vein/great saphenous insertion assessed for tenderness & regurgitation
b. Hernia check medial to femoral vein
19. Horizontal (inferior to inguinal ligament) & vertical (along femoral vein) lymph node assessment
20. Perform the Leg Elevation Test.
If pain or diminished pulses suggest chronic arterial insufficiency, raise both legs to about 60 degrees until maximal pallor of the feet develops (usually 60 secs). In light-skinned persons, either maintenance of normal color or slight pallor is normal. Have patient sit-up, with legs dangling down, and note time required for skin color to return (usually 10 secs). Also, note how long it takes to fill veins of feet & ankles (usually 15 secs).
Peripheral vascular – upper extremity
Systematic Inspection of the Upper Extremity in the Seated Position
1. Full inspection of upper extremity from fingertips to axillae in the seated patient (with gown sleeves rolled away).
2 &3. Pulse assessment (accurate locations & techniques)
c. Allen’s Test
Non-Pulse Arterial Assessment
- Skin & nail color
- Trophic assessment of the skin & the appendages of the skin
- Skin temperature (backs of the hand touching the patient in symmetrical areas)
- Nail compression test/capillary refill
- Hydration status – tissue turgor
a. Pectoral (anterior) – anterior axillary fold
b. Humeral (lateral)
c. Subscapular (posterior)
d. Apical (medial)
Thorax and lung
1. Chest structure, including the A-P & lateral diameters, sternum, clavicles, shoulders, thoracic spine & ribs for any asymmetry or abnormality.
2. Thorax retractions; position & stability of the trachea
3. General, lip & fingernail colors
4. Rate, rhythm, depth & effort of breathing
5. Instructs patient to cross their arms (to move scapulae laterally) for #’s 8 & 9 below.
6. Lateral Chest Expansion
Stand behind the patient & place your hands firmly along the axis of the 7th intercostal space with your fingers extending along the intercostal spaces anteriorly to the angulation of the ribs. Your thumbs should contact each other in the mid-spinal line. Using normal & then forced inspiration, observe & feel for differences in lateral expansion of either side. Your thumbs should separate symmetrically. Repeat the same maneuver while standing in front of the patient, with your hands placed along the subcostal margin of the thorax.
7. Anterior-Superior Chest Expansion
Stand at the patient’s side. Place one hand on the upper thoracic spine & the other hand on the sternum. Observe for anterior-superior movement on normal and forced inspiration.
8. Tactile Fremitus
Instruct patient to cross their arms (to move scapulae laterally). Have the patient say “99, 99, 99…” Using the ulnar edge of the hand or the palmar bases of the fingers (MP jts), palpate for vibrations on the chest wall. This is done B/L comparing one side of the chest to the other, following the MCL (mid-clavicular line) anteriorly & the midscapular line posteriorly.
9. Lungs posteriorly
Instruct patient to cross their arms. While creating tissue pull with pleximeter finger and using a continuous percussive pattern (versus “tap, tap, rest…”), percuss both lungs in the intercostal spaces from top-to-bottom & medial-to-lateral in a ladder pattern (see #12-14 below) listening for normal, dull & tympanic sounds.
11. The patient is instructed to quietly breathe in & out through the mouth with slightly deeper than normal breaths.
12-14. Systematically (i.e., ladder pattern) covers the entire posterior & posterior lateral lung for a full breathing cycle in each location.
The patient’s arms are crossed & the head is slightly flexed for the posterior evaluation. Diaphragm is used for all auscultatory points EXCEPT the apex, in which the bell is used.
15. The presence of normal bronchial, bronchovesicular & vesicular sounds & presence/absence of added (adventitious) sounds are determined.
16. If bronchial sounds are heard in vesicular locations, bronchophony, egophony & whispered pectoriloquy techniques are demonstrated/explained.
In bronchophony, the patient is requested to repeat a word several times while the physician auscultates symmetrical areas of each lung. The number “ninety-nine” is traditionally mentioned. Better phrases in English include “toy boat”, “Scooby Doo”, and “blue balloons”. Increased loudness of word in area of consolidation = bronchophony. Often, the patient does not have to speak for the physician to hear signs of bronchophony. Rather, the normal breath sounds are increased in loudness – referred to by doctors as “increased breath sounds” – over the affected area of the lungs. In egophony, while listening to the lungs with a stethoscope, the patient is asked to say the letter “e.” What is heard is a higher pitched sound that sounds like the letter “a.”
Some doctors refer to this as “e to a transition.” Most commonly, this indicates pneumonia. Auscultate the same areas again, but this time have the patient whisper repeatedly “blue moon”. If there is consolidation in the lung, the whispered sound will be heard quite distinctly on the chest wall (whisper pectoriloquy). All 3 techniques test for similar findings; only one is chosen during an exam.
1. Proper use of TempawayTM/ thermometer cover
2. Instructions to patient (under tongue, close mouth, breath through nose)
3. In mouth for adequate amount of time (10 seconds or until beeps)
4. Knowledge of the normal value (98.6 °F)
5. Knowledge of factors which may influence accuracy
6. Knowledge of causes of abnormal temperature
7. Records results properly
9. Relaxed arm, accurate location of palpation of the pulse
10. Counted pulse for an adequate time period (15 secs), & accurately determined rate (X4)
11. Checked for, noted & recorded any irregularity of the pulse rhythm, contour & intensity
12. Familiar with the normal range & factors which may influence heart rate
13. Records results properly
15. Counted respirations while in “pulse taking position” to prevent altered breathing by the patient
16. Counted for 15 secs (up to 1 min), & was accurate at determining the rate (X4)
17. Checked for, noted & recorded any irregularity in the rhythm, depth & effort of respiration
18. Familiar w/ the normal range & factors which may influence respiratory rate (12-20 rpm)
19. Records results properly
Credit for the above goes to Dr. Stacy M. Thornhill Peterson, DC, DACRB.