1
By: Beker A. (BSc, MSc )

Objective
♀At the end of this unit students will be able to:
Identify the surface- land marks for cardiac assessment
Differentiate normal and abnormal heart sounds
Demonstrate the techniques of cardiac assessment
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By: Beker A. (BSc, MSc )

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By: Beker A. (BSc, MSc )

• Diseases of the CVS are common at any level & diagnosis of
diseases requires thorough history taking and meticulous
physical exam.
Symptoms
Dyspnea – shortness (difficult) of breathing. The degree of
dyspnea is graded based on the New York Heart Association
Class (NHAC):
Class I: No limitation of physical activity
No symptoms with ordinary exertion
Class II: Slight limitation of physical activity
Ordinary activity causes symptoms
Class III: Marked limitation of physical activity
Less than ordinary activity causes symptoms
Asymptomatic at rest
Class IV: Inability to carry out any physical activity without
discomfort or symptoms at rest
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By: Beker A. (BSc, MSc )

Paroxysmal Nocturnal Dyspnea: Is shortness of breath that
occurs during sleep. The pt suddenly wakes up due the
shortness of breath and then sits up or rush to open a
window/door to get fresh air.
Orthopnea: Shortness of breath that occurs during recumbent
position. It is gauged by the number of pillows that are used to
relieve the symptom
Pain (Angina pectoris) is a cardiac pain. It usually on the
retrosternal region and radiates to the left neck, shoulder and
left upper arm. It has piercing character which is aggravated
by exertion and relieved by rest
Body swelling: Usually this starts from the leg
Palpitation: Is subjective unpleasant perception of one’s own
heart beat.
Cough: This usually occurs at night (nocturnal)
Syncope: Sudden episode of fainting related to hemodynamic
derangement.
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By: Beker A. (BSc, MSc )

Physical Examination
• Observe the pt for general signs of CVS disease
- Breathing pattern
- Cyanosis
- Finger clubbing
- Edema
Arterial Pulses
Note Rate, Rhythm, Character & Volume (amplitude) of
pulse
- The radial artery is more preferred
- Compress the artery with your index and middle fingers
- Count the pulse for one full minute.
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By: Beker A. (BSc, MSc )

Cont.…
Major Arteries: Major arteries
 Radial
 Brachial
 temporal
 Carotid
 Femoral
 Popliteal
 Posterior Tibial,
 Dorsalis pedis.
By: Beker A. (BSc, MSc ) 7

By: Beker A. (BSc, MSc ) 8

Pulse classification in adults
Based on the rate
- Normal = 60 - 100 beats / min
- Bradycardia = < 60 beats / min
- Tachycardia: > 100 beats / min
Based on rhythm
- Regular or Irregular
Character and Volume
- Normal (full) or weak (fible)
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By: Beker A. (BSc, MSc )

Blood Pressure
 The pt should not smoked, taken caffeine or engaged in
vigorous exercise within the last 30 mins.
 The room should be quiet and the pt comfortable.
 Position the pt's arm so that the anticubital fold is level
with the heart.
 Center the bladder of the cuff over the brachial artery
approximately 2-3 cm above the anticubital fold.
 Proper cuff size is essential to obtain an accurate reading
 Place the stethoscope over the brachial artery.
 Inflate the cuff 20-30mmHg above the estimated systolic
pressure after the pulse disappears
 it is acceptable in adults to inflate the cuff to 200 mmHg
and go directly to auscultating the BP.
 Release the pressure slowly, no greater than 5 mmHg/sec.
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By: Beker A. (BSc, MSc )

Jugular Venous Pressure (JVP)
- is a reflection of the right atrial pressure and it is the
most important part of venous system examination
- Position the pt supine
- Look for a rapid, double (sometimes triple) wave with
each heartbeat.
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By: Beker A. (BSc, MSc )

♀Position the person any where from a 30-45 degree
angle, where ever you can best see the pulsations.
♀Turn the person’s head slightly away from the
examined side.
♀Note the external jugular vein overlying the
sternomastoid muscle.
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By: Beker A. (BSc, MSc )

♀In some persons, the veins are not visible at all; where
as in others, they are full in the supine position.
♀As the person is raised to a sitting position, these
external jugulars flatten and disappear, usually at 45
degree.
♀Full distention of external jugular veins above 45 degree
signify increased CVP.
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By: Beker A. (BSc, MSc )

♀The internal jugular veins lie deep and medial to the
sternocleidomastoid muscle.
♀The external jugular veins are more superficial; they
lie lateral to the sternocleidomastoid muscle and
above the clavicle.
♀You must be able to distinguish internal jugular vein
pulsation from that of the carotid artery.
♀It is easy to confuse because they lie close together
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By: Beker A. (BSc, MSc )

♀N.B: Identify the highest point of pulsations in the
internal jugular vein and with a centimeter ruler measure
the vertical distance between this point and the sternal
angle. Normally this distance is less than three cm.
♀Increased pressure (> 3cm) when it is bilateral suggests
right-sided heart failure or less commonly tricuspid
stenosis, superior vena cava obstruction or rarely
constrictive pericarditis.
By: Beker A. (BSc, MSc ) 15

JVP
By: Beker A. (BSc, MSc ) 16

Differentiation of the jugular & carotid pulse wave
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By: Beker A. (BSc, MSc )

Palpate for a point of maximal impulse (which usually is
located at the same area to the apical impulse,).
It is normally located in the 4th or 5th intercostals space just
medial to the mid clavicular line.
Auscultate with stethoscope:
Diaphragm: preferred to auscultate high pitched sounds e.g.
S1 (lub), S2 (dub), systoic murmur, etc
Bell: preferred to auscultate low pitched sounds e.g. S3, S4,
diastolic murmur of Miteral stenosis
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By: Beker A. (BSc, MSc )

Areas of auscultation:
1. The right 2nd interspace near the sternum (aortic area).
2. The left 2nd interspace near the sternum (pulmonic
area).
3. 3rd intercostal space left of sternal boarder- erb’s point
3. The left 4th & 5th interspace near the sternum (tricuspid
area)
4. At the apex (mitral area)
* Apical impulse should occupy only one inter space, the 4th
or 5th at or medial to the midclavicular line.
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By: Beker A. (BSc, MSc )

To distinguish S1 from S2
S1 is louder than S2 at the apex; S2 is louder than
S1 at the base
S1 coincides with the carotid artery pulse
Feel the carotid gently as you auscultate at the
apex; the sound you hear as you feel each pulse is
S1
Listen for murmurs
A murmur is a blowing swooshing sound that
occurs with turbulent blood flow in the heart or
great vessels.
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By: Beker A. (BSc, MSc )

If you hear a murmur describe the intensity in terms of six
grades
 Grade 1- barely audible, heard only in a quite room and
with difficulty
 Grade II- clearly audible but faint
 Grade III- moderately loud
 Grade IV- loud associated with a trill palpable on the
chest wall
 Grade V- very loud, heard with one corner of the
stethoscope lifted off the chest wall
 Grade VI- loudest, still heard with entire stethoscope
lifted just off the chest wall
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By: Beker A. (BSc, MSc )

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By: Beker A. (BSc, MSc )

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By: Beker A. (BSc, MSc )

Surface Landmarks:
Abdomen is a large cavity extending from the diaphragm
to the pelvic brim.
It is divided in to four quadrants by a vertical &
horizontal line bisecting the umbilicus.
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By: Beker A. (BSc, MSc )

By: Beker A. (BSc, MSc ) 25

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By: Beker A. (BSc, MSc )

Guideline
 Good light, a relaxed patient, and full exposure of the
abdomen from above the xiphoid process to the
symphysis pubis
 Patient should not have a full bladder
 Position -patient should be supine
 Before Palpation, ask the patient to point to any areas
of pain, and examine painful or tender areas last.
By: Beker A. (BSc, MSc ) 27

Cont.…
Monitor your examination by watching the
patient's face for sign of discomfort
Have a warm hand, a warm stethoscope, and
short fingers nails
Make a habit of visualizing each organ in the
region you are examining.
Proceed in an orderly fashion, Inspection,
auscultation,
By: Beker A. (BSc, MSc ) 28

 Inspects the contour, symmetry, umbilicus, skin,
pulsation or movement, skin markings and hair
distribution is performed best in good light.
 abdominal distension (6 Fs - fat, fluid, faeces, foetus,
fibroids, flatus)
 A scaphoid abdomen can occur in a pt with upper
gastrointestinal obstruction or as a result of starvation.
29
Method of examination
1. Inspection
By: Beker A. (BSc, MSc )

Subjective data
Indigestion or anorexia
Nausea/vomiting
Hematemesis
Abdominal pain
Dysphagia
Change in bowel function
Constipation or diarrhea
Past abdominal surgery
30
By: Beker A. (BSc, MSc )

Objective data
 Equipment needed
 Stethoscope
Small centimeter ruler
Skin marking pain
Order of abdominal examination
Inspection
Auscultation
Percussion
Palpation
Order of exam is critical. Auscultate before percussing and
palpating
By: Beker A. (BSc, MSc ) 31

32
By: Beker A. (BSc, MSc )

Umbilicus
Normally it is midline and inverted with no signs of
inflammation or hernia.
It becomes everted and pushed upward with pregnancy.
Umbilical hernias frequently are present in the infant,
toddler, and younger child, particularly in black children.
Abnormal findings on inspection
 Visible or distended veins- ascites
 Visible peristalsis- obstruction
 Asymmetry/ Distention- mass or intestinal obstruction
 Color changes- jaundice, bluish/cyanotic
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By: Beker A. (BSc, MSc )

2. Auscultation
Auscultate bowel sounds and vascular sounds
Auscultate abdomen next because percussion and
palpation can increase peristalsis.
Use the diaphragm – end piece because bowel sounds are
relatively high pitched.
• Hold the stethoscope lightly against the skin, pushing too
hard may stimulate more bowel sounds.
• Begin in the RLQ at the ileocecal valve because bowel
sounds are always present here normally.
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By: Beker A. (BSc, MSc )

Bowel sounds
originate from the movement of air & fluid through the
small intestine
They are high pitched gurgling occurring from 5-30 times
Do not bother to count it.
• Bowel sounds may be altered in
 diarrhea,
intestinal obstruction,
paralytic ileus, and
 peritonitis.
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By: Beker A. (BSc, MSc )

Judge for presence, hypoactive or hyperactive
One type of hyperactive bowel sounds which is common
is hunger or diarrhea which is hyperperistalsis known as
“borborygmi”
Borborygmus is a rumbling noise in the abdomen, caused
by gas in the intestine.
Active bowel sounds usually are decreased or absent in
pts with appendicitis, intestinal obstruction, following
abdominal surgery or with inflammation of the
peritoneum
Perfectly “silent abdomen” is uncommon; you must listen
for 5 mins before saying absent bowel sounds.
 Stenosis involving the aorta or iliac, femoral, or renal
arteries may give rise to an audible abdominal bruit.
Hyperactive sound are loud, high pitched, rushing
36
By: Beker A. (BSc, MSc )

3. Percussion
 - abdomen is normally tympanic (gas-filled loops of
bowel produce tympany), liver span and splenic areas
are dull.
 Percuss to assess the relative density of abdominal
contents to locate organs and to screen for abnormal
fluid or masses.
 first percuss lightly in all four quadrants to determine the
prevailing amount of tympany and dullness.
 Tympani should predominate because air in the intestine
rises to the surface when the person is supine.
 Abnormal dullness occurs over a distended bladder,
adipose tissue, fluid or a mass.
 Hyper resonance is present with gaseous distention.
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By: Beker A. (BSc, MSc )

 If you suspect ascites, begin percussion peripherally. At
first dullness will be noted.
 As percussion advances centrally, the air-filled loops of
intestine, forced to the midline by ascitic fluid, will emit a
tympanitic sound. When the pt turns to one side or the
other, the locations of tympany and dullness shift as the
fluid moves into dependent areas.
 A fluid wave can be produced when the examiner strikes
one flank area with the tips of the fingers of one hand and
detects gentle pressure with the other hand on the opposite
flank.
 This finding is better demonstrated by employing the aid of
an assistant who at the same time has placed the ulnar
surfaces of both fully extended hands pointing toward one
another along the midline of the abdomen.
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By: Beker A. (BSc, MSc )

4. Palpation
 Palpation is extremely beneficial for determining of certain
organs (liver, kidney & spleen) size, location &
consistency and for detecting abdominal masses or
tenderness.
 An examiner's warm hands & initial gentle, soft touch may
go a long way in gaining the cooperation of the pt for
deeper, more thorough palpation.
 Instruct pt to take a deep breath and then exhale slowly
while you applies firm steady pressure to the abdomen.
 A fairly complete examination can be achieved by
repeating the procedure in all four quadrants.
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By: Beker A. (BSc, MSc )

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By: Beker A. (BSc, MSc )

To enhance complete muscle relaxation
 Bend the person’s knees.
 Take deep inhalation & slow breath out
 Keep your palpation gentle
 Begin with light palpation with fingers close together.
 make a gentle rotary motion, sliding the fingers and skin
together.
 Then lift the fingers and move clockwise to the next
location around the abdomen.
 An objective of superficial palpation is not to search for
organs but to form an overall impression of the skin
surface and superficial musculature
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By: Beker A. (BSc, MSc )

Abnormal: involuntary rigidity is a constant board like
hardness of the muscles as in peritonitis.
 In case of very large or obese abdomen use a bimanual
technique.
 Place your two hands on top of each other.
 The top hand does the pushing, the bottom hand is relaxed
and can concentrate on the sense of palpation
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By: Beker A. (BSc, MSc )

Liver
 For the obese pt, a two-hand technique with the fingers of
one hand applying pressure on top of the fingers of the
other hand may be required.
 stand on the pt's right side when attempting to feel the
liver
 Place your left hand under the person back parallel to the
11th & 12th ribs & lift up to support the abdominal content.
 Place your right hand on the RUQ with fingers parallel to
the midline in a somewhat oblique position.
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By: Beker A. (BSc, MSc )

 Push deeply down and under the right costal margin.
 Palpation should progress in a superior direction until the
lower edge of the liver is detected.
 It is normal to feel the edge of the liver
 Often the liver is not palpable and you feel nothing firm
 Abnormal liver palpated more than 1-2 cm below the
right costal margin is enlarged.
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By: Beker A. (BSc, MSc )

Spleen
• Normally, the spleen is not palpable
 Rich your left hand over the abdomen and behind the left side at
the 11th &12th ribs
 lift up to support place your right hand obliquely the LUQ with
the fingers pointing to ward the left axillae and just inferior to
the rib margin.
 Push your hand deeply down and under the left costal margin
and ask the person to take a deep breath.
Abnormal - enlarged the spleen slides out and bumps your
fingertips
 - if you feel an enlarged spleen return the person but do not
continue to palpate. It is friable and can rupture easily with over
palpation
 - It can grow so large that it extends in to the lower quadrant.
45
By: Beker A. (BSc, MSc )

Cont.…
Costo vertebral angle tenderness
to assess the kidney, place one hand over the 12th
rib at the costo vertebral angle on the back.
Thump that hand with ulnar edge of your other
fist.
The person feels no pain.
Abnormal: - sharp pain occurs with inflammation of
the kidneys
By: Beker A. (BSc, MSc ) 46

Cont.…
Findings: The patient should perceive a thud
but no pain.
CVA tenderness or severe pain may indicate
pyelonephritis, glomerulonephritis, or
nephrolithiasis (kidney stones).
By: Beker A. (BSc, MSc ) 47

Kidneys
 For the right kidney, place your hands together at the
person’s right flank.
 Press your two hands together firmly and ask the person
to take a deep breath.
 In most people, you will feel no change.
 The left kidney sits 1cm higher than the right kidney and
is not palpable normally
 Search for it by reaching your left hand across the
abdomen and behind the left flank for support.
 Push your right hand deep in to the abdomen and ask the
person to breath deeply.
 You feel no change with inhalation
48
By: Beker A. (BSc, MSc )

Tests:
1. Rebound tenderness
 Pain induced or increased by quick withdrawal.
 It results from the rapid mov’t of an inflamed peritoneum.
 Hold your hand
 Push down slowly and deeply perpendicular to the site, then
lift up quickly
 No pain on release of pressure in normal case
 Do at the end of the examination b/c it causes sever pain
and muscle rigidity
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By: Beker A. (BSc, MSc )

 When peritonitis is suspected, rebound tenderness may be
elicited by pressing firmly and slowly on the abdomen
and then quickly releasing pressure
2. Inspiratory arrest (Murphy's sign)
– Normally, palpating the liver causes no pain.
– In a person with inflammation of the gall bladder or
cholecystitis, pain occurs.
– Hold your fingers under the liver border.
– As the descending liver pushes the inflamed
gallbladder on to the examining hand, the person feels
sharp pain and abruptly stops inspiration mid way.
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By: Beker A. (BSc, MSc )

3. Iliopsoas muscle test
 Perform this test when acute abdominal pain or
appendicitis is suspected
 With the person supine, lift the right leg straight up,
flexing at the hip; then push down over the lower part of
the right thigh as the person tries to hold the leg up.
 When the test is negative, the person feels no change
Abnormal - pain in the RLQ indicates appendicitis
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By: Beker A. (BSc, MSc )

4. Obturator Test
 When appendicitis is suspected with the person supine,
lift the right leg, flexing at the hip and 90 degrees at the
knee.
 Hold the ankle and rotate the leg internally and
externally
 Negative or normal response is no pain
5. Rovsing’s sign
 when LLQ is palpated pain will be felt in the RLQ
52
By: Beker A. (BSc, MSc )

ASSESS the abdomen for fluid.
If fluid is suspected within the abdomen, perform the
following tests:
Shifting Dullness
Fluid Wave
Shifting dullness
When ascites is suspected and tympany will be
changed to dullness
By: Beker A. (BSc, MSc ) 53

Cont.…
 Procedure: Ask the patient to lie supine so any fluid pools in the lateral (flank)
area.
 Percuss the abdomen.
 Draw lines on the abdomen to indicate the midline tympany (the expected tone) in
contrast to lateral dullness (tone created by fluid).
 Then have the patient turn to the right side and repeat percussion.
 Listen for the tympanic tone to shift to the upper (left) side and the area of
dullness rises toward the midline.
 Finally have the patient turn to the left lateral position and percuss. Listen as the
dullness rises toward the midline.
By: Beker A. (BSc, MSc ) 54

By: Beker A. (BSc, MSc ) 55

Cont…
Findings: Normally tympany is heard throughout
the abdomen, except over the bladder when it is
distended.
Movement of the area of dullness as the patient
shifts position reflects the shift of fluid in the
peritoneal cavity (ascites).
By: Beker A. (BSc, MSc ) 56

Obstetric Examination
Abdominal examination:
• Inspection: the four ”s”& fetal movement
S- size of the abdomen ( proportional, small and large to GA)
S- shape of the abdomen( oval in primi gravida, round in multi
para, broad in multiple pregnancy and mal presentation)
S- scar( any previous C/S or myomectomy)
S- skin
• Palpation (Leopold’s maneuver):- to determine uterine size
(symphysis fundal height), fetal lie, presentation, attitude and
engagement By: Beker A. (BSc, MSc ) 57

Steps of leopold maneuver
1. Fundal palpation
2. Lateral palpation
3. Pawlk’s grips
4. Deep pelvic palpation
• Auscultation: fetal heart beat
By: Beker A. (BSc, MSc ) 58

The first Leopold’s maneuver
By: Beker A. (BSc, MSc ) 59

Leopold I:
– Fundal palpation.
- Has two purposes: 1) Determination of fundal height, and
2) What occupies the fundus?
Fundal height measurement - should be after correcting for dextrorotation.
There are two methods of measuring the fundal height:
1. Finger method: - below the umbilicus, 1 finger = 1 weeks and
- Above the umbilicus, 1 finger = two weeks
Body marks: - Uterus at symphysis pubis = 12 weeks
- At the umbilicus = 20 weeks
- At Xiphisternum = 36 weeks
- Midways between symphysis & umbilicus = 16 Weeks
- Midways between umbilicus & Xiphisternum = 28 Weeks
By: Beker A. (BSc, MSc ) 60

CONT..
2. Tape measurement:
- Symphysis to fundal height measurement in centimeters with tape meter.
- At 18 – 34 weeks of gestation, tape measurement is accurate to +2 weeks of actual
Gestational age.
- McDonald rule & Johnson formula for GA & Fetal weight estimation
What occupies the fundus?
Soft irregular bulky mass - the breech
Hard round ballotable mass – Head
By: Beker A. (BSc, MSc ) 61

The second Leopold’s maneuver
By: Beker A. (BSc, MSc ) 62

Leopold II:
– Lateral palpation
- Has two purposes: 1) To know the lie
2) To determine side of
the back
1. Lie: - is the longitudinal axis of the fetus in
relation to the longitudinal axis of the mother.
- It can be longitudinal, transverse or oblique.
2. Side of the back – to auscultate the FHR on that
side.
- FHR can be auscultated at 20 weeks by using
the De Lee /Pinard stethoscope or
at 10 - 12 weeks using Doppler Ultrasound
By: Beker A. (BSc, MSc ) 63

The third Leopold’s maneuver
By: Beker A. (BSc, MSc ) 64

Leopold III
– pelvic palpation
– It has three purposes: to know the 1) Presentation
2) Descent of presenting part.
3) Attitude of the fetal head.
Presentation: – is the part of the fetus that occupies the lower uterine pole.
E.g. Cephalic presentation, breech presentation, shoulder presentation
Descent is measured after identifying the anterior shoulder with rule of 5th in
fingers
above pelvic brim.
5/ 5th – floating
2/5th – engaged at the pelvic inlet.
Attitude: is the relationship of the fetal parts to each other particularly the fetal
head to its trunk.
- Cephalic prominence on the side of the back- Extended attitude = >
abnormal
- Cephalic prominence opposite to the side of the back - Flexed
attitude = > normal
- Military Attitude: - neither flexed nor extended
By: Beker A. (BSc, MSc ) 65

The fourth Leopold’s maneuver
By: Beker A. (BSc, MSc ) 66

Leopold IV
– Pawlik’s grip: – It has two purposes.
To know the 1) Presentation and
2) Descent or
mobility of the fetal head – floating or fixed
By: Beker A. (BSc, MSc ) 67

Quiz
1. List steps of leopold maneuver
2. List at least 4 area of pulse
3. List the common area of auscultation to hear
different heart sound
4. What is Rovsing’s sign
5. List at least 4f that cause abdominal
distension
By: Beker A. (BSc, MSc ) 68