for  tenderness,  crepitation,  masses,  and  ab- normal pulsations. Palpate for any signs of vibra- tions  or  thrills.  Percuss  the  chest  for  signs  of resonance,  hyperresonance,  tympany,  dullness, and flatness. Use a stethoscope to auscultate for abnormal  breath  sounds  such  as  rales,  rhonchi, and wheezing. Listen for abnormal voice sounds. . Cardiovascular System—Place the patient in a supine position. Palpate the chest wall in the area  of  the  left  midclavicular  line  to  detect  thrills, rate, rhythm, and precardial heave. Auscultate the heart for abnormal sounds such as friction rubs and heart murmurs. .   Gastrointestinal   System—Inspection, auscultation,  percussion,  and  palpation  are  of significant  value  in  examining  the  gastrointestinal system.  Most  of  the  information  gathered  from the  examination  will  be  from  palpation.  Always perform palpation last because some findings of auscultation can be markedly altered by manipula- tion of the abdomen. Place the patient in a supine position with the head slightly elevated. Visually inspect the exposed skin from the sternum to the pubis.  Observe  for  symmetry,  masses,  and  general nutritional  state.  Note  the  presence  of  scars, stretch marks, blemishes, a visible hernia, or ab- dominal   distension.   Auscultate   to   detect   any abnormal  peristalsis  sounds,  friction  rubs,  and bruits   (e.g.,   a   splashing   or   blowing   sound). Percuss  the  abdominal  area  to  detect  the  presence of   tumors,   fluid,   distension,   and   enlargement of   the   underlying   organs.   Palpation   of   the abdominal walls is the most important of all the steps  and  the  most  difficult  to  perform.  First, make sure your hands are warm. Start to palpate by  placing  your  hand  in  an  area  where  there  is no  pain  and  gently  move  your  hand  over  the entire  abdomen.  Note  any  enlargements  or  masses and  any  pain  produced.  When  examining  the abdomen,  you  should  be  alert  for  any  sign  of  a hernia.  There  are  three  types  of  abdominal hernias: ventral—soft masses that protrude into the  abdominal  wall  anteriorly;  inguinal—a protrusion of peritoneum through the abdominal wall  in  the  inguinal  area;  and  femoral-located on the anterior surface of the thigh just below the inguinal ligament. The last part of the examina- tion is the rectal. This part of the examination is crucial and should be performed in every case in- volving  the  gastrointestinal  tract.  The  perianal area should be inspected for lesions and external hemorrhoids.  Also  palpate  the  anal  canal  for tumors,   polyps,   masses,   and   tenderness.   The prostate should be palpated for size, shape, and consistency.  After  withdrawing  the  gloved  hand from the rectum, check the character of any stool that may be on the glove, and perform a guaiac test. .  Genitourinary  System—Inspect  the  lower abdomen   and   flank   area   for   any   signs   of tenderness  if  kidney  involvement  is  suspected. Whenever possible, do a microscopic examination of  the  urine.  Examine  the  genitalia  for  signs of   discharge,   ulcers,   growths,   phimosis,   para- phimosis,  condylomata  (venereal  warts),  cysts, lipomas  or  any  masses  (any  testicular  mass must  be  considered  as  cancerous  until  proven otherwise), and areas of tenderness and swelling (as in epididymitis). If not already performed, a rectal  examination  is  essential.  If  renal  calculi  are suspected,  screen  all  urine  for  signs  of  “sandy grit,”  pus,  blood. .  Extremities—Compare  upper  extremities for symmetry, muscular development, deformity, evidence   of   nail   biting,   redness,   warmth, tenderness,  and  crepitation.  Examine  the  joints for   range   of   motion,   areas   of   tenderness, swelling,  and  discoloration.  Inspect  and  palpate all lymph nodes in the upper extremities. Examine the legs for symmetry, edema, muscular develop- ment,   abnormalities   in   blood   vessels,   and dermatological  diseases.  Apply  passive  and  active range  of  motion  techniques  and  check  for tenderness,  swelling,  discoloration,  and  deformity in  joints.  Inspect  and  palpate  all  inguinal  and femoral  nodes.  Examine  the  feet  for  changes  in coloration or temperature-indicators of impaired circulation. .   Central   Nervous   System   Checks—The following  are  the  five  testing  categories  in  a neurological  assessment: l  Mental  Status  and  Speech—Note  the patient’s  dress,  grooming  and  personal  habits, expressions, manner, mood, speech, and level of consciousness. l Cranial Nerves—Test the olfactory and optic  nerves  by  having  the  patient  identify  smells, testing  visual  acuity  and  mobility  of  the  eyes, assessing  the  hearing,  and  observing  for  facial weakness  or  tics. l  Muscles—Test  for  muscle  tone,  co- ordination, involuntary movements, and atrophy. 2-5