ASSESSMENT
ABDOMEN
Inspection

Contour:
flat, pendulous, scaphoid
Shine a light across the abdomen
toward you or lengthwise across the person. The abdomen should be symmetric bilaterally.
Note any localized bulging, visible mass, or asymmetric shape. Even small
bulges are highlighted by shadow. Step to the foot of the examination table to
recheck symmetry.
Ask the person to take a deep
breath to further Highlight any change. The abdomen should stay smooth and
symmetric. Or ask the person to perform a sit-up without pushing up with his or
her hands.
Note
umbilicus: midline, inverted, no discoloration, clean, no hernia and no
inflammation.
Normally it is midline and
inverted, with no sign of discoloration, inflammation, or hernia. It becomes
everted and pushed upward with pregnancy. The umbilicus is a common site for
piercings in young women. The site should not be red or crusted.
Observe
skin for:
Lesions
Normally no lesions are present,
although you may note well-healed surgical scars. If a scar is present, draw
its location in the person's record, indicating the length in centimeters.
(NOTE: Infrequently a person may forget a past operation when providing history. If you note a scar now, ask about it.) A surgical scar alerts you to
the possible presence of underlying adhesions and excess fibrous tissue.
Scars
One common pigment change is striae
(lineae albicantes)—silvery-white, linear, jagged marks about 1 to 6 cm long.
They occur when elastic fibers in the reticular layer of the skin are broken
after rapid or prolonged stretching as in pregnancy or excessive weight gain.
Recent striae are pink or blue; then they turn silvery white.
Pigmented nevi (moles): circumscribed
brown macular or popular areas are common on the abdomen
Veins usually are not seen, but a fine venous network may be visible in thin persons.
Pulsations
Normally you may see the pulsations
from the aorta beneath the skin in the epigastric area, particularly in thin
people with good muscle wall relaxation. The respiratory movement also shows in the
abdomen, particularly in males. Finally, waves of peristalsis sometimes are
visible in very thin people. They ripple slowly and obliquely across the
abdomen.
The patient is positioned
comfortably in the supine position as described in Inspection. The stethoscope
is used to listen over several areas of the abdomen for several minutes for the
presence of bowel sounds. The diaphragm of the stethoscope should be applied to
the abdominal wall with firm but gentle pressure. It is often helpful to warm the
diaphragm in the examiner's hands before application, particularly in ticklish
patients. When bowel sounds are not present, one should listen for a full 3
minutes before determining that bowel sounds are, in fact, absent.

Listen for bowel sounds with the diaphragm in all 4 quadrants, beginning with the RLQ.
Listen for Bruits with bell over:
Aorta
Renal
arteries
Iliac
arteries
Percuss abdomen in all 4 quadrants.
Hollow areas should be tympanic
sounding whereas areas containing masses or organs will be dull e.g. liver.
Changes in sound such as dullness may indicate masses, and these can be
percussed and assessed for size.
For instance, you can map out the
size of the liver by percussing from the middle of the right thorax towards the
right costal margin until you hear the dullness of the underlying liver mass
and mark the spot.
You also percuss from down-up by
starting from the umbilical level until again you reach dullness and note that
area.
Keep
your palpating hand low and parallel to the abdomen. Holding the hand high and
pointing down would make anyone tense up.
Teach
the person to breathe slowly (in through the nose and out through the mouth).
Keep
your own voice low and soothing. The conversation may relax the person.
Try
“emotive imagery.” For example, you might say, “Now I want you to imagine that
you are dozing on the beach, with the sun warming your muscles and the sound of
the waves lulling you to sleep. Let yourself relax.”
With
a very ticklish person, keep the person's hand under your own with your fingers
curled over his or her fingers. Move both hands around as you palpate; people
are not ticklish to themselves.
Alternatively, perform palpation just after auscultation. Keep the stethoscope in place and
curl your fingers around it, palpating as you pretend to auscultate. People do
not perceive a stethoscope as a ticklish object. You can slide the stethoscope
out when the person is used to being touched.
If you identify a mass, first
distinguish it from a normally palpable structure or an enlarged organ. Then
note the following:
- Location
- Size
- Shape
- Consistency (soft, firm, hard)
- Surface (smooth, nodular)
- Mobility (including movement with respirations)
- Pulsatility
- Tenderness
Assessment:- Male Reproductive System
Demonstrate Penis
Examination:
·
Inspect
the Penis
The skin normally looks wrinkled,
hairless, and without lesions. The dorsal vein may be apparent.
The glans look smooth and without
lesions. Ask the uncircumcised male to retract the foreskin, or you retract it.
It should move easily. Some cheesy smegma may have collected under the
foreskin. After inspection slide the foreskin back to the original position.
The urethral meatus is positioned
just about centrally. Compress the glans anteroposteriorly between your thumb
and forefinger. The meatus edge should appear pink, smooth, and without
discharge.
Demonstrate
self-testicular exam:
Encourage self-care by teaching
every male (from 13 to 14 years old through adulthood) how to examine his own
testicles. The overall incidence of testicular cancer is rare, accounting for
about 8000 new cases annually. It is rare before 15 years, but it occurs most
often between 15 and 35 years. It is associated with a history of
cryptorchidism.
Some groups consider teaching TSE
controversial because of the harms of causing anxiety and unwarranted medical
costs8 exceed the benefits of selective detection of a relatively rare lesion.
However, testicular cancer has no early symptoms. When detected early and
treated before metastasis, the cure rate is almost 100%. Therefore, include the
teaching but adjust your message to emphasize familiarity with the young man's
own body rather than only cancer detection as the goal.
Inspect and
palpate scrotum:
· Lesions
· Edema
· Hair
distribution/lice
· Epididymis
· Spermatic
cord
Inspect the scrotum as the male
holds the penis out of the way. Alternatively, you hold the penis out of the
way with the back of your hand. Scrotal size varies with ambient room
temperature. Asymmetry is normal, with the left scrotal half usually lower than
the right.
Spread rugae out between your
fingers. Lift the sac to inspect the posterior surface. Normally no scrotal
lesions are present, except for the commonly found sebaceous cysts. These are
yellowish, 1-cm nodules and are firm, nontender, and often multiple
Palpate gently each scrotal half
between your thumb and first two fingers (Fig. 24-8). The scrotal contents
should slide easily. Testes normally feel oval, firm and rubbery, smooth, and
equal bilaterally and are freely movable and slightly tender to moderate
pressure. Each epididymis normally feels discrete, softer than the testis,
smooth, and nontender.
Palpate each spermatic cord between
your thumb and forefinger along its length from the epididymis up to the
external inguinal ring. You should feel a smooth, nontender cord.
Normally no other scrotal contents
are present. If you do find a mass, note:
· Any
tenderness?
· Is
the mass distal or proximal to the testis?
· Can
you place your fingers over it?
· Does
it reduce when the person lies down?
· Can
you auscultate bowel sounds over it?
Inspect inguinal
region for bulge as a person stands and bears down
Inspect and
Palpate for Hernia:

For the right side, ask the male to
shift his weight onto the left (unexamined) leg. Place your right index finger
low on the right scrotal half so you carry as much skin as possible as you
proceed. Palpate up the length of the spermatic cord, invaginating the scrotal
skin as you go, to the external inguinal ring. It feels like a triangular slit-like opening. If positioned properly, it will admit your finger; gently insert
it into the canal and ask the man to “bear down.” Normally you feel no change.
Repeat the procedure on the left side.
Place your right hand upright on
the man's right upper thigh, remembering the acronym NAVEL (Nerve, Artery,
Vein, Empty space, Lymphatics). Locate the femoral Artery pulse with your index
finger; the empty space will be under your 4th finger. Ask the man to bear down
and palpate the femoral area for a bulge. Normally you feel none. Change sides,
using your left hand for the man's left side.
Palpate inguinal
lymph nodes:
· Palpate
Inguinal Lymph Nodes
· Palpate
the horizontal chain along the groin inferior to the inguinal ligament and the
vertical chain along the upper inner thigh. It is normal to palpate an isolated
node on occasion; it then feels small (<1 cm), soft, discrete, and movable.
Assessment: Female Reproductive System
Inspect external genitalia noting:
· Hair
distribution/lice
Hair distribution is in the usual the female pattern of an inverted triangle, although it normally may trail up the
abdomen toward the umbilicus.
Consider delayed puberty if no
pubic hair or breast development has occurred by age 13 years.
Nits or lice at the base of pubic
hair.
· Lesions
No lesions should be present,
except for occasional sebaceous cysts. These are yellowish, 1-cm nodules that
are firm, nontender, and often multiple.
Drainage
Edema
Assess support of pelvic
musculature, with patient bearing down, for any bulging of vaginal wall
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