Clinic Entrance - Abthorax

Front 1

Abdomen:
Inspection

Back 1

• Color
o Yellow skin (jaundice), Blue-grey skin (wilson’s dx),
Striae: pink (new scar), sliver (old scar), Purple
(cushings dx), Cullen’s sign (bruising around navel),
Grey-Turner’s sign (brusing in the flanks) Both =
hemorrhagic pancreatitis.
• Other: lighting above
o Caput medusa (blue veins around navel= portal
hypertension)
o Sister Mary Joseph Nodules= abdominal metastasis,
gastric CA, visible peristalsis, diastasis recti, hernias
• Contour (looking across): tangential lightning for shadows.
o Distended abdomen= due to gas, fat, preg., tumor
o Bulging flanks= due to ascites (fluid in the abdomen)

Front 2

Abdomen:
Auscultation

Back 2

• All 4 quadrants w/ the diaphragm
• Arteries
o Aorta (2/3 b/t xiphoid & umbilicus- No bruits) Pt holds
breath
o Renal (2) lat. to Aorta bilaterally, below ribs (sides)
o Common Iliacs (2) ASIS ½ way across midline (M.C.)
o Femoral (2) above or below mid point of the inguinal
ligament.
• Liver, Spleen for Bruits for Friction Rub
o Friction rub: Pt breathes deeply/open mouth
o Bruits: Pt hold inhale
• What sound do you hear?
o Normal=nothing, bruits=wooshing (due to
stenosis/obstruction of vessels)
o Rubs=inflammation, peritonitis
o Early sounds in early bowel obstruction= hyperperistalsis
o Absent bowel sounds in late bowel obstruction= paralytic
ileus

Front 3

Abdomen:
Palpation

Back 3

(Dr always stands on the R side except for L kidney & peripheral
vascular)
knees bent for deep palpation (mandatory)
• Superficial Palpation: all 4 quadrants-pain, guarding, masses. (entire
area=circular)
o Rebound tenderness: ask Pt where pain is: 1x in each quadrant,
in slow/out quick (never starts where it hurts). Test for
inflammation of peritonitis
• Deep Palpation: all 4 quadrants-explore thoroughly.
• Liver (texture, tenderness, lumps)-hand under back
o Direct: 1 hand below, on inhale, face head @ 45 degrees,
circular motion
o Hooking/Middleton’s: face left foot, Pt fist under, on inhale
groping motion
o Murphy’s sign: feed in on exhale under liver, hold, Pt inhales
(+) sign =pain, halt inspiration= cholecystics (inflammation of
gallbladder)
• Spleen: (face head) L hand reaches across Pt under ribs, press in on
inhale to palp.
(-) normal
• Aorta: 2 tips of hands come in from sides
• Kidney
o Entrapment: 1 hand on top, 1 underneath Pt, on exhale push
hands together, Pt inhales, if u feel kidney push hands apart (+)
sign= enlarge kidney
o Capture: Pt takes deep breath, holds, Dr. pushes in, then Pt
exhale. If feel the kidney slip away (+) sign= enlarge kidney
o Murphy’s Punch: @ costovertebral angle, Pt is seated, Dr. palm
over kidney. Dr. punches back of hand to try to elicit pain
(+)= pyelonephritis.

Front 4

Abdomen:
Percussion

Back 4

Pt exposed properly to top of pubic region
• Percussion of all 4 quadrants thoroughly. Pt bends knees, strike tip of
finger onto root
o (+)= distended bladder, preg., ascites, tumor
• Liver span
o R M.C. (6-12cm) done on Pt ~ hold inhale.
o Midsternal (4-8cm)
• Spleen (not normally positive)-direct method
o 10th ICS-anterior axillary line- percuss, Pt breath deeply through
open mouth, cont. tapping. (+)= dullness due to enlarged spleen
coming from under finger.
• ?
o Test for Ascites: shifting dullness, 500ml fluid necessary, puddle
sign 120 ml
o What if percuss dullness over gastric area? Tumor
o What are some causes of dullness percussed over the lower
abdomen in the midline? Full bladder, preg., ascites, tumor
o what are some causes for enlarged spleen? Malaria, hemolysis
of RBC, sickle cell anemia, hemolytic snake venom
o what are some causes for ascites? CA of bowek, portal
hypertension, many causes.

Front 5

Thorax: Inspection

Back 5

Pt seated
• Breathing (normal resp. rate is 14-20 breaths per min.)
o Resp. rate (Effort-use of accessory mm, cyanosis- lips, fingernail
bed, Dyspnea, Tachypnea, Bradypnea, Symmetry of chest
movement)
• Skin abnormalities
o Cicatrix (scars), CA, Vascular abnormalities, Hairy moles, masses,
lesions
• Bulging/Retraction of ICS
o = (Obstruction in the lungs or airways, working too hard/stress)
• Structure
o Slope of the ribs, AP diameter, barrel chest (normal=child. Elderly,
abnormal= COPD, emphysema), funnel chest, Pigeon chest,
Rachitic rosary (child w/ tender nodules @ costochondral
junction from rickets), gibbus, kyphosis, scoliosis, kyphoscoliosis
o Note: Flail chest= multiple rib fx; Paradoxical breathing= ribs
moving in & out when breathing.
o AP diameter: normal 2:1 ratio, abnormal 1:1 ratio (emphysema)

Front 6

Thorax:
Auscultation

Back 6

Use diaphragm
Cross arms when b/t scapulae
• Breath sounds
o Instruct Pt to breathe deeply, quietly, & slowly through
an open mouth.

Front 7

Thorax: Palpation

Back 7

• Palpate for general tenderness, masses (entire back)
o Cross arms when b/t scapulae
• Palpate 4 areas for tactile fremitus as Pt says “99” (slow deep
voice)
o Ball or ulnar edge of hand used (check for symmetry of
vibration)
o Cross arms when b/t scapulae
• Respiration Expansion (T10 level) if one side doesn’t move as far=
problem w/ that side of the lung inflating. Do over course of 3
breaths
• ?’s
o When is tactile fremitus increased? Lobar pneumonia.
o Decreased? COPD, air in lung, obstruction of lung
o What causes diminished respiratory expansions? Loss of
function of lung, pleural effusion, lobar pneumonia,
diaphragm problem
o What causes increased tenderness? Masses, bruises, fx’s

Front 8

Thorax: Percussion

Back 8

• 14 areas - 7 each side (1:1, 2:2, 3:3)
o Cross arms when b/t scapulae
• Diaphragmatic Excursion (bilaterally)
o Hold inhale-mark, hold exhale-mark, symmetrically 2-3
cm
• 5 percussion tones
o Flat= large pleural effusion, thigh
o Dullness= consolidation (lobar pneumonia), heart, liver
o Resonance= simple chronic bronchitis, normal tone of
lung
o Hyper-resonance= emphysema, pneumonia
o Tympany= large pneumothorax, gastric air bubbles,
puffed out cheek

Front 9

Heart: Inspection

Back 9

• General
o Dyspnea, Cyanosis, edema (look at ankles/around the
eyes)
• Tangential Observation
o Heaves/lifts (from the heart causing the chest to rise & fall)
o Each APETM ISCS for pulsations
o PMI/Apical Impulse (5th ICS-midclavicular line)
o Abdominal Pulsations
• ?’s
o What do heaves/lift (visual pulsations) indicate? Heart
working too hard
o What do APETM pulsations possibly indicate? Too much
resistant (high BP, pulmonary, hypertension, valve stenosis)
o When are they normal? During heavy exercise
o What do pulsations in the R abdomen indicates? Aneurism

Front 10

Heart: Auscultation

Back 10

• APTEM with the Diaphragm
• APTEM with the Bell
• Mitral Maneuver (Bell)
o Mitral only
o Pt @ 45 on L side (accentuates S3 & S4 low pitch murmurs,
mitral stenosis)
o Instruct Pt to breathe quietly thru an open mouth
• Aortic Manuever (Diaphragm)
o All Points except aorta
o Instruct Pt to exhale, hold breath & lean forward
• Carotids (Diaphragm)
o Instruct Pt to inhale & hold breath
• ?’s
o What causes a murmur? Stenosis/regurgitation
o Name some things for which you would listen? Splits,
murmurs, S3, S4 arrhythmias.

Front 11

Heart: Palpation

Back 11

• Pads of fingers over APETM for PULSATIONS!
• PMI/Apical Impulse
• Pads of fingers (or ball of hand) over abdominal aorta for
THRILLS!
• Ball of hand over APETM (THRILLS); but on female Pts use
pads of fingers
• ?’s
o What does a THRILL indicate?

Front 12

Heart: Percussion

Back 12

(practice on males only)
• Percuss R sternal border for any dullness (normally none until the liver @
the 6th ICS
(3.4.5= resonance, 6=dull)
• If dullness is felt, begin percussion lateral to medial (3, 4, 5 ICS) on R
• Then lateral to medial on the L (listen a change from resonance to
dullness- go from lung to heart percussion)
• ?’s
o Conditions that cause cardiac enlargement?

Front 13

Peripheral Vascular

Back 13

• Check for rate, rhythm, amplitude & contour (bilat.) use 3 fingers

Front 14

Vital Signs

Back 14

• Must mention Height, weight, temp, BP, respiratory rate, pulse rate.
• Respiratory rate= 14-20 breaths per minute (30 sec. x 2)
• Temperature (must perform)
• Blood pressure (must perform) must be within 10mmHg B/L
o Palpatory Systolic (bilaterally)