Visceral

Question 1

Respiratory Excursion, state all positives

Answer 1

Take a tissue pull with the ball of the hand from axillary to mid-line and use thumbs as markers.
thumbs on SP @ T10

rest hands on posterolateral surface.
thumbs diverge on quiet and deep breathing

Ask patient to take a deep breath in and out through their mouth. Watch for symmetry of movement bilaterally.

repeat 3x

( + ) Lag
( i ) indicates an underlying lung problem on that side.

Question 2

Palpate heart pulsations

Answer 2

APETME using finger pads
aortic
pulmonic
erb's point
tricuspid
mitral - apiclal impulse (location and amplitude)

Epigastric Pulsations: (hand should be flat and pointing towards left shoulder)
Pulsations coming from superior to inferior to the finger pads
May indicate: right ventricular enlargement
Pulsations coming inferior to superior (actually P-A) to the finger pads
May indicate: abdominal aortic aneurysm
2. Check the A.P.E.T.M. areas for thrills (using the ball of the

Question 3

Auscultate major abdominal arteries

Auscultate and state the arteries of the abdomen

Answer 3

*bell of stethescope

Aorta: 1” above and 1” to left of umbilicus.

Renals: 2” above and 2” lateral from umbilicus. Bilateral.

Common Iliacs: 2” down and 2” lateral from umbilicus. Bilateral.

Question 4

Percuss the posterior thorax

Answer 4

1,2 Apices of lungs
3,4 Interscapular area (arms crossed, avoid TP’s)
5,6 Triangle of auscultation (arms crossed and elevated)
7,8 Medial base of lungs
9,10 Lateral base of lungs

Question 5

Palpate Axillary Lymph Nodes

Answer 5

normally present but not felt.
Infections = soft, tender
and easily moveable.

Cancer = hard, non-tender and non-moveable

Supraclavicular
Infraclavicular
Epitrochlear
Lateral axillary
Medial axillary
Anterior axillary
Posterior axillary

Question 6

Evaluate spinal accessory cranial nerve

Answer 6

(XI) Spinal Accessory Nerve

a) Trapezius Muscle
Inspect
Palpate
Muscle test

b) Sternocleidomastoid Muscle
Inspect
Palpate

Muscle test - Ask patient to rotate head to one side. Dr. instructs patient to hold, while
Dr. attempts to return the head to neutral.

Question 7

Mitral Maneuver

Answer 7

Patient is supine, identify the mitral area, then place patient in left lateral recumbent position

Use bell (low pitched murmurs) at apical impulse area

Ask patient to take in a deep breath and hold.

Question 8

Psoas Sign

Answer 8

Instruct: Patient supine. Examiner places superior hand on right iliac crest and inferior
hand on patient’s right thigh. Instruct patient to raise straight leg on the right side
against resistance.
Positive: Increased pain.
Indicates: Appendicitis

Question 9

Murphy’s sign

Answer 9

Ask patient to breathe in, patient experiences pain and abruptly stops inspiration (reflex apnea,
inspiratory arrest) upon application of any one of the three Feeling Liver Edge tests, or in
palpation of the gallbladder.
Cause: Inflamed gallbladder (aka cholecystitis).

Question 10

Rebound Tenderness

Answer 10

Blumberg’s Sign
 This is a maneuver to access all four quadrants.
 Patient supine, hold your hand at a 900
angle to patient’s abdomen with the fingers extended. Press
gently and deeply into the abdomen region. Rapidly withdraw your hand and fingers.
 The return to position (rebound) of the structures which were compressed by your fingers causes a
sharp stabbing pain at the site of a problem.
 Indicates: peritonitis.

Rovsing’s Sign
 Rebound tenderness test in the lower left quadrant and the patient has pain over McBurney’s point
(lower right quadrant, from the umbilicus to 2/3rd toward the ASIS).
 Indicates: appendicitis.

Question 11

Aortic Maneuver

Answer 11

Patient in seated position
 Listen at the right sternal border (Aortic area) or the left sternal border (at Erb’s Point) for best heart
sounds using the diaphragm (high pitched murmurs).
 Ask patient to take a deep breath in and lean forward while exhaling all the air.

Question 12

Location of Gastric air bubble

Answer 12

Check Tympany of Stomach (1 mark)
 Percuss down the midclavicular line on the left side.
 This is the predominate sound because of air in stomach and intestines

Question 13

Blood Pressure (palpatory and auscultatory)

Answer 13

Palpate each arterial pulse for the following:
1. Rate
 Pulsations per 60 seconds
 Resting pulse rate for a normal adult should be between 60 to 90 pulsations per minute
2. Rhythm
 Regularity of the heart pattern.
 An irregular heart pattern, which then continues in the same regular pattern over and over, may
indicate sinus arrhythmia.
 A pattern less, unpredictable rhythm may indicate heart disease.
3. Amplitude
 Height or intensity of the pulse.
 Measured using the following scale:
 4 = bounding
 3 = full
 2 = expected
 1 = diminished
 0 = absent
4. Contour
 Description of the pulse wave in a healthy artery.
 Should be either rounded, smooth or domed shaped.
 Each wave is compared to the following wave for any differences.

Question 14

Arterial pulses of lower extremities

Answer 14

Use the distal pads of the second and third fingers. Palpate firmly however do not occlude the artery. The
thumb may be used to feel for the brachial and femoral pulses due to the tendency of the arteries to move
or roll during palpation

Carotid: In the neck, just lateral to below thyroid cartilage at the level of C3. Do NOT palpate
both CAROTID ARTERIES at same time.

Subclavian: At base of neck, mid clavicular.
Brachial: Just medial to biceps tendon.
Radial: Lateral and ventral side of wrist.
Ulnar: Medial and ventral side of wrist.
Abdominal Aorta: One inch superior and one inch lateral to left of the umbilicus.
Femoral: Inferior and medial to the inguinal ligament.
Popliteal: Press firmly in popliteal fossa.
Dorsalis pedis: Medial dorsum of the foot.
Posterior Tibialis: Posterior to medial malleolus.

Question 15

Palpate spleen

Answer 15

Check for Dullness of Spleen (1 mark)
The spleen is percussed just posterior to the midaxillary line on the left side.
A small area of splenic dullness may be heard from the 6th to 10th ICS.

Question 16

Obturator sign

Answer 16

Instruct: Patient supine. Instruct patient to flex their hip to 90 degrees and their knee to 90
degrees. Examiner places superior hand on patient’s right knee and inferior hand
around patient’s right ankle. Patient internally and externally rotates their right
hip against resistance, given by the examiner.
Positive: Increased pain.
Indicates: Ruptured appendix or pelvic abscess

Question 17

Light palpation of abdomen (soft palpation of abdomen)

Answer 17

Light Palpation in all (4) quadrants for:
 No more than 1cm depth. Skin should feel smooth with consistent softness.
 Pain
 Unpleasant feeling caused by noxious stimulation of a sensory nerve ending. Present before area was
palpated.
 May be classified as: mild, severe, chronic, acute, piercing, burning, dull or sharp.
 Tenderness
 Unpleasant feeling when a specific area is touched.
 Not present unless area is palpated.
 Muscle guarding
 Patient gasps for breath and/or the abdomen becomes tense (apprehensive).
 Masses
 Collection of cells clumped together.
 Note its size, shape, consistency, motility and/or pulsations.

Question 18

Palpate the arteries of the abdomen and one side of the lower extremity.

Answer 18

Abdominal Aorta
renals
common iliacs

LE:
Femoral
Popliteal
Dorsalis Pedis
Posterior Tibialis

Question 19

Tactile fremitus, state decrease in fremitu

Answer 19

Transmission of the spoken word through the lung and soft tissue being felt by the ball of the hand (most
sensitive to fremitus).
 Using the ball of the hand, have patient say a resonance sound (such as blue moon, toy boat, etc.) each
time you touch the patient’s thorax.
 Check for symmetry of vibration in the following areas:
1, 2 Apices of lungs
3, 4 Interscapular area (arms crossed, avoid Tp’s)
5, 6 Triangle of auscultation (arms crossed and elevated)
7, 8 Medial base of lungs (Dr. should use ulnar surface of the hands)
9, 10 Lateral base of lungs (Dr. should use ulnar surface of the hands)
 Note the fremitus level of the diaphragm bilaterally. The right side maybe slightly higher due to the
density of the liver and there maybe a decrease in fremitus at the heart and aortic area. Fremitus is felt
best parasternally at 2nd intercostal space at the level of bronchi bifurcation.
 Decreased or absent fremitus:
 Air in the lungs
 Emphysema
 Pleural thickening or effusion
 Massive pulmonary edema
 Bronchial obstruction
 Increased fremitus:
 Often coarser or rougher in feel
 Fluids or a solid mass within the lungs
 Lung consolidation
 Heavy but non-obstructive bronchial secretions
 Compressed lung or tumor

Question 20

Blumberg’s

Answer 20

Patient supine, hold your hand at a 900
angle to patient’s abdomen with the fingers extended. Press
gently and deeply into the abdomen region. Rapidly withdraw your hand and fingers.
 The return to position (rebound) of the structures which were compressed by your fingers causes a
sharp stabbing pain at the site of a problem.
 Indicates: peritonitis