【资源】体格检查实习指导（英文版）

智***苦

英文版的，大家看看吧。

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T**NING  MANUAL  

FOR

PHYSICAL  EXAMINATION


Department of Diagnostics
1st Affiliatted Clinical Hospital
Guangxi Medical University

2004-8




CONTENT

Outline for medical interview-----------------------------------------------------------------------------------3
Checklist of inquisition Content--------------------------------------------------------------------------------5
Written record  (for inquisition)-------------------------------------------------------------------------------7
Case record--------------------------------------------------------------------------------------------------------8
Training manual for the eye examination---------------------------------------------------------------------14
Checlist for eye examination-----------------------------------------------------------------------------------18
Training manual for oto-naso-laryngeal examination-------------------------------------------------------19
Checklist for oto-naso-laryngeal examination------------------------------------------------------------- --23
Training manual for the chest examination-------------------------------------------------------------- ----24
Checklist for the chest examination--------------------------------------------------------------------- -----29
Training manual for the cardiovascular examination-------------------------------------------------- ----30
Checklist for the cardiovascular examination----------------------------------------------------------- ----37
Training manual for the abdominal examination-------------------------------------------------------- ---39
Checklist for the abdominal examination-------------------------------------------------------------- -----43
Training manual for the spine examination----------------------------------------------------------- -----44
Checklist for the spine examination---------------------------------------------------------------------- ---46
Training manual for the nervous reflex examination---------------------------------------------------- - 47
Checklist for the nervous reflex examination------------------------------------------------------------ - 49
Training manual for the axillary examination----------------------------------------------------------- -- 50
Complete physical examination training manual-------------------------------------------------------- - 51






Outline for medical interview
(问诊内容大纲)
A. Introduction
      Introduce yourself
      Define role and position
      Address patient as “Mr.”, “Miss” or “Mrs.” Or other suitable name
      Ask patient’s full name,age,race,address(or place of work),etc.
      Converse briefly with patient to make patient comfortable and then start the interview
B. Chief Complaint
      Briefly state symptoms or signs and duration in the patient’s own words.
Use open-ended question to begin interview: e. g., “What brings you here today?”
C. History of the Present Illness
Detailed documentation of patient’s current problem
      Onset (sudden or insidious) and duration “how long have you been ill?”
      Features of chief symptom, including location, radiation, quality, frequency, duration, intensity, alleviating and aggravating factors
      Causes of illness and inducements/precipitating factors
      Progression (chronology of the illness, including the development of main symptom and appearance of other symptoms)
      Associated symptoms and significant negative symptoms
      Previous studies and treatment(medication, dosage, effects, etc.)
      General condition after illness (mental state, appetite, body weight, sleeping, urine, bowel movement, etc.)
      Summarize, clarify and verify
      Transitional statement into past medical history
D. Past Medical History
      Past health status
      Past illness (mainly indicate infections, contagious diseases, and any illnesses which may be relevant to present illness)
      Operations, injuries, accidents and vaccinations (document)
      Allergies (medications, foods, environmental agents)
      Summarize, clarify and verify
      Transitional statement into review of systems
E. Review of Systems
(Student is permitted to use a copy of the review of systems for this section)
If two general items for a system are positive, the interviewer should inquire about the system in detail,If any item has been previously mentioned in the history of the present illness or the past medical history, repetition should be avoided or explained to the patient. Record significant positives and negatives.
F. Personal History
      Place of birth, current residence and duration at current residence, educational background, economic status, living conditions
      Professional and working conditions: includes types of work, work environment, exposure to chemical, radioactive materials or industrial poison and exposure time (if suspected as causative)
      Habits and hobbies: such as sleeping, eating, recreation,tea or coffee drinking, smoking and alcohol consumption (amount, duration), other drugs(including sedatives or **s) or ingestion of unusual substances (dirt, hair, etc.)
      Marital history
Married or unmarried, marriage age
Sexual life, relations of couple, etc.
      Menstrual and reproductive history (for female patients)
Age of onset, interval between periods, duration, amount and character of flow, concomitant symptoms, date of last menstruation, age of menopause Record menstrual history as follows:
                                                  date of last   
age of onset                                                menstruation   
or age of
menopause
Age and date of pregnancy(ies)and childbirth(s). Date of artificial or natural abortions, stillbirths, operative delivery, puerperal fever. Method of family planning (safety period, contraceptive pills, intrauterine device, Dutch cap, condom)
      Summarize, clarify and verify
      Transitional statement to family history
G. Family History
      Ages and health status of parents---document
      Age and health status of spouse---document
      Ages and health status of siblings---document
      Ages and health status of children---document
      Family history of illness similar to patient’s
      Catch-all questions
1)family incidence of infectious diseases(tuberculosis, hepatitis), allergy, cancer, diabetes, etc.
2)any other(genetic) illness that runs in the family
3)if any immediate family members are dead, ask cause of death, age at death
      Summarize, clarify and verify
H. Closure
      Discuss health promotion (e.g., decrease excessive habits, dental care, bicycle and automobile safety)
      Close the interview—allow the patient to discuss any additional questions concerns, perspective on the illness, or expectations for the visit, etc.
      State what the physician will do next, what the patient will do next and the time frame in which these will occur (further diagnostic and therapeutic plans)









Checklist of inquisition Content
（问诊内容训练）

Introduction
      1. Introduce yourself
      2. Define your role and position
      3. Ask the patient’s name
      4. Ask the patient’s age and address
Chief Complaints and HPI(history of present illness)
      5. Upper abdominal pain
      6. Onset and duration-4 years and increasing over the past three months
      7. Features: burning like, dullness and fullness
      8. Location:upper part of abdomen
      9. Radiation:to back
      10. Frequency:half a month each time-4-5 times per year
      11. Rhythmicity:after meals or midnight
      12. Alleviating factors:rest, diet or hot drinks.
      13. Aggravating factors:tiredness, irregular meals
      14. Progression of the illness:has become more serious over the previous three months.
      15. Associated symptoms:black stools, 1 year ago and 3 months ago, vomiting in past three months
      16. Previous diagnostic studies and medications:presumptive diagnosis of upper GI bleeding, antacid and bismuth were used
      17. General condition after illness:loss of weight and appetite
Past History
      18. General condition:good
      19. Acute hepatitis with jaundice 22 years ago, recovered one month later
      20. Acute appendicitis 4 years ago, operated on in 3rd municipal Hospital
      21. Allergic to sulfa, fixed drug rash on left hand
      22. Vaccinated with type B-hepatitis 6 years ago
Review of Systems
      23. Wears glasses for nearsightedness and astigmatism for past 10 years
      24. Diarrhea occasionally because of irregular meals for 20 years
      25. hemorrhoids 8 years before and treated with traditional Chinese method
Personal History
      26. Born and studied in Hongzhou
      27. Cultured background. Postgradute degree 12 years ago.
      28. Occupation: Scientic researcher in Provincial Science Institute.
      29. No toxic exposure
      30. Smokes 10 cigarettes per day for 10 years
      31. Stopped drinking alcohol three years ago
      32. Married for 10 years. Wife is 36 years old and works at the same Institute.
      33. Normal family life
      34. Good living conditions
Family History
      35. Father –66 years old, hypotensive, treated at ZMU
      36. Mother –60 years old CHD-treated at ZMU
      37. Wife –36 years old, occasional insomnia, otherwise normal.
      38. Daughter –9 years old in good health.
Other problems and concerns
      39. That the illness may influence his work and his future.
      40. Does he need gastroscopy and surgery?


Written Record
(问诊纪录)

The patient is a 38 year old male researcher coming to the clinic from Hangzhou. He complains about having abdominal pain for four years. He says that it has been getting worse over the past three months.
For four years, the patient has noticed a dull, burning pain in the upper abdominal region. It is usually caused by fatigue, irregular mealtimes, and occurs mostly after a meal or at midnight. The patient can relieve the pain by eating or drinking hot liquids. The pain radiates to the patient’s back. There is no regurgitation or belching and the pain usually lasts about 15 days each time and occurs four to five times per year. The pain also seems to decrease if he rests or takes regular, mild meals.
Two years ago, the patient visited the outpatient clinic and antacid tablets were prescribed, 3 tablets, 6-7 times per day. After about one month, the patient felt well enough to discontinue the medication．
One year ago，the pain recurred and was accompanied by black stools once a day for one  week． The stool was about 250g each time． He was admitted to the 1st Municipal Hospital．A diagnosis of upper GI bleeding was made． The therapy with antacid complex and infusion fluid was initiated．Afterwards he followed the physician’s orders to take the medication for another two months with good response．
Three months ago，he experienced a recurrence of the upper abdominal pain associated with fullness．He attributed this to a heavy load of research work．He felt he stayed up too late and ate irregular meals．He also experienced nausea and black stools for three days and vomited twice．The vomit contained residual food．He was admitted to the 1st Municipal Hospital again and recovered after one week．
   Since then，he has continued to have intermittent vomiting，which occurs mostly in the  evenings one to two times a week．It contains a large amount of food and has an offending  odor．He has used bismuth powder four times a day without any effect on the symptoms． He visits us because he is worried about a possible malignancy or the need for surgery．
    He has lost approximately 5 kilos over the past four years and feels a little tired． He can only eat half the amount of food he used to consume．He is able to work．
    Prior to this problem the patient was in good health． Twenty-two years ago he suffered from an acute hepatitis with jaundice and was admitted to the Hangzhou Infectious Hospital．He recovered in one month and his liver function was checked for three years with normal results．Four years ago，he had acute appendicitis and underwent surgery． He is allergic to sulfa which is manifested by a fixed rash and itching on his left hand． He was vaccinated with type B hepatitis six years ago． The Patient wears glasses because of near-sightedness with astigmatism for 20 years．He has occasional diarrhea because of reactions to food． A diagnosis of hemorrhoids was made eight years ago and was treated with traditional Chinese binding methods． The patient fully recovered．
    The patient was born and studied in Hangzhou．After he graduated from Zhejiang University with a master’s degree 12 years ago，he came to work in the biology department of the Provincial Science Institute． There is no toxicity in the lab but the work is stressful． He has smoked 10 cigarettes a day for the past 10 years． The patient used to drink a little alcohol but stopped three years ago． He has been married for 10 years and has a 9-year old daughter who is in good health． His father suffers from hypotension and his mother has CHD and was treated at ZMU．Otherwise he is in good health．

   


Case Record

Biographical data:

Name　LUO LEN SHENG  Age: 30  Sex: M  Marital status: Married  Native place: China     Race: Han
Occupation : Mechanic    Date of admission  2003/11/16
Informant:  none

Chief complaint: recurrent abdominal pain and melena for more than one year

History of present illness:
   
Mr. luo has been suffered from abdominal pain and recurrent melena since 2002,  began on May 2,2002 he had upper abdominal pain and melena first time, with no any inducement factors, obscure upper abdominal pain happened with no radiation, no belching ,no vomiting, no fever and tremor. Pain was hungry pain and can be relieved by antacid agent or by meal. Melena occurred three times a day, about 250g each time, continuing for 5 days with little fatigue, no hematomeses. He went to the local county hospital on the third day of melena, where he received gastroscopy that showed duodenal bulb ulcers with bleeding. Then he was administered Omeprazole (PPI) intravenously for 6 days, 40mg each time, twice a day (Bid). On the second day of treatment, the melena disappeared . On Nov. 15, 2003,  without any inducement he had melena again 3 times a day and 250-500gm. Every time accompanied with fatigue and timed but no dizziness and syncope. This time he went to the second People’s hospital. He took PPI but didn’t receive gastroscopy. After receiving PPI., melena disappear. But the OB(occult blood) test was still positive. The next day he was shifted to 1st affiliated hospital of Guangxi Medical University and received further examination and treatment. The general condition is good  and work is not affected in any way since he had such a disease.


Past history:
  Previous health status:  Well     ordinary      bad     infectious disease
  Immunizations    allergies:   N   Y     clinical manifestation:    allergen
  Trauma history:                      surgery history:

Review of systems: (Tick if positive, cross out if negative. If positive, you should write down your disease history and brief course of diagnose and therapy)

Respiratory system:
sore throat   chronic cough   sputum   hemoptysis   wheezing   dyspnea   chest pain

Cardiovascular system:
palpitation    dyspnea on exertion     hemoptysis     syncope    edema of lower limbs   precordial pain      hypertention

Digestive system:
anorexia    sour regurgitation    belching    nausea    vomit    abdominal distention     abdominal pain    constipation      diarrhea      hematemesis      melena
hematochezia     jaundice

Urinary system:
lumbago    frequent micturition    urgent micturition    urodynia   dysuria    hematuria    nocturia    polyuria    oliguria     facial edema

Hemopoietic system:
fatigue    dizziness    blurred vision    gingival bleeding    subcutaneous hemorrhage     ostealgia     epistaxis


Metabolic and endocrine system:
excessive appetite    anorexia    sweets    cold intolerance    olydipsia    polyuria     tremor hands     changeof character  obvious obesity     emaciation     hairiness     hair losing    pigmentation     change of sexual function     amenorrhea

Musculoskeleton system:
floating arthralgia  rthralgia  swelling of joints  deformities  myalgia  atrophy of muscle

Nervous system:
dizziness  headache  vertigo  syncope   degeneration of memory  visual disturbance
insomnia    disturbance of consciousness    tremorspasm    paralysis   paresthesia




Personal history:
birthplace      occupation      sexual history:    N     Y      about     yrs
average   pieces/d     ceased for    yrs   alcohol intake: N  occasional  frequent
about    yrs      average    ml/d     others:

Maritial history:
marrying age      companion’s state of health

Menstruation and Childbering history:
            
menarche age ----------------------- date of last period (age O menopause)
            
amount of flow: little  normal  large    menstrual pain:  N  Y    cycle: regular irregular     pregnancy:  times   natural labor  times   abortions  times   premature delivery  times
stillbiriths  times   difficult labor and its condition:

Family history: (pay attention to the congenital diseases and communicable diseases related to the patient)
father: still alive   illness   died     cause of death     mother: still alive   illness
died     cause of death     siblings:             others:
Physical examination

Vital signs:  T 36.5 ℃         P  70 bpm         R 20/min      Bp 120 /60 mmHg

General Appearance:
development: ortho-sthenic type   asthenic type   sthenic type   nutrition: well  fairly
poor  cachexia  facial features: normal  acute  chronic  others  expressions: natural  painful
anxious  dreadful  indifferent  position: active  semi-recumbent  others gait: normal  abnormal
consciousness:aware  somnolence  confusion  stupor  coma  delirium  cooperation: well  badly


Skin, mucous membrane: color: normal  red  pale  cyanosis  yellow  pigmentation
rash: N  Y (type and distribution)  subcutaneous hemorrhage: N  Y (type and distribution)
hair: normal  scattering  losing (position)  moisture and temperature: normal  cold  dry  wet
elasticity: normal  reduced  edema: N  Y (position and degree)  hepatic palm: N  Y
spider angioma: N  Y (position    numbers)    others:

Lymph nodes:
superficial lymph nodes: non-swelling
swelling (position and characteristics)


Head:
cranium:size:normal  large  small  deformity:N  Y(oxycephaly  squared skull  deforming skull)
others: tenderness   mass   sunk (position    )
eyes: eyelid: normal  edema  ptosis  trichiasis   conjunctive: normal  hyperemia  edema
hemorrhage  eyeball: normal  exophthalmos  depression  tremor
motion dysfunction (left   right)
sclera: normal  yellow    cornea: normal  abnormal (left     right     )
pupils: equal roundness same size   unequal  left     cm,  right     cm
reaction to light: normal  delay (left   right   )  disappear (left     right     )     others:
ears: auricle: normal  deformity  fistula  others (left      right      )
excretions of external c**:  N   Y (left     right      feature           )
tenderness of mastoid: N   Y (left    right    )   audition dysfunction: N    (left   right     )
nose: shape: normal  abnormal(      )   other abnormalities: N  Y      nasal ale flap
obstruction   excretions   nasal sinus tenderness: N   Y (position       )
mouth: lips: red  cyanosis  pale  herpes  fissure  mucous: normal  abnormal (pale   bleeding)
opening of parotid gland duct: normal  abnormal (swelling   pyogenic excretions)
tongue: normal  abnormal (coverings  tremor  leaning to left or right )
gums: normal  swelling  pus overflow  hemorrhage  pigments
teeth: regular  edentulous  carious teeth  false tooth
tonsils:               pharynx:               voice: normal   hoarse

Neck: resistance: N  Y    carotid artery pulsation: normal  increased  decreased (left   right)
jugular vein: normal  distention  high distention    trachea: middle  deviation to (left   right)
hepatojugular reflux: (-)  (+)    thyroid: normal  swelling  degree    symmetry
dominance in one side:
spreading  nodular: soft  hard     others: N   Y (tenderness   tremor   bruits   )

Chest: topography: normal  barrel chest  flat chest  pigeon chest  funnel chest
bulging or retraction (left   right)   bulging in the precordial region   tenderness of sternum
breast: normal symmetrical   abnormal: left   right (gynecomastia   mass   tenderness)
excretions of nipples       )

Lung:
inspection: movement of respiration: normal  abnormal: left   right (increased    decreased)
intercostals space: normal   wide   narrow (position                )
palpation: vocal fremitus: normal  abnormal: left   right   (increased   decreased)
pleural friction rubs: N   Y (position                      )
percussion: resonance   abnormal: dullness   flatness   hyperresonance   tympany
lower borders: scapular line: right    intercostals space     left     intercostals space
range of mobility: right     cm,  left     cm
auscultation: breath:  regular    irregular
breath sound:  normal   abnormal (feature,  position                )
rales:  N   Y:  ronchi: sonorous  sibilant  moist rales: coarse   medium   fine rales   crepitus
vocal conduction: normal    abnormal:  reduced     increased
pleural friction rubs: N   Y (position                              )

Heart:
inspection: bulging in precordial region: N  Y  apex impulse: normal  unseen  increased  diffusing
poisition:    normal    deviation (the distance from midclavicular line     cm)
other precordial pulsations: N    Y (position                       )
palpation:apex impulse: normal   increased    thrust    unclear
thrills: N    Y (position      period        )   pericardial friction rubs  N     Y
percussion: relative cardiac outline: normal     shrink     extant (right   left)
         
           right(cm)                 intercostals space           left(cm)





         
          distance from anterior midline to the left midclavicular line(cm):

auscultation: heart rate   bpm/min     rhythm (regular    irregular    absolutely irregular)
heart sound: S1 normal   increased   decreased   split    S2 normal   increased   decreased
S2 split: normal   fixed   paradoxical     S3  N    Y      S4   N    Y     A2    P2
extra heart sound: N   gallop (diastolic   presystolic summation gallop)   opening snap    others
murmurs:  N    Y
Location: apical region    aortic area    pulmonary area     tricuspid area
left sternal border in 3nd intercostals space       Others
Timing: systolic      diastolic       both
Quality: blowing   rumbling   sighing   musical   Austin Flint     Graham Steell   Gibson
Intensity: Grade    Ⅰ    Ⅱ    Ⅲ    Ⅳ    Ⅴ    Ⅵ
Transmission: N   Y    direction    to left axilla    over the apex     over the carotid arteries
Pericardial friction rubs: N    Y

Pe**heral vessels:  normal    pistol shot: N    Y    Duroziez sign: N    Y
water hammer pulse: N    Y     capillary pulsation: N    Y
pulse deficit: N    Y      paradoxical pulse: N    Y    pulsus alternans: N    Y     others

Abdomen:
inspection: shape: normal    distention     frog belly    cm    scaphoid abdomen   apical belly
gastric pattern    intestinal pattern    peristalsis    abdominal respiration:  exist    disappear
umbilicus: normal    protruding     excretions
others:   N      Y (venous distention of abdomen    purple striae    surgical cars hernia)
palpation: soft    muscle tension    position    tenderness: N   Y    rebound tenderness: N   Y
fluid trill: N    Y    succusion splash:  N    Y     masses  N     Y (position     size)
desc**tion of feature:
liver: not touched     be touched: subcostal      cm
desc**tion of feature:
gallbladder: not touched   be touched: size   cm     tenderness: N   Y   Murphy’s sigh(+)  (-)
spleen: not touched    be touched: from costal margin      cm
desc**tion of feature:
kidney: not touched    be touched: size     consistency     tenderness     mobility
tenderness of ureters: N     Y (position        )
percussion: borders of liver dullness (exist     shrink     obliteration)
upper border of liver: on right midclavicular line     intercostals space
shifting dullness: N    Y       tenderness in renal region: N     Y (right     left    )
auscultation: gurgling sound: normal    increased     decreased    disappear
vessel bruits:   N     Y (position     )

Genitalia: not examined    normal      abnormal:

Rectum and Anus: not examined     normal      abnormal:

Spine and Extremities:
spine: normal    deformities (lateral    anterior    posterior protruding)
acanthi: tenderness    pain at percussion (position    )    mobility: normal    restricted
limbs: normal     abnormal     deformity    swelling of joints     joints stiffness
tenderness of muscles          atrophy of muscles
venous distention of lower limbs (position and feature       )           acropachy
Nervous system:
muscle tone (normal   increase   paratonia)    myodynamia (0  Ⅰ  Ⅱ  Ⅲ  Ⅳ  Ⅴ)
paralysis of limbs: N    Y (left   right   upper   lower)
reflex:  abdominal wall reflex (upper   middle   lower    normal   abnormal)
biceps reflex: left (normal   abnormal   )   right (normal   abnormal    )
triceps reflex: left (normal   abnormal   )   right (normal   abnormal    )
patellar reflex: left (normal   abnormal   )   right (normal   abnormal    )
achilles reflex: left (normal   abnormal   )   right (normal   abnormal    )
Hoffmann sign: left (+)  (-)   right (+)  (-)   Babinski sigh: left (+)  (-)   right (+)  (-)
Oppenheim sigh: left (+)  (-)   right (+)  (-)
Kernign sign: left (+)  (-)   right (+)  (-)     Burdzinski sign: left (+)  (-)   right (+)  (-)

Laboratory findings
(The important laboratory examinations, X-ray, ECG and other result are included)

Abstract
Mr. luo, 30 years old, has been suffered from abdominal pain and recurrent melena for more than one year and admitted to hospital on Nov 16, 2003.  began on May 2,2002 he had upper abdominal pain and melena first time, with no any inducement factors, obscure upper abdominal pain happened with no radiation, Pain was hungry pain and can be relieved by antacid agent or by meal. Melena occurred three times a day, about 250g each time, continuing for 5 days with little fatigue. He went to the local county hospital on the third day of melena, where he received gastroscopy that showed duodenal bulb ulcers with bleeding. Then he was administered Omeprazole (PPI) intravenously for 6 days, 40mg each time, twice a day (Bid). On the second day of treatment, the melena disappeared . On Nov. 15, 2003,  without any inducement he had melena again 3 times a day and 250-500gm. Every time accompanied with fatigue and timed but no dizziness and syncope. This time he went to the second People’s hospital. He took PPI but didn’t receive gastroscopy. The general condition is good  and work is not affected in any way since he had such a disease.
Physical examination revealed normal vital signs; patient’s consiousness seamed good, co-operated well; normal superficial lymph nodes( non-suelling) and pale skin observed. No paecordial protrusion, no enlargement of the border of the heart and nuoverma heard. chest are symmetrical, no vesicular sounds heard; Normal soft abdomen, no engorged vein and shighting dullness negative. Liver, spleen and kidney can’t be palpated and no edema in lower limbs. Physiological reflex is normal, pathological relex is negative. Special examination indudes (a)  decreased hemoglobin level (85g/L) , (b) Occult blood test (+++) positive, for fecal examination and  (c) positive endoscopy, which indicates duodenal ulcer (hemorrhage) located on the anteaior wall of the duodenal bull (ulcer size: 2.0cm×1.5cm)

Diagnosis (Impressions)

Duodenal ulcer with bleeding

Recorder(Signature)

Mahade
Date of record
                                                    2003.11.16

T**NNING MANUL FOR THE EYE EXAMINATION
（眼部检查大纲）

A. Functional Examination of the Eyes (omitted)
1.Visual acuity
2. Near sight vision test
3. Color vision test
4. Confrontation visual field test

B. External Examination of the Eyes
      5. Inspection of eyelids and position of eyes
Examination is carried out in a systematic manner beginning with the skin of the eyelids and continuing inward. The examiner first notices the symmetry and width of the palpebral fissures and the position of the eyes. The eyelids are inspected for defects, blood stasis, inflammation, entropion or ectropion, and any other abnormalities. The eyelids usually conceal the corneoscleral limbus from 11 to 1 0’clock meridians. Proptosis or retraction of the upper eyelids in thyroid ophthalmopathy is often first manifested by exposure of a narrow rim of sclera above the corneoscleral limbus.
The examiner should note the size (microphthalmos or enophthalmos), prominence (exophthalmos), and position (orbital tumor, strabismus) of the eyes. Palpation may be helpful in locating orbital tumors and determining their size, consistency and pulsation.
      6. Evaluation of extraocular muscle function in 6 directions
The examiner positions himself in front of the patient and requests that, without moving the patient’s head, the patient’s eyes follow the examiner’s finger or a pencil in six directions. The usual format is from left to upper left, to lower left, and then to the right, upper right and lower right.
      7. Lacrimal sac examination
(With thumb compression for lacrimal duct obstruction). Ask the patient to look up. Press on the lower lids close to the medial canthus, just inside the rim of the bony orbit. You are thus compressing the lacrimal sac. Observe fluid regurgitation out of the puncta into the eye. Avoid this test if the area is inflamed and/or tender.
      8. Inspection of the lower tarsal, fornical bulbar conjunctivae and sclera
The patient looks upward, and the lower eyelid is drawn downward by the examiner’s thumb applied to its orbital portion, exposing the lower tarsal, fornical, bulbar conjunctivae and sclera. Note the conjunctiva and sclera for color, the vascular pattern, foreign body, etc, With the exception of trachoma and vernal catarrh, nearly all conjunctival inflammations are more marked in the inferior fornix than in the superior fornix.
      9. Inspection of the upper bulbar conjunctiva and sclera
Instruct the patient to look downward. Get the patient to relax the eyes. Raise the upper eyelids slightly so that the eyelashes protrude and then inspect sclera and bulbar conjunctiva.
      10. Inspection of the upper tarsal conjunctiva by eversion of the upper eyelids
Inspection of the upper tarsal conjunctiva requires eversion of the upper eyelids. While the patient looks down, the margin of the upper eyelid is grasped by the examiner between the thumb and the index finger. The eyelid is drawn gently outward to break the suction between the eyelid and the globe. The eyelid is then everted. The tarsal conjunctiva is exposed, and the meibomian glands perpendicular to the eyelid margin may be seen through the transparent tarsal conjunctiva. Sometimes a small portion of the lacrimal gland may be seen at the outer canthus.
      11. Inspection of the anterior segment of eyes
Obvious disorders in the front part of the eye can be seen without any special instruments. The examiner faces the patient and holds a small penlight in his right hand, which provides a concentrated beam of light upon the eye, at an angle of 45 degrees. Examiner observes the cornea, anterior chamber, and iris carefully through a +10 diopter convex lens held in his other hand.
The anterior surface of the cornea should be smooth, regular, and mirror like. The iris pattern should be distinctly seen in all regions. Corneal blood vessels should not be present. In corneal edema, the cornea has a diffuse ground-glass appearance. Marked opacities are usually evident. Corneal vascularization may be superficial or deep and may involve the entire cornea or merely a segment of it. Staining of the cornea with fluorescein solution may be used to demonstrate areas where epithelium is deficient.
The depth of the anterior chamber is estimated as the distance between the posterior surface of the cornea and the front surface of the iris. Usually it measures 3mm or more.
The iris crypts and collarette should be clearly visible. Inability to see them suggests a corneal opacity, cells in the aqueous humor, or an iritis.
      12. Corneal sensitivity examination
The sensory innervation of the cornea is derived from the nasociliary branch of the ophthalmic division of the trigeminal nerve (NV) through the long ciliary nerves. Corneal sensitivity is tested clinically by means of a cotton-tipped applicator with a wisp of cotton twisted to a point. The patient is instructed to look directly ahead and the cornea is touched with the cotton wisp. With normal innervation, an eyelid closure reflex follows almost immediately. Care must be taken not to touch the eyelashes or the eyelid margins with the cotton wisp and not to stimulate eyelid closure by allowing the patient to see the wisp. A different cottontipped applicator should be used for each eye.
Corneal sensitivity is reduced in herpes simplex inflammation of the cornea. It is also reduced after herpes zoseer involving the nasociliary branch of the ophthalmic division of the trigeminal nerve, in adenovirus disease of the cornea, in congenital alacrima, and in many corneal dystrophy. Corneal sensitivity may be reduced in lesions at the apex of the orbit, which may also be associated with involvement of the motor nerves to the eye.
Corneal anesthesia is an important sign in cerebellopontine angle tumors.
      13. Observation of pupillary direct response to light
The pupils should be inspected for size, shape, equality of the pupils, reaction to the stimulation of light.
The direct pupillary response to light is elicited by directing the light of a penlight into the eye and observing the pupillary constriction in the same eye. The pupillary constriction is reversed as soon as the light moves away. Each eye is examined separately. Examination for reaction to light is best performed in a darkened room with the examiner to the side of the patient. The examiner should avoid shining the light into both pupils simultaneously and should not permit the patient to focus on the light source.
      14. Observation of pupillary consensual response to light
With the same method as above, the examiner shines the light into one eye and inspects for pupillary constriction in the opposite eye.
      15. Check for convergence and accommodation
The examiner, positioned in the front of the patient, asks the patient to look ahead and then at his finger held just in front of the bridge of the patient’s nose, while the examiner is observing the patient’s eyes for pupillary constriction and convergence. Convergence means the ability of both eyes to come together as the patient focuses on a near object.
The near reflex includes convergence and pupillary constriction (accommodation) as the patient focuses on the near object.
The accommodation will vanish when cranial nerve Ⅲ is damaged.
      16. Examination of intraocular tension
Examination of intraocular tension can be done by two methods. One is to use fingers and another is to use a tonometer. Finger tension technique is a gross screening procedure for detecting increases or decreases in pressure. It is best to have the patient look down (do not close eyes), and then palpate the sclera through the upper lids. Use two fingers, preferably the forefingers of both hands. Gentle alternating pressure is applied to the upper sclera. The advancing finger holds the whole eye in position against the orbital fat and is not used to interpret softness. The rebound of the depressed sclera against the withdrawing finger is the most reliable criterion of intraocular tension.
Record intraocular tension:Tn indicates normal tension. T+1 indicates slightly increased tension, T+2 indicates moderately increased tension, T+3 indicates much increased tension. T－1 indicates slightly decreased tension, T－2 indicates moderately decreased tension, T－3 indicates much decreased tension.

C. Ophthalmoscopic Examination (omitted)
      17. Positioning patient at height comfortable for examiner
It is best to have the patient positioned at a height comfortable for the examiner.
      18. Dim lights of the room
Dim lights before ophthalmoscopic examination. The examiner should darken the room to facilitate observation of the intraocular structures
      19. Switch on the ophthalmoscopic light and adjust it
Switch on the ophthalmoscope light and adjust it to the large round beam of white light.
Some physicians like to use the large round beam for large pupils and the small round beam for smaller pupils.
      20. Hold the ophthalmoscope properly
Hold the ophthalmoscope properly, keeping your index finger on the lens disc so that you can change lenses during examination. The examiner’s free hand rests on the patient’s eyebrow.
      21. Position of the examiner
To examine patient’s right eye, examiner stands on the patient’s right side, holds the ophthalmoscope with his right hand and uses his right eye. This is reversed to examine the patient’s left eye.
      22. The action of examiner during the fundus examination (1)
During the examination, the examiner holds the patient’s head still by placing his thumb on the patient’s eyebrow, The head of the ophthalmoscope is steadied in the mediosuperior margin of the examiner’s bony orbit. Usually it is not necessary to elevate the patient’s eyelid for an adequate view.
      23. The action of examiner during the fundus examination (2)
Ask the patient to look slightly up and over your shoulder and gaze at a specific point on the wall. Bring one’s own right eye up to the sight-hole and move closer to the patient’s right eye at the angle of 15 degrees lateral to the patient’s line of vision. Then look down into the patient’s eye. This is reversed to examine the patient’s left eye.
      24. Inspection for any opacities in the ocular media
A +8--+10 diopter lens is rotated on the vi***g aperture of the ophthalmoscope, and the patient fixes on an object. The examiner directs the ophthalmoscopic light into the eye at a distance of about 20cm. A red fundus reflex will be observed. Any opacities in the ocular media will stand out as black silhouettes against a red background.
      25. Inspection of optic disc and tracing vessels in four quarters
Keeping attention directed to the red reflex, the examiner gradually approaches the patient’s  eye while steadily decreasing the power of the ophthalmoscope lens (i. e. moves towards “0” or beyond to negative numbers). Once funduscopic details are seen, a blood vessel is followed to its origin at the optic disc, and the systematic examination usually begins with the optic disc.
The disc is pale pink, except for the physiologic cup, which is nearly white. The edges of the disc are usually flat and sharp, but not uncommonly the nasal margin is less distinct than the temporal margin. Pigment may be visible, particularly on the temporal side, sometimes as a continuous arc and at other times as linear streaks concentric with the disc. This is called a choroidal ring and is of no pathologic significance.
The optic disc is about 1.5mm in diameter. The diameter of the disc is the standard unit of measurement in the fundus. The disc is approximately the same size in most patients. Marked enlargement of the disc rarely occurs, but its occurrence suggests a couns, myopia, or posterior staphyloma.
The physiologic cup of the optic disc is a funnel shaped depression that varies in size and shape. In some cases it is located nearly at the center of the disc, and greyish areas of the lamina cribrosa are evident. In other eyes the cup has a more oblique arrangement and its bottom cannot be seen. The ratio of the horizontal diameter of the cup to the horizontal diameter of the disc is important in glaucoma.
During optic disc examination, you should note; color, size, clearness of the margin, etc.
Identify the arterioles and venules. The retinal arterioles have a smaller diameter than the venules; the usual ratio of arteriole to venule being 3∶4 or 2∶3. A broad, bright streak is reflected from the convex surface of arterioles. The reflection from venules is much narrower and not nearly as bright. The oxygenated blood is much brighter red in the arterioles than in the venules. In a complete examination of the fundus, the examiner should trace vessels in four quadrants. The superior and inferior temporal and nasal arteries are followed as far to the pe**hery as they can be seen. Note their relative sizes and the character of the arteriovenous crossings. Identify any lesions of the surrounding retina (e. g. edema, bemorrhage, detachment, degeneration,etc.)and note their size, shape, color and distribution.
      26. Observation of macula
In the usual ophthalmoscopic examination, final attention is directed to the macula area. The macular area is especially important because it is responsible for central vision. By asking the patient to look directly into the light, inspect the macular area. This is an avascular area somewhat larger than the disc but has no distinct margins. The fovea centralis is situated about 2 disc diameters (3mm) temporal to the optic disc. Its center is silghtly below the center of the optic disc. Shimmering light reflections in the fovea centralis are common in young people. Usually pupillary dilation is required for careful examination of this area since pupillary constriction is marked when the fovea centralis is illuminated.
During the examination of the macular area, you should observe for light reflection in the fovea centralis, edema, exudation, hemorrhage and neovascularization, tear (hole) etc.



Checlist for eye examination
（眼部检查大纲）

A. Functional Examination of the Eyes(omitted)
1. Visual acuity
2. Near sight vision test
3. Color vision test
4. Confrontation visual field test
B. External examination of the eyes
5. Inspection of eyelids and position of eyes
6. Evaluation of extraocular muscle function in 6 directions
7. Lacrimal sac examination
8. Inspection of the lower tarsal, fornical, bulbar conjunctivac and sclern
9. Inspection of the upper bulbar conjunctiva and sclera
10. Inspection of the upper tarsal conjunctiva by eversion of the upper eyelids
11. Inspection of the anterior segment of eyes
12. Corneal sensitivity examination
13. Observation of pupillary direct response to light
14. Observation of pupillary consensual response to light
15. Check for convergence and accommodation
16. Examination of intraocular tension
C. Ophthalmoscopic examination (omitted)
17. Position patient at height comfortable for examiner
18. Dim lights of the room
19. Switch on the ophthalmoscopic light and adjusting it
20. Hold the ophthalmoscope properly
21. Position of the examiner
22. The action of examiner during the fundus examination (1)
23. The action of examiner during the fundus examination (2)
24. Inspection for any opacities in the ocular media
25. Inspection of optic disk and tracing vessels in four quadrants.
26. Observation of macula



T**NING MANUAL FOR OTO-NASO-LARYNGEAL EXAMINATION
（耳／鼻／咽／喉／口腔检查）

A. Ears
While examining the ear, patient assumes a seated position and examiner faces the lateral side of the patient.
      1. Inspection of the external ear
Inspection of the external ear is frequently neglected. It requires only a few seconds. The form, size, location, symmetry, malformation, bulge, hyperplasia should be noted. Pleonotia (additional ear), congestion, fistula, scar, neoplasms and damage of the skin around the auricles also should be documented. Swelling, congestion, fistula and scar in the post auricular region indicates mastoidal inflammation. In mastoid infection the auricles shift anterolaterally.
The examiner pulls and palpates the auricles (outer ears) and posterior auricular regions (behind the ears) bilaterally. Tenderness usually indicates inflammation.
      2. Palpation of the temporomandibular joint
The temporomandibular joint (TMJ) is located anteriorly to the external auditory c** of the ear. Swelling in this joint is usually not appreciated.
To palpate the TMJ joint, the examiner presses both sides simultaneously with one or two fingers and asks the patient to open and close his mouth. Then the examiner places his index finger in the patient’s ear and gently pulls forward (anteriorly), asking the patient to open and close his mouth. Marked swelling of the joint would feel like a rounded lump lying over the area. In young individuals, arthritis of the temporomandibular joint may result in a shortened lower jaw (micrognathia).
      3. Move the wax and pus (omitted)
The most important step in preparing to examine the ear c** and eardrum is making sure that they are clean. Wax and secretions must be meticulously removed.
Often the simplest way is to remove particulate matter with a cerumen spoon or cotton applicator while working under direct vision through the ear speculum. The cerumen spoon should be inserted above the impacted wax dislodging the wax. Because the epithelium covering the inner aspect of the ear c** is exquisitely sensitive, great care must be used in these manipulations to prevent pain and bleeding (Figure 3-3).
      4. Inspects the external auditory c** and the tympanic membrane bilaterally (omitted)
The examiner inspects the external auditory c** and the tympanic membrane bilaterally with otoscope. The speculum of the otoscope, like a funnel, is a basic examining instrument. The examiner inserts the speculum of the otoscope without causing the patient pain or discomfor. To facilitate insertion, the examiner might ask the patient to tilt his head to the side opposite that which he is examining. By gently pulling the auricle upward, backward and slightly away from the skull, the examiner can insert the speculum in a downward and forward position and examine the c** and eardrum. The otoscope might be stabilized against the patient’s head. This is especially important for children and uncooperative patients. This can be done by holding the handle pointing upwards and placing the 4th and 5th fingers on the patient’s head. It can also be stabilized with the handle pointing downwards.
When the external auditory c** is inspected, check for swelling, congestion, furuncle, neoplasms, fistula, and narrowing of the c**. If there are secretions, their quality (such as purulent, mucopurulent, mucous, serous, etc. ) odor and color should be observed and described. Purulent secretions usually indicate inflammation of the alvearium (ear c**) or a parotid abscess which has ruptured into the ear c**; mucopurulent secretions always indicate otitis media (OM) or middle ear inflammation. Bad smelling secretions usually indicate that inflammation in middle ear is very serious and the patient must be operated on as soon as possible to avoid intracranial or extracranial complications caused by OM.
The tympanic membrane, or eardrum, may be regarded as a translucent membrane through which the otologist views normal anatomy and also pathologic processes in the middle ear. When examining the eardrum, the examiner should note the presence of swelling, retraction, thickness, perforation, scar or hydrops. Auditory ossicles are also important to examine.
A swollen eardrum may be st**ed, radial or have total tumefaction which often indicates inflammation in the middle ear. If there is a perforation in the eardrum, its location (pars flaccida or pars tensa), size (large, middle or small perforation), and appearance (round, elliptical or heterogeneous shape) must be noted. If the cone of light becomes shortened, deformed or disappears, the projection protrudes, and the eardrum is retracted. Retraction of the eardrum indicates nonpurulent inflammation in middle ear. When there is a furuncle in the ear c**, the use of the speculum should be omitted (Figure 3-4).
      5. Auditory acuity (omitted)
      6. Distinguish between conductive deafness and sensorineural deafness (omitted)

B. Nose
      7. Observe and palpate external nose
Begin by examining the external nose. The examiner may stand or sit and face the patient. Observe and palpate for any changes of skin and loss of structure of support. The saddle-nose may happen is syphilis and leprosy. Fracture of the nasal bones probably occurs more often than any other fracture, except those of the wrist and the clavicle. Any trauma to the nose that canses bleeding from the nose may signify that the bone or cartilage has been broken or displaced.
      8. Inspect the nasal vestibule and anterior part of nasal cavities
A better view of the nasal cavities is obtained by tilting the patient’s head back and elevating the tip of the nose with the thumb. The nasal vestibule is lined with skin and contains the nasal hairs, or vibrissae. Folliculitis and fissures are common diseases in the vestibule.
      9. Test for patency (omitted)
To test for patency, the examiner asks the patient to breathe through each nostril separately while the opposite nostril is held occluded. Normally there is free and equal egress of air through each nasal passage.
      10. Inspect the nasal cavity with speculum on the otoscope is held in the left hand whether the examiner is examining the left or right side of the nose. The speculum is inserted gently through the nostril about 1cm into the vestibule while avoiding painful pressure against the nasal septum which is the most sensitive area. The examiner’s right hand is the real key to intranasal inspection because it positions the head. Except when used for instrumentation, the right hand is placed firmly on the top of the patient’s head and is used to change the head’s position from time to time. Ideally, the lower portions of the nose will be examined first and then the examiner will ask the patient to tilt his head slightly backward, stabilizing it with his hand to examine the upper portions of the patient’s nose. This presents a different view and is a good teaching point. For example, with the patient’s head erect, the examiner can see the floor of the nose and the inferior turbinate. When the head is tilted back 30 degrees, he can see middle turbinate, middle meatus and a part of the olfactory sulcus. When the head is tilted back 60 degrees, the front portions of the middle turbinate, olfactory sulcus, anteroinferior portions of middle meatus and superior portions of the nasal septum can be observed. The use of the headrest is discouraged because it fixes the patient’s head and defeats the proper use of the examiner’s right hand. When a furuncle of the nasal vestibule exists, the use of the speculum should be omitted.
The nasal mucosa is red, smooth and wet. A soft and elastic sensation can be felt when the lower concha is gently pressed by a cotton applicator. Normally there is no accumulation of secretions on any meatus. The examiner should inspect for the presence of swelling, thickness, dryness, atrophy, secretions (describe its location and quantity), polyps, neoplasms or perforation on examining the nasal chambers (omitted).
      11. Examination of the paranasal sinuses
Examination of the paranasal sinuses is done more indirectly than other otolaryngeal procedures. Palpation and percussion might be used over the maxillary and frontal sinuses. Simultaneous finger pressure over both maxilla will demonstrate differences in tenderness. Palpation under the upper lip may demonstrate fullness not appreciated by inspection. The frontal sinuses are palpated by finger pressure directed upward toward the floor of the sinus where the sinus wall is thin. Tenderness may be elicited in this way. Swelling caused by tumors or retained or retained secretions may cause a downward bulge in the floor of the frontal sinus. The ethmoid sinus can be palpated for tenderness between the bridge of nose and medial angle of eye. This can also be accomplished by tapping over the sinus areas. The sphenoid sinus cannot be examined except by intranasal inspection. The presence of swelling and bulge should be documented. The location of the eyes is very important in examination of the paranasal sinuses. Many diseases of them such as inflammation, cyst, neoplasms can constrict the eyes and make them bulge, shift position, or produce diplopia.

C. Mouth, Pharynx, Larynx
      12. Inspects the lips, all surfaces of the tongue, gums, roof of the mouth and buccal mucosa. The examiner inspects the lips, all surfaces of the tongue, gums, roof of the month, buccal mucosa (the tissue lining the cheeks) by asking the patient to open his month and by shining a light into the area to be examined. The examiner may use a tongue depressor to aid inspection. To examine the floor of the mouth and the base of the tongue, the examiner will ask the patient to touch the roof of his mouth with the tip of his tongue.
a)Lips:The healthy lips are wet and a red colout. This is caused by a rich capillary network. Pale lips are seen in anemia or collapse. Cyanosis of the lips is present in failure of the heart or lungs. Xerocheilia may exist in dehydration and enlargement of lips may be seen in acromegaly.
b) Buccal mucosa: To examine the buccal mucosa, it is necessary to inspect in natural light or by shining a light. The healthy buccal mucus is pink and smooth. Pigmentation and blue-black plaques may appear on the buccal mucosa in Addison’s disease. Ulcers and hemorrhages should be also observed. The duct of the parotid gland opens onto the buccal mucosa opposite the upper second molar.
c)Teeth: There are 32 teeth in the full ** dentition. The teeth are inspected for evidence of caries and malocclusion.
d)Gums: the gums should be inspected for the presence of swelling, bleeding or prgmentation.
e)Tongue:The tongue is inspected for its shape, movement and ulceration.
      13. Inspect and palpate the floor of the mouth
The floor of the mouth is a region where palpation is important. Tissues are loose, and neoplasms are sometimes detectable only by palpation. The submaxillary salivary ducts may contain calculi that are best felt by palpation. Bimanual examination, using one gloved finger inside the mouth and the other hand outside, is best.
      14. Observe the elevation of the palate
The examiner can observe the elevation of the palate as the patient says “AH”. Simultaneously, hoarseness can be detected.
      15. Inspection of the pharynx
To visualize the pharynx, the examiner asks the patient to open his mouth without sticking out his tongue. The tongue depressor is held in the left hand so that the right hand is free to hold other instruments. The blade is best placed on the middle third of the tongue. If placed too far anteriorly, the blade causes the posterior part of the tongue to mound up so as to obscure rather than to expose the pharynx. On the other hand, most patients gag if the blade touches the posterior third of the tongue. The posterior pharyngeal wall is that part of the pharynx that is visible when the examiner uses only a tongue blade. Students are prone to speak of hyperemia or “injection” of the throat when they see vessels on the posterior pharyngeal wall. Usually these small vessels are normal and do not present inflammatory changes. The same appearances may be seen on the tonsillar pillars and the soft palate. Small irregular spots of lymphoid tissue are common in the mucosa of the posterior pharyngeal wall. They are red or pink. The lateral pharyngeal bands are found posterior to the pillars running downward from the nasopharynx toward the base of the tongue. These pink bands are also composed of lymphoid tissue. The pharynx should be inspected for evidence of congestion, swelling, pus, pseudomembranes and protrusion.
Examination of the (palatine) tonsil. The tongue is depressed with a spatula, and while the patient says “AH”, the tonsils are inspected. To decide whether the tonsils (absent in the newborn) are normal in size and healthy or enlarged and/or diseased, it is necessary to display them. The best method is to depress the tongue with one depressor while the tip of a second depressor gently compresses the anterior pillar. This everts the tonsil from its bed. Increasing pressure will discharge the crypts content. Pus (yellow) signifies inflammation; a whitish discharge may be normal.
With the advent of puberty, lymphoid tissue diminishes, and the tonsils become smaller. Following recurrent attacks of tonsillitis the tonsillar lymph node are frequently palpable. Enlarged tonsils are not necessarily infected. Extensive protrusion of the tongue or its forcible depression make the tonsils appear larger. Unlateral enlargement may signify carcinoma or lymphosarcoma of the tonsil.
Enlargement of tonsils is classified by three degrees.
1) Tonsil lies between the anterior and posterior pillars, recorded as “Ⅰ”;
2) Tonsil is beyond the posterior pillar, recorded as “Ⅱ”;
3) Tonsil reaches or is beyond the midline, recorded as “Ⅲ”.
      16. External laryngeal examination.
External laryngeal examination. The larynx moves upwards on deglutition and sometimes when singing high notes. It moves downwards during inspiration in cases of laryngeal stenosis but is immobile in tracheal stenosis.
Complete examination of the larynx calls for palpation of the neck. The shape of the thyroid cartilage is noted, and the space between the thyroid cartilage and the hyoid bone is palpated. This is a common site for a thyroglossal duct cyst. The space between the thyroid and cricoid cartilages is also palpated. Sometimes a lymph node is felt in patients with carcinoma of the larynx. The cricothyroid space is the site where an emergency tracheotomy may be done with the least bleeding.
Laryngeal crepitation is elicited by grasping the larynx (thyroid cartilage) between the thumb and index finger and rocking it vigorously from side to side. This maneuver should canse a crepition felt on eigher side. If it does not, a postcricoid neoplasm may be present that cushions movements of the laryngeal joints.


Checklist for oto-naso-laryngeal examination
（耳／鼻／咽／喉／口腔检查大纲）

A. Ears
1. Observe and palpate auricles and postauricular regions bilaterally
2. Palpate temporomandibular joint for tenderness and swelling
3. Meticulously remove the wax and pus from the ear c** for examination of the eardrum.
4. Gently pull the auricle upward and insert the speculum to inspect external auditory meatus (ear c**) and tympanic membrane (eardrum, drumhead) for mass, pus and perforation.
5. Perform preliminary evaluation of auditory acuity, each ear separately, by rubbing fingers, whispered sounds or ticking watch.
6. Distinguish between conductive deafness and sensorineural deafness by tuning fork.
B. Nose
7. Inspect and palpate external nose
8. Inspect nasal vestibule and anterior part of nasal cavity
9. Test nasal patency by asking patient to breath through each nostril separately whiles the opposite nostril is held occluded.
10. With speculum inspect septum, inferior and middle turbinate, and corresponding meatus, for secretion, swelling, atrophy or perforation.
11. Palpate and percuss maxillary, ethmoid and frontal sinuses for swelling and tenderness.
C. Mouth, Pharynx Larynx
12. Inspect lips, buccal mucosa, teeth, gum and gongue for ulcer, pigmentation and caries.
13. Inspect and palpate the floor of mouth for neoplasms.
14. Observe elevation of the palpate by asking patient to say “AH” and detect hoarseness.
15. Press a tongue blade firmly down on the tongue to inspect tonsils, anterior and posterior tonsillar pillars, lateral pharynx bands and posterior pharynx for congestion, swelling or pus.
16. Palpate and move thyroid cartilage with two fingers for malformation and movability.








T**NING MANUAL FOR THE CHEST EXAMINATION
（胸部／肺部检查）

Review
Get familiar with the normal and artificial landmarks of the chest surface, so you can correctly locate physical findings in the chest.
Skeletal landmarks include Louis’ angle, suprasternal notch, supraclavicular fossae, infraclavicular area, infrasternal angle (costal angle), xiphoid process, intercostal space, medial scapular border, costovertebral angle.
Artificial vertical landmarks include midsternal line, midclavicular line, midclavicular line, anterior, posterior and midaxillary line, midspinal line, scapular line.
Tomographic desc**tion of location for may positive physical findings: normal or abnormal The best way of describing location is by using a horizontal line first, and then a vertical line to locate the finding precisely, e. g. “the point of maximal impulse is located in the left 5th intercostal space 1cm medial to the midclavicular line.”
A. Inspection
      1. Examiner should stand facing the patient and observe the shape and symmetry of the chest Estimate the ratio of the anteroposterior (AP) diameter to transverse diameter (normal is 1 to 1.5). Pay attention to the variety of chest shapes. Flat chest-AP diameter is decreased and is usually less than half of transverse diameter. Funnel chest is a depression of the sternum which will produce a restrictive lung problem if the depression is marked. Pigeon breast results from an anterior protrusion of the sternum. It is a common deformity but does not compromise ventilation. Fig 3-7 illustrates the various configurations of the chest.
      2. Measure respiratory rate
Never ask the patient to breathe “normally” when you assess respiratory rate. Individuals will voluntarily change their breathing pattern and rate once they are aware of it. A less conspicuous way is, to direct your eyes to the chest and evaluate the respirations after taking the radial pulse but while still holding the wrist. The patient is unaware that you are no longer taking the pulse, and voluntary changes in breathing will not occur. Counting the number of respirations in a 30 second period and multiplying this number by 2 will provide an accurate respiratory rate per minute.
The normal ** breathes about 16-20 times a minute. Bradypnea is an abnormal slowing of respiration; tachypnea is an abnormal increase. Apnea is the temporary cessation of breathing. The term hyperpnea is an increased depth of breathing, usually associated with metabolic acidosis: It is also known as Kussmaul’s breathing. There are many types of abnormal breathing patterns. Dyspnea means rapid breathing with increased effort, The normal ratio of inspiration to expiration is 1～2.5. If effort is the greatest in the inspiratory phase, it is called inspiratory dyspnea. If effort is the greatest in the expiratory phase, it is called expiratory dyspnea. In late stages of pregnancy, a woman’s diaphragmatic movement is decreased and chest respiration is predominant; this should not be considered abnormal. In children and men, breathing depends predominantly on the diaphragm and is called abdominal respiration; in women it depends predominantly on the chest muscles and is called chest respiration.
B. Palpation
      3. Palpate trachea and evaluate position of the trachea
Ask the patient to look straight ahead. Both shoulders should be horizontal and at the same level. The examiner puts his index and fourth finger at sternoclavicular joints. Palpate trachea or the gaps between the trachea and the joints with middle finger to determine the position of the trachea. The space between the trachea and the clavicles should be equal. The position of the trachea can also be determined by placing the right index finger in the suprasternal notch and moving silghtly lateral to feel the location of the trachea. This technique is repeated, moving the finger from the suprasternal notch to the other side. Some lung diseases, pleural diseases and a shift of the mediastinum that either pushes or pulls the trachea can displace the trachea.
      4. Palpate for tenderness
All chest areas should be evaluated for of tenderness. A complaint of “chest pain” may be related only to local musculoskeletal disease and not to disease of the heart or lungs. Be eticulous in assessing for areas of tenderness. Put one hand against the patient’s back and at the same time exert pressure with the other hand on the sternum. If pain occurs, the point of maximal pain may indicate the location of a rib fracture. Pay attention to the elasticity of the chest wall (be concerned with the aging factor), the horizontal degree of the ribs, and the width of the intercostal spaces. Crackling sensation is a special feeling when palpating the chest skin. It suggests that air is present. The feeling is just like holding snow and crushing it.
      5. Breastse (see ***rmation included in manual for Breast and Pelvic Examination)
      6. Evaluate posterior chest excursion
Pay a attention to The degree and symmetry of chest excursion. Localized pulmonary disease and pleural disease may cause one side of the chest to move less than the opposite side.
      7. Evaluate Anterior Chest Excursion
The examiner stands facing the patient. The range and symmetry of anterior chest excursion is assessed by placing your hands along the lateral rib margins, with both of thumb directed to the midsternal line. Instruct the patient to inhale deeply and observe the motion and symmetry of the movement of the hands.
      8. Palpate for pleural friction rubs
Ask the patient to breath deeply and place both hands on the inferior anteriolateral portion of the chest. Feel for rubbing sensation (fremitus) to find pleural friction rub. The friction rubs are usually palpated in both phases of respiration, but sometimes only during inspiration.
      9. Check for tactile fremitus
When the examiner palpates the chest wall while the patient is speaking’ these vibrations can be felt. This is tactile fremitus. Tactile fremitus provides useful ***rmation about the density of the underlying lung tissue and abnormality of the chest cavity. Conditions that increase the density of the lung and make it more solid (such as consolidation) will increase the transmission of these sound waves and increase tactile fremitus. If there is excess fat tissue on the chest, air or fluid in the chest cavity, or an overexpanded lung, tactile fremitus will be diminished. Normally, Examiner use both hands on the symmetrical positions of chest wall to check for tactile fremitus simultaneously.
To be convenient, Tactile fremitus can also be evaluated in one of two single hand ways. The first technique involves the examiner placing the ulnar side of the right hand against the chest wall, as shown in Fig 3-8, and asking the patient to say “E”. Tactile fremitus is evaluated, and the examiner’s hand is moved to the corresponding position on the other side. Tactile fremitus is then compared with the opposite side. By moving the hand from side to side and from top to bottom, the examiner can detect differences in the transmission of the sound to the chest wall. “E” is one of the phrases used because it causes good vibratory tones. Asking the patient to speak either louder or deeper will enhance the tactile sensation. Tactile fremitus should be evaluated in the five or six locations shown in Fig.
The other method of evaluating tactile fremitus uses the finger tips instead of the ulnar side of the hand. The same side to side and top to bottom positions as shown in fig 3-9 are used. It is only necessary to perform one of these techniques. The examiner should try both methods initially to determine which one he prefers.

C. Percussion
The principle of percussion: Percussion refers to the tapping on a surface to determine the underlying structure. It is very similar to a radar or echo detection system. Tapping on the chest wall is transmitted to the underlying tissue, reflected back, and perceived by the examiner’s tactile and auditory senses. The sound heard and the tactile sensation felt are dependent upon the air-tissue ratio. The vibrations set up by the percussion of the chest can evaluate the lung tissue only to a depth of 5～6cm, but percussion is valuable because many changes in the air-tissue ratio are readily apparent.
Percussion over a solid organ covered by lung, such as the liver, produces a dull, low amplitude, short duration note without resonance. Percussion over a structure containing air and tissue, such as the lung, produces a resonant, higher amplitude, lowerpitched note. Percussion over a hollow air containing structure, such as the stomach, produces a tympanic, high-pitched, hollow quality note. Percussion over a solid organ such as the liver and heart, produces a flat, high-pitched note.
Normally in the chest, dullness over the heart covered by the lung and resonance over the lung fields are heard and felt. As the lungs are filled with fluid and become more dense, as in pneumonia, resonance is replaced by dullness. The term hyperresonance has been applied to the percussion note obtained from a lung of decreased density, as is found in emphysema. Hyperresonance is a low-pitched, hollow quality, sustained resonant note bordering on tympany.
The normal distribution of percussion sounds over the lung fields is seen in Fig 3-10.
Two principle methods that may be used for percussion of the chest are: mediate percussion (finger-finger percussion) and immediate percussion (direct percussion). The former is the method in almost universal use today.
Mediate Percussion
Percussion of the chest uses the distal interphalangeal joint of the middle finger of the left hand placed firmly against the chest wall parallel to the ribs on the area between the scapulae, be parallel to the posterior midspinal line in an interspace with the palm and other fingers held off the chest. The tip of the right middle finger strikes a quick, sharp blow to the distal interphalangeal joint of the left finger on the chest wall. The motion of the striking finger should come from the wrist. And not from the elbow. The technique of percussion is diagrammed and shown in Fig.
Immediate Percussion
This can be done by striking the chest wall with tips of the three middle fingers held firmly together. Pay attention to the feeling and sound from percussion on the chest wall.
      10. Percuss supraclavicular fossae
The supraclavicular fossae indicate the apices of the lungs. The examiner stands behind the patient and performs finger to finger percussion from the middle point of the trapezious muscle and moves laterally until he finds the dull point. This point is then marked. He then percuesses from above middle point towards the neck until he finds a dull point and makes a mark. The distance between the 2 marks is considered the width of apex of the lung. Normally, it is 4-6cm and the distance on the right is a bit smaller than that on the left. If the percussion sound becomes dull in the apex, consolidation of the lung apex might be present.
      11. Percuss the posterior chest
The examiner stands behind the patient. The sites for the posterior chest percussion are above, between, and below the scapulae in the intercostal spaces. The bony scapulae are not percussed. The examiner should start at the top and work downward, proceeding from side to side, comparing one side with the other. For each intercostal space, a minimum of 2 points should be percussed on each side.
      12. Percuss the lower margins of the lungs
This is usually done in the midclavicular lines, midaxillary lines, and scapular lines of both sides Ask the patient to breath quietly. The examiner percusses from a resonantarea (usually 2nd or 3rd intercostal space anteriorly and 8th intercostal space on the scapular line), working down to a dull point. Normally, in the midclavicular lines, midaxillary lines and scapular lines, the lower margins are 6th, 8th and 10th intercostal spaces respectively.
      13. Percuss to detect diaphragmatic movement at scapular lines
Percussion is also used to detect diaphragmatic movement at the scapular lines. The patient is asked to take a deep breath and hold it . Percussion at the right lung base determines the lowest area of resonance, which represents the lowest level of the diaphragm. Below this level is dullness from the liver. The patient is then instructed to exhale as much as possible, and the percussion is repeated downward. With expiration, the lung will contract, the liver will move up and the level of dullness will have moved upward. The difference between the inspiration and expiration levels represents the diaphragmatic movement, which is normally 4-5cm. Left side should be detected by tha same method. Patients with emphysema have a reduced movement. Patients with a phrenic nerve palsy will have absent diaphragmatic movement.
      14. Percuss the anterior and lateral chest
The examiner stands in front of the patient. Percussion of anterior and lateral chest starts at the top and works downward, proceeding from side to side, comparing one side with the other. For each intercostal space, a minimum of 2 to 3 points should be percussed on each side.

D. Auscultation
Because most breath sounds are high pitched, the diaphragm of the stethoscope is used to evaluate lung sounds.
Auscultation is the technique of listening for sounds produced in thd body. Auscultation of the chest is used to identify lung sounds. The stethoscope usually has two heads; the bell and the diaphragm. The bell is used to detect low-pitched sounds, whereas the diaphragm is better at detecting high-pitched sounds. The bell must be loosely applied to the skin; if it is pressed too tightly, the skin will act as a diaphragm and the lowerpitched sounds will be filtered out. In conrast, the diaphragm is applied firmly to the skin. In very thin individuals, the bell may be used and converted to a diaphragm by using firm pressure. Placement of the diaphragm is more difficult in these patients becanse of the protrusion of their ribs. The correct placement of the heads of the stethoscope is shown in Fig.
It is never acceptable to listen through clothing! The bell or the diaphragm of the stethoscope must always be in contact with the skin.
Auscultation should be performed in a quiet environment. The patient is asked to breathe in and out through his mouth. The examiner should first concentrate on the length of inspiration and then on expiration. When the breath sounds are very soft, the term distant is used. Distant breath sounds are commonly found in patients with hyperinflated lungs, as in emphysema. Pay attention to the change of intensity and nature of the breath sounds. Differentiate normal from abnormal breath sounds (including bronchial and bronchovesicular breath sounds heard in any areas of the lunds that normally have vesicular breath sounds, as well as, increased, decreased, or absent breath sounds).
Rales and rhonchi should be noticed.
Rales: including fine rales and coares rales
Fine rales: fine bubbling sound or crackling-like sound
Coarse rales: these are usually coarse and lower-pitched rales
Rhonchi: including wheezing (sibilant) and sonorous.
Wheezing (sibilant): high-pitched sound caused by air flow through constricted airways, most often heard in expiratory phase
Sonorous: lower-pitched sound caused by air flow through trachea or main bronchi. It sounds like snoring.
      15. Auscultate supraclavicular fossae
In small of female patients, it might be helpful to use the bell of the stethoscope with firm pressure applied (to convert it acoustically to a diaphragm) to auscultate apices in the supraclavicular fossae.
      16. Auscultate the anterior and lateral chest
Auscultation of the anterior chest is performed in the anterior and lateral chest interspaces, as illustrated in Fig3-13.
In each intercostal space, at least 2-3 points should be auscultated. The breath sounds of one side are compared with the breath sounds in the corresponding position on the other side.
      17. Auscultate the posterior chest
The examination should proceed from side to side and from top to bottom, comparing one side with the other.
      18. Ask patient to breathe deeply and examine for pleural friction sounds
The most common area where a pleural friction sound is heard is in the lower part of the chest in the midaxillary line. The sound is a coarse sound usually beginning at the end of inspiration or the beginning of expiration. It sounds like sand paper rubbed together.
      19. Examine for vocal audible resonance
The spoken work creates vibrations that can be heard when one listens to the chest and lungs. This is termed vocal audible resonance. The sound is conducted from the larynx through the bronchial tree to the lung and the chest wall. Its clinical significance is the same as tactile fremitus, but it is more sensitive.
Ask the patient to say “E” or “1, 2, 3” and auscultate the lung fields angeriorly and posteriorly with a diaphragm head of the stethoscope. Pay attention to the intensity and nature of the sound and compare both sides.
Get familiar with the factors that decrease the vocal audible resonance. Get familiar with the following pathological characteristics of vocal audible resonance:
1)Bronchophony-the sound becomes louder, clearer and even the pronunciation of words can be heard.
2) Pectoriloquy-much louder than normal, pronunciation of the words can be heard clearly.
3) Egophony-nature of the sound changes. When patient says “E” it sounds like “A”.
4) Whispered pectoriloquy-ask the patient to whisper “1, 2, 3.” In a normal patient, the sound is very weak. In a patient with lung consolidation, it sounds very clear, and high-pitched.
Things Need to Know
a) The chest examination is taught step by step in a logical sequence: inspection, palpation, percussion and auscultation. Because the chest includes the anterior, lateral and posterior lung fields, the physical examination should be done in a sequence that reduces the number of times the patient needs to change body position. In the case of the supine patient, inspection, palpation, percussion and auscultation of the anterior and lateral chest should be done first. Then the examiner should move to the back of the patient and do the inspection, palpation, percussion and auscultation on the posterior chest. If the patient is in a sitting position, start with the posterior lung field and then examine the anterior and lateral lung fields.
b) In this chapter the techniques and maneuvers of the physical examination of the chest are emphasized. In clinical practice, the examination should be performed in conjunction with general assessment and examination in other systems. For example: Is the patient in acute distress? Is there nasal flaring or pursed lip breathing? Are there audible signs of breathing, such as stridor and wheezing? Is cyanosis present? Is the patient positioned to support his arms and fix the muscles of the shoulder and neck to aid in respiration, i. e., to increase his effort to breathe?
The examination of other systems includes checking for clubbing of he fingers, edema, etc.
c) For the lung examination it is preferable to have the patient in a sitting position. For examination of the back of the lungs, have the patient bend forward with both hands touching opposite shoulder. This will move the scapular out of the way and expose the interscapular area. For the heart examination, have the patient in lying or semirecumbent position, or even lying of his left side. If the patient’s general condition is poor, do not have him sit up or changing position frequently.
d) If the patient is a man, his gown should be removed to his waist. If the patient is a woman, the gown should be positioned to prevent unnecessary or embarrassing exposure of thebreasts. Never examine a patient over clothing.



Checklist for chest examination
（胸部／肺部检查大纲）

A. Review
1. Review skeletal landmarks.
2. Topographic desc**tion of location for any positive physical findings: normal or abnormal.
B. methods
3. Examiner should stand facing the patient and observe the shape and symmetry of the chest.
4. measure respiratory rate.
5. palpate trachea and evaluate position of the trachea.
6. Palpate for tenderness.
7. Breasts.
8. Evaluate posterior chest excursion.
9. Evaluate Anterior Chest Excursion.
10. Palpate for pleural friction rubs.
11. Check for tactile fremitus.
12. Percuss supraclavicular fossae.
13. Percuss the posterior chest.
14. Percuss the lower margins of the lungs.
15. Percuss to detect diaphragmatic movement at scapular lines.
16. Percuss the anterior and lateral chest.
17. Auscultate supraclavicular fossae.
18. Auscultate the anterior and lateral chest.
19. Auscultate the posterior chest.
20. Ask patient to breathe deeply and examine for pleural friction sounds.
21. Examine for vocal audible resonance.




T**NING MANUAL FOR THE C**IOVASCULAR EXAMINATION
（心血管系统检查）

A. Heart
A-1. Patient in supine position
Inspection
Observe patient in the supine position, head elevated to 15-30 degrees
      1. Inspect the general appearance.
Inspect position, breath, skin, facies, eyes, mouth, chest configuration, extremities and nails to evaluate.
      2. Observe precordium.
Observe protrusion of the precordium and abnormal pulsations in this area. The character and location of any visible cardiac impulses should be noted. For example, the location, range and intensity of apical impulses should be observed. Minor precordial movements can be amplified by observing during expiratory apnea, Check for other movement in other areas and if present describe its location, range and intensity.
      3. Tangential lighting is necessary.
Examiner moves toward the foot of the bed when abnormality is discovered. Observing the chest surface tangentially is helpful, allowing you to see the pulsations at their maximal amplitude.
Palpation
Palpation serves: to confirm the observations made during inspection, to detect pulsatile movements that are not visible, and to reveal thrills or friction rubs in the presence of specific cardiac diseases.
      4. Palpate apical (mitral) area with two steps (palm first, then use fingertips).
The palm is especially useful for detecting thrills, fingertips are more helpful in detecting and **yzing pulsations. First the examiner uses his Palm or fingertips to palpate the apical impulse, and then use two fingertips to further localize the impulse. The normal point of maximum impulse (PMI) is usually in the fourth or fifth interspace, should not be felt in more than one interspace, usually occupies less than the first one-half of systole, and should not be felt further to the left than halfway between the midsternal line and lateral thoracic border. Left ventricular hypertrophy produces a sustained, systolic apical impulse that may be displaced laterally and downward. If the apical impulse can’t be felt, palpate with the patient on his left side (see Item 20)
      5. Palpate pulmonary area (2nd ICS-LSB)
Examine for any pulsstion, thrill, shock.
      6. palpate aortic area (2nd ICS-RSB)
Examine for any pulsation, thrill, shock.
      7. Palpate precordium (3rd, 4th, 5th, ICS, both sides of lower half of the aternum).
Palpate any pulsation, thrill, or pericardial friction rub. Right ventricular hypertrophy and dilation produce a movement that is usually more diffuse and can be felt along the left sternal esge. If a pericardial friction rub is suspected, palpate with the patient in a sitting position (see Item 22).
      8. Palpate epigastric area noting any pulsations
The pulsation of the abdominal aorta may often be felt here in the normal patient. The impulse of the volume or pressure-loaded right vertricle frequently can be felt with a finger placed under the xiphoid process while the patient gently inhales. To distinguish these two, plae the palm of your hand on the epigastric area and move your fingers up under the rib cage. The examiner can feel the aorta pulsating forward against the palmar surface of your fingers, or the right ventricle beating downward against your fingertips. Detection of thrills (palpable murmurs), is usually best accomplished using the sensitive area just proximal to the metacarpophalangeal joints.
If an abnormality is discovered on palpation, there are 2 techniques for timing it:
1) Listen simultaneously to the heart with a stethoscope. When listening at the apex you may watch the movement of the stethoscope as it usually reflects left ventricular contraction and can note its relation to the first and second heart sounds. You can also listen at the apex while watching or feeling impulses elsewhere on the chest, in order to comfirm the relation to the cardiac cydle.
2) Feel the carotid impulse in the neck with your left 2nd and 3rd fingers as you inspect or palpate the chest. The carotid impulse is systolic.
The methods of detecting and significance of thrills and shock:Thrills most often accompany loud harsh or rumbling murmurs such as those of aortic stenosis, patent ductus arterious, ventricular septal defect, and mitral stenosis. In order to time what you observe in relation to the cardiac cycle, you can use two metnods mentioned above. Short, highfrequency vibrations are known as shocks. They are palpable heart sounds, such as accentuated aortic or pulmonic valve closure; there are usually due to hypertension.
Percussion
      9. Percuss the relative dullness of the entire heart border and record the margin of the dullness
As more detailed knowlede of normal and abnormal precordial movements has been accumulated, palpation has largely replaced percussion in cardiac examination. Generally, percussion starts well to the left on the chest, from outside of the apical impulse ICS toward cardiac dullness which is normally at or medial to the midclavicular line in the fifth or possibly the fourth interspaces (See the complete physical examination Item 137). The methods of direct and indirect percussion are occasionally applicable to the estimation of heart size. When the left border of cardiac dullness falls outside the midclavicular line, the heart is usually enlarged. An actual decrease or absence of cardiac dullness per se is an important sign suggestive of pulmonary emphysema. When one cannot feel the apical impulse, percussion may suggest where to search for it. Occasionally, percussion may be your only tool. For example, a large pericardial effusion may make the impulse undetectable. Under these circumstances cardiac dullness often occupies a large area. Starting well to the left on the chest, percuss from resonance toward cardiac dullness in the 3rd, 4th, 5th. and even possibly the 6th interspaces, and then to the right of the chest above the liver dullness. Note the change with the patient’s position from reclining to sitting.
Auscultation
Five reference points are used for localization of sounds on the surface of the chest see Fig2-27 The content of auscultation includes heart rate, rhythm, heart sound, murmur and friction rub.
Endpieces of the stethoscope are of two standard types, the diaphragm and the bell. The diaphragm acts as a filter, eliminating low-pitched sounds. High-pitched sounds, such as the second heart sound, and high-pitched murmurs are best heard with the diaphragm. With the bell, the skin becomes the diaphragm, and the natural frequency varies depending on the amount of pressure exerted. When you try to detect low-pitched sounds and murmurs, therefore, the bell should be applied as lightly as possible.
While auscultating, you should follow the following sequence: Pulmonic area, Aortic area, 2nd Aortic area, Mitral area, Thicuspid area, OR Mitral area, Pulmonic area, Aortic area, 2nd Aortic area, Tricuspid area, because mitral valve diseases are more common.
      10. Using diaphragmatic chestpiece, auscultate apex at least 1 minute. If atrial fibrillation is suspected, auscultate at apex and simultaneously palpate radial pulse. Note any pulse deficit.
Use deaphragmatic chestpiece to listen at apex, for the heart beat and rhythm, for at least 1 minute. Normally the rate ranges from 60-100 per minute, and the apical beat corresponds to the radial pulse. The rhythm is regular and may change slightly with respiration, becoming faster during inspiration and slower during expiration. This is called respiratory sinus arrhythmia.
Rate lower than 60 is called bradycardia. Rate higher than 100 is called tachycardia
Many arrhythmias can be detected by careful auscultation and examination of the radial pulse simultaneously at the bedside. Pay attention to pulse deficit. Some of the common arrhythmias and their associated physical findings are listed in the Table 3-1 below. Pay attention to the characteristics of sinus arrhythmia, premature beats, paroxysmal tachycardia, atrial fibrillation, etc.

TABLE 3-1.   Characters of Common Arrhythmias
Common Arrhythmias        Arterial Pulse        Cardiac Examination
Premature contraction        Irregular        Loud S1, premature cardiac cycle with or without subsequent pause
Paroxysmal supraventricular
tachycardia        Rapid, often diminished        “bouncing precordium” with rate of 150-240 per minute
Atrial fibrillation        Irregular, pulse deficit        Variable intensity S1, Irregular rhythm

It is important that identify the first and second sounds which divide the cardiac cycle into systolic and diastolic phases, and listen to them separately. Place the diaphragm over the pulmonary area. Normally there are two sounds: S1 and S2, S1 is lower pitched, softer and longer than S2. With normal rhythm the interval between S1 and S2 is shorter than between S2 and the next S1.
Sometimes it may be difficult to identify S1 and S2, especially if they are abnormal. The following three techniques may be of value:
1) It is easy to correlate the sounds with the apex impulse, which is systolic in timing. The S1 should just precede these phenomena because of the time required for the mechanical transmission of the pulse wave.
2) The sounds can be confirmed by simultaneously feeling the carotid pulse, which is systolic in timing. The pulse corresponds to S1.
3) You can familiarize yourself with the S2 at the pulmonic area, which is invariably the louder sound, and then move the stethoscope “inch by inch” downward toward the apex, keeping the S2 sound and rhythm clearly in your mind.
Pay attention to the changes of intensity, nature and splitting of the heart sounds.
In some conditions, S1 may be intensified, i. e. , this includes high fever, tachycardia, hyperthyroidism. In other conditions, S2 may be intensified, i. e. , this includes systemic hypertension and pulmonary hypertension.
The splitting of the heart sounds may indicate cardiac abnormalities but can also occur in people with otherwise health hearts. Splitting of the second sound: In some individuals there is a slight difference in closure of the two valves. This results in the slight separation of the S2 called splitting of the second. The splitting is more prominent during inspiration. Splitting of the first sound: S1 may also be split because the mitral valve closes slightly before the tricuspid.
If an extra heart sound is discovered in systole or diastole, note its timing, intensity and pitch.
Gallop: In people with an accentuated S3, there is a t**le sound like a horse running, and, it is called a gallop. It is often associated with tachycardia. Fig .
Opening snap: In paients with mitral stenosis there may be a higher pitched, short crackling sound, immediately after S2, which is more predominant slightly to the right of the mitral area. This is called the opening snap of the mitral valve. It occure early in ventricular diastole prior to the rupid filling phase. Fig.
If a heart murmur is discovered, auscultate it carefully. To detect murmurs, concentrate on the interval between the heart sounds in each area. Differentiate systolic from diastolic murmurs. In each area, use both diaphragm and bell.
Heart murmurs are of longer duration than heart sounds. They originate within the heart itself or in its great vessels and are usually caused by one of several mechanisms, including: valve stenosis, valve regurgitation, increased flow, shunting, great vessel dilation and rupture of a valve or chordae.
Pay attention to timing, location, duration, quality, conduction, intensity, pitch and the relationship with position of the body, respiration and exercise, etc.
Timing: systolic, diastolic, continuous.
Location: point of maximum intensity. Described in terms of anatomic landmarks: apex, left sternal border, interspace and centimeters from the midsternal, midclavicular or one of the axillary lines.
Duration: Table 3-2 and Fig
TABLE 3-2. Duration of Murmurs
Short Duration        Long Duration        Medium Duration
Systolic-early, late        Pansystolic        Mid-systolic
Diastolic-early, late        Pandiastolic        Mid-diastolic
        Continuous       

Quality: blowing, rumbling, harsh or musical.
Conduction: to determine its distribution and radiation. For example, murmurs in the aortic area may radiate to the neck or down the left sternal border to the apex; those in the mitral area may radiate to the axilla.
Intensity: grade 1 to 6
Grade 1-very faint, heard only after listener has “tuned in. ”
Grade 2-quiet but heard immediately upon placing the stethoscope on the chest
Grade 3-moderately loud, not associated with a thrill
Grade 4-loud, may be associated with a thrill
Grade 5-very loud, may be heard with stethoscope partly off the chest, associated with a thrill
Grade 6-may be heard with stethoscope off the chest, associated with a thrill.
Pitch: high, medium, or low.
      11. Auscultate pulmonary area (2nd ICS-LSB)
Carefully auscultate for splitting of the second sound and murmurs.
Note the changes in the splitting related to respiration.
Differentiate among narrow, wide, paradoxical or fixed splitting related to pulmonary and pulmonary valvalar diseases.
      12. Auscultate aortic area (2nd ICS-RSB)
Carefully auscultate changes in heart sounds and murmurs related to aortic, aortic valvular disease, etc.
      13. Auscultate 2nd aortic area (3rd, 4th ICS-LSB)
Carefully auscultate changes in heart sounds and murmurs related to aortic valvular disease, ventricular septal defect, etc. Auscultate any pericardial friction rub.
      14. Auscultate tricuspid area (4th, 5th, ICS-both sides of lower half of sternum)
Pay attention to changes in heart sounds and murmurs related to tricuspid valvular, right ventricular disease, etc.
      15-19. Auscultate each area-use bell-type chestpiece and make light contact with the chest wall lightly
Pay attention to the sequence as above.
A-2. Place patient in left alteral decubitus position
      20. Palpate apical area
Ask the patient to roll partially onto the left side. The apical impulse is always more powerful with the patient on his left side, which usually displaces the apex 2-3 cm to the left and brings it closer to the chest wall. For purposes of auscultation and **ysis of the configuration of the apical impulse, this is a useful maneuver, but assessment as to location and duration of the apical impulse should be made with the patient supine.
      21. Auscultate apical area
Carefully listen at apex with the patient on his left side.
1) The third heart sound (S3) may be heard at the apex. It occurs after S2 and mimics S2, but is softer. It is low pitched and is often difficult to detect. Auscultation of the cardiac apex in the left lateral decubitus position with light application of the bell of the stethoscope is imperative for detection of this sound. It can be heard easily in mitral area. In children and young **s, it is often heard and doesn’t indicate heart disease.
2) Diastolic rumbling murmur may be heard or increased at the apex with the patient in the left lateral decubitus position.
A-3. Patient in sitting position
      22. Palpate the same areas of the precordium-as when patient was supine
Check for a pericardial friction rub. Pericardial friction rub is a to-and-fro grating sensation, which is usually present during the systolic and diastolic phases of the cardiac cycle, especially with the patient sitting erect and learning forward. It is best palpated in the left third and fourth ICS at the sternal border. It is caused by a fibrinous carditis.
      23. Auscultate each area of precordium-use diaphragm. When atrial myxoma is suspected, use bell
1) If you suspect an aortic murmur, especially the murmur of aortic regurgitation, ask the patient to sit up, lean forward, exhale completely and hold his breath in expiration. With the diaphragm of your stethoscope pressed on the chest, listen at the aortic area and down the left sternal border to the apex, pausing periodically so the patient may breath. The murmur of obstructive hypertrophic myocardiopathy may increase with the patient in the sitting position.
2) Pericardial friction rub of pericardium is a to-and-fro rubbing or grating sound, heard in both phases of the cardiac cycle and unaffected by respiration. It is increased when the patient is sitting upright or leaning forward, and when the examiner presses the diaphragm of the stethoscope firmly against the patient’s chest wall.
3) If atrial myxoma is suspected and a rumbling diastolic murmur is not heard clearly, auscultate the apical area with bell contacting the chest wall lightly and patient in a sitting position. This will cause the murmur to increase and be easily heard.

B. Vessel
B-1. Upper limbs
      24. Measure blood pressure in right arm. If hypertension is discovered, measure blood pressure in left arm. When secondary hypertension is suspected, also measure blood pressure in both lower limbs.
In order to determine the systolic blood pressure adequately and to exclude an error as a result of an auscultatory gap, blood pressure is first assessed by palpation. In this procedure, the right brachial or radial artery is palpated while the cuff is inflated above the pressure required to obliterate the pulse. The systolic pressure is identified by the reappearance of the brachial pulse while the cuff is deflated. Measurement of blood pressure by auscultation is described in the complete physical examination Items 7-10. The normal ** blood pressure varies over a wide range. The normal systolic pressure varies from 95 to 140mmHg, generally increasing with age. The normal deastolic range is from 60 to 90 mmHg. Pulse pressure is the difference between the systolic and diastolic pressures. Mean pressure can be approximated by dividing the pulse pressure by three and adding this value to the diastolic pressure. The pressure should be determined in both arms, at least during the initial evaluation. One may have a normal variation of up to 10mmHg between the two arms. When it is advisable to measure the blood pressure in the leg, such as when a congenital narrowing (coarctation) of the aorta or dissecting aortic aneurysm is suspected, the palpation method should be employed with the patient prone. Apply the cuff to the calf or thigh and estimate the systolic level by palpating the tibial or dorsalis pedis artery. The systolic pressure in the leg is normally equal to or higher than that in the arm. It is never critical to measure the diastolic pressure in the leg.
High blood pressure may be present in essential hypertension, kidney disease, Cushing’s syndrome, etc. Low blood pressure may of course be present in shock states or may accompany cachexia, prolonged bed rest, pericardial effusion, constrictive pericarditis and adrenal insufficiency.
      25. Examine nail beds and hands. Check for cyanosis, clubbing.
Examine the color of nail beds and angle between nail and basic bed of the nail.
      26. Check for capillary pulsation when wide pulse pressure is present
Examine capillary pulsation by pressing on nails or lips with a clean glassand looking at the change of color from pink to white. Capillary pulsation occurs in aortic insufficiency and other abnormalities associated with wide pulse pressure.
      27. palpate radial (wrist) pulse (at least 30 seconds), check for rate, rhythm.
It is described in the complete physical examination Item 4. Check strength of the beat and elasticity of artery. If left heart failure is discovered, check if there is pulsus alternans.
      28. Palpate radial pulses simultaneously for symmerty
It is described in the complete physical examination Item 5.
      29. Check if there is water-hammer pulse when wide pulse pressure is present.
It is a bounding pulse and re***rced by elevating the arm above the head. It occurs in aortic insufficiency and other abnormalities associated with wide pulse pressure.
      30. Palpate radial pulses and check for pulsus paradoxus when pericardial effusion is suspected
Pulsus paradoxus is an important sign of cardiac tamponade. It is found with tense pericardial effusions and less freauently with chronic constrictive pericarditis. The term refers to a weakening of the pulse during normal inspiration. It is really a misnomer, however, because this is an exaggeration of the normal (up to 10 mmHg) inspiratory decline in systolic blood pressure. Although pulsus paradoxus may be detected by palpation, it is more reliably quantitated by using the sphygmomanometer. As the pressure in the cuff is slowly reduced, the first Korotkoff sound will appear only during expiration (upper systolic level). As one lowers the pressure, the sounds begin to occur in both inspiration and expiration (lower systolic level). A difference of greater than 10 mmHg between there two points is abnormal. A common non cardiac cause of pulsus paradoxus is the labored respiration of the patient with obstructive pulmonary disease (asthma, emphysema).

B-2. Neck
      31. Observe and approximately measure the venous pressure in either the internal or external jugular vein
Check the jugular veins (also see the complete physical examination Item 133). Both external and internal jugular veins require careful inspection: external vein for estimation of mean right atrial pressure, and internal vein for wave form as well as pressure. Ask patient to assume a sitting or 30-45 degree semirecumbent position. If an engorged external jugular vein can be seen above the clavicle, this indicates increased venous pressure. This can be measured by adding 5cm to the vertical distance in centimeters between the sternal angle and the highest point of oscillation in the internal jugular veins. Fig. 3-17. Normally the highest point is no more than 3cm above the sternal angle with the patient semi-recumbent. In most positions, whether upright or supine, the sternal angle is roughly 5-7cm above the right atrium. Venous pressure varies from 5 to 10cm of H20. Jugular venous pressure elevation is an important sign of congestive heart failure, pericardial constriction, pericardial effusion and superior vena cava syndrome which may result from mechanical obstruction to venous inflow.
      32. Observe neck, check for jugular venous wave form in internal jugular vein when the pressure of vein is increased
Jugular venous pulses (wave form) are not easy to see normally, but may demonstrate specific changes in complete atrioventricular block, tricuspid stenosis or regurgitation, and pulmonary hypertension with right ventricular hypertrophy. This will be studied in Internal Medicine. It is important to differentiate venous from arterial pulsations. The venous pulse is diffuse and andulant. Venous pulsations in the neck are lower and more lateral, either under or just behind the sternocleidomastoid muscle, without a palpable impulse. Arterial pulsations in the neck are localized and brisk and are usually best seen high and medial to the sternocleidomastoid muscle. The differential key points are as follows:
1) The level of visible pulsation in the neck vein descends with inspiration, (although the venous waves may become more prominent during inspiration) because thoracic pressure decreases. Arterial pulsations do not vary with respiration.
2) Venous waves can usually be obliterated by moderate pressure at the base of the neck. Arterial pulsations can be obliterated by much more pressure.
3) Arterial pulsations are unaffected by position but the venous pulse usually disappears or markedly decreases in a sitting position.
4) Venous waves are polyphasic during normal sinus rhythm, including A, C, V positive deflections and X, Y negative deflections. Fig3-18. Arterial pulse has only one positive deflection. Perhaps the simplest method is to use vision and touch, observing the venous pattern while palpating the oppositc carotid pulse.
      33. Examine hepato-jugular reflux
Examine hepato-jugular reflux with patient recumbent so that the highest level of pulsation is readily identifiable in the lower half of the neck. Press over the patient’s right upper abdominal quadrant firmly for 30-60 seconds and look at the external jugular vein. Normally it is not engorged. The engorgement indicates that blood is being transmitted from the liver to the superior vena cave and is called hepato-jugular reflux. A rise of more than 1 cm is abnormal and usually is an important sign of right ventricular failure or pericardial effusion or constriction.
      34. Palpate carotid artery bilaterally
It is described in the complete physical examination Item 64.
      35. Auscultate both sides of neck, check for carotid bruit
Generally, use the diaphragmatic chestpiece of the stethoscope to listen for a bruit. Pay special attention to the carotid artery and the lower half of the neck.

B-3. Abdomen
      36. Auscultate abdominal aorta (midline of abdomen)
Place diaphragmatic chestpiece firmly in the midline of abdomen about 5cm above the umbilicus, auscultate for any bruits.
      37. Auscultate reanl arteries (RUQ and LUQ)
Place diaphragmatic chestpiece firmly about 5 cm above the umbilicus and 3-5cm laterally to the right and to the left of midline, auscultate for any bruits.

B-4. Lower limbs
      38. Palpate femoral artery
Feel the femoral impulse midway between the pubic symphysis and the anterior superior iliac spine. palpate both sides for symmetry.
      39. Auscultate femoral artery, note if there pistol-shot sound and Duroziez sign when aortic insufficiency is suspected.
If one of the femoral pulses is diminished or absent, auscultation for a bruit is necessary. Place diaphragmatic chestpiece firmly over the femoral artery and auscultate for any bruits. The presence of a bruit may indicate obstructive aorto-ilio-femoral disease.
When aortic insufficiency is suspected, put the bell head on the femoral artery to auscultate for a pistol-shot like “Ta-Ta” sound. Press the distal edge of the bell over the femoral artery to hear the to and fro bruit called Duroziez sign. Both of the sounds are associated with increased pulse pressure. Normally a systolic murmur can be heard in severe anemia only when the proximal edge of the bell head is pressed over the femoral artery.
      40. Palpate dorsalis pedis pulse
Palpate both sides for symmetry. It is described in the complete physical examination Item 168.
      41. Check for pitting edema (at least 15 seconds)
It is described in the complete physical examination Item 169.



Checklist for the cardiovascular examination
（心血管系统检查大纲）
A. Heart
A-1. Patient in supine position
Inspection
1. inspect the general appearance.
2. Observe precordium.
3. Tangential lighting is necessary.
Palpation
4. Palpate apical (mitral) area with two steps (palm first, then use fingertips). If the apical impulse can’t be felt, palpate with the patien ton his left side (see Item 20)
5. Palpate pulmonary area (2nd ICS-LSB)
6. Palpate aortic area (2nd ICS-RSB)
7. Palpate precordium (3rd, 4th, 5th, ICS, both sides of lower half of the sternum). If pericardial friction is suspected, palpate with the patient in a sitting position (see Item 22)
8. Palpate epigastric area
Percussion
9. Percuss the relative dullness of the entire heart border and record the margin of the dullness
Auscultation
10. Using diaphragmatic chestpiece, auscultate apex at least 1 minute. If atrial fibrillation is suspected, auscultate at apex and simultaneously palpate radial pulse. Note any pulse deficit.
11. Auscultate pulmonary area (2nd ICS-LSB)
12. Auscultate aortic area (2nd ICS-RSB)
13. Auscultate 2nd aortic area (3rd, 4th ICS-LSB)
14. Auscultate tricuspid area (4th , 5th , ICS-both sides of lower half of sternum)
Auscultate each area-use bell-type chestpiece and make light contact with the chest wall lightly
15. Using bell chestpiece, auscultate apex
16. Auscultate pulmonary area
17. Auscultate aortic area
18. Auscultate 2nd aortic area
19. Auscultate tricuspid area
A-2. Place patient in left lateral decubitus position
20. Palpate apical area
21. Auscultate apical area
A-3. Patient in sitting position
22. Palpate the same areas of the precordium-as when patient was supine
23. Auscultate each area of precordium-use diaphragm. When atrial myxoma is suspected, use bell

B. Vessel
B-1. Upper limbs
24. Measure blood pressure in right arm. If hypertension is discovered, measure blood pressure in left arm. When secondary hypertension is suspected, also measure blood pressure in both lower limbs.
25. Examine nail beds and hands. Check for cyanosis, clubbing.
26. Check for capillary pulsation when wide pulse pressure is present
27. Palpate radial (wrist) pulse (at least 30 seconds), check for rate, rhythm.
28. Palpate radial pulses simultaneously for symmetry
29. Check if there is water-hammer pulse when wide pulse pressure is present.
30. Palpate radial pulses and check for pulsus paradoxus when pericardial effusion is suspected
B-2. Neck
31. Observe and approximately measure the venous pressure in either the internal or external jugular vein
32. Observa neck, check for jugular venous wave form in internal jugular vein when the pressure of vein is increased
33. Examine hepato-jugular reflux
34. Palpate carotid artery bilaterally
35. Auscultate both sides of neck, check for carotid bruit
B-3. Abdomen
36. Auscultate abdominal aorta (midline of abdomen)
37. Auscultate renal arteries (RUQ and LUQ)
B-4. Lower limbs
38. Palpate femoral artery
39. Auscultate femoral artery, note if there is pistol-shot sound and Duroziez sign when aortic insufficiency is suspected.
40. Palpate dorsalis pedis pulse
41. Check for pitting edema (at least 15 seconds)


T**NING MANUAL FOR THE ABDOMINAL EXAMINATION
（腹部检查）

The following anatomic landmarks should be recognized in order to describe the location of pain, tenderness and other abnormal findings:
—xiphoid (ensiform) process of sternum
—costal margin
—umbilicus
—anterosuperior iliac spine
—inguinal ligament
—superior margin of os pubis
—anterior midline
—lateral border of rectus muscle
Abdominal mapping-there are two commonly used methods of subdividing the abdomen—the abdomen is divided into four quadrants. A line is dropped from the sternum to the pubic bone through the umbilicus and a second line is placed at a right angle to the first through the umbilicus. Four areas can be outlined utilizing the quadrant map i. e. RUQ, LUQ, RLQ, LLQ. The content of the abdomen underlying each of the four quadrants in both males and females should be known.
—the abdomen is divided into nine sections (this method is less commonly used). Draw imaginary, parallel, horizontal lines across the lowest border of the costal margin and the anterior superior iliac crest. The two vertical lines are dropped from the middle of Ponpat’s ligament, approxmating the lateral borders of the abdominal recti muscles. Nine areas can be outlined with these four lines. The content of the abdomen underlying lack of the nine areas should also be known.

A. Preparation
      1. Ask the patient to urinate completely to be sure that the bladder is empty.
      2. Patient should be lying on his back with a pillow under his head and his knees bent to relax his abdominal muscles.
Be sure the arms are on either side, not behind his head. A little conversation or repeating of the patient’s history might help to relax the patient.
      3. Expose abdomen completely from the breasts to pubis
For female patients, breasts should be covered with a sheet.
B. Inspection
      4. Observe abdominal contour and symmetry
Check skin for straie and scars. Check umbilicus for location and shape. Observe abdominal contour for symmetry, distension, protuberance, flatness, or scaphoid shape should be judged according to an ideal level from xiphoid to pubis. The distribution of pubic hair and its relationship to sex of patient should be noted.
      5. Observe abdominal veins
If a vein is engorged, the direction of flow can be demonstrated by placing the index fingers side by side over the vein, pressing laterally, separating the fingers one by one, and observing the time it takes the veins to refill from each direction; the flow of venous blood is in the direction that fills the fastest; In the presence of inferior vena caval obstruction, superficial veins may dilate and drain upward toward the head. This is reversed in superior vena caval obstruction, i. e. they drain downward towards the feet with portal hypertension, the dilated veins appear to radiate outward from the umbilicus. (Fig 3-20).
      6. Observe respiration, peristalsis or pulsation tangentially
Respiratory movements—respiration in a female is mainly costal, little movement of the abdominal wall occure; in males and children , the breathing is quiet with the major respiratory movement being abdominal. Restriction of the abdominal phase of respiration, especially in the male patient, may be found in disease and inflammation below the diaphragm (particularly peritonitis).
Visible peristalsis—in lean individuals, even in the absence of disease, motility of the stomach and intestines may be reflected in movement of the abdominal wall. When strong contractions are visible through an abdominal wall of average thickness, the possibility of bowel obstruction should be investigated. Reverse peristalsis indicates pyloric stenosis, duodenal stenosis, or malrotation of the bowel.
      7. Measure the abdominal circumference
Circumference should be measured in centimeters at the level of the umbilicus with a soft tape measure during normal abdominal breathing.
      8. Observe inguinal area for mass or enlarged lymph nodes
With the patient lying in the bed, examiner should ask him to cough while examiner inspects the inguinal/femoral area. By increasing intra-abdominal pressure, examiner may produce a sudden bulging in this area which may be related to a hernia.
C. Auscultation
      9. Bowel sounds
Auscultate bowel sounds with diaphragmatic head of stethoscope for at least one minute. If there are no bowel sounds, listen until you hear them or for at least 5 minutes. Normal bowel sounds are a glue-glue, glue-glue-like sound occurring either separately or together, approximately 3-5 times per minute. Pay attention to the frequency, pitch and intensity. High-pitched (gurgling) sounds with increased frequency are regarded as hyperactivity. Lack of bowel sounds indicate little or no peristalsis.
      10. Murmurs or bruits
Murmurs from arteries are called bruits and are similar to lowerpitched heart murmurs. Murmurs from veins sound like a hum and are more continuous; they are called venous bruits. Auscultate abdominal murmurs with bell-type head of stethoscope:
Left upper quadrant to include (L) renal artery
Right upper quadrant to include (R) renal artery
Right lower quadrant to include (R) iliac artery
Left lower quadrant to include (L) iliac artery
Aorta along the midsternal line
      11. Succussion splash in the epigastric area
Succession splash is the splash sound over the upper abdomen. It should be checked by rocking the upper abdomen to the left and rigth. In normal patients this is negative about 6-8 hours after eating food. If positive, it indicates gastric retention.
      12. Friction rubs over the liver and spleen
Listen with stethoscope over liver and spleen while patient breathes deeply.
D. Percussion
      13. General percussion
All four quadrants of the abdomen are evaluated by percussion.
Tympany is the most common percussion sound in the abdomen due to gas collection. It is appreciated over the stomach, small intestine, and colon.
      14. Percussion of the liver
Percussion of liver span: should be done with the patient breathing normally. Percussion should occur through the right midclavicular line from resonance over the lung field downward to dullness and from tympany over abdomen upward to dullness. Measure from upper to lower border of dullness for liver span. It is normally about 9-11 cm in the midclavicular line.
Fist percussion of liver—tell the patient what you intend to do before you start. Examiner places one palm over the area of liver dullness. Examiner then hits that hand gently with the fist of his other hand. Examiner should watch the patient’s facial expression and withdrawal effort and ask him if it hurts. If pain occurs, do fist percussion at the same site on the left side for comparison and pay attention to the intensity and site of the pain. (Fig 3-21).
      15. Percussion of the spleen
percuss for splenic dullness. This should be done when splenic enlargement is suspected.
Percuss the lowest intercostal space in the left axillary line. This area is usually tympanitic. Then ask the patient to take a deep breath. When the size of the spleen is normal, Fist percussion of spleen— as discussed in fist percussion of liver
      16．Percussion of the stomach
Percuss the stomach over the left upper quadrant for the range of Traube tympanic area. Percussion may pass through left midclavicular line vertically and back to the posterior axillary line.
      17．Percussion for shifting dullness
Percuss shifting dullness with the patient supine. Fluid dullness is percussed laterally. The line of demarcation between the dull and tympanitic sounds is marked, and the patient is then asked to lie on his right side. All of the ascites will flow to a dependent portion on the right side of the abdomen. A new line is marked and the change is measured in centimeters. Subsequently, the patient is turned to the left side and the procedure repeated and the change is recorded. A volume of free fluid in the peritoneal cavity greater than 1000 ml can be detected with this method. To simplify the procedure, the examiner first determines the point from tympany to dullness with the patient in the supine position. The patient is then asked to turn on his side while the examiner holds his pleximeter on the point where the change in percussion sound occurred. The examiner then percusses this same point again. If the sound changes from dullness to tympany, it means that the dullness has been shifted to a more dependent position. This implies that ascites is present. (Fig3-22).
      18．Testing for a fluid wave
Examiner places one of the patient’s hands, or the hand of another examiner, in the middle of the patient’s abdomen to indent the abdominal wall and stop transmission of the impulsed wave. The examiner then taps one flank while palpating the other side. Detection of a fluid wave is quite specific for ascites.

E. Palpation
      19．palpate four quadrants superficially from LLQ counterclockwise
Palpate all areas of the abdomen counterclockwise and superficially from left lower quadrant screening for tenseness, tenderness, masses, etc. Examination is begun with gentle maneuvers and then palpation occurs more deeply. Examiner uses the palms of his hands with fingers together and arm relaxed and forearm on a horizontal plane. The examiner presses with his fingers. (Fig2-24).
      20．Palpate four quadrants deeply
Using the palmar surface of the fingers, examiner palpates in four quadrants to identify masses, tenderness, pulsations, etc. The abdominal wall should be depressed more than 2 cm. When deep palpation is difficult,examiner may want to use left hand placed over right hand to help exert pressure. If a mass is suspected, determine its size, contour, mobility, tenderness, smoothness, irregularity, the hardness or softness and listen with stethoscope for a bruit over the mass. If there is tenderness, determine the point of maximum tenderness and distribution.
To check for rebound tenderness, palpate deeply at the point of tenderness, Pause briefly, then remove the fingers quickly. Watch the patient’s face to see if it hurts. Then check other areas in the same manner for comparisom.
      21．Palpate liver at midclavicular and midsternal lines
In the midclavicular starting at the anterior superior iliac crest, examiner presses down firmly and asks patient to inhale deeply. This allows the liver to move down to meet your fingertips. If you feel nothing, press up a few centimeters toward the rib cage and repeat the maneuver. Do this continuously until you feel the liver or reach the costal margin. In the midsternal line, from the level of the umbilicus, repeat the above maneuvers to palpate the liver. If you feel the liver, detect the edge (sharp of  round ), tender or not, hard or soft and repeat the process laterally and medially to define the contour. For masses within the liver, describe the same characteristics as above and listen for a bruit over the mass. Normally, the liver can not be felt more than 1 cm below the lower costal margin, and can not be felt more than upper 1/3 distance of the line from xiphoid to umbilicus. Failure to feel the liver does not mean that the liver is mormal. Measurement of the liver is done in the midclavicular line and midsternal line. Most doctors like to use bimanual maneuvers to palpate the liver. To do this, place the left hand at right lower posterior chest wall parallel to, or supporting patient’s right 11-12th ribs or at lower sternal area to limit the chest respiration to make right hand palpation more effective.
      22．Palpate spleen from umbilicus to left costal margin
For palpation of the spleen examiner puts his left hand behind the left rib cage while his right hand palpates the spleen in the left upper quadrant. Starting from the level of the umbilicus (or below the percussed dullness). The maneuver is similar to that used to palpate the liver, but is more subtle because the spleen is more mobile and deeper than the liver. If the spleen is not palpated, have the patient roll on tis right side and repeat palpation. Measurement of the spleen is the same as that of the liver and is usually expressed as centimeters under the costal margin in the midclavicular and under the xiphoid process in the midsternal lines. A moderately or greatly enlarged spleen is best described by a drawing, especially the three lines which are presented schematically in the following diagram (NOTE: Severe splenomegaly may cause rupture when spleen is vigorously palpated, so palpate gently and carefully).
      23．Palpate gall bladder
Put right hand below the costal margin or lower border of liver at midclavicular line (grossly equal to the lateral border of the right rectus muscles) and palpate deeply to check for tenderness of bulging
      24．Check for Murphy’s sign
If pain is found in the gall bladder area, examiner should put his left hand on the hower lateral rib cage with the 4 fingers stretching superiorly and the thumb hooked under the costal margin. Press down to the point of gallbladder tenderness and ask the patient to breathe deeply and check to see if patient stops breathing, changes facial expression, or complains of pain.
      25．Palpate kidneys bimanually
For palpation of the kidney, examiner puts his left hand below left rib cage, at the costospinal angle, and lifts up. Examiner uses his right hand to palpate deeply from umbilical level in the left midclavicular line, and moves progressively upward. The lower pole of the kidney may be felt as a smooth, round, and deep structure that moves relatively little with respiration. This maneuver is repeated on the right side to palpate the right kidney. The lower pole of the right kidney may be felt in normal patients. Repeat the maneuver with the patient in sitting and standing positions if you wish to expose the kidney further. (Fig3-30).
      26．Test for pain or touch sensation on abdominal wall (see neurological examination)
      27．Test for abdominal reflex (see neurological examination)

Checklist for the abdominal examination
（腹部检查大纲）

A．preparation.
1.  Ask the patient to urinate completely to be sure that the bladder is empty
2．Patient should be lying on his back with a pillow under his head and his knees bent to relax his abdominal muscles.
3．Expose abdomen completely trom the breasts to pubis
B．Inspection
4．Observe abdominal contour and symmetry
5．Observe abdominal veins
6．Observe respiration, peristalsis or pulsation tangentially
7．Measure the abdominal circumference
8．Observe inguinal area for mass or enlarged lymph nodes
C．Auscultation
9．Bowel sounds
10．Murmurs or bruits
11．Succussion splash in the epigastric area
12．Friction rubs over the liver and spleen
D．Percussion
13．General percussion
14．Percussion of the liver span
15．Percussion of the spleen
16．Percussion of the stomach
17．Percussion for shifting dullness
18．Testing for a fluid wave
E．Palpation
19．Palpate four quadrants superficially form LLQ counterclockwise
20．Palpate four quadrants deeply
21．Palpate liver at midclavicular and midsternal lines
22．Palpate spleen from umbilicus to left costal margin
23．Palpate gall bladder
24．Check for Murphy’s sign
25．Palpate kidneys bimanually
26．Test for pain or touch sensation on abdominal wall
27．Test for abdominal reflex








T**NING MANUAL FOR THE SPINE
（脊柱检查训练）

      1．Inspect spine
With the patient in a standing position, carefully inspect the spine for any postural abnormalities. Three basic types of abnormalities are generally recognized.
①A lateral curvature of the spine is known as scoliosis. It is a sign of poliomyelitis and rickets.
②Kyphosis is the term used to tescribe backword curvature of the spine. It can be seen in the patient with tuberculosis, fracture or tumor of vertebra, and ankylosing spondylitis.
③Lordosis refers to a forward curvature of the spine. It may be seen in patients with a large amount of ascites, tumors of the abdominal cavity and tuberculosis of the hip joint. The normal concave curvature of the lumbar spine is called lumbar lordosis.
To check for abnormllities, the examiner presses his index and middle finger on the patient’s spinous process from top to bottom rapidly. The skin shows a red line. This can indicate lateral curvature of the spine.
      2．Check for tenderness of spine to palpation
The patient with organic spinal disease including disease of the lumbar, thoracic and cervical vertebra may have obvious tenderness and percussion pain. Tenderness-the examiner presses firmly on the patient’s spinous process with his thumb from top to bottom. Normally the spine exhibits no tenderness. In the patient with tuberculosis, fracture of vertebra, or protrusion of the intervertebral disc, there will be obvious tenderness. If the spinous process or paraspinal muscles exhibit tenderness, this indicates that the patient has acute strain or injury of the muscles of the back.
      3．Check for indirect percussion pain
Indirect percussion-the patient is in a seated position. The examiner places the patient’s left hand on top of the patient’s head and makes a partial fist to percuss on the patient’s left hand with hypothenar eminence and notes the patient’s painful appearance.
      4．Check for direct percussion
The examiner birectly percusses every spinous process with a percussion hammer of finger. This method mainly is used in examination of the lumbar and thoracic vertebra. Normal individuals have no percussion pain while the patient with TB or fracture of the lumbar spine has obvious percussion pain.
      5．Check for cervical spine motion: flexion
The normal concave curvature of the cervical spine is called cervical lordosis. Straightening of this should be noted. The examiner instructs the patient to touch his chin to his chest. The examiner is estimating the number of degrees the patent can move his neck from the erect position. This motion is performed only actively (moving neck without assistance). Examiner should never push down on the patient’s head, thying to see if patient can go any further. Normal flexion of the cervical spine is about 35 degrees. Decreased flexion may be seen in patients with rheumatoid arthritis.
      6．Extension
The examiner asks the patient to tip his head backward as for as possible, or look up at the ceiling. The normal cervical spine can be extended backword about 40 degrees.
      7．Lateral bending
The examiner asks the patient to touch his right ear to his right shoulder, ther his left ear to his left shoulder. The occurrence of pain on the side opposite to which the patient is bending suggests muscle pain. Normal lateral bending allows about 40 degrees to eaah side.
      8．Rotation
To test the rotation of a patient’s neck, the examiner asks the patient to touch his chin to each shoulder without raising his shoulder to meet the chin. Normal rotation allows abut 60-80 gegrees of movement in each direction.
      9．Test rotation of patient’s head against resistance
Test the muscles of the patient’s neck (sternocleidonastoid muscle) by asking the patient to bring his chin to his shoulder against the resistance exerted by the examiner. Both sides should be checked.
      10．Brachial plexus tightening test
The examiner holds the patient’s hand, abducts the upper extremity, while pushing the patient’s head to opposite side (ear to shoulder) to stretch the patient’s upper limb. Pain indicates compression of the cervical spine nerve roots.
      11．Lumbar flexion
The xeaminer asks the patient to bend forward at the waist and attempt to touch his toes and notes the degree of fleion. Normally, the entire spine flexes about 45°from an upright position. The examiner should note the presence of sharp, abnormal angulation of the spine.
      12．Picking up thing test
If the patient has a demonstrated limited movement of the lumbar spine as he bends for ward, the examiner asks the patient to pick up something which has already been placed on the ground. Normally, individuals can bend from the waist to pick ou the material. This is called negative picking up thing test. In the patient with spinal disease, the patient’s sacrospinalis is spastic and the patient can’t bend from the waist. He then flexes hips and knees and keeps the lumbar spine straight. The patient places one hand on his own knee and carefoully picks up the object with the other hand. This kind of behavior is called positive picking up thing test.
      13．Extension
To test extension, the examiner asks the examiner asks the patient to bend backward as far as possible. The examiner can stabilize the patent’s hips and pelvis by standing hehind the patient, holding the patient’s pelvis on either side. Nornal extension is usually about 30 degrees from the upright position.
      14．Lateral bending
lateral motion of the spine is sideways bending. The examiner can stabilize the patient’s hips in the manner described above, asking the patient to bend at the at the waist to his right, then to his left. Normally, the spine bends about 30°in cach direction from the upright position.
      15．Rotation
The examiner stabillzes the patient’s hips and pelvis as described above, and has the patient turn his shoulder to the right, and then to the left. Normally, the trunk can rotate about 30 degrees to either side when the pelvis is stabilized. Rotation of the trund includes both lumbar and thoracic spine movements.

Checklist for the spine
（脊柱检查大纲）

1．Expose and inspect spine
2．Check for tenderness of spine to palpation
3．Check for indirect percussion pain
4．Check for direct percussion
5．Check for cervical spine motion: flexion
6．Extension
7．Lateral bending
8．Rotation
9．Test rotation of patient’s head against resistance
10．Brachial plexus tightening test
11．Lumbar flexion
12．Picking up thing test
13．Extension
14．Lateral bending
15．Rotation

T**NING MANUAL FOR REFLEX SYSTEM
（神经反射检查训练）

Reflexes are graded as follows:
（－）absence of the feflex
（＋）hypoactive without movement of the joint; may be normal or abnormal
（＋＋）physiological or normal
（＋＋＋）hyperactive without clonus, may be normal or abnormal
（＋＋＋＋）hyperactive with transient clonus
（＋＋＋＋＋）markedly hyperactive with sustained clonus; it is pathological, e. g. ankle clonus and patellar clonus

E-1．Deep Reflex
      1．Biceps reflex
The patient bends his elbow at about 90°with the palm down. Examiner places finger of thumb on the biceps tendon and taps it with the reflex hammer. The reaction is rapid flexion of the forearm.
      2．Triceps reflex
Hold the patient’s arm flexed at the elbow away from the body and with a reflex hommer percuss the tendon of the triceps above the olecranon. The reaction is extension of the forearm.
      3．Brachioradialis reflex
The patient’s arm should rest on his abdomen of in his lap with palm down. The examiner strikes the tendon overlying the radius with a reflex hommer. The reaction is flexion and pronation (moving the palm downward) of the forearm.
      4．Patellar reflex (knee jerk)
Patient in supine position: The examiner holds the patient’s leg below the knee, and taps the quadriceps femoris muscle tendon below the patella with a reflex hommer. The reaction is extension of the knee.
Patient in sitting position: The patient flexes his knee to about 90°. Examiner taps pstient’s quadriceps femoris muscle tendon.
      5．Achilles tendon reflex (ankle jerk)
Pattent in supine position: The examiner asks the patient to partially flex and externally rotate the thigh and dorsiflex the ankle. Examiner grasps the patient’s forefoot with left hand and with reflex hammer in right hand, taps the Achilles tendon. The reaction is plantar flexion of the ankle.
(The followitn two tests were initially thought to be pathological feflexes. In facet, they are hyperactive deep tendon feflex. If the clonus is sustained, it is a important sign of disease of the pyramidal tracts.)
      6．Patellr clonus
The patient is in supine position with hip and knee extended. The examiner places one hand under the knee and holds the upper edeg of the patellar with the thumb and index finger of the other hand, pushes it down suddenly and maintains constant downward force. The patellar shows a series of regular upward and downward movements.
      7．Ankle clonus
With slightly bended patiet’s hipand knee joints. The examiner supports the leg under the knee with his left hand and grasps the front part of the patient’s foot with his right hand and dorsiflexes the foot suddenly and maintains it in that position. The reaction is the regular contraction of of the Achilles tendon.

E-2．Superficial feflex
      8．Abdominal reflex
The patient is in the supine position. With a bamboo pick, the examiner lightly strokes the abdomen moving from lateral to medial portion at coastal margin (T7-8), level of umbilicus (T9-10) and above groin (T11-12). The reflex is contraction of the abdominal muscles.
      9．Cremasteric feflex
The patient is in the supine position with his thighs slightly abducted. With a bamboo pick, the examiner strokes the inner aspect of the patient’s thigh downward. The reflex is elevation of the testicle.

E-3．Pathologic Reflex
Pathologic reflexes are abnormal and only occur in the patient with central nervous system damage.
      10．Hoffman reflex
Patient’s middle phalanx of the middle finger is supported by examiner’s index and middle finger. Patient’s wrist is in dorsiflexion. The examiner taps the nail of patient’s middle finger with thumb. The reflex is flexion of thumb and other fingers. It results from disease of the pyramidal tract.
      11．Babinski reflex
The lateral aspect of the sole is stroked with a bamboo stick from the heel to the ball of the foot and curved medially across the head of the metatarsal bones. The positive sign is that the big toe shows dorsiflexion and the other toex show fanning (abduction). It is called Babinski’s reflex abd results from pyramidal tract disease. The following tests described in items 72—74 have the same positive sign but are less sensitive.
      12．Chaddock sign
Stroke the skin along the outside aspect of the foot from the heel to the toes below the external malleolus.
      13．Oppenheimer sign
With index and middle finger, the examiner strokes the skin along the medial side of the tibia beginning just below the knee and carries the stimulus rather slowly downward to the ankle.
      14．Gordon sign
Place thumb and other fingers on patient’s gastrocnemius muscle and pinch and compress it with proper strength.

E-4．Meningeal Stemulation Sign
The meningeal signs will occur in patients with stimulation of the meningeus, e. g. infection (meningitis) or blood (as in subarachoid hemorrhage)
      15．Neck rigidity
The patient is in a supine position. Examiner supports patient’s head with left hand and flexes the patient’s neck toward the chest wall to observe the resistance.
      16．Kerning sign
The patient is in a supine position with flexed hip and knee at about 90°，then the examiner elevates the patient’s leg. Normally the knee can be extended to about 135°. The positive response is less than 135°accompanied by pain.
      17．Brudzinski sign
The patient is in supine position with both legs extended and relaxed. The patient’s neck is flexed passively and the examiner observes if the patient flexes his hips and knees. If so, we call it a positive Brudzinski sign.

Checklist for the Reflex System
（神经反射检查大纲）

1．Biceps reflex
2．Triceps reflex
3．Brachioradialis feflex
4．Patellar reflex (knee jerk)
5．Achilles reflex (ankle jerk)
6．Abdominal reflex
7．Gremasteric reflex
8．Hoffman reflex
9．Babinski reflex
10．Haddock’s sign
11．Oppenheimer’s sign
12．Gordon’s sign
13．Patellar clonus
14．Ankle clonus
15．Neck rigidity
16．Kerning’s sign
17．Brudzinski’s sign


T**NING MANUAL FOR AXILLARY EXAMINATION
(腋窝检查训练)

Axillary lymphatic nodes can be divided into 5 groups:
The top (apex) group is located at the top of the axilla and gets drainage from the other axillary lymph nodes.
The anterior (pectoral) nodes are located within the anterior axillary fold, behind the pectoral muscles.
The posterion (sub scapular) nodes are felt in the posterior axillary fold.
The medial nodes are located in the center of the axilla and the most frequently palpable.
The lateral nodes are felt along the upper portion of the humerus.
      1．Inspect the patient’s right axilla
Hold the patient’s right wrist and raise her arm up with your right hand to inspect the right axilla.
      2．Palpate 5 chains of lymph nodes on right
Rest the patient’s right arm on your examining arm and put you left hand to the very top of the axilla to feel the top group. Then turn your palm forward to feel the anterior group. Then turn your hand towards the chest wall and gently move down to feel the middle group. Then raise the patient’s arm again. This time turn your hand backwards to feel the posterior group. Then feel the lateral group along the upper humerus.
      3．Inspect the patient’s left axilla
      4．Palpates five chains of lymph nodes on left: top, medial, anterior, posterior, and lateral


















COMPLETE PHYSICAL EXAMINATION T**NING MANUAL
(全身体格检查内容和顺序)

   This manual with its companion checklist for the complete physical examination emphasizes the sequence of the complete physical examination and the relevant techniques for each item. The student should master the examination item by item including appropriate sequence. This will enable him to perform the complete physical examination smoothly and efficiently from head to toe. Some additional details of techniques and the clinical significance of various findings will be described in the appropriate organ system examinations. For more in depth learning and theoretical explanations, please refer to textbooks and reference books.


A. GENERAL EXAMINATION/VITAL SIGNS
（一般检查）

      1. Introduce yourself to patient, usually last name and title and have a little conversation to relax the patient and to judge mental state.
      2. Wash hands before starting examination
Preferably, this should be done in view of the patient.
      3. Patient is seated in a chair
      4. Palpate radial (wrist) Pulses for at least 30 seconds and record
The examiner places the pad of his index, middle and ring fingers over the radial artery. If properly done, the examiner should be able to feel the artery pulsating under the examiner’s fingertips. The radial pulse may be measured for 30 seconds, then the pulse perminute can be found by multiplying by two. Attention should also be paid to the rhythm. The examiner should not use his thumb to palpate any pulse.
      5. Palpate both radial (wrist) pulses simultaneously for symmetry for at least 30 seconds
      6. Measure respiratory rate for 30 seconds and record
The examiner unobtrusively measures patient’s respiratory rate. This may be accomplished by the examiner leaving his hands on the patient’s wrists for another 30 seconds after measuring the radial pulses so the patient does not realize that the examiner is watching him breathe. The depth and rhythm should also be noticed. The respiratory rate can also be measured during the back exam.
      7. Measure blood pressure on right arm
Blood pressure may be measured with the patient in a sitting or lying position. In each position, the artery in which the blood pressure is to be measured should be at the level of the heart (at the level of the fourth intercostal space in the sitting position; at the level of the middle axillary line in the lying position). The patient’s arm should be resting on a smooth table or supported by the examiner, and slightly flexed at the elbow.
      8. Place cuff in correct location 2-3 cm above the atecubital crease
The examiner secures the blood pressure cuff snugly over the upper, arm so that one finger can be admitted under the cuff. The cuff should be positioned 2～3 cm above the antecubital crease or elbow joint. Put the middle of the cuff over the brachial artery.
      9. Palpate brachial artery
The examiner can locate the brachial artery which lies slightly medial to the tendon of the biceps muscle in the antecubital fossa. The mercury column on the manometer dial should be properly calibrated with the pointer at “0” before the cuff is inflated (i. e. , all the air should be pressed out of the cuff before it is inflated).
The stethoscope is placed firmly over the brachial artery. The examiners  inflates the cuff slowly but steadily. Until the brachial artery pulse disappears. Then he continues to inflate cuff 2.6～4.0kPa (20～30 mmHg higher, generally to about 21.3kPa (160mmHg)).
      10. Measure blood pressure over brachial artery twice and record the lower reading
Deflate the cuff slowly at the rate of about 0.26kPa (2mmHg) Per second. The number where the examiner hears the first pulse sound is the systolic pressure. The pulse sound will waken and then disappear. The number where the pulse sound disappears is the diastolic pressure. If the difference between weakening of the sound and its disappearance is 2.6kPa (20mmHg) or greater, the examiner should record these two numbers. The cuff must be completely emptied with the pointer at “0” before it is reinflated. The same procedure may be followed for a second measurement of B. P. in the same or opposite arm. The lower pressure is recorded as the patient’s blood pressure. After finishing the measurement, the examiner deflates and rolls up the cuff, leans the manometer over a little so the mercury column disappears, closes the mercury column switch, puts the balloon in order, and closes the manometer.

B. HEAD AND NECK
（头颈部）
Skull
      11. Palpate and observe scalp (parting hair, and observing hair density, color, lustre and distribution)
The examiner palpates the entire skull using both hands and simultaneously examines symmetrical areas. The examiner parts the hair to observe the scalp, noting any scaliness, deformities, lumps, tenderness, lesions or scars. The examiner also observes the density, color, lustre and distribution of the hair.
Eyes
      12. Visual screening:（omitted）
      13.Observe cornea, sclera, conjunctiva and lacrimal puncta by gently moving lower eyelids down.
Cornea Examination-With oblique lighting inspect the cornea for opacities, foreign bodies etc. Inspect lower palpebral, fornical, bulbar conjunctiva and sclera. Ask the patient to look up as you depress lower eyelid with your thumb exposing lower palpebral, fornical, bulbar conjunctiva and sclera. Inspect the conjunctiva and sclera for color, and note the vascular pattern against the white scleral background.
Lacrimal sac examination by digital compression for nasolacrimal duct obstruction-Ask the patient to look up. Press on the lower lid close to the medial canthus, just inside the rim of the bony orbit. You are thus compressing the lacrimal sac. Look for fluid regurgitation out of the puncta into the eye. Avoid this test if the area is inflamed and/or tender(Figure 2-3).
      14. Observe sclera and bulbar conjunctiva by gently elevating upper eyelid while patient looks down,
Instruct the patient to look down.
Raise the upper eyelid slightly so that the eyelashes protrude, and then inspect sclera and bulbar conjunctiva. Be gentle so patient doesn’t tear (Figure 2-4).
      15.Check crn Ⅶ upper division: raised eyebrows, wrinkle forehead or forced eyelid closing Nerve Ⅶ is the facial nerve.
Upper facial nerve-To test the upper division, the examiner observes the patient’s forehead and palpebral fissure, then asks patient to raise his eyebrows, wrinkle his forehead and close his eyes. When the patient closes his eyes tightly, the examiner attempts to pry them open to determine the strength. If one side of pe**heral upper facial nerve is impaired (nuclear or below nuclear) the patient’s ability to wrinkle forehead decreases and the patient can’t close his eye on the affected side. If one side of central nerve is impaired, the patient’s ability to close his eyes and wrinkle forehead will not be influenced because the upper facial muscles are controlled by both sides of the corticocerebral motor area.
      16. Evaluate extraocular muscle function in both eyes in 6 directions (left, upper left, and lower left, right, upper right, lower right)
The examiner positions himself in front of the patient and requests that, without moving the patient’s head, the patient’s eyes follow examiner’s finger or a pencil in six directions. Finger or pencil should be 30～40 cm away from patient’s head. The usual format is from mid left, to upper left and then down and then to the right (Figure 2-5).
      17.Observe pupillary direct response to light
The examiner asks the patient to look forward and shines a penlight or the light of the ophthalmoscope into each pupil in turn. He should avoid shining the light into both pupils simultaneously and should ask the patient not to focus on the light source.
When observing the direct pupillary response to light, the examiner will shine the light into one eye and inspect for pupillary constriction in the same eye. The pupillary constriction is reversed as soon as the light moves away. Use the same method to check the other eye.
      18.Observe pupillary consensual response to light
With the same method as obove, the examiner shines the light into one eye and inspects for pupillary constriction in the opposite eye OR observes pupillary dilation in opposite eye as light is extinguished.
      19.Check for convergence and accommodation
The examiner, positioned in front of the patient, asks the patient to look into the distance and then at his finger. The examiners finger starts from 1 meter away, the examiner will immediately move 5 cm away from the bridgeof the patient’s nose. The examiner is observing the patient’s eyes for:a) pupillary constriction, and b) convergence (the coordinated movement of both eyes toward fixation at the same near point as the patient focuses on a near object). Accommodation includes convergence and pupillary constriction as the patient focuses on the near object. The accommodation will vanish when cranial nerve Ⅲ is damaged.
Ears and Temporomanaibular joint
      30. Observe and palpate the auricles and observe postauricular regions bilaterally
The examiner pulls and palpates the auricles (outer ears), palpates the preauricular(in front of) and posterior auricular regions (behind the ears) bilaterally. Tenderness usually indicates inflammation.
      31. Palpate temporomandibular joint for tenderness and swelling (omitted)
The temporomandibular joint (TMJ) is anterior to the external auditory c** of the ear. Examine for swelling and tenderness.
      32. Feel the movement of the TMJ with index fingers inside patient’s ears or over joint
To palpate the TMJ joint, the examiner presses both sides simultaneously with one or two fingers and asks the patient to open and close his mouth, or the examiner places his index finger in the patient’s ear and gently pulls forward (anteriorly), asking the patient to open and close his mouth. (omitted)
Nose
      38. Inspect and palpate external nose for malformation and inflammation
Begin by examining the external nose. The examiner faces the patient. Observe skin color and shape of nose any palpate for and loss of structure or tenderness from bridge, to tip, to wings of nose.
      39. Observe nasal vestibule without otoscope
A view of the nasal cavities is obtained by tilting the patient’s head back and elevating the tip of the nose with the thumb. The examiner should use a light. The nasal vestibule contains the nasal hairs, or vibrissae. Pay attention to any folliculitis, fornicles, or deviated nasal septum.
      40. Turn the tip of the nose upwards and insert the tip of the speculum to inspect nasal vestibule and anterior part of nasal cavity for ulcer, crust, swelling, discharge, atrophy or perforation
      41.Test patency by inhaling through each nostril separately while the opposite nostril is held occluded (omitted)
      42. Palpate and/or percuss maxillary sinus for swelling and tenderness
Examination of the paranasal sinuses is done more indirectly than other otolaryngeal procedures. The examiner cannot see into any of the sinuses. Palpation and percussion may be used over the maxillary sinuses. Simultaneous finger pressure over both maxillae will demonstrate differences in tenderness.
      43. palpate and /or percuss frontal sinus for swelling and tenderness
The frontal sinuses are palpated at the inner part of the upper border of the bony orbit by finger pressure directed upward toward the floor of the sinus where the sinus wall is thin. Tenderness may be elicited in this way. Swelling caused by tumors or retained secretions may cause a downward bulge in the floor of the frontal sinus. The frontal sinuses may also be percussed.
Mouth, lips, Pharynx
      44. Observe lips, buccal mucosa, teeth, gums and tongue
The examiner inspects the lips, all surfaces of the tongue, gums, roof of mouth, and the buccal mucosa (the tissue lining the cheeks) by asking the patient to open his mouth and by shining a light into the area to be examined. The examiner may use a tongue depressor to aid inspection.
Lips-The healthy lips are wet and red in color, This is caused by a rich capillary network.
Buccal mucoss-To examine the buccal mucosa it is necessary to shine a light into the patient’s mouth. The healthy buccal mucosa is pink and smooth. The duct of the parotid gland opens onto the buccal mucosa opposite the upper second molar.
Teeth-There are 32 teeth in the full ** dentition. The teeth are inspected for evidence of cavities and malocclusion.
Gums-The gums should be inspected for the presence of swelling, bleeding or pigmentation.
Tongue-The tongue is inspected for its shape, motion and ulceration.
      45. Observe the floor of mouth
Inspect the mouth for pigmentation, hemorrhage or masses (ask patient to touch tip of tongue to roof of mouth).
Generally, palpation is not done in a normal exam. However, if a mass is found on the floor of the mouth, palpation is important. If neoplasms are suspected, they are detectable only by palpation. Also, the submaxillary, salivary ducts may contain calculi that are best felt by palpation. Bimanual examination, using one gloved finger inside the mouth and the other hand outside, is best.
      46. Inspect the posterior structures of the mouth for congestion, swelling or pus, position of uvula, and elevation of the palate.
Press a tongue blade, positioned over middle 1/3 of tongue, firmly down to inspect tonsils, anterior and posterior tonsillar pillars, and posterior pharynx. The examiner can observe the elevation of the palate as the patient says “ah”. Simultaneously, hoarseness can be detected. The conscious patient should not be gagged.
      47. Observe midline protrusion of the tongue (cr n Ⅻ)
The examiner asks patient to stick out his tongue and observes midline protrusion, atrophy and fibrillation.
      48. Show teeth, puff out cheeks or purse lips (lower division of cr n Ⅶ) (omitted)
      49. Test contraction of masseter (jaw) muscle or forced opening of mouth against resistance (motor division cr n Ⅴ) (omitted)
      50. Test for facial sense of pain and touch (must check at least 2 out of 3 sensory divisions for cr n Ⅴ) (omitted)
      51. Expose neck correctly to observe appearance and skin of neck
The patient sits upright.
Ask patient to expose neck entirely when the neck is to be examined. All clothing should be removed as far as the axillae, which allows the whole neck to be seen in relationship to the thorax and permits inspection and palpation of the supraclavicular fossae.
Observe the appearance of the skin of the neck. The examiner should observe the neck for symmetry and pay attention to its appearance. Abnormal lumps and pulsations may be seen in this area. Generally, the thyroid cartilage will show convexity in a male. The examiner inspects the skin of the neck for erythema, spider angioma, infections, ulcers or scars.

Facial and cervical lymph nodes
Palpate lymph nodes bilaterally. The examiner may be positioned in front of or behind the patient and examine the lymph nodes with the pads of his index and middle fingers. This should be done slowly and carefully to make certain that there aren’t any abnormalities present. It is better if the examiner moves the skin over the underlying tissue rather than move his fingers over the surface of the skin. The examiner may have the patient position his head with his neck slightly flexed forward. The examiner palpates all nodes bilaterally.
For palpation of lymph nodes, be sure to keep the skin and muscles relaxed. If the lymph nodes are enlarged, note their location, size, number, hardness, mobility, tenderness, adhesion, fusion, swelling, fistula or scars (Figure 2-14).
      52. Palpate preauricular nodes (front of ears)
      53. Palpate post-auricular nodes (back of ears)
      54. Palpate occipital nodes (base of skull)
      55. Palpate submaxillary nodes (by bending finger under patient’s jaw)
      56. Palpate submental nodes (by bending finger under patient’s chin)
      57. palpate anterior cervical nodes (superficial group under mastoid and in front of sternomastoid muscle)
      58. Palpate posterior cervical nodes (behind sternomastoid muscle)
      59. Palpate supraclavicular nodes (by bending finger above patient’s collarbone)
Thyroid gland
      60. Palpate and/or move thyroid cartilage with two fingers checking for malformation and movability
      61. Palpate thyroid in correct anatomical location in front of or behind the patient with
both hands.The lateral lobes of the thyroid curve posteriorly around the sides of the trachea and
the esophagus. In addition, they are partially covered by the sternomastoid muscle.There are
several different techniques for examining the thyroid gland. Many examiners will palpate the
thyroid gland both in front of and/or behind the patient. The examiner should identify the thyroid
gland which lies across the trachea below the cricoid cartilage. (If the examiner has the patient
flex his neck or turn his chin slightly toward the side to be examined, it will secure the relaxation
of the sternomastoid muscle, which is essential for adequate examination of the thyroid.)
      62. Palpate isthmus of thyroid with and without swallowing: using the pads of his fingers, the examiner feels below the cricoid cartilage for the isthmus of the thyroid gland. If examiner stands in front, he examines with his thumbs, from behind, with his index fingers. Examiner asks patient to swallow as he feels for the isthmus rising upward against his fingers. A good teaching point is that the thyroid gland is one of the few soft tissue structures in the neck that moves with swallowing.
      63. Palpate thyroid gland (lobes) with and without swallowing
Palpation from the front-The thyroid is displaced to one side by applying pressure with the thumb upon the thyroid cartilage. With the opposite hand, the dislodged lobe of the thyroid can now be palpated between the thumb (held in front of the sternomastoid) and the 2nd and 3rd fingers (Placed behind the sternomastoid) This should be done before and during swallowing. The procedure is repeated for the opposite side (Figure 2-16).
Palpation from behind-Procedure is similar to palpation from the front except the thyroid cartilage is displaced with the 2nd and 3rd fingers. The thumb of the opposite hand is now behind the sternomastoid muscle and the 2nd and 3rd fingers are in front of it. (Figure 2-17).
If thyroid is enlarged, notice its size, symmetry, hardness, surface, tenderness, nodules, thrills, bruits, etc.
Carotid Artery
      64. Gently palpate carotid artery
With the pads of his fingers, the examiner exerts gentle pressure on patient’s carotid arteries in the lower half of the neck on the inside edge of patient’s sternomastoid muscle. One should not palpate both carotids simultaneously as the patient might flle faint if both carotids are palpated at the same time.
Trachea
      65. Palpate the position of trachea
Place the patient’s head erect and facing forward and make sure both shoulders are at the same horizontal level. Put index and fourth fingers at the sternoclavicular joints. Palpate trachea or the gaps between the trachea and the joints with the middle finger to determine the position of the trachea.
Movement of Cervical Spine
      66. Flexion (actively, if possible; if abnormal, do passively)
      67. Extension (actively, if possible; if abnormal, do passively)
      68. Lateral bending [ear-to-shoulder]; (actively, if possible; if abnormal, do passively)
      69. Rotation (chin-to-shoulder), (actively, if possible; if abnormal, do passively)
      70. Test rotation of patient’s head against resistance or check resistance of shrugged shoulders (cr n Ⅵ)
C. UPPER LIMBS (omitted)
      71. Expose upper limbs
Hands
      72. Inspect dorsa and palms and palpate all joints of hand
      73. Check fingernails for clubbing or cyanosis
      74. Ask patient to extend fingers
      75. Ask patient to make a claw
      76. Ask patient to make a fist
      77. Check patient’s ability to perform thumb opposition
      78. Check for distal muscle strength
Wrist
      79. Observe and palpate wrist (for lumps, swelling, deformities, and tenderness)
      80. Extension of wrist (bend backward)
      81. Flexion of wrist (bend forward)
Elbow
      82. palpate olecranon process and epicondyles
      83. Palpate epitrochlear lymph nodes
      84. Flexion
      85. Check for upper arm muscle strength
      86. Extension
      87. Pronation and supination (with elbows locked at patient’s side)
Shoulder
      88. Palpate both shoulders
      89. Functional examination (3 screening maneuvers:hand over head to opposite ear, hands behind head, touch lower border of opposite scapula)
      90. Check for proximal muscle strength
      91. Test sense of pain or touch; at least 2 of 3 positions (upper arm, forearm, & hand) on each upper extremity bilaterally and symmetrically
      92.Barre’s upper limb test (test for drift of outstretched arms with eyes closed)Deep Tendon Reflexes(The reflexes should be checked bilaterally and both sides compared.)

Deep Tendon Reflexes
      93. Biceps reflex
The examiner supports the patient’s arm which should be relaxed with the elbow bent at about             90 degrees with the palm up. The examiner places his thumb against the biceps tendon on the inside of the patient’s elbow and taps it with the reflex hammer. A reflex should be elicited. The normal reflex is contraction of the biceps causing a rapid flexion of the forearm. The reflex center is C5-6.
      94. Triceps reflex
The examiner should support the patient’s forearm or hold the patient’s arm flexed at the elbow away from the body and with a reflex hammer, taps the tendon of the triceps above the olecranon. The reflex elicited is extension of the forearm. The reflex center is C7-8.
      95. Brachioradialis reflex
The patient’s arm should rest in his lap or on examiners arm, relaxed, with his palm down. The examiner strikes the tendon overlying the radius (the bone on the side of the thumb) with the reflex hammer. The reflex clicited is flexion (bending) and pronation (moving the palm downward) of the forearm. The reflex center is C5-6.
Coordination
(The reflexes should be checked bilaterally and both sides compared.)
      96. Rapid alternating movement (omitted)
      97. Finger to nose test (with open eyes) (omitted)
      98. Finger to nose test (with closed eyes) (omitted)

D. BACK
      99. Expose the back correctly
Have the patient undress except for his underwear. With the patient seated, the examiner stands behind the patient and carefully inspects the spine for any postural abnormalities, configuration and symmetry of chest, and landmarks of posterior thorax (midspinal line, scapula line, costovertebral angle)
      100. Palpate spinous processes one by one (check for scoliosis and tenderness)
With the index and middle fingers, the examiner presses on the patient’s spinous processes from top to bottom rapidly. The skin shows a red line which should be straight. Normally, no tenderness exists.
      101. Test for percussion pain of spinal column one by one (or by indirect method)
For the direct method, the examiner uses a reflex hammer or finger and directly percusses every spinous process. This method is used mainly for the examination of the lumbar and thoracic vertebeae. Normal individuals have no percussion pain. For the indirect method, the examiner places his left hand on the top of the patient’s head and makes a partial fist with his right hand and percusses the left hand with the hypothenar eminence. The examiner should note the patient’s expression, especially if it is painful.
      102. Test CVA for kidney tenderness by pressure and indirect fist percussion
First, the examiner places both thumbs on both Costovertebral Angles and presses. If there is no pain, then the examiner uses his first to strike gently just below the costovertebral angle on both sides. If there is no pain, then the examiner should strike with moderate force. This also can be done by indirect first percussion over the examiners hand placed on the C. V. A. Pay attention to the reaction of the patient.
      103. Palpate thoracic expansion and symmetry
Confirm expansion and symmetry of respiratory movement by putting both hands gently on the patient’s rib cage from behind with fingers between the ribs, thumbs vertical and parallel to the spinal column, at the 10th costal level, and have patient breath in and out. The thumbs and fingers are placed as in the figure. Estimate the movement of the chest and check the resistance of the shest wall at the same time. The examiner notes divergence of his thumbs and the symmetry of the pump handle effect of both his forearms.
      104. Have patient cross arms in front and touch opposite shoulder
Examine the back of the patient’s lungs by asking the patient to bend slightly forward and have both hands touch the opposite shoulder to expose the interscapular area as widely as possible.
      105. percuss posterior lung fields
To percuss, place the palmar surface of the distal interphalangeal joint of the midfinger of the left hand on the chest and keep the other fingers of the left hand off the chest wall. The midfinger tip of the right hand strikes over the distal interphalangeal joint on the chest wall. The strike should be sharp, occur repeatedly, with the movement coming from the wrist. Each point should be percussed two or three times.
      106. Percuss posterior lung fields comparatively and symmetrically
Percuss posterior lung fields comparatively and symmetrically from top to bottom and from lateral to medial. When percussing interscapular area, middle finger should be parallel to spine, below the scapulae area, middle finger should be parallel to ribs. Pay attention to the sound and the feeling on the left midfinger.
      107. Measure diaphragmatic excursion
Percuss for bottom of lung during normal breathing and then ask patient to take a deep breath and hold it. Percuss to the lower border of the posterior lung fields. Ask patient to exhale completely. Percuss to the lower border of the posterior lung fields again, Note the difference between the two points, which should be 6～8cm
      108. Instruct the patient to breathe a little deeply with mouth open slightly
      109. Auscultate posterior lung fields (see 110)
      110. Auscultate comparatively and symmetrically
Auscultate the lungs in the same order as percussed. Pay attention to the change of intensity and nature of the breath sounds. Differentiate normal breath sounds from abnormal including the presence of bronchial and bronchovesicular breath sounds that are heard in any area of the lungs that normally have vesicular breath sounds. Also note increased, decreased, or absent breath sounds, At each point listen to at least one or two full breath cycles. Use the diaphragmatic chest piece and place it between ribs with moderate pressure.
      111. Vocal audible resonance
The examiner asks the patient to whisper “one”, “two”, “three” while examiner auscultates lung fields. Compare both sides of lung fields
bilaterally and symmetrically.

F. ANTERIOR CHEST AND LUNGS
      128. Inspect and palpate configuration and symmetry of chest.
Pay attention to the bony structure and topographical landmarks including: the sternal angle, suprasternal fossa, supraclavicular fossa, infraclavicular fossa, xiphoid process, epigastric angle, mid sternal line, mid-clavicular line, scapula line, mid spinal line, anterior axillary line, mid-axillary line, and posterior axillary line.
Inspect thoracic shape and symmetry, direction of anterior lower ribs, size of epigastric angle, breathing motion and depth, and use of auxiliary muscles and retractions during breathing. Then palpate the anterior and lateral inferior chest wall with the whole hand, placing fingers between the ribs. Push the chest wall posteriorly and medially, then release quickly. Pay attention to elasticity and chest.
      129. Percuss supraclavicular fossae bilaterally and symmetrically.
Ask the patient to relax and drop his arms to his sides. Percuss supraclavicular fossae bilaterally and symmetrically.
      130. Percuss anterior and lateral lung fields. Percuss top to bottom, lateral to medial, right to left. When percussing lateral fields, have patient raise his arms and put his hands behind his head. Percuss each ICS and compare to opposite side. Pay attention to sound and feeling of sensing finger. This can be combined with percussion of the posterior thorax.
      131. Auscultate supraclavicular fossae bilaterally and symmetrically.
It might be helpful to use the bell of the stethoscope with firm pressure applied (to convert it acoustically to a diaphragm) to auscultate apices in the supraclavicular fossae, especially in female patients.
      132. Auscultate anterior and lateral lung fields.
Ask patient to breathe a little deeply through slightly open mouth. Auscultate anterior and lateral lung field with diaphragmatic chest piece, bilaterally and symmetrically. Pay attention to changes in intensity and nature of breath sounds.

E. BREASTS (FEMALE) (omitted)
      112. Expose both breasts completely
      113. Inspect both breasts symmetrically in sitting position
      114. Inspect both breasts symmetrically with patient leaning forward
      115. Inspect both breasts symmetrically with arms raised above head
      116. Inspect both breasts symmetrically with hands on hips and squeeze
      117. Palpate patient’s right breast with pads of fingers of right hand, applying gentle pressure
      118. Palpate right breast in the 5 following areas: superinternal, superlateral, tail, inferinternal, inferlateral (at least 4 of 5 parts of the breast should be palpated)
      119. Palpate nipples, areola, attempt to express discharge from nipple.
      120. palpate patient’s left breast with pad of fingers and palm, apply gentle gressure.
      121. Palpate left breast in the following areas: superinternal, superlateral, tail, inferinternal, inferlateral.
      122. Palpate nipples, areola, attempt to express discharge from nipple.
      123. Teach patient breast self-examination.
Axillary Examination
      124. Inspect the patient’s right axilla.
      125. Palpate chains of lymph nodes on right: top, medial, anterior, posterior, lateral
      126. Inspects patients left axilla.
      127. Palpate chains of lymph nodes on left: top, medial, anterior, posterior, lateral.

G. HEART
      133. Screening test for elevated venous pressure.
Place patient in semirecumbent position with head elevated to 15～30 degrees.
Observe neck and note distension of external jugular vein. Ask patient to change to a sitting position. In a normal patient, the distension of the vein will disappear. The distension level should be limited in lower two thirds of the distance between super clavicle and jaw at supine position.
      134. Observe precordium (view tangentially).
Observe precordium with the patient supine. The character and location of any visible cardiac impulses should be noted. For example: the location, range and intensity of apical impulse should be observed. Normally the PMI can be located at the 5th left ICS,. 5～1cm medial to the midclavicular line. The area of the pulse will be 2～2.5cm in diameter. In some normal patients this may not be found. Minor precordial movements can be amplified by observing during expiratory apnea. Tangential lighting may be necessary to see these movements.
      135. Palpate apical area with palm and fingertips.
Palpation serves to confirm the findings detected during inspection and may reveal pulsatile movements or thrills or friction rubs suggesting specific cardiac disease. Palpate apical (mitral) area with two steps. First, use palm to palpate apical impulse, and then use one or two finger tips to further localize the impulse. The palm is especially useful in detecting thrills; fingertips are more helpful in detecting and **yzing pulsations. When you feel the apical pulse, this indicates the beginning of systole. The apical impulse can be used to distinguish the first and second heart sounds and to time thrills and murmurs. The apical impulse is always more powerful with the patient on his left side, which usually displaces the apex 2～3 cm to the left and brings it closer to the chest wall. For purposes of auscultation and **ysis of the configuration of the apical impulse, this is a useful maneuver, but assessment as to location and duration of the apical impulse should be made with the patient supine.
      136. Palpate precordial area with palm.
Palpate the precordium including the : lower half of the sternum, the 3rd, 4th, and 5th ICS at the left sternal border, 2nd ICS at the left sternal border, 2nd ICS at the right sternal border, epigastrium and right lower parasternal border. Examine for pulsation, thrill, pericardial friction rub.
      137. Percuss relative dullness of the heart.
Percuss the relative dullness of the heart at the left 5th ICS and record the margin of dullness.
Generally, percussion starts on the left side of the chest, 2～3cm outside of the apical impulse, and moves medially until cardiac dullness is perceived in the 5th or possibly the 4th interspace.
If you cannot palpate the apical impulse, you can percuss from 1～2cm outside of the mid clavicular line in the 5th or 4th ICS and move medially until cardiac dullness is appreciated. Usually, the left border of relative dullness of the heart in the 5th ICS is located 1～2 cm medial to the MCL in normal persons. As more detailed knowledge of normal and abnormal precordial movements has been accumulated, palpation has largely replaced percussion in cardiac examination. When one cannot feel the apical impulse, percussion may suggest where to search for it. Occasionally percussion may be your only tool. For example, a large pericardial effusion may make the impulse undetectable. Under these circumstances. Cardiac dullness often occupies a large area. Starting well to the left on the chest, percuss from resonance toward cardiac dullness in the 3rd, 4th, 5th and possibly the 6th interspaces, and note the change with the patient’s position from reclining to sitting.
Auscultate with diaphragm
Use diaphragmatic head first to auscultate the chest wall using firm pressure. The diaphragm is best for listening to high frequency sounds. Five reference points are used for localization of sounds on the surface of the chest. The examiner should follow the following sequence for auscultation:Pulmonic area→Aortic area→2nd Aortic area→Mitral area→Tricuspid area. One should auscultate for heart rate rythym, heart sounds, murmurs, and friction rub, Listen at each area for 15 seconds to 1 min. Identify the first and second sounds. Pay attention to the changes of intensity, nature, splitting of heart sounds, and extra heart sounds. To detect a murmur, pay attention to the timing, location, duration, quality, radiation, intensity, pitch, and relationship with position of the body, respiration, exercise, etc. The sounds of greatest importance are the S1 and S2 sounds which divide the cardiac cycle into systole and diastole. Place the diaphragm onto the pulmonary area. Normally there are two sounds: S1 and S2. Normally, S1 is lower pitched and is softer and longer than S2. With normal rhythm, the interval between S1 and S2 is shorter than between S2 and the next S1. Sometimes it may be difficult to identify S1 and S2 especially with an abnormal S1 and/or S2. In this case, three techniques may be of value; the apex impulse, carotid pulses, and the “inch by inch” move. See details of these techniques in Organ System Manual.
      138. Pulmonary area (second left ICS).
      139. Aortic area (second right ICS).
      140. Second aortic area (third and fourth left ICS).
      141. Mitral area (Apical area).
      142. Tricuspid area (fourth, fifth left ICS, LSB).
Auscultate with bell
Use bell-type head to auscultate the chest wall using light pressure without leaving a mark. Otherwise, low frequency sounds may be missed.
      143. Pulmonary area
      144. Aortic area
      145. Second aortic area
      146. Mitral area (Apical area)
      147. Tricuspid area

H. ABDOMEN
      148. Expose abdomen
Both breasts of women should be covered. Expose abdomen completely from just below breasts to just above pubis.
      149. Place pillow under head, bend knees, arms at side, have patient breathe normally. A suitable pillow should be placed beneath the head. Ask patient to bend his knees, put arms at sides, relax abdominal muscles, breathe normally.
      150. Observe abdomen.
Visualize the abdomen divided into 4 quadrants by a pair of imaginary lines drawn perpendicular to each other through the umbilicus.
Look at abdominal contour and symmetry. Observe the skin of abdomen, hair, striae (vertical stretch marks which result from expansion and contraction of abdominal wall such as with pregnancy), scars, location and shape of umbilicus.
Check respiratory movement as mentioned before. Observe abdominal contour and peristalsis wave tangentially. Observe abdominal veins. Observe groin area for hernia.
      151. Auscultate for bowel sounds. Place stethoscope in area of umbilicus Auscultate bowel sounds with diaphragmatic head for at least one minute. If there are no bowel sounds, listen until you hear them or for at least five minutes. Pay attention to the frequency, pitch and intensity.
      152. Percuss abdomen
Using indirect percussion, percuss the abdominal four quadrants, from LLQ counterclockwise, and get general ***rmation about the percussion sound (tympany or dullness) of abdomen.
      153. Percuss liver span
Percussion should be done with the patient breathing normally through right midclavicular line downward from resonance in lung field (usually 2～3 ICS) to dullness and upward from tympany in abdominal field (usually umbilicus level) to dullness. Estimate or measure from upper to lower dullness for liver span. It is normally about 9～11 cm in midclavicular line.
      154. Watch patient’s face and response as you palpate abdomen
When examining abdomen, intermittently pay attention to the patient’s face and withdrawal response which indicate discomfort and pain.
      155. Palpate superficially
Examination is begun with a gentle maneuver. Use the palm of hand, put the four fingers together, with arm relaxed, press with fingers about 1 cm deep. Palapte all areas of the abdomen counter-clockwise from LLQ. Look for tenderness or resistance of abdominal muscles and/or enlargement of organs.
      156. Palpate deeply
Using right hand , palpate more deeply to find the deep lesions in the abdomen. In some cases, the examiner should use both hands. (left fingertips on right DIP joints) to palpate more deeply. Use a forward and backward circular motion. The order of palpation is the same as for superficial palpation. Screen for tenderness, masses, etc.
      157. Palpate liver at midclavicular with monomanual method.
In the midclavicular line, press down firmly and ask the patient to inhale deeply and allow the liver to move down to meet your fingertips. If you feel the liver, describe the edge (sharp or round and tender or not, hard or soft) and repeat the process laterally and medially to define the contour. For a mass within the liver, describe the same characteristics as above and listen for a murmur over the mass. Normally, the liver cannot be felt more than 1 cm below the costal margin. But failure to feel the liver, does not mean that it is normal.
      158. Palpate liver at midclavicular line with bimanual method
Right upper quadrant
With patient lying comfortably on his back, put your left hand on the top of lower rib cage or posteriorly beneath the right lower rib cage to restrict the movement and thereby encourage abdominal breathing. Place right hand on the abdominal wall a few centimeters below the lower border of liver dullness. Use the same maneuver as monomanual method (Figure 2-30).
      159. Palpate liver at midsternal line
Palpate superiorly from umbilicus along midsternal line to attempt to locate the medial inferior liver edge, using the monomanual method.
      160. Palpate spleen with bimanual method.
For palpation of spleen, put the left hand behind left rib cage, from about 7th to 10th rib, and press towards umbilicus. Right hand palpates the spleen starting from umbilical level or below the dullness. The maneuver is the same as that for the liver but more subtle because the spleen is more mobile and deeper.
      161. Palpate spleen with patient rolled toward his right side.
If the spleen is not palpated, have the patient roll on his right side and palpate again.
      162. Palpate kidneys with bimanual method.
For palpation of left kidney, put left hand below left rib cage, at the costospinal angle and lift up. Right hand palpates deeply from umbilicus level in the left midclavicular line and moves progressively upward following each period of breath. Palpate both kidneys respectively.
      163. Test for pain or light touch on abdominal wall.
Ask patient to close his eyes and to respond whenever he feels his skin touched and /or pricked. The examiner performs this in upper, middle, and lower parts of the abdomen bilaterally and symmetrically.

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