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Overview : 1. General examination 2. Pulse, BP 3. Neck & Praecordium General examination 1. General inspection: Well/unwell Breathlessness on rest Visible cyanosis Overweight/cachectic BMI Features of Insulin R (Acanthosis nigricans, central obesity) Genetic syn. Down, Marfan, Turner 2. Face: Pallor Conjuntival petechiae Around eyelids xantholesma Tongue & lips central cyanosis Inside mouth ulcers, dental caries Mitral facies rosy cheeks 3. Hands: Tobacco (tar) stains Vasculitic lesions (Olsers, Janeway) Splinter haemorrhages Clubbing early/late Cyanosis 4. Ankle oedema Pulse & BP 1. Radial pulse - rate, rhythm, volume - if bounding, look for collapsing pulse - check both pulses - Radio-radial delay 2. Brachial & Carotid pulses - character 3. Pedal pulses 4. BP - if HTN, check radio femoral delay Neck - JVP measure height from sternal ang. Praecordium 1. Inspection: - visible pulsations (large ventricular/aortic aneurysms) - surgical scars (sternal, left lateral) - abnormal movements - asymmetry in shape of chest (check spine) - chest wall deformities (pectus excavatum) 2. Palpation - Apex beat if cannot feel, ask pt. to roll to his L side. Assess character. - parasternal heave ask to hold breath in Expiration nd - Pulse in L 2 ICS for severe pul. HTN 3. Auscultation: st nd - 1 bell, 2 diaphragm - listen for - apex beat (Mitral) - lower L st.edge (Tricuspid) - upper L st.edge (pulmonary) - upper R st.edge (Aortic) st nd st - 1 & 2 heart sounds (1 with carotid pulse) - look for murmurs & added sounds

Overview: 1. General examination 2. Exam. of neck, chest & back General examination 1. General inspection: Well/unwell Breathlessness on rest Resp. rate (tachypnoea = >13/min) Hyperventilation (rapid, short breaths) Kussmauls breathing (air hunger) Use of accessory muscles (SCM, pectoral & paltysma) Stridor Hoarsness (L recc. Laryngeal N damage) Visible cyanosis Cachexia 2. Face: Conjunctiva - pallor/plethora Tongue & lips central cyanosis 3. Hands: Tobacco stains Clubbing (early/late) Wrist swelling & tenderness (HPOA) Warm hands (CO2 retention) Tremor - fine : with salbutamol - flapping: asterixis 4. Ankle oedema Examination of the neck 1. Inspection: Scars Distended veins JVP Distance b/w cricoids & suprast.notch (Usually 3, hyperinflated less.) Use of SCM & platysma for resp. 2. Palpation: - LN :, submental Submandibular Superficial cervical Supraclavicular Scalene LN Posterior Occipital Post. auricular Preauricular - Trachea : Feel trachea Put finger b/w SCM & trachea to detect deviations Examination of the front of the chest 1. Inspection: Dilated veins (SVC obstruction) Thoracotomy scars Suprasternal, intercostal & subcostal recesses (COPD) Symmetry in shape & movement in breathing (@ the foot of the bed) Shape of the chest - pectus carinatum - pectus excavatum Measure chest expansion (@ nipple level) 2. Palpation: Apex beat (deviation of mediastinum) Symmetry of chest expansion (upper, middle & lower zones, use thumbs) Check vocal fremitus (ulnar border on ICS) 3. Precussion: Compare sides. Upper zone tap clavicle Middle & lower tap finger Go laterally 4. Auscultation: If hairy, use bell. Intensity over 3 zones check similarity. Vesicular & bronchial breathing Added sounds rhonchi/wheezing - crepitations fine / coarse - pleural rub (louder > crepi.) Confirm vocal resonance by saying 99 Whispering pectotriloquy Examination of the back of the chest 1. Inspection: Shape of the chest - barrel chest - kyphosis & scoliosis 2. Palpation: Symmetry of chest expansion (upper, middle & lower zones, use thumbs) Check vocal fremitus (ulnar border on ICS) 3. Precussion: Ask to cross arms in front. (seperate scpula) Compare sides. Go laterally. Median area is full. 4. Auscultation: If hairy, use bell. Intensity over 3 zones check similarity. Vesicular & bronchial breathing Added sounds rhonchi/wheezing - crepitations fine / coarse Confirm vocal resonance by saying 99 Whispering pectotriloquy

Overview: 1. Exam. of higher functions 2. Exam. of cranial nerves 3. Exam. of upper limbs 4. Exam. of lower limbs + gait Examination of cranial nerves 1. Olfactory N: Not routine Check if the nasal passages are clear Eyes closed Close 1 nostril & identify the smell. 2. Optic N: Visual acuity - Snellen Near vision Colour vision not routine Visual field confrontation technique Fundoscopy

Reflexes - corneal reflex (touch a cotton wool on eye) - Jaw jerk (close eyes, open mouth, tap vertically downwards) 5. Facial N: Inspect - symmetry of face - symmetry of nasal furrows Taste - ant. 2/3 of the tongue Motor - wrinkle forehead (frontalis) - close eyes against resistance (orbicularis occuli) - show teeth - blow cheeks against R (buccinator) - purse lips (orbicularis oris) - show lower teeth (platysma) 6. Vestibulococchlear N: Whispered voice - close other ear - @ hands breadth Weber 256 Hz tuning fork @ the middle of the forehead. Rinne - tuning fork first at the mastoid process then in front of the auricle 7. Glossopharyngeal & Vagus N: Open mouth wide, say Ah Watch the symmetrical movement of uvula & soft palate. 8. Accessory N: Look for wasting of trapezius or SCM Ask to shrug against R (trapezius) Turn chin to a side against R (opp. SCM) 9. Hypoglossal N: While tongue is inside the mouth, look for: - fasciculations - wasting - involuntary movement Ask to put out the tongue deviations? Move tongue side to side

3. III , IV & VI N: Inspection - position of eyelids - symmetry of the pupils - proptosis - periorbital oedma Keep head steady, move pen in an H Ask for double vision th Vestibular copm. of VIII N: for nystagmus Light reflex (+ consensual reflex) Accommodation-convergence reflex 4. Trigeminal nerve: Sensory face & tongue (ant. 2/3) - touch, pain & temp.




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Motor - wasting of temporalis - clench jaw (temporalis & masseter) - open jaw against R (Pterygoids) - any deviations jaw when opening

Examination of the Upper limb Overview: 1. Motor system 2. Coordination 3. Sensory system

Compare sides
Motor system 1. Inspection: - Proximal/distal muscle wasting - Hand - dorsal guttering - wasted thenar/hypothenar - If wasted, check for fasciculations - Deformities (wrist drop, claw hand) - Involuntary movements tremor - Pronator drift To detect mild weaknesses. Ask to close eyes & keep both upper limbs outstretched in front. The limb with the weakness pronates & slowly drifts down. 2. Muscle tone: - Ask to relax. - flex/extend/pronate/supinate forearm. - If hypertonic, check for wrist cogwheeling (alternating & tone in Parkinsonism) 3. Muscle power: Grade power (0-5). First ask to move against gravity. If possible, move against R. If not, move after eliminating the G. st 0 Shoulder - 1 30 abduction supraspinatus 0 - @ 90 abduction deltoid keep - External rotation infraspinatus elbows - Internal rotation together - push against a wall serratus ant. (look for winging of scapula.) - put hands on hips, push arms backwards against R (Rhomboides) Elbow - flexion (biceps & brachialis) - extension (triceps) Wrist - flexion & extension Hand - finger abduction (dorsal interossei) - finger adduction (palmar interossei) - thumb abduction (abd. pol. brevis) - thumb opposition (opponens pollicis)

4. Tendon reflexes: Biceps jerk 0 support elbow, flex 90 Triceps jerk Supinator jerk - tap brachioradialis tendon (elbow flexion & flicker of fingers) Coordination Rebound phenomenon ask to stretch arms in front, quickly push hands down & observe returning movement. Test for dysdiochokinesia repeatedly patting palm of 1 hand with palm & back of other hand rapidly. Finger nose test - ask to touch the nose & touch ur finger. Repeat while changing the position of the target finger. Sensation Test for pain, fine touch, & temp. Compare sides, going along dermatomes.

Proprioception - fix distal phalanx of the index finger. Hold distal phalanx by the sides, first show pt. upward & downward movement, then ask to identify when eyes closed.

Examination of the Lower limb Overview: 1. Motor system 2. Coordination 3. Sensory system 4. Observing gait

Coordination: - heel-shin test - Raise 1 leg & place the heel on the opposite knee, & then slide the heel down the shin. - If needed, ask to close eyes. Sensation Test for pain, fine touch & temperature. Compare sides, going along dermatomes.

Compare sides
Motor system 1. Inspection: - Wasting (Quadriceps, peroneal, calf) - If wasted, check for fasciculation - Deformities (club foot, tropic change, ulcers) 2. Tone: - roll leg to & fro. - briskly lift knee into a flexed position (if hypertonic, whole leg will jerk up & slowly lowers.) - If hypertonic, check for clonus; Plantar clonus: - keep fist behind the knee. - push patella down sharply with other hand. - If (+), jerky patellar movement. Ankle clonus: - keep hand behind knee. 0 - rest both knee & ankle in 90 position. - briskly dorsiflex and keep for 2-3 s. - if (+), ankle will jerk for sometime. 3. Power: Hip - flexion, extension, abd, add. Knee - flexion, extension Ankle - dorsiflex, palntarflex, invert, evert Big toe - Dorsiflexion, plantar flexion Grade power (0-5) 4. Reflexes: Knee jerk knee semiflexed. Ankle jerk expose ankle by keeping 1 leg on top of the other. - slightly dorsiflex the ankle. Babinski sign stroke along the lateral border of the sole. Usually, big toe must plantarflex.

Proprioception fix the big toe, hold the distal phalanx @ the sides, move upwards & downwards.

General examination Comfortable/in pain Breathing well/wince during breathing Face - pallor, polycythemia - sclera for jaundice - parotid shading/enlargement - inside mouth (for ulcers) Neck - cervical LN - Virchows N/supraclavicular N enlargement (Troisiers sign) Chest - pigmentation - distribution of hair ( in males?) - spider navei - gynaecomastia (males) Hand - clubbing (in IBD, cirrhosis) - white nails (leukonychia) - palmar erythema - Dupuytrens contracture - Flapping tremor (LF, HL, RF) Leg - ankle oedema - ulcers (chr. haemolytic anaemia) Inspection Foot end of the bed look for abd. distension Distension generalized/localized Umbilicus inverted/everted Surgical scars Striae Distended veins (IVC/portal V ob.) Fat distribution Palpation 1. Superficial palpation: Ask about pain before starting. If pain +, start further away from it. Palpate 9 zones. 2. Palpation for liver: Start from R iliac fossa. Fingers parallel to the inf. border of the liver. Deeply palpate while asking to breathe deeply If enlarged, inf. border will roll under the fingers during inspiration. Cant get above it. Check tenderness (infl.) & regularity Check whether liver has been pushed down by hyperinflated lungs (percuss upper border) 3. Palpation for GB tenderness: th Palpate tip of the 9 rib & ask to breathe. If pt. wince in mid-inspiration (Murphys sign) 4. Palpation for spleen: Start from R iliac fossa. Tips of the fingers in the direction of spleen. Deeply palpate & ask to breathe deeply If enlarged, tip of the spleen will roll under the fingers. Cant get over it. If not sure, ask pt. to turn to the right side, flex L hip & knee, & palpate again. 5. Palpation for kidney mass: 1 hand anteriorly in the lumbar region, other hand directly behind, in the back. Ballot posteriorly placed hand, and feel for a mass under the ant.ly placed hand. Moves with respiration, can get above it. Percussion Percuss from resonance to dullness. Percuss parallel to the border of the dullness. (every direction from the umbilicus) If flank dullness is present, ask pt. to roll to the opposite side while keeping the hand to mark the area of the dullness, then palpate again. If previously dull area is resonant, it is shifting dullness. Fluid thrill in gross ascites keep pt.s ulnar border of the hand on the midline, tap on 1 side of the abd., while palpating other side. Auscultation Listen to bowel sounds (below & left of the umbilicus) Renal bruit - 2cm lateral to the midpoint b/w xiphisternum & umbilicus ask pt. to hold the breath. Listen over enlarged liver & spleen for; Bruit Rub (ask to breathe quietly)