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Exam 1 Question 17	 	0 / 1 point

If bronchial breath sounds are heard in locations distant from their usual location, which of the following responses is most likely? A)	Pneumothorax B)	Emphysema C)	Asthma D)	Lung Cancer E)	Could be a normal finding Treatment Questions

RS #3: HPI

RS #4: Harrisons

Question 29	 	0 / 1 point

Which of the following is the best test to diagnose pancreatitis? Serum amylase Plain x-rays of the abdomen Ultrasound CT scan

Exam 2 Question 5	 	0 / 1 point

A patient that you are seeing in the office complains of headaches that occur frontally. They also complain of facial pain and feel congested. Which of the following statements is MOST true regarding this patients condition? Acute Sinusitus is defined as disease of less than 3 months duration. Migraine headaches more often do NOT have Nausea associated with them. The Frontal Sinus is the most common location for Sinusitus to occur. Tension Headaches usually wake a person up in the middle of the night and are associated with hypnopompic hallucinations. Brain abscess is a potential life-threatening complication of this condition. Joint Disease

Bates

Headache

Physical Exam

Question 26	 	0 / 1 point

Oral cancer most commonly occurs in which of the following locations? Base of the tongue Lip Side of the tongue Soft palate Uvula Question 30	 	0 / 1 point

A 36 year old man with which of the following blood pressures would be considered to have pre-hypertension? 115/75 120/80 140/90 160/100 100/60 Miscellaneous

Exam 3 Question 2	 	0 / 1 point

A 24 year old woman comes to the physician with nasal congestion. During the examination of the nose, the nasal speculum is inserted close to the lateral wall. This is in order to avoid causing trauma to which of the following? Sphenopalatine artery Anterior ethmoid artery Facial artery Kiesselbach's plexus Sphenoid sinus Question 3	 	1 / 1 point

What is the most common cause of hospital errors involving patient safety? Family interferrence Misdiagnosis Patient noncompliance Miscommunication among hospital staff Equipment failure Question 4	 	0 / 1 point

A 70 year old woman comes to the physician with a three week history of increasing shortness of breath. She also complains of chest tightness. She has no cough. She normally sleeps on one pillow and is now sleeping on three pillows to be able to breath more comfortably. On physical exam, she has a respiratory rate of 26 per minute. Examination of the heart shows a regular rate and rhythm with no murmurs. Examination of the lungs shows rales. A diagnosis of congestive heart failure is being considered. Which of the following signs or symptoms would help rule in this diagnosis? History of cigarette smoking Wheezes Pain relieved by antacid S3 Fever Question 5	 	1 / 1 point

Which of the following medications is commonly associated with a cough? Proton pump inhibitors Anti-depressants ACE-Inhibitors H2 blockers Anti-virals Question 6	 	1 / 1 point

Which of the following is a feature of chronic respiratory distress that can be seen in the extremities? Radial deviation Motor dysfunction Ulnar deviation Sensory loss Clubbing Question 7	 	0 / 1 point

A 74 year old woman comes to the physician for a routine health maintenance examination. The blood pressure in her right arm is 150/90 and in her left arm is 130/70. Which of the following is the most likely cause of these findings? Obstruction of the right brachial artery Aortic valve stenosis Mitral valve stenosis Obstruction of the left pulmonary artery Obstruction of the left axillary artery Question 8	 	0 / 1 point

Which of the following is the MOST true statement regarding woman and heart disease? Woman face the same barriers to quitting smoking as men do. Low dose Aspirin does not lower the Risk of Coronary Heart Disease in woman. Heart disease is the second leading cause of death in women. Woman receive more interventions to treat heart disease than men. A woman who has diabetes should be treated the same AS IF she actually has diagnosed Coronary Heart Disease. Question 9	 	1 / 1 point

In the primary care office, a 39 y.o. male complains of sharp chest pain that radiates to the back and neck. Which of the following statements would be most true regarding the condition he mostly likely has? It is most likely a case of Angina Pectoris A chest x-ray is the most appropriate next step Recommend the patient return in 3 days for follow up Call 911 and have the patient be transported to the closest emergency room. Treatment with Nitroglycerin is indicated Question 10	 	1 / 1 point

In the primary care office, a 47 y.o. female complains of her heart fluttering and pounding. It does not get worse upon exertion. Which of the following statements is most true regarding her condition? She should be told to go to the Emergency Room immediately Treatment with Nitroglycerin is indicated A chest x-ray is the most appropriate next step An EKG is the most appropriate next step Recommend the patient return in two weeks for follow up Question 11	 	0 / 1 point

You are examining a 67 y.o. female who complains of dyspnea. On exam the lung fields are hyperesonant bilaterally, breath sounds are decreased, and tactile fremitus is decreased. Which of the following statements would be most consistent with this patient's condition? Examination reveals a traumatic piercing injury to the right chest wall A history of fever & purulent sputum X 2 weeks Patient reports a seasonal pattern to the symptoms A pleural effusion is noted on chest x-ray A history of smoking 2 packs of cigarettes a day X 20 years Question 12	 	0 / 1 point

A hospitalized patient has pneumonia in the superior aspect of the right lower lobe. It is suspected that the pathogen is either anaerobic or gram-negative bacilli. Additional history includes the patient has difficulty swallowing. Which of the following statements would be most consistent with the patient's condition? Treatment with Nitroglycerin is indicated The patient is elderly and reports a history of drinking heavily The patient has a history of Congestive Heart Failure Family history reveals carcinoma of the lung in the father The patient reports a history of difficulty urinating Question 13	 	0 / 1 point

A 50 y.o. otherwise healthy woman is admitted to the hospital for treatment of pneumonia. Which of the following statements is most true? A respiratory rate of less than 10 breaths/min is the best indicator for severity of symptoms Blood and sputum cultures should be obtained after initiation of treatment Clear sputum is likely to be present Streptococcus Pneumoniae is the most likely etiology This patient is most likely immuno-compromised Question 14	 	1 / 1 point

A 45 year old woman comes to the physician because of some mild difficulty breathing for the past two weeks. She complains of some chest tightness but no pain. She has an occasional cough with no sputum production. She has had no fever or chills and no previous similar episodes. She has never smoked. On auscultation of the lungs, wheezes are heard. Which of the following is the most likely diagnosis? Pneumonia Congestive heart failure Asthma Lung cancer Upper airway obstruction due to a foreign body Question 15	 	0 / 1 point

A 15 year old boy comes to the physician because of increasing shortness of breath over the past month. He has been coughing several times each hour with the production of minimal clear sputum. He has not had any chest pain, fever, or chills. On physical examination of the lungs he has decreased air movement in all lung fields. His complete blood count shows eosinophilia. Which of the following is the most likely diagnosis? Vocal cord dysfunction Pneumonia Asthma Upper airway obstruction due to a foreign body Lung cancer Question 16	 	1 / 1 point

A 70 year old man comes to the physician because of increasing shortness of breath over the past week. He has been coughing several times each hour with the production of yellow sputum. On physical examination he has a temperature of 101 degrees. The lung exam shows egophany over the lower left lung field. Which of the following is the most likely diagnosis? Asthma Upper airway obstruction due to foreign body Congestive heart failure Pneumonia Lung cancer Question 17	 	0 / 1 point

A 70 year old man comes to the physician because of increasing shortness of breath over the past week. He has been coughing several times each hour with the production of yellow sputum. On physical examination he has a temperature of 101 degrees. The lung exam shows egophany over the lower left lung field. Which of the following is the best first step in making the diagnosis? CT scan of the chest Chest x-ray Sputum acid fast stain for M. tuberculosis Urine antigen test for Legionella pneumophila Serum IgM Question 18	 	1 / 1 point

An 8 year old girl comes to the physician because of some difficulty breathing for the past two days. She complains of some chest tightness but no pain. She has an occasional cough with no sputum production. She has had no fever or chills and no previous similar episodes. The family had gotten a new cat two days ago. On auscultation of the lungs, wheezes are heard. Which of the following is the best first step in management? Alpha adrenergic agonist Systemic glucocorticoid Remove the inciting agent Desensitization Beta blocker Question 19	 	1 / 1 point

A 65 year old man comes to the emergency department with sharp substernal chest pain for the past two hours. The pain began after eating a big meal and vomiting. The pain has been constant and does not radiate. He has hypertension treated with a beta-blocker and a 40 pack year smoking history. On physical examination, his respiratory rate is 28 and he has a temperature of 102 F. Examinaltion of the heart is normal and the lung exam shows decreased breath sounds in the left lower lobe with egophany. Examination of the abdomen shows no tenderness or masses with normoactive bowel sounds. Which of the following is the most likely cause of this patient's current symptoms? Lung cancer Asthma Ruptured esophagus Aortic dissection Myocardial infarction Question 20	 	1 / 1 point

A 44 year old woman is hospitalized four days after an open cholecystectomy when she develops shortness of breath and sharp pain in the left upper chest. She is coughing up blood tinged sputum. She has no history of any major medical illnesses. On physical examination, her respiratory rate is 32 per minute and her temperature is 100 F. Examination of the heart shows a regular rate and rhythm and examination of the lungs shows bibasilar rales. The abdomen has minimal incisional tenderness. Which of the following is the most likely diagnosis? Aortic dissection Asthma Congestive heart failure Pneumothorax Pulmonary embolus Question 21	 	1 / 1 point

A 60 year man complains of left leg pain two days after undergoing a colectomy for colon cancer. He also complains of mild abdominal pain. He has no history of previous leg pain. He has a 40 pack year history of smoking and no other major medical illnesses. On physical examination, he has a temperature of 99.8 F. Examination of the lungs shows crackles bilaterally at the bases and examination of the heart shows regular rate and rhythm. The abdomen has minimal distention and moderate incisional tenderness with bowel sounds present. Examination of the left leg shows normal skin color, 2 plus pitting edema, dorslis pedis pulse present, and positive Homan's sign. Which of the following is the most likely diagnosis? Deep venous thrombosis Chronic venous insufficiency Acute lymphangitis Acute arterial occlusion Superficial thrombophlebitis Question 22	 	0 / 1 point

A 60 year old man comes to the emergency department because of a one month history of "squeezing"anterior chest pain. The pain occurs several times a week and is exacerbated with climbing stairs and relieved by rest. The pain began as a 2 out of 10 and is now 8 out of 10. He has hypertention that is being treated by diet and exercize. On examination, he is afebrile with a blood pressure of 130/90 and a respiratory rate of 20 per minute. Examination of his heart shows a normal S1 and S2 with an S3 and no murmur. His lungs are clear to auscultation and percussion and his abdomen is soft and non tender. Which of the following is the most important first step in management? Beta blocker Calcium antagonist Motrin Nitroglycerin Intravenous fluid bolus Question 23	 	0 / 1 point

When a 512 Hz tuning fork is placed into strong vibration and placed on the top of a patient's head, the patient says they can only hear the sound in the right ear. You follow up with a Rinne test that shows that air conduction is not as good as bone conduction in the right ear but air conduction is better than bone conduction in the left ear. Which of the following is the best interpretation of these results? The patient has sustained damage to their right 8th cranial nerve The patient has a conductive hearing loss in their left ear An auditory acuity check must be performed to correctly interpret these findings The patient has a conductive hearing loss in their right ear The patient has sustained damage to their left 8th cranial nerve Question 24	 	0 / 1 point

While percussing for the left heart border, hyperresonance is heard over the entire left chest. Which of the following conditions is most likely to be present? Cardiac hypertrophy Pneumonia Pleural effusion Chronic obstructive pulmonary disease Lung cancer Question 25	 	0 / 1 point

A 40 year old man complains of one week of burning pains in his substernal area. They last a couple of minutes and have been noticed every night for the last week with no change in intensity or duration. He particularly notices these pains at night when he is sleeping, but sometimes he also gets them when he reclines in the sofa. He has been treating himself by getting up and drinking some water or milk and this does seem to relieve the pain. He has not seen any physicians about this problem before and has never had similar symptoms in the past. He is concerned because his father died of a heart attack and prior to his death would often complain of chest pains. Which of the following key elements of the history of present illness is missing in the example above? Previous evaluation Self treatment and the response to this treatment Timing Pertinent negatives Setting Question 26	 	0 / 1 point

A 49 y.o. patient complains of significant stress since beginning a new job. You notice that the patients blood pressure, which has been previously controlled with diet and exercise is significantly elevated (160/100). Which of the following statements is most true regarding this patient's symptoms? The patients exacerbation of blood pressure is likely the result of eustress. Negative self talk is the most likely cause of the increased stress. Leaving the job is the best option for getting the blood pressure back under control. A thorough history & physical exam is the next best step to managing the patient. Sharing your stress with the patient will show you empathize with his/her situation. Question 27	 	0 / 1 point

When examining a 25 y.o patient, you notice that the sounds of the patient's pulse disappears on inflating the cuff around the 130 mm/hg Mark. Because of the excellent training you have had in ECR, you are palpating the radial pulse, and notice that it persists. You continue to inflate the cuff and you begin to hear the pulse over the brachial artery around the 160 mg/hg Mark. Which of the following statements regarding this patient is most true? The Sphygmomanometer is not working correctly and should be discarded. This patient most likely has hypertension. This patient does not have Korotkoff sounds. This patient most likely has an arrhythmia. Auscultating over ERB's point will likely reveal a tricuspid murmur. Question 28	 	0 / 1 point

A patient is giving a history and states that they are coughing up red-streaked material. Which of the following signs should be recorded in the patient record? Dyspnea Hematemasis Hematochezia Hemoptysis Melena Question 29	 	1 / 1 point

During morning rounds on patient S.G., an attending physician asks a resident to complete the following task. "Order morning labs for the patient with renal failure": In regards to patient safety, what should the attending physician say instead to more effectively communicate with the resident? Choose the ONE best answer. "Please order a complete blood count and basic metabolic panel for patient S.G. in Room 475." "Order CBC and BMP for the patient on the fourth floor." "Order routine labs for the patient S. G. on the fourth floor" "Please order a complete lood count and basic metabolic panel for the patient with renal failure on the 4th floor. "Please order CBC and BMP for the patient with renal failure in room 475." Question 30	 	1 / 1 point

Which of the following is the most common age for diagnosis of lung cancer? 35-44 45-54 55-64 65-74 75-85 Question 31	 	1 / 1 point

A 45 y.o. woman with a recent myocardial infarction is noted to have insulin resistance, hypertension, dyslipidemia (triglycerides > 200 mg/dl), and central obesity. Additional history reveals that she has smoked 2 packs of cigarettes a day for the past 25 years. Which of the following statements is most true concerning this patients condition? This patient should NOT be told to quit smoking due to the possibility of depression. This patient would NOT benefit from Aspirin therapy. Her condition puts her in the low risk category for Cardiac Disease. She has a greater than 20% risk of having a Cardiac event over the next 10 years. Blood pressure should be maintained around 140/90.

Exam 4 Question 19	 	0 / 1 point

You are in a family practice waiting room, and notice a patient next to you who is audibly sighing every 3rd or 4th breath. His respiratory rate appears to be normal. Which of the following statements is MOST accurate regarding this patient? He has Ataxic Breathing. Consult a neurosurgeon. This is Kussmaul breathing. THe patient may be in metabolic acidosis. This patient must be old. This is a classic example of Cheyne-Stokes Breathing. This patient may next experience dyspnea and dizziness. You should suggest to them they might want to lay down. The patient is likely on the verge of a diabetic coma. Procure a small glass of orange juice and suggest to the patient he drink it. Question 22	 	0 / 1 point

A 27 year old man comes to the emergency department with an 8 hour history of abdominal pain and nausea with no vomiting. He has had no diarrhea or constipation. The pain is in his right flank and radiates to the groin. It is 8 out of 10 and comes and goes. He has had no similar previous abdominal pain and no history of any major medical illnesses. On physical examination, his temperature is 99.2 and his lungs are clear to auscultation and percussion. His abdomen is not distended and there are no palpable masses. There is minimal right lower quadrant tenderness without guarding. Which of the following is the most likely diagnosis? Abdominal aortic aneurysm Appendicitis Cholecystitis Diverticulitis Ureterolithiasis Question 28	 	0 / 1 point

A 50 year old man complains of abdominal pain and vomiting for the past 2 days. After taking the history, you begin performing the physical exam. When palpating for the spleen, you noticed that it is normal in size and not tender to palpation. Where is the spleen normally located? Anterior to the left midaxillary line Posterior to the left midaxillary line Left costovertebral angle Epigastric region Left lower quadrant of abdomen Question 33	 	0 / 1 point

During an abdominal examination you note abdominal distention and high-pitched tinkling bowel sounds. Which of the following is the most likely cause of these findings? Adynamic ileus Diarrhea Intestinal obstruction Peritonitis 1 of 2

Question 36	 	0 / 1 point

A 29 y.o. male patient presents with acute abdominal pain. Which of the following physical examination maneuvers would be ESSENTIAL in this patient? Pelvic Examination Sensory examination of the lower extremity Range of Motion of the Back Evaluation for Berry Anauerism Rectal Examination

Exam 5

Question 5	 	0 / 1 point

A 74 year old man is brought to the physician's office by his daughter because he has been more forgetful recently. Which of the following is the best way to directly test for attention in this patient? 1)	Finger-to-nose test 2)	Inquire if he has any thoughts of suicide 3)	Ask him to name 3 Presidents 4)	Ask him to spell "world" backwards 5)	Observation of how he is dressed and groomed Question 6	 	0 / 1 point

A patient believes he is being controlled by an outside force. At times he sees alien objects which no one else can see. Which of the following statements is MOST true regarding this patient? 1)	This patient may have poor hygiene and innapropriate dress 2)	This patient would score an 11 on the Glasgow Coma Scale 3)	This patient is not at risk for suicide 4)	This diagnosis would best be coded under the cluster B personality disorders 5)	This diagnosis would best be recorded under Axis Three Question 9	 	0 / 1 point

You are on hospital rounds and are called to examine a patient. Upon examining the patient you notice they are unresponsive to stimuli, even to sternal rub. A CT scan of the brain shows no mass lesions. A spinal tap reveals a WBC (White Blood Cell count) that is significantly elevated. The MOST likely cause of this patients condition is? 1)	Metabolic Coma 2)	Glioblastoma Multiforme 3)	Epidural hemorrhage 4)	Viral encephalitis 5)	Acute bacterial meningitis Question 10	 	0 / 1 point

A 50 year old woman with a history of atherosclerosis presents with aphasia, right sided hemiparesis and sensory loss in the face. In addition, she has gaze preference toward the left side and homonymous hemianopsia. Which of the following vascular territories is most likely affected? 1)	Right middle cerebral artery 2)	Left middle cerebral artery 3)	Left anterior cerebral artery 4)	Right posterior cerebral artery 5)	Left anterior cerebral artery Question 15	 	0 / 1 point

A 14 month old girl is brought to the physician by her mother because of trouble breathing. The child is in her mother's arms and appears fatigued, with a loud inspiratory stridor. Before beginning the physical examination, which of the following is the MOST helpful factor in the immediate assessment of this child? 1)	Assessment of the child's overall appearance 2)	Determining if her immunizations are up to date 3)	Complete abdominal review of systems 4)	Assessment of risk for child abuse 5)	Assessment of family history of cardiac disease Question 19	 	0 / 1 point

A 28 year old man comes to the physician because of abdominal pain for several weeks. The pain is located in the upper abdomen, is a 4/10 and radiates to the back. He has not had any nausea or vomiting. He admits to drinking at least three beers/day. On physical examination there is mild tenderness in the epigastric region with no masses and normoactive bowel sounds. Which of the following is the best way to determine if the patient has problems with alcohol? 1)	Obtain a CT of the abdomen 2)	Ask the patient the CAGE questions 3)	Check liver function tests 4)	Ask for any family history of alcoholism 5)	Refer him to an alochol counseling treatment center Question 21	 	0 / 1 point

You are the first person to examine a patient who presents to the emergency room. On examination of this patient you determine their Glasgow Coma Score as 5. Which of the following would be the next MOST appropriate step in the care of this patient? 1)	Do an MRI of the abdomen looking for a primary source of metastatic cancer to the brain 2)	Administer the CAGE questionaire 3)	Administer glucose and thiamine 4)	Refer the patient to a psychiatrist for treatment 5)	Administer a narcotic agent such as morphine Question 26	 	0 / 1 point

A 58 year old man comes to the hospital because of an acute exacerbation of his congestive heart failure. He has a history of alcoholism. During the second day of admission, the patient suffers a grand-mal seizure. The patient recovers but several hours later begins to become confused, shows autonomic instability and has fluctuating consciousness. After evaluating the patient, you order Ativan (lorazepam), a benzodiazepine, to be administered intravenously to this patient. What is the Most Appropriate Clinical rationale for ordering this medication? 1)	To calm the patient's anxiety over having a seizure 2)	To prevent the development of delirium tremens 3)	To prevent the development of Wernicke - Korsakoff syndrome 4)	To prepare the patient for intubation 5)	To prevent the patient from developing violent outbursts when he regains consciousness Question 27	 	0 / 1 point

You are evaluating a 78 year old woman who lives by herself. You want to ask about her instrumental activities of daily living, since they are often "lost" first. Which of the following would you MOST likely ask about? 1)	Remembering the names of her grandchildren 2)	Eating and dressing 3)	Shopping, cleaning, and cooking 4)	Ability to ambulate around her home 5)	Bathing, toileting and transfers Question 29	 	0 / 1 point

A 53 year old white male comes to the office at the urging of his wife who states over the last two weeks he has lost interest in playing with the grandchildren, can't sleep, has lost 6 pounds and has little energy. He remains quietly sitting in his chair without lifting his head. When greeted by the physician, he slowly picks his head up to make eye contact. His eyes look tired and sad. His affect is dysphoric. Which of the following is the MOST important part of this patient's history and physical examination? 1)	Examination of the thyroid 2)	Performance of a mini mental state exam 3)	Obtaining a social history 4)	Assessment for suicide risk 5)	Examination for a Babinski's sign

ECR bates old
Interviewing and Health History: Health History Interview: -	Conversation with a purpose o	Establish a trusting and supportive relationship o	Gather information o	Offer information -	Health history format – structured framework for organizing patient information in written and verbal form for other health care provider -	Interviewing process – the process of generating the same piece of information o	Demand effective communication and relational skills with fluidity -	All new pt  comprehensive health Hx -	Pt w/ specific complaints  problem-oriented Hx Approaching the interview: -	Self-reflection o	Professional development in clinical work o	Personal awareness -	Reviewing the chart -	 Setting goal o	Balance provider-centered goal with patient-centered goal -	Reviewing your own clinical and appearance o	Guard your feelings against criticisms when talking to pt and colleagues -	Adjusting the environment o	Make pt feel comfortable -	Taking notes Sequences of the Interview: -	Must ALWAYS be attuned to pt’s feelings, help pt express them, responds to their content, and validate their significance. o	1) greeting and establishing rapport 	Maintain pt’s confidentiality 	Attune to their comfort 	Stay w/in several feet of pt •	intimacy w/out intrusive o	2) invite pt’s story 	Being w/ open-ended questions 	Follow pt’s lead 	Active listening •	w/out interruption o	3) establish agenda 	Establish pt’s confidence o	4) expanding and clarifying pt’s story 	Guided questioning •	Lead to focused questionings •	Elicits graded responses •	Ask a series of questions - one at a time •	Offer multiple choices •	Request clarifications •	Contineurs and encouragement •	Echoing 	Validation 	Reassurance – identifying and acknowledging pt’s feeling o	5) generating and testing diagnostic hypotheses 	Pertinent positives and negatives o	6) share understanding of problem 	Disease – explanation that the clinician brings to the symptoms 	Illness – how the pt experiences symptoms •	take into account the perspective on illness of the pt. 	*Find out pt’s expectation! o	7) negotiating plans 	Empowering approach to pt’s role 	Involvement of clinicians’ self on emotional and reflective levels o	8) planning follow-up and closing 	Reaffirm mutually developed plan 	Reconfirm your continued commitment to pt -	Adapting interview to specific situations: o	Silent patients 	Appear attentive 	Give brief encouragement 	Watch patient for nonverbal cues 	Pt w/ depression or dementia •	explore mental status examination o	Confusing patients 	Emphasize pt’s perspectives 	Shift to psychosocial assessment 	Pt w/ inconsistent and cannot provide clear chronology of events •	Acute illness or intoxicated  delirium •	Elderly  dementia 	If suspect psychiatric or neurologic disorder, shift to mental status examination •	Level of consciousness, orientation, memory, comprehensive capacity o	Patients with altered capacity 	Pt cannot provide their own histories 	MUST determine their decision-making capacity •	ability to understand information related to health •	make medical choices based on reasons •	consistent set of values •	declares Tx preferences 	Pt w/ psychiatric conditions or cognitive impairments  decision-making remains intact o	Talkative patients 	Allow pt to talk for 5-10 min 	Be directive and set limit when needed 	DO NOT show impatience o	Crying patients 	Pt on the verge of tears •	pausing, gently probing, and responding w/ empathy •	give pt permission to cry 	Pt cries •	Offer a tissue and wait for recovery •	Positive remark o	Disruptive and angry pt. 	Accept pt’s feelings and allow for expression •	AVOID joining feelings •	can validate w/out agreement 	Overtly disruptive patient •	Alert security staffs before approaching •	DO NOT try to lower pt’s voice •	Stay calm and accepting – relaxed postured •	Listen carefully •	AVOID confrontation •	Once established rapport, suggest moving to private location o	Patient with language barrier 	Find interpreter •	Translate everything! 	Short, clear, and simple questions 	Speak directly to pt 	Be patient. o	Patient w/ low literacy 	Explore reasons 	Asking education level is helpful •	Maybe misleading 	Quick screen •	Hand written text upside down 	Respond sensitively •	Illiteracy and lack of intelligence are not synonymous o	Patient w/ impaired hearing 	Find preferred method of communication 	Ask when hearing loss occurred, kinds of school 	Determine patient’s identification •	 ‘Deaf culture’ or ‘Hearing culture’ 	Pt w/ hearing aid  make sure it works 	Pt w/ unilateral hearing  sit on the hearing side 	Pt w/ hard of hearing  eliminate background noise 	Pt w/ partial hearing and can read lips  face them directly 	When closing, write out oral instructions o	Patient w/ impaired vision 	Shake hand – establish contact 	Orient patient to surroundings and people present 	Helpful to adjust light o	Patient w/ limited intelligence 	Pt can give adequate Hx 	If suspect problem, pay attention to their schooling and ability to function independently 	Sexual Hx •	Active? •	Provide information about pregnancy and STD 	If unsure of level of intelligence •	Smooth transition to mental status examination 	Patient with severe mental retardation •	Turn to family or caregiver •	ALWAYS show interest in pt first •	AVOID talking down or condescending behavior o	Patient w/ personal problem 	DO NOT give answer 	Let pt talk through problems •	Explore the choices they have considered •	Relate pro and con --- Comprehensive Adult Physical Examination I)	General survey – continues throughout hx and examination II)	Vital signs – BP, pulse, RR, and Temp III)	Skin – lesion, color, hair, and nail, etc. IV)	HEENT (head, eyes, ears, nose, throat) V)	Neck – lymph nodes, trachea, breathing, and thyroid glands VI)	Back – spine and muscles VII)	Posterior thorax and lungs – inspection, palpation, and percussion a.	Level of diaphragm dullness b.	breath and voice sounds VIII)	Breast, axillae, and epitrochlear nodes a.	Breast – arms relaxed, elevated with hands on hip IX)	Anterior thorax and lungs X)	Cardiovascular system a.	Jugular venous pulsation (elevated head about 30degree), carotid pulsation, etc. XI)	Abdomen XII)	Lower extremity a.	Patient is supine. i.	Peripheral vascular system – femoral and popliteal pulses, inguinal lymph node, edema, etc ii. Musculoskeletal system – joints, ROM, etc iii. Nervous system – tone, strength, sensation, reflex, and ROM b.	Patient is standing. i.	Peripheral vascular system – varicose veins ii. Musculoskeletal system – alignment of spine, leg, and feet & ROM iii. Genitalia and Hernias in Men – penis and scrotal iv. Nervous system – gait and Romberg and pronator drift tests XIII)	Nervous system – pt is standing or supine. a.	Mental status – positional orientation, mood, thoughts, perceptions, insight, judgement, memory, attention, and communication b.	Cranial nerves c.	Motor system – cerebellar function d.	Sensory system – pain, temperature, touch, vibration, etc i.	Right vs. left e.	Reflexes Additional examinations: -	Rectal examination – pt lying on left side -	Genital and rectal examination in women – pt is supine in lithotomy position o	Pap smear, etc. --- TECHNIQUE S OF EXAMINATION: Head -	Hair o	Fine hair  hyperthyroidism o	Coarse hair  hypothyroidism o	Tiny white granules  eggs of lice or nits -	Scalp o	Redness and scaling  seborrheic dermatitis, psoriasis o	Soft lumps  pilar cysts (wens) -	Skull o	Enlarged skull  hydrocephalus or Paget’s disease o	Tenderness after trauma -	Face -	Skin o	Facial hair  hirsutism or PCOS Eyes -	Visual acuity o	Snellen eye chart – 20/20: the 1st = pt distance; the 2nd = distance a normal eye can read 	20/200 or less  legally blind o	“myopia” = impaired vision o	“presbyopia” = impaired near vision o	If pt cannot read large letters, test ability to count and distinguish light -	Visual field by confrontation o	Screen in temporal field b/c most defects involve these areas 	Homonymous hemianopsia 	Bitemporal hemianopsia 	Quadrantic defects o	Further testing 	If defect is detected, establish the boundaries 	Test one eye at a time 	Temporal defect in one visual field  contralateral nasal defect 	Small visual defect and enlarged blind spot requires finer stimulus •	Normal blind spot – 15 degree temporal to the line of gaze •	Enlarged blind spot  glaucoma, optic neuritis, and papilledema -	Position and alignment of eyes o	Inward/outward deviation o	Protrusion  Graves’ disease or ocular tumors -	Eyebrows o	Scaliness  seborrheic dermatitis o	Lateral sparseness  hypothyroidism -	Eyelids o	Width, edema, color, lesion, condition and direction of eyelashes, and closure adequacy 	Red inflamed lid margins  blepharitis 	Failure to close exposes cornea to serious damage -	Lacrimal apparatus o	Check glands and sacs for swelling, tearing or dryness 	Excessive tearing b/c: •	increased production  conjunctival inflammation and corneal irritation •	impaired drainage  ectropian and nasolacrimal duct obstruction -	Conjunctiva and sclera o	Inspect sclera and palpebral conjunctiva 	Pt look up as you depress both lower lids with thumbs •	color, nodules, or swelling o	Yellow  jaundice o	Inspect sclera and bulbar conjunctiva 	Pt look up and down as you spread the lids •	Local redness  nodular episcleritis -	Cornea and lens o	With olique lighting, inspect for opacities -	Iris o	With light from temporal side o	crescentic shadow on the medial side  abnormal iris bowing forward 	increases risk for acute narrow-angle glaucoma •	increased intraocular pressure w/ occluded drainage of humor 	open-angle glaucoma (common)  iris is fully lit •	b/c spatial relation is preserved. -	Pupils o	inspect size, shape, and symmetry o	Large (>5mm) and small (<3mm) 	Constriction  miosis 	Dilation  mydriasis 	Contralateral inequality less than 0.5mm  normal anisocoria •	20% in normal people •	If papillary reaction is normal  benign anisocoria o	Compare with Horner’s syndrome, oculomotor nerve paralysis, and tonic pupil o	Reaction to light – darken the room 	Direct reaction 	Consensual reaction 	*Near reaction in normal light – if reaction to light is impaired/questionable •	Helpful in diagnosing Argyll Robertson and tonic (Adie’s ) pupil -	Extraocular muscles o	Pupilllary response 	2 ft from pt, shine light onto eyes, and pt look at light •	Inspect reflections in the cornea o	Visible slightly nasal to the center of pupil  normal o	Asymmetry  abnormal ocular alignment (nasal deviation, dysconjugate gaze, etc) o	“cover-uncover test” – reveal slight/ latent muscle imbalance o	Movement: 	6 cardinal directions of gaze (H) •	Conjugate and deviated movement •	Pause during upward and lateral gaze  detect nystagmus 	Nonconjugate left lateral gaze  left infranuclear ophthalmoplegia 	Nystagmus – fine rhythmic oscillation of eyes •	Few beats at extreme later gaze  normal. •	Sustain w/in binocular field  neurologic conditions 	Lid lag (as eye moves up and down)  hyperthyroidism •	If suspected lid lag, re-test slowly o	Lid should overlap iris slightly throughout •	Visible rim of sclera and lid lags behind eyeball  hyperthyroidism/lid lag 	“convergence test” •	Follow the object w/in 5-8cm of nose  normal •	Poor convergence  hyperthyroidism -	Ophthalmoscopic examination o	In general healthcare, examine pt w/out dilating their pupils 	Mydriatic drops – for peripheral structures, evaluate macula well, investigate visual loss •	NOT USE in head injury, coma, and suspicion of narrow-angle glaucoma o	Opthalmoscope – physician should not wear glasses 	Darken room 	Start w/ 0 diopter (unit that measures power of lens to converge or diverge light) •	if physician and pt have no refractive error 	Hold with R hand when examining R eye and vice versa 	Tilted laterally 20 degrees slant from vertical 	15 inches from pt at 15 degree lateral to pt’s line of vision 	Lower brightness of light beam to avoid hippus (spasm of pupil) and improve observations 	Look for the red reflex •	Absence  opacity of lens (cataract) or vitreous; detached retina; retinoblastoma (children) o	Optic disc – yellowish orange to creamy pink oval/round structure 	About 1.5 mm -	Optic disc and retina examination: o	Optic disc 	Vessel size enlarges at junction when approaching disc 	Adjust lens of ophthalmoscope  bring to sharp focus •	Myopic (nearsighted)  rotate counterclockwise (- diopters) •	Hyperopic (farsighted)rotate clockwise (+ diopters) •	Refractive error – light does not focus on retina o	Myopia – focus anterior; retinal structures appear large. o	Hyperopia – focus posterior 	Inspect: •	Sharpness of outline o	Blurred nasal portion  normal •	Color of disc o	White/pigmented crescents around  normal •	Size of central physiologic cup – yellowish white (if present) o	Normal: horizontal diameter < ½ diameter of disc o	Enlargement: chronic open-angle glaucoma •	Comparative symmetry o	Papilledema – swelling of optic disc and anterior bulging of physiologic cup 	increased intracranial pressure to optic nerve  stasis of axoplasmic flow, intra-axonal edema, swelling of optic nerve 	serious brain disorder •	meningitis, subarachnoid hemorrhage, trauma, and mass lesion 	Detection of this disorder is the priority! 	Elevation of optic disc (if the disorder detected) •	Difference in diopters needed to focus elevated disc and uninvolved retina •	At retina, 3 diopters = 1mm 	Venous pulsation – normal in many •	Loss  head trauma, meningitis, mass lesion o	early sign of elevated intracranial pressure o	Retina – arteries, veins, fovea, and macula 	Follow peripherally in 4 directions for abnormalities 	Disc diameter = measurement term of lesion in retina from optic disc 	Inspect fovea and macula •	Light beam laterally or pt look directly into light •	Shimmering light reflection – common in young ppl •	Macular degeneration – cause of poor central vision in elders o	Dry atrophic – common and less severe o	Wet exudative/ neovascular •	Drusen – undigested cellular debris o	Hard and sharply defined o	soft and confluent with alter pigmentation 	Inspect anterior structure •	Opacities in vitreous or lens •	+10 or +12 diopters •	Vitreous floaters – dark specks or strands b/n fundus and lens •	Cataracts – densities in lens --- Ears -	Auricle o	“tug test” – movement of auricle and tragus 	Painful in acute otitis externa (inflammation of ear canal) •	Not in otitis media (inflammation of middle ear) 	Tenderness maybe present in otitis media -	Ear canal and drum o	Use otoscope w/ largest speculum 	Insert speculum downward and forward o	Grasp auricle firmly but gently 	pull it upward, backward, and away o	inspect: 1) ear canal 2) eardrum 3) handle of malleus o	Exostoses – non tender nodular swelling covered by skin 	Nonmalignant overgrowth 	May obscure drum o	Acute otitis externa – canal is swollen, narrowed, moist, pale, tender, and maybe redden o	Chronic otitis externa – thickened canal skin, red, and itchy o	Acute purulent otits media – red bulging drum 	Amber drum  serous effusion o	Retracted drum – unusual prominent short process and a prominent horizontal handle of malleus o	Pars flaccid – superiorly in the canal o	Pars tensa o	Pneumatic otoscope – evaluate mobility of drum 	Decreased mobility  serous effusion, thicken drum, or purulent otitis media -	Auditory acuity o	Test hearing one ear at a time -	Air and bone conduction o	If hearing is diminished 	 distinguish conductive vs. sensorineural hearing loss o	Use 512 Hz tuning fork 	Frequency falls in human speech (300-3000Hz) o	Weber test 	Place on top of pt’s head or midforehead 	Unilateral conductive hearing loss  acute otitis media, perforated eardrum, obstruction in ear canal o	Rinne test 	Place vibrated fork on mastoid bone, level w/ canal 	When pt can no longer hear •	Quickly bring fork closer to canal 	Normal: still heard b/c conduction through air > bone 	Conductive hearing loss  DO NOT hear or hear longer w/ bone 	Sensorineural hearing loss  heard longer w/ air

Nose and Paranasal Sinuses -	tenderness of nasal tip or alae local infection ie. furuncle -	Inside the nose o	nasal obstruction; deviation o	use largest ear speculum 	AVOID contact w/ nasal septum -	Nasal mucosa o	Red and swollen  viral rhinitis o	Pale and bluish red  allergic rhinitis -	Nasal septum o	Epistaxis(noseblood) – usually from lower anterior portion 	b/c trauma, surgery, intranasal cocaine or amphetamine o	polyps – pale, semitranslucent masses o	ulcer – from nasal cocaine o	tenderness (+pain, fever, discharge)  acute sinusitis --- MOUTH AND PHARYNX -	Lips – color, moisture, lumps, ulcers, cracking, scaliness o	#1 cancer of mouth -	Oral mucosa – light and tongue blade o	Color, ulcer, white patches, nodules o	White line of buccal mucosa intensified  sucking or chewing o	Aphthous ulcer -	Gums and teeth – pink color, brown patch(esp, black ppl), swelling, ulceration, looseness, mishapen o	Pt. removes dentures 	Thickening ulcers/ nodules  malignancy 	Bright red edematous mucosa  sore mouth 	Ulcers or papillary granulation tissues o	Gingivitis  swollen interdental papillae -	Roofs of mouth – color and architecture of hard palate o	Torus palatines  midline lump -	Tongues and floor of mouth o	Top of tongue - symmetry, color, texture 	Asymmetric protrusion  lesion of CN XII o	 Undersurface of tongue and floor of mouth – prone to cancer 	Cancer of tongue – 2nd most common in mouth •	Mostly found on side on tongue o	Next most often is at base. •	Nodule, ulcer, red or white •	Men over 50 yrs old, esp. smokers and alcohol drinkers 	Palpate w/ gloves and tissues -	Pharynx and soft palate o	Anterior and posterior pillars, uvula, tonsils o	Symmetry, color, swelling, ulceration, tonsillar enlargement, tenderness - Neck: I)	lymph nodes – use pads of index and middle fingers a.	preauricular b.	posterior auricular c.	occipital d.	tonsillar i.	pulsate  carotid artery ii.	tender, high, and deep b/n mandible and sternomastoid styloid process e.	submandibular f.	submental g.	superficial cervical h.	posterior cervical i.	deep cervical j.	supraclavicular II)	trachea and thyroid glands a.	goiter – enlarged thyroid gland b.	soft  Graves’ disease c.	firm  Hashimoto’s thyroiditis, malignancy d.	tenderness benign and malignant nodules e.	systolic or continuous bruit hyperthyroidism III)	carotid arteries and jugular veins --- LUNGS: Techniques of examination: -	Pt. sitting  examine posterior thorax and lungs o	Pt. hugging him/herself -	Pt. supine  examine anterior thorax and lungs o	Wheeze – easily heard o	Women – easier b/c breasts can be gently displaced -	Pt. unable to sit up w/o aid o	Get help to examine posterior field 	If impossible, roll pt on side and the other o	Percuss upper lungs and auscultate o	Wheezes and crackles in dependent lungs  easily heard 	b/c ventilation is greater in dependent lungs -	Inspect  palpate  percuss  auscultate -	Draping: o	Male: see chest fully o	Female: 	posterior exam  cover anterior chest 	anterior exam  cover un-examining half -	 Initial survey: o	Re-inspect RR, rhythm, depth, effort/ difficulty 	RR = 14-20 times/min 	Inspiration is longer than expiration 	Occasional sign is normal. o	Color of cyanosis  hypoxia 	Clubbing of nails  lung abscesses, malignancy, congenital heart disease o	Listen to breathing 	Wheezing and during what part of cycle 	Audible stridor (high-pitched wheeze) – airway obstruction in larynx or trachea o	Inspect neck 	Contraction of accessory muscles during inspiration •	Severe difficulty inspiration 	Lateral displacement of trachea •	Pneumothorax, pleural effusion, atelectasis o	Inspect shape of chest 	Aging or COPD  increased anteroposterior diameter -	Inspection: o	Shape of chest and movement – posterior midline position 	Deformities/ asymmetry 	Abnormal retraction during inspiration •	Apparent in lower interspaces •	Present w/ supraclavicular retraction •	Severe asthma, COPD, airway obstruction 	Impaired respiratory movement •	Unilateral impairment/lagging movement  disease of underlying lung/pleura -	Palpation: o	Focus on areas of tenderness, abnormalities, respiratory expansion, and fremitus 	Intercostals tenderness  inflamed pleura o	Identify tender areas 	Site of lesion or bruises •	Bruises  fractured rib o	Assess any observed abnormalities – masses, sinus tracts 	Sinus tracts(blind, inflammatory, tube-like structures opening onto the skin)  infection of pleura and lungs •	Tuberculosis, actinomycosis o	Test chest expansion 	Thumbs at 10th rib and fingers grasping parallel to lateral rib cage •	slide medially to raise loose fold of skin on spine 	Pt. inhale deeply 	Observe symmetry of rib cage and movement of thumbs during inspiration 	*unilateral decrease of delayed expansion •	CF, pleural effusion, lobar pneumonia, pleural pain, bronchial obstruction o	Feel for tactile fremitus 	Fremitus = palpable vibration transmitted through bronchopulmonary tree to chest wall when pt. speaks 	To detect - use ball of palm or ulnar surface of one hand  optimize vibration detection •	Also, 2 hands  increase speed of examination and facilitate detection of difference 	Pt. repeats the word ‘ninety-nine’ or ‘one-one-one’ •	If fremitus is faint, speak louder and deeper o	Otherwise, COPD, pleural effusion, fibrosis, pneumothorax, tumor, thick chest wall, etc. o	Palpate and compare symmetric areas 	Identify and locate areas of increased, decreased, or absent fremitus •	Prominent in interscapular area on R side •	Disappear below diaphragm 	Rough assessment o	Listening to breath, voice, and whisper sounds 	Usually increase or decrease together -	Percussion: o	Air-filled, fluid-filled, or consolidation o	Penetrates about 5-7 cm 	DOES NOT detect deep lesions o	Pleximeter finger = hyperextended middle finger of L hand o	Percussion notes: 	Lightest percussion  clear notes 	For louder note  apply pressure w/ pleximeter finger 	Lower posterior chest •	Stand to the side of pt. •	Place pleximeter finger firmly 	Comparing 2 areas •	Twice in each location 	Identify 5 percussion notes – intensity, pitch, and duration •	Normal lungs – resonance •	Dullness o	Pneumonia – fluid/blood cell-filled alveoli o	Pleural effusion – serous fluid-filled pleura o	Hemothorax – blood-filled pleura o	Empyema – pus-filled pleura •	Generalized hyperresonance o	Hyperinflated lungs 	Emphysema, asthma (not reliable) •	Unilateral hyperresonance o	Large pneumothorax, air-filled bulla Intensity	Pitch	Duration	Example location	Pathologic examples Flatness	Soft	High	Short	Thigh	Large pleural effusion Dullness	Medium	Medium	Medium	Liver	Lobar pneumonia Resonance	Loud	Low	Long	Normal lungs	Chronic bronchitis Tympany	Loud	High	-	Gastric air bubble/ puffed cheek	Large pneumothorax Hyperresonance	Very loud	Lowest	Longest	None	Emphysema, pneumothorax o	Ladder-like pattern 	DO NOT percuss over scapulae o	Identify diaphragmatic excursion (descent of diaphragm) 	determine diaphragmatic dullness during quiet respiration •	Infer probable location of diaphragm from level of dullness •	Abnormally high  pleural effusion, atelectasis, diaphragmatic paralysis o	Estimate the extent of diaphragmatic excursion 	Determine difference b/n full inspiration and expiration 	Normal: 5-6 cm -	Pt. in supine position o	Arm somewhat abducted -	Pt. w/ difficulty breathing o	Pt. sits up or supine on elevated bed o	Pt. w/ severe COPD  sit and lean forward 	lip pursed during expiration 	arms on knees or table -	Inspection o	Shape and movement of chest o	Deformity/ asymmetry o	Abnormal retraction during inspiration 	Severe asthma, COPD, upper airway obstruction o	Lag/ impairment during respiration 	Underlying disease of lungs or pleura -	Palpation o	1.) identify tender areas 	Tender pectoral muscles and costal cartilages •	Chest pain  musculoskeletal origin o	2.) assessment of observed abnormalities o	3.) assessment of chest expansion 	Thumb along costal margin •	Hand along lateral rib cage 	Slide hands medially to raise skin fold 	Pt. inhales deeply 	Feel for symmetric extent of respiration o	4.) assessment of tactile fremitus 	Use ball of palm or ulnar surface of hand 	Fremitus – usually absent or decreased at precordium 	Women – gently displace breasts as necessary -	Percussion o	Heart  dullness L of sternum over 3rd-5th interspaces 	COPD  hyperresonance replaces cardiac dullness o	Dullness  fluid or solid tissues 	Anteriorly  only detect very large effusion o	Women – gently displace breast or ask pt. to move 	Esp., dullness of R middle lobe  usually behind R breast o	Identify upper border of liver 	COPD •	displaces upper border of liver downward •	lower diaphragmatic dullness posteriorly Auscultation: -	Use diaphragm of stethoscope -	Patient breathes deeply through open mouth -	Compare symmetry o	at least 1 full breathe at each location 	1) listen to sound of breathing 	2) listen to adventitious sounds 	3) listen to sounds of pt’s speaking and whispered voice (if abnormalities suspected) -	If suspect abnormality, auscultate adjacent areas Breath sounds: -	Vesicular = soft and low pitch o	Heard through inspiration w/out pause to expiration 	Longer during inspiration o	Fade 1/3 through expiration o	Location: most of both lungs -	Bronchiovesicular = intermediate intensity and pitch o	Equal length in inspiration and expiration 	Separate by a silent interval o	Expiration – easy to detect different pitch and intensity o	Location: 1st and 2nd interspaces anteriorly and b/n scapulae 	Deviated location  fluid-filled or solid lung tissue -	Bronchial = loud and high pitch o	Longer during expiration than inspiration 	Separate by short silence o	Location: over manubrium -	Tracheal = very loud, harsh and high pitch o	Equal length in inspiration and expiration o	Location: over trachea in neck -	*breath sounds are usually louder in the lower posterior lung fields -	*hair on chest  crackling sound -	* cold/tense pt and valsalva maneuver  muscle contraction sound – muffled, low-pitched rumbling or roaring noise -	Breath sound decreases b/c decreased air flow o	Obstructive or restrictive lung disease o	Muscular weakness Adventitious sounds - crackles (rales), wheezes, and rhonchi -	Crackles/ Rales o	pneumonia, fibrosis, early CHF, bronchitis, bronchiectasis o	Discontinuous 	Intermittent, brief 	Like dots in time o	Fine crackles 	Soft, high-pitched, very brief (5-10 msec) 	If at late inspiration and persisted  abnormality o	Coarse crackles 	Louder, lower pitched, brief (20-30 msec) o	If crackles is heard, esp. do not clear w/ cough 	Listen carefully for: •	Loudness, pitch, and duration  fine vs. coarse •	Numbers  few vs. many •	Timing during cycle •	Location •	Persistence •	Changes after cough or positional change o	Clearing adventitious sounds  bronchitis or atelectasis 	Inspissated secretion o	Normal: heard at lung bases after prolonged recumbency -	Wheezes and Rhonchi o	Continuous 	Prolonged (≥250 msec) - not necessarily persisting 	Like dashes in time o	Wheeze 	High-pitched w/ hissing or shrill 	Narrowed airways – asthma, COPD, bronchitis o	Rhonchi 	Low-pitched w/ snoring quality 	Secretions in large airway o	If heard, note timing, location, and changes w/ coughing or deep breathing Transmitted voice sounds – w/ stethoscope -	Increased transmission  airless lungs -	Bronophony test = clearer, louder voice sound o	Pt. says ‘ninety-nine’ 	Should be muffled and indistinct -	Egophony test = E-to-A change o	Pt. say ‘ee’ 	Should be muffled, nasal long E sound o	Egophony  pneumonia 	lobar consolidation -	Whispered pectoriloquy test = louder, clearer whispered sounds o	Pt. whispers ‘ninety-nine’ or ‘one-two-three’ 	Should be faintly and indistinctly Special techniques: -	Clinical Assessment of Pulmonary Function o	Assess complaint of breathlessness o	Walk w/ Pt. down hallway, climb stairs o	Observe rate, effort, and sound of breathing -	Forced Expiration Time o	Slow in obstructive pulmonary disease 	≥ 6 sec  obstructive pulmonary disease o	Pt. takes deep breath 	Exhales as fast as possible w/ open mouth o	Listen over trachea w/ diaphragm of stethoscope o	Get 3 consistent reading 	Allow short rest b/n efforts -	Identification of a Fractured Rib o	Anteroposterio compression  distinguish fracture vs. soft-tissue injury 	Increase local pain  rib fractures •	Not just soft-tissue injury o	One hand on sternum and the other on thoracic spine 	Squeeze chest --- Vital Signs -	Blood pressure o	If BP is high, re-check at later examination o	Sphygmomanometer’s cuff 	Too short, too narrow, loose cuff  false hypertension 	Non relaxed patient  false hypertension o	Auscultatory gap = silent interval b/n systolic and diastolic pressures 	If unrecognized over- or underestimation o	Aortic regurgitation – sound never disappears o	Venous congestion – due to slow, repetitive inflation 	Yield falsely low systolic and high diastole BP o	Venous obstruction/compression 	>10mmHg difference b/n L and R sides o	BP 	Normal: <120/80 	Prehypertension: 120/80 – 139/89 	Hypertension: •	Stage 1: 140/90 – 159/99 •	Stage 2: ≥160/100 o	Special situation: 	Weak/inaudible korotkoff sounds •	Estimate systolic pressure by palpation or Doppler technique •	Raise arm before and during inflation o	Lower to get BP •	Make fist several time after inflation 	Arrhythmia •	Average from several observations 	Anxious patient/office or white-coat HTN •	Try to relax pt 	Unequal BP in arms and legs of HTN pt •	Compare volume and time b/n radial and femoral pulses -	HR and rhythm o	Irregular irregularity  atrial fibrillation and atrial/ventricular premature contraction -	RR and rhythm o	Prolonged expiration narrow bronchioles -	Temperature o	Oral - under tongue for 3-5 min 	Normal = 37C 	Lower in early morning 	Higher in late afternoon/evening o	Rectal – hip flexed; 3-4cm in anal canal for 3 min 	Normal = 37.5C 	Temp > 41.1C  Hyperpyrexia 	Temp < 35C  Hypothermia o	Axillary: = 36C 	Less accurate 	Need 5-10 min o	Tympanic membrane – 2-3min 	Measure core body temp = 37.8C •	Higher than normal oral temp
 * tender nodes  inflammation
 * hard nodes  malignancy
 * diffuse lymphadenopathy suspicion of HIV or AIDS
 * Examination of Posterior Chest:
 * Examination of Anterior Chest
 * Clinical:
 * Discrepancy b/n oral and rectal temp due to rapid RR  rectal temp is more reliable.

HEART Cardiac examination: -	Pt. positions and sequence of examination o	Supine and elevated at 30 degree 	Inspect and palpate precordium •	2nd R and L interspace •	R ventricle •	L ventricle o	Apical impulse (diameter, location, amplitude, duration) o	L lateral decubtius - turning on L side 	Palpate apical impulse 	Listen at apex w/ bell of stethoscope 	Accentuated findings: S3, opening snap, diastolic rumble of mitral stenosis o	Supine and elevated at 30 degree 	listen at tricuspid area w/ bell o	Sitting, leaning forward, after full expiration 	Listen along L sternal border and at apex w/ diaphragm of stethoscope 	Accentuated findings: diastolic murmur of aortic insufficiency o	*these positions bring ventricular apex to chest wall  detection of maximal impulse and aortic insufficiency -	Examiner: on R side of pt. -	Identify findings by both: 1) anatomical location 2) their timing in cardiac cycle -	HR ≥ 120bpm  indistinguishable S1 and S2 o	*S1 decreases  first-degree heart block o	*S2 decreases  aortic stenosis o	Assist w/ carotid pulse 	Murmur w/ pulse  systolic 	Murmur after pulse  diastolic Inspection and Palpation: -	Palpation: o	S1 and S2 – firm pressure o	S3 and S4 – light pressure o	Thrills – ball of hand firmly 	Accompany loud, harsh, rumbling murmurs -	Dextrocardia – right-sided heart o	w/ normal placement of other organs  associated w/ congenital heart disease -	Point of maximal impulse(PMI)/ apical impulse  left ventricular area(apex of heart) o	Location: 	Upward displacement  pregnancy or high left diaphragm 	Lateral displacement  CHF, cardiomyopathy, ischemic heart disease, deformities, and mediastinal shift o	Diameter 	Normal: <2.5 cm 	>3 cm at lateral decubtitus  L ventricular enlargement o	Amplitude 	Normal: brisk, tapping, hyperkinetic(after exercise) 	Increase  hyperthyroidism, severe anemia, pressure or volume overloads o	Duration 	*most useful to identify L ventricular hypertrophy •	Sustained high amplitude 	Normal: DOES NOT continue to S2 	Hypokinetic(sustained low-amplitude)  dilated cardiomyopathy -	R ventricular area o	Increased amplitude w/ normal duration  volume overload 	Atrial septal defect o	Increased amplitude and duration  pressure overload 	Pulmonic stenosis or pulmonic hypertension o	Hyperinflated lung (in obstructive lung disease) may shied detection of R ventricular hypertrophy -	Pulmonic area o	Palpable S2  pulmonary hypertension -	Aortic area o	Palpable S2  systemic hypertension o	Pulsation  aneurismal aorta Percussion -when apical impulse is inpalpatable. Auscultation: -	Diaphragm – press firmly o	High pitched sounds of S1 and S2 o	Murmurs of aortic and mitral regurgitation o	Pericardial friction rubs -	Bell – press lightly o	Low pitched sounds of S3 and S4 o	Murmur of mitral stenosis o	Use at apex  medially along lower sterna border -	Left lateral decubitus position – roll partly onto the left side o	Bring left ventricle to the chest wall 	Accentuates left-sided S3 and S4 and mitral murmur from stenosis -	Listen during w/held breathing after complete exhalation Clinical: -	Split S2 o	Expiratory splitting – abnormal o	Normal: persistent splitting 	delayed closure of pulmonary valve 	early closure of aortic valve -	Intensity of A2 and P2 o	Loud P2 – pulmonary hypertension -	Extra sound in systole o	Click of mitral valve prolapsed – most common

Abdomen Examination: 1.	Inspection a.	Skin - scars, striae, dilated veins, rashs and lesions i.	Pink-purplish striae  Cushing syndrome ii. Dilated veins  hepatic cirrhosis or IVC obstruction b.	Umbilicus – contour, inflammation, or hernia c.	Contour of Abd i.	Bulging flanks  ascites ii. Suprapubic bulge  distended bladder or pregnancy iii. Hernias iv. Asymmetry  enlarged organ/mass v.	Lower mass  ovarian or uterine tumor d.	Peristalsis i.	Increased wave  intestinal obstruction e.	Pulsations – aortic pulsation i.	Increased pulsation  aortic aneurysm/ increased pulse pressure 2.	Auscultation – use diaphragm a.	Normal sound i.	Clicks and gurgles of 5-34 times/min ii. Borborygmi – long prolonged gurgles of hyperperistalsis (growling) b.	Altered sound b/c of diarrhea, obstruction, paralytic ileus, and peritonitis c.	Pt w/ high BP: i.	Epigastric systolic with diastolic bruits  renal artery stenosis ii. Aortic, iliac, and femoral systolic with diastolic bruits partial occlusion or insufficiency 1.	Systolic bruit – common and do not signify occlusion d.	Friction rubs  liver tumor, gonococcal infection of liver, and splenic infarction 3.	Percussion – amount of gas distribution, identify solid or fluid-filled mass, and size of liver and spleen a.	Tympany – gas i.	Throughout  protuberant abd and intestinal obstruction 1.	If flanked by dullness  ascites b.	Dull – fluid, feces, underlying masses, or enlarged organ i.	Pregnancy, ovarian tumor, distended bladder, large liver or spleen c.	*situ inversus – organs are reversed (rare) 4.	Palpation a.	Light - tenderness, muscular resistance, superficial masses or organ i.	Patient should be relaxed. ii. If resistance presents, distinguish voluntary from involuntary muscular spasm 1.	Voluntary relaxation w/ exhalation a.	Ask pt to mouth-breathe with jaw open 2.	Involuntary spasm  peritoneal inflammation b.	Deep – required delineate abd masses i.	Abd masses: 1.	 physiologic; 2) inflammatory; 3) vascular; 4) neoplastic; 5) obstructive c.	Assessment for peritoneal inflammation i.	Characteristics: abd pain, tenderness, and muscular spasm ii. Localization 1.	Ask pt to cough  locate pain 2.	Light palpation  induce pain 3.	Rebound tenderness a.	Caused by rapid movement inflamed peritoneum b.	If tenderness is felt elsewhere unexpected  the area is the source of problem Liver: 1.	Percussion – dullness from umbilicus upward along right midclavicular line a.	Greater in men than women b.	Decreased span of dullness i.	Liver is small, or ii. Free air below diaphragm  perforated hollow viscus, hepatitis, CHF, or progression of fulminant hepatitis c.	Downward displacement of dullness with normal span i.	Lower diaphragm  COPD d.	False estimation of dullness i.	False increase  dullness of right pleural effusion/ consolidated lung ii. False decrease  gas in colon 2.	Palpation – ask patient to relax and breathe deeply with abdomen a.	“hooking technique” - obese pt b.	Firmness or hardness, bluntness or round edge, irregular contour  abnormality c.	Oval mass with dull percussion  obstructed, distended gallbladder 3.	Assessment of tenderness in nonpalpable liver a.	Strike with ulnar surface of right fist b.	Tenderness  inflammation of hepatitis or CHF Assessment of Possible Appendicitis: -	I) Ask pt to: o	1) Point the progression of pain 	Near umbilicus  RLQ o	2) Cough and locate pain 	Pain worsen with cough o	*older pt. might not report these. -	II) Locate local tenderness  RLQ or right flank -	III) Involuntary muscular rigidity -	IV) Rectal examination (or pelvic examination for women)  right-sided tenderness o	Identify atypical inflamed appendix or other causes 	Inflamed adnexa, inflamed seminal vesicle, tubule pregnancy, etc. o	Not distinguishing normal and inflamed appendix -	Additional techniques: o	“Rovsing sign” – press deeply in LLQ 	RLQ pain = “positive Rovsing sign” o	Referred rebound tenderness – press deeply in LLQ and quickly w/draw 	RLQ pain o	“Psoas sign” 	1) raise right thigh against force, or 	2) extend pt’s right leg at hip while lying on left side, stretching psoas muscle 	Pain  “positive psoas sign” (irritated muscle) o	“Obturator sign” - actively flexed right thigh and leg and internally rotate thigh 	Pain in R. hypogastric  “positive obturator sign” (stretched muscle) o	Cutaneous hyperesthesia - Gently pick folds of skin w/o pinching 	Localized pain in RLQ -- HEADACHES -	Primary HA o	Tension 	Bilateral generalized or localized to the occipital, frontotemporal, or upper neck 	Pressing/ tightening; mild to moderate 	Gradual; min. to day; recurrent or persistent; annual prevalence 	Photophobia(sometimes); phonophobia 	Aggravated by sustained muscle tension 	Relieved by massage and relaxation o	Migraines (w/ and w/o aura) 	Neuronal dysfunction; imbalance of NT and craniovascular modulation 	70% unilateral; 30% bifrontal or global 	Throbbing or aching; varied severity 	Rapid; peak w/in 1-2hr; lasts 4-72 hr; prevalence in women; monthly 	Nausea; vomit; photophobia; phonophobia; visual, motor, and sensory auras 	Aggravated by EtOH, food, tension, premenstrual, noise, light 	Relieved by quietness and darkness o	Cluster 	Extracranial vasodilation; neural dysfunction; CN V pain 	Unilateral; behind or around eyes 	Deep, continuous, and severe pain 	Abrupt; peaks w/in min; last 3 hr; episodic 2-3times/day x 3-4 wks 	Lacrimation; rhinorrhea; miosis; ptosis; eyelid edema; conjunctival infection 	Sensitive to EtOH -	Secondary HA o	Analgesic rebound 	Time, location, and sx depend on previous HA 	Aggravated by fever, carbon monoxide, hypoxia, w/drawal of caffeine o	Eye disorder-related 	Error of refraction •	Pain around eyes; radiates to occipital •	Gradual, steady, aching, dull pain •	eye fatigue, “sandy” sensation; red conjunctiva •	aggravated by prolonged usage of eyes 	Acute glaucoma •	Sudden increase in intraocular pressure •	Pain in and around 1 eye •	Rapid, steady, aching, severe pain •	Diminished vision, nausea (sometimes), and vomit •	Aggravated by drops that dilate pupils o	Sinusitis 	Mucosal inflammation of paranasal sinus 	Pain around frontal or maxillary sinus 	Aching, throbbing pain over 2-3hr; recurrent over days 	Tenderness, nasal congestion, discharge, fever 	Aggravated by cough, head, and jar in the head o	Meningitis 	Generalized HA 	Rapid, steady, throbbing, very severe 	Persistent with acute illness 	Fever and stiff neck o	Giant cell (temporal) arteritis 	Immune response to elastic lamina of artery 	Age-related 	Gradual or rapid, throbbing, generalized, persistent, and severe pain 	Recurrent or persistent over week to month 	Tenderness of scalp; fever; fatigue, weight loss; jaw claudication; visual loss; polymyalgia rheumatic 	Aggravated by neck and shoulder movements o	Posttraumatic 	Similar to tension HA and migraine w/o aura 	Pain localized to injured area 	Generalized, dull, aching, and constant 	Onset w/in 1-2 days after injury; diminished over time 	Poor concentration and memory; irritability; fatigue 	Aggravated by mental and physical exertion, alcohol o	Subarachnoid hemorrhage – ruptured intracranial aneurysm 	Abrupt; generalized HA; very severe; “the worse of my life”; persistent 	Nausea; vomit; loss of conscious; neck pain o	Brain tumor 	Displacement of or traction on pain sensitive vessels; pressure on nerve 	Pain depends on location of tumor 	Aching; stead; brief; intermittent but progressive 	Aggravated by cough; sneeze; sudden movement of head o	Cranial neuralgias 	Compression of CN V 	Pain in cheek, jaws, lips, gums (division 2 & 3 > 1) 	Abrupt, shocklike, stabbing, burning, and severe pain •	Each sharp pain lasts seconds but frequent 	Last and disappear for months; uncommon at night 	Exhaustion from pain 	Aggravated by touching and movement of areas - CRANIAL NERVES -	CN I (olfactory) – smell o	Use familiar, non irritating odor o	One nose at a time o	Ask for presence of smell and identification of the smell o	Loss of smell  nasal disease, head trauma, smoking, aging, cocaine usage, congenital etc. -	CN II (optic) – visual acuity, fields, and ocular fundi o	Test visual acuity o	Inspect optic fundi w/ ophthalmoscope  optic atrophy, papilledema o	Test visual field by confrontation 	Esp. stroke patient •	Homonymous hemianopsia  visual extinction o	*visual extinction 	Subtle impairment, detected only when testing both eyes 	Suggests lesion in parietal cortex -	CN II, III (optic and oculomotor) – papillary reaction o	Inspect pupil o	Test papillary reaction to light and near response -	CN III, IV, VI (oculomotor, trochlear, and abducens) – extraocular movement o	Test 6 cardinal direction o	Look for nystagmus and ptosis 	Ptosis = drooping of upper lids •	 Ptosis in 3rd nerve palsy •	Horner’s syndrome = ptosis, meiosis, anhidrosis) •	Myasthenia gravis -	CN V(trigeminal) – corneal reflexes, facial sensation, jaw movement o	Strength of masseter muscle – clenched teeth 	Bilateral weakness •	Difficult to interpret w/o teeth o	Pain sensation o	Temperature sensation o	Light touch – touch skin lightly with cotton o	Corneal reflex – touch cornea lightly with cotton 	Use of contact lens may abolish the reflex -	 CN VII (facial) – facial movement o	Observe symmetry 	Flatten nasolabial fold and drooped lower eye lid  facial weakness o	Raise both eyebrows o	Frown o	Test muscular strength to close eyes 	Abnormal upper and lower face  Bell’s palsy; peripheral injury 	Abnormal lower face  central lesion o	Show teeth o	Smile 	Unilaterally mouth droops  unilateral facial paralysis o	Puff out cheeks -	CN VIII(acoustic ) – hearing o	Assess hearing o	Test lateralization o	Compare air and bone conduction o	Test vestibular function 	Nystagmus may indicate vestibular dysfunction -	CN IX, X(glossopharyngeal and vagus) – swallowing and rise of palate, gag reflex o	Voice 	Hoarseness  vocal cord paralysis 	Nasal voice  palate paralysis o	Swallow 	Pharyngeal or palatal weakness o	Movement of soft palate and pharynx 	Normal – rise symmetrically; uvula in midline 	Palate fails to rise  bilateral lesion of vagus 	One side fails to rise  unilateral lesion o	gag reflex 	unilateral absence  lesion of CN IX or X -	CN V, VII, X, XII – voice and speech -	CN XI(spinal accessory) – shoulder and neck movement o	Atrophy and fasciculation  peripheral disorder o	Shoulder droops & scapula is displaced downward and laterally  paralyzed trapezius o	Test trapezius strength o	Test contraction of contralateral sternomastoid muscles 	Difficult raising head off pillow  bilateral weakness of sternomastoid -	CN XII(hypoglossal) – tongue symmetry and position o	Inspect tongue movement 	Fasciculation = fine, flickering, irregular movements in small muscle fibers 	Dysarthria = poor articulation 	Atrophy and fasciculation  amyotropic lateral sclerosis, polio 	In unilateral cortical lesion, tongue deviates contralateral to lesion --- Deep Tendon Reflexes: -	Reflex hammer o	Point end – striking small areas 	Finger on bicep tendon o	Flat end – brachioradialis reflex -	Patient relaxed -	Hyperactive reflexes  CNS disease o	Confirmed with clonus (rhythmic oscillation b/n flexion and extension) -	If reflexes are symmetrically diminished or absent o	Use reinforcement – isometric contraction of other muscle to increase reactivity o	Diminished or absent reflexes  damaged spinal segments or peripheral nerves; neuromuscular disease -	Biceps reflex (C5,6) o	Strike on your finger o	Use point end -	Triceps reflex (C6,7) o	Use point end -	Brachioradialis reflex (C5,6) o	Use flat end; 1-2 inches above wrist -	Abdominal reflex (T8-12) o	Lightly but briskly stroking each side of abd -	Knee reflex (L2,3,4) -	Ankle reflex (S1) – Achilles tendon o	Passively dorsiflex the foot o	Watch and feel for plantar flexion 	Slow relaxation  hypothyroidism -	Plantar response (L5,S1) o	Babinski response 	Normal – plantar flexion 	Dorsiflexion of big toe and fanning of digits  CNS lesion in corticospinal tract •	Positive Babinski response •	 Occasionally w/ hip and knee flexion -	Clonus - test for ankle clonus o	Knee partly flexed o	Passively dorsiflex and plantar flex a few times 	Sharply dorsiflex the foot and maintain position 	Feel for rhythmic oscillations •	positive sign  CNS disease -- JOINTS -	Joint pain o	I) localized, diffused, or systemic 	Monoarticular •	localized and involved 1 joint •	trauma, arthritis, tendinitis, bursitis •	pain near greater trochanter  trochanteric bursitis 	Polyarticular •	2-3 joints •	rheumatic fever; gonococcal arthritis; RA 	Nonarticular •	Bone, muscles, tissues, tendons, bursae, skin o	Bursitis, tendinitis, tenosynovitis, sprains, etc. •	Aches and pains: o	Myalgias  - in muscles o	Arthralgias – no evidence of arthritis o	II) timing and mechanism 	Rapid, severe pain, swollen joint w/o trauma •	Adult  acute septic arthritis or gout •	Children  osteomyelitis o	III) inflammation or not 	w/ fever, chills, warmth, redness  septic arthritis, gout, rheumatic fever 	generalized systemic  RA, systemic lupus erythematosus(SLE), PMR o	IV) ROM 	Stiffness •	“gelling” in DJD o	After inactivity and lasts a few min •	RA o	Last > 30 min •	Fibromyalgia; polymyalgia rheumatic (PMR) o	V) skin condition 	Butterfly rash on cheeks  SLE 	Scaly rash and pitted nails of psoriasis  psoriatic arthritis 	Papules w/ red bases on distal extremities; sore throat; urethritis  gonococcal arthritis 	Expanding erythematous patch; mental status change; facial weakness; stiff neck  lyme disease w/ CNS involvment 	Hives  serum sickness, drug reaction 	Erosion; scale on penis, soles, and palms; red, burning, itchy eyes; urethritis  Reiter’s syndrome 	Maculopapular rash of rubella  arthritis of rubella 	Clubbing of fingernails  hypertrophic osteoarthropathy 	Conjunctivitis (red, burning, itchy eyes)  Behcet’s syndrome 	Sore throat  acute rheumatic fever 	Diarrhea, abd pain, cramping  arthritis w/ ulcerative colitis, regional enteritis, scleroderma

Joint Pains: -	RA o	Inflammation of synovial membrane o	Affects hands, feet, wrists, knees, elbows, and ankles o	Symmetrical and progressive o	Swollen, tender, stiffness after inactivity (morning), limited ROM o	weakness, fatigue, low fever, weight loss -	OA o	Degenerative loss of cartilage o	Affects knees, hips, hands, cervical and lumbar spines, wrists o	One or more joints involved; slow progression o	Small effusion, tender, seldom warm, rarely red o	brief stiffness but frequent after inactivity (morning), limited ROM o	no generalized symptom -	Gout o	Acute – inflammation due to microcrystals of sodium urate 	Base of big toe, dorsum of feet, ankles, knees, and elbows 	Usually 1 joint 	At night; after injury, surgery, fasting, excessive food or alcohol 	Isolate attack; lasts 2days-2wks; increase frequency and severity 	Swollen, tender, hot, and red; no stiffness; limited ROM from pain 	Fever o	Chronic – with or w/o inflammation from sodium urate 	Feet, ankles, wrists, fingers, and elbows; not symmetric, but additive 	Swollen, tender, warm, red, stiff, limited ROM 	Fever; may develop sx of renal failure or renal stones -	Polymyalgia rheumatic o	Usually in women > 50yr old o	Hip and shoulder girdles; symmetric o	Abrupt (can occur overnight); chronic o	Tender (not swollen, warm or red); prominent in the morning; no limited ROM o	Malaise, depression, anorexia, weight loss, fever -	Fibromyalgia syndrome o	Musculoskeletal pain and tender o	Pain is “all over”, esp. neck, shoulders, hands, low backs, knees; worsen with immobility or excessive use; vague descriptions o	Stiffness in the morning; limited ROM only at extreme movement o	Disturbed sleep and morning fatigue

Neck Pain -	Simple stiff neck o	Acute, episodic, localized o	Appears on awakening x 1-4 days o	Muscular tenderness and pain from movements -	Aching o	Persistent, dull posteriorly o	Due to postural strain, tension, and depression o	Muscular tenderness 	If systemic  fibromyalgia syndrome -	Cervical sprain o	Acute, recurrent, severe, long-lasting o	Due to sudden movement, heavy lifting o	Local tenderness and pain with movement -	With dermatomal radiation o	Sharp, burning, tingling; radiate to shoulders, back and arms o	Due to compression of 1+ nerves o	Muscular tenderness, spasm, limited ROM, weakness, decreased reflexes -	Possible compression of cervical SC o	Associated with weakness/paralysis of legs and/or radicular symptoms o	Due to compression of spinal nerves o	Limited ROM; loss of proprioception, pain, temperature; Babinski response; etc -- SHOULDER -	Inspection o	Elevation of one shoulder  scoliosis o	Lateral flatten of shoulder  anterior dislocation of shoulder o	Anterior flatten of shoulder w/ prominent humeral  posterior dislocation of shoulder -	Palpation -	ROM o	Acromioclarvicular joint: 	“crossover test” •	Adduct arm across chest o	Subacromial and subdeltoid bursae 	Passively lift elbow posteriorly 	Palpate for tenderness and swelling •	Tenderness  bursitis, degenerative changes or calcification •	Swelling  bursar tear o	Overall shoulder rotation 	“Apley scratch test” •	External and internal rotations o	Rotator cuff 	Passively lift elbow posteriorly 	Palpate 1) supraspinatus, 2) infraspinatus, 3) tere minor muscles •	Common tenderness  supraspinatus muscle 	“drop-arm” sign •	Fully abduct arm to shoulder level o	Failure  positive “drop arm” test 	Tear in the rotator cuff o	Bicipital groove and tendon 	Rotate arm and forearm externally •	Palpate biceps 	Forearm flexed at right angle •	Supinate arms against resistance o	Articular capsule, synovial membrane, and glenohumeral joing -- Shoulder pain: I)	Rotator cuff tendinitis a.	Repeated motion  edema  hemorrhage  inflammation i.	Common in supraspinatus tendon 1.	Max. tenderness below tip of acromion b.	Provoked by activities, esp. in athletes II)	Rotator cuff tears a.	Injury from fall  partial or compete tear  pain, tenderness i.	>40 yrs old ii.	With forward flexion of arm b.	Atrophy of supraspinatus and infraspinatus muscles c.	Positive “drop arm” test – shrugging of shoulder III)	Calcific tendinitis a.	Calcium deposit  degeneration of tendon  tender and inflamed i.	Common in supraspinatus tendon b.	Acute, disabling attacks of pain, limited ROM from pain i.	>30yrs old women IV)	Bicipital tendinitis a.	Inflammation of long head of biceps tendon b.	Shoulder instability; tenderness in bicipital groove c.	Elbow flexed and actively supinate forearm against resistance i.	increased pain at bicipital groove V)	Acromioclavicular arthritis a.	Not common cause of shoulder pain b.	Direct injury to shoulder girdle  degenerative changes c.	Tenderness over acromioclavicular joint i.	Painful with scapular movement 1.	Not painful with glenohumeral joint movement VI)	Adhesive capsulitis (Frozen shoulder) a.	Mysterious fibrosis of glenohumeral joint capsule b.	Unilateral, diffuse, dull, aching pain; progressively limited ROM from MI i.	50-70 yr old c.	No tenderness d.	Chronic (from months – years) i.	Often resolve spontaneously, even partially -- Elbow – swollen & tender I)	Olecranon bursitis a.	Trauma/ RA/gout  swelling and inflammation of olecranon bursa II)	Arthritis of elbow a.	Synovial inflammation i.	b/n olecranon process and epicondyles III)	Rheumatoid nodules a.	Subcutaneous nodules at pressure point i.	Along extensor surface of ulna in RA ii. Firm and non tender IV)	Epicondylitis a.	Lateral (tennis elbow) i.	Repetitive wrist extension or pronation-supination of forearm ii.	Pain and tenderness 1.	pain increases with extension against resistance b.	Medial (pitcher’s, golfer’s, little league elbow) i.	Repetitive wrist flexion ii.	Pain and tenderness 1.	Pain increases with flexion against resistance -- Wrist and Hands: -	Inspection o	Osteoarthritis 	Heberden’s nodes – DIP joints 	Bouchard’s nodes – PIP joints o	RA 	Symmetric deformity in PIP, MCP, and wrist joint 	Ulnar deviation o	Carpal tunnel syndrome 	Median nerve compression o	Ulnar nerve compression 	Hypothenar atrophy o	Dupuytren’s contractures 	Flexion contractures in 3rd, 4th, 5th fingers 	Thicken palmar fascia -	Palpation o	Colle’s fracture 	Tenderness over distal radius o	De Quervain’s and gonococcal tenosynovitis 	Tenderness over extensor and abductor tendons of thumbs at radial styloid o	Scphoid fracture 	Tenderness over ‘snuffbox’ 	Risk of avascular necrosis -	ROM o	Wrists 	Flexion, extension, ulnar and radial deviation 	“grip strength” o	Fingers 	Flexion and extension •	Make fist and spread fingers 	Abduction and adduction •	Spread fingers apart and back together o	Thumbs 	Flexion, extension, abduction, adduction -	Sensation o	Median nerve – index finger o	Ulnar nerve – 5th finger o	Radial never – dorsal webspace of thumb and index finger --- Arthritis in Hands: -	RA o	Acute 	Fusiform/spindle-shaped swelling of proximal IPJ’s o	Chronic 	Swelling and thickening of MCP’s and proximal IPJ’s 	“swan neck” deformities” •	Hyperextension of proximal IPJ’s •	Fixed flexion of distal IPJ’s 	“boutonniere” deformities •	Fixed flexion of proximal IPJ’s •	Hyperextension of distal IPJ’s 	Presences of rheumatoid nodules -	OA (DJD) o	“Heberden’s nodes” 	Dorsal lateral aspect of distal IPJ’s o	“Bouchard’s nodes” 	Proximal IPJ’s -	Gout o	Can mimic RA and OA 	Asymmetric o	Knobby swelling o	White chalklike urate discharge Hands – swelling and deformities I)	Dupytren’s contracture a.	Thickened plague on flexor tendon of ring finger b.	Puckered skin and thick fibrotic cord c.	Flexion contracture II)	Trigger finger a.	Painless nodules in the flexor tendon b.	Audible and palpable snaps with flexion and extension of fingers III)	Thenar atrophy a.	Disorder of median nerve i.	Pressure on nerve ie. carpel tunnel syndrome b.	“Hypothenar atrophy” – disorder of ulnar nerve IV)	Ganglion a.	Round, cystic, nontender swelling on tendon sheaths/ joint capsules i.	Dorsum of wrist ii. More prominent when flexed

Tendon Sheath and Palmar Space Infection; Felons I)	Acute tensosynovitis a.	Infection and swelling of flexor tendon sheaths b.	Finger extension is very painful. i.	Finger is held slightly flexed. II)	Acute tenosynovitis and thenar involvement a.	Infection from tendon sheaths spreads to fascial spaces III)	Felon a.	Injury in fingertips  infection of fascial space i.	Severe pain, localized tenderness, swelling, redness - The Spines I)	Inspection: a.	Erect, anatomical position i.	Expose entire back b.	Assess posture, spinal curvature i.	Lateral deviation and rotation of head  torticollis 1.	Contraction of sternocleidomastoid muscle ii. Thoracic kyphosis iii. Scoliosis iv. Unequal shoulder heights 1.	Scoliosis; Sprengel’s deformity; “wing” scapulae; contralateral weakness of trapezius v.	Unequal height of iliac crest/ ‘pelvic tilt’ 1.	Unequal length of leg; scoliosis; hip abduction/adduction vi. ‘Listing’ of trunk 1.	Herniated lumber disc c.	Birthmarks, post-wine stains, hairy patches, and lipomas  spina bifida d.	Café-au-lait spots, skin tags, fibrous tumor  neurofibromatosis II)	Palpation: a.	Spinous process i.	Tenderness  infection, arthritis (esp. C2-7 facet joints) 1.	w/ trauma  fracture, dislocation b.	“step-off”  spondylolisthesis i.	Forward slippage of vertebra c.	Sacroiliac joint i.	Tenderness  sacroiliitis, ankylosing spondylitis d.	Paravertebral muscles i.	Spasm (firm and knotted)  degeneration, inflammation e.	Sciatic nerve (L4-S3) i.	Tenderness  herniated disc, mass lesion f.	Costovertebral angle i.	Tenderness  kiney infection III)	Percussion: a.	Tenderness, pain  osteroporosis, infection, or malignancy IV)	ROM and maneuvers a.	Neck i.	Skull and C1 – flexion and extension ii.	C1-2 – rotation 1.	Tenderness w/ RA  subluxation and high cervical compression iii.	C2-7 – lateral bending b.	Trunk – flexion, extension, rotation, and lateral bending i.	Degree of flexion 1.	Standing and bending forward 2.	Lumbosacral joint and mark a.	10cm above & 5cm below b.	Normal: 2 top marks increases ≤ 4cm ii.	Lumbar lordosis  spasm, ankylosing spondylitis

Hip I)	Inspection a.	Stance – 60% of walking cycle i.	Most problems found b.	Swing c.	Gait i.	Width of base 1.	Normal: 2-4cm from heel to heel 2.	Wide  cerebellar disease, foot problem ii.	Waddling gait  contralateral pelvis drop 1.	Hip dislocation, arthritis, abductor weakness d.	Lumbar portion i.	Loss of lordosis  paravertebral spasm ii.	Excess lordosis  flexion deformity of hip e.	External rotation, leg shortening  hip fracture II)	Palpation a.	Patient supine, heel on opposite knee i.	Inguinal ligament - NAVEL 1.	Buges  inguinal hernia, aneurysm 2.	Lymph node  infection of lower extremity 3.	Tenderness  synovitis, bursitis, psoas abscess ii. Psoas bursa 1.	Below inguinal ligament b.	Patient lies on one side, hip flexed and internally rotated i.	Trochanteric bursa 1.	over greater trochanter a.	tenderness  bursitis, tendinitis, muscle spasm ii. Ischiogluteal bursa 1.	Over ischial tuberosity a.	Tenderness  bursitis, ‘weaver’s bottom’ i.	Mimic sciatica III)	ROM and maneuvers a.	Flexion i.	Flexion deformity 1.	Masked by increase lumbar lordosis, anterior pelvic tilt a.	Not flattening lumbar lordosis b.	Extension c.	Abduction i.	One hand presses down contralateral ASIS ii.	One hand grasp ankle and abduct until ASIS move 1.	Restriction  osteroarthritis d.	Adduction e.	External and internal rotations i.	Restriction  arthritis (sensitive test) --- Knee -	Inspection o	Stumbling, pushing knees into extension with hand  quadriceps weakness o	Genu varum and valgum o	Swelling 	patellar  prepatellar bursitis 	over tibial tubercle  infrapatellar bursitis 	medial tibial tubercle  anserine bursitis -	Palpation o	Patellar 	Tenderness over tendon, inability to extend leg  partial, complete tear of tendon 	Pain and crepitus  roughening of patellar 	Pain with compression, patellar movement  chondromalacia, degeneration o	MCL and LCL 	Flex knee 90degree with foot rest on table o	Medial/Lateral meniscus 	Tenderness of medial meniscus  common o	Suprapatellar pouch 	Thickening, bogginess, warmth  synovitis, effusion o	Prepatellar bursa & anserine bursa 	Excessive kneeling  prepatellar bursitis, “housemaid’s knee” 	Running, valgus knee deformity, fibromyalgias, osteoarthritis  anserine bursitis 	Distention of gastrocnemius semimembranosus bursa  popliteal/”baker’s” cyst o	“Bulge sign” – minor effusion 	Knee extended, hand over suprapatellar •	Milk fluid downward •	Apply medial pressure •	Tap laterally •	Tap and watch for fluid wave 	Positive bulge sign  effusion o	“Balloon sign” – major effusion 	Thumb and index finger of R hand on sides of patellar 	Compress suprapatellar against femur with L hand •	Feel for fluid toward R hand o	Ballotting the patella 	Compress suprapatellar pouch against femur •	Watch for fluid returning to pouch o	Gastrocnemius and soleus 	Tenderness and swelling of muscles  ruptured Achilles tendon 	Tenderness and thickening of tendon, protuberant posterolateral bony process of calcaneus  Achilles tendinitis -	ROM and maneurvers o	Medial collateral ligament 	Location of most injuries 	Abduction (Valgus) Stress test •	Pt supine, knee slightly flexed, thigh 30degree laterally •	R hand on lateral knee to stabilize femur o	L hand on medial ankle •	R hand pushes medially o	L hand pulls laterally o	Lateral collateral ligament 	Adduction (Varus) Stress test •	Pt supine, knee slightly flexed, thigh 30 degree laterall •	L hand on medial knee to stabilize femur o	R hand on lateral ankle •	L hand pulls laterally o	R hand pushes medially o	Anterior cruciate ligament 	Anterior Drawer Sign •	Pt supine, hip and knee flexed at 90degree, feet flat on table •	Hands around knees o	Thumbs in front and fingers posterior of knees •	Draw tibia forward 	Lachman Test •	Pt supine, knee flexed at 15degree and externally rotated •	R hand on distal femur o	L hand on upper tibia •	R hand moves femur back o	L hand moves tibia forward o	Posterior cruciate ligament 	Posterior Drawer sign •	Pt supine, hip and knee flexed at 90degree, feet flat on table •	Hands around knees o	Thumbs in front and fingers posterior of knees •	Push tibia backward o	Medial and lateral meniscus 	McMurray test •	Pt supine, knee flexed •	R hand on posterior knee joint o	L hand on ankle •	Rotate leg internally and externally •	Apply valgus stress o	Rotate leg externally o	Slowly extend it •	*click or pop with valgus stress, external rotation, leg extension  tear of posterior portion of medial meniscus o	Achilles tendon 	Pt prone, knee and ankle flexed at 90degree/ pt kneeled on chair 	Squeeze calf for plantar flexion 	*absence of plantar flexion  positive test •	Rupture of Achilles tendon - Ankle and Foot -	Inspection -	Palpation o	Ankle joint 	Tenderness  arthritis, ligamentous injury, infection o	Achilles tendon 	Rheumatoid nodule 	Tenderness  tendinitis, bursitis, tear from trauma o	Plantar fascia and heels, esp. posterior and inferior calcaneus 	Bone spur 	Faciitis 	Gout o	Matatarsophalangeal joint 	Tenderness  early RA 	Acute inflammation  gout o	Heads of metatarsal and groove inb/n 	Pain and tenderness  metatarsalgia •	Trauma, arthritis, vascular compromise 	Tenderness over 3rd and 4th metatarsal heads on plantar surface  Morton’s neuroma -	ROM and maneuvers o	Ankle (Tibiotalar) joint 	Dorsiflex and plantarflex the foot o	Subtalar (talocalcaneal) joint 	Stabilize ankle 	Invert and evert the foot 	*sprain ankle (common) •	inversion and plantar flexion  pain o	eversion and plantar flexion  no pain o	Transverse tarsal joint 	Stabilize heel 	Invert and evert the foot o	Metatarsophalangeal joint 	Flex toes -- Special techniques -	Carpel Tunnel Syndrome o	Pain and numbness on ventral surface of 1st 3-digits 	Esp. at night o	Weak abduction of thumb o	Median nerve compression in carpel tunnel 	w/in flexor retinaculum o	Thumb Abduction 	Pt raises thumb perpendicular to palm 	Physician applies downward pressure on distal phalanx o	Tinel’s sign 	Percuss lightly over the median nerve in carpel tunnel 	*tingling or electric sensation  carpal tunnel syndrome o	Phalen’s test 	Hold pt’s wrist in acute flexion •	60 sec 	Pt press back of both hands together •	Compress median nerve 	*tingling sensation  carpal tunnel syndrome -	Low Back Pain W/ Radiation into the Leg o	Pt supine o	Check straight leg raising 	Passively raise pt’s relaxed and straightened leg •	Pain occur  dorsiflex the foot •	Record degree of elevation with pain o	*sharp radicular pain with L5, S1 distribution 	Herniated lumbar disc o	Dorsiflexion increases pain 	In pain in contralateral side  confirmed radicular pain •	Positive “crossed straight leg-raising” sign -	Measuring the length of legs o	B/n ASIS and medial malleolus -	Describing limited motion of joint o	Elbow flexion: 45-90 degrees o	Elbow supination: 0-30 degrees o	Elbow pronation: 0-45 degrees -- Muscles strength of trunk -	Hip flexion (L2,3,4 - iliopsoas) o	Hand on pt’s thigh o	Raise leg against hand’s downward pressure -	Hip Adduction (L2,3,4 – adductors) o	Hand firmly on bed b/n pt’s knees o	Pt bring both legs together -	Hip Abduction (L4,5,S1 – gluteal medius and minimus) o	Hand firmly on bed outside pt’s knees o	Pt spread both legs against hands -	Hip extension (S1 – gluteus maximus) o	Pt pushed posterior thigh against hand -	Knee extension (L2,3,4 – quadripceps) o	Support knees in flexion o	Pt tries to straighten legs against hands 	Forceful response -	Knee flexion (L4,5,S1,2 – hamstrings) o	Knee flexed o	pt forces against hands straightening legs -	dorsiflexion (L4,5) and plantarflexion (S1) o	pt pulls up or pushes down against hand

Gait -	walk across the room o	Ataxia 	Lack coordination w/ reeling and instability 	Cerebellar disease, loss of position sense, intoxication -	walk heel-to-toe/ tandem walking -	walk on toes, then on heels o	walk on toes problem  distal muscular weakness o	walk on heels problem  corticospinal tract weakness -	hop in place o	involved proximal and distal muscles, good position sense, normal cerebellar function -	do a shallow knee bend o	one leg at a time o	difficulty  extensor of hip weakness, extensor of knees weakness, or both -	rising from a sitting position w/out arm support o	difficulty  pelvic girdle and leg muscular weakness Stance -	Romberg test o	Position sense test o	Stand w/ feet together 	Eye opened 	Eye closed – 20-30sec •	w/out support o	maintain upright posture o	*cerebellar ataxia  difficulty w/ eye opened and closed -	Pronator drift test o	Pt stands w/ arms straight forward 	Palms up 	Eye closed – 20-30sec 	*contralateral lesion in corticospinal tract  pronation of one forearm 	*pronator drift  downward drift of arm w/ flexion of fingers and elbow o	Tap the arms briskly downward w/ eye closed 	Normal: return to smoothly 	Weakness: difficulty returning 	Lacking position sense: cannot/ poorly return 	Cerebellar incoordination: return, but overshoot and bounce --- Sensory System -	Sensory testing quickly fatigue pt  unreliable results -	Special attention: o	Numbness or pain o	Abnormal motor and reflexes o	Trophic changes (sweats, ulceration, etc) -	Patterns of testing: o	Compare symmetry o	Compare distal vs. proximal o	Vibration: test toes and fingers 	Normal  assume normal for proximal areas o	Vary pace of testing o	Map out boundaries of abnormalities in details 	*bilateral loss of sensation  “glove and stocking” sensory loss •	Polyneuropathy in alcoholism and diabetes -	I) Pain and temperature (spinothalamic tracts) o	Pain: 	Analgesia = absence of pain sensation 	Hypalgesia = decreased sensitivity to pain 	Hyperalgesia = increased sensitivity to pain -	II) Position and vibration (posterior column) o	Vibration: 	*Often the first to be lost in peripheral neuropathy •	Diabetes, alcoholism, tertiary syphilis, Vit B12 deficiency -	III) Light touch (both spinothalamic tract and posterior column) o	Anesthesia = absence of touch sensation o	Hypesthesia = decreased sensivity to touch o	Hyperesthesia = increased sensitivity to touch -	*disease of sensory cortex: o	Normal or slightly impaired touch and position sense o	Disproportionate decrease loss of discriminative sense -	Discriminative sensation: o	Stereognosis = ability to identify obj. by feeling it 	Astereognosis = inability to recognize obj. in hand o	Graphesthesia = number identification from drawing on palm 	Ability to do so  lesion in sensory cortex o	Two-point discrimination 	Touch two points on hand simultaneously 	Normal: less than 5mm on finger pads o	*posterior column disease: 	Impaired stereognosis, number identification, two-point discrimination o	Point localization 	Pt w/ eye opened localizes location of touch during eye closed o	Extinction 	Simultaneously stimulate corresponding areas on both sides of body

ROS -	If pt remembers important illnesses/major health event during ROS o	Record such illnesses as part of HPI or past illnesses -	Start with general questions o	i.e. How are your ears and hearing?; How is your digestion?, etc. -	may uncover problems that pt overlooked -	Systems: o	General – weight, weight change, fatigue, fever, etc. o	Skin – rashes, lumps, itching, color, nails, hair, moles, etc. o	Head, Eyes, Ears, Nose, Throat (HEENT) 	HA, dizziness, glasses, contact lenses, pain, hearing, vertigo, infection, discharge, itch, nosebleeds, sinus, dentures, sore tongue, sore throat, etc. o	Neck – swollen glands, goiter, pain, stiffness o	Breasts – lumps, pain, discomfort, nipple discharge, etc. o	Respiratory – cough, sputum (color & quantity), dyspnea, wheezing, chest x-ray, asthma, COPD, tubercolosis, etc. o	Cardiovascular – BP, CVD, rheumatic fever, dyspnea, edema, pain, palpitation, murmurs, paroxysmal nocturnal dyspnea, etc. o	Gastrointestinal 	trouble swallowing, heartburn, nausea, bowed movement, rectal bleeding, tarry stools, hemorrhoids, constipation, food intolerance, hepatitis, jaundice, etc. o	Urinary - polyuria, urgency, dysurea, infection, kidney stones, dribbling, etc. o	Genital 	Male: Hernias, sore penis, discharge, pain, masses, Hx of STD, habits, interest, satisfaction, function, condom use, HIV infection, treatment, etc. 	Female: age at menarch; regularity, frequency, duration of period; spotting; dysmenorrheal; menopause; discharge; itch; sore; STD and Tx; pregnancies; abortion; OCP; interest; function; satisfaction; HIV infection, etc. 	Pt born before 1971 •	DES exposure and cervical carcinoma o	From maternal use during pregnancy o	Peripheral vascular 	claudication, cramps, varicose vein, swelling lower limbs, color changed in fingers and toes during winter, redness, tenderness, etc. o	Masculoskeletal 	pain, stiffness, arthritis, gout, backache, location, tenderness, weakness, limited ROM, timing, duration, Hx of trauma, systemic fever, chills, rash, anorexia, weight loss, etc. o	Psychiatric – nervousness, tension, mood, depression, memory, suicide, etc. o	Neurologic 	mood change, attending span, speech, orientation, HA, dizziness, vertigo, syncope, seizure, paralysis, weakness, tingling, tremors, insight, etc. o	Hematologic – anemia, bruising, bleeding, transfusion Hx and rxn, etc. o	Endocrine 	thyroid problems, temperature intolerance, sweating, thirst, hunger, polyuria, glove and shoe size change, etc. - CARDIOVASCULAR SYSTEM Jugular Venous Pressure (JVP) -	venous pressure depends on: o	L ventricle contraction o	BV o	Pumping capacity of R heart -	JVP = height of venous column of blood in the internal jugular veins -	Reflects R atrial pressure o	Cardiac function o	R heart hemodynamics -	Usually on R side o	b/c more direct anatomic channel to R atrium -	Use internal jugular vein o	Deep to sternomastoid muscles o	If cannot find, external JV can be used 	Not as reliable 	Unilateral distention of external JV  local obstruction/kinking •	Occasionally, also bilateral -	Pt. lies at 30 degree. o	Face away from observing side -	Use tangential lighting o	Examine both sides of neck -	Find highest point of oscillation, meniscus o	Measure vertical distance above sternal angle 	Sternal angle – 5 cm above R atrium o	≤3 cm above sternal angle (8 cm above R atrium) 	Elevated and abnormal •	Common  R-sided CHF •	Less common  constrictive pericarditis, tricuspid stenosis, superior vena cava obstruction 	Elevated only during expiration •	Obstructive lung disease o	Veins collapsed during inspiration o	Below sternal angle  not elevated and seldom need measurement -	Easy to find in euvolemic pt. o	Hypovolumic pt.  lower the elevation o	Hypervolumic pt.  raise the elevation -	Unobserved in children younger than 12yrs old Jugular Venous Pulsations -	Reflects R atrial pressure -	Observe amplitude and timing of pulsation -	2 quick peaks + 2 troughs -	“A” wave o	First elevation o	Atrial contraction o	Before 1st heart sound and carotid pulse o	If prominent  resistance to R atrial contraction 	Hypertrophied R ventricle (common) •	Decrease compliance 	Tricuspid stenosis o	If disappear  atrial fibrillation -	‘C’ wave o	Carotid transmission o	Not visible -	‘X’ descent o	Atrial relaxation o	R ventricle contraction o	Before 2nd heart sound -	‘V’ wave o	Atrial filling o	If prominent  tricuspid regurgitation -	‘Y’ descent o	Passive flow of blood from R atrium to R ventricle 	Atrial emptying o	Follow 2nd heart sound -	‘x’ and ‘y’ descents are visible. Distinguish Internal Jugular and Carotid Pulsations -	Internal jugular pulsation: o	Rarely palpable o	Soft, rapid, undulated o	2 elevations + 2 troughs/ heart beat o	Eliminated by light pressure above sternal end of clavicle o	Level of pulsation changes w/ position o	Level of pulsation descends w/ inspiration -	Carotid pulsation: o	Palpable o	Vigorous w/ a single outward component o	NOT eliminated by pressure o	Level DOES NOT change w/ position o	Level DOES NOT change w/ inspiration Carotid Pulse -	Cardiac function and aortic pulsations -	Detect stenosis/ insufficiency of aortic valve -	Pt. elevated at 30 degree -	Inspect for pulsation o	Medial to sternomastoid muscles -	Palpate at lower third of neck -	Press medially at level of cricoids cartilage o	AVOID carotid sinus on thyroid cartilage 	Will reflex  drop in pulse rate and BP -	NEVER press both carotid a. at the same time -	Amplitude o	Tortuous and knicked unilateral pulsatile bulge o	Decreased pulsation  decreased SV, atherosclerotic occlusion o	small, thread, weak pulse  cardiogenic shock o	bounding pulse  aortic insufficiency o	Pulsus alternans = bigeminal pulse (beat-to-beat variation) o	Paradoxical pulse = respiratory variation -	Contour o	speed of upstroke 	brisk, smooth, rapid, follow S1 immediately 	delayed  aortic stenosis o	duration of summit 	smooth, rounded, roughly midsystolic o	speed of downstroke 	less abrupt than upstroke -	Thrills or bruits o	Thrill = humming vibration detected during palpation o	Bruit = murmur-like sound of vascular origin detected during auscultation 	W/ diaphragm of stethoscope o	Pt. holds breath. o	Listen w/ bell of stethoscope o	Carotid bruit w/ and w/o thrill 	Suggests aterial narrowing or radiating sound of aortic murmurs -	Brachial artery o	In pt. w/ carotid obstruction, kinking, thrills o	Use same technique for amplitude and contour o	Feel pulse medial to bicep tendon o	Pt.’s arm rest w/ extended elbow and palm up Changes Over Life Span -	Aging affect: o	Location of apical impulse 	Harder to find o	Pitch of heart sound and murmurs 	Splitting of 2nd heart sound •	Harder to hear – pulmonic component is less audible. 	Murmurs •	Innocent normal murmurs •	Jugular venous hum o	Also common in children •	Cervical systolic murmur o	Children: common o	Adult: arterial obstruction o	Stiffness of arteries o	BP

Speedy deletion of Ecr bates
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