INTERNAL STATUS

▸ Conciousnes : Compos mentis

▸ Level of consciousness Compos mentis 15-14

based of GCS remain Apatis 13-12

Delirium 11-10
Somnolen 9-7
Stupor 6-4
Coma 3

▸ The level of consciousness is examined by Glassgow Coma Scale (GCS) Score. GCS
Score is contain with 3 components, they are eye, verbal and movements which must be
done by order due to its importance.

Score (E) Eye Response (V) Verbal Response (M) Motoric Response
(Opening)
1 No Response No Response No Response
2 To Pressure (to pain) Incomprehensible Abnormal Extension
sounds
3 To Sound (to speech) Inappropriate Abnormal Flexion
4 Spontaneously Confused Flexion withdrawal from
pain
5 - Oriented to time, place, Moves to localized pain
person
6 - - Obeys commands

▸ Vital Sign

▸ Blood Pressure : 120/80 mmHg, left arm, sitting position, appropriate cuff
size
 Systolic blood pressure (the upper number) indicated how much pressure
the blood is exerting againts your artery walls when the heart beats
  Dyastolic blood pressure (the lower number) indicated how much pressure
the blood is exerting against your artery walls when the heart is resting
between beats
 Pulse pressure is the systolic pressure minus the diastolic pressure. If the
aorta becomes rigid in conditions such as artheriosclerosis or
artherosclerosis, the pulse pressure would be very high.
• Low if its lessthan 25% of the systolic valve, cause may because of
low stroke volume, a sign of congetive heart failure and or
cardiogenic shock.
• High, because of the stiffness of the major arteries failure, aortic
regulation, (a leak in the aortic volume), arteriovenosus
malformation, hypertiroidism, or some combinations of those
illness
Based on JNE 8, the increased of blood pressure can be classified :
Blood Pressure Sistole BP (mmHg) Diastole BP (mmHg)
Classification
Pre Hypertension 120-130 Or 80-89
Stage 1 Hypertension 140-159 Or 90-99
Stage 2 Hypertension >= 160 Or >=100

▸ Heart Rate : 80 x/minute, regular, filling and tention enough

 Rhytm : a normal pulse is regular in rhytm and forte. An irregular pulse
maybe due to a sinus arrhythmia, ectopic beats, atrial fibrillation, paroxysmal
atrial tachycardia, atrial flutter, partial heart block, etc. Intermittent dropping
out of beats at pulse is called ‘Intermittent Pulse’. For example of regular
intermittent (regularly irregular) pulse, includes pulses trigeminus, second
degree atrial ventricular block. An example of irregular intermittent pulse is
atrial fibrillation.
 Volume : the degree of expansion displayed by artery during diastolic and
diastolic-state is called volume.
 a. Hypokinetic pulse : a weak pulse signifies narrow pulse preassure. This
may due to low cardiac output (as seen in shock, congestive cardiac failure
hypovolemia, valvular heart disease (such as aortic out flow tract
obstruction, mitral stenosis, airtic arch syndrome, etc).
b. Hyperkinetic pulse : a bounding pulse signifies high pulse preassure. It
may be due to low peripheral resistance (as seen in fever, anemia,
thyrotoxicosis, hyperkinetic heart syndrome, AV fistula, pagets disease,
beri-beri, liver cirrhosis, increased cardiac output, increased stroke volume
(as seen in anxiety exercise, complete heart block, aortic regurgitation),
decreased distensibillity of arterial system (as seen in atherosclerosis,
hypertension and coarctation of aorta). The strength of
0=Absent; 1=barely palpable; 2=easily palpable, 3=full; 4=bounding
pulse.
 Pattern : several pulse pattern can be of clinically signifies, these includes :
a. Pulsus alternans : an aminous medical sign that indicates progressive
systolic heart failure. To trained fingertips, the examiner notes a pattern of
strong pulse signals a flagging effort of the heart to sustain itself in
systole.
b. Pulsus bigeminus : indicates affair of loofbeats within each heart beats.
Concurrent auscultation of the heart may reveal a gallop rhytm of the
native heartbeats. Example : digitalis intoxication.
c. Pulsus tardus et parvus : also pulsus parvus et tardus, slow rising pulse and
anacrotic pulse, is a pulse with a weak or small (parvus) and late (tardus)
relative to its expected charactheristic its caused by a stiffened aortic value
that makes it progressively harder to open, thus rewiring increased
generation of blood preassure in left ventricle. It is seen in aortic values
stenosis.
d. Pulsus besferiens : an unusual physical finding typically seen in patient
with aortic valve disease. If the aortic value does not normally open and
close, trained fingertips will observe two pulsus tu each heartbeats instead
of one.
 e. Pulsus paradoxus : a condition in which same heartbeats cant be detected
at the radial artery during the inspirational phase and is diagnostic of a
variety of cardiac and respirator conditions of varying urgency. For
example : asthmas, restrictive cardiomyopathy, restructure pericarditis.
f. Tachycardia : an elevates resting heart rate, in general an ECG is recuired
to identify the type of tachycardia, for example : atrial fibrillation, atrial
flutter, SVT, Ventricular tachycardia, ventricular fibrillation.
g. A collapsing pulse is a sign of hyperdinamic circulation :

▸ Respiration Rate: 20 x/menit, regular, symetric, thoracoabdominal type

 Abnormal respiratory pattern :
a. Apneu : absence of breathing
b. Epnea : normal breathing
c. Orthopnea : only able to breathe comfortable in upright positition (such as
sitting in chair) unable to breath while lying down.
d. Dyspnea : subjective sensation related by patient as to breathing difficulty
paroxysmal bocturnal dyspnea-attacks of severe shortness of breath that
wakes a person from sleep, such that they have to sit up to catch up their
breath, commont patient with congestive heart failure (CHF)
e. Hyperpnea : increase depth of breathing, increased volume with or without
and increased frecuency, normal blood present
f. Hyperventilation : over ventilation – ventilation in excess of the bodys
need to CO2 elimination presult in a decreased PaCO2 and respiratory
alkalosis.
g. Hypoventilation : under ventilation – ventilation that is less than needed
for CO2 elimination and inadequate to maintence normal PaCO2. Result
in respiratory acidosis
h. Tachypnea : increased frequency without blood gas abnormality
i. Kussmauls respiration : increased rate and depth of breathing over
aprolonged period of thime in response to metabolic acidosis the body
attempt to blow off CO2 to buffer a fixed acid such as ketones
ketoacidosis is seen in diabetes.
j. Cheyne strokes respiration (CSR) : gradual increased in volume and
frequency, followed by gradual decrease in volume an frequency, with
apnea periods of 10-30 seconds between cycles. Described as a crescendo
– decrescendo pattern, charactherized by cyclic waxing and waning
ventilation with apnea gradually during way to hyperneic breathing. Seen
with low cardiac output state (CHF) with compromised cerebral perfusion.
k. Blots respiration : similar to CSR but Vt is consistant except during apneic
period. Short episodes of rapid, deep inspirations followed by 10-30
second apneic period.
▸ Temperature : 36,5° C, Axilla.
a. Continuous fever : the temperature remains above normal throughout the day
and doesn’t fluctuate more that 1 degree celcius in 24 hours. This type of
fever occur in lobar pneumonia, typhoid, urinary tract infection, infective
endocarditis typhoid, etc.
b. Remittent fever : the temperature remains above normal through out the day
and fluctuate more that 2 degrees celcius in 24 hours. Thy type of fever is
usually seen patient of typhoid infection and infective endocarditis.
c. Intermittent fever : the temperature is present only for same ours in a day and
remains to normal for the remaining hours. When the spike occurs daily, its
voditian, when every alternate day its tertian and when every third day, its
quartian. Intermittent fever seen in malaria, pyemia, septicemia.
d. Septic fever : the body temperature gradually rises to a very high at night and
back to normal in the morning. Septic fever is seen in thypoid fever.
e. Relapsing fever : febrile episodes are separated by intervals of normal
temperature. The fever when occur may lost from 2-9 days and then
 temperature get normal. The fever may relaps after a periode of few days
repeating same cycle. Its typically seen in bacterial infection.

f. Step ladder fever : temperature rise gradually to a higher level with every
spike so tjat new plateau is higher that precesing of just like step ladder.

g. Pel ebstein fever : in this type, there is a regular alternation of recurrent bouts
of fever and afebrile periods. The temperature may be take 3 days to rise,
remains high for 3 days and remits in 3 days, followed by apyremia for 9
days. Caused by : hodgin lymphoma, TBC
 h. Siclic fever : arise in body temperature over several days followed by a fever
free period for a few days then followed by an initial temperature rise.
Example : malaria vivax and ovale

▸ Head
o Head : normocephali (+), trauma (-), deformity (-)
o Eyes : conjungtival anemi (-/-), icterous sclera (-/-), pupil siochor (+), red eye (-
/-)
 Red Eyes
o Nose : deformity (-), secrete (-/-), septal deviation (-), trauma (-), inflammation
(-), nasal flare (-)
o Ears : normotia (+/+), secrete (-/-), inflammation (-), cerumen (+/+)
o Mouth : sianosis (-), drymouth (-), hyperemic mucous (-), Tonsil T1/T1, muscle
paralysis (-)
o Neck : lymphnode enlargement (-), skin decolorization (-), JVP (5±2), mass (-),
scar (-)

• Neck masses due to benign masses

A : parotid gland tumor (pleomorphic
adenoma, warthin’s tumor)
B : parotid gland tumor (pleomorphic
A adenoma, warthin’s tumor) glomus
jugulare (paraganglioma)
C : submandibular gland tumor (pleomorphic
adenoma, warthin’s tumor)
B D : lymphaneitis
E : branchial cleft anomallies, carotid body
C humors (paraganglioma) schwamiomas
D F : thyroglossal duct cyst, laryngocele
G : thyroid cysts, goiter
E FG

• Neck masses due to cancer

A :cancer of nasopharynx, paratiroid
gland
B :cancer involving the submandibular
gland, anterior 2/3 tongue, floor of
mouth gums, or oral cavity mucose
C :lips cancer
D :cancer of the nasopharynx, posterior
scalp, ear, temporal bone, skull base
E :cancer of the oral cavity, pharynx,
tonsil, base of tongue, larynx
A
C F :cancer of thyroid, pyriform sinuses,
B upper esophagus, lung
G :cancer of thyroid
E FG
 • Neck masses due to infection
The vast majoring of infection
causes of neck masses is due to
lymphadenitis, other wise known as
inflammed lymph due to infection
somewhere else in the head and neck
region
A : mastoiditis
B B : parotitis
C : submandibular sialodenitis
A D : branchial cleft anomaly infection
C E : infected thyroglossal duct cyst
F : thyroiditis

E
D
F

▸ Thorax
Cor
• Inspection : deformity (-) scar (-) ictus cordis (-)
• Palpation : ictus cordis is palpable on ICS V linea midclavicula sinistra
• Percution : cor enlargement (-)
• Auscultation : s1-s2 regular (+) heart murmur (-) s3 gallop (-)
Lung
• Inspection : simetrical movement (+) use of acessory muscles (-) trachea
deviation (-)
• Palpation : tactile fremitus (-) movement (-) pain (-)
• Percution : sonor
• Auscultation : vesicular sound (+/+) ronchi (-/-) wheezing (-/-) crepitation (-/-)

▸ Abdomen
• Inspection : swelling (-) scar (-) inflammation (-)
• Auscultation : intestinal murmur (n) 1x/minute
• Percution : tympanic sound (+) in 13 points, liver span (n) 8 cm, spleen
enlargement (-)
 • Palpation : Superficial pain (-), deep pain (-) hepar and lien is palpable (-) skin
turgor(n)

▸ Extremity
General Appearance

Body posture Normal

Abnormal movement -

Walking style Normal

Motoric Upper limb Lower limb

Tonus + +

Trophy Eutrophy Eutrophy

Power of movement 5 5

Clonus - -

Rom Normal Normal

Sensoric Upper limb Lower limb

Fine touch Normal Normal

Crude touch Normal Normal

Vibration Normal Normal

Pain Normal Normal

Temperature Normal Normal

Upper Limb (Physiological Reflex)

Biceps Reflex (+/+)

Identify the location of the biceps tendon
• Allow the arm to rest in ptient arm lap forming on angle sight > 90 of
the elbows
• Make sure the muscles is completely relaxed
• Placed your thumb/ middle finger of contrallateral hand to the patient
( which hold patient arm) on the tendon
• Ask ptient to look on the other side while you stroke the hammer

Triceps Reflex (+/+)

• Identify the location of the triceps tendon
• Make sure the muscles completely relaxed
• Placed your thumb/ middle finger of contra-lateral hand to the patient
( which hold patient arm) on the tendon
• Ask patient to look on the other side while you stroke the hammer

Upper Limb (Patological Reflex)

Hoffman Reflex (-/-)

• Tapping the nail and flicking the terminal phalanx of
the middle or ring finger
• Positive result showed by flexion of the terminal
phalanx of the thumb

Trommer Reflex (-/-)

• Patient finger is partically flexed while you gently hold
their finger, tapping of volar aspect of the middle finger
• Positive result showed by flexion or abduction all four
finger

Lower Limb (Physiological Reflex)

Patella Reflex (+/+)

• After tapping the hammer on patella
tendon, leg is normally extended

Achilles Reflex (+/+)

• After tapping the hammer on achilles
tendon on dorsal maleolus, foot is
normally dorsoflexi

Lower Limb (Pathological Reflex)

Babinsky Reflex (-/-)

• The reflex occur upon strolling of the plantar side with blunt object,
Chaddock Reflex (-/-)
positive result show by dorsoflexion of the hallux
• The reflex occur upon strolling over the lateral malleolus with blunt object,
positive result show by dorsoflexion of the hallux
Gordon Reflex (-/-)
• Squeezing the calf muscles, positive result show by dorsoflexion of the hallux
Oppenheim Reflex (-/-)
• Irritation downward of the medial side of the tibia, positive result show by dorsoflexion of
the hallux
Rosalimo Reflex (-/-)
• Percussion of the ball of the foot, positive result show by plantarflexion of the hallux
Schuffner Reflex (-/-)
• Squeezing / pinching the achilles tendon, positive result show by dorso-flexion of the hallux
 Meningeal Sign
Kernig sign (-)
• Patient was supine with straight extremity behind,
• Tight flexed towards hip and kness 90º, extended lower leg while hold the knee normally
can reach up to 135º
• Positive result showed by pain or resistance before reach 135º
Brudzinsky I (-)
• Patient relax and supine with staright extremity beside,
• Examiner hold patient’s head and flexed till chin reach sternum,
• Neck stiffnes (+) if chin can’t reach sternum,
• Brudzinsky 1 (+) : while flexed the neck, also for lower leg

Brudzinsky II(-)/ brudzinsky contralateral leg sign

• Patient was supine with straight extremity beside,
• flexed of one leg with straight position maximally,
• positive result showed by flexion of contrallateral leg
Brudzinsky III (-)
• Patient was supine with straight extremity beside,
• Press patient’s cheeks/infraorbital bilateral with hand,
• Positive result showed by flexion of both hands
Brudzinsky IV
• Patient was supine with straight extremity beside,
• press os pubic of patient with hands,
• positive result showed by flexion of both legs

Cerebellum Function Examination

• Heal to toe/ tendem gait test(normal)/ walking on staright line

• Romberg test (+) stand with closely foot and close eyes for 30 minutes
• Whist romberg test (+) stand with heel to toe foot and close eyes for 30 minutes
• Dysdiadochokinesis (-) clap with alternating the palmar and dorsal surface of the hand as
fast as possible and repeat with other hand
• Finger to nose (-) nose to nose (-) finger to finger (-)

Mc Murray Testing

 Packing the patient knee supine

 Bringing the knee into full flexion
 Medially rotate the tibia of the extending knee for testing of the lateral meniscus with a
positive shown by there’s a snap of clicking or pain