The patient is sitting on the

edge of the bed or examining table, unless this position is contra-indicated. You should be standing in front of the patient, moving to either side as needed.

The room should be darkened for the ophthalmoscopic examination. This promotes papillary dilation and visibility of the fundi.

Move behind the sitting patient to feel the thyroid gland and to examine the back, posterior thorax, and the lungs.

Posterior Thorax and Lungs. Inspect and palpate the spine and muscles of the upper back. Inspect, palpate, and percuss the chest. Identify the level of diaphragmatic dullness on each side. Listen to the breath sounds; identify any adventitious (or added) sounds, and, if indicated, listen to the transmitted voice sounds (see p._).

Breasts, Axillae, and Epitrochlear Nodes. In a woman, inspect the breasts with her arms relaxed, then elevated, and then with her hands pressed on her hips. In either sex, inspect the axillae and feel for the axillary nodes. Feel for the epitrochlear nodes.

A Note on the Musculoskeletal System: By this time, you have made some preliminary observations of the musculoskeletal system. You have inspected the hands, surveyed the upper back, and at least in women, made a fair estimate of the shoulders' range of motion. Use these and subsequent observations to decide whether a full musculoskeletal examination is warranted. If indicated, with the patient still sitting, examine the hands, arms, shoulders, neck, and temporomandibular joints. Inspect and palpate the joints and check their range of motion. (You may choose to examine upper extremity muscle bulk, tone, strength, and reflexes at this time, or you may decide to wait until later.)

The patient is still sitting. Move to the front again.

Palpate the breasts, while at the same time continuing your inspection.

Anterior Thorax and Lungs. Inspect, palpate, and percuss the chest. Listen to the breath sounds, any adventitious sounds, and, if indicated, transmitted voice sounds.

Cardiovascular System. Observe the jugular venous pulsations, and measure the jugular venous pressure in relation to the sternal angle. Inspect and palpate the carotid pulsations. Listen for carotid bruits.

Inspect and palpate the precordium. Note the location, diameter, amplitude, and duration of the apical impulse. Listen at the apex and the lower sternal border with the bell of a stethoscope. Listen at each auscultatory area with the diaphragm. Listen for the first and second heart sounds, and for physiologic splitting of the second heart sound. Listen for any abnormal heart sounds or murmurs.

Abdomen. Inspect, auscultate, and percuss the abdomen. Palpate lightly, then deeply. Assess the liver and spleen by percussion and then palpation. Try to feel the kidneys, and palpate the aorta and its pulsations. If you suspect kidney infection, percuss posteriorly over the costovertebral angles.

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ower Extremities. Examine the legs, assessing three systems while the atient is still supine. Each of these three systems can be further assessed Xhen the patient stands.

The patient position is supine.

Ask the patient to lie down. You should stand at the right side of the patient's bed.

Elevate the head of the bed to about 30° for the cardiovascular examination, adjusting as necessary to see the jugular venous pulsations.

Ask the patient to roll partly onto the left side while you listen at the apex. Then have the patient roll back to the supine position while you listen to the rest of the heart. The patient should sit, lean forward, and exhale while you listen for the murmur of aortic regurgitation.

Lower the head of the bed to the flat position. The patient should be supine.

The patient is supine.

Examination with the patient supine

■ Peripheral Vascular System. Palpate the femoral pulses, and if indicated, the popliteal pulses. Palpate the inguinal lymph nodes. Inspect for lower extremity edema, discoloration, or ulcers. Palpate for pitting edema.

■ Musculoskeletal System. Note any deformities or enlarged joints. If indicated, palpate the joints, check their range of motion, and perform any necessary maneuvers.

■ Nervous System. Assess lower extremity muscle bulk, tone, and strength; also sensation and reflexes. Observe any abnormal movements.

Examination with the patient standing The patient is standing. You should sit on a chair or stool.

■ Peripheral Vascular System. Inspect for varicose veins.

■ Musculoskeletal System. Examine the alignment of the spine and its range of motion, the alignment of the legs, and the feet.

■ Genitalia and Hernias in Men. Examine the penis and scrotal contents and check for hernias.

■ Nervous System. Observe the patient's gait and ability to walk heel-to-toe, walk on the toes, walk on the heels, hop in place, and do shallow knee bends. Do a Romberg test and check for pronator drift.

Nervous System. The complete examination of the nervous system can The patient is sitting or supine. also be done at the end of the examination. It consists of the five segments described below: mental status, cranial nerves (including funduscopic examination), motor system, sensory system, and reflexes.

Mental Status. If indicated and not done during the interview, assess the patient's orientation, mood, thought process, thought content, abnormal perceptions, insight and judgment, memory and attention, information and vocabulary, calculating abilities, abstract thinking, and constructional ability.

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