You are on page 1of 9

ENDOCRINE SYSTEM 3.

Explain the procedures : to alleviate anxiety and


promote cooperation
Preparatory Phase In community/health center: explain
1. Prepare reflex hammer with the other necessary in their cognitive level
materials.
2. Explain the procedure to the client. 4. Perform Physical Assessment in orderly
3. Take the height and weight. sequence/manner: cephalocaudal, IPPA
4. Assist the client in a sitting position. 5. Position client: sitting, supine (30-45), left lateral
(heart comes close to chest wall)
Inspection and Palpation 6. Inspection:
5. Inspect the skin for hyperpigmentation (Addison’s a. NECK AREA: warm, neck vein engorgement
disease); hypopigmentation (seen in patients with Locate: jugular vein
Diabetes Mellitus); yellow cast of skin
(Hypothyroidism); purple striate over abdomen AF: > distented jugular vein: congestive heart
and bruising (Cushing syndrome)
failure (too much blood
6. Palpate the skin for texture, moisture and the
presence of lesions (rough and dry skin in
Hypothyrodism); smooth and flushed skin (in volume in the body)
Hyperthyroidism and lesions)
> pulsation
7. Assess the nails and hair as to texture and
condition, increased pigmentation of nails b. CAROTID ARTERY: use finger pads (index
(Addison’s Disease); dry, thick, brittle nails and and middle finger)
hair (Hyperthyroidism); excessive facial, chest and Location: between trachea,
abdomen hair (Cushing syndrome) jawline, sternocleidomastoid

8. Inspect the symmetry and form of the face, Note: > rate: # of beats (60-
position of the eyes (variations indicate 100bpm)
Acromegaly), protruding eyes (Hyperthyroidism)
> rhythm:
Thyroid Gland
9. Palpate the thyroid gland for size and consistency; regular/irregular
a. Stand behind the client and place the fingers
on either side of the trachea below the thyroid > amptitude: strong and
cartilage. weak pulsation bounding

b. Ask the client to tilt his/her head to the right. AF: use ball of the hand

c. Ask the client to swallow, as he/she swallows Thrills – turbulent blood


displace the left lobe while palpating the right flow of the area
lobe.
Pulsation –
d. Repeat and palpate the left lobe (enlarged
with Grave’s Disease; multiple nodules in 7. Identify various area: use finger pad
Metabolic Disorders; presence of nodules may Palpate: Aortic Area – 2nd right ICS parasternal
indicate a cyst, or benign or malignant tumor)
border
Musculoskeletal Structure
10. Inspect the size and proportion of the client’s Pulmonic Area – 2nd left ICS parasternal
body structure (Short stature indicates Dwarfism; border
large bone indicates Acromegaly)
Erb’s point area – 3rd left ICS parasternal
Hypocalcemic Tetany border

Assess for Trousseau’s Sign Tricuspid Area – 4th-5th left ICS


11. Inflate the pressure cuff above antecubital space parasternal border
to occlude blood supply to the arm (Carpal Spasm
indicates low calcium level) Mitral or Apical Area – 5th left
midclavicular area/near nipples/point of maximal point
Assess for Chvostek’s Sign
12. Tap the finger in front of the client’s ear at the
angle of the jaw (contraction of the lateral facial Epigastric pulse: below xiphoid process;
muscles indicates decreased calcium levels) pulsation ( aortic valve)

Cardiovascular System AF: thrills vibrations

1. Prepare necessary equipment – stethoscope and Note: rate, rhythm of pulses


wristwatch
2. Provide adequate lighting.
8. Identify heart sound: use stethoscope: 11. Liver – right midclavicular area (upward); – below
Auscultate: Intensity , characteristics, rate and umbilicus – liver
rhythm, timing, pitch, regularity 12. Outline boundary of liver dullness
a) Midsternal ine
S1 : Apex of the heart “LUB” ; closure b) Right midclavicular line
of tricuspid and mitral valve 13. Stomach – tympany of gastric bubble – lower
anterior ribs
14. Spleen – left lower anterior chest, changes from
S2 : Base of the heart “DUB” ;
tympany to dullness
closure of aortic and pulmonic valve PALPATION
15. Light palpation – ribs of fingers – light dip
a) Muscular resistance.guarding
b) Abdominal tenderness
S1 low pitch; shorter sound c) Superficial organs
d) Mass
S2 high pitch; longer sound 16. Deep palpation – palmar surface – 4 quadrant
masses and organomegaly – identify
 Location, size, shape, consistency,
tenderness, pulsation, mobility
AF: Timing and pitch 17. Liver
a) Left hand, behind, support right
S3 ventricular gallop; Heart failure, 11th and 12th ribs
MI; heard after S2; “Kentucky” b) Press left hand – liver
c) Check liver  tenderness, contour,
S4 atrial gallop; hypertension, Aortic size and shape
stenosis, MI; heard before S1; “Tennessee” 18. Spleen
a) Right palm on abdominal wall (LUQ), tips of
Friction rub gallops index and middle finger on inferior to rib
margin – left anterior axillary line
Carotid artery b) Left palm on left midaxillary region of thorax,
support thoracic wall (11th and 12th ribs)
AF: use diaphragm: BRUIT (hold 1-2 c) Right fingers push posteriorly and upward
seconds) behind the costal margin (x - spleen)
d) Check for: tenderness, size
GASTROINTESTINAL SYSTEM

1. Prepare the client


a) Explain procedure, “relax”
LOWER GIT (Anus and Rectum)
b) Empty bladder
2. Self: short fingernails, warm hands, stethoscope
INSPECTION AND PALPATION
3. Good lighting, privacy
4. IAPP sequence
Male client
a) Inspect: Sacro-coccygeal and perianal
UPPER GIT
areas – lumps, inflammation, rashes or excoriation
b) Lubricated and gloved index finger – anus
INSPECTION
c) Insert fingertip – anal area – pointing to
5. Abdomen
umbilicus
a) Skin: scars (location and size), striae (size and
d) Lesions, tone of sphincter, tenderness,
color), dilated veins (fine venous network),
nodules, blood & characteristic of stool – finger
rashes & lesions, petechiae, glistening taut
skin
Female Client
b) Umbilicus: contour, shape, location,
a) Lithotomy position
inflammation, discharge/drain
b) Inspect: Sacro-coccygeal and perianal areas –
c) Abdomen: contour (flat, rounded, protuberant,
lumps, inflammation, rashes or excoriation
scaphoid, concave), symmetry, mass, visible
c) Lubricated and gloved index finger – anus
peristalsis, pulsation (epigastrium)
d) Letter (c)
AUSCULTATION
e) Letter (d)
6. Listen – quadrants and regions – right lower
quadrant (ileocecal valve) – clockwise
MUSCULOSKELETAL SYSTEM
7. Characteristic and frequency of bowel sounds
(soft clicks and gurgles) – 1 minute
1. Prepare the equipment needed for physical
8. Bell – vascular sounds; bruits (turbulent blood
examination (tape measure, goniometer – to
flow) – aneurysm or partial obstruction of a vessel
measure joint angles, skin marking pen)
9. Liver and spleen – friction rubs, hepatic tumor and
2. Follow an orderly manner of examination
splenic inflammation
(cephalocaudal manner – IPPA, ROM, muscle
PERCUSSION
testing)
10. Percuss – abdomen quadrants
a) General proportions
TEMPOROMANDIBULAR JOINT
b) Distribution of tympany and
Inspection
dullness
3. Inspect the area anterior to the ear for any Muscle Strength
swelling or redness. 17. Direct the patient to flex, extend, laterally bend
4. Ask the client to open mouth maximally and and rotate spine.
measure the space vertically (normal range is 3-6 18. Repeat above while applying opposing force.
cm or 3 fingers inserted sideways)

Palpation UPPER EXTREMITIES


5. Palpate each side of temporomandibular joint for Inspection
swelling or tenderness (place the tip of your two 19. Inspect and compare both shoulders posteriorly
fingers in front of each ear and ask the client to and anteriorly. Check for the size and contour of
open and close mouth. Drop your fingers into the the joint and compare shoulders for equality of
depressed area over the joint and palpate for any bony landmarks. Check the anterior aspect of the
bulges over the joint). joint capsule and the subacromial bursa for any
6. Palpate the contracted temporalis and masseter swelling.
muscle as you ask the client to clench his/her 20. Inspect for the size and contour of the elbow in
teeth. Compare right and left sides for size, both flexed and extended positions for any
firmness and strength. deformity, redness or swelling.
7. Note for the movement of the temporomandibular 21. Inspect the hands and wrist on the dorsal and
joint (an audible sharp or click occurs in many palmar sides, noting position, contour and shape.
normal people as the mouth opens).
8. Ask the client to partially open mouth, then Palpation
protrude lower jaw and move it side to side, then 22. While standing in front of the client, palpate both
stick out lower jaw. shoulders noting any muscular spasm or atrophy,
swelling, heat or tenderness.
Muscle Strength 23. Palpate the elbow flexed about 70 degrees and as
9. Ask the client to move jaw forward and laterally, relaxed as possible. Palpate the olecranon process,
open mouth against resistance. olecranon bursa, medial and lateral epicondyles of
humerus, using varying pressures (normally
CERVICAL SPINE present tissue and fat pads feel fairly solid). Note
Inspection for any synovial thickening, swelling, nodules or
10. Inspect the alignment of head and neck (spine tenderness.
should be straight and head erect). Note for any 24. Palpate each joint in the wrist and hands,
deformity. metacarpophalangeal joints, interphalangeal joints
and identify the normal depressed areas that
Palpation overlie the joint space. Use gentle but firm
11. Palpate the spinous process and the pressure. Take note of any swelling, bogginess,
sternocleidomastoid, trapezium andparavertebral nodules or tenderness.
muscles from behind the patient. Note for any
muscle sparm or tenderness. Percussion
12. Ask the client to do the following motions: 25. Direct percussion on the location of the median
a. Touch his/her chin to chest nerve at the wrist (Client should not feel anything
(flexion) upon percussion) – Tinnel’s sign. Note for any
b. Lift the chin toward the ceiling limited movements, pain, tenderness of the
(extension) extremities.
c. Touch each ear toward the 26. Cup one hand over shoulder during ROM and take
corresponding shoulder. Do not lift up the note of any crepitation.
shoulder (lateral bending). 27. Ask the client to perform four motions:
d. Turn the chin toward each a. With arms at sides and elbows
shoulder (rotation) extended, move both arms forward and up
in wide vertical arcs. Then move them
Muscle Strength back.
13. Repeat the motions done in examining ROM while b. With arms at sides and elbows
applying opposing force (Normally, a person can extended, raise both arms in wide arcs in
oppose resistance applied) the coronal plane. Touch palms together
above the head.
c. Touch both hands behind the head,
with elbows flexed and rotated posteriorly.
THORACOLUMBAR SPINE 28. Elbow – ask the client to perform the following
Inspection motions:
14. While the patient is in standing position, note for a. Bend and straighten the elbows
gross deformity, muscle atrophy, local swelling, b. Hold the hand midway, then touch
abnormal curvature (lateral deviation). front and back side of hand to the table.
29. Wrist and Hand – Ask the client to do the motions
Palpation
for testing the ROM of hands and wrists.
15. Palpate for tenderness, hardened muscle for
a. Bend the hand up the wrist
spasm.
b. Bend the hand down at the wrist
c. Bend the fingers up and down at
Percussion
the MCP joints
16. Percuss each spinous process with finger or
d. With palm flat on the table, turn
rubber hammer for tenderness.
them outward and in
e. Spread fingers apart; make a fist
f. Touch the thumb to each finger 42. Palpate the joint spaces of ankle and foot noting for
and to the base of the little finger any fullness, swelling or tenderness.
43. Palpate the metatarsophalangeal joints and
interphalangeal joints with your thumbs and
fingers. Note for the temperature, swelling or
Muscle Strength tenderness.
(Upper Extremities) 44. Palpate the spinous processes and the
30. Test the muscle strength by asking the client to paravertebral muscle for tenderness or spasms.
do the following:
a. Shrug the shoulders Note for any limited movements, pain and tenderness
b. Flex forward and up, abduct of the extremities.
against resistance
c. If muscle damage is suspected in Hip
the rotator cuff, abduct the client’s arm Ask the client to perform the following:
and ask the client to lower it slowly 45. Raise each leg with knee extended (hip flexion of
(normally arm lowers slowly) 90 degrees)
(Elbow) 46. Bend each knee up to the chest while keeping the
31. Stabilize the client’s arms with one hand, then other leg straight (hip flexion of 120 degrees. The
have the client flex the elbow against your opposite thigh should remain on the table).
resistance applied just proximal to the wrist. Then 47. Flex knee and hip to 90 degrees (stabilize by
ask the client to extend the elbow against holding the thigh with one hand and the ankle with
resitance. the other hand. Swing the foot outward and inward
(Wrist and Hand) – foot and thigh move in opposite directions).
 Position the client’s forearms supinated (palm up) 48. Swing leg laterally, then medially, with knee
and resting on a table. Stabilize by holding your straight. (Stabilize pelvis to eliminate exaggerated
hand at the client’s mid forearm. lumbar lordosis. The most efficient way is to ask
32. Ask the client to flex the wrist against your the client to bend over the table and to support the
resistance at the palm. trunk on the table. Or the client can lie prone on
33. Ask the client to hold both hands back to back the table).
while flexting the wrist 90 degrees (acute flexion
of the wrist for 60 seconds produces no symptoms Knee
in the normal hands) – Phalen’s test. Ask the client to do the following:
49. Bend each knee (flexion is 130 to 150 degrees)
LOWER EXTREMITIES 50. Extend each knee and check knee ROM during
ambulation.
Inspection
34. Inspect the skin of the lower extremities (skin
normally looks smooth, with even coloring and Ankle and Foot
free of lesions). Ask the client to perform the following motions:
35. Inspect for leg alignment, shape of the knees and 51. Point toes toward the floor (plantar flexion of 45
contour, note for swelling or fullness. degrees)
36. Inspect the quadriceps muscle in the anterior 52. Point toes toward the client’s nose (dorsiflexion of
thigh for any atrophy. 20 degrees)
37. Inspect the ankle and foot when client is in a 53. Turn soles of feet out, then inward (stabilize the
sitting position, non-weightbearing position, as ankle with one hand, hold heel with the other to
well as standing and walking. Compare both feet, test the subtalar joint) – (eversion of 20 degrees
noting position of feet and toes, take note of the and inversion of 30 degrees)
contour of joints, and skin characteristics. Note for 54. Flex and straighten toes
locations of any calluses or bursal reactions.
38. Inspection of the hip joint together the spine as Spine
the client stands. Note for the symmetric levels of Ask the client to:
iliac crests, gluteal folds, size of the buttocks. 55. Bend forward and touch the toes (look for flexion of
75 to 90 degrees and smoothness and symmetry
Palpation for movement. The concave lumbar curve should
39. Position the client in a supine position. Palpate the disappear with this motion and the back should
hip joints for any tenderness or swelling (joints have a single convex C-shaped curve).
should feel stable and symmetric, with no
tenderness or crepitance). Stabilize the pelvis of the client with your hands. Then ask
40. Palpation of the knee is done in a supine position. the client to:
Start high on the anterior thigh (about 10 cm 56. Bend sideways (lateral bending of 35 degrees)
above the patella). Palpate wit thumb and fingers 57. Bend backward (hyperextension of 30 degrees)
in grasping fashion. Proceed down toward the 58. Twist shoulders to one side, then the other
knee, exploring the regions of the suprapatellar (rotation of 30 degrees bilaterally)
pouch. (Take note of the consistency of the
tissues, the muscles, and soft tissues, and Muscle Strength
smoothness of the joints. Take note also for any Lower Extremities
tenderness, roughness of the muscles, 59. Ask the client to maintain knee flexion, while you
temperature, thickening or nodularity). oppose by trying to pull the leg forward.
41. Palpate the tibiofemoral joints. Take note of the
texture of the joint margins, tenderness, check for
crepitus. NERVOUS SYSTEM
Ask the patient to write his name on a page of blank paper.
A. Techniques of Neurological Examination Then ask him to copy some figures drawnby the examiner
Organize your thinking into six (6) major categories: on the page including a circle, cross, square and diamond
1. Cerebral function and a row of dots.
2. Cranial nerves
3. Motor system 1.6.6. Testing Specific Functions which includes:
4. Sensory system
5. Reflexes 1.6.6.1. Cortical Sensory Interpretation
6. Cerebellar Refers to the ability to recognize objects through different
senses
B. Physical Examination
1.6.6.1.1. Visual perception
1. Test for Cerebellar Function “Find it” e.g. “We are going to play a game to see how
1.1.Over-all appearance, behavior, psychomotor good you are in finding things. I’m going to put these 6
activity, attitude towards the examiner things out of my desk and when I name one you have to
1.2.Level of consciousness hand me the object.”
1.2.1. Level I – Alert
1.2.2. Level II – Lethargy, somnolence, 1.6.6.1.2. Stereognosis
drowsy Ability to recognize an object from its feel and can also be
1.2.3. Level III – Obtundation assessed through games.
1.2.4. Level IV – Stupor Ask the patient to close both eyes and put one of the 3
1.2.5. Level V - Coma things in the patient’s hands and take it back, upon
1.3.Mood and affect opening the eyes ask the patient what object it is.
1.4.Speech (quantity, quality, rate of production)
1.5.Thought process and perception 1.6.6.1.3. Graphestesia
1.5.1. Note coherency and the
 Ability to identify shapes by outlines drawn on the
relevance of thought processes
skin (palm of hand)
1.5.2. Note the thought content and inquire
about compulsions, obsessions, ruminations,
1.6.6.1.4. Kinestesia
doubting and indecision, phobias and free-floating
anxieties  Ability to perceive direction of movement.
1.5.3. Note for perceptual disturbances such as
hallucinations, illusions, delusions 1.6.6.1.5. Texture discrimination
1.6. Cognitive Functions  Ability to perceive “roughness” or “smoothness”
1.6.1. Note orientation to time, place, person
1.6.2. Note the attention and concentration that 1.6.6.1.6. Auditory Agnosia
includes attention span  Is tested by having the client close his/her eyes
1.6.3. Memory and identify sounds such as sound of a bell or clap

1.6.3.1. Brief Retention 1.6.6.2. Cortical Motor Integration


Test of an idea, sound, or object  Can be tested by having the client perform a semi-
e.g. Client will listen and repeat 4,2,1 skilled task such as folding a piece of paper and
sealing it in an envelope.
1.6.3.2. Recent Memory
Show an object and tell client that you will ask him to tell
you afterwards, after 5 minutes.
1.6.6.3. Language
Later ask him to recall what was the object.
 Both spoken or written is a specific function of
1.6.3.3. Remote Memory certain areas in the cerebral cortex.
Ask the patient what he had for dinner.
2. TEST FOR CRANIAL NERVES
1.6.4. Vocabulary
2.1.First Cranial Nerve (Olfactory)
Ask the patient to give you the meaning of the following
 Be sure that both nasal passages
words or to use the words in a sentence.
are patent.
1.6.5. Abstract Reasoning  Ask the client to close his eyes.
Tested in 2 ways: by noting the relevance to the answers,  Test each nostril by occluding the
and by their degree of concreteness or abstractness opposite side. Ask the patient to
identify odors. Use coffee, soap or
vanilla.
2.2.Second Cranial Nerve (Optic)
1.6.5.1. Similarities 2.2.1. Test for visual acuity
Ask the patient to tell you how the following are alike (e.g.  Ask the patient to read any
an orange and an apple) available print by using each eye
1.6.5.2. Judgement separately, covering the other with
an opaque card.
Noting the patient’s judgement with respect to his
2.2.2. Test for papillary reactions
personal life (e.g. “What should you do if you use a
librarybook?”)  Inspect the size and shape
1.6.5.3. Sensory Perception&Coordination of the pupils, and compare one
side with the other. Test the
reaction to light using a penlight  Ask the patient to shrug both
(Test for CN II and III) shoulders upward against your hands.
 Note the strength and contraction
2.3.Third, Fourth and Sixth Cranial Nerve of the trapezius muscle.
(Occulomotor, Trochlear and Abducens)  Ask the patient to turn his/her head
 Test the extraocular movements to each side against your hand.
in the six cardinal directions of gaze, Observe the contraction of the opposite
and look for loss of conjugate sternocleidomastoid and note the force
movements in any of the six of the movement against your hand.
directions.
 Identify ptosis and nystagmus
2.9.Twelfth Cranial Nerve (Hypoglossal)
2.4.Fifth Cranial Nerve (Trigeminal)  Inspect the client’s tongue as it lies
2.4.1. Motor in the floor of the mouth.
 While palpating the  Note for any fasciculations. then,
temporal and masseter muscle, with the client’s tongue protruded, look
ask the client to clench his/her for symmetry, atrophy, or deviation
teeth. Note the strength of the from the midline.
muscle contraction, jerky
movement and mastification. 3. MOTOR SYSTEM
2.4.2. Sensory
 With the client’s eyes 3.1.Assessment of Muscle Tone
closed, test the forehead, cheeks  Persuade the client to relax. Take
and jaw on each side for pain one hand with yours and while
sensation. supporting his/her elbow, flex and
 Use a safety pin, extend the client’s fingers, wrist and
occasionally alternating the blunt elbow and put his/her shoulders
and pointed end as a stimulus. through a moderate range of motion.
Ask the client to report whether it  On each side, note his muscle tone
is sharp or dull to compare sides.
2.4.3. Test for the corneal reflex 3.2.Testing Muscle Strength
 Ask the client to look up,  Test muscle power against
approaching from side and resistance, against gravity only or with
avoiding the eyelashes, touch the effects of gravity removed.
cornea lightly with a wisp of  On each side, try to depress his/her
cotton. outstretched arms against resistance,
 Note tearing and blinking. note his/her strength and watch the
scapula on the side for winging or
2.5.Seventh Cranial Nerve (Facial) displacement suggesting a weak
 Inspect the face, both at rest and serratus anterior muscle.
during conversation, note any  Test for flexion and extension of
asymmetry, and or other abnormal the elbow by having client pull and
movements; ask the patient to: push against your and.
a. Raise his/her eyebrows  Test dorsiflexion at the wrist by
b. Frown asking the client to make a fist and
c. Close eyes tightly so that resist your pulling it down.
you cannot open them  Test for the grip by asking the
d. Show his/her teeth client to squeeze two of your fingers as
e. Smile hard as possible and not let them go.
f. Puff out his/her cheeks  Ask the client to spread his/her
fingers, check abduction by trying to
2.6.Eight Cranial Nerve (Acoustic) force them together.
 Assess hearing by whisper test;  Ask the patient to touch the tip of
testing lateralization and comparing the little finger with a thumb against
air and bone conduction. your resistance.
 Test abduction of the hip by
2.7.Ninth and Tenth Cranial Nerve
placing your hands firmly on the bed
(Glossopharyngeal and Vagus Nerve)
outside the patient’s knees. Ask the
 Ask the client to say “ah” or yawn; patient to spread both legs against our
observe the upward movement of the hands.
soft palate and uvula and the inward
 Test flexion and extension of the
“curtain” movement of the posterior
knee. Flexed with foot resting in the
parynx; identify any asymmetry
bed. Ask the client to keep his/her foot
 Stimulate the back of the throat down and straighten his/her legs
lightly on each side in turn and note against your hands.
the gag reflex
 Test for plantar flexion and
dorsiflexion at the ankle by asking the
2.8.Eleventh Cranial Nerve (Spinal Accessory
client to push down and pull up against
Nerve)
your hands.
4. SENSORY SYSTEM stretched and strike the tendon briskly,
producing a sudden additional stretch.
4.1.When testing sensation 5.1.2. Hold the reflex hammer between
4.1.1. Note the client’s ability to perceive thumb and finger so that it swings
the stimulus. freely in an arc, yet controlled in its
4.1.2. Compare the symmetrical areas on direction. If the client’s reflexes are
the two sides of the body. symmetrically diminished or absent,
4.1.3. Compare distal with the proximal use reinforcement.
areas of the extremities when testing
pain, temperature and touch. Initiate 5.2.Test for Reflex status
testing of vibration and position sense 5.2.1. Deep Reflexes
distally.  The deep reflexes are
4.1.4. Scatter the stimuli so that you cover elicited by tapping briskly on a
most of the dermatomes and major tendon or a bony prominence,
peripheral nerves. evoking the following reflexes:
4.1.5. When you detect an area of sensory a. Biceps
loss or hypersensitivity, map out its b. Brachioradialis
boundaries in detail. c. Triceps
d. Patellar
e. Achilles
4.2.Ask the client to close his/her eyes, test 5.2.2. Superficial Reflexes
sensation of the arms, trunk and legs using  These are tested by
the following stimuli: stroking the skin with an object
4.2.1. Pain – use a safety pain, occasionally that is moderately sharp but not
substituting the blunt end for the sharp enough to break the skin.
point. Ask the client to report whether a. Upper abdominal –
it is sharp or dull. umbilicus moves upward
4.2.2. Temperature – use 2 test tubes filled and towards the area being
with hot and cold water. Touch the stroked.
skin, and ask the client to identify b. Lower abdominal –
“hot” or “cold”. umbilicus moves down
c. Cremasteric –
4.2.3. Light Touch – use a fine wisp of
scrotum elevates
cotton. Ask the client to respond
d. Plantar – flexion of
whether you touch his/her skin.
toes
4.2.4. Vibration – Place a tuning fork firmly e. Gluteal- skin tenses
over a distal interphalangeal joint of at gluteal area
the big toe. Ask what the client feels. 5.2.3. Babinski – Stroke the lateral aspect of
4.2.5. Position – Grasp one of the client’s the sole from the heel to the ball of the
fingers, holding its sides between your foot, curving medially across the ball.
thumb and index finger, then move it Dorsiflexion of the big toe and fanning
up or down. of the other toes means a positive
Babinski reflex.
4.2.6. Discriminative Sensations
4.2.6.1. Number Identification – 6. CEREBELLAR FUNCTION
With a blunt end of a pen or
pencil, draw a large number in the 6.1.Gait
client’s palm. Ask the client to  Ask the client to walk across the
identify what number it is. room, preferably down the hall, turn
4.2.6.2. Two-point discrimination – and come back. Observe the posture,
Using the sides of 2 pins, touch balance, the swimming of the arms and
the skin simultaneously. Alternate movements of the legs.
the stimulus irregularly with one 6.2.Romberg’s Test
point touch. Find the minimal  Ask the client to stand with his/her
distance which the patient can feet together. Note his ability to
discriminate one from two points. maintain an upright posture, first with
4.2.6.3. Point Localization – Touch his eyes open, then with his eyes
a point on the clients’ skin. Ask closed.
him/her to open his/her eyes and
point to the place touched. 6.3.Pronator Drift
 Ask the client to close his/her eyes
4.2.6.4. Extinction –
and for 20-30 seconds, hold his/her
Simultaneously stimulate
arms straight in front of him/her. With
corresponding areas on both sides
palms up, watch how well he/she
of the body.
maintains this position.
6.4.Assessing Coordination
5. REFLEXES
6.4.1. Coordination in the arms may be tested
6.4.1.1. Rapid Rhythmic Alternating
5.1.To elicit a deep tendon reflex
Movement – Test each hand
5.1.1. Persuade the client to relax, position
separately, ask the client to:
the limbs so that the muscle is mildly
a. Pat his/her hand as fast as 2. Help the client in a supine position.
he/she can with his/her hands 3. Place the bell of the stethoscope lightly in the
b. Turn his/her hand over and areas of the renal arteries, located in the left and
back as rapidly as he/she can right upper abdominal quadrants (systolic bruits
c. Touch each of his fingers with like whooshing sounds indicate renal artery
his/her thumb in rapid stenosis)
sequence
d. Note for any awkwardness of PERCUSSION
the movement
6.4.1.2. Point to Point Testing For Indirect Percussion
 Ask the client to touch 1. Assist the client into a sitting position and stand
your index finger then his/her behind the client.
nose alternately several 2. Place the palm of the non-dominant hand over the
times. Note any awkwardness costovertebral angle.
or tremor then repeat the 3. Strike this area with ulnar surface of your dominant
maneuver with the client’s hand, curled into fist. Repeat the technique on the
eyes closed. other kidney.
6.4.2. Assessing the Coordination in the legs
6.4.2.1. Rapid Rhythmic Alternating For Direct Percussion
Movement 4. Strike the area over the Costovertebral angle with
 Ask the client to tap your the ulnar surface of your hand, curled into a fist
hand rapidly or quickly as (tenderness may indicate glumerulonephritis or
possible with the ball of each pyelonephritis).
foot in turn, note any 5. Repeat the technique on the other kidney.
slowness or awkwardness.
6.4.2.2. Point to Point Testing Pointers to take note in performing percussion of the
o Ask the client to place his/her heel on the kidneys
opposite knee, then run down his/her shin a. Perform percussion with enough force so that the
client feels a gentle thud.
to the foot. Note any tremor or
b. Percussion is done at the end of the assessment.
awkwardness (e.g. Ataxia).
URINARY BLADDER
1. Palpate the bladder for distentin.
2. Gently palpate over the symphysis pubis and
URINARY SYSTEM abdomen (distended bladder may be palpated at
any point from symphysis pubis to the umbilicus
1. Prepare the equipment like specimen cup, and is felt as a firm, rounded organ)
disposable gloves. 3. Percuss the bladder for tone and position.
2. Provide gown and maintain privacy when 4. Help the client assume a supine position (Dull
necessary. percussion tone over the bladder of a client who
3. Collect clean catch urine specimen; assess for had just urinated may indicate urinary retention)
color, odor and clarity before sending to the
laboratory.
IMMUNE SYSTEM
INSPECTION
1. Inspect the skin and the mucous - Review biographic data of the client
membrane (note color, turgor)
2. Inspect the abdomen. Help client assume
a. Age
a supine position (note for the size, symmetry
swelling, prominent veins, distention, glistening or
b. Sex
skin tightness)
3. Inspect the urinary meatus. (Not a part of
a routine but an important component with c. C. Race
problems in the urinary system)
d. Ethnic background
Male:
 Help the client assume a sitting or standing e. Family medical history
position.
 Compress the tip of the glans penis with gloved - Assess general appearance – does the age coincide
hand to open the urinary meatus. with the appearance?

Female: - Note fatigue or weaknesses


 Assist the client assume a dorsal recumbent - Note the height, weight and body type of the patient
position.
 Spread the labia with gloved hand to expose the o Apparent weight loss or body wasting
urinary meatus. - Observe the client’s ease for movement – note for

PHYSICAL ASSESSMENT OF THE KIDNEYS evidence of stiffness or difficulty in moving


- Check vital signs – Temp, BP, RR, PR
AUSCULTATION
1. Auscultate the renal arteries. - Assess skin color, temperature and moisture
o Pallor – indicates bone marrow suppression o Ratio of anteposterior and
o Pale – decreased blood transverse diameter is 1:1
- Inspect skin for rashes, lesions, petechieae, numerous 9. Palpate for bulges, tenderness, painful areas and
bruises, purple or blue patches (may indicate caposis abnormal movements
sarcoma), infected wounds – inflamed or unhealed 10. Respiratory Expansion
- Note location and distribution of rashes and lesions - Result: full symmetric chest expansion =
- Inspect the color and condition of the mucus divergence
membrane of nose and mouth (using penlight) - Unilateral delay / lag = not symmetrical
- Inspect and palpate cervical lymph nodes 11. Vocal or Tactile Fremitus  “99”
- Assess musculoskeletal system by inspecting and - For lateral thorax – use ulnar side of hand
palpating joints for redness, swelling – rheumatitis 12. Percuss thorax
- Check range of motion of joints including that of the - To determine whether lung tissue is filled with air,
spine liquid or solid material
- Percuss ICS at about 5cm / 2in intervals

RESPIRATORY SYSTEM - If posterior, ask patient to fold arms across the


chest
1. The usual…
- Area of Resonance – over the lungs
- Identify the patient and explain the
- Area of Dullness – over the organs
procedure
o Heart is in the 3rd– 5th L ICS
- Prep environment, provide privacy, hand
hygiene
13. Auscultate Chest  diaphragm
- Prepare equipment – stethoscope! 14. Normal Breath Sounds:

2. Inspect the shape and configuration of the chest - Vesicular – heard over lungs; I>E

wall - Bronchial – heard over trachea; I<E

3. Note the breathing pattern and position - Bronchovesicular – heard over the scapulae and
4. Note for any manifestations of respiratory 1st-2nd ICS; I=E
distress: 15. Adventitious Breath Sounds
- Grasping - Crackles
- Grunting - Ronchi
- Central cyanosis - Friction Rub
- Flared nostrils - Wheezes
- Open mouth
- Dyspnea
5. Note the rate, rhythm, depth and effort of
breathing
- Rate: 12-20 breaths / minute
6. Inspect the use of accessory muscles
7. There should be no retraction of supraclavicular
areas during inspiration (intercostals retraction)
8. Note the Shape of chest (deformities) :
- Pigeon Chest
o Narrow transverse diameter
o Protruding sternum
- Funnel Chest
o Narrow anteposterior diameter
o Depressed sternum
- Barrel Chest