Cmca Rle 13

REVIEW OF
SYSTEMS
PHYSICAL ASSESSMENT
JOHN PAUL N. REGANIT, RN, MSN, LPT

CLINICAL INSTRUCTOR
REVIEW OF SYSTEMS
PHYSICAL ASSESSMENT
GENERAL: ABDOMEN:
•Inspection Inspection
•Palpation Auscultation
•Percussion Percussion
•Auscultation Palpation

CLINICAL INSTRUCTOR
•Let’s start….

CLINICAL INSTRUCTOR
PAIN ASSESSMENT
• Pain is an unpleasant sensory and emotional

experience associated with actual por potential
tissue damage or described in terms of
damage.
• Pain is subjective thus a careful
assessment and evaluation is needed
• Assessment of pain is crucial part in the role
of nurses, and as such utilizing a problem-
solving process becomes part of the equation.

CLINICAL INSTRUCTOR
PAIN ASSESSMENT
• “fifth vital sign,”

• should be assessed regularly and frequently.
• Pain is individualized and subjective;
therefore, the PATIENT’S SELF-REPORT of
pain is the MOST RELIABLE GAUGE of the
experience.
• If a patient is unable to communicate, the
family or caregiver can provide input.
• Use of interpreter services may be necessary.
Components of pain assessment include: a)
history and physical assessment; b) functional
assessment; c) psychosocial assessment; and
d) multidimensional assessment.
CLINICAL INSTRUCTOR
PAIN ASSESSMENT

CLINICAL INSTRUCTOR
PAIN ASSESSMENT

CLINICAL INSTRUCTOR
PAIN ASSESSMENT

CLINICAL INSTRUCTOR
PAIN ASSESSMENT
ABCDE Mnemonic of Pain Interview
A Ask about pain regularly; assess pain systematically
B Believe the patient and family in their reports of pain
C Choose pain control options appropriate for the

patient, family and setting
D Deliver interventions in a timely, logical and

coordinated fashion.
E Empower patients and their families

CLINICAL INSTRUCTOR
PAIN ASSESSMENT
OPRSTU Mnemonic of Pain Interview

CLINICAL INSTRUCTOR
PA: SKIN
Assessment Normal Abnormal
procedure
Inspection
Inspect -evenly colored Pallor – loss of color, d/t decrease
GENERAL skin tones with blood supply or anemia
skin color out unusual Cyanosis – makes white skin
discolorations appear blue tinged, dark skin
appears blue, dull and lifeless
Jaundice –characterized by yellow
skin tone, from pale to pumpkin,
particularly in the sclera, oral
mucosa, palms and soles
Note any Client has light A strong odor of perspiration or
odors or no odor of foul odor may indicate disorder of
coming from respiration, the sweat glands.
the skin depending on
activity
CLINICAL INSTRUCTOR
PA: SKIN
Normal Abnormal
Inspect for Keep in mind that some Rashes,
color clients have suntanned Albinism – generalized loss
variations areas, freckles, or of pigmentation
white patches known Erythema – skin redness and
as vitiligo warm r/t inflamation,
allergic reaction or trauma
Skin Skin is intact and there Skin breakdown

integrity are no reddened areas
Inspect for Smooth, with out Presence of lesions from

lesions lesions. Stretch allergic reactions
marks(striae), healed
scars, freckles, moles &
birthmarks are
common findings
CLINICAL INSTRUCTOR
PA: SKIN – BLISTER

CLINICAL INSTRUCTOR
PA: SKIN - PUSTULE

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PA: SKIN - WARTS

CLINICAL INSTRUCTOR
PA: SKIN - CYST

CLINICAL INSTRUCTOR
PA: SKIN - RASHES

CLINICAL INSTRUCTOR
PA: SKIN - ULCERS

CLINICAL INSTRUCTOR
PA: SKIN - SCALES

CLINICAL INSTRUCTOR
PA: SKIN – VASCULAR FINDINGS
PETECHIAE PURPURA
ECCHYMOSES HEMATOMA

CLINICAL INSTRUCTOR
PA: SKIN

CLINICAL INSTRUCTOR
PA: SKIN
Assessment
Normal Abnormal
procedure
Palpation Skin is smooth and even Rough, flaky, dry
Skin is normally thin but Very thin skin is
calluses are common in found in clients
areas of the body part that taking steroid
are exposed to constant therapy
pressure
Skin surface varies from Diaphoresis –
moist to dry depending on excessive sweating
the situation
Decreased moisture
– sign of DHN
Mobility and Skin pinches easily and Decreased mobility

skin turgor immediately returns to its and decreased turgor
original position
CLINICAL INSTRUCTOR
PA: SKIN
EDEMA
• swelling
• Body parts swell from
injury or inflammation
EDEMA PITTING SCALE
1 + --Mild pitting, sl. Indentation
2 + --Moderate pitting, dent subsides quickly
3 + --Deep Pitting, dent remains a short period
4 + --Very Deep Pitting, dent lasts a long time

CLINICAL INSTRUCTOR
PA: SKIN
EDEMA

CLINICAL INSTRUCTOR
PA: SKIN
EDEMA

CLINICAL INSTRUCTOR
PA: SCALP AND HAIR
Assessment
Normal Abnormal
procedure
Inspection
and palpation
Inspect for Natural hair color Patchy gray color d/ t
gen hair color nutritional deficiencies
and condition
Scalp Scalp is Clean and dry . Dermatitis – excessive
Hair is smooth and scaliness
firm, however as
people age, hair feels Presence of abnormal
coarser and drier. lesions
Amount of Finely distributed Patchy hair loss – result
hair from infection or result of
chemo
Hirsutism – prominent
JOHN PAUL N. REGANIT, RN, MSN, LPT facial hair on females
CLINICAL INSTRUCTOR
PA: SCALP WOUND

CLINICAL INSTRUCTOR
PA: HEAD AND FACE
Assessment
Normal Abnormal
procedure
Inspection and
Palpation
Inspect the head Head is symmetric, Acromegaly – the
round, erect and skull and facial
midline. bones are larger and
thicker
Acorn shaped
Head should be still Tremors
and upright Involuntary nodding
Palpate for Head is normally Lesions or lump may
consistency hard and smooth indicate trauma or
cancer
Face is symmetric Drooping of one
side of the face
CLINICAL INSTRUCTOR
PA: NAILS
Assessment
Normal Abnormal
procedure
Inspection
Inspect nail Nails are clean Dirty, broken, jagged
grooming, & and manicured
cleanliness
Nail color Pink tones Pale or cyanotic
Shape of nails 1600 angle Clubbing (1800 – more than) can occur
between nail from hypoxia
base and skin
Spoon nails
Texture Smooth and firm Paronychia ( inflammation) -indicates
local infection
Onycholysis – detachment of nail plate
from nailbed
Capillary refill Pink tone returns Slow or greater than 2 secs before it
immediately returns to pink tone
CLINICAL INSTRUCTOR
PA: NECK
Assessment
Normal Abnormal
procedure
Inspection
Inspect the neck Symmetric with head centered Swelling, enlarged
and without bulging masses masses or nodules
Inspect movement As client swallows, the thyroid Enlargement
of the neck gland etc moves upward
Range of motion Neck movement should be Muscle spasm,
smooth and controlled inflammation
Palpation
Palpate the trachea Trachea is midline Pulled to one side in
cases of a tumor
Auscultation
Auscultate the No bruits upon auscultation A soft, blowing,
thyroid only if you wishing sound
find an enlarge auscultated over
JOHN PAUL thyroid gland
N. REGANIT, RN, MSN, LPT the thyroid lobes
CLINICAL INSTRUCTOR
PA: EYES
Assessment Procedure Normal Abnormal
Evaluating vision
TEST DISTANT VISUAL ACUITY Normal vision is Myopia –
– position pt 20 ft from the 20/20 or with impaired far
Snellen or E chart & ask her to out corrective vision
read each line until she cant lenses Presbyopia –
decipher letters or their impaired near
direction. vision
Eye Structures-
Inspection & Palpation
Width and position Ptosis – drooping
of the upper lid
Assess ability of the eyelids to Upper and lower Failure of lids to
close lids closed easily close

CLINICAL INSTRUCTOR
PA: EYES
Assessment procedure Normal Abnormal
Observe for redness, Skin on both eyelids is Presence of
swelling, discharge and without redness, swelling redness and
lesion or lesions crusting
Observe for the position Eyeballs are Exophthalmos –
of the & alignment of symmetrically aligned protrusion of the
the eyeball in the eye with out protruding or eyeballs
socket sinking
Inspect the lacrimal No swelling or redness Swelling and
apparatus redness
Inspect the cornea and The cornea is transparent Areas of
the lens with no opacities roughness or
dryness
Inspect the iris and pupil The iris is typically round, Irregular shaped
flat and evenly colored. iris , miosis,
The pupil is round and midriasis &
centered in the iris anisocoria
CLINICAL INSTRUCTOR
PA: EYES
Assessment
Normal Abnormal
procedure
Test pupillary Constriction of the No reaction
reaction to light pupils
Test accommodation Pupils constrict and No constriction

of pupils convergence of the
eyes when focusing
on a near object
Other ABNORMALITIES of the eyes in terms of extraocular muscle

dysfunction
Pseudostrabismus Normal in babies 1-3 If it is retain until

months adulthood
Esotropia Eye turns inward

Exotrapia Eye turns outward
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PA: EYES
EXOTROPIA
CLINICAL INSTRUCTOR
PA: EYES
ESOTROPIA
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CLINICAL INSTRUCTOR
PA: EARS
Assessment
Normal Abnormal
procedure
Inspection &
Palpation
In terms of the Ears are equal in Ears are smaller than 4 and
auricle, tragus & size bilaterally (4- larger than 10 cm
lobule 10 cm)
Misaligned or low set ears
The skin is smooth *Tophi

with no lesions, *Black sebaceous glands
lumps or nodules *Pale blue ear color
*Tenderness
External auditory Small amount of *Foul smelling discharge

canal odorless cerumen *blood or watery drainage
is normally *impacted cerumen
present
CLINICAL INSTRUCTOR
PA: EARS
TOPHI
CLINICAL INSTRUCTOR
PA: EARS
IMPACTED CERUMEN
CLINICAL INSTRUCTOR
PA: EARS
2 Types of Hearing Loss
Sensoneural Results when Possible causes:
Hearing loss damage is Prolonged
located in the exposure to
inner ear loud noises
Using ototoxic
medications
Conductive Occurs when Causes:
Hearing loss something Cerumen build
blocks or up
impairs the Fluid in the
passage of middle ear
vibrations from
getting to the
inner ear
CLINICAL INSTRUCTOR
PA: EARS
Hearing and Normal Abnormal
Equilibrium Test
Weber’s test Vibrations are heard There is presence of
equally on both ears “poor ear”
Rinne‘s test Air conduction is Bone conduction is
normally longer longer than air
Romberg’s Test Client maintains Client moves feet
position for 20 apart to
secs with out prevent fall
swaying or with from loss of
minimal balance
swaying
Watch tick test The pt will be able Can’t hear
to determine
the origin of the
sound

CLINICAL INSTRUCTOR
PA: MOUTH
Assessment
Normal Abnormal
Procedure
Inspection
Inspect the lips- Pink in light skinned clients Pallor around the lips
color and as are bluish or freckled in Reddish in cases of COPD
consistency some dark skinned clients Swelling of the lips
Teeth and gums 32 pearly white teeth, others Presence of tooth decay
have 28 if the 4 wisdom
teeth do not erupt Red, swollen, bleeding
gums
Gums are pink. No lesions or
masses
Buccal mucosa Pink in light skin Leukoplakia
Tissue pigmentation typically Thrush
increases in dark skin Koplik spots

CLINICAL INSTRUCTOR
PA: MOUTH
LEUKOPLAKIA
CLINICAL INSTRUCTOR
PA: MOUTH
ORAL THRUSH
CLINICAL INSTRUCTOR
PA: MOUTH
KOPLIK SPOTS
CLINICAL INSTRUCTOR
PA: MOUTH
Assessment
Normal Abnormal
Procedure
Tongue Pink, moist, Presence of
moving pain, swelling,
lesions, sores,
loss of taste
Tonsils May be Red, enlarge,
present or swelling
absent
Pink and
symmetric
Throat Pink without Bright red,
exudate or swelling
lesions
CLINICAL INSTRUCTOR
PA: NOSE
Assessment
Normal Abnormal
Procedure
Inspect and Color is the Nasal
palpate the same as rest of tenderness on
external nose the face, the palpation
client reports no
tenderness
Check patency of Client is able to Client cant sniff
airflow sniff to each on a nosetril that
nostril when one is not occluded
is occluded

CLINICAL INSTRUCTOR
PA: SINUSES

Procedure
Percuss the The sinuses are Tender upon
sinuses not tender on percussion
percussion

CLINICAL INSTRUCTOR
PA: LUNGS
Assessment
Normal Abnormal
Procedure
Inspection
Inspect for nasal Nasal flaring is Nasal flaring is seen with
flaring and purse not observed. respirations (especially in young
lip breathing children).
Purse lib breathing may be seen
in asthma, emphysema, CHF as a
physiologic response to help slow
down expiration and keep alveoli
open longer
Inspect color and Pink Pale or cyanotic
shape of nails

CLINICAL INSTRUCTOR
PA: LUNGS
Posterior Normal Abnormal
thorax
Inspect Scapula Spinous process that
configuration symmetric and deviate laterally in
non protruding. the thoracic area
may indicate
scoliosis.
Inspect the Client should be Client leans forward,
client’s sitting up & and uses arms to
positioning relaxed, support weight and
breathing easily lift chest to increase
with arms at breathing capacity –
sides or in lap. tripod position.
Often seen in COPD
clients
CLINICAL INSTRUCTOR
PA: LUNGS
Palpation Normal Abnormal

Palpate for No tenderness, Tender or painful
tenderness and pain, or unusual areas
sensation sensations. Temp
should be equal
bilaterally
Palpate for No palpable Crepitus can be
crepitus- crackling crepitus palpated if air
sensation like escapes from the
bones or hair lungs or other
rubbing together airways into the
subcutaneous tissue

CLINICAL INSTRUCTOR
Sequence of PALPATION
1 2
4 3
5 6
8 7
9 10

CLINICAL INSTRUCTOR
PA: LUNGS
Assessment
Normal Abnormal
Procedure
Palpate surface Free from lesions Any unusual palpable
characteristics and masses mass
Palpate for Fremitus is Unequal fremitus
fremitus symmetric
Asses chest The examiner’s Unequal chest
expansion thumbs should expansion can occur
move 5-10 cm with severe atelectasis
part
Percuss for tone Resonance is the Hyperresonance – in
percussion tone cases of trapped air
elicited over Dullness – when fluid
normal lungs or solid tissues replace
the air in the lungs
CLINICAL INSTRUCTOR
PA: LUNGS
Procedure
Auscultate for 3 types of normal Diminished or absent
breath sounds breath sounds:
Bronchial,
bronchovesicular,
vesicular
Normal Breath Sounds
Type Pitch Location
Bronchial High Trachea, thorax
Bronchovesic Moderate Over the major bronchi
ular
Vesicular Low Peripheral lung fields
CLINICAL INSTRUCTOR
PA: LUNGS
Procedure
Auscultate for No Presence of adventitious
adventitious adventitious lung sounds
breath sounds sounds
ADVENTITIOUS BREATH SOUNDS
Sound Source Associated conditions
Crackles Air is in -COPD
contact with -pneumonia
fluids -pulmonary edema
Wheezes:
Sibilant – high Air passes -asthma
pitch through -emphysema
Sonorous – low constricted
pitch passages

CLINICAL INSTRUCTOR
PA: LUNGS
Assessment pro N A
Auscultate
breath sounds :
Bronchopny – Voice Clear
“ninety-nine” transmission is
soft, muffled
and indistinct
Egophony - E Letter E is “A”
distinguishable
Whispered May be Very audible
pectoriloquy – inaudible
whispered one
two three
CLINICAL INSTRUCTOR
PA: LUNGS
Assessment
NORMAL ABNORMAL
procedure
Anterior Thorax
Palpate for No tenderness Tenderness
tenderness, sensation or pain
or surface masses
Palpate for fremitus Fremitus is Diminished
symmetric vibrations
Palpate anterior chest Thumbs move Unequal chest
expansion outward expansion

CLINICAL INSTRUCTOR
PA: LUNGS
Assessment pro NORMAL ABNORMAL
Percuss for tone Resonance over Hyperesonance

lungs
Auscultate for Same with Sane with
breath, posterior thorax posterior thorax
adventitious and
voice sounds

CLINICAL INSTRUCTOR
PA: LUNGS

CLINICAL INSTRUCTOR
PA: LUNGS
random, sudden
dependent
Crackles re-inflation of
lobes
alveoli fluids
Rhonchi trachea, bronchi fluid, mucus
severely
Wheezes all lung fields narrowed
bronchus
Pleural friction lateral lung

inflamed pleura
rub fields
ABNORMAL BREATH SOUNDS

CLINICAL INSTRUCTOR
PA: THORAX

CLINICAL INSTRUCTOR
PA: THORAX
LANDMARK OF THE
THORAX
CLINICAL INSTRUCTOR
PA: THORAX
Elderly: Physical Changes of Thorax and Breathing Patterns
• Kyphosis
• Anteroposterior diameter of
the chest widens
• Breathing rate and rhythm are
unchanged at rest
• Inspiratory muscles become
less powerful, and inspiration
reserve volume decreases.
• Expiration may require the
use of accessory muscles
• Deflation of the lung is
incomplete.

CLINICAL INSTRUCTOR
PA: BREAST
Female BREAST NORMAL ABNORMAL
Inspect size and Slight asymmetry A recent increase in
symmetry the size of one
breast may indicate
inflammation or
abnormal cell
For old clients, breast growth
becomes less firm and
saggy Pigskin or orange
peel
Inspect for color Texture is smooth with Redness
and texture no edema
Linear stretch marks

may be seen during or
after pregnancy or
with a sig weight loss
CLINICAL INSTRUCTOR
PA: BREAST

CLINICAL INSTRUCTOR
PA: BREAST
ORANGE PEEL
CLINICAL INSTRUCTOR
PA: BREAST
ASSESSMENT NORMAL ABNORMAL
Inspect the areolas Varies from dark pink to Pau d orange – cancer
dark brown Red, scaly, crusty –
paget’s disease
Inspect for Breasts rise Dimpling or retraction
retraction or symmetrically with no
dimpling sign of dimpling or
retraction
Restricted movements
Breast should hang
freely
Palpate texture and Smooth, firm and elastic Thickening
elasticity
Palpate tenderness Increase in nodules Presence of pain and
and temp during menstruation, heat
JOHN PAUL N. REGANIT, RN, MSN, LPTwith normal body temp
CLINICAL INSTRUCTOR
PA: BREAST
Assessment NORMAL ABNORMAL
Palpate for No masses Malignant tumors – unilateral
masses should be with irregular, poorly defined
palpated boarders. Hard, nontender and
fixed to underlying tissues
Benign tumors - mass of tissue

that, like a malignant
(cancerous) tumor, has
developed from cells that have
multiplied and grown
abnormally.
Palpate the The nipple Presence of discharge with out
nipples erects in normal rationale
response to
stimulation
CLINICAL INSTRUCTOR
PA: BREAST
TUMORS

CLINICAL INSTRUCTOR
PA: BREAST
BREAST SELF-EXAM
CLINICAL INSTRUCTOR
PA: BREAST
BREAST SELF-EXAM
CLINICAL INSTRUCTOR
PA: BREAST
Inspect the axillae No rash or Redness and

infection inflammation
palpate the axillae No palpable nodes Enlarged

CLINICAL INSTRUCTOR
PA: BREAST
MALE BREAST
Inspect and No swelling, Soft, fatty

palpate the breast, nodules, or enlargement of
areolas, nipples, ulceration breast tissue is
and axillae seen in obesity
Gynecomastia

CLINICAL INSTRUCTOR
PA: BREAST
GYNECOMASTIA

CLINICAL INSTRUCTOR
PA: HEART
Inspect pulsations The apical pulse may Pulsations, which may also be
or may not be visible called heaves or lifts other than
the apical pulsations.
- it occurs from an enlarged

ventricle from an overload of
work.
Palpation Apical pulse is The apical pulse may be
Palpate the apical palpable impossible to palpate in cases of
pulse. emphysema.
Suspect cardiac enlargement if it

is more forceful than the usual
Palpate for No pulsations or Presence of pulsations where it is
abnormal vibrations are not present
pulsations palpated in the areas
of the apex, left
JOHN PAUL N. REGANIT, RN, MSN,sternal
LPT border or base
CLINICAL INSTRUCTOR
PA: HEART
Auscultate heart rate Normal rate is 60-100 Bradycardia
and rhythm Tachycardia
-If you detect an Radial and apical Presence of pulse
irregular rhythm, pulse should be deficit
auscultate for a pulse identical
deficit
Auscultate to identify Only Presence of:
S1 and S2 ( supine S1 – “lab” & S 3– echo of lab
position) S2 – “dubb” is heard while
S4 – murmurr
S1S3 S2
S1S3S2 S4
S1 S2 S4
Auscultate in with the Only lab - dubb Presence of S3 and S4
client assuming other
positions
CLINICAL INSTRUCTOR
PA: HEART
• LUB or S₁ - ASSOCIATED WITH CLOSURE OF THE

TRICUSPID & MITRAL VALVES
• DUB or S₂ - ASSOCIATED WITH CLOSURE OF THE
PULMONIC & AORTIC VALVES
 S1 - mitral and tricuspid closure

 S2 - aortic and pulmonic closure
 S3, S4 - may be normal in children and athletes
 S4 - considered normal in older adults

CLINICAL INSTRUCTOR
PA: HEART
• 3rd heart sound (S₃) - extra, protodiastole (rapid

filling of ventricle), after S₂ associated
w/ heart failure & volume overload due to
decreased contractility/ ventricular gallop
• 4th heart sound (S₄) - extra, end of diastole at
presystole just before S₁ (atrial contraction),
(resistance to ventricular filling) associated w/
CAD, aortic stenosis/ atrial gallop
• Normal physiologic splitting of S₂ –
split at pulmonic area at end of inspiration,
aortic closes just before the pulmonic

CLINICAL INSTRUCTOR
PA: HEART
• Diastole – AV open, Vent. Relaxed, higher

pressure in atria forces blood to Vent
(passive filling / protodiastolic)
• Systole – Vent pressure is now higher due

to volume, AV shut (S₁) very briefly all 4
valves are shut, Vent contract, 
pressure forcing SL valves open, 
pressure & SL valves shut (S₂)

CLINICAL INSTRUCTOR
PA: HEART

CLINICAL INSTRUCTOR
PA: HEART

CLINICAL INSTRUCTOR
PA: HEART
JUGULAR VEINS
JUGULAR VENOUS
PRESSURE
= 6-8 CMH2O

CLINICAL INSTRUCTOR
PA: HEART
JUGULAR VENOUS PRESSURE

CLINICAL INSTRUCTOR
PA: HEART
Internal Jugular Pulsations Internal Carotid Pulsations
Rarely palpable Palpable
Soft undulating quality, usually A more vigorous thrust with a
with 2 elevations and 2 troughs single outward component
Pulsation eliminated by light Pulsation not eliminated by
pressure on the veins just light pressure
above the clavicle
Level of pulsation usually Level of the pulsation not
descends with expiration affected by respiration
Level of the pulsation changes Level of the pulsation
with position, dropping as unchanged by position
patient becomes more upright
DISTINGUISHING FEATURES OF INTERNAL JVP

FROM INTERNAL CAROTID PULSATIONS
CLINICAL INSTRUCTOR
PA: HEART
Assess for the following

Chest pain Angina – squeezing
around the heart, a
steady severe pain and a
sense of pressure
Palpitations

CLINICAL INSTRUCTOR
PA: PERIPHERAL CIRCULATION
INSPECT Color
Edema
Stasis ulcers/lesions
Varicosities
Hair/nail changes
PALPATE  Temperature
 Edema
 Tenderness
 Symmetry of pulses

CLINICAL INSTRUCTOR
Intermittent
Pain
claudication
Pulse Decreased
Color Pale
Temperature Cool
Edema Absent or mild
Thin, shiny atrophic
Skin Changes skin, hairloss,
thickened nails
Ulceration Toes/points of trauma
Gangrene May develop
CHRONIC ARTERIAL INSUFFICIENCY

CLINICAL INSTRUCTOR
None to aching pain on

Pain
dependency
Pulse Normal
Normal to cyanotic;
Color petechiae or brown
pigmentation
Temperature Warm
Edema Present
Dermatitis skin
Skin Changes
pigmentation
Ulceration Medial side of ankle
Gangrene Does not develop
CHRONIC VENOUS INSUFFICIENCY

CLINICAL INSTRUCTOR
PA: ABDOMEN
• The bladder should be empty.

• Place patient in a supine
position with knees slightly
flexed.
• Have warm hands, warm
stethoscope and short
fingernails.
• Ask for tender areas and
examine them last.
• Monitor your examination by
watching the patient’s face

CLINICAL INSTRUCTOR
PA: ABDOMEN
THE QUADRANTS WITH

UNDERLYING ORGANS
CLINICAL INSTRUCTOR
PA: ABDOMEN
Observe for skin Abdominal skin may be Grey Turner Sign – purple
coloration paler than the gen skintone discoloration of the flanks
because this skin is so which indicates bleeding
seldom exposed to natural
elements Jaundice
Pale, taut skin is seen with pt

with ascites
Redness
Bruises
Note any striae White striae or stretch
marks fr past pregnancies
or wt gain are normal
Inspect for scars Pake, smooth, minimally Nonhealing scars, redness,
raised old scars inflammation
CLINICAL INSTRUCTOR
PA: ABDOMEN
Inspect for the umbilicus Umbilical skin tone is Cullen’s sign – bluish or
similar to surrounding purple discoloration
abdominal skin ton e around the umbilicus
Observe umbilical Midline Deviated umbilicus
location
Assess contour of Inverted or slight Everted umbilicus
umbilicus protruding
Inspect abdominal Flat, rounded Scaphoid – severe
contour weight loss
Distended / Proturbent
– d/t obesity, air, gas or
fluid accumulation
Inspect abdominal Abdominal respiratory Diminished abdominal
movement when the movement may be seen respiration
client breathes especially in male clients
Observe for peristaltic Normally, peristaltic Peristaltic waves are
waves waves are not seen increased and progress
JOHN PAUL N. REGANIT, RN, MSN, LPT in a ripple like fashion
CLINICAL INSTRUCTOR
PA: ABDOMEN
Auscultate for “borborygmi” – Hypoactive bowel sound
bowel sounds normal bowel Hyperactive bowel sounds
sounds Decreased or absent bowel
sound
Percuss for tone Tymphany – general Hyperresonnance
part Enlarged area of dullnes
Liver & spleen –
dullness
Perform blunt No tenderness is Tenderness is elicited
percussion on the elicited
liver
Perform blunt No tenderness With tenderness
percussion on the
kidneys
Perform light Abdomen is non Tender
palpation tender and soft
Perform deep Normal tenderness Severe tenderness
palpation Presence of masses
CLINICAL INSTRUCTOR
PA: ABDOMEN
Palpate the liver: Not usually Hard, firm liver
Bimanual and palpable although may indicate
hooking technique it may be felt in cancer
some thin clients.
Firm, smooth and Hepatomegaly –
even enlarged
Palpate the spleen The spleen is Enlarged spleen
seldom palpable
Palpate the kidney The kidneys are Enlarged kidney
normally not
palpable
Palpate the urinary Normally, the Distended bladder
bladder bladder is not – smooth, round
papable and somewhat
firm
CLINICAL INSTRUCTOR
PA: ABDOMEN
Type Cause Character Example

Visceral Occurs when hollow abdominal Dull Hepatomegaly
pain organs, such as intestines Aching Spleenomegaly
become distended, or contract Burning
forcefully or when the capsule Cramping
of solid organs are stretched Colicky
Parietal Occurs when the parietal More severe Appendicitis
pain peritoneum becomes inflamed Steady pain Peritonitis
Referred Occurs at distant sites that are Labor pains
pain innervated at approximately Kidney pains
the same level as the disrupted
abdominal organ
TYPES OF PAIN

CLINICAL INSTRUCTOR
PA: ABDOMEN
INSPECTION
• Contour of abdomen
• Inspect skin
• Umbilicus
• Masses
• Peristalsis
• Pulsations
AUSCULTATION
 Bowel motility
(5-34/minute)
 bruits

CLINICAL INSTRUCTOR
PA: ABDOMEN
PERCUSSION
• Percuss all quadrants of
the abdomen.
• Percuss for liver dullness
(4-8 cm midsternal line;
6-12 RMCL line)
• Percuss for splenic
dullness
PALPATION • Masses
• Tenderness
• Palpate the liver palpable 4
cm below right subcostal area
• Palpate the spleen enlarged
if palpable 2cms below L
subcostal margin
• Aorta
CLINICAL INSTRUCTOR
PA: ABDOMEN
PALPATION
Ascites
• Fluid wave
• Shifting dullness
CLINICAL INSTRUCTOR
PA: ABDOMEN

CLINICAL INSTRUCTOR
PA: ABDOMEN

CLINICAL INSTRUCTOR
PA: ABDOMEN

CLINICAL INSTRUCTOR
PA: ABDOMEN
Special tests Test for
APPENDECITIS
Assess for rebound No pain The client has
tenderness and rebound tenderness
Rovsing’s sign
Assess for Psoas sign No abd pain is Pain in the RLQ
present
Assess for Obturator No abd pain present Pain in the RLQ
sign
Perform The client feels no Presence of pain
Hypersensitivity test pain and no and exaggerated
exaggerated sensation
sensation

CLINICAL INSTRUCTOR
PA: ABDOMEN

CLINICAL INSTRUCTOR
PA: ABDOMEN
ELDERLY: PHYSICAL CHANGES IN
GI TRACT
• The side effects of drugs are often manifested in the
gastrointestinal tract, (eg, nausea, vomiting, and diarrhea)
• Gastrointestinal pain needs to be differentiated from
cardiac pain.
• Difficulty swallowing is a common complaint of older
adults.
• Older individuals have increased esophageal spasms and
less efficient action of the lower esophageal sphincter.

CLINICAL INSTRUCTOR
PA: EXTREMITIES
INSPECTION
• Structural deformities
• symmetry
• Nodes
• Swelling/signs of inflammation
PALPATION
 Crepitus
 Tenderness
TEST
 Muscle strength/ROM

CLINICAL INSTRUCTOR
PA: GENITALIA
Mons pubis Pubic hair is distributed in an Absence of pubic hair
inverted triangular pattern Lice or nits (egg) at the
base of the pubic hairs
indicates infestations.
“crabs”
Inguinal lymph No enlargement or swelling Enlarged and swelling
nodes
Vaginal The client should be able to Absent or decreased
musculature squeeze the clients finger ability to squeeze
Inspect the Smooth, pink and even Bluish in non pregnant
cervix – cyanosis
redness
Palpate the The normal uterus moves Fixed or tender,
uterus freely and is not tender indicates fibroid,
infection or masses

CLINICAL INSTRUCTOR
PA: GENITALIA

CLINICAL INSTRUCTOR
PA: GENITALIA
Abnormalities of the External Genitalia and Vaginal Opening
Syphilitic chancre Silvery white papules that Painless

become superficial red ulcers

CLINICAL INSTRUCTOR
PA: GENITALIA
Genital Caused by human papilloma virus Painless
warts
moist, fleshly lesions on the labia and with in the
vestibule

CLINICAL INSTRUCTOR
PA: GENITALIA
Genital Herpes Small, red based ulcer like lesions of herpes Painful
Simplex simplex virus

CLINICAL INSTRUCTOR
PA: GENITALIA
Cystocele Bulging, anterior vaginal wall, caused by
thickening of the pelvic musculature

CLINICAL INSTRUCTOR
PA: GENITALIA
Uterine Uterus protrudes in the vagina
prolapse

CLINICAL INSTRUCTOR
PA: GENITALIA
Other Abnormal Findings
Candida Infection caused by overgrowth of yeast in the vagina
Vaginitis
It causes thick, white , cheesy discharge.
The labia may be inflamed or swollen and causes intense

itching and discomfort

CLINICAL INSTRUCTOR
PA: GENITALIA
Other Abnormal Findings
Bacterial Vaginosis Infection caused is unknown but thought to be a STD
The discharge is thin and grey white and has a fishy smell

CLINICAL INSTRUCTOR
PA: MALE GENITALIA: PENIS
Inspect the base of The pubic hair is Absence or scarcity
the penis & pubic coarser than the of pubic hair.
hair scalp hair, and it Presence of “crabs”
covers the entire
groin region
Inspect the skin of The skin is wrinkled Rashes, lesions or
the shaft & hairless lumps
Palpate the shaft The penis in non tenderness
erect state is soft,
flaccid and non
tender
Palpate the urethral The urinary meatus Yellowish discharge
discharge is normally free of is present –
discharge gonorrhea
CLINICAL INSTRUCTOR
PA: MALE GENITALIA
SCROTUM
Inspect the size, Asymmetric An enlarged scrotal
shape and position sac w/c may result
from:
Fluid – hydrocele
Blood – hemetocele
Bowel – hernia
Tumor – cancer
Inspect the scrotal Scrotal skin is thin Rashes, lesions and
skin and rugated inflammation
Palpate the scrotal Testes are ovoid, Absence of testis –
contents smooth, free from cryptorchidism
lumps (undescended
testis)
CLINICAL INSTRUCTOR
PA: MALE GENITALIA
Abnormalities of the Penis

Syphilitic Initially, a small silvery Painless
Chancre white papule that develops
a red oval ulceration
Herpes Clusters of pimple like, clear Painful

Progenitalia vesicles that erupt and
become ulcers
Genital Warts Single or multiple, moist, painless
fleshy papules
Cancer in the Hardened nodule or ulcer Painless
Glans penis in the glands

CLINICAL INSTRUCTOR
PA: MALE GENITALIA

CLINICAL INSTRUCTOR
PA: MALE GENITALIA
Abnormalities of the Penis
Phimosis Foreskin is so tight that it cant be retracted
over the glans
Paraphimosis Foreskin is so tight that once retracted, it
cant be returned back over the glans
Hypospadias -Urethral meatus is located underneath the
glans
-ventral side
-congenital defect
Epispadias -The urethral meatus is located on the top of
the glans (dorsal sisde)
-occurs rarely
-congenital defect

CLINICAL INSTRUCTOR
PA: MALE GENITALIA

CLINICAL INSTRUCTOR
PA: MALE GENITALIA

CLINICAL INSTRUCTOR
PA: MALE GENITALIA
Abnormalities of the Scrotum

Hydrocele Collection of serous fluid in the Usually painless
scrotum
Scrotal Hernia A loop of bowel protrudes into the Hernia appears as if
scrotum to create what is known as swelling but soft
an indirect inguinal hernia
Testicular Presence of mass which in later, Feels enlarged and
Tumor replaces the testis smooth
Cryptorchidism Undescended testis
Orchitis Inflammation of the testis,
associated frequently with mumps

CLINICAL INSTRUCTOR
PA: MALE GENITALIA

CLINICAL INSTRUCTOR
PA: MALE GENITALIA

CLINICAL INSTRUCTOR
PA: MALE GENITALIA

CLINICAL INSTRUCTOR
REVIEW OF
SYSTEMS
PHYSICAL ASSESSMENT

CLINICAL INSTRUCTOR

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REVIEW OF

JOHN PAUL N. REGANIT, RN, MSN, LPT

JOHN PAUL N. REGANIT, RN, MSN, LPT

JOHN PAUL N. REGANIT, RN, MSN, LPT

• Pain is an unpleasant sensory and emotional

JOHN PAUL N. REGANIT, RN, MSN, LPT

• “fifth vital sign,”

JOHN PAUL N. REGANIT, RN, MSN, LPT

JOHN PAUL N. REGANIT, RN, MSN, LPT

JOHN PAUL N. REGANIT, RN, MSN, LPT

ABCDE Mnemonic of Pain Interview

A Ask about pain regularly; assess pain systematically

B Believe the patient and family in their reports of pain

C Choose pain control options appropriate for the

D Deliver interventions in a timely, logical and

E Empower patients and their families

JOHN PAUL N. REGANIT, RN, MSN, LPT

JOHN PAUL N. REGANIT, RN, MSN, LPT

Skin Skin is intact and there Skin breakdown

Inspect for Smooth, with out Presence of lesions from

JOHN PAUL N. REGANIT, RN, MSN, LPT

JOHN PAUL N. REGANIT, RN, MSN, LPT

JOHN PAUL N. REGANIT, RN, MSN, LPT

JOHN PAUL N. REGANIT, RN, MSN, LPT

JOHN PAUL N. REGANIT, RN, MSN, LPT

JOHN PAUL N. REGANIT, RN, MSN, LPT

JOHN PAUL N. REGANIT, RN, MSN, LPT

JOHN PAUL N. REGANIT, RN, MSN, LPT

JOHN PAUL N. REGANIT, RN, MSN, LPT

Mobility and Skin pinches easily and Decreased mobility

1 + --Mild pitting, sl. Indentation

2 + --Moderate pitting, dent subsides quickly

3 + --Deep Pitting, dent remains a short period

4 + --Very Deep Pitting, dent lasts a long time

JOHN PAUL N. REGANIT, RN, MSN, LPT

JOHN PAUL N. REGANIT, RN, MSN, LPT

JOHN PAUL N. REGANIT, RN, MSN, LPT

JOHN PAUL N. REGANIT, RN, MSN, LPT

JOHN PAUL N. REGANIT, RN, MSN, LPT

Test accommodation Pupils constrict and No constriction

Other ABNORMALITIES of the eyes in terms of extraocular muscle

Pseudostrabismus Normal in babies 1-3 If it is retain until

Esotropia Eye turns inward

The skin is smooth *Tophi

External auditory Small amount of *Foul smelling discharge

JOHN PAUL N. REGANIT, RN, MSN, LPT

JOHN PAUL N. REGANIT, RN, MSN, LPT

JOHN PAUL N. REGANIT, RN, MSN, LPT

Assessment Normal Abnormal

JOHN PAUL N. REGANIT, RN, MSN, LPT

JOHN PAUL N. REGANIT, RN, MSN, LPT

Palpation Normal Abnormal

JOHN PAUL N. REGANIT, RN, MSN, LPT

JOHN PAUL N. REGANIT, RN, MSN, LPT

JOHN PAUL N. REGANIT, RN, MSN, LPT

JOHN PAUL N. REGANIT, RN, MSN, LPT

Assessment pro NORMAL ABNORMAL

Percuss for tone Resonance over Hyperesonance

JOHN PAUL N. REGANIT, RN, MSN, LPT

JOHN PAUL N. REGANIT, RN, MSN, LPT

Rhonchi trachea, bronchi fluid, mucus

Pleural friction lateral lung