Head to Toe Assessment with Examinations

Head to Toe Assessment with Examination

1. Head-to-Toe Assessment
Sreenu Thalla
Assistant Professor
Department of Pharmacology

2. What is Head-to-Toe Assessment?
•Ahead-to-toeassessmentisacomprehensivephysicalassessmentdatacollectionmethodto
gatherpatientdataanddeterminethepatient’shealthstatus.
•Itinvolvesexaminingtheentirebodyfromheadtotoeinasystematicandthoroughmannerto
identifyhealthissuesthepatientmaybeexperiencing.
•Attheendofthehead-to-toeassessment,healthcareprovidershouldhavegathered
informationthatcanhelpthepatient’streatmentplanandhaveaclearunderstandingofthe
patient’soverallphysicalhealthandanypotentialissuesthatmayneedtobeaddressed.

3. Assessment Techniques
Inspection
➢Involvesusingthesensesofvision,smell,andhearingtoobserveanddetectanynormalor
abnormalfindings.
Palpation
➢Consistsofusingpartsofthehandtotouchandfeelforthefollowingcharacteristicsaretexture,
temperature,moisture,mobility,consistency,thestrengthofpulses,size,shapeanddegreeof
tenderness.
Percussion
➢Involvestappingbodypartstoproducesoundwaves.
➢Thesesoundwavesorvibrationsenabletheexaminertoassessunderlyingstructures.
Auscultation
➢Involvestheuseofastethoscopetolistenforheartsounds,movementofbloodthrough
thecardiovascularsystem,movementofthebowel,andmovementofair

4. Mnemonic General Question
Character Describe the sign or symptom (appearance, feeling, sound, smell, or taste)
Onset When did it begin?
Location Where is it? Does it radiate? Does it occur anywhere else?
Duration How long does it last? Does it recur?
Severity How bad is it? How much does it bother you?
Pattern What makes it better or worse?
Associated factors What other symptoms occur with it? How doe it affect you?
COLDSPA mnemonic

5. HistoryofPresentHealthConcerns
•Severalaspectsofthehealthproblemandasksquestionswhoseanswerscanprovideadetailed
descriptionoftheconcern.
PastHealthHistory
•Thesearequestionstoelicitdatarelatedtotheclient’spast,strengths,andweaknessesintheir
healthhistory.
FamilyHealthHistory
•Thefamilyhistoryshouldincludeasmanygenericrelativesastheclientcanrecall;inadditionto
geneticpredisposition,itisalsohelpfultoseeotherhealthproblemsthatmayhaveaffectedthe
clientbyvirtueofhavinggrownupinthefamilyandbeingexposedtotheseproblems.
LifestyleandHealthPractices
•Thesequestionsareusedtoassesshowtheclientsaremanagingtheirlives,theirawarenessof
health,andunhealthylivingpatterns.
•Theseareusuallyopen-endedquestionstopromotedialoguewiththeclient.

6. Skin Physical Assessment
•Physicalassessmentoftheskin,hair,andnailsprovidesthelocalorsystemicproblems.
Inspectionoftheskin
Inspectgeneralskincoloration
•Keepinmindthattheamountofpigmentintheskinaccountsfortheintensityofcolouras
wellashue.
Inspectforcolourvariations
•Inspectlocalizedpartsofthebody,notinganycolourvariation.
Checkskinintegrity
•Especiallycarefullyinpressurepointareas(e.g.sacrum,hips,elbows);ifanyskinbreakdown
isnoteduseascaletodocumentthedegreeofskinbreakdown.
Inspectforlesions.
•Observetheskinsurfacetodetectabnormalities;notecolour,shape,andsizeoflesion;suspect
afungus,shineaWood’slight(anuvlightfilteredthroughaspecialglass)onthelesion.

7. Palpationof the skin
Palpateskintoassesstexture
•Usethepalmarsurfaceofthethreemiddlefingerstopalpateskintexture.
Palpatetoassessthickness
•Iflesionsarenotedwhenassessingskinthickness,putglovesonandpalpatethelesions
betweenthethumbandfinger;observethedrainageorothercharacteristics.
Palpatetoassessmoisture
•Checkunderskinfoldsandinunexposedareas.
Palpatetoassesstemperature
•Usethedorsalsurfacesofthehandstopalpatetheskin.
Palpatetoassessmobilityandturgor
•Asktheclienttoliedown;usingtwofingers,gentlypinchtheskinonthesternumorunderthe
clavicle.
Palpatetodetectedema
•Useyourthumbstopressdownontheskinorthefeetoranklestocheckforedema.

8. Hair
InspectionandPalpationofthehair
Inspectthescalpandhair
•Havetheclientremoveanyhairclips,hairpins,orwigs,theninspectthescalpandhairfor
generalcolourandcondition.
Inspectandpalpateforcleanliness,drynessoroiliness,parasites,andlesions
•At1-inchintervals,separatethehairfromthescalpandinspectandpalpatethehairandscalp
forcleanliness,dryness,oroiliness,parasites,andlesions;wearglovesiflesionsaresuspected
orifhygieneispoor.
Inspecttheamountanddistributionofscalp,body,axillae,andpubichair
•Lookforunusualgrowthelsewhereinthebody.

9. Nails
Inspectionofthenails
Inspectnailgroomingandcleanliness
•Normalfindingswouldbethenailsshouldbecleanandmanicured.
Inspectnailcolourmarkings
•Normalfindingsshouldbepinktonesshouldbeseen;somelongitudinalridgingisnormal.
Inspectshapeofnails
•Thereisnormallya160-degreeanglebetweenthenailbaseandtheskin.
Palpationofthenails
Palpatenailtoassesstexture–Nailsarehardandbasicallyimmobile.
Palpatetoassesstextureandconsistency–Notewhetherthenailplateisattachedtothenailbed.
Testcapillaryrefill-Testcapillaryrefillinnailbedsbypressingthenailtipbrieflyandwatchingfor
colourchange.

10. Assessment of the Head and Neck
•Headandneckassessmentfocusesonthecranium,face,thyroidgland,andlymphnodestructures
containedwithintheheadandneck.
Historyofpresenthealthconcern
Assessforpain
•Doyouexperienceneckpain?Doyouexperienceheadaches?Describe.
•Doyouhaveanyfacialpain?Describe.Doyouhaveanydifficultymovingyourheadorneck?
•Haveyounoticedanylumpsorlesionsonyourheadorneckthatdonothealordisappear?
Describetheirappearanceandlocation.
•Haveyouexperiencedanydizziness,light-headedness,spinningsensation,orlossof
consciousness?Describe.
•Haveyounoticedachangeinthetextureofyourskin,hair,ornails?
•Haveyounoticedchangesinyourenergylevel,sleephabits,oremotionalstability?
•Haveyouexperiencedanypalpitations,blurredvision,orchangesinbowelhabits?

11. Pasthealthhistory
•Thisportionofthehealthhistoryfocusesonquestionsrelatedtotheclient’spast,fromthe
earliestbeginningstothepresent.
•Describeanypreviousheadorneckproblemsyouhavehad.
•Howweretheytreated?Whatweretheresults?
•Haveyoueverundergoneradiationtherapyforaprobleminyourneckregion?
Familyhistory
•Isthereahistoryofheadandneckcancerinyourfamily?
•Isthereahistoryofmigraineheadachesinyourfamily?

12. Lifestyleandhealthpractices
•Thisisaveryimportantsectionofthehealthhistorybecauseitdealswiththeclient’shuman
responses.
•Doyousmokeorchewtobacco?Ifyes,howmuch?
•Doyouwearahelmetwhenridingahorse,bicycle,motorcycle,orotheropensportsvehicle?
Doyouwearahardhatforhazardousoccupations?
•Whatisyourtypicalposturewhenrelaxing,duringsleep,andwhenworking?
•Inwhatkindsofrecreationalactivitiesdoyouparticipate?Describetheactivity.
•Haveanyproblemswithyourheadorneckinterferedwithyourrelationshipswithothersor
theroleyouoccupyathomeoratwork?

13. Head and Face
Inspection
•Inspectthehead–Inspectforsize,shape,andconfiguration.
•Inspectforinvoluntarymovement–Headshouldbeheldstillandupright.
•Inspecttheface–Inspectforsymmetry,features,movement,expression,andskincondition.
Palpation
•Palpatethehead–Palpateforconsistency;theheadisnormallyhardandsmoothwithout
lesions.
•Palpatethetemporalartery–Thisshouldbelocatedbetweenthetopoftheearandtheeye.
•Palpatethetemporomandibularjoint–Toassessthetemporomandibularjoint,placeyour
indexfingeroverthefrontofeachearasyouasktheclienttoopenyourmouth.

14. Neck
Inspection
Inspecttheneck
•Observetheclient’sslightlyextendedneckforposition,symmetry,andlumpsormasses.
•Shinealightfromthesideoftheneckacrosstohighlightanyswelling.
Inspectthemovementoftheneckstructures
•Asktheclienttoswallowasmallsipofwater.
•Observethemovementofthethyroidcartilageandthyroidgland.
Inspectthecervicalvertebrae
•Asktheclienttoflextheneck(chintochest,eartoshoulder,twistlefttorightandrighttoleft,
andbackwardandforward.
Inspectrangeofmotion
•Asktheclienttoturntheheadtotherightandtotheleft(chintoshoulder),toucheachearto
theshoulder,touchchintochest,andliftthechintotheceiling.

15. Palpation
Palpatethetrachea
•Placeyourfingerinthesternalnotch.
•Feeleachsideofthenotchandpalpatethetrachealrings.
•Thefirstupperringabovethesmoothtrachealringsisthecricoidcartilage
Palpatethethyroidgland
•Locatekeylandmarkswithyourindexfingerandthumb;asktheclienttoswallowasyou
palpate
Auscultation
•Auscultatethethyroidglandonlyifyoufindanenlargedthyroidglandduringinspectionor
palpation.
•Placethebellofthestethoscopeoverthelaterallobesofthethyroidgland;asktheclientto
holdhisbreath(toobscureanytrachealbreathsoundswhileyouauscultate).

16. Lymph nodes of the head and neck
Palpation
Palpatethepreauricularnodes,postauricularnodes,occipitalnodes
•Thereshouldbenoswellingorenlargementandnotenderness.
Palpatethetonsillarnodes
•Palpatethetonsillarnodesattheangleofthemandibleontheanterioredgeofthe
sternomastoidmuscle.
Palpatethesubmentalnodes
•Whichareafewcentimetresbehindthetipofthemandible.
Palpatethesuperficialcervicalnodes
•Intheareasuperficialtothesternomastoidmuscle.
Palpatetheposteriorcervicalnodes
•Intheareaposteriortothesternomastoidandanteriortothetrapeziusintheposteriortriangle.

17. Palpatethedeepcervicalchainnodes
•Deeplywithinandaroundthesternomastoidmuscle.
Palpatethesupraclavicularnodes
•Byhookingyourfingersovertheclaviclesandfeelingdeeplybetweentheclaviclesand
sternomastoidmuscles.

18. Assessment of the Eye and Vision
•Toperformathoroughassessmentoftheeye,oneneedsagoodunderstandingoftheexternal
structuresoftheeye,theinternalstructuresoftheeye,thevisualfieldsandpathways,andthe
visualreflexes.
Historyofpresenthealthconcern
•Wheninterviewingaclientabouteyehealthandvision,remembertoinvestigateandanalyse
anyreportedsymptomsorsignsfurther.
Pasthealthhistory
•Haveyoueverhadproblemswithyoureyesorvision?
•Haveyoueverhadeyesurgery?
•Describeanypasttreatmentsyouhavereceivedforeyeproblems.
•Werethesesuccessful?Wereyousatisfied?

19. VisualProblems
•Describeanyrecentchangesinyourvision.Weretheysuddenorgradual?
•Doyouseespotsorfloatersinfrontofyoureyes?
•Doyouexperienceblindspots?Aretheyconstantorintermittent?
•Doyouseehalosorringsaroundlights?
•Doyouhavetroubleseeingatnight?
•Doyouexperiencedoublevision?
•Doyouhaveanyeyepainoritching?Describe.
•Doyouhaveanyrednessorswellinginyoureyes?
•Doyouexperienceexcessivewateringortearingoftheeye?Oneeyeorbotheyes?
•Haveyouhadanyeyedischarge?Describe.

20. Familyhistory
•Thefamilyhistoryshouldincludeasmanygenericrelativesastheclientcanrecall;inaddition
togeneticpredisposition
•Itisalsohelpfultoseeotherhealthproblemsthatmayhaveaffectedtheclientbyvirtueof
havinggrownupinthefamilyandbeingexposedtotheseproblems.
•Isthereahistoryofeyeproblemsorvisionlossinyourfamily?
Lifestyleandhealthpractices
•Areyouexposedtoconditionsorsubstancesintheworkplaceorhomethatmayharmyour
eyesorvision?Doyouwearsafetyglassesduringexposuretoharmfulsubstances?
•Doyouwearsunglassesduringexposuretothesun?
•Whattypesofmedicationdoyoutake?Whenwasyourlasteyeexamination?
•Hasyourvisionlossaffectedyourabilitytocareforyourself?Towork?
•Doyouhaveaprescriptionforcorrectivelenses?Doyouwearthemregularly?Ifyouwear
contacts,howlongdoyouwearthem?Howdoyoucleanthem?

21. Evaluation of Vision
Testdistantvisualacuity
•Positiontheclient20feetfromtheSnellenorEchartandaskhertoreadeachlineuntilshe
cannotdecipherthelettersortheirdirection.
Testnearvisualacuity
•Usethistestformiddle-agedclientsandotherswhocomplainofdifficultyreading.
•Givetheclientahand-heldvisioncharttohold14inchesfromtheeyes.
•Havetheclientcoveroneeyewithanopaquecardbeforereadingfromtoptobottom.
Testvisualfieldsforgrossperipheralvision
•Toperformtheconfrontationtest,positionyourselfapproximately2feetawayfromtheclientat
eyelevel.
•Havetheclientcoverhislefteyewhileyoucoveryourrighteye.Lookdirectlyateachother
withyouruncoveredeyes.
•Nextfullyextendyourleftarmatmidlineandslowlymoveonefingerupwardfrombelowuntil
theclientseesyourfinger.

22. External eye structures
InspectionandPalpation
Inspecttheeyelidsandeyelashes
•Notethewidthandpositionofpalpebralfissures.
•Assesstheabilityofeyelidstoclose.Notethepositionoftheeyelidsincomparisonwiththe
eyeballs.
•Observeforredness,swelling,discharge,orlesions.
Observethepositionandalignmentoftheeyeballintheeyesocket
•Eyeballsaresymmetricallyalignedinsocketswithoutprotrudingorsinking.
Inspectthebulbarconjunctivaandsclera
•Havetheclientkeepherheadstraightwhilelookingfromsidetosideandthenuptowardthe
ceiling.
•Observeclarity,colour,andtexture.

23. Inspectthepalpebralconjunctiva
•Putonglovesforthisassessmentprocedure.
•First,inspectthepalpebralconjunctivaofthelowereyelidbyplacingyourthumbsbilaterallyat
thelevelofthelowerbonyorbitalrimandgentlypullingdowntoexposethepalpebral
conjunctiva.
Inspectthelacrimalapparatus
•Assesstheareasoverthelacrimalglands(lateralaspectofuppereyelid)andthepuncta(medial
aspectoflowereyelid).
Inspectthecorneaandlens
•Shinealightfromthesideoftheeyeforanobliqueview.Lookthroughthepupiltoinspectthe
lens.
Testpupillaryreactiontolight
•Testfordirectresponsebydarkeningtheroomandaskingtheclienttofocusonadistantobject.

24. Testaccommodationofpupils
•Holdyourfingerorapencilabout12to15inchesfromtheclient.
•Asktheclienttofocusonyourfingerorpencilandtoremainfocusedonitasyoumoveit
closertowardtheeyes.
Palpation
Palpatethelacrimalapparatus
•Putondisposableglovestopalpatethenasolacrimalducttoassessforblockage.
•Useonefingerandpalpatejustinsidethelowerorbitalrim.

25. Internal eye structures
Inspection
Inspecttheopticdisc
•Keepthelightbeamfocusedonthepupilandmoveclosertotheclientfroma15-degreeangle.
•Youshouldbeveryclosetotheclient’seye(about3to5cm),almosttouchingtheeyelashes.
•Notetheshape,color,size,andphysiologiccup.
Inspecttheretinalvessels
•Remaininthesamepositionasdescribedpreviously.
•Inspectthesetsofretinalvesselsbyfollowingthemouttotheperipheryofeachsectionofthe
eye.
•Notethenumberofsetsofarteriolesandvenules.
Inspectretinalbackground
•Remaininthesamepositiondescribedpreviouslyandsearchtheretinalbackgroundfromthe
disctothemacula,notingthecolorandthepresenceofanylesions.

26. Inspectthefovea(sharpestareaofvision)andmacula
•Remaininthesamepositiondescribedpreviously.
•Shinethelightbeamtowardthesideoftheeyeorasktheclienttolookdirectlyintothelight.
•Observethefoveaandthemaculathatsurroundsit.
Inspecttheanteriorchamber
•Remaininthesamepositionandrotatethelenswheelslowlyto+10,+12,orhighertoinspect
theanteriorchamberoftheeye.

27. Assessment of the Ear
•Theassessmentofhearingprovidesinformationabouttheabilitytointeractwiththeenvironment.
Historyofpresenthealthconcern
•Iftheclientcomplainsoforreportsahistoryofearinfectionsorsuspectshearingloss,collectas
muchrelateddataaspossible.
ChangesinHearing
•Describeanyrecentchangesinyourhearing.
•Areallsoundsaffectedbythischange,orjustsomesounds?
OtherSymptoms
•Doyouhaveanyeardrainage?Describetheamountandanyodor.
•Doyouhaveanyearpain?Ifso,doyouhaveanaccompanyingsorethroat,sinusinfection,or
problemwithyourteethorgums?Doyouexperienceanyringingorcracklinginyourears?
•Doyoueverfeellikeyouarespinningorthattheroomisspinning?Doyoueverfeeldizzyor
unbalanced?

28. Pasthealthhistory
•Haveyoueverhadanyproblemswithyourearssuchasinfections,trauma,orearaches?
•Describeanypasttreatmentsyouhavereceivedforearproblems.
•Werethesesuccessful?Wereyousatisfied?
Familyhistory
•Isthereahistoryofhearinglossinyourfamily?
Lifestyleandhealthpractices
•Doyouworkorliveinanareawithfrequentorcontinuousloudnoise?
•Howdoyouprotectyourearsfromthenoise?
•Doyouspendalotoftimeswimmingorinthewater?Howdoyouprotectyourears?
•Hasyourhearinglossaffectedyourabilitytocareforyourself?Towork?
•Hasyourhearinglossaffectedyoursocializingwithothers?
•Whenwasyourlasthearingexamination?
•Howdoyoucareforyourears?

29. External ear structures
InspectionandPalpation
Inspecttheauricle,tragus,andlobule
•Notesize,shape,andposition.Observeforlesions.discolorations,anddischarge.
Palpatetheauricleandmastoidprocess
•Normallytheauricle,tragus,andmastoidprocessarenottender.
Internal ear structures
Inspection
Inspecttheexternalauditorycanal
•Usetheotoscope.
•Asmallamountofodourlesscerumenistheonlydischargenormallypresent.
Inspectthetympanicmembrane(eardrum)
•Notecolour,shape,consistency,andlandmarks.

30. PerformWeber’stestiftheclientreportsdiminishedorlosthearinginoneear
•Strikeatuningforksoftlywiththebackofyourhandandplaceitinthecentreoftheclient’s
headorforehead.
•Askwhethertheclienthearsthesoundbetterinoneearorthesameinbothears.
PerformtheRinnetest
•TheRinnetestcomparesairandboneconduction.
•Strikeatuningforkandplacethebaseoftheforkontheclient’smastoidprocess.
•Asktheclienttotellyouwhenthesoundisnolongerheard.
•Movetheprongsofthetuningforktothefrontoftheexternalauditorycanal.
•Asktheclienttotellyouifthesoundisaudibleaftertheforkismoved.
PerformtheRombergtest
•Asktheclienttostandwithfeettogetherandarmsatthesidesandeyesopenandthenwith
eyesclosed

31. Assessment of the Mouth, Throat, Nose, Sinus
•Subjectivedatarelatedtothemouth,throat,nose,andsinuscanaidindetectingdiseasesand
abnormalitiesthatmayaffecttheclient’sactivitiesofdailyliving.
Historyofpresenthealthconcern
TongueandMouth
•Doyouexperiencetongueormouthsoresorlesions?Aretheypainful?
•Howlonghaveyouhadthem?
•Dotheyrecur?Isitsingle,ordoyouhavemany?
•Doyouexperienceredness,swelling,bleeding,orpaininthegumsormouth?
•Howlonghasthisbeenhappening?
•Doyouhaveanytoothache?
•Haveyoulostanypermanentteeth?

32. NoseandSinuses
•Doyouhavepaininyoursinuses?
•Doyouexperienceanynosebleeds?Howmuchbleeding?Whatcolouristheblood?
•Doyouexperiencefrequentclearormucousdrainagefromyournose?
•Canyoubreathethroughbothofyournostrils?Doyouhaveastuffynoseattimesduringthe
dayornight?
•Doyouhaveseasonalallergies?Describethetimingoftheallergiesandsymptoms.
•Haveyouexperiencedachangeinyourabilitytosmellortaste?
Throat
•Doyouhavedifficultychewingorswallowingfood?Howlonghaveyouhadthis?Doyouhave
anypain?
•Doyouhaveasorethroat?Howlonghaveyouhadit?Describe.Howoftendoyougetsore
throats?
•Doyouexperiencehoarseness?Howlong?

33. Pasthealthhistory
•Haveyoueverhadanyoral,nasal,orsinussurgery?
•Doyouhaveahistoryofsinusinfections?Describeyoursymptoms.Doyouusenasalsprays?
Familyhistory
•Isthereahistoryofmouth,throat,nose,orsinuscancerinyourfamily?
Lifestyleandhealthpractices
•Doyousmokeorusesmokelesstobacco?Ifso,howmuch?Areyouinterestedinquittinghabit?
•Doyoudrinkalcohol?Howmuchandhowoften?Doyougrindyourteeth?
•Describehowyoucareforyourteethordentures.Howoftendoyoubrushandusedental
floss?Whenwasyourlastdentalexamination?
•Iftheclientwearsbraces:Howdoyoucareforyourbraces?Doyouavoidanyspecifictypesof
foods?Describeyourusualdietaryintakeforaday.
•Iftheclientwearsdentures:Howdoyourdenturesfit?Doyoubrushyourtongue?
•Howoftenareyouinthesun?Doyouuselipsunscreenproducts?

34. Mouth
InspectionandPalpation
Inspectthelips
•Observelipconsistencyandcolor.
Inspecttheteethandgums
•Asktheclienttoopentheirmouth.
•Notethenumber,colour,condition,andalignmentoftheteeth.
Inspectthebuccalmucosa
•Useapenlightandtonguedepressortoretractthelipsandcheekstocheckcolourand
consistency.
•Also,noteStenson’sducts(parotidducts)locatedonthebuccalmucosaacrossfromthesecond
uppermolars.

35. Inspectandpalpatethetongue
•Asktheclienttostickoutthetongue.Inspectforcolor,moisture,size,andtexture.
•Observeforfasciculations(finetremors),andcheckformidlineprotrusions.
•Palpateanylesionspresentforinduration.
Assesstheventralsurfaceofthetongue
•Asktheclienttotouchthetonguetotheroofofthemouth,anduseapenlighttoinspectthe
ventralsurfaceofthetongue.
InspectforWharton’sducts
•Theseareopeningsfromthesubmandibularsalivaryglandslocatedoneithersideofthe
frenulumonthefloorofthemouth.
Observethesidesofthetongue
•Useasquaregauzepadtoholdtheclient’stonguetoeachside.
•Palpateforanylesions,ulcers,ornodulesforinduration.

36. Checkthestrengthofthetongue
•Placeyourfingersontheexternalsurfaceoftheclient’scheek.
•Asktheclienttopressthetongue’stipagainsttheinsideofthecheektoresistpressurefrom
yourfingers.
Checktheanteriortongue’sabilitytotaste
•Byplacingdropsofsugarandsaltywateronthetipandsidesofthetonguewithatongue
depressor.
Inspectthehard(anterior)andsoft(posterior)palatesanduvula
•Asktheclienttoopenthemouthwidewhileyouuseapenlighttolookattheroof.
•Observecolourandintegrity.
Noteodour
•Whilethemouthiswideopen,noteanyunusualorfoulodour.

37. Assesstheuvula
•Applyatonguedepressortothetongueandshineapenlightintotheclient’swide-open
mouth.
•Notethecharacteristicsandpositioningoftheuvula.
•Asktheclienttosay“Aaah”andwatchfortheuvulaandsoftpalatetomove.
Inspectthetonsils
•Usingthetonguedepressortokeepthemouthopenwide,Inspectthetonsilsforcolour,size,
andpresenceofexudateorlesions.
•Tonsilsshouldbegraded.
Inspecttheposteriorpharyngealwall
•Keepingthetonguedepressorinplace,shinethepenlightonthebackofthethroat.
•Observethecolourofthethroat,andnoteanyexudateorlesions.

38. Nose
InspectionandPalpation
Inspectandpalpatetheexternalnose
•Notenasalcolour,shape,consistency,andtenderness.
Checkthepatencyofairflow
•Throughthenostrilsbyoccludingonenostrilatatimeandaskingtheclienttosniff.
Inspecttheinternalnose
•Toinspecttheinternalnose,useanotoscopewithashortwide-tipattachment.
•Useyournon-dominanthandtostabilizeandgentlytilttheclient’sheadback.
•Inserttheshortwidetipoftheotoscopeintotheclient’snostrilwithouttouchingthesensitive
nasalseptum.

39. Palpation
Palpatethesinuses
•Palpatethefrontalsinusesbyusingyourthumbstopressuponthebrowoneachsideofthe
nose.
•Palpatethemaxillarysinusesbypressingwiththumbsuponthemaxillarysinuses.
Percussion
Percussthesinuses
•Lightlytapoverthefrontalsinusesandoverthemaxillarysinusesfortenderness.
Transillumination
Transilluminatethesinuses
•Transilluminatethefrontalsinusesbyholdingastrong,narrowlightsourcesnuglyunderthe
eyebrows.Useyourotherhandtoshieldthelight.
•Transilluminatethemaxillarysinusesbyholdingastrong,narrowlightsourceoverthe
maxillarysinusandaskingtheclienttoopenhisorhermouth.

40. Assessment of the Thoracic and Lung
•Subjectivedatarelatedtothethoracicandlungassessmentprovidemanycluesaboutunderlying
respiratoryproblemsandassociatedriskforthedevelopmentoflungdisorders.
Historyofpresenthealthconcern
Difficultyofbreathing
•Doyoueverexperiencedifficultybreathing?Describethedifficulty.
•Doyouexperienceanyothersymptomswhenyouhavedifficultybreathing?
•Doyouhavedifficultybreathingwhenresting,ordoanyspecificactivitiescausethedifficulty?
•Doyouhavedifficultybreathingwhenyousleep?Doyouusemorethanonepilloworelevate
theheadofthebedwhenyousleep?
•Doyousnorewhenyousleep?
•Haveyoubeentoldthatyoustopbreathingatnightwhenyousnore?

41. Chestpain
•Doyouhavechestpain?Isthepainassociatedwithacold,fever,ordeepbreathing?
Coughing
•Doyouhaveacough?Whenandhowoftendoesitoccur?
•Doyouproduceanysputumwhenyoucough?Ifso,whatcolouristhesputum?
•Howmuchsputumdoyoucoughup?
•Hasthisamountincreasedordecreasedrecently?
•Doesthesputumhaveanodour?
•Doyouwheezewhenyoucoughorwhenyouareactive?
GIsymptoms
•Doyouhavegastrointestinalsymptomssuchasheartburn,frequenthiccups,orchronic
cough?

42. Pasthealthhistory
•Haveyouhadpriorrespiratoryproblems?
•Haveyoueverhadanythoracicsurgery,biopsy,ortrauma?
•Haveyoubeentestedforordiagnosedwithallergies?
•Haveyoueverhadachestx-ray,tuberculosis(TB)skintest,orinfluenzaimmunization?
•Haveyouhadanyotherpulmonarystudiesinthepast?
•Haveyourecentlytravelledoutsideofthecountry?
•HaveyoubeeninclosecontactwithanyoneknownorsuspectedtohaveSARS?
Familyhistory
•Isthereahistoryoflungdiseaseinyourfamily?
•Didanyfamilymembersinyourhomesmokewhenyouweregrowingup?
•Isthereahistoryofotherpulmonaryillnesses/disordersinthefamily?

43. Lifestyleandhealthpractices
•Haveyoueversmokedcigarettesorothertobaccoproducts?Doyoucurrentlysmoke?At
whatagedidyoustart?
•Howmuchdoyousmoke,andhowmuchhaveyousmokedinthepast?Whatactivitiesdo
youusuallyassociatewithsmoking?Haveyouevertriedtoquit?
•Areyouexposedtoanyenvironmentalconditionsthataffectyourbreathing?Wheredoyou
work?Areyouaroundsmokers?
•Doyouhavedifficultyperformingyourusualdailyactivities?Describeanydifficulties.
•Whatkindofstressareyouexperiencingatthistime?Howdoesitaffectyourbreathing?
•Areyoucurrentlytakingmedicationsforbreathingproblemsorothermedicationsthataffect
yourbreathing?
•Doyouuseanyothertreatmentsathomeforyourrespiratoryproblems?
•Haveyouusedanyherbalmedicinesoralternativetherapiestomanagecoldsorother
respiratoryproblems?

44. Posterior thorax
Inspection
Inspectfornasalflaringandpursedlipbreathing
•Nasalflaringisnotobservedinnormalfindings.
Observethecolouroftheface,lips,andchest
•Theclienthasanevenlycolouredskintonewithoutunusualorprominentdiscoloration.
Inspectthecolourandshapeofthenails
•Pinktonesshouldbeseeninthenailbeds.
•Thereisnormallya160-degreeanglebetweenthenailbaseandtheskin.
Inspectconfiguration
•Whiletheclientsitswithherarmsathersides,standbehindherandobservethepositionof
thescapulaeandtheshapeandconfigurationofthechestwall.
Observetheuseofaccessorymuscles
•Watchastheclientbreathesanddoesnotuseit.

45. Inspecttheclient’spositioning
Notetheclient’spostureandabilitytosupportweightwhilebreathingcomfortably.
Palpation
Palpatefortendernessandsensation
•Palpationmaybeperformedwithoneorbothhands;however,thesequenceofpalpationis
established.
•Starttowardthemidlineattheleveloftheleftscapulaandmoveyourhandfromlefttoright,
comparingfindingsbilaterally.
•Movesystematicallydownwardandouttocoverthelateralportionsofthelungsatthebases.
Palpateforcrepitus
•Crepitus,alsocalledsubcutaneousemphysema,isacracklingsensationthatoccurswhenair
passesthroughfluidorexudate.
•Useyourfingersandfollowtheabovesequencewhenpalpating.

46. Palpatesurfacecharacteristics
•Useglovesandyourfingerstopalpateanylesionsyounoticedduringtheinspection.
Palpateforfremitus
•Followingtheabovesequence,usetheballorulnaredgeofonehandtoassessforfremitus
(vibrationsofairinthebronchialtubestransmittedtothechestwall.
Assesschestexpansion
•PlaceyourhandsontheposteriorchestwallwithyourthumbsatthelevelofT
9orT
10and
presstogetherasmallskinfold.

47. Percussion
Percussfortone
•Startattheapicesofthescapulaeandpercussacrossthetopsofbothshoulders.
•Thenpercusstheintercostalspacesacrossanddown,comparingsides.
•Percussthelateralaspectsatthebasesofthelungs,comparingsides.
Percussfordiaphragmaticexcursion
•Asktheclienttoexhaleforcefullyandholdtheirbreath.
•Beginningatthescapularline,percusstheintercostalspacesoftherightposteriorchestwall.
•Percussdownwarduntilthetonechangesfromresonancetodullness.
•Next,asktheclienttoinhaledeeplyandholdit.
•Percusstheintercostalspacesfromthemarkdownwarduntilresonancechangestodullness.

48. Auscultation
Auscultateforbreathsounds
•Tobegin,placethediaphragmofthestethoscopefirmlyanddirectlyontheposteriorchest
wallattheapexofthelungatC
7.
•Asktheclienttobreathedeeplythroughhisorhermouthforeachareaofauscultationinthe
auscultationsequencesoyoucanbesthearinspiratoryandexpiratorysounds.
Auscultateforadventitioussounds
•Adventitioussoundsaresoundsaddedorsuperimposedovernormalbreathsoundsand
heardduringauscultation.
Auscultatevoicesounds
•Bronchophony–Asktheclienttorepeatthephrase“ninety-nine”whileyouauscultatethe
chestwall.

49. OtherAssessmentTechniques
Egophony
•AsktheclienttorepeattheletterEwhileyoulistenoverthechestwall.
WhisperedPectoriloquy
•Asktheclienttowhisperthephrase“one-two-three”whileyouauscultatethechestwall.

50. Anterior thorax
Inspection
Inspectforshapeandconfiguration
•Havetheclientsitwithherarmsathersides.Standinfrontoftheclientandassessshapeand
configuration.
Inspectthepositionofthesternum
•Observethesternumfromananteriorandlateralviewpoint.
•Watchforsternalretraction.
Inspecttheslopeoftheribs
•Assesstheribsfromananteriorandlateralviewpoint.
Observethequalityandpatternofrespiration
•Notebreathingcharacteristicsaswellasrate,rhythm,anddepth.
Inspectintercostalspaces
•Asktheclienttobreathenormallyandobservetheintercostalspaces.

51. Observeforuseofaccessorymuscles
•Asktheclienttobreathenormallyandobserveforuseofaccessorymuscles.
Palpation
Palpatefortenderness,sensation,andsurfacemasses
•Useyourfingerstopalpatefortendernessandsensation.
•Startwithyourhandpositionedovertheleftclavicleandmoveyourhandlefttoright,
comparingfindingsbilaterally.
•Moveyourhandsystematicallydownwardtowardthemidlineatthelevelofthebreastsand
outwardatthebasetoincludethelateralaspectofthelung.
Palpateforfremitus
•Usingthesequencefortheanteriorchestabove,palpateforfremitususingthesametechnique
asfortheposteriorthorax.
Palpateanteriorchestexpansion
•Placeyourhandsontheclient’santerolateralwallwithyourthumbsalongthecostalmargins
andpointingtowardthexiphoidprocess.

52. Percussion
Percussfortone
•Percusstheapicesabovetheclavicles.
•Thenpercusstheintercostalspacesacrossanddown,comparingsides.
Auscultation
Auscultateforanteriorbreathsounds,adventitiousbreathsounds,andvoicesounds
•Placethediaphragmofthestethoscopefirmlyanddirectlyontheanteriorchestwall.
•Auscultatefromtheapicesofthelungsslightlyabovetheclaviclestothebasesofthelungsat
thesixthrib.
•Listenateachsiteforatleastonerespiratorycycle.
•Followthesequenceforanteriorauscultation.

53. Assessment of the Breast and Lymphatic System
Historyofpresenthealthconcern
•Haveyounoticedanylumpsorswellinginyourbreasts?Ifso,where?whendidyoufirst
notice?hasthelumpgrownorhastheswellingincreased?Isthelumporswellingassociated
withotherproblems?Doesthelumporswellingchangeduringyourmenstrualcycle?
•Haveyounoticedanylumpsorswellingintheunderarmarea?
•Haveyounoticedanyredness,warmth,ordimplingofyourbreasts?Anyrashonthebreast,
nipple,oraxillaryarea?
•Haveyounoticedanychangeinthesizeorfirmnessofyourbreasts?
•Doyouexperienceanypaininyourbreasts?Ifso,where?Doesitoccuratanyspecifictime
duringyourmenstrualcycle?
•isthereacertainactivitythatseemstoinitiatethepain?
•Doyouhaveanydischargefromthenipples?Ifso,describeitscolor,consistency,andodor,if
any.Whendiditstart?Whichnipplehasthedischarge?

54. Pasthealthhistory
•Haveyouhadanypriorbreastdisease?
•Haveyoueverhadbreastsurgery,abreastbiopsy,breastimplants,orbreasttrauma?
•Ifso,whendidthisoccur?Whatwastheresult?
•Howoldwereyouwhenyoubegantomenstruate?Haveyouexperiencedmenopause?
•Haveyougivenbirthtoanychildren?
•Atwhatagedidyouhaveyourfirstchild?
•Whenwasthefirstandlastdayofyourmenstrualcycle?
Familyhistory
•Isthereahistoryofbreastcancerinyourfamily?Who?
Lifestyleandhealthpractices
•Areyoutakinganyhormones,contraceptives,orantipsychoticagents?
•Doyouliveorworkinanareawhereyouhaveexcessiveexposuretoradiation,benzene,or
asbestos?

55. •Whatisyourtypicaldailydiet?
•Howmuchalcoholdoyoudrinkeachday?
•Howmuchcoffee,tea,andcoladoyouconsumeeachday?
•Doyouengageinanyregularexercise?Ifso,whattypeofbradoyouwearwhenyouexercise?
•Howimportantareyourbreaststoyouinrelationtoapositivefeelingaboutyourselfandyour
physicalappearance?
•Doyouhaveanyfearsregardingbreastdisease?
•Doyouexamineyourownbreasts?
•Describewhenyoudothis.Haveyounotedanychangesinyourbreastssuchasalump,
swelling,skinirritation,ordimpling,nipplepainorretraction,rednessorscalinessornippleof
breastskin,ordischarge?
•Ifyes,haveyoureportedthistoyourhealthcareprovider?
•Haveyoueverhadyourbreastsexaminedbyaphysician?Whenwasyourlastexamination?
•Haveyoueverhadamammogram?Ifso,whenwasyourlastone?

56. Female breasts
Inspection
Inspectsizeandsymmetry
•Havetheclientdisrobeandsitwitharmshangingfreely.
•Explainwhatyouareobservingtohelpeaseclientanxiety.
Inspectcolourandtexture
•Besuretonotetheclient’soverallskintonewheninspectingthebreastskin.
•Noteanylesions.
Inspectsuperficialvenouspattern
•Observethevisibilityandpatternofbreastveins.
Inspecttheareolas
•Notethecolour,size,shape,andtextureoftheareolasofbothbreasts.

57. Inspectthenipples
•Notethesizeanddirectionofthenipplesofbothbreasts.
•Alsonoteanydryness,lesions,bleeding,ordischarge.
Inspectforretractionanddimpling
•Toinspectthebreastsaccuratelyforretractionanddimpling,asktheclienttoremainseated
whileperformingseveraldifferentmaneuvers.
•Asktheclienttoraiseherarmsoverhead,thenpressherhandsagainstherhips.
•Next,askhertopressherhandstogether.
Palpation
Palpatetextureandelasticity
•Smooth,firm,elastictissueisanormalfinding.
Palpatetendernessandtemperature
•Ageneralizedincreaseinnodularityandtendernessmaybeanormalfindingassociatedwith
themenstrualcycleorhormonalmedications.

58. Palpateformasses
•Notelocation,sizeincentimetres,shape,mobility,consistency,andtenderness.
•Also,notetheconditionoftheskinoverthemass.
Palpatethenipples
•Wearglovestocompressthenipplegentlywithyourthumbandindexfinger.
•Noteanydischarge.
Palpatemastectomyorlumpectomysite
•Iftheclienthashadamastectomyorlumpectomy,itisstillimportanttoperformathorough
examination.
•Palpatethescarandanyremainingbreastandaxillarytissueforredness,lesions,lumps,
swelling,ortenderness.

59. Axillae
InspectionandPalpation
Inspectandpalpatetheaxillae
•Asktheclienttositup.Inspecttheaxillaryskinforrashesorinfections.
•Holdtheclient’selbowwithonehand,andusethethreefingerpadsofyourotherhandto
palpatefirmlytheaxillarylymphnodes.
•First,palpatehighintotheaxillae,movingdownwardagainsttheribstofeelforthecentral
nodes.
•Continuetomovedowntheposterioraxillaetofeelfortheposteriornodes.
Male breasts
InspectionandPalpation
Inspectandpalpatethebreasts,areolas,nipples,andaxillae
•Noteanyswelling,nodules,orulceration.
•Palpatetheflatdiscofunderdevelopedbreasttissueunderthenipple.

60. Assessment of the Heart and Neck Vessels
Historyofpresenthealthconcern
ChestpainandPalpitations
•Doyouexperiencechestpain?
•Whendiditstart?
•Describethetypeofpain,location,radiation,duration,andhowoftenyouexperiencethe
pain.
•Ratethepainonascaleof0to10,with10beingtheworstpossible.
•Doestheactivitymakethepainworse?
•Didyouhaveperspirationwiththechestpain?
•Doyouexperiencepalpitations?

61. OtherSymptoms
•Doyoutireeasily?
•Doyouexperiencefatigue?
•Describewhenthefatiguestarted.Wasitsuddenorgradual?
•Doyounoticeitatanyparticulartimeoftheday?
•Doyouhavedifficultybreathingorshortnessofbreath?
•Doyouwakeupatnightwithanurgentneedtourinate?Howmanytimesatnight?
•Doyouexperiencedizziness?
•Doyouexperienceswelling(edema)inyourfeet,ankles,orlegs?
•Doyouhavefrequentheartburn?Whendoesitoccur?Whatrelievesit?Howoftendoyou
experienceit?

62. Pasthealthhistory
•Haveyoubeendiagnosedwithaheartdefectoramurmur?
•Haveyoueverhadrheumaticfever?
•Haveyoueverhadheartsurgeryorcardiacballooninterventions?
•Haveyoueverhadanelectrocardiogram?
•Whenwasthelastoneperformed?Doyouknowtheresults?
•Haveyoueverhadabloodtestcalledalipidprofile?
•Basedonyourlasttest,doyouknowwhatyourcholesterollevelswere?
•Doyoutakemedicationsoruseothertreatmentsforheartdisease?
•Howoftendoyoutakethem?Whydoyoutakethem?
•Doyoumonitoryourownheartrateorbloodpressure?

63. Familyhistory
•Thefamilyhistoryshouldincludeasmanygenericrelativesastheclientcanrecall;in
additiontogeneticpredisposition
•Itisalsohelpfultoseeotherhealthproblemsthatmayhaveaffectedtheclientbyvirtueof
havinggrownupinthefamilyandbeingexposedtotheseproblems.
•Isthereahistoryofhypertension,myocardialinfarction,coronaryheartdisease,elevated
cholesterollevels,ordiabetesmellitusinyourfamily?

64. Lifestyleandhealthpractices
•Doyousmoke?Howmanypacksofcigarettesperdayandforhowmanyyears?
•Whattypeofstressdoyouhaveinyourlife?Howdoyoucopewithit?
•Describewhatyouusuallyeatina24-hourperiod.
•Howmuchalcoholdoyouconsumeeachday/week?
•Doyouexercise?Whattypeofexerciseandhowoften?
•Describeyourdailyactivities.Howaretheydifferentfromyourroutine5or20yearsago?
Doesfatigue,chestpain,orshortnessofbreathlimityourabilitytoperformdailyactivities?
Describe.Areyouabletocareforyourself?
•Hasyourheartdiseasehadanyeffectonyoursexualactivity?
•Howmanypillowsdoyouusetosleepatnight?Doyougetuptourinateduringthenight?
Doyoufeelrestedinthemorning?
•Howimportantishavingahealthyhearttoyourabilitytofeelgoodaboutyourselfandyour
appearance?Whatfearsaboutheartdiseasedoyouhave?

65. Neck Vessels
Inspection
Observethejugularvenouspulse
•Inspectthejugularvenouspulsebystandingontherightsideoftheclient.
•Theclientshouldbeinasupinepositionwiththetorsoelevated30to45degrees.
•Asktheclienttoturntheheadslightlytotheleft.
•Shineatangentiallightsourceontothenecktoincreasevisualizationsofpulsationsaswellas
shadows.
Evaluatejugularvenouspressure
•Evaluatejugularvenouspressurebywatchingforthedistentionofthejugularvein.

66. AuscultationandPalpation
Auscultatethecarotidarteries
•Auscultatethecarotidarteriesiftheclientismiddle-agedorolderorifyoususpect
cardiovasculardisease.
•Placethebellofthestethoscopeoverthecarotidarteryandasktheclienttoholdhisorher
breathforamomentsobreathsoundsdonotconcealanyvascularsounds.
Palpatethecarotidarteries
•Palpateeachcarotidarteryalternatelybyplacingthepadsoftheindexandmiddlefingers
medialtothesternocleidomastoidmuscleontheneck.

67. Heart
Inspection
Inspectpulsations
•Withtheclientinasupinepositionwiththeheadofthebedelevatedbetween30and45
degrees,standontheclient’srightsideandlookfortheapicalimpulseandabnormal
pulsations.
Palpation
Palpatetheapicalpulse
•Remainontheclient’srightsideandasktheclienttoremainsupine.
•Usethepalmarsurfacesofyourhandtopalpatetheapicalimpulseinthemitralarea.
Palpateforabnormalpulsations
•Useyourpalmarsurfacestopalpatetheapex,leftsternalborder,andbase.

68. Auscultation
Auscultateheartrateandrhythm
•Placethediaphragmofthestethoscopeattheapexandlistencloselytotherateandrhythmof
theapicalimpulse.
Ifyoudetectanirregularrhythm,auscultateforapulseratedeficit
•Thisisdonebypalpatingtheradialpulsewhileyouauscultatetheapicalpulse.
•Countforafullminute.
AuscultatetoidentifyS
1andS
2
•Auscultatethefirstheartsound(S
1or“lub”)andthesecondheartsound(S
2or“dub”).
•UsethediaphragmofthestethoscopetobesthearS
1.
•UsethediaphragmofthestethoscopetohearS
2andasktheclienttobreatheregularly.

69. Auscultateforextraheartsounds
•Usethediaphragmfirst,thenthebell,toauscultateovertheentireheartarea.
•Notethecharacteristicsofanyextrasoundheard.auscultateduringthesystolicpause.
Auscultateformurmurs
•Usethediaphragmandthebellofthestethoscopeinallareasofauscultationbecausemurmurs
haveavarietyofpitches.
•Also,auscultatewiththeclientindifferentpositionsbecausesomemurmursoccurorsubside
accordingtotheclient’sposition.
Auscultatewiththeclientassumingotherpositions
•Asktheclienttoassumealeftlateralposition.
•Usethebellofthestethoscopeandlistenattheapexoftheheart.
•Asktheclienttositup,leanforward,andexhale.
•Usethediaphragmofthestethoscopeandlistenovertheapexandalongtheleftsternalborder.

70. Assessment of the Peripheral Vascular System
Historyofpresenthealthconcern
•Haveyounoticedanycolor,temperature,ortexturechangesinyourskin?
•Doyouexperiencepainorcrampinginyourlegs?Describethepain(aching,stabbing).how
oftendoesitoccur?Doesitoccurwithactivity?Doesitwakeyoufromsleep?
•Doyouhaveanylegveinsthatareropelike,bulging,orcontorted?
•Doyouhaveanysoresoropenwoundsonyourlegs?Wherearetheylocated?Arethey
painful?
•Doyouhaveanyswelling(edema)inyourlegsorfeet?
•Atwhattimeofdayisswellingworst?Anypainwithswelling?
•Doyouhaveanyswollenglandsorlymphnodes?Ifso,dotheyfeeltender,soft,orhard?
•Formaleclients–Haveyouexperiencedachangeinyourusualsexualactivity?Describe.

71. Pasthealthhistory
•Describeanyproblemsyouhadinthepastwiththecirculationinyourarmsandlegs.
•Haveyouhadanyheartorbloodvesselsurgeriesortreatmentssuchascoronaryarterybypass
grafting,repairofananeurysm,orveinstripping?
Familyhistory
•Doyouhaveafamilyhistoryofdiabetes,hypertension,coronaryheartdisease,orelevated
cholesterolortriglyceridelevels?

72. Lifestyleandhealthpractices
•Doyou(ordidyouinthepast)smokecigarettesoruseanyformoftobacco?Howmuchand
forhowlong?
•Doyouexerciseregularly?
•Forfemaleclients–Doyoutakeoralortransdermalcontraceptives?
•Describethedegreeofstressyounormallyhave.
•Howhaveproblemswithyourcirculationaffectedyourabilitytofunction?
•Dolegulcersorvaricoseveinsaffecthowyoufeelaboutyourself?
•Doyouregularlytakemedicationsprescribedbyyourphysiciantoimproveyourcirculation?
•Doyouwearsupporthosetotreatvaricoseveins?

73. Arms
Inspection
Observearmsizeandvenouspattern;alsolookforedema
•Armsarebilaterallysymmetricwithminimalvariationinsizeandshape.
•Noedemaorprominentvenouspatterning.
Observethecolorationofthehandsandarms
•Colourvariesdependingontheclient’sskintone,althoughcolourshouldbethesame
bilaterally.
Palpation
Palpatetheclient’sfingers,hands,andarms,andnotethetemperature
•Skiniswarmtothetouchbilaterallyfromfingertipstoupperarms.
Palpatetoassesscapillaryrefilltime
•Compressthenailbeduntilitblanches.releasethepressureandcalculatethetimeittakesfor
thecolourtoreturn.

74. Palpatetheradialpulse
•Gentlypresstheradialarteryagainsttheradius.Noteelasticityandstrength.
Palpatetheulnarpulses
•Applypressurewithyourfirstthreefingertipstothemedialaspectsoftheinnerwrists.
Palpatethebrachialpulsesifyoususpectarterialinsufficiency
•Dothisbyplacingthefirstthreefingertipsofeachhandattheclient’srightandleftmedial
antecubitalcreases.
Palpatetheepitrochlearlymphnodes
•Taketheclient’slefthandinyourrighthandasifyouwereshakinghands.
•Flextheclient’selbowabout90degrees.
•Useyourlefthandtopalpatebehindtheelbowinthegroovebetweenthebicepsandtriceps
muscles.

75. PerformtheAllentest
•TheAllentestevaluatesthepatencyoftheradialorulnararteries.
•Thetestbeginsbyassessingulnarpatency.
•Havetheclientrestthehandpalmside-upontheexaminationtableandmakeafist.
•Thenuseyourthumbstooccludetheradialandulnararteries.
•Notethatthepalmremainspale.
•Releasethepressureontheulnararteryandwatchforcolourtoreturntothehand.

76. Legs
Inspection,Palpation,andAuscultation
Observeskincolorwhileinspectingbothlegsfromthetoestothegroin
•Asktheclienttoliesupine.
•Thendrapethegroinareaandplaceapillowundertheclient’sheadforcomfort.
Inspectthedistributionofhair
•Haircoverstheskinonthelegsandappearsonthedorsalsurfaceofthetoes.
Inspectforlesionsorulcers
•Legsarefreeoflesionsorulcerations.
Inspectforedema
•Inspectthelegsforunilateralandbilateraledema.
•Noteveins,tendons,andbonyprominences.

77. Palpateedema
•Ifedemaisnotedduringinspection,palpatetheareatodetermineifitispittingornonpitting.
•Presstheedematousareawiththetipsofyourfingers,holdforafewseconds,thenrelease.
Palpatebilaterallyforthetemperatureofthefeetandlegs
•Usethebacksofyourfingers.
•Compareyourfindingsinthesameareasbilaterally.
Palpatethesuperficialinguinallymphnodes
•First,exposetheclient’singuinalarea,keepingthegenitalsdraped.
•Feelovertheuppermedialthighfortheverticalandhorizontalgroupsofsuperficialinguinal
lymphnodes.
Palpatethefemoralpulses
•Asktheclienttobendthekneeandmoveitouttotheside.
•Pressdeeplyandslowlybelowandmedialtotheinguinalligament.
•Releasepressureuntilyoufeelthepulse.

78. Auscultatethefemoralpulses
•Ifarterialocclusionissuspectedinthefemoralpulse,positionthestethoscopeoverthefemoral
arteryandlistenforbruits.
Palpatethepoplitealpulses
•Asktheclienttoraisethekneepartially.
•Placeyourthumbsonthekneewhilepositioningyourfingersdeepinthebendoftheknee.
•Applypressuretolocatethepulse.
Palpatethedorsalispedispulses
•Dorsiflextheclient’sfootandapplylightpressurelateraltoandalongthesideoftheextensor
tendonofthebigtoe.
Palpatetheposteriortibialpulses
•Palpatebehindandjustbelowthemedialmalleolus.
•Palpatingbothposteriortibialpulsesatthesametimeaidsinmakingcomparisons.

79. Inspectforvaricositiesandthrombophlebitis
•Asktheclienttostandbecausevaricoseveinsmaynotbevisiblewhentheclientissupine
andnotaspronouncedwhentheclientissitting.
•Astheclientisstanding,inspectforsuperficialveinthrombophlebitis
CheckforHoman’ssign
•First,flextheclient’skneeabout5degrees,placeyourhandundertheclient’scalfmuscle,
andquicklysqueezethemuscleagainstthetibia.
•Asktheclienttoreportanypainortenderness.

80. Assessment of the Abdomen
Historyofpresenthealthconcern
AbdominalPain
•Areyouexperiencingabdominalpain?
•Howwouldyoudescribethepain?Howbadisthepain(severity)onascaleof1to10,with10
beingtheworst?
•Howdid(does)thepainbegin?
•Whereisthepainlocated?Doesitmoveorhasitchangedfromtheoriginallocation?
•Whendoesthepain(timingandrelationtoparticularevents)?
•Whatseemstobringonthepain(precipitatingfactors)makeitworse(exacerbatingfactors),or
makeitbetter(alleviatingfactors)?
•Isthepainassociatedwithanyothersymptoms suchasnausea,
vomiting,diarrhoea,constipation,gas,fever,weightloss,fatigue,oryellowingoftheeyesor
skin?

81. Indigestion
•Doyouexperienceindigestion?Describe.
•Doesanything,inparticular,seemtocauseoraggravatethiscondition?
NauseaandVomiting
•Doyouexperiencenausea?Describe.
•Isittriggeredbyanyparticularactivities,events,orotherfactors?
•Haveyoubeenvomiting?Describethevomitus.
•Isitassociatedwithanyparticulartriggerfactors?
Appetite
•Haveyounoticedachangeinyourappetite?
•Hasthischangeaffectedhowmuchyoueatoryournormalweight?

82. BowelElimination
•Haveyouexperiencedachangeinboweleliminationpatterns?Describe.
•Doyouhaveconstipation?Describe.Doyouhaveanyaccompanyingsymptoms?
•Haveyouexperienceddiarrhoea?Describe.Doyouhaveanyaccompanyingsymptoms?
•Haveyouexperiencedanyyellowingofyourskinorwhitesofyoureyes,itchyskin,dark
urine,orclay-colouredstools?

83. Pasthealthhistory
•Haveyoueverhadanyofthefollowinggastrointestinaldisorders:ulcers,gastroesophageal
reflux,inflammatoryorobstructiveboweldisease,pancreatitis,gallbladderorliverdisease,
diverticulosis,orappendicitis?
•Haveyouhadanyurinarytractdiseasessuchasinfections,kidneydiseaseornephritis,or
kidneystones?
•Haveyoueverhadviralhepatitis?Haveyoueverbeenexposedtoviralhepatitis?
Familyhistory
•Isthereahistoryofanyofthefollowingdiseasesordisordersinyourfamily:colon,stomach,
pancreatic,liver,kidney,orbladdercancer,liverdisease,gallbladderdisease,orkidney
disease?

84. Lifestyleandhealthpractices
•Doyoudrinkalcohol?Howmuch?Howoften?
•Whattypesoffoodsandhowmuchfooddoyoutypicallyconsumeeachday?
•Howmuchcaffeinedoyouthinkyouconsumeeachday?
•Howmuchandhowoftendoyouexercise?Describeyouractivitiesduringtheday.
•Whatkindofstressdoyouhaveinyourlife?Howdoesitaffectyoureatingorelimination
habits?
•Ifyouhaveagastrointestinaldisorder,howdoesitaffectyourlifestyle,andhowdoyoufeel
aboutyourself?

85. Abdomen
Inspection
Observethecolorationoftheskin
•Abdominalskinmaybepalerthanthegeneralskintonebecausethisskinissoseldom
exposedtotheelements.
Notethevascularityoftheabdominalskin
•Scatteredfineveinsmaybevisible.
Noteanystriae
•Old,silvery,whitestriaeorstretchmarksfrompastpregnanciesorweightgainarenormal.
Inspectforscars
•Askaboutthesourceofascar,anduseacentimetrerulertomeasurethescar’slength.
•Documentthelocationbyquadrantandreferencelines,shape,length,andspecific
characteristics.

86. Assessforlesionsandrashes
•Theabdomenisfreeoflesionsorrashes.
•Flatorraisedbrownmoles,however,arenormalandmaybeapparent.
Inspecttheumbilicus
•Notethecolouroftheumbilicalarea.
•Observetheumbilicallocation.
•Assessthecontouroftheumbilicus.
Inspectabdominalcontour
•Lookacrosstheabdomenateyelevelfromtheclient’ssidefrombehindtheclient’shead,and
fromthefootofthebed.
•Measureabdominalgirthasindicated.
Assessabdominalsymmetry
•Lookattheclient’sabdomenassheliesinarelaxedsupineposition.

87. Inspectabdominalmovementwhentheclientbreathes
•Abdominalrespiratorymovementmaybeseen,especiallyinmaleclients.
Observeaorticpulsations
•Aslightpulsationoftheabdominalaorta,whichisvisibleintheepigastrium,extendsfull
lengthinthinpeople.
Observeforperistalticwaves
•Normallyperistalticwavesarenotseen,althoughtheymaybevisibleinverythinpeopleas
slightripplesontheabdominalwall.

88. Auscultation
Auscultateforbowelsounds
•Usethediaphragmofthestethoscopeandmakesurethatitiswarmbeforeyouplaceitonthe
client’sabdomen.
Auscultateforvascularsounds
•Usethebellofthestethoscopetolistenforbruitsovertheabdominalaortaandrenal,iliac,and
femoralarteries.
Auscultateforafrictionrubovertheliverandspleen
•Listenovertherightandleftlowerribcagewiththediaphragmofthestethoscope.

89. Percussion
Percussfortone
•Lightlyandsystematicallypercussallquadrants.
Percussthespanorheightoftheliverbydeterminingitslowerandupperborders
•Toassessthelowerborder,beginintheRLQatthemid-clavicularlineandpressupward.
•Notethechangefromtympanytodullness.
•Toassesstheupperborder,percussovertheupperrightchestattheMCLandpercuss
downward,notingthechangefromlungresonancetoliverdullness.
Percussthespleen
•Beginposteriortotheleftmid-axillaryline(MAL),andpercussdownward,notingthechange
fromlungresonancetosplenicdullness.
Performbluntpercussionontheliver
•Percusstheliverbyplacingyourlefthandflatagainstthelowerrightribcage.
•Usetheulnarsideofyourrightfisttostrikeyourlefthand.

90. Palpation
Performlightpalpation
•Usingthefingertips,beginpalpationinanon-tenderquadrant,andcompresstoadepthof1cm
inadippingmotion.
•Thengentlyliftyourfingersandmovetothenextarea.
Deeplypalpateallquadrantstodelineateabdominalorgansanddetectsubtlemasses
•Usingthepalmarsurfaceofthefingers,compresstoamaximumdepth(5to6cm).
•Performbimanualpalpationifyouencounterresistanceorassessdeeperstructures.
Palpateformasses
•Notetheirlocation,size,shape,consistency,demarcation,pulsatility,tenderness,andmobility.
•Donotconfuseamasswithanormallypalpatedorganorstructure.
Palpatetheumbilicusandsurroundingareaforswellings,bulges,ormasses
•Umbilicusandthesurroundingareaarefreeofswellings,bulges,ormasses.

91. Palpatetheaorta
•Useyourthumbandfirstfingerortwohandsandpalpatedeeplyintheepigastrium,slightlyto
theleftofthemidline.
•Assessthepulsationoftheabdominalaorta.
Palpatetheliver
•Noteconsistencyandtenderness.
•Topalpatebimanually,standattheclient’srightsideandplaceyourlefthandunderthe
client’sbackattheleveloftheeleventhtotwelfthribs.
•Layyourrighthandparalleltotherightcostalmargin.
•Asktheclienttoinhale,thencompressupwardandinwardwithyourfingers.
Palpatethekidneys
•Topalpatetherightkidney,supporttherightposteriorflankwithyourlefthandandplace
yourrighthandintheRUQjustbelowthecostalmarginattheMCL.

92. Palpatethespleen
•Standattheclient’srightside,reachovertheabdomenwithyourleftarm,andplaceyour
handundertheposteriorlowerribs.
•Pullupgently.Placeyourrighthandbelowtheleftcostalmarginwiththefingerspointing
towardtheclient’shead.
•Asktheclienttoinhaleandpressinwardandupwardasyouprovidesupportwithyourother
hand.
Palpatetheurinarybladder
•Palpateforadistendedbladderwhentheclient’shistoryorotherfindingswarrant.
•Beginatthesymphysispubisandmoveupwardandoutwardtoestimatebladderborders.

93. Assessment of the Female Genitalia
Historyofpresenthealthconcern
•Beforeproceedingwiththeinterview,keepboththetopicofthehealthhistoryandtheclient’s
cultureclearlyinmind.
•Insomecases,yourgendermayinterferewithaccurateresults.
MenstrualCycle
•Whatwasthedateofyourlastmenstrualperiod?Doyourmenstrualcyclesoccuronaregular
schedule?
•Howlongdotheylast?Describethetypicalamountofbloodflowyouhavewithyourperiods.
Anyclotting?
•Whatothersymptomsdoyourexperiencebeforeorduringyourperiod?
•Howoldwereyouwhenyoustartedyourperiod?
•Haveyoustoppedmenstruating,orhaveyourperiodsbecomeirregular?
•Doyouhaveanyspottingbetweenperiods?Whatsymptomshaveyouexperienced?

94. Menopause
•Areyoustillhavingperiods?Haveyourperiodschanged?
•Areyouexperiencinganysymptomsofmenopause?
•Areyouonahormonereplacementtherapyregimen?Ifso,whattypeanddosage?Areyou
satisfiedwithHRT?
•Whatareyourconcernsaboutgoingthroughmenopause?
Vaginaldischarge,pain,masses
•Areyouexperiencingvaginaldischargethatisunusualintermsofcolor,amount,orodor?
•Doyouexperiencepainoritchinginyourgenitalorgroinarea?
•Doyouhaveanylumps,swelling,ormassesinyourgenitalarea?

95. Urination
•Doyouhaveanydifficultyurinating?
•Doyouhaveanyburningorpainwithurination?
•Hasyoururinechangedcolourordevelopedanodour?
•Haveyounoticedanybloodinyoururine?
•Doyouhavedifficultycontrollingyoururine?
SexualDysfunction
•Doyouhaveanyproblemswithyoursexualperformance?
•Haveyourecentlyhadachangeinyoursexualactivitypatternorlibido?
•Doyouexperienceproblemswithfertility?

96. Pasthealthhistory
•Describeanypriorgynecologicproblemsyouhavehadandtheresultsofanytreatment.
•Whenwasyourlastpelvicexaminationbyahealthcareprovider?WasaPaptestperformed?
Whatwastheresult?
•Haveyoueverbeendiagnosedwithasexuallytransmitteddisease?Ifso,what?Howwasit
treated?
•Haveyoueverbeenpregnant?Howmanytimes?Howmanychildrendoyouhave?
•Isthereanychancethatyoumightbepregnantnow?Anymiscarriagesorabortions?
•Haveyoueverbeendiagnosedwithdiabetes?
Familyhistory
•Isthereahistoryofreproductiveorgenitalcancerinyourfamily?
•Whattype?Howisthefamilymemberrelatedtoyou?

97. Lifestyleandhealthpractices
•Doyousmoke?
•Howmanysexualpartnersdoyouhave?
•Doyouusecontraceptives?Whatkind?Howoften?
•Doyouhaveanygenitalproblemsthataffectedyourlife?
•Whatisyoursexualpreference?
•Doyoufeelcomfortablecommunicatingwithyourpartneraboutyoursexuallikesand
dislikes?
•Doyouhaveanyfearsrelatedtosex?Canyouidentifyanystressinyourcurrentrelationship
thatrelatestosex?
•Doyouhaveconcernsaboutfertility?Ifyouhavetroublewithfertility,howhasthisaffected
yourrelationshipwithyourpartnerorfamily?
•Doyouperformmonthlygenitalself-examinations?
•Howdoyoufeelaboutgoingthroughmenopause?

98. •Doyoutakeestrogenreplacementtherapy?
•HaveyoueverbeentestedforHIV?Whatwastheresult?Whywereyoutested?
•Whatdoyouknowabouttoxicshocksyndrome?
•WhatdoyouknowaboutSTDsandtheirprevention?
•Doyouwearcottonunderwearandavoidtightjeans?
•Afterabowelmovementorurination,doyouwipefromfronttoback?
•Doyoudouchefrequently?

99. External female genitalia
Inspection
InspecttheMonsPubis
•Washyourhandsandputongloves.Asyoubegintheexamination,notethedistributionof
pubichair.Also,bealertforsignsofinfestation.
Observeandpalpateinguinallymphnodes
•Thereshouldbenoenlargementorswellingofthelymphnodes.
Inspectthelabiamajora
•Observethelabiamajoraandperineumforlesions,swelling,andexcoriation.
Inspectthelabiaminora,clitoris,urethralmeatus,andvaginalopening
•Useyourglovedhandtoseparatethelabiamajoraandinspectforlesions,excoriation,
swelling,and/ordischarge.

100. Palpation
PalpateBartholin’sglands
•Iftheclienthaslabialswellingorahistoryofit,palpateBartholin’sglandsforswelling,
tenderness,anddischarge.
•Placeyourindexfingerinthevaginalopeningandyourthumbonthelabiamajora.
•Withagentlepinchingmotion,palpatefromtheinferiorportionoftheposteriorlabiamajora
totheanteriorportion.
Palpatetheurethra
•Iftheclientreportsurethralsymptomsorurethritis,orifyoususpectinflammationof
Skene’sglands,insertyourglovedindexfingerintothesuperiorportionofthevaginaand
milktheurethrafromtheinside,pushingupandout.

101. Internal female genitalia
Inspection
Inspectthesizeofthevaginalopeningandtheangleofthevagina
•Insertyourglovedindexfingerintothevagina,notingthesizeoftheopening.
•Thenattempttotouchthecervix.
•Next,whilemaintainingtension,gentlypullthelabiamajoraoutward.
•Notehymenalconfigurationandtransections.
Inspectthevaginalmusculature
•Keepyourindexfingerinsertedintheclient’svaginalopening.
•Asktheclienttosqueezearoundyourfinger.
•Useyourmiddleandindexfingerstoseparatethelabiaminora.
•Asktheclienttobeardown.

102. Inspectthecervix
•Withthespeculuminsertedinpositiontovisualizethecervix,observethecervicalcolour,size,
andposition.
•Also,observethesurfaceandtheappearanceoftheos.
•Lookfordischargeandlesionsaswell.
Inspectthevagina
•Unlockthespeculumandslowlyrotateandremoveit.
•Inspectthevaginaasyouremovethespeculum.
•Notethevaginalcolour,surface,consistency,andanydischarge.

103. Assessment of the Male Genitalia
Historyofpresenthealthconcern
Pain
•Doyouhavepaininyourpenis,scrotum,testes,orgroin?
Lesions
•Haveyounoticedanylesionsonyourpenisorgenitalarea?Ifso,dothelesionsitch,burn,or
sting?Pleasedescribethelesions.
Discharge
•Haveyounoticedanydischargefromyourpenis?Ifso,howmuch?
•Whatcolourisit?Whattypeofodourdoesithave?
•Lumps,swelling,masses
•Doyouhaveanylumps,swelling,ormassesinyourscrotum,genital,orgroinarea?Haveyou
noticedachangeinthesizeofthescrotum?
•Doyouhaveaheavy,draggingfeelinginyourscrotum?

104. Urination
•Doyouexperiencedifficultyurinating?Howmanytimesdoyouurinateduringthenight?
•Haveyounoticedanychangeinthecolour,odour,oramountofyoururine?
•Doyouexperienceanypainorburningwhenyouurinate?
•Doyoueverexperienceurinaryincontinenceordribbling?
SexualDysfunction
•Haveyourecentlyhadachangeinyourpatternofsexualactivityorsexualdesire?
•Doyouhavedifficultyattainingormaintaininganerection?
•Doyouhaveanyproblemwithejaculation?Doyouhavepainwithejaculation?
•Doyouhaveorhaveyouhadanytroublewithfertility?

105. Pasthealthhistory
•Describeanypriormedicalproblemsyouhavehad,howtheyweretreated,andtheresults.
•Whenwasthelasttimeyouhadatesticularexaminationbyaphysician?
•Whatwastheresult?
•HaveyoueverbeentestedforHIV,humanpapillomavirus,herpessimplex,chlamydia,
gonorrhea,and/ortrichomoniasis?
•Whatweretheresults?Whywereyoutested?
Familyhistory
•Isthereahistoryofcancerinyourfamily?
•Whattypeandwhichfamilymember(s)?

106. Lifestyleandhealthpractices
•Howmanysexualpartnersdoyouhave?Whatkindofbirthcontrolmethoddoyouuse?
•Areyousatisfiedwithyourcurrentlevelofactivityandsexualfunctioning?
•Doyouhaveconcernsregardingyourfertility?Ifyouexperiencefertilitytroubles,howhas
thisaffectedyourrelationship?
•Whatisyoursexualpreference?Doyouhaveanyfearsrelatedtosex?
•Canyouidentifyanystressinyourcurrentrelationshipthatrelatestosex?
•Doyoufeelcomfortablecommunicatingwithyourpartneraboutyoursexuallikesand
dislikes?
•WhatdoyouknowaboutSTDsandtheirprevention?
•Areyoucurrentlyexposedtochemicalsorradiation?Haveyoubeenexposedinthepast?
•Describetheactivityyouperformonatypicalday.Doyoudoanyheavylifting?
•Doyouperformtesticularself-examinations?
•Whenwasthelasttimeyouperformedthisexamination?

107. Penis
InspectionandPalpation
Inspectthebaseofthepenisandpubichair
•Sitonastoolwiththeclientfacingyouandstanding.
•Asktheclienttoraisehisgownordrape.
•Notepubichairgrowthpatternandanyexcoriation,erythema,orinfestationatthebaseofthe
penisandwithinthepubichair.
Inspecttheskinoftheshaft
•Observeforrashes,lesions,orlumps.
Palpatetheshaft
•Palpateanyabnormalitiesnotedduringtheinspection.
•Also,noteanyhardenedortenderareas.

108. Inspecttheforeskin
•Observethecolour,location,andintegrityoftheforeskininuncircumcisedmen.
Inspecttheglans
•Observeforsize,shape,lesions,orredness.
Palpatetheurethraldischarge
•Gentlysqueezetheglansbetweenyourindexfingerandthumb.

109. Scrotum
Inspection
Inspectthesize,shape,andposition
•Asktheclienttoholdhispenisoutoftheway.
•Observeforswelling,lumps,orbulges.
Inspectthescrotalskin
•Observecolour,integrity,andlesionsorrashes.
•Toperformanaccurateinspection,youmustspreadoutthescrotalfoldsoftheskin.
•Liftthescrotalsactoinspecttheposteriorskin.
Palpation
Palpatethescrotalcontents
•Palpateeachtestisandepididymisbetweenyourthumbandfirsttwofingers.
•Notesize,shape,consistency,nodules,andtenderness.

110. Auscultation
Continueexaminationofascrotalmassbyauscultatingwithastethoscope
•Normalfindingsarenotexpected.
•Bowelsoundsmaybeauscultatedoveraherniabutwillnotbeheardoverahydrocele.
Transillumination
Transilluminatethescrotalcontents
•Ifanabnormalmassorswellingwasnotedinthescrotum,transilluminationshouldbe
performed.
•Darkentheroomandshinealightfromthebackofthescrotumthroughthemass.
•Lookforaredglow.

111. Inguinal area
Inspection
Inspectforinguinalorfemoralhernia
•Inspecttheinguinalandfemoralareasforbulges.
•Asktheclienttoturntheirheadandcoughortobeardownasifhavingabowelmovement,
andcontinuetoinspecttheareas.
Palpation
Palpateinguinallymphnodes
•Ifnodesarepalpable,notesize,consistency,mobility,ortenderness.
Palpateforfemoralhernia
•Palpateonthefrontofthethighinthefemoralcanalarea.
•Asktheclienttobeardownorcough.
•Feelforbulges.
•Repeatontheoppositethigh.

112. Inspectandpalpateforscrotalhernia
•Asktheclienttoliedown;notewhetherthebulgedisappears.
•Ifthebulgeremains,auscultateitforbowelsounds.
•Finally,gentlypalpatethemassandtrytopushitupwardintotheabdomen.
Palpateforinguinalherniaandinguinalnodes
•Asktheclienttoshifthisweighttotheleftforpalpationoftherightinguinalcanalandvice
versa.
•Placeyourrightindexfingerintotheclient’srightscrotumandpressupward,invaginatingthe
loosefoldsofskin.
•Palpateupthespermaticcorduntilyoureachthetriangular-shaped,slitlikeopeningofthe
externalinguinalring.
•Trytopushyourfingerthroughtheopeningand,ifpossible,continuepalpatingupthe
inguinalcanal.

113. Assessment of the Anus, Rectum, Prostate
Historyofpresenthealthconcern
BowelPatterns
•Whatisyourusualbowelpattern?Haveyounoticedanyrecentchangesinthepattern?
•Anypainwhilepassingabowelmovement?
•Doyouexperienceconstipation?
•Doyouexperiencediarrhoea?Isyourdiarrhoeaassociatedwithanynauseaorvomiting?
•Doyouhavetroublecontrollingyourbowels?
ItchingandPain
•Doyouexperienceanyitchingorpainintherectalarea?
Stool
•Whatisthecolourofyourstool?Hardorsoft?
•Haveyounoticedanybloodonorinyourstool?Ifso,howmuch?
•Haveyounoticedanymucusinyourstool?

114. Pasthealthhistory
•Haveyoueverhadanalorrectaltraumaorsurgery?
•Wereyoubornwithanycongenitaldeformitiesoftheanusorrectum?
•Haveyouhadprostatesurgery?Haveyouhadhemorrhoidsorsurgeryforhemorrhoids?
•Whenwasthelasttimeyouhadastooltesttodetectblood?
•Haveyoueverhadaproctosigmoidoscopy?
•Whenwasthelasttimeyouhadadigitalrectalexamination(DRE)byaphysician?
•Haveyoueverhadbloodtakenforaprostatescreening,whichmeasuresthelevelofprostate-
specificantigeninyourblood?
•Whenwasthetest,andwhatwastheresult?
Familyhistory
•Isthereahistoryofpolyps,colon,rectalcancer,orprostatecancerinyourfamily?

115. Lifestyleandhealthpractices
•Doyouuseanylaxatives,stoolsofteners,enemas,orotherbowelmovement-enhancing
medications?
•Doyouengageinanalsex?
•Doyoutakeanymedicationsforyourprostate?
•Howmuchhigh-fiberfoodandroughagedoyouconsumeeveryday?
•Doyoueatfoodshighinsaturatedfats?
•Doyouengageinregularexercise?
•Doyouusecalciumsupplements?
•Forpostmenopausalwomen:Doyouusehormonereplacementtherapy?
•Hasanyanalorrectalproblemaffectedyournormalactivitiesofdailyliving?

116. Anus and Rectum
Inspection
Inspecttheperianalarea
•Spreadtheclient’sbuttocksandinspecttheanalopeningandsurroundingarea.
Inspectthesacrococcygealarea
•Inspectthisareaforanysignsofswelling,redness,dimpling,orhair.
Palpation
Palpatetheanus
•Informtheclientthatyouaregoingtoperformtheinternalexaminationatthispoint.
•Lubricateyourglovedindexfinger;asktheclienttobeardown.
•Astheclientbearsdown,placethepadofyourindexfingerontheanalopening.
•Whenyoufeelthesphincterrelax,insertyourfingergentlywiththepadfacingdown.

117. Palpatetherectum
•Insertyourfingerfurtherintotherectumasfaraspossible.
•Next,turnyourhandclockwise.
•Thisallowspalpationofasmuchrectalsurfaceaspossible.
•Notetenderness,irregularities,nodules,andhardness.
Palpatetheperitonealcavity
•Thisareamaybepalpatedinmenabovetheprostateglandintheareaoftheseminalvesicles
ontheanteriorsurfaceoftherectum.
•Inwomen,thisareamaybepalpatedontheanteriorrectalsurfaceintheareaofthe
rectouterinepouch
•Notetendernessornodules.

118. Prostate gland
Palpation
Inmaleclients,palpatetheprostate
•Theprostatecanbepalpatedontheanteriorsurfaceoftherectumbyturningthehandfully
counterclockwisesothepadofyourindexfingerfacestowardtheclient’sumbilicus.
•Notethesize,shape,andconsistencyoftheprostate,andidentifyanynodulesortenderness.
Inspectthestool
•Withdrawyourglovedfinger.
•Inspectanyfecalmatteronyourglove.
•Assessthecolour,andtestthefecesforoccultblood.
•Providetheclientwithatoweltowipetheanorectalarea.

119. Assessment of the Musculoskeletal System
•Assessmentofthemusculoskeletalsystemhelpstoevaluatetheclient’sleveloffunctioningwith
activitiesofdailyliving.
Historyofpresenthealthconcern
•Haveyouhadanyrecentweightgain?
•Describeanydifficultythatyouhavechewing.Isitassociatedwithtendernessorpain?
•Describeanyjoint,muscle,orbonepainyouhave.Whereisthepain?whatdoesthepainfeel
like?
•Whendidthepainstart?Whendoesitoccur?
•Howlongdoesitlast?Anystiffness,swelling,orlimitationofmovement?

120. Pasthealthhistory
•Describeanypastproblemsorinjuriesyouhavehadtoyourjoints,muscles,orbones.
•Whattreatmentwasgiven?Doyouhaveanyafter-effectsfromtheinjuryorproblem?
•Whenwereyourlasttetanusandpolioimmunizations?
•Haveyoueverbeendiagnosedwithdiabetesmellitus,sicklecellanaemia,
systemiclupuserythematosus,orosteoporosis?
Formiddle-agedwomen
•Haveyoustartedmenopause?
•Areyoureceivingestrogenreplacementtherapy?
Familyhistory
•Doyouhaveafamilyhistoryofrheumatoidarthritis,gout,orosteoporosis?

121. Lifestyleandhealthpractices
•Whatactivitiesdoyouengageintopromotethehealthofyourmusclesandbones?
•Whatmedicationareyoutaking?
•Doyousmoketobacco?Howmuchandhowoften?
•Doyoudrinkalcoholorcaffeinatedbeverages?Howmuchandhowoften?
•Describeyourtypical24-hourdiet.Areyouabletoconsumemilkormilk-containingproducts?
Doyoutakeanycalciumsupplements?
•Describeyouractivitiesduringatypicalday.Howmuchtimedoyouspendinthesunlight?
•Describeanyroutineexercisethatyoudo.
•Describeyouroccupation.

122. •Describeyourpostureatworkandatleisure.
•Whattypeofshoesdoyouusuallywear?
•Doyouhavedifficultyperformingnormalactivitiesofdailyliving?
•Doyouuseassistivedevicestopromoteyourmobility?
•Howhaveyourmusculoskeletalproblemsinterferingwithyourabilitytointeractorsocialize
withothers?
•Havetheyinterferedwithyourusualsexualactivity?
•Howdidyouviewyourselfbeforethismusculoskeletalproblem,andhowdoyouview
yourselfnow?
•Hasyourmusculoskeletalproblemaddedstresstoyourlife?Describe.

123. Gait
Inspection
Observegait
•Observetheclient’sgaitasthecliententersandwalksaroundtheroom.
Assess for the risk of falling
•backward in the older or handicapped client by performing the “nudge test”.
•Stand behind the client and put your arms around the client while you gently nudge the
sternum

124. Temporomandibular joint
InspectionandPalpation
InspectandpalpatetheTMJ.
•Havetheclientsit,andputyourindexandmiddlefingersjustanteriortotheexternalear
opening.
•Asktheclienttoopenthemouthaswidelyaspossible;movethejawfromsidetoside;and
protrudeandretractthejaw.
Testrangeofmotion
•Asktheclienttoopenthemouthandmovethejawlaterallyagainstresistance.
•Next,astheclientclenchestheteeth,feelforthecontractionofthetemporalandmasseter
musclestotesttheintegrityofcranialnerveV.

125. Sternoclavicular joint
InspectionandPalpation
•Withtheclientsitting,inspectthesternoclavicularjointforlocationinmidline,colour,
swelling,andmasses.
•Thenpalpatefortendernessorpain.

126. Cervical, Thoracic, Lumbar spine
InspectionandPalpation
Observethecervical,thoracic,andlumbarcurvesfromthesideandthenfrombehind
•Havetheclientstandingerectwiththegownpositionedtoallowanadequateviewofthespine.
•Observeforsymmetry,notingdifferencesinheightoftheshoulders,theiliaccrests,andthe
buttockareas.
Palpatethespinousprocesses
•Theparavertebralmusclesonbothsidesofthespinefortendernessorpain.
TestROMofthecervicalspine
•TestROMofthecervicalspinebyaskingtheclienttotouchthechintothechestandtolookupat
theceiling.

127. TestROMofthethoracicandlumbarspine
•Asktheclienttobendforwardandtouchthetoes.
•Observeforsymmetryofshoulders,scapula,andhips.
Testforbackandlegpain
•Iftheclienthaslowbackpainthatradiatesdowntheback,performLasegue’stest(straightleg
raising)tocheckaherniatednucleuspulpous.
•Asktheclienttolieflatandraiseeachrelaxedlegindependentlytothepointofpain.
•Atthepointofpain,dorsiflextheclient’sfoot.
Measureleglength
•Ifyoususpecttheclienthasoneleglongerthantheother,measurethem.
•Asktheclienttoliedownwiththeirlegsextended.
•Withatape,measurethedistancebetweentheanteriorsuperioriliacspineandthemedial
malleolus,crossingthetapeonthemedialside.

128. Shoulders, arms, elbows
InspectionandPalpation
Inspectandpalpateshouldersandarms
•Withtheclientstandingorsitting,inspectanteriorlyandposteriorlysymmetry,colour,
swelling,andmasses.
•Palpatefortenderness,swelling,orheat.
TestROM
•Asktheclienttostandwithbotharmsstraightdownatthesides.
•Nest,askhimtomovethearmsforwardandthenbackwardwithelbowsstraight.
•Thenhavetheclientbringbothhandstogetheroverhead,elbowsstraight,followedbymoving
bothhandsinfrontofthebodypastthemidlinewithelbowsstraight.
Inspectforsize,shape,deformity,redness,orswelling
•Inspectelbowsinbothflexedandextendedpositions.

129. Test ROM
•Ask the client to flex the elbow and bring the hand to the forehead, straighten the elbow, hold the
arm out, turn the palm down, then turn the palm up.
Hands, Wrists, Fingers
InspectionandPalpation
Inspectwristsize,shape,symmetry,colour,andswelling
•Thenpalpatefortendernessandnodules.
•Palpatetheanatomicsnuffbox(thehollowareaonthebackofthewristatthebaseofthefully
extendedthumb.
TestROM
•Asktheclienttobendtheirwristdownandback.
•Next,havetheclientholdthewriststraightandmovethehandoutwardandinward.

130. Testforcarpaltunnelsyndrome
•PerformPhalen’stest.Asktheclienttoplacethebacksofbothhandsagainsteachotherwhile
flexingthewrists90degreesdownward.
•Havetheclientholdthispositionfor60seconds
Inspectsize,shape,symmetryswelling,andcolour
•Palpatethefingersfromthedistalendproximally,notingtenderness,swelling,bony
prominences,nodules,orcrepitusofeachinterphalangealjoint.
TestROM
•Asktheclienttospreadthefingersapart,makeafist,bendthefingersdownandthenup,
movethethumbawayfromotherfingers,andtouchthethumbtothebaseofthesmallfinger.

131. Hips
InspectionandPalpation
Withtheclientstanding,inspectthesymmetryandshapeofthehips
•Palpateforstability,tenderness,andcrepitus.
Test ROM
•With the client supine, ask the client to
➢Raise the extended leg
➢flex the knee up to the chest while keeping the other leg extended
➢move an extended leg away from the midline of the body as far as possible and then
toward the midline of the body as far as possible.
•Bend the knee and turn the leg inward and then outward.

132. Knees
InspectionandPalpation
•Withtheclientsupineandthensittingwithkneesdangling,inspectforsize,shape,symmetry,
swelling,deformities,andalignment.Observeforquadricepmuscleatrophy.
Testforswelling
•Thebulgetesthelpsdetectasmallamountoffluidintheknee.
•Withtheclientinthesupineposition,usetheballofyourhandfirmlytostrokethemedialside
ofthekneeupward,threetofourtimes,todisplaceanyaccumulatedfluid.
•Thenpressonthelateralsideofthekneeandlookforabulgeonthemedialsideoftheknee.
TestROM
•Asktheclienttobendeachkneeuptowardthebuttocksorback,straightentheknee,andwalk
normally.

133. Performtheballottementtest
•Withtheclientinasupineposition,firmlypressyournon-dominantthumbandindexfinger
oneachsideofthepatella.
•Thenwithyourdominantfingers,pushthepatelladownonthefemur.
Testforpainandinjury
•Withtheclientinthesupineposition,asktheclienttoflexonekneeandhip.
•Thenplaceyourthumbandindexfingerofonehandoneithersideoftheknee.
•Useyourotherhandtoholdtheheelofthefootup.
•Rotatethelowerlegandfootlaterally.
•Slowlyextendtheknee,notingpainorclicking.

134. Ankles and feet
InspectionandPalpation
•Withtheclientsitting,standing,andwalking,inspectposition,alignment,shape,andskin.
Palpateanklesandfeetfortenderness,heat,swelling,andnodules
•Palpatethetoesfromthedistalendproximally,notingtenderness,swelling,boney
prominences,nodules,orcrepitusofeachinterphalangealjoint.
TestROM
•Asktheclienttopointtoesupwardthendownward,turnsolesoutwardtheninward,rotate
footoutwardtheninward,turntoesunderfootandthenupward.

135. Assessment of the Neurologic System
•Problemswithotherbodysystemsmayaffecttheneurologicsystem,andneurologicsystem
disorderscanaffectallotherbodysystems.
•Regardlessofthesourceofneurologicproblems
•Theclient’stotallifestyleandleveloffunctioningareoftenaffected.
Historyofpresenthealthconcern
NumbnessandTingling
•Doyouexperienceanynumbnessortingling?
•Whenandwheredoesthisoccur?
Headaches
•Doyouexperienceheadaches?Whendotheyoccur,andwhatdotheyfeellike?

136. Seizures
•Doyouexperienceseizures?
•Describewhathappensbeforeyouhavetheseizureandwhereonyourbodytheseizurestarts.
•Doesanythingseemtoinitiateaseizure?
•Doyoulosecontrolofyourbladderduringtheseizure?
•Howdoyoufeelafterward?
•Doyoutakemedicationsforseizures?
•Doyouwearmedicalidentificationtoalertothersthatyouhaveseizures?
•Doyoutakesafetyprecautionsregardingdrivingoroperatingdangerousmachinery?
MemoryLoss
•Doyouexperienceanymemoryloss?
DifficultySwallowing
•Doyouexperiencedifficultyswallowing?

137. Dizziness
•Doyouexperiencedizzinessorlightheadednessorproblemswithbalanceorcoordination?If
so,howoften?
•Doesitoccurwithactivity?Orhaveyouexperiencedanyfalling?
•Doyouhaveanyclumsymovements?
Senses
•Haveyounoticedadecreaseinyourabilitytosmellortaste?
•Haveyouexperiencedanyringinginyourearsorhearingloss?
•Haveyounoticedanychangeinyourvision?
DifficultySpeaking
•Doyouhavedifficultyunderstandingwhenpeoplearetalkingtoyou?
•Doyouhavedifficultyinmakingothersunderstandyou?
•Doyouhavedifficultyformingwordsorverballyinterpretingyourthoughts?

138. MuscleControl
•Haveyoulostbowelorbladdercontrol,ordoyouretainurine?
•Doyouhavemuscleweakness?Ifso,where?
•Doyouexperienceanytremors?Ifso,where?
Pasthealthhistory
•Haveyoueverhadanytypeofheadinjurywithorwithoutlossofconsciousness?
•Ifso,describeanyphysicalormentalchangesthathaveoccurredasaresult.
•Whattypeoftreatmentdidyoureceive?
•Haveyoueverhadmeningitis,encephalitis,injurytothespinalcord,orastroke?
•Ifso,describeanyphysicalormentalchangesthathaveoccurredasaresult.
•Whattypeoftreatmentdidyoureceive?
Familyhistory
•Doyouhaveafamilyhistoryofhighbloodpressure,stroke,Alzheimer’s
disease,epilepsy,braincancer,orHuntington’schorea?

139. Lifestyleandhealthpractices
•Doyoutakeanyprescriptionornonprescriptionmedications?Howmuchalcoholdoyoudrink?
Doyouuserecreationaldrugssuchasmarijuana,tranquilizers,barbiturates,orcocaine?
•Doyousmoke?
•Doyouwearyourseatbeltwhenridinginvehicles?
•Doyouwearprotectiveheadgearwhenridingabicycleorplayingsports?
•Describeyourusualdailydiet.
•Haveyoueverhadprolongedexposuretolead,insecticides,pollutants,andotherchemicals?
•Doyoufrequentlyliftheavyobjectsorperformrepetitivemotions?
•Canyouperformyournormalactivitiesofdailyliving?
•Hasyourneurologicproblemchangedthewayyouviewyourself?Describe.
•Hasyourneurologicproblemaddedmuchstresstoyourlife?Describe.

140. Neurological status, Mental status, and LOC
Inspection
Observethelevelofconsciousness
•Calltheclient’snameandnottheresponse.
•Iftheclientdoesnotrespond,callthenamelouder.
•Ifnecessary,shaketheclientgently.
•Iftheclientstilldoesnotrespond,applyapainfulstimulus.
Observepostureandbodymovements
•Bealertfortense,nervous,fidgety,andrestlessbehavioru,whichmaybeseeninanxietyor
maysimplyreflecttheclient’sapprehensionduringaphysicalexamination.
Observedress,grooming,andhygiene
•Keeptheexaminationsettingandthereasonfortheassessmentinmindasyounotethe
client’sdegreeofcleanlinessandattire.

141. Observefacialexpressions
•Noteparticularlyeyecontactandaffect.
Observespeech
•Observeandlistentothetone,clarity,andpaceofspeech.
Observemood,feelings,andexpressions
•Asktheclient,“Howareyoufeelingtoday?”and“Whatareyourplansforthefuture?”
Observethoughtprocessesandperceptions
•Observethoughtprocessesforclarity,content,andperceptionbyinquiringabouttheclient’s
thoughtsandperceptionsexpressed.
Perform the Mini-Mental State Examination
•If time is limited and a quick standard measure is needed to evaluate or reevaluate the
cognitive function.

142. Observecognitiveabilities
•Askfortheclient’snameandnamesoffamilymembers,thetime,andwheretheclientlives
orisnow.
•Notetheclient’sabilitytofocusandstayattentivetoyouduringtheinterviewand
examination.
•Asktheclient,“Whatdidyouhavetoeattoday?”or“Whatistheweatherliketoday?”.
•Asktheclient,“Whendidyougetyourfirstjob?”or“Whenisyourbirthday?”
•Asktheclienttorepeatfourunrelatedwords.
•Thewordsshouldnotrhyme,andtheycannothavethesamemeaning.
•Havetheclientrepeatthesewordsin5minutes,againin10minutes,andagainin30minutes

143. Cranial nerves
Inspection
TestCNI(olfactory)
•Forallassessmentsofthecranialnerves,havetheclientsitinacomfortablepositionatyour
eyelevel.
•Asktheclienttoclearthenosetoremoveanymucus,thentoclosetheireyes,occludeone
nostril,andidentifyascentedobjectthatyouareholding.
TestCNII(optic)
•UsetheSnellencharttoassessvisionineacheye.
•Asktheclienttoreadanewspaperormagazineparagraphtoassessnearvision.
•Assessthevisualfieldsofeacheyebyconfrontation.
•Useanophthalmoscopetoviewtheretinaandopticdiscofeacheye.

144. AssessCNIII(oculomotor),IV(trochlear),andVI(abducens)
•Inspectthemarginsoftheeyelidsofeacheye.
•Assessextraocularmovements.
•Ifnystagmusisnoted,determinethedirectionofthefastandslowphasesofmovement.
•Assesspupillaryresponsetolightandaccommodationinbotheyes.
AssessCNV(trigeminal)
•Testmotorfunction.
•Asktheclienttoclenchtheteethwhileyoupalpatethetemporalandmassetermusclesfor
contraction.
•Testsensoryfunction.Telltheclient:“Iamgoingtotouchyourforehead,cheeks,andchin
withthesharpordullsideofthissafetypinorpaperclip.
•Pleasecloseyoureyesandtellmeifyoufeelasharpordullsensation.also,tellmewhereyou
feelit.”

145. TestCNVII(facial)
•Testmotorfunction.
•Asktheclienttosmile,frownandwrinkletheforehead,showteeth,puffoutcheeks,purse
lips,raiseeyebrows,andcloseeyestightlyagainstresistance.
TestCNVIII(acoustic/vestibulocochlear)
•Testtheclient’shearingabilityineachearandperformtheWeberandRinneteststoassess
thecochlear(auditory)componentofcranialnerveVIII.
TestCNIX(glossopharyngeal)andX(vagus)
•Testmotorfunction.Asktheclienttoopentheirmouthwideandsay“ah”whileyouusea
tonguedepressorontheclient’stongue.
•Testthegagreflexbytouchingtheposteriorpharynxwiththetonguedepressor.

146. TestCNXI(spinalaccessory)
•Asktheclienttoshrugtheshouldersagainstresistancetoassessthetrapeziusmuscle.
•Asktheclienttoturntheheadagainstresistance,firsttotherightandthentotheleft,to
assessthesternocleidomastoidmuscle.
TestCNXII(hypoglossal)
•Toassessthestrengthandmobilityofthetongue,asktheclienttoprotrudethetongue,move
ittoeachsideagainsttheresistanceofatonguedepressor,thenputitbackinthemouth.

147. Motor and cerebellar systems
Inspection
Assesstheconditionandmovementofmuscles
•Assessthesizeandsymmetryofallmusclegroups.
•Assessthestrengthandtoneofallmusclegroups.
•Noteanyunusualinvoluntarymovementssuchasfasciculations,tics,ortremors.
Evaluatebalance
•Toassessgait,asktheclienttowalknaturallyacrosstheroom.
•Noteposture,freedomofmovement,symmetry,rhythm,andbalance.
•Asktheclienttowalkinheel-to-toefashion,nextontheheels,thenonthetoes.
•PerformRombergtest.
•Asktheclienttostanderectwitharmsatthesideandfeettogether.
•Noteanyunsteadinessorswaying.

148. Assesscoordination
•Demonstratethefinger-to-nosetesttoassesstheaccuracyofmovements,thenasktheclientto
extendandholdarmsouttothesidewitheyesopen.
•Next,say,“Touchthetipofyournosefirstwithyourrightindexfinger,thenwithyourleft
indexfinger.
Sensory systems
Inspection
Assesslighttouch,pain,andtemperaturesensations
•Foreachtest,askclientstoclosebotheyesandtellyouwhattheyfeelandwheretheyfeelit.
•Scatterstimulioverthedistalandproximalpartsofallextremitiesandthetrunktocovermost
ofthedermatomes.
•Totestthelighttouchsensation,useawispofcottontotouchtheclient.
•Totestpainsensation,usethebluntandsharpendsofasafetypinorpapercliptotest
temperaturesensation,usetesttubesfilledwithhotandcoldwater.

149. Testvibratorysensation
•Strikealow-pitchedtuningforkontheheelofyourhandandholdthebaseonabonysurfaceof
thefingersorbigtoe.
•Asktheclienttoindicatewhathefeels.
Testsensitivitytoposition
•Asktheclienttoclosebotheyes.
•Thenmovetheclient’stoesorafingerupordown.
•Asktheclienttotellyouthedirectionitismoved.
Assess tactile discrimination (fine touch)
•Remember that the client should have her eyes closed.
•To test stereognosis, place a familiar object such as a quarter, paper clip, or key in the client’s
hand and ask the client to identify it.
•To test point localization, briefly touch the client and ask the client to identify the points
touched to test graphesthesia, use a blunt instrument to write a number on the palm of the
client’s hand. Ask the client to identify the number.