The Health History

 Chief complaint
o Ask the patient the reason they are seeking care at this time.
o Document using the patient’s own words, if possible.
 History of present illness (HPI)
o The HPI is a clear, concise summary of the problem(s) prompting the visit.
o Ask about symptom attributes, including location, timing (onset, duration,
frequency), quality or severity, factors that worsen or alleviate the symptom, and
associated manifestations.
 Family history
o Gather information about the patient’s immediate relatives, including age and
health; if they are living or deceased; cause of death; age of death of parents,
grandparents, siblings, children, and grandchildren.
 Social history
o Gender identification
o Sexual orientation
o Occupation
o Education
o Relationships and relationship safety
o Home environment
o Life experiences
o Leisure activities
o Sexual history
o Spirituality
o Support systems
o Tobacco, drug and alcohol use
o Exercise and nutrition
o Safety, including seat belt and bike helmet use, sun protection, firearms, and
smoke detectors.
 Review of systems
o Ask patient about the health of different organ systems.
o For each system, ask, “Have you ever had any…?”
 General: changes in weight, sleep disturbance, weakness, fatigue, or
fever/chills
 Skin: Rashes, lumps, sores, itching, dryness, changes in color; changes
in hair, nails or moles
 Head, eyes, ears, nose, throat (HEENT): headache, head injury,
dizziness, lightheadedness; vision changes, glasses or contact lenses,
pain, redness, excessive tearing, double or blurred vision, spots, specks,
flashing lights, glaucoma, cataracts; hearing problems or hearing aid use,
tinnitus, vertigo, earaches, infection, discharge; nasal stuffiness,
discharge, or itching, nosebleeds, sinus trouble; problems with teeth and
gums, bleeding, dentures, sore tongue, dry mouth, frequent sore throats,
hoarseness
 Neck: swollen glands, goiter, lumps, pain, or stiffness
  Breasts: lumps, pain, or discomfort, nipple discharge
 Respiratory: cough, changes in sputum, shortness of breath, wheezing,
pain, sleep apnea
 Cardiovascular: cardiac issues, hypertension, rheumatic fever, murmurs;
chest pain, palpitations, orthopnea, paroxysmal nocturnal dyspnea,
swelling
 Gastrointestinal: trouble swallowing, heartburn, appetite, nausea, change
in bowel habits, pain with defecation, rectal bleeding or black or tarry
stools, hemorrhoids, constipation, diarrhea, abdominal pain, food
intolerance, excessive gas, jaundice, liver, or gallbladder problems
 Peripheral vascular: claudication, leg cramps, varicose veins, clots,
swelling, color change with cold weather, redness or tenderness
 Urinary: changes in frequency of urination, polyuria, nocturia, urgency,
burning or pain during urination, hematuria, urinary infections, kidney or
flank pain, kidney stones, ureteral colic, suprapubic pain, incontinence; in
males, change force of the urinary stream, hesitancy, dribbling
 Genital:
 Male: hernias, discharge or sores on the penis, testicular pain or
masses, scrotal pain or swelling, history of sexually transmitted
infections (STI), libido, changes in sexual function or satisfaction
 Female: menstrual details, bleeding between periods or after
intercourse, dysmenorrhea, premenstrual tension, menopausal
symptoms, postmenopausal bleeding, vaginal discharge, itching,
sores, lumps, STI, changes in sexual interest or satisfaction,
dyspareunia
 Musculoskeletal: muscle or joint pain, stiffness, arthritis, gout, backache,
neck pain
 Psychiatric: nervousness, tension, depression, memory change, suicidal
ideation
 Neurologic: changes in mood, attention, speech, orientation, memory,
insight, or judgment; paralysis, numbness or loss of sensation, tingling,
tremors, seizures
 Hematologic: anemia, easy bruising or bleeding.
 Endocrine: Heat or cold intolerance, excessive sweating, polydipsia,
polyphagia, or polyuria
 PEARLS
o Follow the patient’s cues to guide your conversation.
o Use communication skills – verbal and nonverbal – to get the information you
need, while also providing empathy.
o Use open-ended questions as needed; for example, “Can you tell me more about
that?”
o Anything uncovered during the review of systems that is related to the chief
complaint should be documented in the section related to the HPI.
General Assessment

 Observational Assessment
 o Note patient’s level of consciousness, mood, and behavior, as well as any type of
distress.
o Note patient’s gait and any movement abnormalities, such as limping.
o Include general appearance, grooming, dress, facial expressions, eye contact,
odors, and posture.
o Document the patient’s description of their current state of health.
o Describe the patient’s distinguishing characteristics, such as tattoos, scars,
amputations, or other unique features.
o Observe for distress, noting type and response.
 Vital Signs
o Measure height and weight to determine body mass index (BMI).
o Measure blood pressure in both upper extremities, ensuring properly sized cuff.
 Isolated hypertension may be situational, such as “white coat syndrome.”
 Home BP monitoring may reveal better control.
o Measure orthostatic blood pressure if indicated.
o Examine pulse rate and rhythm by palpating the radial pulse.
 Normal rate falls between 60-90 beat per minute, although it may be
altered due to medications or medical conditions.
 Pulse should be counted for a full minute, particularly if irregular.
 Rhythm should be regular. Abnormalities include irregularly irregular and
regularly irregular.
o Examine the quality of peripheral pulses.
 Radial pulse is most commonly assessed due to accessibility.
 Pulses should be strong, but not bounding.
o Observe respiratory rate and quality of breathing.
 Normal respiratory rate is 12-20 breaths per minute in an adult.
 Breathing should be regular, although an occasional sigh is normal.
o Measure and note temperature.
 Temperature may be measured in several ways.
 Oral and rectal temperatures remain the most common, with oral
temperatures usually slightly lower than the core temperature and
rectal being more accurate to the core temperature.
 Temporal and tympanic temperatures can be variable, and
dependent on the user.
 Axillary temperatures are the least accurate and take at least 5-10
minutes to register.
 Pain Assessment
o Onset/Timing
 Note circumstances and timing of pain.
 Note causes of pain.
o Location
 Note where the pain is located.
 Note if the pain radiates to other areas.
o Duration
 Constant
 Intermittent
 Chronicity
o
 Acute pain defined as a predicted response to noxious stimulus.
 Chronic pain defined as lasting longer than 1 month beyond illness/injury
recovery, lasting longer than 3-6 months due to chronic illness.
o Aggravating/Alleviating Factors
 Note if the patient experiences relief or aggravation with movement, rest,
cold/heat, etc.
 Note if the pain has been relieved with any medications.
o Type of pain
 Somatic – emanates from muscles and soft tissues
 Neuropathic – emanates from nerves
 Visceral – emanates from deep structures/organs
 Document the pain as the patient describes it.
o Severity
 Utilize rating scales to assist in obtaining baseline.
 Utilize same scale to evaluate the effectiveness of interventions.
 Note patient’s baseline level of pain in those with chronic pain.
 PEARLS
o Provide privacy for the patient; interview the patient alone to allow for personal
questions they might be reluctant to discuss with others present.
o Orthostatic blood pressures may be indicated in patients presenting with syncope
or near-syncope, dizziness, tachycardia, or palpitations.
o Ensure the use of a properly sized cuff, as erroneous values can be obtained
with a cuff that is either too small or too large.
o In documenting the general assessment, be as descriptive as possible to create
a visual depiction of the patient.
o Elicit from the patient what expectations they have for pain relief.

Head to Toe Assessment

General Survey

 Observe the patient’s general state of health and note posture, motor activity, grooming
and hygiene.
 Pain Assessment.
o PQRST
 Obtain the patient’s height and weight. Calculate the body mass index.
Vital signs

 Measure blood pressure, heart rate, respiratory rate, and temperature.

 Obtain pulse oximetry measurement, if indicated.
Skin

 Observe the skin of the face.

 Integumentary Assessment
o Inspection
 Assess the hair, noting the distribution, texture, and quantity.
  Use your fingers or cotton-tipped applicator to separate the hair and
examine the scalp from one side to the other.
 Inspect the head and neck, including forehead, eyebrows, eyelids,
eyelashes, conjunctivae, sclerae, nose, ears, cheeks, lips, oral cavity,
chin, and beard.
 Have the patient lean forward to assess the upper back.
 Inspect the shoulders, arms, and hands, including the fingernails.
 Inspect the anterior chest and abdomen, followed by the anterior thighs
and legs.
 Assess the feet and toes including the soles, interdigital areas, and
toenails.
 Inspect the lower back, followed by the posterior thighs and legs.
 Lastly, inspect the breasts, axillae, and genitalia including hair in the
axillae and pubic area.
o Palpation
 While inspecting the integumentary system, palpate the fingernails and
toenails, and also any lesions to determine texture, firmness, and
scaliness.
o PEARLS
 Pallor indicates anemia. Cyanosis can indicate decreased oxygen in the
blood or decreased blood flow in response to a cold environment.
Jaundice, or yellowing of the skin, results from increased bilirubin.
 Longitudinal bands of pigment on the nails are normal in people with
darker skin.
 Special considerations for darkly pigmented skin:
 Erythema may appear dark brown, instead of pink or red
 Eczema may appear as scaly lesions with grayish or dark brown
hue
 Wheals may appear lighter in color
 Dry skin may appear whitish or ashy and/or a reduction in
shininess of skin
 If performing a routine physical assessment, integrate aspects of the
integumentary assessment into that examination. For example, when
auscultating the lungs posteriorly, fully assess the back at that time.
 Teach the patient about regular skin self-examination and the ABCDE-
EFG method for assessing moles.
 Asymmetry: if a lesion is cut in half, one side is not identical to the
other; may be higher on one side, a different texture, or color
 Border irregularity and bleeding: jagged edges, tails, bleeding or
ulceration are signs of melanoma
 Color variegation: 2 or 3 colors present or distributed unevenly
 Diameter: greater than or equal to 6 mm
 Evolving: any change in mole over weeks to months in size, shape
or color
 Document your findings using the correct terminology to describe skin
lesions
  Bullae – Raised; fluid-filled; greater than 1 cm
 Burrow – Small linear or serpiginous pathways in the epidermis
 Carbuncle – multiple inflamed hair follicles (furuncles)
 Furuncles – Inflamed hair follicle
 Macules – Flat; smaller than 1 cm
 Nodule – Raised, larger and deeper than a papule
 Papules – Raised; smaller than 1 cm
 Patches – Flat; greater than 1 cm
 Plaques – Raised; greater than 1 cm
 Pustules – Small; palpable; appear white
 Subcutaneous mass/cyst – encapsulated collections of fluid or
semisolid; may be mobile or fixed
 Vesicles – Raised; fluid-filled; less than 1 cm
 Wheals – Localized edema; evanesces (comes and goes) within
1-2 days
HEENT Assessment

 Assessing the Head

o Inspect the head and face for symmetry.
o Inspect the hair for color, distribution, and texture.
o Palpate the scalp and skull for tenderness and inspect for flaking, lesions,
deformities, or tenderness.
 Assessing the Eyes
o Note position and alignment of the eyes and presence of discharge, irritation, and
redness.
o Observe the eyelids.
 Check for drooping of the upper eyelids (ptosis).
 Check strength of upper eyelids by having patient squeeze their eyes
shut. You should not be able to open the patient’s eyelids (cranial nerve
VII).
o Inspect sclera and conjunctiva of each eye; sclerae should be white and clear.
o Inspect each cornea, iris, and lens, checking for transparency.
o Compare the pupils and test each reaction to light.
 Pupils are normally round and vary in size.
 Use the mnemonic PERRLA (Pupils Equal, Round and Reactive to Light
and Accommodation) to test pupil reflexes.
 Test for reactivity to light.
o Darken the room and shine a flashlight on each pupil.
Normally, pupils constrict with light and dilate in the dark.
 Test for accommodation (ability of the lens to adjust to objects at
varying distances).
o When moving an object close to the eye, the pupil will
constrict; when moving an object away from the eye, the
pupil will dilate.
o Assess extraocular movements for abnormalities.
  Assess the 6 cardinal positions of the gaze: right, right up, right down, left,
left up, left down.
 Check for conjugate gaze (ability of the eyes to move in the same
direction at the same time). Eyes normally move in unison, except when
converging on an object that is moving closer.
 Check for nystagmus, a condition in which the eyes move rapidly and
uncontrollably side to side (horizontal nystagmus), up and down (vertical
nystagmus), or in a circle (rotary nystagmus). This may be seen on lateral
movement due to eye fatigue; watch for vertical nystagmus or prolonged
nystagmus.
o Screen visual fields in both eyes: medially/laterally, superiorly/inferiorly (cranial
nerve II).
o Perform a visual acuity test with the Snellen Chart (cranial nerve II)
o For fundoscopic examination, use an ophthalmoscope to inspect the ocular fundi.
 Check transparency of the anterior and posterior chambers.
 Observe the red reflex of the retina; it can be observed by the clinician 1
foot from the eye in a dimly lit room.
 Assessing the Ears
o Examine each ear using an otoscope. Gently pull the pinna of the ear up and
back to straighten the external canal.
 Inspect the auricle, canal, and ear drum for color, symmetry, elasticity,
tenderness, or lesions.
 Inspect the external ear canal for color, drainage, cerumen (ear wax)
buildup, canal edema, erythema, or masses.
 Assess the tympanic membrane for color, shape, transparency, integrity,
bulging, and scarring.
o Test auditory acuity in each ear with the whisper test (cranial nerve VIII).
 Stand about 2 feet behind the seated patient.
 Occlude the non-test ear with a finger.
 Whisper a combination of three words of numbers and letters and ask the
patient to repeat them back to you.
 If acuity is decreased, perform the Weber and Rinne tests (cranial nerve
VIII).
 Sensorineural: the sound-transducing system that involves the
inner ear, cochlea, and auditory nerve.
 Conductive: caused by factors that limit the amount of sound that
enters the inner ear such as ear wax buildup or middle ear fluid.
 Mixed loss: is a combination of both conductive and sensorineural
hearing loss.
 Weber Test (Wahid, Hogan & Attia, 2022; Weber, 2022)
o Normally, we hear equally in both ears. The Weber test is
primarily used to assess patients with unilateral hearing
loss and to characterize conductive versus sensorineural
loss.
o Using a 512-Hz tuning fork, strike the tines on your forearm
just in front of your elbow and place the stem of the fork on
 the top of the head or midline of the forehead. Other sites
such as the chin or bridge of nose, are sometimes used.
The vibrations travel through the skull to the cochlea.
o Ask the patient “Is the sound louder in your right ear, left
ear, or the same on both sides?”.
o Results:
 Normal hearing is confirmed when the sound is
heard midline and equally on both sides.
 Unilateral sensorineural hearing loss is observed if
the patient hears the sound louder (lateralizes) in
the unaffected or “good” ear.
 Unilateral conductive hearing loss is observed if the
patient hears the sound louder (lateralizes) in the
affected or “bad” ear.
 Symmetrical conductive hearing loss is observed if
the patient does not exhibit lateralization.
 Rinne Test (Kong & Fowler, 2022; Weber, 2022)
o The Rinne test helps to discerns sound transmitted through
air versus sound transmitted through bone. This
comparison also helps to assess unilateral hearing loss.
o Using a 512-Hz tuning fork, strike the tines on your forearm
just in front of your elbow and place the stem of the fork on
the mastoid bone behind the ear.
o Ask the patient to cover the other ear with their hand and
to report when the sound can no longer be heard.
o When the patient can no longer hear the vibration on the
mastoid process, move the vibrating tuning fork near the
external auditory canal and ask the patient to tell you when
the sound can no longer be heard.
o Results:
 Normal result is observed when the vibrating fork
positioned near the ear is louder and lasts twice as
long than when placed on the mastoid bone (i.e.,
air conduction is better than bone conduction).
 Abnormal result is observed when sound is at least
equally loud or louder when the fork is placed on
the bone compared to when it is held next to the
ear (i.e., bone is better than air conduction).
 Assessing the Nose and Sinuses
o Inspect the external nose for color, size, shape, symmetry, and presence of
drainage, tenderness, and masses.
o Using a light and nasal speculum or otoscope, inspect the nasal passages for
patency, nasal mucosa for color, nasal septum for deviation, and turbinates for
color and swelling.
o Check the patency of each nare by asking the patient to occlude one nare and
breathe through the other.
 o Assess the patient’s sense of smell (cranial nerve I) with an orange or lemon
peel, coffee, vinegar, or essence bottles of vanilla or peppermint.
o Palpate the frontal and maxillary sinuses for tenderness and assess for signs of
infection.
 Assessing the Throat (Mouth and Pharynx)
o Inspect:
 Lips for color, moisture, masses, cracks, sores, fissures, and symmetry.
 Oral mucosa for color, lesions, dryness/moisture, masses, and swelling.
 Tongue for color, thickness, moisture, symmetry of movement left and
right, and deviations from midline (cranial nerve XII). Palpate the tongue
and floor of the mouth for masses and swelling.
 Teeth for their general condition and evaluate if any are missing.
 Gums for color, texture, swelling, retraction, and bleeding.
 Uvula for movement, position, size, symmetry, and color.
 Pharynx (hard and soft palate) for color, redness, inflammation, exudate,
masses, and lesions.
 Tonsils for size, color, inflammation, and exudate.
 Salivary glands (parotid, sublingual, and submaxillary) for patency and
signs of inflammation or redness.
o Check the patient’s ability to swallow and their gag reflex (cranial nerves IX and
X).
 The thyroid is typically not visible. Assess for an enlarged thyroid gland at
the suprasternal notch.
 Assessing the Neck
o Check neck muscles for symmetry, masses, swelling, and range of motion.
o Palpate cervical lymph nodes for signs of swelling or tenderness; cervical lymph
nodes should not be fixed (unmovable) or palpable (unless the patient is very
thin). Lymph nodes should be small and freely moving.
o Assess head and neck range of motion.
o Check trapezius muscle strength. Ask the patient to shrug their shoulders against
your hands as you apply resistance (cranial nerve XI).
o Check cervical muscle strength. Ask the patient to turn their chin/jaw against your
hand.
o Assess trachea for deviation; it should be midline.
o Evaluate thyroid gland noting enlargement or presence of nodules and masses; it
should be smooth.
o Examine the carotid arteries as part of the cardiac assessment, taking care to
palpate the carotid arteries one at a time, noting symmetry, strength, amplitude,
and presence of an abnormal thrill. Listen for bruits using the diaphragm of your
stethoscope.
o Assess for cervical point tenderness along the posterior aspect of the neck.
 PEARLS
o Compare any new findings with the patient’s past medical history.
o The elements of the HEENT assessment can be interwoven with the cranial
nerve assessment.
 o Ptosis may be congenital or caused by a disorder affecting the muscle tendon,
muscle, or nerve of the eyelid. Unilateral ptosis with impaired extraocular
movement suggests a compressive third cranial nerve palsy.
o A yellowish discoloration of the sclera indicates jaundice.
o Pain with movement of the auricle and tragus of the ear occurs in acute otitis
externa (inflammation of the ear canal), but not in otitis media (inflammation of
the middle ear).
o In viral rhinitis, the nasal mucosa is often red and swollen; in allergic rhinitis, it
may be pale, bluish, or red.
o Tracheal deviation could be a serious sign of tension pneumothorax, pleural
effusion, tumor, or goiter.
Back/Posterior thorax and lungs

 Inspect and palpate the spine and back muscles.

 Inspect, palpate, and percuss the chest (identify dullness of the diaphragm).
 Listen to breath sounds.
Breasts and axillae

 Guidelines for Clinical Breast Examination

o The National Comprehensive Cancer Network screening guidelines suggest that
women between 25 and 40 years old who are asymptomatic and have no special
risk factors for breast cancer undergo a clinical breast exam every 1 to 3 years.
Women older than age 40, women with increased risk factors for breast cancer,
history of breast cancer, and/or symptomatic patients are recommended to
receive more frequent clinical breast exams (Bevers et al, 2018).
o The American Congress of Obstetricians and Gynecologists recommends
offering a clinical breast exam for average-risk women aged 25 to 39 every 1-3
years, and an annual breast exam to women aged over 40 years (Pearlman,
2017).
 Breast Assessment
o Breast inspection
 With the patient seated and arms at sides, visualize both breasts noting
the skin color, any rashes or lesions, skin thickness, size, and symmetry.
In males, gynecomastia may be identified.
 Observe breast contour, including dimpling, masses, or flattening.
 Inspect the nipples and areolae for discharge, size, shape, inversion, or
lesions.
 Ask the patient to raise the arms over the head, place hands on hips, and
lean forward to observe for any dimpling or change in contour.
o Breast palpation
 Examine the patient in a supine position with the ipsilateral arm raised to
rest on the forehead or behind the patient’s head.
 A vertical strip pattern is the best technique for evaluating for breast
masses. Palpate using the pads of the second, third, and fourth fingers,
keeping the fingers slightly flexed, in small concentric circles applying
ascending pressure to each area. Starting at the axilla, work in a vertical
 pattern, moving inward to the midline. Once the nipple line is reached, the
patient should place the ipsilateral hand on that same shoulder with the
elbow at the level of the shoulder for best positioning, as the assessment
continues to the medial breast. It is important to be systematic.
 The examiner should note the consistency of the tissues, tenderness,
lesions, or nodules. Location of any nodules or masses should be
described in a clock pattern or quadrant.
 Palpate each nipple, noting the color, consistency, and quantity of any
discharge and exactly where it appears.
o Axilla inspection and palpation
 While patient is supine, inspect the axilla for excoriation, lesions, or
rashes.
 Palpate for masses, nodules, and lymphadenopathy. The patient’s arm
should be relaxed at his/her side and the examiner cups his/her fingers,
reaching as far into the axilla as possible reaching behind the pectoral
muscle to palpate the lymph nodes. To do so, use your right hand to
examine the left axilla, and the left hand to examine the patient’s right.
The patient should be advised that this examination may be
uncomfortable.
o PEARLS
 Female breasts contain hormonally sensitive tissue, with uneven texture
known as physiologic nodularity. Male breasts lack the development of
ductal branching and lobules, making it difficult to discern from pectoral
muscle tissue.
 Palpating the breast tissue while the patient is supine is helpful as the
tissue flattens out.
 While performing the breast assessment, teach and reinforce the
importance of breast self-exams.
Anterior thorax and lungs

 Pulmonary Assessment
o Inspection
 Inspect the color of lips, tongue, and oral mucosa.
 Observe respiratory rate, depth, and patterns; symmetry; shape and
movement of thorax; and position of trachea.
 Remember, normal breathing is regular and occurs at a rate of 12
to 20 breaths per minute; the normal ratio of inhalation to
exhalation (I:E ratio) is 1:2.
 Observe for dyspnea, tripod positioning, retractions, accessory muscle
use, chest wall deformities, and bruising.
 When supine, observe for paradoxical breathing.
o Palpation
 Palpate for tenderness, crepitus (the sensation of crackles or “rice
crispies” under the fingertips), and step-offs (bones not lined up properly).
 Examine for symmetrical excursion/expansion.
  Place your thumbs at about the level of the 10th ribs and loosely
grasp the chest parallel to the lateral rib cage. Ask the patient to
inhale; as your thumbs move apart during inspiration, feel for the
range and symmetry of the rib cage as it expands and contracts.
 Feel for tactile fremitus (vibrations that are transmitted through the lungs
to the chest wall when the patient speaks).
 Have the patient fold their arms across the chest to displace the
scapulae.
 Use the ball of your hand or the ulnar surface on the patient’s back
and ask the patient to say “ninety-nine.”
 Assess in a ladderlike pattern and compare results bilaterally.
o Percussion
 Percussion helps determine if the underlying structures are air, fluid, or
solid filled.
 Place the middle finger of the non-dominant hand firmly over the chest
wall along the intercostal space and tap the distal interphalangeal joint
with middle finger of the opposite hand. The movement of tapping should
come from the wrist. Tap 2-3 times in a row.
 Percuss the posterior lung fields, alternating, from top to bottom and
comparing sides. Note the resonance and the feel of percussion.
 Percuss the chest all around. Ask the patient to cross arms to shoulder
which will wing the scapula and expose the posterior thorax. Then, have
the patient keep their hands over head and percuss the axillae. Then
move to the front and percuss the anterior chest, clavicles and
supraclavicular space.
 Percuss to assess the movement of the diaphragm by identifying the
lower limits of resonance during deep inspiration and deep expiration.
 Normal findings:
 The left anterior chest is dull due to the presence of the heart.
 The left lower anterior chest is hyperresonant due to the air-filled
stomach.
 The right lower chest is dull due to the liver.
 The rest of the lung fields are resonant.
 Normal diaphragmatic excursion is 5-6 cm.
o Auscultation
 Be alert for audible sounds heard without a stethoscope, such as
wheezing in an asthmatic patient.
 The sitting position is the best position for auscultation. If a patient must
remain recumbent, roll the patient from one side to the other to examine
the back.
 When auscultating, the patient should take deep breaths through the
mouth, deeper than their usual breaths.
 Listen in a ladder pattern over the posterior and anterior chest, using the
diaphragm of the stethoscope.
 Auscultation should occur symmetrically between the two
hemithoraces so that sounds may be compared between sides.
 Start near the apices and move down in a ladderlike pattern until
below the level of the diaphragm is reached or breath sounds are
no longer appreciated. This should be performed over the anterior
and posterior chest.
 Note the presence and location of normal breath sounds:
 Tracheal sounds are loud and equal in duration on inspiration and
expiration; they are heard over the trachea.
 Bronchial sounds are loud and longer on expiration than
inspiration; they are heard over the manubrium.
 Bronchovesicular sounds are of medium volume, with inspiration
and expiration about equal; they are heard over the 1st and 2nd
intercostal spaces between the scapulae.
 Vesicular sounds are soft and longer on inspiration than
expiration; they are heard over most of the lung fields.
 Abnormal findings include stridor, wheezes, crackles (coarse or fine),
rhonchi, pleural friction rubs, as well as diminished or absent breath
sounds.
 Wheezing is a continuous high-pitched musical sound on expiration or
inspiration. A wheeze is the result of narrowed airways. Common causes
include asthma, emphysema, anaphylaxis, a foreign body in the
mainstem bronchus, or a fixed lesion such as a tumor.
 Rhonchi are characterized by low pitched sounds heard on inspiration
and expiration. Rhonchi are a lower pitched variant of the wheeze. It has
a snoring, gurgling or rattle-like quality. Rhonchi, unlike wheezes, may
disappear after coughing, which suggests that secretions play a role.
Although many clinicians still use the term rhonchi, some prefer to refer to
the characteristic musical sounds simply as high-pitched or low-pitched
wheezes.
 Crackles or rales may be described as fine (soft, high-pitched) or coarse
(louder, low-pitched). The sound of hair being rubbed between one’s
fingers is often used as an example to describe these types of sounds.
Crackles suggest the presence of intra-alveolar fluid as seen with
congestive heart failure, pneumonia, and interstitial lung disease.
 Stridor is a high-pitched musical breath sound resulting from turbulent air
flow in the larynx or lower in the bronchial tree. It is often intense and can
be heard without a stethoscope. Stridor usually requires immediate
intervention.
 Inspiratory stridor suggests obstruction above the vocal cords (i.e.,
angioedema, epiglottitis, foreign body).
 Expiratory stridor or mixed inspiratory/expiratory stridor suggests
obstruction below the vocal cords (i.e., croup, bacterial tracheitis, tumor,
foreign body).
 Diminished breath sounds can be caused by anything that prevents air
from entering the lungs. Such conditions include atelectasis, severe
COPD, severe asthma, pneumothorax, tension pneumothorax, and
extrinsic bronchial compression from tumor.
  If adventitious breath sounds are identified, assess how these sounds
change as the patient speaks. Voice generated sounds can provide
important clues about respiratory abnormalities. Perform examinations for
egophony, bronchophony, and whispered pectoriloquy.
 Whispered pectoriloquy: Ask the patient to whisper a sequence of words
such as “one-two-three,” and listen with a stethoscope. Normally, only
faint sounds are heard. However, over areas of tissue abnormality, the
whispered sounds will be clear and distinct.
 Bronchophony: Ask the patient to say "99" in a normal voice. Listen to the
chest with a stethoscope. The expected finding is that the words will be
indistinct. Bronchophony is present if sounds can be heard clearly.
 Egophony: While listening to the chest with a stethoscope, ask the patient
to say the vowel “e”. Over normal lung tissues, the same “e” (as in "beet")
will be heard. If the lung tissue is consolidated, the “e” sound will change
to a nasal “a” (as in "say").
 Also, be alert for non-pulmonary sounds that may be heard during
auscultation, such as mediastinal crunch and pleural rubs.
 Mediastinal crunch is caused by pneumomediastinum. This sound is
characterized by precordial crackles that correlate with the heartbeat
rather than respiration. The patient can be asked to temporarily cease
respiration to appreciate this difference.
 Pleural friction rub results from the movement of inflamed and roughened
pleural surfaces against one another during movement of the chest wall.
This sound is non-musical, and described as “grating,” “creaky,” or “the
sound made by walking on fresh snow.” Inflammation or neoplasia can
cause thickening of the pleural surfaces, which then creates more friction
when sliding along one another, creating this sound. Any potential cause
of pleural effusion, pleuritis, or serositis can result in a pleural friction rub
(i.e., inflammation, neoplasm). Patients may be able to describe the
localization of the rub based on pain. A pleural friction rub is a
manifestation of pleural disease, though its absence does not exclude this
pathology.
o PEARLS
 Fremitus is decreased when there is something blocking its transmission
(mucous plug, pleural effusion, tumor, or pneumothorax); fremitus may be
increased with pneumonia.
 The presence of dullness on percussion is suspicious for pneumonia or
pleural effusion; generalized hyperresonance on percussion may be
heard over hyperinflated lungs, as with chronic obstructive pulmonary
disease (COPD) or asthma.
 The presence of crepitus is concerning for subcutaneous emphysema or
fractures.
 Stridor is heard more prominently in the anterior neck and usually
represents airway obstruction.
 Absent breath sounds in patients with asthma is concerning for extreme
bronchospasm.
 The presence of egophony, bronchophony, and pectoriloquy is concerning
for pneumonia due to the transmission of sound through consolidated
tissue.
 Diminished bibasilar breath sounds is common in patients who are supine
in a hospital bed. If able, sit patients upright on the edge of the bed for a
more accurate assessment.
 The left lung has two lobes; the right lung has three lobes. (Remember L
comes before R, and 2 comes before 3).
 Assess the respiratory rate while taking the patient’s pulse; if the patient
knows you are counting respirations, they may subconsciously alter the
rate.
 The ratio of inspiration to expiration (I:E) is normally about 1:2.
 To check for tactile fremitus, ask patient to fold his arms across chest; this
shifts the scapulae out of the way.
 Production of pink, frothy sputum is a classic sign of acute pulmonary
edema.
 Absent breath sounds in patients with asthma is concerning for extreme
bronchospasm.
 In acute respiratory distress syndrome (ARDS), the alveolar membranes
are more permeable, and spaces are fluid filled. The alveoli collapse,
impairing gas exchange. BLOG
 Positive end-expiratory pressure (PEEP) reduces cardiac output by
increasing intrathoracic pressure and reducing the amount of blood
delivered to left side of heart.
 A patient with orthopnea (shortness of breath while lying down) tends to
sleep with their upper body elevated. Ask how many pillows they use.
 The most common causes of massive hemoptysis are lung cancer,
bronchiectasis, active tuberculosis (TB) infection, and cavitary pulmonary
disease from necrotic infections or TB.
 Subcutaneous emphysema feels like puffed rice cereal crackling under
the skin; it indicates air leaking from the airways or lungs. If it involves the
neck or upper chest, airway patency may be compromised.
 Clubbing is thickening of the flesh under the toenails and fingernails and
causes the nails to curve down. Clubbing is typically a sign of pulmonary
or cardiovascular disease, such as emphysema, chronic bronchitis, lung
cancer, or heart failure.
 A barrel chest indicates loss of lung elasticity and flattening of the
diaphragm. It is seen in patients with chronic obstructive pulmonary
disease (COPD).
 To prevent ventilator-associated pneumonia (VAP), keep the head of bed
elevated 30 to 45 degrees, unless contraindicated.
 Dead space ventilation means there is normal ventilation (air movement)
but without adequate perfusion (blood flow). This can be caused by
pulmonary embolism.
 With shunting, there is perfusion without adequate ventilation, and this
usually results from airway obstruction, as with atelectasis or pneumonia.
Cardiovascular system

 Measure jugular venous pressure and inspect and palpate the carotid arteries; listen for
bruits.
o Bruits
 The presence of a bruit suggests stenosis or disruption of normal blood
flow, such as through a tortuous vessel (Bickley et al., 2021). It is often
described as a “whooshing” sound. The diaphragm of the stethoscope is
used first to better hear the higher frequency of arterial bruits. In cases
where the patient has high-grade stenosis, the frequency is lower (and
sometimes absent) which can be better heard with the bell (Bickley, et al.,
2021). A bruit may be heard in two phases.
 When assessing for carotid bruits, ask the patient to hold their breath for
no more than 10 seconds while auscultating to better distinguish bruits
from sounds transmitted from the trachea. Other areas to assess for
bruits includes the abdominal aorta, as well as the renal and iliac arteries.
o Thrills
 A thrill is a vibration felt upon palpation of a blood vessel or over the
precordium. The examiner may perceive a systolic and diastolic
component to the vibration (Bickley et al., 2021). The presence of a thrill
suggests stenosis, either of the underlying vessel or it may be transmitted
from another source. The grading of systolic murmurs is influenced by the
presence of a palpable thrill.
 A bruit is the auscultated equivalent of the thrill and has the same
significance.
 A thrill felt at the carotid artery may signify aortic stenosis, as the vibration
is transmitted through the tissue from the second intercostal space.
(Bickley et al., 2021).
 A thrill and a bruit at the site of an arteriovenous (AV) fistula, commonly
used for hemodialysis, is a normal finding (Beathard, 2021).
 Perform a complete cardiac assessment, including inspection and palpation of the
precordium, and auscultation of heart sounds.
 Palpate the radial and brachial pulses.
 Neck
o Inspection
 Observe pulsations of the jugular veins and carotid arteries, often visible
just medial to the sternocleidomastoid (SCM) muscles.
 JVP measured at greater than 3 cm above the sternal angle, or
more than 8 cm in total distance above the right atrium, is
considered elevated above normal
 Heart failure (HF) is a major cause of elevated right heart
pressures, so estimating JVP can help diagnose HF or detect
exacerbations.
 To distinguish between carotid artery and jugular vein pulsations
recognize that carotid pulsations are easily palpable, are not eliminated
by pressure/palpation, and do not vary with position changes or
respirations.
  Assess the jugular veins for distention.
 Estimate the jugular venous pressure (JVP); the JVP gives an estimation
of central venous pressure, or right atrial pressure, and gives valuable
information about a patient’s volume status.
 Inspect both sides of the neck, using tangential lighting. Turn the patient’s
head slightly away from the side you are inspecting.
 Identify the external jugular veins and find the internal jugular vein
pulsations.
 While visualizing the right internal jugular vein, look for pulsations in the
suprasternal notch, between the attachment of the SCM on the sternum
and clavicle, or just posterior to the SCM.
 Find the highest point of pulsation in the right jugular vein; use a card
horizontally from this point and a centimeter ruler vertically from the
sternal angle, to make an exact right angle.
 Measure the vertical distance in centimeters above the sternal angle
where the horizontal object crosses the ruler and add to this distance 5
cm (the distance from the sternal angle to the center of the right atrium).
 Add the numbers together to get an estimated JVP.
o Auscultation
 Auscultate the carotid arteries.
 Listen for carotid bruits bilaterally.
 Listen for referred murmurs in the left neck.
o Palpation
 Use your index and middle fingers to palpate the carotid arteries one at a
time; note the character of pulsation, including the amplitude of the pulse
and the contour of the pulse wave.
 Note the presence of vibrations, or thrills.
 Chest
o Inspection
 Examine the chest for visible point of maximum impulse (PMI) and for the
presence or absence of heaves.
 The point of maximum impulse is usually located at the fifth
intercostal space near the left midclavicular line and locates the
left border of the heart.
 A heave is a sustained impulse that visibly lifts the soft tissue or
can be felt through the pads of the examiner’s fingers.
o Auscultation
 Listen to the anterior chest from base to apex, at the six points for cardiac
auscultation:
 Second intercostal space (ICS), near the right sternal border
(aortic area)
 Second ICS, along the left sternal border (pulmonic area)
 Third ICS, along the left sternal border
 Fourth ICS, along the left sternal border (tricuspid area)
 Fifth ICS, along the left sternal border (tricuspid area)
 Near the midclavicular line at the fifth ICS (mitral area)
 Identify the S1 and S2 heart sounds
 The diaphragm of the stethoscope is best for hearing S1 and S2.
 S1 and S2 can be identified by palpating the right carotid artery
while listening to the heart tones; S1 will be noted just before the
carotid upstroke, with S2 following.
 Note any splitting of S1 or S2 and the location where this is noted.
 Note the clarity of heart tones (muffling) and listen for extra heart sounds
including opening snaps, systolic clicks, rubs, S3 or S4 gallops, or
splitting of S1 or S2 .
 Splits (S1 split, S2 split)
o An S1 split occurs when the earlier mitral and later
tricuspid closure sounds separate. This can be a normal
finding. During expiration, the aortic and pulmonic valves
close nearly simultaneously creating a single sound of S2.
An S2 split occurs occasionally on inspiration where the
pulmonic valve slightly delays its closing. An S2 split can
also be a normal finding.
 Gallops (S3, S4)
o An S3 gallop is sometimes heard after S2 due to
deceleration of blood against the ventricular wall. This may
be a normal finding in children, younger adults, and
athletes. In older adults, however, this is considered
pathological and may indicate heart failure.
o The S4 heart sound would be heard immediately before S1
of the next beat. If present, this could be suggestive of
ventricular stiffness and may be seen in those with
hypertension or acute MI. In athletes, this may be a normal
finding.
 Opening Snaps
o An opening snap may be heard as the mitral valve opens if
there is restriction of the valve leaflets. This is heard just
after S2 and could indicate mitral stenosis.
 Systolic Clicks
o A clicking sound heard during systole may be indicative of
mitral valve prolapse.
 When documenting S1 and S2 split sounds it is important to
identify at what point during the respiratory cycle the sound is
heard.
 In older adults, S3 and S4 heart sounds should be reported to the
responsible provider.
 Systolic clicks are the most common extra heart sound.
 Auscultate for murmurs, noting timing, shape, location of maximal
intensity, radiation or transmission from PMI, grade (intensity), and
character (pitch - high, medium, low, and quality - blowing, harsh,
rumbling, musical).
  Position patient in left lateral decubitus to assist in auscultating for
S3, S4, or murmur of mitral stenosis.
 Position patient in sitting, forward-leaning position after full
exhalation with breath held to assist in auscultating murmur of
aortic insufficiency/regurgitation.
 Murmur Grading
o Grade 1: Very faint, may not be heard in all positions
o Grade 2: Quiet, but easily heard with stethoscope on chest
o Grade 3: Moderately loud
o Grade 4: Loud
o Grade 5: Very loud, may be heard with stethoscope partly
off chest
o Grade 6: Loudest, be heard with stethoscopy entirely off
chest
o Palpation
 Palpate precordium for PMI, heaves, or thrills.
 Use your palm or fingerpads to palpate for heaves.
 Press the ball of your hand firmly on the chest to assess for thrills.
 You can also feel for a palpable S1 and S2, S3 or S4, and murmurs.
 Left ventricular apical impulse or apex beat is normally localized in the
fourth to fifth left intercostal space medial to the left midclavicular line and
is 2 to 3 cm in diameter. This is best palpated when the patient lays in the
left lateral decubitus position.
 Extremities
o Inspect for cyanosis, pallor, coolness of extremities, edema or diaphoresis.
o Palpate peripheral pulses for quality and presence of pulsus paradoxus or pulsus
alternans.
 PEARLS
o Use both the bell and the diaphragm of the stethoscope when auscultating the
heart.
 The bell is best to identify lower pitched sounds such as S3 and S4, and
murmurs associated with mitral stenosis.
 The diaphragm is more sensitive to pick up higher pitched sounds, such
as S1 and S2, friction rubs, and murmurs associated with aortic and mitral
regurgitation.
o Pulsus paradoxus can be a sign of pericardial tamponade if presenting with
muffled heart tones, tachycardia, and hypotension. A pericardial rub may also be
present.
o Carotid stenosis or atherosclerosis may present with a bruit. Use caution if
palpating the carotids in the presence of a bruit, as there is danger of plaques
breaking off and causing a stroke.
o Never palpate both carotid arteries simultaneously, as could seriously impede
blood flow to the brain.
o Palpation of the carotid arteries may cause a vagal response.
o Pulsus alternans may indicate severe left ventricular dysfunction.
o When measuring the pulse rate for the first time, obtaining baseline data, if the
rhythm is irregular or the patient has a pacemaker, count the beats for a full
minute.
o Use the pads of your index and middle fingers to take a pulse. Don’t use your
thumb; it has a strong pulse of its own.
o Don't palpate both carotid arteries at the same time or press too firmly; the
patient could faint or become bradycardic.
o Ensure the use of a properly sized blood pressure cuff, as erroneous values can
be obtained with a cuff that is either too small or too large.
o If you need to repeat a blood pressure measurement, wait at least 2 minutes
before retaking.
o To calculate mean arterial pressure (MAP), add the systolic blood pressure and
twice the diastolic blood pressure, then divide result by 3. BLOG PODCAST
o The three positions for cardiac auscultation are supine with the head of bed
elevated 30-45 degrees, sitting up, and lying on left side.
o When auscultating the heart, if the heart sounds are faint, try repositioning the
patient in the left lateral decubitus position or seated, forward-leaning position.
o The six characteristics of heart sounds are location, intensity, duration, pitch,
quality, and timing.
o A thrill is a palpable vibration felt over the heart or a blood vessel; it results from
turbulent blood flow.
o A displaced apical impulse may indicate an enlarged left ventricle; possible
causes include heart failure or hypertension.
o When describing a murmur, crescendo means it increases in intensity;
decrescendo means it decreases in intensity. BLOG
o The first heart sound, S1, which produces the "lub" sound, is associated with
closure of the mitral and tricuspid valves.
o The second heart sound, S2, which produces the "dub" sound, is associated with
closure of pulmonic and aortic valves.
o An S3 is a normal finding in a child. In an adult, however, this heart sound can
indicate heart failure. BLOG
o An S4 heart sound may be heard in elderly patients or those with hypertension,
aortic stenosis, or history of myocardial infarction. BLOG
o The right side of the heart pumps blood to the lungs to get oxygen; the left side of
the heart pumps oxygenated blood to rest of body.
o The myocardium is the middle layer of the heart wall; it has striated muscle fibers
that cause the heart to contract. Think Myocardium=Middle=Muscle.
o Cardiac output (CO) is the amount of blood the heart pumps in one minute. CO
equals the heart rate multiplied by the stroke volume (amount of blood ejected
with each heartbeat). BLOG
o The stroke volume depends on three factors: preload, contractility, and afterload.
o Preload equals stretching of muscle fibers in the ventricles. This stretching
results from blood volume in the ventricles at end-diastole. BLOG
o Contractility equals the inherent ability of the myocardium to contract normally; it
is influenced by preload (the greater the stretch, the more forceful the
contraction).
 o Afterload equals the pressure that the ventricular muscles must generate to
overcome the higher pressure in the aorta to get blood out of the heart. BLOG
o The normal pacemaker of the heart is the sinoatrial (SA) node; it generates
impulses 60-100 times/minute.
o On the horizontal axis of ECG paper, a large block equals 0.2 seconds and a
small block equals 0.04 seconds.
o The QRS complex represents ventricular depolarization; it's normally 0.10
second or less.
o The QRS complex in bundle branch block is 0.12 second or greater because the
ventricles aren't depolarized simultaneously.
o The predisposing factors for venous thromboembolism (VTE) are venous stasis,
endothelial or vessel wall injury, and hypercoagulable states.
o Post-op atrial fibrillation usually occurs within five days after open heart surgery,
with peak incidence on day two.
o The clinical consequences of atrial fibrillation include decreased cardiac output
and potential for thrombus formation.
o An enlarged waist circumference indicates central obesity and is a key risk factor
for metabolic syndrome.
o Patients with metabolic syndrome are at increased risk for coronary artery
disease, stroke, and type 2 diabetes.
o Pulsus paradoxus is characterized by increases and decreases in pulse
amplitude associated with the respiratory cycle (decreased with inhalation). It is
associated with pericardial tamponade, heart failure, constrictive pericarditis.
BLOG
o Pulsus alternans refers to an alternating pattern of weak and strong pulse; it is
associated with left-sided heart failure. BLOG
o A fever, plus a new or changed heart murmur, is the classic sign of endocarditis.
o The most common causes of orthostatic hypotension are volume depletion and
autonomic dysfunction
o

Heart Murmurs

 Timing
o The timing of murmurs is identified by when the murmur is heart in the cardiac
cycle. Systolic murmurs are heard between S1 and S2; diastolic murmurs are
heard between S2 and S1. They can be further characterized by how long they
‘occupy’ systole or diastole. Continuous murmurs begin in systole and continues
to diastole without interruption.
 Intensity
o Different grading systems are used to describe the intensity, or loudness, of
murmurs; a six-point scale is used to grade systolic murmurs and a four-point
scale is used to grade diastolic murmurs. In general, the grading is expressed as
a fraction, with the numerator representing the intensity at its loudest and the
denominator being 4 or 6, depending on the scale used.
 o The intensity of murmurs can be decreased due to obesity, emphysema, and
pericardial effusion.
 Shape
o The shape or configuration of a murmur refers to its intensity over time.
Crescendo is used to describe murmurs that increase or grow louder.
Decrescendo refers to those that soften or decrease in intensity. Crescendo-
decrescendo means the murmur increases and then decreases. Plateau means
unchanged in intensity.
 Location & Radiation
o When describing the location of a murmur, it’s important to identify where the
murmur is best heard, which is typically the site where it originates. When
thinking about radiation of the murmur, ask “Where else is the murmur heard?” In
some instances, it can be heard over the left scapula or in the axilla.
 Pitch & Quality
o Murmurs can be described as high-pitched, medium-pitched or low-pitched. The
quality can be described as blowing, harsh, scratching, rumbling or musical.
 Systolic Murmurs
o Mitral regurgitation; tricuspid regurgitation; septal defect; increase in flow rate;
aortic valve sclerosis; pulmonic/aortic outflow obstruction
 Diastolic Murmurs
o Aortic/pulmonic regurgitation; mitral stenosis; prosthetic mitral valve; increase
flow across AV valve; shunts; myxoma; complete AV block
 Continuous Murmurs
o Aortopulmonary window; shunts; AV fistulas; coarctation of aorta

Pulsus Paradoxus

 Pulsus paradoxus. It’s an intimidating term and a sign not to be taken lightly. What is it
and how do you detect it? In its simplest form, pulsus paradoxus is defined as a drop in
peak systolic blood pressure more than 10 mm Hg during inspiration (York et al., 2018).
The paradox refers to the variable strength of the pulse palpated on exam and not the
drop in blood pressure (Borlaug, 2019). It seems harmless but what makes this sign so
ominous is that it may signal cardiac tamponade, a serious life-threatening complication
of pericardial effusion that requires immediate treatment.
 To understand pulsus paradoxus we must first review normal cardiac physiology. During
normal inhalation, there is a slight decrease in intrathoracic pressure which promotes an
increase in venous return and right-sided atrial and ventricular filling. The filling on the
right side of the heart pushes the septum to expand into the left side of the heart,
decreasing left-sided filling, stroke volume, and typically systolic blood pressure.
Exhalation increases intrathoracic pressure and promotes left-sided atrial and ventricular
filling. The normal pattern of breathing usually causes a decrease in peak systolic
pressure of less than 10 mm Hg during inhalation. However, in restrictive conditions in
which the left side of the heart cannot fill adequately with blood, there is an exaggerated
drop in systolic blood pressure during inspiration (York et al., 2018). Borlaug (2019)
describes pulsus paradoxus as a “direct result of competition between the right and left
sides of the heart for limited space; for the right heart to fill more, the left heart must fill
 less.” This leads to a decrease in left ventricular diastolic volume, a lower stroke volume,
and a decrease in systolic pressure during inspiration.
 How to Detect Pulsus Paradoxus (Lippincott Advisor, 2020)
o Using a sphygmomanometer
 Make sure the patient is breathing normally.
 Inflate the blood pressure cuff 10 to 20 mm Hg beyond the peak systolic
pressure.
 Then deflate the cuff slowly at a rate of 2 mm Hg/second until you hear
the first Korotkoff sound during expiration; note the systolic pressure.
 Continue to deflate the cuff, observing the patient’s respirations. In pulsus
paradoxus, the Korotkoff sounds will disappear with inspiration and return
with expiration.
 Continue to deflate the cuff until the Korotkoff sounds emerge during both
inspiration and expiration; note the systolic pressure.
 Subtract the second systolic reading from the first. A difference of more
than 10 mm Hg is abnormal. Peripheral pulses may not be palpable or
may disappear completely with a drop in systolic blood pressure greater
than 20 mm Hg.
o Palpating the patient’s pulse
 Palpate the patient’s radial pulse over several cycles of slow inspiration
and expiration.
 A significant decrease in the strength of the pulse during inspiration may
indicate pulsus paradoxus.
o Observe the intra-arterial blood pressure waveform
 For a patient in the intensive care unit with an intra-arterial line, you can
assess the waveform. With pulsus paradoxus you will see a decrease in
the amplitude of the systolic pressure on inspiration.
 Medical Causes (Borlaug, 2019)
o Cardiac tamponade occurs when fluid accumulated in the pericardial sac
prevents the heart from adequately filling with blood. (Check out our
recommended resources below for more information about cardiac tamponade.)
o Cardiac pericarditis
o Right ventricular myocardial infarction
o Restrictive cardiomyopathy
o Asthma and chronic obstructive pulmonary disease (COPD) cause wide
fluctuations in intrathoracic pressure (as high as 40 mm Hg) that may result in
pulsus paradoxus.
o Obstructive sleep apnea
o Tension pneumothorax
o Pulmonary embolism
o Bilateral pleural effusion
o Hypovolemic shock
o Significant obesity
 Assessment
o If the patient exhibits pulsus paradoxus, be sure to obtain a thorough medical
history (Lippincott Advisor, 2020):
  Chronic cardiac or pulmonary disease
 Recent trauma or cardiac surgery
 Other signs and symptoms such as cough or chest pain
o Your physical assessment should include (Lippincott Advisor, 2020):
 Auscultation for abnormal breath sounds
 Vital signs
 Cardiopulmonary assessment
 Obtain an electrocardiogram and laboratory tests such as cardiac
enzymes, coagulation studies, electrolytes, and complete blood count
 Important Clinical Considerations
o Irregular heart rhythms and tachycardia can cause variations in pulse amplitude
and should be ruled out before a diagnosis of pulsus paradoxus is made
(Lippincott Advisor, 2020).
o Patients who are intubated and on positive pressure ventilation will not have the
normal drop in intrathoracic pressure during inspiration (York et al., 2019).
o Pulsus paradoxus may not occur in patients with tamponade if the diastolic
pressure in one of the ventricles is greater than that of the pericardial space, or if
there is an intracardiac shunt or valvular leak (Borlaug, 2019).
o Other conditions that will counteract pulsus paradoxus include severe aortic
regurgitation, severe left ventricular hypertrophy, and left ventricular dysfunction
(York et al., 2019).
o Pulsus paradoxus may not be detectable in patients who have significant
hypovolemia with hypotension (York et al. 2019).
o An echocardiogram may be performed to evaluate cardiac motion and to
determine the underlying cause. Prepare the patient and monitor the vital signs
closely, checking the degree of paradox. An increase in the degree of paradox
may indicate a worsening of cardiac tamponade or potential respiratory arrest in
severe COPD (Lippincott Advisor, 2020).
Pulsus Alternans

 When performing a cardiovascular assessment, the rhythm and character of peripheral

pulses are observed. While palpating the radial or femoral pulses, one may note that
although the rhythm is regular, the strength of the pulse may alternate between weaker
and more forceful impulses. Hence, the term pulsus alternans.
 The beat-to-beat variability of pulsus alternans can be confirmed using a blood pressure
cuff and listening closely as the cuff is deflated. Initially, only the stronger Korotkoff
sounds are heard, but as the pressure in the cuff continues to deflate, the softer sounds
appear, though they will eventually fade away (Bickley et al., 2021).
 The presence of pulsus alternans strongly suggests severe left ventricular dysfunction
(Bickley et al., 2021; Corlucci & Borlaug, 2021). Pulsus alternans may be noted in those
with dilated cardiomyopathy with left ventricular outflow obstruction, severe aortic
regurgitation, or cardiac tamponade, but rarely without the presence of associated left
ventricular dysfunction (Gersh, 2021).
 Asking the patient to sit upright during physical examination may highlight this finding.
 Pulsus alternans is frequently associated with left ventricular failure, and this finding
should prompt further diagnostic investigation.
Abdomen – GI Assessment

 Inspection
o Observe for nonverbal cues of discomfort, such as grimacing.
o Inspect the contour of the abdomen, noting any bulges, masses, pulsations,
asymmetry, protuberance or scaphoid appearance.
o Inspect the surface of the abdomen for striae, ecchymosis, scars, rash, or dilated
veins.
o Observe the umbilicus for bulges or inflammation.
 Auscultation
o Utilizing the diaphragm of the stethoscope, listen for no more than 5 minutes for
bowel sounds (gurgling of varying pitches) of the right lower quadrant.
o A frequency of 5 to 34 sounds per minute is considered normal, whereas less
than 5 sounds per minute is considered hypoactive and more than 34 considered
hyperactive.
o Note the character of the bowel sounds, such as tinkling, rumbling, etc.
o Auscultate over the abdominal aorta, renal arteries, iliac arteries, and femoral
arteries and note the character of the sound, particularly if a bruit is heard.
 Percussion
o Percuss all four quadrants to assess for tympany or dullness.
o Tympany will be heard over air-containing organs such as the stomach or
intestines, whereas dullness is heard over solid organs or organs containing solid
matter.
o Measure the liver size at the right midclavicular line by percussing from the RLQ
and moving cephalad while listening for dullness to indicate the inferior border.
o Percuss along Traube’s space to determine splenic size by listening for dullness.
 Traube’s space is a crescent-shaped region that is bordered by the left
6th rib, the left costal margin, and the left midaxillary line.
o Traube-s-space-(1).png
o Percuss over the bladder to evaluate for distention or tenderness.
o Note any unexpected dull areas that may suggest organomegaly or mass.
 Light palpation
o Utilizing the forearm and hand with fingers together on a horizontal plane,
palpate using a gentle downward motion in all four quadrants.
o Assess for superficial masses, tenderness, guarding, or rigidity.
 Deep palpation
o Deep palpation is performed with one hand over the other, using the pads of the
fingers to press more deeply into each quadrant.
o Assess for the liver edge, masses, tenderness, pulsatile masses, or rebound
tenderness.
 The McBurney point is point tenderness located in the center of the right
lower quadrant, approximately 3-4cm towards the midline from the iliac
spine.
 Rovsing sign is a referred (indirect) tenderness in the right lower quadrant
associated with rebound; it’s located in the middle of the left lower
 quadrant when deep palpation is applied. Pain in this location tends to
escalate when pressure is released from the area.
 Psoas sign is assessed by having the patient lie supine and placing your
hand just above the knee. Ask the patient to lift the right leg against
resistance of your hand. This motion causes friction of the psoas muscle
over the inflamed appendix, causing pain.
 To assess for the obturator sign, position the patient supine with their right
knee bent and leg bent at the hip. Rotate the leg internally at the hip,
causing the internal obturator muscle to stretch providing indirect
pressure over the appendix.
o Palpate the liver edge below the right costal margin for consistency (smooth or
nodular) or tenderness.
 Murphy’s sign: during deep palpation of the right upper quadrant, the
patient has difficulty with inspiration; releasing palpation relieves this
sensation.
o The liver margin can also be identified by placing the fingertips at the lower
border of the liver well below the costal margin and palpating toward the chest,
asking the patient to take a deep breath to better identify the liver edge.
Alternatively, in obese patients “hooking” may be employed by standing on the
patient’s right side, placing fingertips below the percussed level of dullness and
palpating deeply while directing fingers toward the chest. Ask the patient to take
a deep breath to feel the liver edge.
o Palpate the splenic edge for consistency or tenderness (best performed with
patient supine, and right decubitus position).
 Percussion of flanks
o Place the patient in a seated position.
o Place palm of one hand over the costovertebral angle (CVA) of one side.
o Use fist of other hand to strike the back of the flat hand with the ulnar aspect of
the fist.
o Repeat with the patient’s other side.
o Pain upon this maneuver is considered positive for CVA tenderness.
 Pearls
o Auscultation of the abdomen should occur prior to any percussion or palpation,
as these may alter the bowel sounds.
o Bowel sounds are transmitted throughout the abdomen, allowing for auscultation
at the right lower quadrant, although you may elect to listen to all four quadrants
if necessary.
o Pulsatile masses identified on inspection should be further evaluated by
auscultation to determine the presence of a bruit.
o Guarding may be voluntary or involuntary, with the latter indicating rigidity.
o Rebound tenderness is defined as an increase in pain when deep palpation is
suddenly released. Rebound tenderness and rigidity together are highly
suspicious for peritonitis/acute abdomen and is a clinical emergency.
o Positive CVA tenderness may indicate renal pathology versus a musculoskeletal
source.
 o Auscultate the abdomen before percussion or palpation, as these may alter the
bowel sounds.
o Abdominal angina is abdominal pain resulting from compromised perfusion to
digestive tissue. It is usually due to mesenteric atherosclerosis.
o McBurney's point is located between umbilicus and the right anterior iliac crest;
pain here associated with appendicitis. BLOG
o If you suspect appendicitis, check for Rovsing sign (right lower quadrant pain
during left-sided pressure) and referred rebound tenderness. BLOG
o Appendicitis pain typically begins near the umbilicus, and then shifts to the right
lower quadrant. Coughing usually worsens the pain.
Lower extremities

 Palpate the femoral and popliteal pulses, and the inguinal lymph nodes.
 Inspect the lower extremities for edema, discoloration, ulcers, and varicose veins.
 Assess lower extremity muscles and reflexes.
Musculoskeletal system

 Exam methods
o Inspection. Examine for joint symmetry, deformities or malalignment. Inspect the
surrounding tissues, noting any swelling, muscle atrophy or skin changes.
o Palpation. Palpate the musculoskeletal structures keeping in mind the underlying
anatomy of the joints. Note any crepitus, tenderness, fluid collection, or
inflammation.
o Range of motion (ROM). Assess the two phases of range of motion: active and
passive. Note any limitations in movement or joint instability.
o Special maneuvers. Special maneuvers can help identify common conditions
specific to certain joints. Perform stress maneuvers (if indicated) to assess joint
stability, ligaments, tendons, and bursae.
 Temporomandibular Joint (TMJ)
o Inspection. Assess for swelling or redness, noting the laterality. Observe for
symmetry.
o Palpation. Palpate the masseter, temporal, and pterygoid muscles.
 The masseter muscle is located at the angle of the mandible.
 The temporal muscles are palpated at the temple bilaterally with
clenching and relaxation of the jaw.
 The pterygoid muscles are located internally between the tonsillar pillars
and can be difficult to palpate.
o ROM. Observe for crepitus or clicking upon opening and closing of the mouth.
Observe for symmetry of motion. Range of motion of the TMJ includes three
movements:
 Opening and closing of the mouth
 Protrusion and retraction (pushing the mandible forward)
 Lateral (side-to-side) motion of the mandible
 Shoulder
 o Inspection. Anterior inspection of the shoulder involves the shoulder girdle, with
posterior inspection of the scapula and related muscles. Observe for swelling,
bulges, atrophy, deformity, fasciculations, or abnormal positioning.
o Palpation. Observe carefully for tenderness, crepitus, and deformities. Palpate
from the sternoclavicular joint along the clavicle laterally to the acromioclavicular
joint. Posteriorly, follow the bony spine of the scapula laterally and upward until
fingers meet the acromion. Identify the anterior tip of the acromion. Then place
your thumb on the distal end of the clavicle at the acromioclavicular joint. Moving
the thumb immediately and down, the coracoid process of the scapula is then
identified. To palpate the biceps tendon, your thumb should remain on the
coracoid process with fingers on the lateral aspect of the humerus. Then place
your index finger midway between the coracoid process and the greater tubercle
on the anterior surface of the arm. Then palpate the subacromial subdeltoid
bursa and the SITS muscles (supraspinatus, infraspinatus, teres minor, and
subscapularis) by lifting the elbow posteriorly, rotating the structures to position
them anterior to the acromion. Lastly, palpate the capsule and synovial
membrane beneath the anterior and posterior acromion.
o ROM. The shoulder girdle accommodates six movements: flexion, extension,
abduction, adduction, internal rotation, and external rotation. These motions are
assessed by the following, observing for crepitus, deformity, or pain:
 Flexion. Ask the patient to raise arms in front and overhead.
 Extension. Ask the patient to raise arms behind him/her.
 Abduction. Ask the patient to raise arms out to the side and overhead.
 Adduction. Ask the patient to cross his/her arm across the front of their
body.
 Internal rotation. Ask the patient to reach behind to touch their shoulder
blade, noting the highest midline spinous process they can reach.
 External rotation. Ask the patient to place their hand behind his or her
neck.
o Special Maneuver.
 If atrophy of the shoulder muscles is noted, assess for scapular winging.
Have the patient extend both arms and push either against your hand or
against a wall; observe the scapulae. If the scapulae protrude away from
the thorax, this is a positive finding for scapular winging.
 Elbow
o Inspection. Support the patient’s forearm with the elbow flexed to 70°. Inspect the
contours of the elbow, extensor surface of the ulna and olecranon process for
nodules or swelling.
o Palpation. Palpate the olecranon process and epicondyles observing for
tenderness or warmth. The synovium and olecranon bursae are not normally
palpable.
o ROM. The elbow accommodates four movements: flexion, extension, pronation,
and supination. These motions are assessed by the following, observing for
crepitus, deformity, or pain:
 Flexion. Ask the patient to bend arm at the elbow.
 Extension. Ask the patient to extend their arm.
  Pronation. Ask the patient to turn their palms up.
 Supination. Ask the patient to turn their palms down.
o Special Maneuver.
 Cozen test. This tests for lateral epicondylitis (tennis elbow). Palpate the
lateral epicondyles, then ask the patient to pronate and extend the wrist
against resistance. If pain is reproduced along the lateral aspect of the
elbow, the Cozen test is positive.
 Wrist and Hand Joints
o Inspection. Inspect the position of the hands while in motion and at rest. The
wrist, hand, and finger bones should be observed for swelling, deformities,
atrophy, thickening, or contractures.
o Palpation. Observe for swelling or tenderness while palpating the distal radius
and ulna, as well as the grooves of each wrist joint on the dorsum of the wrist.
Palpate the anatomic snuff box, a hollow depression distal to the radial styloid
process at the base of the thumb. This is identified more easily with abduction of
the thumb. The carpal bones should be palpated proximally to distally, followed
by the metacarpophalangeal (MCP), proximal interphalangeal (PIP), and distal
interphalangeal (DIP) joints assessing for bogginess, tenderness, bony
enlargement, or swelling. Also palpate along tendons to assess for inflammation,
tenderness, or focal thickening.
o ROM. The wrist joint accommodates for flexion, extension, adduction, and
abduction. The fingers and thumb also accommodate the same movements, but
with different maneuvers.
 Wrist flexion. Ask the patient to point his/her fingers towards the floor with
their palm facing downward.
 Wrist extension. Ask the patient to point his/her fingers upwards with their
palm facing downward.
 Wrist adduction. Ask the patient to move fingers towards midline with the
palm facing downward.
 Wrist abduction. Ask the patient to move fingers away from midline with
the palm facing downward.
 Fingers and thumb flexion. Ask the patient to make a fist.
 Fingers and thumb extension. Ask the patient to straighten out his/her
fingers and thumb.
 Fingers and thumb adduction and abduction. Ask the patient to spread
his/her fingers apart and then back together.
 Thumb opposition. Ask the patient to cross the thumb over the palm to the
base of the fifth digit.
o Special Maneuvers.
 Handgrip strength. Ask the patient to squeeze the examiner’s index and
middle finger. Of note, assess whether weakness is related to pain or an
inability to perform the task (which could indicate a neurologic
dysfunction).
 Finkelstein test. Ask the patient to grasp the thumb against the palm and
move wrist towards midline in ulnar deviation (similar to casting a fishing
rod). Pain indicates de Quervain tenosynovitis, otherwise known as
“gamers thumb.”
  Phalen sign. Ask the patient to hold their wrists in full flexion against each
other for 60 seconds with the elbows fully extended. Resulting numbness
and tingling are suggestive of carpal tunnel syndrome involving the
median nerve.
 Tinel sign. Repeatedly tap over the course of the median nerve along the
carpal tunnel on the dorsum of the wrist. Resulting shooting pain, aching,
or numbness are suggestive of carpal tunnel syndrome involving the
median nerve.
 Spine
o Inspection. With the patient standing, visually assess the spinous processes,
paravertebral muscles on either side of the midline, the iliac crests, posterior
superior iliac spines from both the side and from behind the patient. The spinal
curvatures should also be assessed, noting any deviation of the spine from the
midline, excessive curvatures, or abnormal prominences. The shoulders and iliac
crests should be at equal heights unless abnormal curvature of the spine or
unequal leg lengths are present.
o Palpation. Palpate the spinous processes of each vertebra from the cervical to
lumbar spine, including the facet joints between C1 and C2 vertebrae and the
sacroiliac joint. Observe for tenderness, vertebral “step-offs” (unusual
prominence or recession), or deformities. Also, palpate the paravertebral
muscles, noting any tenderness, spasm, or radiation of pain through the
buttocks, perineum, or legs.
o ROM. The cervical spine and thoracolumbosacral spine can accommodate
flexion, extension, rotation, and lateral bending. These are assessed through the
following maneuvers, taking note of any pain, tenderness, crepitus, or stiffness:
 Cervical flexion. Ask the patient to bring their chin to chest.
 Cervical extension. Ask the patient to look to the ceiling.
 Cervical rotation. Ask the patient to look to the right and the left.
 Cervical lateral bending. Ask the patient to touch each ear to their
shoulder.
 Thoracolumbosacral flexion. Ask the patient to bend forward as though
touching their toes.
 Thoracolumbosacral extension. Ask the patient to bend back as far as
possible.
 Thoracolumbosacral rotation. Ask the patient to twist at the waist, side to
side.
 Thoracolumbosacral lateral bending. Ask the patient to bend side to side
at the waist.
o Special Maneuvers.
 Spurling test. While positioned behind the patient, Ask the patient to look
over their shoulder and up to the ceiling. Then carefully apply downward
pressure on the patient’s head. Neck pain with radiation to the arm on the
same side the patient’s head is turned would be suggestive of cranial
nerve root compression.
 Hip
o Inspection. Observe the patient’s gait making note of stance, swing, and stride. A
waddling, or Trendelenburg, gait can result from abductor weakness, arthritis,
 unequal leg lengths, or hip subluxation. Symmetrical leg length and the
anterior/posterior aspects of the hip should also be observed. Asymmetrical leg
length is concerning for hip fracture with shortening and internal rotation being
common on the affected side.
o Palpation. Examine for tenderness, pain, deformity, or crepitus.
 Anterior hip. Palpate the iliac crest following downward the anterior curve
to the iliac tubercule and continuing down to the anterior superior iliac
spine. Thumb should be placed on the anterior superior spines and
fingers moved downward and laterally from the iliac tubercles to identify
the greater trochanter of the femur. Continue medially and obliquely to the
pubic tubercle lying at the same level as the greater trochanter. Focal
tenderness may indicate tendinitis or bursitis. Finally, with the patient lying
supine, position the heel of the leg being examined on the opposite knee
to palpate along the inguinal ligament. Bulging along the ligament
suggests inguinal hernia.
 Posterior hip. Palpate and place the left thumb and index finger over the
posterior superior iliac spine, locating the greater trochanter laterally with
fingers at the level of the gluteal fold to place the thumb medially on the
ischial tuberosity. The sacroiliac joint may be difficult to palpate, however
tenderness should be assessed at this location. Tenderness may indicate
tendinitis or bursitis.
o ROM. The hip can accommodate flexion, extension, abduction, adduction,
internal rotation, and external rotation. Observe for tenderness, pain, swelling,
instability, or crepitus.
 Flexion. Ask the patient to bring their knee to the chest and pull against
the abdomen while lying supine.
 Extension. Ask the patient to lie face down, lifting their knee off the table.
 Abduction. Ask the patient to move their lower leg away from the midline
while lying supine.
 Adduction. Ask the patient to move their lower leg across the midline
while lying supine.
 Internal rotation. Ask the patient to bend at the knee and turn the lower
leg and foot away from the midline while lying supine.
 External rotation. Ask the patient to bend at the knee and turn the lower
leg and foot toward the midline while lying supine.
o Special Maneuvers.
 Patrick or FABER test. The Patrick test, also known as FABER (Flexion,
ABduction, External Rotation) test is performed by positioning the leg into
90° of flexion and externally rotating and abducting with ipsilateral ankle
resting distal to the knee on the contralateral leg while the patient is lying
supine. If pain is elicited, this may suggest sacroiliac joint pathology.
 Kendall test: The Kendall test is performed to test for hip flexion deformity.
Have the patient seated with their thighs half off the exam table, legs
dangling. Then ask them to lie down and flex one leg toward the chest
and hold long until the lower back is flat against the table. The posterior
thigh on the other leg should touch the table and that knee should be able
to passively flex.
 Knee
o Inspection. Observe the gate for knee flexion and inspect the knee and quadricep
for alignment, contour, swelling, atrophy, or bruising.
o Palpation. Examine the muscles, tendons, and ligaments for areas of tenderness,
pain, swelling, bulging, deformity, instability, or crepitus which may suggest injury
or arthritis.
 Tibiofemoral joint. Place thumbs in the soft tissue depressions on either
side of the patellar tendon, identifying the group for the tibiofemoral joint
while in the flexed position. Pressing the thumbs downward, the edge of
the tibial plateau can be felt. Follow medially and laterally until stopped by
converging femur and tibia, and then upward toward the midline of the top
of the patella to the distal femur, identifying the margins of the joint.
 Medial meniscus. Press on the medial soft tissue along the upper edge of
the tibial plateau with tibia slightly internally rotated. Slightly flex the knee
and palpate the lateral meniscus along the lateral joint line.
 Medial joint compartment. With the knee flexed on the examining table at
approximately 90°, palpate the tibiofemoral joint while moving thumbs
medially and upward to palpate the medial femoral condyle. Palpate
posteriorly to assess the adductor tubercle and inferiorly to palpate the
medial tibial plateau. Along the medial aspect posteriorly, also identify the
MCL (medial collateral ligament) connecting the medial epicondyle of the
femur to the medial surface of the tibia.
 Lateral joint compartment. Palpate the tibiofemoral joint in the same
position, lateral to the patellar tendon moving thumbs upward to palpate
the lateral femoral condyle and downward to palpate the lateral tibial
plateau. Ask the patient to cross one leg so the ankle rests on the
opposite knee to assess the LCL (lateral collateral ligament) connecting
the lateral epicondyle of the femur to the head of the fibula.
o ROM. The knee joint can accommodate flexion and extension.
 Knee flexion. Ask the patient to bend at the knee.
 Knee extension. Ask the patient to extend their leg at the knee.
o Special Maneuvers.
 McMurray test. With the patient supine, grasp the heel and flex the knee
with the opposite hand at the knee joint with fingers and thumb along the
medial joint line. With the leg externally rotated, apply pressure on the
lateral side to apply valgus stress on the medial meniscus. The leg is
slowly extended in external rotation. The same technique is repeated with
internal rotation to stress the lateral meniscus. A palpated click or pain is
suggestive of meniscal tear.
 Valgus stress test. Also known as abduction stress test, the patient lies
supine with the knee slightly flexed and the thigh about 30° laterally to the
side of the table. Place one hand on the lateral knee to stabilize the femur
and the other hand around the medial ankle, pushing medially against the
knee and laterally at the ankle to open the knee joint on the medial side.
Assess for excessive widening of the joint that may signal ligamentous
injury.
  Varus stress test. Also known as the adduction stress test, the patient lies
supine with the knee slightly flexed and the thigh about 30° laterally to the
side of the table. Place one hand on the medial knee to stabilize the
femur and the other hand around the lateral ankle, pushing laterally
against the knee and medially at the ankle to open the knee joint on the
lateral side. Assess for excessive widening of the joint that may signal
ligamentous injury.
 Anterior drawer sign. As the patient lies supine with hips flexed and knees
flexed at 90° with feet flat on the table, wrap your hands around the knee
with the thumbs on the medial and lateral joint line and fingers on the
medial and lateral insertions of the hamstrings. Sit on the patient’s foot to
anchor it while drawing the tibia forward and observing if it slides forward
from under the femur with comparison to the opposite knee. Excessive
movement may indicate anterior cruciate ligament injury.
 Lachman test. Position the knee in 15 degrees of flexion and slight
external rotation. Hold the lateral side of the distal femur with one hand
and the medial side of the proximal tibia with the other, placing your
thumb on the joint line. Forcefully and simultaneously pull the tibia
forward and the femur back. There should be a firm endpoint to any
forward movement. Absence of a firm endpoint with excessive movement
may indicate an ACL injury.
 Posterior drawer sign. As the patient lies supine with hips flexed and
knees flexed at 90° with feet flat on the table, wrap your hands around the
knee with thumbs at the medial and lateral joint line of fingers on the
medial lateral insertions of the hamstrings. Sit on the patient’s foot to
anchor it while pushing the tibia posteriorly, observing it for backward
movement to the femur. Excessive movement suggests a posterior
cruciate ligament injury.
 Ankle and Foot Joints
o Inspection. Observe the ankle and foot for deformities, swelling, nodules, and
skin impairments.
o Palpation. Palpate the ankle joint and foot for swelling, tenderness, crepitus, and
deformities. Use your thumbs to assess the anterior aspect of the ankle joint for
bogginess or swelling, and your fingertips to assess the Achilles tendon for
nodules or tenderness, as the hands are wrapped around the ankle. Palpation
should extend over the medial and lateral ankle ligaments and the medial and
lateral malleolus. Continuing to the metatarsophalangeal joints, compress the
forefoot between the thumb and the fingers exerting pressure just proximal to the
heads of the first and fifth metatarsal to assess for tenderness or crepitus.
o ROM. The ankle and foot accommodate flexion (plantar flexion), extension
(dorsiflexion), inversion, and eversion. Observe for tenderness or crepitus on
movement.
 Flexion. Ask the patient to point their foot downward.
 Extension. Ask the patient to point their foot upward.
 Inversion. Ask the patient to point the sole of their foot towards midline.
 Eversion. Ask the patient to point the sole of their foot laterally.
 PEARLS
 o Restricted range of motion occurs in bursitis, capsulitis, connective tissue tears,
and tendinitis.
o Unequal shoulder heights may be suggestive of scoliosis or abnormal curvature
of the spine.
o Radiating pain down extremities elicited by spinal range of motion maneuvers is
concerning for spinal nerve involvement.
o Internal rotation and shortening of the leg are suggestive of hip fracture.
o Tenderness of the MCL on palpation is suggestive of injury or tear.
o Adduction is to move a limb toward body's midline (think “added” to the body”);
abduction is to move a limb away from midline.
o Osteoarthritis is a localized disease; rheumatoid arthritis is systemic.
o Restricted range of motion occurs in bursitis, capsulitis, connective tissue tears,
and tendinitis.
o Unequal shoulder heights may be suggestive of scoliosis or abnormal curvature
of the spine.
o Radiating pain down the extremities elicited by spinal range of motion maneuvers
is concerning for spinal nerve involvement.
o Internal rotation and shortening of the leg are suggestive of hip fracture.
o Tenderness of the medial collateral ligament of the knee on palpation is
suggestive of injury or tear.
Neurovascular Assessment

 Pulses
o Assess upper extremity peripheral pulses (brachial, radial, and ulnar) and lower
extremity peripheral pulses (femoral, popliteal, posterior tibialis, and dorsalis
pedis) bilaterally. Be sure to assess for the presence of pulses distal to any injury.
o Use a 0 to 4 point scale (0=absent and 4=strong/bounding), noting also if the
pulse is weak, diminished or absent.
o Use a marker to indicate a pulse palpation site that is difficult to locate; this can
help others with their assessment and provide consistency.
o A manual Doppler scan should be utilized if a pulse palpation site is challenging
to find or if the pulse is weak.
o If palpable pulses are not assessable due to casting, assess all other
parameters.
o Document if a change in the pulse is detected and notify the appropriate health
care provider.
 Capillary refill
o Assess capillary refill by pressing on the nailbeds to evaluate the peripheral
vascular perfusion.
o Note how long it takes for the distal capillary bed to regain its color after pressure
has been applied to cause blanching (Pickard, Karlen, & Ansermino, 2011).
o Capillary refill time of two seconds or less is normal for an adult; prolonged
capillary refill time can indicate abnormal perfusion.
o Capillary refill time can be affected by age, temperature, ambient light, and
pressure application (Pickard, Karlen, & Ansermino, 2011).
 Skin color
o Compare the color of the skin bilaterally.
o Consider the patient’s usual skin tone and any skin conditions when performing
this assessment; cyanosis can present differently in different skin tones.
o Pallor or cyanosis may indicate inadequate arterial supply; dusky, cyanotic,
mottled, or purple black coloration may indicate inadequate venous return.
o Shiny and pale skin, suggesting pressure in the affected area, may be a sign of
compartment syndrome, which requires immediate intervention to prevent
vascular compromise that can result in muscle and nerve ischemia (Schreiber,
2016).
 Temperature
o Use the back of your hands to assess skin temperature bilaterally.
o Skin should be warm to touch. Cool skin may indicate inadequate arterial supply;
warmth may indicate inadequate venous return or infection (Schreiber, 2016).
 Sensation
o Ask the patient about changes in sensation, such as tingling, numbness
(paresthesia), pressure, or burning.
o A pressure sensory exam often consists of assessing light touch with a cotton
swab and assessing temperature discrimination with warm and cold stimuli;
pinprick sensation can be tested using the sharp end of a disposable safety pin.
o If indicated, consider using the 2-point discrimination test.
o Complaints of numbness or tingling in an extremity should be investigated
immediately, with the assessment proximal and distal to the site of injury or
surgery (if not precluded by a cast or splint).
o Nerve involvement, compromised blood flow, or the use of ice can alter a
patient's sensory function.
 Motor function
o Assess range of motion and strength. The patient's ability to perform specific
movements is a key indicator of motor function of specific nerves.
o Loss of motor function is often a late sign of neurovascular compromise; thus,
frequent assessment and careful attention is required to detect these subtle
changes in the patient.
 Pain
o Complications can be prevented when pain is identified and treated early.
o Pain can be caused by sensory nerve damage and/or diminished blood flow.
o Use a pain assessment tool to assess severity of pain. A hallmark of
neurovascular compromise is pain disproportionate to the injury.
o Note the location, severity, and areas of radiating pain.
o In sedated patients or those who can’t verbalize information, be aware of non-
verbal pain cues including grimacing, guarding, tachycardia, and hypotension.
 Edema
o Edema can result from musculoskeletal injury, contribute to vascular
compromise, and cause damage to muscle and nerve tissue.
o Preexisting disease processes (i.e., heart failure, cirrhosis, or kidney disease)
can place a patient at increased risk for edema-related complications.
 o Elevating the limb, no higher than heart level, can help decrease edema.

Nervous system – Neurologic Assessment

Mental Status Exam
o Appearance and behavior
 Assess the patient’s level of consciousness.
 Level of consciousness (LOC) is a sensitive indicator of neurologic function
and is typically assessed based on the Glascow Coma Scale including eye
opening, verbal response, and motor response. Document your patient’s LOC
based on the following categories.
o Alert: the patient opens their eyes spontaneously, looks at you when
spoken to in a normal voice, responds appropriately to stimuli, and
movements are purposeful.
o Lethargic: the patient appears drowsy but opens their eyes to loud
verbal stimuli and looks at you, responds to questions, and then falls
back asleep.
o Obtundation: the patient opens their eyes with tactile stimuli and looks
at you but responds to you slowly and may be confused.
o Stupor: the patient awakens only after painful stimuli is applied (i.e.,
applying pressure to the nailbed). The patient’s verbal responses are
slow or absent. The patient will fall into an unresponsive state when
the stimuli stops.
o Coma: patient is unarouseable and their eyes remain closed. There
are no purposeful responses to internal or external stimuli. However,
nonpurposeful responses to painful stimuli and brain stem reflexes
may still be present.
 Altered LOC (Hinkle, 2021)
o There are several underlying conditions that can cause an altered
level of consciousness, including neurologic (head injury, stroke),
toxicologic (drug overdose, alcohol intoxication), or metabolic
disorders (hepatic or kidney injury, diabetic ketoacidosis). Early signs
of an altered LOC include behavioral changes such as restlessness or
anxiety. As the patient’s LOC declines, changes will occur in the
pupils, eye opening, verbal responses, and motor responses.
Specifically, the pupillary light reflexes become sluggish. If the patient
progresses to coma, the pupils may become fixed and non-reactive to
light and neurologic disease is suspected as the cause. If the patient
is comatose but pupillary light reflexes are intact, the cause may be
metabolic or toxicologic.
o Diagnostic tests are needed to help determine the cause of significant
changes in LOC. Tests may include a computed tomography (CT)
scan, perfusion CT, magnetic resonance imaging (MRI), magnetic
resonance spectroscopy (MRS), or electroencephalography (EEG).
Several common laboratory tests should be obtained: blood glucose,
electrolytes, serum ammonia, liver function tests, blood urea nitrogen
(BUN), serum osmolality, calcium, partial thromboplastin and
 prothrombin times. Additional tests may include serum ketones,
alcohol and drug concentrations, and arterial blood gases.
 Nursing Management
o As you care for a patient with an altered or decreasing LOC,
remember that maintaining the patient’s airway remains the priority.
Monitor the patient’s blood pressure and heart rate to ensure
adequate perfusion to the brain. Insert an intravenous (IV) catheter to
administer IV fluids and medications as needed and initiate nutritional
support. Determine and treat the underlying cause.
 Is the patient awake and alert?
 Does the patient understand your questions and respond appropriately and
reasonably quickly? If the patient doesn’t respond to questions, escalate the stimulus
in steps to elicit a response.
 Note the patient’s posture and motor behavior.
 Does the patient sit or lie quietly or prefer to walk around?
 Are movements voluntary and spontaneous? Are any limbs immobile?
 Do posture and motor activity change based on what is being discussed or who is in
the room?
 Observe the patient’s dress, grooming, and personal hygiene.
 Is the clothing clean and presentable? Is it appropriate for age?
 How do the grooming and hygiene compare with that of peers of comparable age
and lifestyle?
 Are there differences from one side of the body to the other?
 Assess the patient’s facial expression at rest and during conversation.
 Are there appropriate changes in expression for the topics being discussed or is the
expression relatively unchanged throughout?
 Assess the patient’s manner, affect, and relationship to people and things.
 Are they appropriate to the topics being discussed or is the affect labile, blunted, or
flat? Does it seem exaggerated at certain points?
 Does the patient hear or see things not present or converse with someone who is not
there?
o Speech and language
 Is the patient talkative or unusually quiet? Are comments spontaneous, or limited to
direct questions?
 Is speech fast or slow? Loud or soft?
 Are words clear and distinct? Is there a nasal quality to the patient’s speech?
 Are there any abnormalities in fluency, such as gaps in the flow and rhythm of words;
disturbed inflections; circumlocutions (phrases or sentences are substituted for a
word the person cannot think of); or paraphasia, in which words are malformed,
incorrect, or invented?
 In Broca aphasia, or expressive aphasia, the patient possesses normal
comprehension but exhibits slow, nonfluent speech and cannot express
oneself. It is named for the Broca area of the brain that connects to the
motor neurons of the mouth and larynx, and controls spoken language
(Clark, 2022). Broca aphasia is often associated with damage to the left
frontal lobe.
  Wernicke aphasia, or receptive aphasia, is an impairment in which the
patient has abnormal comprehension with fluent speech. This is named
for the Wernicke area of the brain that receives information from the
auditory cortex and then assigns word meanings (Clark, 2022). The
patient cannot understand words and it is often associated with damage
to the temporal lobe.
 Global (mixed) aphasia is a combination of both receptive and expressive
aphasia.
o Mood
 Ask the patient to describe their mood, including usual mood level and changes due
to life events.
 If the patient tells you they are depressed or you suspect depression, assess its
severity and suicide risk, by asking further questions, for example:
 Do you feel discouraged or depressed?
 Have you had thoughts of death?
 Have you thought about killing yourself?
 Have you thought about how or when you would try to kill yourself? Do you have a
plan?
o Thoughts and perceptions
 Listen for patterns of speech that suggest disorders of thought processes.
 Thought Process Abnormalities
 Blocking: Abrupt disruption of speech midsentence or before the idea is
finished; patient “loses their thought” (Marked in schizophrenia)
 Circumstantiality: Mild thought disorder; speech with too much detail, indirect,
slow to reach the point (Appears in people with obsessions)
 Clanging: Words chosen based on sound instead of meaning
(rhyming/punning); Occurs in schizophrenia and manic episodes.
 Confabulation: Responds to questions with fake facts or events to fill in gaps
from memory loss (Observed in Korsakoff syndrome from alcoholism)
 Derailment (loosening of associations): Extraneous speech and changing
topics that are loosely connected or unrelated (Observed in schizophrenia,
manic episodes, and other psychotic disorders)
 Echolalia: Repeating others’ words and phrases (Occurs in manic episodes
and schizophrenia)
 Flight of Ideas: Continuous flow of increased speech with quick changes of
topic; changes are based on associations, play on words, or distracting
stimuli, but ideas are not well connected (Frequently observed in manic
episodes)
 Incoherence: Incomprehensible and irrational speech, without meaningful
connections, abrupt changes in topic; disordered grammar or word use
(Observed in severe psychotic episodes (common in schizophrenia))
 Neologisms: Fictional, made-up, or distorted words (Observed in
schizophrenia, psychotic disorders, and aphasia)
 Perseveration: Continual repetition of words or ideas (Occurs in
schizophrenia and other psychotic disorders)
 Thought Content Abnormalities
  Anxiety: Apprehension, worry, distress, and/or physical symptoms of tension
 Compulsion: Repetitive behaviors the patient performs in response to an
obsession with the goal to reduce anxiety; the behaviors are excessive
 Delusions: Distorted personal beliefs that do not change even with conflicting
proof; delusions include:
o Persecutory - torment
o Grandiose - pompous
o Jealous - envious
o Erotomanic – belief that another person is in love with the individual
o Somatic – bodily functions or sensations
o Unspecified – delusions with no particular persecutory or grandiouse
component; belief that external events, objects, or people have a
personal significance (i.e., commands from the radio or television)
 Depersonalization: Feeling that one’s self or identity is different, changed,
unreal, lost or detached from one’s mind or body
 Derealization: Feeling that the environment is strange, unreal, or remote

 Obsession: Persistent thoughts, images, or urges that feel invasive and

undesireable; the patient attempts to ignore or suppress the feeling with other
thoughts or behaviors (i.e., compulsive behavior)
 Phobias: Persistent irrational fears
 To assess thought content, follow the patient’s cues by asking them to expand on
something you’ve already discussed, for example, “Can you tell me more about
that?”
 Perception includes sensory awareness of objects in the environment and their
interrelationships (external stimuli), as well as internal stimuli such as dreams or
hallucinations. When false perceptions are present, explore them further. For
example, ask, “When you heard the voice speaking to you, what did it say?”
o Insight and judgment
 Assess if the patient is aware that symptoms or disturbed behaviors are normal or
abnormal; for example, distinguishing between daydreams and hallucinations that
seem real.
 Note whether the patient is aware that a particular mood, thought, or perception is
abnormal or part of an illness.
 Assess judgment by noting the patient’s responses to certain situations, such as
family circumstances, jobs, or use of money.
o Cognitive function
 Is the patient oriented to self, place and time?
 Assess attention by using digit span (have the patient repeat a series of numbers
back to you); serial 7s (ask the patient to count backward from 100 by 7s); spelling
backward (say and spell a five-letter word, then ask the patient to spell it backward.)
 Assess remote memory by asking about important dates or events in the patient’s
past.
 Test recent memory by asking about events of the day.
 Assess the patient’s ability to learn new things by telling them three or four words,
having them repeat them, then asking them to repeat them again three to five
minutes later.
 If indicated, tests for higher cognitive functions may be performed.
 Information and Vocabulary (Bickley et al., 2021)
o Take into account the patient’s culture and level of education when
evaluating information and vocabulary. Start with simple questions –
ask about their work or hobbies – before asking more complex
questions, such as naming government leaders or questions about
geography. Observe their understanding of information, level of
complexity of ideas, and word choice.
o Testing helps differentiate individuals with life-long intellectual
challenges, who possess limited information and vocabulary, from
individuals with mild or moderate dementia, whose information and
vocabulary are intact
 Calculating Capacity (Bickley et al., 2021)
o Ask the patient to perform mathematical calculations, beginning with
simple, single-digit addition and multiplication. Progress to harder
tasks using two-digit numbers; longer, written word problems; or
practical questions related to paying for an item and calculating
change.
o Patients who cannot perform these types of calculations may have
dementia or aphasia. Remember to take into consideration the
patient’s knowledge base and level of education.
 Abstract Thinking (Bickley et al., 2021)
o An individual’s ability to think abstractly can be tested using proverbs
and asking about similarities between two things. For example, ask
what the proverb, “A stitch in time saves nine” means. Most patients
will provide abstract or semiabstract responses. Individuals with
intellectual disability, delirium, or dementia typically respond
concretely but this may also be a sign of limited education. Patients
with schizophrenia often respond concretely or with personal and
strange interpretations.
o You can also ask the patient to tell you how two things are alike, for
example, a banana and a peach. Evaluate whether the answer is
correct and relevant as well as how concrete or abstract it is.
 Constructional Ability (Bickley et al., 2021)
o Ask the patient to copy graphics of progressing complexity onto a
piece of blank unlined paper. Show each figure one at a time and ask
the patient to copy it using their best effort. If the patient has normal
vision and motor ability, but cannot perform the task, this may indicate
dementia, intellectual disability, or parietal lobe damage.
 Clock-Drawing Test (CDT) (Mendez, 2019)
o An alternative option to drawing the graphics above is to ask the
patient to draw the face of an analog clock, including all the numbers.
Have them set the hands to a specific time (i.e., 5 minutes before
 12:00). The CDT helps assess visuospatial abilities, executive
function, motor execution, attention, language comprehension, and
numerical knowledge. It can be utilized to test a wide range of
patients, irrespective of language, education, or cultural background.
o PEARLS
 Studies show that asking at-risk individuals if they are suicidal does not increase
suicides or suicidal thoughts (Mathias et al., 2012).
 Patients with psychotic disorders often lack insight into their illness.
 When assessing memory, be sure you can validate responses.
 Remote memory is usually preserved in early stages of dementia but may be
impaired in its later stages. Recent memory is impaired in dementia and delirium.
Neurological Exam

 Motor System
o Assess the motor system for involuntary movements, muscle bulk, and muscle
tone. Throughout your assessment, also consider body position and
coordination. Note whether abnormal findings occur with movement or at rest.
 Involuntary movements
 Look for tremors, tics, chorea (sudden, unintentional jerking
movements), or fasciculations.
 Note location, quality, rate, rhythm, and amplitude.
 Observe relation to posture, activity, fatigue, emotion, and
distraction.
 Muscle bulk
 Assess the size and contour of muscles.
 Muscle tone
 Assess tone by feeling the muscle’s resistance to passive stretch.
o Encourage the patient to relax; then hold one hand with
yours and support the elbow. Flex and extend the patient’s
fingers, wrist, and elbow, and put the shoulder through a
moderate range of motion.
 To assess muscle tone in the legs, support the patient’s thigh with
one hand, grasp the foot with the other; flex and extend the
patient’s knee and ankle on each side.
 Note the presence of spasticity or rigidity.
o Spasticity is a sustained increase in the tension of a
muscle when it is passively lengthened or stretched. It is
often velocity-dependent and worsens at extreme ranges
of motion. Spasticity may indicate central diseases of the
corticospinal tract.
o Rigidity is increased muscle tone at rest that remains the
same throughout the range of motion, regardless of speed.
Rigidity may indicate central disorders affecting the basal
ganglia, such as Parkinson disease.
 Ask the patient to close their eyes. Test for pronator drift by having the
patient hold both arms straight forward with palms up.
  Pronator drift occurs when one arm and palm turn inward and
downward. This is an indication of muscle weakness and an
abnormal function of the corticospinal tract, the upper motor
neurons in the brain and spinal cord that control voluntary muscle
movement, in the hemisphere opposite to the affected limb. The
palm may remain upward while the arm drifts downward with the
fingers and elbow flexed. If the patient loses their position sense
(proprioception), the arms may drift to the side or upward and the
hands may writhe. The patient may not be aware of these
movements and when asked to correct them, is unable to properly
correct the position.
 If the arms remain in the raised position equally without any drift,
use your fingers to tap the arms briskly downward. The arms
should return easily and smoothly to the horizonal position,
indicating appropriate muscle strength, coordination, and normal
proprioception. If the patient has cerebellar incoordination, the arm
will bounce upward and miss its original starting position.
 Pronator drift can occur with stroke or cervical spinal injury (Rank,
2013). Remember to document signs of pronator drift, which arm
is affected, and the direction of the drift. Additional diagnostic
tests, such as computed tomography or magnetic resonance
imaging, may be needed, especially if this is a new finding (Rank,
2013).
 Test muscle strength by asking the patient to actively resist your
movement.
 Test abduction at the shoulder.
o Ask the patient to raise the arm from the side to shoulder
level. Then press down firmly on the patient’s upper arm
with shoulder abducted
o Both arms can be tested simultaneously to aid in side-to-
side comparison.
 Test elbow flexion and extension.
o Have the patient pull and push against your hand.
 Test extension at the wrist.
o Ask the patient to make a fist and resist as you press down
or ask the patient to extend the forearms with fingers
straight and palms up, then press the palms downward.
 Test finger extension.
o Grasp the patient’s forearm or palm with one hand. Use
the fingers of your other hand to press down on the
patient’s outstretched fingers
 Test finger abduction.
o Position the patient’s hand with palm down or on its side
and with fingers spread. Instruct the patient to prevent you
from moving any fingers as you try to force them together.
 Test abduction of the thumb.
 o Place the forearm in a fully supinated position. Ask the
patient to point the thumb straight upwards toward the
ceiling. Try to push the thumb straight down into the palm.
 Test flexion at the hips.
o With the patient sitting or supine, place your hand on the
patient’s mid-thigh and asking the patient to raise the leg
against your hand.
 Test adduction at the hips.
o Place your hands firmly on the bed between the patient’s
knees. Ask the patient to bring both legs together.
 Test abduction at the hips.
o Place your hands firmly outside the patient’s knees. Ask
the patient to spread both legs against your hands.
 Test extension at the hips.
o Have the patient lie on the stomach and lift the leg off the
bed. Push down on the posterior thigh.
 Test extension at the knee.
o With the patient supine, support the knee in flexion and
ask the patient to straighten the leg against your hand.
o This can also be performed with the patient sitting.
 Test flexion at the knee.
o With the patient supine, position the patient’s leg so that
the knee is flexed with the foot resting on the bed. Tell the
patient to keep the foot down as you try to straighten the
leg.
 Test foot dorsiflexion and plantarflexion at the ankle.
o Ask the patient to pull up and push down against your
hand.
o Heel and toe walk also assess foot dorsiflexion and plantar
flexion, respectively.
o Assess coordination.
 Rapid alternating movements – Observe speed, rhythm, and smoothness.
 Have the patient repeat striking one hand on the thigh, flipping it
over, and striking the back of the hand down on the same place.
 Ask the patient to repeatedly tap the distal joint of the thumb with
the tip of the index finger as rapidly as possible.
 Instruct the patient to tap the ball of each foot in turn as quickly as
possible on your hand or the floor.
 Point-to-point movements: Observe for accuracy and smoothness.
 Finger-to-nose test: Ask the patient to touch your index finger and
then his or her nose alternately several times. Move your finger so
that the patient must change directions and extend the arm fully to
reach your finger. Observe the accuracy and smoothness of
movement and watch for any tremor.
 Heel-to-shin test: With the patient supine, ask the patient to place
one heel on the opposite knee, then run it down the shin to the big
 toe. Observe this movement for smoothness and accuracy.
Repetition with the patient’s eyes closed tests for proprioception.
o Gait: Observe posture, balance, and stance.
 Have the patient walk across the room and back, then walk on toes and
on heels, and walk heel to toe in a straight line (tandem).
o Assess proprioception (Romberg test).
 Have the patient first stand with feet together and eyes open and then
close both eyes for about 30 seconds without support. Note the patient’s
ability to maintain an upright posture.
 Sensory System
o Assess the sensory system for light touch, pain, temperature, proprioception,
vibration, and discriminative sensation (stereognosis).
o Have the patient close their eyes for this testing.
o For pain, temperature, and touch sensation, compare distal to proximal areas of
the extremities, and scatter the stimuli.
 Light touch
 Use a fine wisp of cotton and touch the skin lightly. Ask the patient
to respond when a touch is felt.
 Pain
 Use the stick portion of a broken cotton swab, or other suitable
tool.
 Occasionally, substitute the blunt end for the point. Ask, “Is this
sharp or dull?” or, “Does this feel the same as this?”
 Apply the lightest pressure needed.
 Temperature
 This is often omitted if pain sensation is normal, however if
sensory deficits are noted, you can use a tuning fork warmed or
cooled by running water and ask the patient to identify “hot” or
“cold.”
 Proprioception
 Holding the patient’s big toe by its sides between your thumb and
index finger, then move it gently away from the other toes.
Demonstrate “up” and “down” as you move the patient’s toe
clearly upward and downward. Then, ask the patient to say “up” or
“down” when moving the large toe.
 Vibration
 Using a tuning fork, tap the prongs on the heel of your hand and
place the base firmly over a distal interphalangeal joint of the
patient’s finger, then over the interphalangeal joint of the big toe.
Ask what the patient feels. If it’s unclear whether the patient is
feeling pressure or vibration, ask the patient to tell you when the
vibration stops; then touch the tuning fork to stop it from vibrating.
 Stereognosis
 Place a familiar object (for example, a coin, paper clip, key, or
cotton ball) in the patient’s hand and ask the patient to tell you
what it is.
 If necessary, proceed with other methods of assessing
discriminative sensations.
 To test a patient’s sense of touch, have them close their eyes,
then lightly touch the skin (without pressure) with a wisp of cotton,
left hand, right hand, and then both simultaneously. Ask the patient
to tell you when they feel something and compare one area with
another. Document any areas where the patient experiences
anesthesia (no sensation), hypesthesia (decreased sensitivity to
touch), or hyperesthesia (increased sensitivity).
 Joint position sense or proprioception can be tested with the
patient’s fingers and toes. For example, hold the tip of the patient’s
thumb and move it slightly upward and downward telling the
patient the directions. Pic_JointPositionSense_1.jpegThen ask the
patient to close their eyes and have them identify the direction of
the movement of the thumb position. Repeat this several times.
Patients can normally identify movements of a few degrees or less
(Gelb, 2022). If the patient cannot tell you the correct position of
the thumb, try different fingers. Then move to the wrist and repeat
the test while flexing the hand up and down. If abnormalities are
found, continue to more proximal joints (elbows, shoulders) in the
same limb until a joint is found where position sense is intact. Test
both upper arms and then move to the lower limbs, beginning with
the big toes and advancing to ankles and knees as needed.
 If touch and position sense are normal, you can then test for
discriminative sensation.
 Reduced or absent discriminative sensation may be a sign of a
lesion in the sensory cortex (Bickley et al., 2021). Perform the
following tests with the patient’s eyes closed.
 Stereognosis is the ability to identify an object by touching and
feeling it. With the patient’s eyes closed, place a familiar object
(i.e., paper clip, key, pencil) in the patient’s hand and ask the
patient what it is. The patient should be able to correctly identify
the object within 5 seconds. Begin with stereognosis, and if
abnormalities are found, move on to other methods listed below.
 Graphesthesia, or number identification, should be performed if
the patient is unable to maneuver an object in their hand well
enough to identify it. With the blunt end of a pen or pencil, draw a
large number in the patient’s palm. An inability to recognize
numbers indicates a lesion in the sensory cortex.
 Using point localization, briefly touch a point on the patient’s skin
with the patient’s eyes closed. Have the patient open both eyes
and point to the place where they were touched. The patient
should be able to perform this accurately.
 Perform extinction by touching each arm individually, then
simultaneously touch the same area on both arms. Ask where the
patient feels your touch. Normally, both touches are felt. If the
 patient is experiencing sensory neglect, stimuli are ignored on one
side of the body even if the primary senses are intact. In extinction
to double simultaneous stimulation, patients will correctly identify a
touch if the affected side is touched individually but will sense the
touch only on the unaffected side if both sides are touched
simultaneously. Lesions in the cerebral hemisphere may cause
extinction of the contralateral side, particularly lesions in the right
parietal lobe or right basal ganglia (Bickley et al., 2021). You can
also perform this test on the face and legs.
 Reflexes
o Elicit muscle stretch reflexes.
 Biceps reflex
 With the patient’s elbow partially flexed, and the forearm pronated,
place your thumb or finger firmly on the biceps tendon. Strike the
reflex hammer directly through your finger toward the biceps
tendon.
 Look for flexion at the elbow and contraction of the biceps muscle.
 Triceps reflex
 With the patient sitting or supine, flex the patient’s arm at the
elbow, with palm toward the body, and pull it slightly across the
chest. Strike the triceps tendon with a direct blow directly behind
and just above the elbow. Watch for contraction of the triceps
muscle and extension at the elbow.
 You can also elicit this reflex by supporting the upper arm and
asking the patient to let the arm go limp. Then strike the triceps
tendon.
 Brachioradialis reflex
 With the patient’s hand resting on the abdomen or the lap, and the
forearm partly pronated, strike the radius with the point or flat
edge of the reflex hammer, about 2 to 4 inches above the wrist.
Watch for flexion at the elbow and supination of the forearm.
 Quadriceps (patellar) reflex
 With the patient sitting or lying down, make sure the knee is
flexed, and briskly tap the patellar tendon just below the patella.
Note contraction of the quadriceps with extension at the knee.
 Achilles (ankle) reflex
 With the patient’s foot dorsiflexed at the ankle, strike the Achilles
tendon and watch and feel for plantar flexion at the ankle.
 If the reflexes seem hyperactive, test for ankle clonus.
o lonus is an abonormal movement marked by a rhythmic
alternating muscle contraction and relaxation occurring in
rapid succession brought on by stretching the tendon
(Gelb, 2022; Hinkle, 2021).
o Clonus is a marker of hyperreflexia, and may be
associated with lesions in the upper motor neurons
(Zimmerman & Hubbard, 2022). It is generally
 accompanied by other upper motor neuron signs including
spasticity and weakness.
o Elicit cutaneous or superficial stimulation reflexes.
 Abdominal reflexes
 With the patient supine, lightly, but briskly stroking each side of the
abdomen toward the umbilicus. Note the contraction of the
abdominal muscles and movement of the umbilicus toward the
stimulus.
 Plantar reflex
 Stroke the lateral aspect of the sole from the heel to the ball of the
foot, curving medially across the ball. Observe movement of the
big toe, normally plantar flexion.
 Anal reflex
 Using the broken end of an applicator stick, lightly stroke the anus
on both sides. Watch for reflex contraction of the external anal
sphincter.
o Scale for Grading Deep Tendon Reflexes (Bickley et al., 2021)
 4 = Very brisk, with clonus (rhythmic oscillations between flexion and
extension)
 3 = Brisker than average; possibly but not necessarily indicative of
disease (hyperactive)
 2 = Average; normal
 1 = Somewhat diminished, or requires reinforcement (hypoactive)
 0 = Reflex absent
o PEARLS
 Patients with Parkinson disease may have a slow, “pill-rolling” tremor at
rest.
 Fasciculations with atrophy and muscle weakness suggest peripheral
motor neuron disease.
 Remember that when testing muscle strength, the patient’s dominant side
is usually slightly stronger than the nondominant side.
 When assessing vibration and position sense, test the fingers and toes
first. If these are normal, you may safely assume that more proximal
areas will also be normal.
 When testing the plantar response, dorsiflexion of the big toe is a positive
Babinski response, arising from a CNS lesion affecting the corticospinal
tract. It may be transiently positive in unconscious states from drug or
alcohol intoxication and during the postictal phase.
Male genitourinary assessment

 Penis
o Inspect the skin on the penis, the prepuce or foreskin (if present), and the glans
for lesions, excoriations, or inflammation.
o If the prepuce is present, gently retract to examine the glans beneath.
Alternatively, the examiner may ask the patient to do so. Ensure the prepuce is
replaced over the glans to avoid phimosis.
 o Inspect the urethral meatus by gently compressing the glans to open the meatus,
noting any inflammation or abnormal discharge.
o Palpate the shaft of the penis for indurations, ulcers, masses, or tenderness.
 Scrotum
o Inspect the skin of the scrotum, and the contour. Note any lesions, tenderness,
masses, veins, or asymmetry.
o Palpate each testis, epididymis, and spermatic cord between the thumb and first
two fingers, noting mobility, consistency, descent, symmetry, and any tenderness.
 Inguinal canals
o Observe the inguinal regions for bulges, masses, asymmetry, or excoriation.
o To palpate the inguinal canals, ask the patient to stand with examiner facing the
patient.
o Place your dominant index finger at the base of the scrotum on the side to be
examined. Then insert your index finger toward the external inguinal ring by
invaginating the scrotal skin, ensuring the testis is not pulled.
o Palpate the external inguinal ring for masses, asking the patient to cough. Note
any masses or bulging felt at the inguinal ring.
o Repeat for the other side, using the dominant index finger.
o Palpate the inguinal lymph nodes and note any tenderness or swelling.
 Digital Rectal Exam
o If indicated, digital rectal examination may be performed. Indications include
concern for prostatic hypertrophy or prostatitis. (See Digital Rectal Examination)
 PEARLS
o If any discharge is noted from the urethra, a culture should be obtained.
o Phimosis is swelling of the glans due to constriction of the prepuce.
o Any hernias identified may be reduced using gentle pressure, unless the patient
reports tenderness or nausea/vomiting. In such a case, prompt surgical
evaluation is necessary.
Female genitourinary assessment

 External examination
o Tell the patient that they will feel you touching the genitalia.
o Examine the mons pubis, labia majora, and perineum for inflammation,
indurations, swelling, or any lesions.
o Separate the labia to expose the labia minora, clitoris, urethral meatus, and
introitus observing for inflammation, indurations, swelling, lesions, or discharge.
 Internal visual examination
o Inform patient a speculum will be inserted for internal visual examination.
o Warm speculum under water (do not use lubricant at this time as it may interfere
with specimen media).
o Separate the labia minora and introduce the speculum, with a 30⁰ downward
angle toward the cervix; open the speculum gently once fully inserted.
o Note the color and position of the cervix, as well as any lesions or discharge.
o At this time, cervical specimens may be obtained.
 o Once completed, gently close the speculum, and withdraw it slowly, observing
the vaginal walls and note any lesions, abnormal discharge, or bleeding.
 Bimanual examination
o Advise the patient that you will be inserting two fingers into the vagina for the
bimanual examination.
o Use water-soluble lubricant on the index and middle fingers.
o From a standing position, insert index and middle fingers into the vagina with
slight posterior pressure. Your thumb should be abducted and third and fourth
fingers folded into the palm.
o Palpate the cervix, noting position, shape, consistency, mobility, and any
tenderness.
o Palpate the uterus by placing the other hand just above the symphysis pubis and
lifting the cervix and uterus with the internal hand, grasping the uterus between
the two hands.
o Palpate each ovary by placing the abdominal hand on the lower quadrant
pressing downward toward the pelvic hand, mobilizing the ovary between the
fingers of both hands. Note position, consistency, presence of masses, and any
tenderness.
o Assess pelvic floor muscles by asking the patient to squeeze down on your
fingers for three seconds, and then bearing down to observe for urinary leakage.
 Rectovaginal examination
o A rectovaginal exam is indicated for examination of a retroverted uterus and
assessing for pelvic pathology.
o Change your gloves and lubricate your index and middle fingers.
o Tell the patient that the index and middle fingers will be inserted simultaneously,
one into the vagina and one into the rectum.
o Insert the index finger into the vagina, and the middle finger into the rectum while
asking the patient to bear down to allow sphincter relaxation.
o Also inform the patient that they may experience a sensation of having a bowel
movement but reassure them this will not happen.
o Apply pressure against the anterior and lateral walls with the pelvic examination
fingers, while exerting pressure on the abdomen to palpate the pelvic structures.
o Palpate the rectal vault and note any masses, blood, tenderness, or
hemorrhoids.
 PEARLS
o Cervical motion tenderness may be a sign of pelvic inflammatory disease.
o Obesity or posterior position of the uterus may make palpation of the uterus
during a bimanual examination difficult or impossible.
o Ovaries atrophy after menopause making them unable to be palpated.
o Full pelvic floor strength is defined by a full three second hold during
assessment.
o Provide a soft tissue or towel to the patient to wipe away any excess lubricant.

Digital rectal exam

 Inspection
 o Gently separate the butt cheeks. Inspect the sacral, coccygeal, and perianal
areas for inflammation, lesions, masses, tenderness, or excoriation.
o Inspect the skin over the buttocks, noting any lesions or masses.
o Inspect the anus noting any lesions, hemorrhoids, masses, fistulae, fissures or
tenderness.
 Palpation
o Explain to the patient that the examiner will be placing a gloved finger into the
rectum.
o Using a water-based lubricant, insert a gloved finger into the rectum, pausing to
allow the sphincter to relax.
o Ask the patient to bear down to relax the sphincter and advise the patient that
there may be a sensation of a bowel movement but that this is normal and will
not happen.
o Insert finger toward the umbilicus, palpating circumferentially to identify any
masses, tenderness, or mucosal lesions.
o If an anal fissure is suspected by history, by inspection or by local tenderness
upon insertion of the tip of a gloved finger, further digital examination should be
deferred until healing.
o If the patient has a prostate, palpate for position, size, texture, mobility,
tenderness, and any masses. Advise the patient he may have an urge to urinate
during the prostate exam.
o Ask the patient to squeeze their anus onto the gloved finger to assess rectal
tone.
o Upon withdrawing the examining finger, note any gross blood. Test for occult
blood.
o Offer patient soft tissues or a towel to wipe away any excess lubricant.
 PEARLS
o Hemorrhoids and anal fissures are the two most common causes of anorectal
discomfort.
o Digital rectal examination may trigger a vagal response in some patients resulting
in bradycardia or hypotension. This is usually self-limiting after aborting the
examination.
o Digital rectal examinations, once a staple of preventative screening for prostate
cancer in men over 50, is considered optional with PSA testing being favored.
o Tenderness on palpation of the prostate may indicate prostatitis, with follow up
required.
Renal system

 The kidneys form urine to remove wastes from the body, maintain acid-base and fluid-
electrolyte balance, and assist in blood pressure control.
 The kidneys help manage acid-base balance by regulating bicarbonate concentration of
the blood.
 The rate of bicarbonate formation by the kidneys is affected by the amount of CO2 in the
blood and the potassium content of the tubular cells.
  The kidneys secrete erythropoietin in response to low arterial O2 tension; it travels to
bone marrow to stimulate red blood cell production.
 In renal failure, the kidneys are no longer able to excrete potassium, resulting in
hyperkalemia. BLOG
 To help prevent catheter-related urinary tract infections, keep the drainage bag below the
level of the bladder at all times.
 Diabetes insipidus is characterized by polydipsia and large amounts of dilute urine with
specific gravity 1.001 to 1.005.
 Patients with syndrome of inappropriate diuretic hormone need to be closely monitored
for hyponatremia.
Hematologic/immunologic systems

 Neutropenia is defined as a neutrophil count less than 1000 cells/mm3. Infection risk
increases as neutrophil count decreases.
 The functions of the spleen are to break down worn out red blood cells, filter and remove
bacteria and other foreign substances, and interact with lymphocytes to initiate immune
response.
 Acute hemolytic transfusion reactions can occur anytime during transfusion, but usually
appear within the first 5 to 15 minutes.
 Compatible blood groups are type A with A or O; type B with B or O; Type AB with A, B,
AB, or O; and type O with O only.
Nutritional Assessment

 History
o Ask about the patient’s current dietary practices.
o Use a nutritional screening tool to assess for adequate nutrition; the Mini
Nutritional Assessment is a commonly used, well-validated tool to identify older
adults who are malnourished or at risk of becoming malnourished.
o Ask about health problems associated with poor nutrition, such as obesity,
osteoporosis, cirrhosis, diverticulitis, Crohn’s disease, ulcerative colitis and eating
disorders.
o Inquire about previous surgeries, including bariatric surgery.
o Ask about food insecurity. Use the Hunger Vital Sign™ two-question screening
tool (Hager et a., 2010) to identify households at risk.
 Have the patient or caregiver reply often true, sometimes true or never
true to the statements below.
 “Within the past 12 months, we worried whether our food would
run out before we had money to buy more.”
 “Within the past 12 months, the food we bought just didn’t last and
we didn’t have money to get more.”
 Collect dietary data
o To help estimate adequacy and appropriateness of food intake, collect data by
having the patient complete a food record or perform a 24-hour food recall, or
conduct a dietary interview.
o Consult with a nutritionist or registered dietician, as needed.
 Physical examination
o Calculate the body mass index (BMI) and waist circumference.
o Throughout the head-to-toe assessment, look for signs that suggest possible
nutritional deficiency, such as muscle wasting, poor skin integrity, loss of
subcutaneous tissue, and obesity.
o Other tissues that serve as physical indicators of nutrition status include the hair,
skin, teeth, gums, mucous membranes, mouth and tongue, skeletal muscles,
abdomen, lower extremities, and thyroid gland.
o Perform a biochemical assessment, which includes these tests of serum and
urine.
 Low serum albumin and prealbumin are most often used as measures of
protein deficit in adults.
 Transferrin is a protein that binds and carries iron from the intestine
through the serum. Low levels of transferrin can also lead to a deficiency
in iron.
 Measurement of retinol-binding protein may be a useful means of
monitoring acute, short-term changes in protein status.
 The total lymphocyte count may be reduced in people who are acutely
malnourished.
 Serum electrolyte levels provide information about fluid and electrolyte
balance and kidney function.
 A 24-hour urine collection can be utilized to calculate the creatinine/height
index that assesses metabolically active tissue and indicates the degree
of protein depletion.
 PEARLS
o Some signs and symptoms that appear to indicate nutritional deficiency may
reflect other systemic conditions, such as endocrine disorders or infection, or
may result from impaired digestion, absorption, excretion, or storage of nutrients.
o Inadequate dietary intake in older adults may result from physiologic changes in
the gastrointestinal tract, financial factors, limited ability to shop and cook, drug
interactions, disease, and poor dentition.
o A waist circumference greater than 40 inches for men or 35 inches for women
indicates excess abdominal fat.
o Decreased albumin levels may be caused by overhydration, liver or renal
disease, or excessive protein loss due to burns, major surgery, infection, or
cancer.
 ABCDs of the Nutritional Assessment
o Anthropomorphic Measurements
 Height, weight, and BMI
 Circumference (arm, abdomen, and thigh) measurements are indicators
of protein stores
 Skinfold thickness (biceps, triceps, subscapular, and suprailiac skinfold) is
an indicator of energy (fat) stores.
o Biochemical Measurements
  Routine laboratory tests such as serum electrolytes, blood urea nitrogen
(BUN), creatinine, blood glucose levels, lipid profile, liver enzymes,
complete blood count, and cholesterol can identify malnourishment.
 Proteins such as albumin, prealbumin, transferrin, and retinol-binding
protein can help evaluate nutritional status but should not be used alone.
 Micronutrient level of B vitamins (thiamine, riboflavin, niacin, pyridoxine,
folic acid, B12), vitamins A, C, D, E, and K, iron, zinc, selenium can be
measured if deficiencies are suspected.
o Clinical Signs
 Low body weight, prominent bones
 Muscle wasting
 Poor skin integrity, dry, inelastic skin, rashes, and lesions
 Loss of subcutaneous fat tissue
 Low body temperature
 Low heart rate and blood pressure
 Thin arms and legs with edema in the abdomen and face
 Reduced handgrip strength, weakness, fatigue
 Irritability, apathy, or inattention
 Poor dental health
 Brittle hair, hair loss, or hair color loss
 Conversely, these physical signs may indicate overnutrition (Chu &
Delmore, 2020; Cleveland Clinic, 2022):
 Obesity
 Is adipose tissue distributed evenly, concentrated over the upper torso, or
around the hips?
 High blood pressure
 Insulin resistance and hyperglycemia
o Dietary
 Have you experienced a loss of appetite?
 Can you describe your eating habits?
 Do you eat fruits and vegetables daily?
 What do you eat on a typical day?
 Have you maintained the same weight, or has it fluctuated?
 How do you feel about your current weight?
 Do you prepare your meals at home?
 How many meals do you eat each day and what are your portion
sizes?
 How often do you eat out?
 Do you follow any restrictive diets (i.e., vegan, vegetarian)?
 Do you exercise and if so, how often?
 Have you experienced nausea or vomiting?
 Have you noticed any changes in your menstrual cycle?