Physical Diagnosis Exam 3

Updated 2007-04-18 08:49

PD - Exam 3

Breast - Palpation

Question Answer
check forconsistency, tenderness, nodules
noduleslocation, size, shape, consistency, delimitation, tenderness, mobility
Paget's diseasedermatitis of nipple and areola
edema of skinorange peel sign, lymphatic blockage

Breast - Inspection

Question Answer
noteappearance of skin (color, thickening), size and symmetry, contour
characteristics of nipplessize and shape, direction in which they point, rashes, ulceration, discharge
4 positionsarms at side, arms over head, hands on hips, leaning forward


Question Answer
inspectionsymmetry, masses, scars, enlarged glands/ulcer, thracheal deviation
auscultationcarotid bruits
complete exam1. inspection; 2. auscultation; 3. palpation
palpationareas of tenderness, masses, thyroid, anterior and posterior triangles


Question Answer
testinspection, palpation, gag reflex
oropharynxsize, inflammation, discharge, mass, duct openings
nasopharynxadenoids (children), chonae, lateral walls, eustachian tube, cancer (adults) with unilateral ear blockage of Eustachian tube
larynxcolor and movement/vibration of true/false vocal cords, voice production
hypopharynxposterior walls, piriform recesses

Oral Cavity

Question Answer
symptomspain, ulceration, bleeding, mass, halitosis
complete exam - palpate and inspectlips, buccal mucosa, gingivae, teeth, tongue, floor of mouth, hard and soft palates, salivary glands, cranial nerve XII
paincolor, swelling
buccal mucosalesions, color changes
gingivaeswelling, bleeding, inflammation
teethcleanliness, dentition
tonguelesions, masses, stick out tongue onto gauze and hold to inspect sides
floor of mouthlift tongue, bimanual palpation
hard and soft palatesinspect for ulcers, masses
salivary glandspalpate Stenson's and Wharton's, symmetry, tenderness
cranial nerve XIIstick out tongue and see if it deviates, if it does than lesion on side it deviated to

Nose and Sinus

Question Answer
symptoms of nasal diseaseobstruction, bleeding, discharge
symptoms of sinus diseasefever, malaise, cough, nasal congestion, maxillary toothache, purulent discharge, headache, pain worsened by bending over, little improvement by decongestant
internal exam of noseinflammation, septum deviation, perforation, discharge, trauma, color, size, mucosal condition of turbinates
external exam of noseswelling, trauma, congenital abnormalities
palpatesinuses for tenderness
complete nose and sinus exam1. external inspection; 2. nasal obstruction test; 3. internal inspection; 4. Palpation

Ear Exam - Special Tests

Question Answer
Auditory Acuity testwhisper into unoccluded ear
Rinne Testcompares air conduction with bone conduction
normal Rinne Testsound is heard, AC > BC
abnormal Rinne Testsound not heard, hearing loss, BC > AC
can Rinne detect sensorineural deafness?No
Weber Testdetermines if impairment is neural or conductive
conductive loss in Weber Testsound lateralized to affected side
sensorineural loss in Weber Testsounds lateralized to unaffected side
otoscope examlook for inflammation, foreign bodies, scales, discharge
tympanic membrane is made up ofpars tensa (bottom 4/5), pars flaccida (upper 1/5)
can see with otoscopemalleus, pars flaccida, pars tensa, light reflex, important landmarks
insufflationtests mobility of tympanic membrane
balance testtests for vertigo

Ear Exam

Question Answer
Major symptoms of ear diseasehearing loss, vertigo, tinnitus, otorrhea, otalgia, pruritis
vertigosense of turning while seated
tinnitushear a buzzing or ringing sound in the absence of environmental source
otorrheadischarge from ear
otalgiaear pain
if symptoms referred to one earexamine that ear last
complete ear exam1. external inspection and palpation; 2. auditory acuity test; 3. rinne test; 4. Weber test; 5. Otoscope Exam; 6. Balance Test

Rectal Exam

Question Answer
prostatein males, anteriorly, bilobed, symmetric, midline groove called median sulcus
palpationpalpate walls (ant, post, lat), note nodules, tenderness, stool character
inspectionanus, note hemorrhoids, lesions, masses, fissures

GU and Pelvic - Male Special tests

Question Answer
cremasteric reflexabsent in testicular torsion
scrotal transillumination - will iluminatefluid filled mass (hydrocele, spermatocele)
scrotal transillumination - won't iluminatesolid mass (tumors, blood clots, hernias)

GU and Pelvic - Male Palpation

Question Answer
inguinal regionlymph nodes, hernias
penisscar tissue, nodules, masses
testesmass, size, tenderness, consistency
epididymisposterior aspect of testes, tenderness, size, nodularity
vas deferenscan be palpated as part of spermatic cord
spermatic cordpalpate by inserting a finger up to external inguinal ring, hernias
scrotummasses, try to determine origin

GU and Pelvic - Mass in Testicle, Scrotum, Vagina

Question Answer
notetime course for mass, pain, trauma, if mass bilateral, unilateral, history of venereal disease
groin or scrotum massinguinal hernia, hydrocele, varicocele, abscess
labial masssyphilis, Bartholin's gland abscess
vaginal masscystocele, rectocele, uterine prolapse

GU and Pelvic - Urinary Patterns

Question Answer
changes in flowhesitancy, incontinence, frequency, polyuria
polyuriaincreased amount of voided urine

GU and Pelvic - Pain

Question Answer
notetime, acuteness, location, localization, charcter, radiation
in women noteonset to timing of menstrual cycle, determine if pregnant
testicular painreferred from renal colic or appendicitis, or from diseases of testis or epididymis (torsion, infection, tumor)
flank painhydronephrosis of kidney, distention of bladder or ureter may be referred from testicle or labia
low pelvic painsalpingo-oophoritis, cystitis, complication of pregnancy, hernia

GU and Pelvic

Question Answer
diseasesSTDs, hernias, cervical cancer, prostate cancer
2nd most common cancer in malesprostate cancer
symptomspain, dysuria, change in urine/flow pattern, red urine, penile discharge, penile lesions, scrotal enlargement, groin mass or swelling, impotence, infertility, abnormal vaginal bleeding, dysmennhorrea, vulvar masses or lesions, vaginal discharge, vaginal itching, dyspareunia
dyspareuniapain during intercourse
abnormal vaginal bleedingage of menarche, normal menstrual period flow, duration and timing, use of contraception, clots, sexual activity, qualify any abnormal bleeding
vaginal pruritiscandida infection, glycosuria, contact dermatitis
inspection - femaleclitoris, urethral opening, labia, perineum
speculum exam inspectsvagina and cervix
palpate in bimanual examvaginal canal, cervix, uterus, adnexa, posterior fornyx
rectovaginal exam allows better palpation ofposterior wall of vagina
special tests - femaleauscultate fetal heart sounds with doppler stethoscope
inspection - maleskin, hair for lice, masses, rashes, fungus, penis, glans, urethral opening
penis inspectioncircumcision, phimosis, masses, lesions, ulcers
percent of syphillis patients that present symptoms25%
phimosiscan't retract foreskin
inspect glansfungal infection, mass, warts, nodules, inflammation
female GU exam1. inspection; 2. speculum exam; 3. bimanual exam; 4. abdominal exam; 5. rectal exam; 6. special tests (fetal heart sounds)
male GU exam1. inspection; 2. palpation (standing and lying down); 3. abdominal exal; 4. rectal exam (prostate); 5. special tests

Abdomen - Special Tests

Question Answer
Fluid wavesascites
obturator signinflammation, appendicitis, peritoneal irritation
psoas signintra-abdominal inflammation, appendicitis
murphy's signcute cholecystitis, inflamed gallbladder
Rovsing's signappendicitis

Abdominal Pruritis

Question Answer
generalizeddiffuse skin disorder, chronic renal, hepatic disease
intense itchinglymphoma, hodgkin's, GI malignancies
elderlydry skin
anal skinfistulas, fissure, psoriasis, parasite, poor hygeine, diabetes

Abdominal Mass

Question Answer
due totumor, hernia, organomegaly, stool, pregnancy
noteswelling, pulsation, duration, location, pain
groin or scrotalinguinal hernia, hydrocele, varicocele
pulsatileabdominal aortic aneurysm

Abdominal Distention

Question Answer
due toincreased gas in GI tract or ascites
increased gas is due tomalabsorption, iriitable colon, air swallowing
ascites due tocirrhosis, congestive heart failure, portal hypertension, peritonitis, meoplasia
ask aboutduration, onset, relation to eating, associated conditions, what relieves it
intermittent distention that is relieved by belching or flatusgas related to eating
ascites and loss of apetitecirrhosis, malignancy, congestive heart failure
ascites and shortness of breathcongestive heart failure or decreased pulmonary capacity with ascites from other causes

Abdomen - Jaundice

Question Answer
ask aboutduration, onset, rapidity, associated symptoms, ingestion of raw shellfish, drugs, travel, transfusions, tattooing, friends with similar symptoms, work, urine and stool characteristics
viral hepatitisjaundice, nausea, vomiting, lack of apetite, aversion to smoke
obstructive jaundiceslowly developing, clay colored stool, cola colored urine
colangitisjaundice with fever and chills due to stasis of bile in duct because of gallstone or cancer to head of pancreas

Abdomen - Rectal Bleeding

Question Answer
hematocheziabright red blood per rectum (BRBPR)
tenesemuspainful, continued, ineffective straining at stool
melenablack, tarry stool
hematochezia is associated withcolonic tumor, diverticular disease, ulcerative colitis
blood mixed with stooltumor, diverticulitis, ulcerative colitis, hemorrhoids
tenesemus is associated withinflammation, tumor at anus or distal rectum
melena is associated withbleeding of 1st section of duodenum
silver colored stoolrare cancer or ampulla of Vater in duodenum

Abdomen - Changes in Bowel Movements

Question Answer
what to noteduration, # movements per day, is change associated with meal (type of meal)?, characterization, constipation, weight loss, type of stool
acute onsetacute infection, toxin
watery stoolsmall bowel and colon inflammation or protein-losing enteropathies
bloody diarrheashigellosis, amebiasis
alternate diarrhea and constipationcolon cancer, diverticulitis
loose bowel movementleft colon disease
floating stoolmalabsorption syndrome, excessive gas
stool mixed with blood and mucusulcerative colitis
blood with stool and undigested foodinflammation of small bowel and colon
morning diarrheairritable bowel syndrome
pencil thin stoolanal or distalrectal carcinoma
clay-colored stoolobstruction of bile flow or decreased production of bile
constipation and weight gainhypothyroidism
constipation and weight losscolon cancer

Abdomen - Nausea and Vomiting

Question Answer
causessevere irritation of diaphragm from perforation of abdominal organ; abdominal obstruction of bile duct, ureter, intestine; toxins, stimulus of central vomiting center; inflammation of intra-abdominal structures or extra-abdominal conditions (MI, pregnancy, CNS disorders, toxicity)
episodic at height of painobstruction
pain preceding vomitacute appendicitis
green, yellow vomitousbiliary colic
feculant smellingintestinal obstruction
nausea without vomitinghepatocellular disease, pregnancy, metastatic disease
does intraperitoneal bleeding cause vomiting?No

Abdomen - Pain

Question Answer
what do you need to recordtime, acuteness, location, radiation, character
where is right shoulder pain referred from?cholecystitis or anything affecting right hemidiaphragm
what is testicular pain referred from?renal colic or appendix
what is periodic epigastric pain 1 hour after eating due to?gastric peptic ulcer
what is pain 2-3 hours after eating due to?duodenal peptic ulcer
what is back pain due to?perforation of duodenal peptic ulcer, pancreatic pain
what is noturnal pain due to?duodenal peptic ulcer
what is postprandial pain?pain after eating
what is abdominal angina triad?postprandial pain, anorexia, weight loss

Abdomen - Percussion

Question Answer
normal soundtympanic
if tympanic everywhereair everywhere
if dull everywherefluid in peritoneal cavity
anything felt that cannot be adequetely explained is amass
spleen is felt atleft anterior axillary line and lowest intercostal space
resonance to dullness in right uper quadrantliver edge
dullness in left upper quadrantabnormally large spleen
shifting dullnessdetect ascites or fluid in abdominal cavity
guiac negative stoolno blood in stool
what is is used to determine?size of organs, presence of gas, solid mass
what can you normally tell?size and location of liver, spleen, and sometimes liver edge
what can give false positives?lung disease, distention of colon, obesity
where do you percuss the liver?upper border in midclavicular line and proceed posteriorly
how big is the liver normally?10 cm
which direction does spleen enlarge in?AP direction

Abdomen - Palpation

Question Answer
where to startsuperficially and away from site of discomfort
guardingwon't allow you to touch
what to feel forliver edge, masses, hernias, other organ structures
rebound tendernessvery painful when you push in and let go
what is light palpation used to detect?tenderness and areas of muscular spasm or rigidity
what is rigidity and involuntary muscle spasms indicative of?peritoneal irritation
what is deep palpation used for?determining organ size and detecting abnormal masses
what does right hand appreciate?abnormal masses
what does left hand do?apply pressure
ways to test for peritoneal signsbump edge of table, pump up gurney, ask patient to cough, ask if had pain on bumps in car ride over
normal edge of liver isfirm, regular smooth
normal spleen isnot palpable
kidneys areusually not palpable
lower pole of kidneyround, smooth

Abdomen - Auscultation

Question Answer
how many min. should you listen before determining that no bowel sounds can be heard2 min
obstruction causes what kind of soundshigher pitched sounds, of either higher or lower frequency
where would you want to listen for bruits?abdominal aorta, renal arteries
what part of stethoscope do you use?diaphragm
how often do normal sounds occur?5-10 sec
borborygmihyperperistalsis, low-pitched rumbling due to acute intestinal obstruction
what is a possible cause of absence of bowel sounds?paralytic ileus due to diffuse peritoneal irritation
what else should you listen for?peritoneal friction rub
where do you listen for hepatic and splenic problems?RUQ, LUQ

Abdomen - Inspection

Question Answer
what to look for in shape of abdomenobese, morbidly obese, protruberant, scaphoid (normal), flat
what to look for on surface of abdomenscars need to be explained, venous patterns (caput medusa), peristaltic waves
when might you see peristaltic wavesobstruction, thin abdominal walls
other things to look forrespiratory rate, face, hands, skin

Abdomen - General

Question Answer
second most common neoplasm in Americanscolon cancer
colickypain that comes and goes
colicky is frequently present incramps
child with projectile vomiting may be due topyloric stenosis
bilious vomit in child may bemalrotation of gut
patient lying completely still, won't move around at allperitoneal sign
whites of eyes show no evidence of jaundiceanicteric
if oral mucosa drysign of dehydration
dehydration is often associated withtachycardia
level of bilirubin that is detectable in adults2
jaundiced child will have bilirubinover 10 sometimes
why do pulm exam?because lower quadrant of pulm. is sometimes confused with upper quad of abdomen
abdomen exam1. inspection; 2. auscultation; 3. percussion; 4. palpation; 5. rectal exam; 6. special tests
gall bladder disease is confirmed withultrasound, multiple gall stones, fluid
4 F's for risk factors for gall bladder diseasefemale, fat, forties, fertile
Diseases of abdomenpeptic ulcer, diverticular, cancer of large bowel (colon)
increases risk of colorectal cancerulcerative colitis, polyposis
lowers mortality of colorectal cancerhigh fiber, low fat diet with early physical diagnosis
symptoms of abdominal diseasepain, nausea and vomiting, change in bowel movements, rectal bleeding, jaundice, abdominal distention, mass, pruritis
what is pruritis?itching