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General Inspection
- stand at the end of the bed
- 10 seconds: carefully observe the patient before commenting 11 things (PCLC RP HNG MA)
1. Position - is the patient lying flat, 45, sitting, left lateral or right lateral etc.
2. Comfortability - Is the patient comfortable or not?
3. Look - does the patient look well / ill?
4. Consciousness & alertness - must ask about time, place & person (dont just say that person is
conscious/alert without even asking a question)
5. Pain - is the patient in pain?
6. Respiratory distress - is the pt in respiratory distress?
*note: 6 features of respiratory distress
I. tachypnoea (>20 brath/minr)
ii. flaring of the nasal alae
iii .pursed lips
iv. use of accessory muscles
v. subcostal & intercostal muscle retraction
vi. cyanosis (in sver resp. distrss)
7. Hydrational status - examine the tongue, mucous rnernbran, skin turgor, sunken eyeball
8. Nutritional status
-cachexic/obese (check BMI)
-any obvious muscle wasting? (look at temporal muscle, vastus muscles & small muscles of the
hand / interosseous mus.)
9. Gross deformity
10. Movement - any abnormal / involuntary movement?
11. Attachments (e.g. IV canulla)
B. Neck
access the jugular venous pressure
0
- 45 , head is turned away from the midline (to relax the sternocleidomastoid muscle), detect a
pulsatile movement, differentiate it from carotid pulsation, measure it, assess the character if
abnormal.
C. Auscultation
listen with the bell at apex beat (mitral area), roll the patient to the left side (listen for mitral stenosis)
change to diaphragm(for low pitch murmurs), listen again at the apex beat, trace up to axilla
(radiation of murmur in mitral regurgitation)
listen with diaphragm at the tricuspid, pulmonary & aortic areas, trace up to the right side of the
neck (radiation of murmur in aortic stenosjs)
sit the patient up and listen at these 3 areas again
perform the dynamic manoeuvres (respiration) if the murmur is present
listen at subclavian area (When patent ductus arteriosus is puspected)
*example. theres a pansystolic murrmur best heard over mitral area with radiat ion to the axilla.
Graded 3/6 and is accentuate during inspiration and on left lateral position -
2. the chest
sit the patient up
perform on the back
look for evidence of pleural effusion (in right heart failure)
auscultate for basal crepitations (in left heart failure)
*note: evidences for signs of heart failure
a. right heart failure
- hepatomegaly (tender in acute case)
- ascites
- elevated JVP
- pitting oedema (sacral @ ankle)
- pleural effusion (small)
-b. left heart failure
- displaced apex beat
- basal crepitation (pulmonary oederna)
- gallop rhythm
- peripheral cyanosis
- pulsus alternans (rare)
3. the back - while the patient is sitting, feel the sacral oedemas
-
4. the fundus
- look for Roths spots in retina (in infective endocarditis)
- look for hypertensive retinopathy
the Keith - Wagener classification for retinopathy;
Grade 1: arterial narrowing & increase tortuosity
Grade 2: arteriovenous nipping
Grade 3: haernorrhage & soft exudates
Grade 4: Grade 1-3 + papilloedema
3. General examination
A.Upper limbs - examine both sides
i. Palms
- moisture - dry @ moist
- temperature warm @ cold
- colour - pink @ pale
ii. Fingers & nails
- cyanosis - peripheral cyanosis
- capillary refilling
- nicotine stained fingers
- clubbing
*note: Respiratory causes of clubbing
A. lung abscess
B. bronchoectasis
C. lung carcinoma, cystic carcinoma
D. emphysema
E. pulmonary fibrosis, cyctic fibrosis
iii. Dorsal part of the hands
small muscle wasting
weakness of finger abduction
(reason: apical lung neoplasm, Pancoasts Syndrome cause destruction of the T 1
intercostal nerve)
iv. Wrists
palpate and look for tenderness
(reasons : pericostal reaction in pulmonary hypertrophic osteoarthropathy d/t primary
lung carcinoma or pleural mesothelium)
v. Pulse
rate
rhythm
volume (increase volume bounding pulse in carbon dioxide retention)
pulsus paradoxus (the pulse weakens on inspirations)
*note: causes of pulsus paradoxus:
a. severe asthma
b. constrictive pericarditis
c. pericardial effusion
d. cardiac tamponade
C. Neck
jugular venous pressure
- elevated in cor pulrponale (right heart failure secondary to disease of the lung)
trachea deviation
- explain to the pt briefly about what is going to be done to him/her
- tell the patient that he/shell feel uncomfortable for awhile
- relax the sternocleidomastoid muscles by dropping his chin and to lean slightly forward
- rest the middle finger on the suprasternal notch and pass it on either side of the trachea as deeply
and inferiorly as possible
- significant displacement of the trachea suggests, but is not specific for dss Of the upper zones of
the lung
D. Lower limbs
- pitting oedema
c. scars?
- Including previous surgery & chest drains
d. dilated veins?
- occur in superior vena caval obstruction in lung neoplasm at the hilum
e. skin discoloration?
f. visible pulsation?
g. radiotherapy marking or skin changes
- erythema & thickening of the skin over the irradiated area
- indicate previous treatment for underlying rnalignancy
B. Palpation
- do not present in running commentary, present the summary of the findings after the
examination
a. chest expansion
- place the hand firmly on the chest laterally after a full expiration with the fingers apart and
thumb lifted off the chest wall touching each other then ask the patient to inspire fully
- perform on upper, middle and lower parts
- the chest expansion also can be measured from deep inspiration to full expiration, using a
tape measure (at the level of nipples)
- the lung should expand symmetrically by at least 5 cm
- reduced expansion on the side indicates a lesion on that side
c. vocal resonance
- same as for vocal fremitus (ninety-nine)
- now ask the patient to sit up, repeat the examination on the back of the chest while
percussing, ask the patient to move the elbows forward across the front of the chest to move
the scapulae away from the lung field
- while the patient is sittihg, palpate for cervical lymph nodes cervical & other lymph nodes: -
- submantel
- submandibular
- preaurical
- pthstaurical
- occipital
- deep cervical chain
- posterior triangular
- supracla-vicular
- scalene (importapt in lung carcinoma)
- look for the vertebrae tenderness (metastaais from lung carcinoma)
- examine the heart for signs of cor pulmonale (e.g.: loud pulmonary 2nd heard sound, right
heart gallop rhythm)
- examine the sputum if possible (colour, consistency, volume)
example: there is pleural effusion over the left lower zone evidenced by reduced chest expansion,
decreased vocal resonance & fremitus, stony dull notes and reduced breath sounds over the left
lower zone.
3. General examination
A. Upper limbs - examine both sides
i. Palms
- Moisture - dry @ moist
- Temperature - warm @ cold
- Colour - pink @ pale
*note: Some GIT cause of anaemia
a. gastrointestinal blood loss (e.g.; tumour, ulcer, etc)
b. malabsorption (e.g.; folate, vit. B 12,)
c. haemolysis (e.g.: hypersplenism)
d. bleeding disorders (clotting abnormalities in chronic liver dss)
e. chronic dss
- palmar erythema
*note: causes of palmar erythema
1. physiology
- pregnancy
- puberty
- familial
2. pathology
- chronic liver dss
- rheumatoid arthritis
- thyrotoxicosis
- oral contraceptive pill
- polycvthaemia
ii. Fingers & nails
- cyanosis - peripheral cyanosis
- clubbing
*note : GI causes of clubbing
a. cirrhosis (esp biliary cirrhosis)
b. inflammatory bowel ds
c. coeliac ds
d. GI lymphoma
e. chronic active hepatitis
D) lower limb
- pitting oedema
Example: The abdomen is not distended moves symmetrically with each respiration. The
Umbilicus is centrally located and inverted. Theres no surgical scar, dilated vein, skin
discoloration and visible peristalsis. The hernia orifices are not intact.
Characteristic features which distinguish between the left kidney & the spleen
c. Murphys sign
- done only if acute cholecystitis is suspected
- 2 methods:
i. the tips of the finger of the right hand are hooked under the right costal margin (9th costal
cartilage) at lateral border of rectus
ii.the left hand hold the abdomen laterally with the left thumb hooked beneath the costa!
margin at the midclavicular line
- then ask the patient to inspire deeply
- if the gallbladder inflamed, the patient will immediately wince with a catch in the breath
Palpate gall bladder
- start from RIF same like liver
- ask pt breath deeply
C. Auscultation
a. bowel sound
- place the stethoscope(diaphragm) to the lower right of the umbilicus
- if present comment on its intensity (normally increased or decreased) character, intensity,
frequency
- comment absent only after listening for 2 minutes with no bowel sound heard
b. renal bruits
place the stethoscope(bell) at the upper left and right of the umbilicus and compress
- sit the patient up and examine the cervical lymph nodes esp. left supraclavicular lymph nodes
(Virchows node) involved with advanced gastric (Troisiers sign) or other gastrointestinal
malignancy, involvement of these nodes gives a hint toward inoperatibility of tumour
- proceed to external genitalia and per rectal examination
1. flapping tremor
2. fetor hepaticus
3. cough impulses
4 supraclavicular lymph nodes
5. external genitalia and per rectal examination
Example: the abdomen is soft and non tender. There was no mass palpable on deep palpation. The liver
was palpable 3 cm below the costal margin, it was firm in consistency, smooth in surface, well defined in
margin, non tender and non pulsatile. There was no bruits heard. The spleen and kidneys were not
palpable. Shifting dullness was negative. The bowel sounds were present and normal intensity. There
were no renal bruits.
3. General examination
A.Upper limbs - examine both sides
i. Palms
- Moisture - dry @ moist
- Temperature - warm @ cold
- Colour - pink @ pale
i. CN I (Olfactory):
Sensory only, not routinely tested
Asked if patient have noticed anything abnormal about their sense ofsmell
Test by using bottles containing coffee or pepper mint (Close one nostril while the patient sniff
with the other)
ii. CN 2 (Optic):
Sensory only, 5 components
Visual acuity:
- ask patient to read some letters from a hand held eye chart (with glasses if normally worn).
Test each eye separately.if severe deficit, acuity is reported as counting fingers, seeing hand
movements or perception of light.
Color vision
Visual field (Confrontation)
- test each eye individually. Remove patients eyeglasses first. Make sure your eyes are on
same level as patients. Both cover one opposing eye with one hand. Move a red hat pin from
beyond your visual field inwards and ask the patient to tell you when they can see them;
Check each quadrant. Map the blind spot by asking about the disappearance of the pin around
iv. CN 5 (Trigeminal):
Sensory and motor motor nerve
- sensory: sensation to face (ophthalmic, maxilary and mandibular branches)
- motor: muscle of mastication (temporalis, masseter and pterygoid muscles)
4 components:
1. facial sensation: test sensation in distribution of each division comparing with the other
(pin prick for pain and cotton wool for light touch). Map out the sensory deficit if present
and test from the abnormal to normal region
2. corneal reflex
3. motor supply to mastication muscles: look for any wasting of temporal and masseter
muscles. Ask patient to clench teeth and palpate for contraction of the masseter and
temporalis muscles. Ask them to hold the mouth open while you try to push it shut.
Protrusion of jaw is by the pterygoid muscles and can be assessed against rsistance.
4. jaw jerk: increased in pseudobulbar palsy, decreased or absent in bulbar palsy
v. CN 7 (Facial):
Sensory, motor and parasympathetic supply:
- sensory sensation of taste from floor of the mouth, soft palate and anterior 2/3 of tongue;
somatic sensation from external auditory meatus and back of ear
- motor supply muscles of facial expression
- parasympathetic: supply saliva and lacrimal gland
3 components:
1. motor supply to facial muscle:
a) inspection, look for symmetry of face, flattening of nasolabial fold and drooping from the
corner of the mouth
b) ask the patient to wrinkle his forehead by Iooking upwards while you try to feel the muscle
strength (frontalis), close eyes while you attempt to open them (orbicularis oculi), blow the
cheeks oUt while you press the cheeks (buccinator) and show the teeth (orbicularis oris)
vi. CN 8 (Vestibulotrochlear):
Sensory to utricle, saccule and semicircular canals (vestibule) and organ of Corti (cochlear)
Ask if the patient has noticed any difficulty in hearing
Whisper in front of each of the patients ears while occluding the other and ask if she or he can hear it
and repeat on the other side
If grossly defect, proceed to Rinnes and Webers test to differentiate between conductive and nerve
deafness
viii. CN 11 (Accessory):
Cranial root provides the motor supply to some muscles of soft palate and larynx.
Spinal root provides the motor supply to trapezius and sternocleidomastoid muscles.
Ask patient to shrug shoulders and test against resistance
Ask patient to turn his/her head to each site and test against resistance while feeling it bulk
(sternocleidomastoid).
ix. CN 12 (Hypoglossal):
Provides motor supply to styloglossus, hypoglyssus and all intrinsic muscles of tongue.
Inspect for wastjng and fasciculation in lower neuron lesion.
Ask the patient to protrude tongue, if there is unilateral Iesion, the tongue will deviated towards side of
lesion
C. Upper limb
1. Motor system (IPT PRC)
a. Inspection (SSS WAA DF):
-skin
-scar
-symmetry
-wasting
-attitude and posture
-abnormal movement
-deformity
b. Pronator drift
Ask patient to hold his/her arms outstretched with palms facing upwards then ask patient to close
their eyes
The weak arm gradually pronates and drifts downwards
Only 3 causes:
1.upper motor neuron lesion (pyramidal)
2. cerebellar disease (hypotonia)
3.loss of proprioception
c. Tone
Ensure the patient is relaxed
Assess tone by:
1. rotation, supination and pronation of elbow joints
2. flexing and extending elbow and wrist joints
Decide if tone is normal, increased (hypertonic) or decreased (hypotonic)
Increased tone could be: clasp knife, lead pipe or cog wheel
d. Power
Compare muscle power of one side to other of each group
When testing muscle groups, think pf root supply and nerve supply
Grade the power (0-5), testing the following movements:
I. shoulder abduction and adduction
II. flexion and extension of arm
Ill, elbow flexion with hand fully supinated and with the hand in mid position
IV. elbow extension
V. fingers flexion and extension
VI. fingers abduction and adduction
VII. thumb opposition
VIII. hand grip
e. Reflexes
Make sure the patient is resting comfortably
If absent, test again following reinforcement maneuver (e.g. clenched teeth)
Record the reflexes with number of +, from 0 (absent reflex) to +++ (exaggerated reflex and
clonus)
3 jerks to be tested:
i. biceps jerk (C5, C6)
ii. triceps jerk (C7,C8)
iii. Supinator jerk (C6,C7)
f. Coordination
Mainly to test cerebella function (coordination voluntary movement)
Can do these either now or at the end of the examination
3 test:
i. finger nose test: look for intention tremor and past pointing
ii. rapidly alternating movements: slow and clumsy in dysdiachokinesia (inability to perform rapid
alternating movements)
iii. rebound
2. Sensory system
a. Pain:
- Test lateral spinothalamic tract
b. Light touch:
- Posterior columns and anterior spinothaIamic tract
- With similar manner, testing by touching the skin with a wisp of cotton wool, ask the patient to
shut the eyes and say yes when the touch is felt.
d.Vibration:
- Posterior column
- Place a vibrating tuning fork (128Hz) on a bony prominence, e.g. radius and ask if the patient can
feel vibration
- Vibration test is of value in the early detection of demyelination disease and peripheral
neuropathy
e. temperature:
- lateral spinothalamic tract
D. Lower limb
1. Motor system( IT PRC)
a. Inspection: (SSS WAA DF)
b. Tone and cIonus
- Tone: relax the patient,then:
i. alternately flex and extend knee joint
ii. roll the patients leg from side to side
iii. flex and extend the ankle joint
- Clonus of ankle and knee: presept in upper motor neuron lesion due to hypertonia
c. Power:
- test the following movements
i. Hip flexion and extension Hip flexion - psaos, iliacus (L2, L3)
ii. Hip abduction and adduction Hip extension gluteus maximus (L5, S1, S2)
iii. Knee flexion and extensipn Hip abduction gluteus medius, minumus, tensor fasciae latae
iv. Dorsiflexion and plantar flexion (L4,L5,S1)
v. Toe extension and flexion Hip adduction adductor longus, brevis, magnus (L2,L3,L4)
d. Reflexes:
- Knee jerk: L3, L4
- Ankle jerk: S1 ,S2
- When it is absent, ask the patient to clench teeth or try to pull clasped hands apart (Jendrassiks
manoeuver)
- Babinski reflex (L5,S1 ,S2): extension of big toe indicates an upper motor neuron lesion
e. Coordination: heel shin test
2. Sensory system:
- Test pain, light touch, joint positiOn and vibratiOn sensation as in the upper limbs
B. Head:
a. Eyes:
Jaundice?
Anemia?
b. Mouth and tongqe:
Tongue: moist, dry or coated?
Central cyanosis
Glossitis: in iron deficiency anemia and megaloblastic anemia
Angular stomatitis: in Vit B6, B12, folate and iron deficiency anemia
hypertrophy of gums: in acute monocytic leukemia and scurvy
gum or mucosa bleeding: petechiae, telangiectasia
Mucosa ulceration
Tonsillomegaly and adenoid enlargement (Waldeyers ring): involved in lymphoma
c. Face
Frontal bossing
Plethora: in polycythemia
3. Small:
Above causes
Infection: infection mononucleosis, hepatitis, infective endocarditis, TB, brucelliosis, schistomiasis
Hemolytic anemia
Megaloblastic anemia
Connective tissue disease: SLE, rheumatoid arthritis
lnfiltration:amyloidosis, saccoidosis
Others: myeloproliferation disorders, polycythemia rubra vera, essential thrombocytopenia
*Extra:
Look for proximal myopathy by asking the patient to stand up from squatting position
Look for neurological features are suspected, e.g. cranial nerve lesions, cerebellar, ataxia etc.
Urine dipstick for proteinuria, e.g. in neprhotic syndrome
*note: Long term effects of steroid therapy (check these features during physical examination)
1. Gushing appearance moon like faces, central obesity and thin limbs
2. Bruising and poor wound healing
3. Proximal myopathy
4. buffalo hump
5. bony tenderness and pathological features in osoporosis
6. psychosis
7. acne and hirustism
8. purple striae
9. edema: due to sodium and water retention
10. peptic ulceration
11. hypertension, aldosterone effect
12. DM, due to steroids which are diabetogenic
13. Avascular necrosis of femoral head
3.General examination:
A. Upper limb:
a. palms
- warm or cold?
- dry or moist? (warm, moist and sweaty in thyrotoxicosis, cold and abnormal dryness and
coarseness of hair, difficulty in swallowing in hypothyroidism)
- pink or pale?
- palmar erythema? Present in thyrotoxicosis
- jaundice? (hypocarotenarmia in hypothyroidism)
b. fingers and nails
- peripheral cyanosis
- thyroid acropathy (clubbing)
- Fingers clubbing might be rare manifestation of thyrotoxic Graves disease
- onycholysis (plummers nail, separation of the nail from its bed d/t sympathetic activity, other
causes are fungal nail infection ,psoriasis and trauma)
- tingling sensation in hypothyroidism
c. pulse
- rate
- rhythm
- volumn
- collapsing pulse?
d. wrist
- tap over the flexor retinaculum for Tinels sign (carpel tunnel is thickened in myxoedema)
e. reflex
- biceps (hyperreflexia in thyrotoxicosis, normal contraction followed by delayed relaxation in
hypothyroidism)
f. BP
g. Tremor
- ask the pt to straight out the arms in front and spread the fingers
- rest a piece of paper on the hands to highlight the tremor more clearly
- fine and high frequency tremor in thyrotoxicosis
h. proximal myopathy (in active disease or steroid treatment)
- abduction of the shoulder jt and tested against resistence
c. Ophthalmoplegia:
i. Weakness of ocular muscles due to edema and cellular infiltration of these muscles
ii. Most often the superior and lateral rectus and inferior oblique muscles are affected
iii. Paralysis of these muscles prevents the patient to looks upwards and outwards
d. Chemosis:
i. Edema of conjunctive
ii. The conjunctiva becomes edematous, thickened and crinkled
iii. Caused by obstruction of venous and lymphatic drainage of conjunctiva by increased retro-
orbital pressure
B. Palpation:
Inform the patient what you are going to do
Begin the palpation from behind
Thumbs of both hands are placed behind the neck and outer 4 fingers of each hand are
placed on each lobes and the isthmus
C. Percussion:
Percuss over the swelling
Percuss over the manubrium sternum to exclude retrosternal goiter
D. Auscultation:
Listen over each lobe for bruit: increased vascular supply in hyperthyroidism or usage of anti-
thyroid drug
Pembertons sign:
ask the patient to rise both arms as high as possible, look for sign of congestion (plethora),
cyanosis, respiratory distress, in respiratory stridor, neck veins distension
a test for thoracic inlet obstruction due to retreosternal goiter
C. Evidence of metastasis
If carcinoma is suspected
Besides cervical lymph nodes, also look for bony, lung etc metastasis
3. General examination
A) inspection:
- ask the pt to stand up
- kneel down in front of pt
- always examine both sides
- ask the pt to cough until the size of the swelling becomes mximum
- carefully inspect for few seconds
- observe the following features:
1. position and extent
- left or right, or both?
- inguinal, inguinal-scrotal (swelling in inguinal region extend down into the scrotum, or labia majora)
or scrotal region?
- is the swelling in the groin above or below the inguinal legament?
2. overlying skin
- reddened?
- discoloration?
- ulceration?
- dilated vein?
- surgical scar?
3. peristaltic movement?
4. cough impulses
- ask pt to turn his face away from the examiner and cough
- observe if the swelling expends with coughing
- presence of expansile cough impulse is almost diagnostic of a hernia, but absence of this sign
does not exclude it (impulse on coughing will be absent in case of strangulated hernia,
incarcerated hernia and when the neck of the sac becomes blocked by adhesions)
B) palpation
- kneel down at the side of the pt, on the same side as the hernia
- ask the pt if and where is any tenderness and examine with this in mind
1) the lump
- size
- shape
- surface (smooth, nodular etc)
- margin (well or ill confined)
- consistency (soft, hard or firm)
- tenderness
- temperature
- relation to overlying skin
- trans-illumination test (to exclude hydrocele), by place the pen torch laterally over the lump
- to get above the swelling, to differentiate a scrotal swelling from an inguinal-scrotal swelling (hernia)
or rarely an infantile hydrocele
3) Brodie-trendelenberg test:
lie the patient down, elevate the limb to empty the veins, then apply tourniquet or press
over the saphenous opening and then ask patient to stand up again
5) Pratts test:
this test is performed to know the position of the leg perforators
An elastic compression bandage (Esmarch) is applied from toe to upper thigh which cause
an emptying of varicose veins
Then a tourniquet is applied at the upper end of the compression bandage
While the tournique in place, the compression bandage is unwind in a downward direction
A blow-out will appear at the site constant perforator, indicated incompetent perforator
7) Fegans method:
With the patient standing, mark the veins (ask the patients permission 1st), then with the
patient lying down, elevate the limb to empty the vein
Palpate down the course of the vein and locate the gaps or pits in the deep fascia which
transmit the incompetent perforators
Auscultation:
Listen for venous hum: can be heard at the saphena varix in severe cases
Continuous bruits: in anterior- venous fistula causing varicosities
Dorsal aspect
- wrist
- skin : scar, redness, atrophy, rash
- swelling : distribution
- deformity
- muscle wasting, hollow ridges, btw metacarpel bone
Examination of hands
- feel and move passively
- wrist, MCP, DIP, PIP
- Synovitis
- effusion
- range of movement
- crepitus
- ulnar styloid tenderness
Palmar surface
- palmar tenderness by open close examiner hand with pts hand
- 30s tingling in carpal tunnel synd?