c
c


    to CC of your patient
Having abdomen pain on left side
-  : left upper quadrant/lower quadrant abdomen pain
- : pain is localized and does not radiate
-
  : cramping with occasional sharp pain
-  ! : pain scale 7/10
- "#: started 2 days ago, intermittent or constant, it lasted for 1 hr
- # in which it occurs: pain worsen after meal and with certain movements (e.g. bending)
-##! #!#$ : pain relieved by Tylenol OTC
-  $ : ate a large amount of meal/seafood yesterday
-% % : unable to perform certain duties due to increase in pain level

&'( ! 

-change in appetite and weight?
-any dysphagia?
-any food intolerances (due to allergic reaction, pyrosis (heart burn), eructation (belching),
bloating, indigestion?
-nausea/vomiting (amount, how often, color, odor, taste, blood)
-any changes in bowel habits (how often, color, consistency, how long) use laxatives?
-past history of GI problems: ulcer, gallbladder, hepatitis/jaundice, appendicitis, colitis, hernia

c'"'( !c" 

Inspection
-)  describes nutritional state: flat, scaphoid, rounded, protuberant
- ""  (should be symmetric bilaterally) note any localized bulging/hernia, visible mass, or
asymmetric shape.
-"' : normally midline and inverted with no sign of discoloration, inflammation, or
hernia. Everted with acites (excess fluid in space between abdomen tissue lining and organs)
-Bluish periumbilical color occurs with intraabdominal bleeding
-*: surface is smooth and even with homogeneous color. Judge pigment pink/blue/purple
(striae from prolonged stretching as in pregnancy or excessive weight gain)
-  ++
 (measure)
-,* # reflects healthy nutrition and poor occurs with dehydration
-  (normally may see pulsations from aorta beneath skin in epigastric area) Marked
pulsation occurs with widened pulse pressure.
-- '  (pattern of pubic hair growth normally has diamond shape in adult males and
inverted triangle in adult females). Patterns alter with endocrine or hormone abnormalities.
-
" (comfortable person is relaxed quietly on examining table)
cuscultation (bowel and vascular sounds)
# at ileocecal valve area where bowel sounds always present
. (RUQ/RLQ, LUQ/LLQ)
/ are high pitched, gurgling, cascading sounds occurring irregularly. Judge if they
are normal, hypoactive/absent (follow abdominal surgery or inflammation of the peritoneum),
or hyperactive (hyperperistalsis).
0  /
': note bruits (check over aorta, renal arteries, iliac, and femoral
arteries) usually no sound is present.

Palpation (surface and deep areas)

To (# the size, location, and consistency of certain organs and to screen for abnormal
masses, pain, or tenderness
#/
#
%%  by first four fingers, depress skin about 1cm and move clockwise
cs you circle, discriminate between voluntary muscle guarding and involuntary rigidity
Now perform %%%  using same technique but push down about 5 to 8cm

Percussion (density of abdominal contents, locate organs and screen abnormal fluid or masses)
 lightly in all 4 quads to determine the amt of tympany and dullness, move clockwise.
 "% : air in intestines rises to the surface when person is supine.

: occurs over a distended bladder, adipose tissue, fluid, or mass.
- % : present with gaseous distention.

Identify Organs
  !!: valve between ileum of small intestine and cecum of large intestine that
prevents the backflow of material from large to small intestine, found on RLQ.
c%%1: fingerlike pouch attached to large intestine, located in RLQ.
#" : part of the large intestine that is closest to rectum and anus, located LLQ.
 "
: organ between esophagus and small intestine, located in LUQ.
%: organ above stomach and under ribs on left side, LUQ.
 : gland located behind stomach, it stretches across posterior abdominal wall to LUQ
(head RUQ, body LUQ)
!: sits under rib cage on right side of abdomen (RUQ, left lobe of liver LUQ)
,': small organ that aids digestion and stores bile produced by liver, RUQ.
 2#
* : rests 1-2cm lower than left kidney due to placement of liver, RUQ.
 2$ * : lies at eleventh and twelfth ribs, LUQ.
 ) %
0 

   ))
Chest pain and numbness/tingling in left arm and fingers
-  : left chest pain with numbness/tingling on left arm and fingers
- : may radiates to whole chest area L>R
-
  : dull pain constant with occasional sharp/shooting pain
-  ! : pain scale 3/10 dull, and 7/10 sharp
- "#: started 1 week ago, and progressively getting worse
- #: pain worsens with exertion and activity
-##! #!#: aggravates with movement and temporary relieved by Tylenol OTC
-  $ : noticed more with anxiety attacks
-% % : limits daily workload and functioning

&'( !
-chest pain/tightness -dyspnea (SOB)/orthopnea (upright position to breathe) -fatigue -edema
-cough/sputum production -cyanosis or pallor -nocturia -cardiac history, FH, personal habits
(PV)-leg pain or cramps -skin changes on extremities -swelling-lymph node enlargement/glands

) %
0 '( !c" 
Inspection Precordium/Carotid crteries
%  
 (pulsations): describe location of apical impulse (4th or 5th intercostal
space, at or inside the midclavicular line). Supine with head & chest slightly elevated.
 
!$ : sustained forceful thrusting of ventricle during systole, and occurs with
ventricular hypertrophy as a result of increased workload. Right ventricular heave is seen at
sternal border; left ventricular heave is seen at the apex.
To evaluate   , person can be sitting up (observe and palpate)
Observe (#!%: position in supine 30-45 angle where you best see pulsations.
Turn person͛s head away from examined side and note external jugular veins overlying
sternomastoid muscle. cs person is raised to sitting position, these external jugulars flatten and
disappear, usually at 45 degrees.
): alert and cooperative
*): general pigmentation: dark brown/flesh tone
)"$ !: comfortable and relaxed posture

Palpation
)  : located in groove between trachea and sternomastoid muscle, higher and
medial to and alongside that muscle.
)  : contour is smooth with a rapid upstroke and slower downstroke, and normal
strength is 2+ or moderate. Findings are same bilaterally.


": Regular  ""  : Present  : Strong
c% 2"*: (PMI) O
 
 

  
cpical impulse should occupy only one interspace, the fourth or fifth, and be at or medial to the
midclavicular line. c"% : short/gentle tap
cuscultation
) : for presence of a bruit (blowing, swishing sound indicating blood flow turbulence)
c  : second right interspace
" : second left interspace
 %: left lower sternal border
 : fifth interspace at around left midclavicular line
 $3" 
-note rate and rhythm (60-100 beats/min, rhythm: regular)
-identify S1 and S2 (S1 louder than S2 at apex, S2 louder than S1 at base)
-assess S1 and S2 separately (note normal, accentuated, diminished, or split)
-listen for extra heart sounds (not timing and characteristics)
-listen for murmurs (blowing, swooshing sound that occurs with turbulent blood flow)

Inspection Upper/Lower Extremities

Note color of skin and nail beds, temperature (B/L warm), texture, turgor of skin, presence of
any lesions, edema, or clubbing.
)''#: u
 angle straightens to >180 degrees and nail base feels spongy to palpation.
Profile sign (normal 160 degrees) nail base is firm to palpation.
Ö": u
  arms and legs should be symmetric in size.
UE: occurs when lymphatic drainage is obstructed
LE: B/L occurs with systemic illnesses. DVT (unilateral, painful swelling, asymmetry of calves)
)
Pallor-white: local arterial insufficiency, decreased blood flow to skin
Cyanosis-blue: increased deoxyhemoglobin from hypoxia
Erythema-red: hyperemia, increased blood flow in skin, inflammation
Jaundice-yellow: yellow sclera, increased bilirubin from liver inflammation or hemolytic disease
Brown-Tan: increased melanin from sun exposure
Necrosis-black: due to death of body tissue

Palpation UE & LE (pulses should be palpated bilaterally) 60-100 rate

: 2+ normal

: equal B/L

: top of foot/extensor tendon of big toe
 ': inner side of ankle/medial malleolus
4": below inguinal ligament
% : behind knee
"% " : B/L warm and dry
Ö": 1+mild pitting, 2+moderate pitting, 3+deep pitting, 4+very deep pitting
)% $: hands near heart level; depress and blanch nail beds, release and note time for
color return (<2secs).
 %  

   ))
Having difficulty breathing and coughing that produces chest pain
-  : produces left sided chest pain upon deep coughing
- : localized pain
- : stabbing type
-! : 7/10
- "#: 1 week
- #: anytime can happen
-##! #!#: worsen at lying position and deep coughing. Relieved by inhalers.
-  $ : heavy smoker
-% % : unable to breathe fully

&'( !
-describe cough/sputum -SOB -CP w/ breathing -Hx: respiratory infections
-smoking hx -environmental exposure -self-care behaviors

Inspection (cnterior/Posterior) Chest expands symmetrically with each respiration.

 : 12-20  : automatic/effortless 

": regular/even (produces no noise)
): lips and nail beds are free of cyanosis or unusual pallor
c  " : none (scalene, sternomastoid, trapezius use w/ heavy exercise)

%c : spinous processes should appear in a straight line. Thorax is symmetric;
scapulae are placed symmetrically. cnteroposterior to transverse diameter is from 1:2 to 5:7
(should be less than transverse diameter)
 % * '
: relaxed posture and ability to support own weight with arms
comfortably at the sides or in the lap.

% : midline; palpate for any tracheal shift
): alert and cooperative

Palpation

": place index finger on trachea in sterna notch and slip it off to each side
)
 1%c
c :  ""  
 1% (place hands on anterolateral wall with thumbs along
costal margins and pointing toward xiphoid process) ask person to take a deep breath and
watch your thumbs move apart symmetrically.
 ! $" : begin palpating over lung apices in supraclavicular areas and compare
vibrations from one side to other as person repeats 99.
 : confirm  ""  
 1% by placing hands on posterolateral chest wall
with thumbs at level of T9 or T10. Slide hands medially to pinch up a small fold of skin between
thumbs. csk person to take deep breaths and your thumbs should move apart symmetrically.
 4"  (palpable vibration): use palmar base of fingers or ulnar edge, touch person͛s
chest while repeats words 99. Note any areas of abnormal fremitus.
Palpate entire chest wall to note areas of tenderness, skin temp and moisture, detect
lumps/masses, skin mobility/turgor, or any skin lesions.
Percussion
c : begin in supraclavicular areas, to the interspaces and to the anterior chest (p. 460).
Note resonance (low-pitched, clear, hollow sound), dullness and tympany.
 : start at resonant tissue across tops of both shoulders, then interspaces (make
comparison) all the way down to lung region (p. 452). Note resonance or dullness.

cuscultation (breath sounds)

c : start at supraclavicular areas down to 6th rib. Progress from side to side; listen to one
full respiration in each location. (Use percussion sequence) evaluate normal breath sounds.
 : person is sitting, leaning forward slightly. Instruct person to breathe through the
mouth, little deeper than usual. Use diaphragm and listen one full respiration in each location.
Listen to following lung areas-C7 to the bases around T10 and laterally from the axilla down to
7th or 8th rib (p. 455).
Should hear 3 types of normal breath sounds: bronchial (high), bronchovesicular (moderate),
and vesicular (low) (p. 456).

c!  '

  " 

#
Discontinuous sounds
Crackles fine rales: discontinuous, high-pitched, short crackling popping sounds
Crackles coarse rales: loud, low-pitched, bubbling and gurgling sounds
ctelectatic crackles rales: sounds like fine crackles but do not last
Pleural friction rub: superficial sound that is coarse and low pitched
Continuous sounds
Wheeze/high-pitched (sibilant): high-pitched squeaking sounds that sound polyphonic
Wheeze/low-pitched (sonorous rhonchi): low-pitched, monophonic, moaning sounds
Stridor: high-pitched, monophonic, inspiratory, crowing sound

c   

 % + 
 1%+#5
Sternocleidomastoid
Scalene
Trapezius
Intercostals
Rhomboid
cnterior serrati


 # )')# !   

   ))
Sudden weakness/numbness in face, arm, and leg
  : right facial area, right arm and right leg
 : travels up and down numbness/tingling sensations
 : average
! : N/c
"#: 1 week
 #: none noted
c##! #!#: not much difference
c  $ : hx of mini-stroke
 % : unable to retain full-strength and normal function

&'( !
Headache head injury dizziness/vertigo seizures tremors weakness incoordination past hx
Numbness/tingling difficulty swallowing/speaking environmental/occupational hazards

'( !
): alert and aware of the environment
Öc: pupils equal, round, react to light, and accommodation
Reaction: equally constriction of pupil response to light
Size: 3mm in resting state/1mm in response to light
  : aware of personal identity, place, and time (requires both memory and attention)
" : recent or short-term memory cover minutes, hours, or days. Remote or long-term
refers to intervals of years.
%
: pace of conversation is moderate, and stream of talking is fluent. crticulation (ability to
form words) is clear and understandable. Word choice is effortless and appropriate.
c%% : person appears stated age. Person alert and oriented; attends to questions and
responds appropriately. Facial features are symmetric with movement.

!: person maintains eye contact, expressions are appropriate to situation.
Ö"   : Person is comfortable, cooperative, and interacts pleasantly.
)!36
1.? CNI: Olfactory
2.? CNII: Optic
3.? CNIII: Occulomotor
4.? CNIV: Trochlear
5.? CNV: Trigeminal
6.? CNVI: cbducens
7.? CNVII: facial
8.? CNVIII: cccoustic
9.? CNIX: Glossopharyngeal
10.?CNX: Vagus
11.?CNXI: cccessory
12.?CNXII: Hypoglossal
 # )')# !
"
   ))
"'( !

"'( !
)
Öc: reaction, size, accommodation (ask person to focus on distant object (pupils dialte),
then shift the gaze to a near object (pupillary constriction and convergence of axes of eyes).
  : person, place, time
" : STM/LTM
 %
+c%% + 
!+Ö"   

)'" 
,   : observe as person walks 10-20ft, turns, and returns to the starting point. The gait is
smooth, rhythmic, and effortless. Tandem walking: ask person to walk a straight line in heel to
toe fashion (walk straight and stay balanced).
"'#: ask person to stand, feet together and arms at sides; then ask to close eyes and hold
position for 20 seconds. csk person to perform a shallow knee bend or hop in place.
Ö: %c  #!" cask person to touch thumb to each finger on same
hand, starting with index finger then reverse direction. csk person to pat knees with both hands
with pronate and Supinate rapid motion.
4# $#  : person͛s eyes open, ask to use index finger to touch your finger, then his
own nose (try different spot).
4#   : person͛s eyes close and stretch out arms. csk person to touch tip of his
nose with each index finger, alternating hands and increasing speed.
Ö: - 
  : test coordination by asking person in supine position to place heel on
opposite knee and run down the shin from knee to ankle. clso, may use gait test.
cssess sensory system: %
"  (person͛s ability to perceive a pinprick) ask person
sharp or dull depending on sensation felt in the area).
Test for "% #

(p. 676)
 )" 70'  (person͛s ability to feel vibrations of tuning fork over bony
prominences) ask when vibration starts and stops.

  #

 #
 % %: (p. 618 & 621)
-#%#" 
 
$1  : (p. 628)

 %+ +!' + "%

 #
+%$ !' : (p. 668, 669,675,676, 677, 678)

$1&
 %+ %+ +c
+ : (p. 678-684)
'*: abnormal response is dorsiflexion of big toe and fanning of all toes (p. 684)