OSCE Clinical Examination Guide

Basic of Clinical
Examination for
OSCE
1
1) Cardiovascular system
a. Physical examinations
b. Blood pressures
c. JVP and its concept
d. Peripheral vascular disease
e. ECG* and murmurs
2) Respiratory system
a. Physical examinations
b. Peak flow meter
3) Hematological system
a. Cervical / Neck
b. Axillary
c. Inguinal
4) Gastrointestinal system
a. Abdominal examination
b. Fluid thrill & shifting dullness
c. Examination for hepatosplenomegaly
d. Per rectum
1) Endocrine system
a. Diabetes
b. Thyroid gland (hyper & hypo thyroidism)
2) Reproductive system
a. Breast examination
b. Pelvic examination (PAP smear)
c. Gestational examination
3) Renal system
4) Musculoskeletal system
a. Shoulder
b. Hip
c. Spine (plus neck)
2
Semester III
Semester V
5) Nervous system
a. Motor
b. Sensory
c. Cranial nerves
3
HISTORY TAKING
History Taking
4
Personal details
1) Name
2) Age
3) Address
4) Occupation*
5) Religion / race
6) Marital status
Past medical history
1) Hospitalization
a. Year
b. Reason for admission
c. Diagnosis
d. Where / medical center
e. Duration of stay
f. Treatment
2) Surgery
a. Diagnosis / reason for
surgery
b. Year
c. Where / medical center
d. Treatment
3) Long standing illness
a. Year & how long
b. Diagnosis
c. treatment
4) Allergy
a. Type of allergy
i. Drugs
ii. Food
iii. Animal
iv. Others
b. What happens when in
contact (reaction) with
the allergens
Social history
1) Smoking
a. How many per day
b. How long the patient
have been smoking
2) Alcohol
a. Type of alcohol
b. How much
c. How long has the patient
been drinking
3) Home
a. Type of housing
b. Environment
4) Work
a. Working environment
b. Stress levels at work
5) Diet
a. Meal habits
b. Type of food
6) Hobbies
a. Exercise
b. Any other activities
Family history
1) Must cover 3 generation
a. Parents
b. Siblings
c. Wife/husband
d. Children
2) If alive
a. Age
b. Major illness
3) If passed away
a. When
b. Why
5
Always follow sequence
1-Personal details
2-Presenting complaints
3-Past medical history
4-Social history
5-Family history
6-Drugs history
*always use open ended questions
**systemic history for SEM 5
History of
presenting illness
(HOPI)
GENERAL
I. Onset
II. Site / character
III. Aggravating / relieving factors
IV. Timing progression, duration,
time of the day
V. Severity
VI. Associated symptoms
VII. What have you done about it?
VIII. medication
Pain (chest / abdomen)
=SOCRATES
1) Site
2) Onset
3) Character
4) Radiation/spread
5) Associated symptoms
6) Timing
7) Elevating/relieving factor
8) Severity
*further explanation will be at The 15
wisdom of Dr. Htin Aung >>>
Shortness of breath (SOB)
1) Onset
2) Duration
3) Progression
4) Aggravating / relieving
5) Severity? Affecting sleep?
Cough
1) Productive/non productive
2) Intermittent / continuous
3) Time of the day
4) Blood
5) Severity
6) Aggravating / relieving factors
7) Progression
Sputum
1) Amount
2) Volume
3) Color
4) Smell
5) Consistency
6) Blood
Stool / Vomitus
1) Amount
2) Volume
3) Color
4) Blood
5) Smell
6) Consistency
Constipation
1. Frequency
2. Feeling of incomplete evacuation
3. Consistency of feaces
4. Acute / chronic
5. Associated symptoms pain,
bleeding.
6. Time spent straining
7. Stool?
8. Aggravating / relieving factors
Diarrhea
1. Everything about stool,
especially on consistency
2. Frequency
3. Urgency of defecation
4. Abdominal pain
5. Aggravating / relieving factors
6. Severity
Dysphagia
1. Liquid / solid
2. Painful
3. Regurgitates? Into nose?
4. Where (specific location) the
food sticks
6
The History THY FORMAT
from Dr. Htin Aung
1) Site : site of pain
2) Duration :
a. /12 (month)
b. /7 (days)
c. /24 (hours)
d. /60 (minutes)
3) Onset : rate of s/s comes / spread
a. Sudden: - vascular
- injury
- mechanical
b. Slowly : - infection
- metabolic
- endocrine
4) Triggers : what cause the pain
5) Progression: getting worse, comparing workload.
6) Timing : intermittent / continuous (if intermittent, ask how long the pain last and
how long rest needed)
7) Character :
a. Stabbing
b. Crushing
c. Gripping
d. Shooting ; e.g. headache
e. Sharp tearing ; inflamed, sliding, pleurae, two surface sticking
f. Burning pain ; chemicals (gastric acid in the esophagus)
g. Cramping
h. Colliding ; GIT, colon, esophagus, urinary tract
i. Dull aching ; organs with coverings
8) Frequency
+ How often?
+ Increase lately?
+ Time of the day?
+ Etc
9) Severity : mild / dull
+ B/D o NE
+ B/D o E
+ B/D o R
+ B/D o less exertion than normal
7
IHD
Breathlessness
Dyspnoea
On
Exertion/Non-exertion/Resting
MI: >10min
AP: 5-10min
10) Spread :
11) Implication:
a. Weight
b. Work
c. Appetite
d. Sleep
e. Micturation
f. Bowel
12) Aggravating factor
13) Relieving factor
14) Seen other doctors
8
IHD
- neck, jaw, left arm
- nerve cardiac plexus C4-T1
- REFERRED PAIN
CVS RESPIRATORY
Complaint: Chest tightness SOB:
Dyspnoea, Orthopnea, Paroxysmal
Nocturnal Dyspnoea, Palpitation, Chest
pain.
Heart failure: ankle edema, Cough, SOB
PAD / PVD Intermittent claudication
(claudication distance for PAD)
Epistaxis, hemoptysis, SOB, cough, sputum
color
Asthma, Smoking
Wheezing due to narrowed airway
DD for Supra-clavicular swelling
Metastasis: solid, hard, fixed
Infection: warm, tender
Lymphoma: firm
1. Rheumatic fever
Sore throat (relapsing RF)
Fever, sweat ,chills ( exposure to rain)
Relieve: panadol
Worries: excessive sweating,
embarrassing history of RF, check
family
1. TB:
Productive cough, high fever with night
sweats, wt loss, lymphadenopathy,
decrease appetite
Investigation: AFB culture, CXR,
Mantoux
2. IHD (Angina Pectoris)
Pain: Location, Radiation, Duration,
Exertion, Frequency, Progression,
Severity, Precipitating Factors
Risk: F/H, Diet (hi salt / fat), exercise,
stress, smoke and alcohol. E.g.:
2. Pneumonia
SOB
Sputum: color, consistency, volume,
blood, frothy
Relieve, aggravator
Investigation: Sputum culture, PBS.
X-ray
Heart (boot shaped) Tetralogy of Fallot
Cardiophrenic angle
Costophrenic angle
Kerley B line (heart failure)
Air fluid level (pleural effusion)
Pneumoconiosis
TB coin lesion, consolidation and cavitation
Renal IVP - hydroureter, calculi
Fracture - colles (radial bone), dinner fork
Osteoarthritis - osteophyte
Osteosarcoma - sunburst
Rheumatoid arthritis - Pannus
Past 3mth Past 1wk
Severity Can do work Crushing,
limited
activities
Frequency Twice a wk everyday
Precipitating
factors
Carry >20kg Carry >5kg
climb 3 stairs
3. Peripheral Arterial Disease (PAD)
Pain and cramp at unilateral limb
Aggravate: walking claudication dist
Relieve: sit down, rest
F/H of arterial disease: HT, Heart
attack
Worry: unable to move leg anymore
Systemic review: over wt
Actions: Low fatty diet, light exercise,
decrease smoke and wt
Not PVD as PVD has edema, warm,
and pain anytime.
HAEMATOLO GIT
9
GY
Bleeding disorder
Haemophilia A/ B
Malabsorption/Gastrectomy: IDA
Vegetarian/ Pernicious anemia: B 12 def
Folate: no vegetables, pregnant
Iron: Vegetables and liver and meat
Malaria
Hodgkin lymphoma: Reedsternberg cell
(owl's eye)
1. Peptic ulcer (benign)
Clinical indication: Pain aggravate by
eating (Gastric Ulcer) Relieve by eating
(Duodenal Ulcer)
Relieve: Biscuits, Antacid
Aggravate: hard liquor, smoking, stress,
NSAIDs
Assoc symptoms: dyspepsia, vomiting,
nausea, diarrhea, melena, blood in vomit
F/H
1. Hemophilia A / B (A more common)
-X-link recessive
Pain of knee, swelling, hemoarthroses
Significant Past medical history
Profuse bleeding on tooth extraction,
wound Hemoarthoses, hematoma,
bruise
PT, BT norm, APTT prolonged
F8/F9 assay
F8/9 concentrate
3 Cx of ulcer
Perforation => peritonitis
Bleeding of stomach => hemorrhage
Cancer
2. Hernia
Occupation: wt lifter, pregnant
Sign: swelling in left groin, size, pain,
radiation
Aggravate: wt lifting, standing up, cough
Relieving: lie down
Risk factor, chronic coughing,
constipation, obesity
2. Lymphoma with metastases to bone
Pain in left leg
Other: swelling of painful leg,
swelling n lump at groin area,
Polyuria, Polydipsia
(due to Na, Hypercalcemia, Sugar in
DM) F/H Leukemia
Ix: BM aspiration, BM trephine
biopsy, Serology
3. Cholecystitis
Aggravate: Fatty food, egg
Associated symptoms: nausea, burping,
indigestion, fever, diarrhea, vomiting
3. Haemolytic Anemia with pneumonia
Yellow eye (pre-hepatic jaundice) Cough,
with bloody, yellowish phlegm
Aggravate by cold relieve cough syrup
and antibiotic,
Assoc symptoms: fever, muscle ache,
tiredness, SOB
Causative organism atypical mycoplasma
pneumonia
Ix: Sputum culture, PBS, Coombs test,
serology. Test for blirubin
4. Colorectal Cancer:
Wt loss, appetite, bowel habits, nature of
stool, strain and pain (tenesmus)
What he done, laxative (useful?)
Risk factor: F/H altered bowel habits, wt
loss, age
Left side: Constipation, blood in stool
Right: IDA, diarrhea, melena
5. Diarrhea
Food poisoning Melena / hematemesis
Hernia (Inguinal (direct/indirect),
umbilical. etc)
Environment clean food / water supply
Palpable LN: question to ask
How long? Lump changed size? Painful?
Lost wt? Generally well?
10
ENDOCRINE RENAL
1. Hypothyroid
Afraid of cold, gain wt, depression,
croaky voice (hoarseness),
menorrhagia Aggravating for
hoarseness: sour food
Myxoedema (legs fatter)
Common cause: iodine deficiency,
Hashimoto's thyroiditis
Urination (further refer to paper)
When's last time
when started, for how long
Frequency
Nocturia (Sleep Disturbed)
Quantity (normal l500ml, Polyuria,
Oliguria <500m1; Anuria negligible)
Retention, Hesitancy
Incontinence (Urge. Stress-cough,
sneeze, laugh)
Pain? (Dysuria, Strangury, Renal colic)
Radiation?
Color (tea colored blood-hematuria)
Smell ( pungent- ammoniacal)
Males:
Hesitancy, Post Micturation dribbling,
incontinence, sexual function, impotence,
Urgency (BPH)
Females:
Stress incontinence
Menstrual and obstetric History
Sexual Function=> UTI, dyspareunia
Systemic:
Headache / fever (UTI)
Sleep disturbance due to nocturnal
Work condition (with lack of water)
Renal Calculi -
Eg. Drink too much mineral water as work
require on the go. Pain from loin to groin, hi
uric acid level. Hematuria.
Prostate Problem that caused the urgency.
IX: FBC, UFEME, X-ray KUB, Ultrasound.
IVP Urine sample: Casts, Crystals, Pyuria,
and Protein.
Uraemia
Weakness, lethargy, oedema, proteinuria,
HT, uraemic frost.
2. Hyperthyroid
Intolerant of heat, lost of wt, increase
appetite, irritable, tearful
Palpitations, Diarrhea, amenorrhoea
3. Diabetes
Very thirsty, Polyuria, polydipsia,
nocturia (disturbed sleep)
Diminished sensation (numbness),
muscle wasting, vaginal discharge
( immunosuppressive - candida)
diabetic retinopathy (blurred vision),
nephropathy metformin / insulin
(injection or oral or both)
Inquire more on drugs, compliance,
and latest blood glucose level and
check up. F/H
Pregnant mother: big babies
4. Cushing
Truncal obesity, thin skin, bruising,
pink/purple striae, HT, Proximal
muscle weakness
5. Acromegaly (pit adenoma)
Complaint: headache, vision affected,
bitemporal hemianopia
Change in appearance: big hands / feet
/ macroglossia, oily skin, dentures not
fitting. excessive sweating
+ve symptoms: visual deterioration
(double vision)
6. Prolactinoma
Complaint: white watery discharge
from breasts
Assoc symptoms: headache; irregular
period, amenorrhea.
Ix: MRI, CT scan of pit gland, Serum
PRL level
11
Menarche ( primary amenorrhea)
Cycles, days, heaviest on when
Regular/Irregular (can predict?)
Flow (no of pads/soak/half soak)
-menorrhagia, oligomenorrhea clots, spotting
Pain - Dysmenorrhea e.g. endometriosis
Associated Symptoms: Nausea, vomiting,
headache, diarrhea, water retention, pelvic
congestion, breast tender and swelling
Tx: Diuretics (congestion),
NSAIDS(mediators), diazepam(nerve)
ED: duration. onset, progress, severity, freq,
- Implication: depress, suspicion,
stress/affect at work, wife, sad,
frustration,
- His own remedy: Viagra, porn,
- Risk: HT, diabetes, psychology, drugs(b-
blocker, Heart disease), SID,
- Ask about size, swelling of
scrotum/penis if present.
- Other symptoms swelling of legs,
fatigue, weakness, anemia
SEXUAL HX
- Dyspareunia e.g. endometriosis
- Itchy (pruritus), Rash, Discharge
- Blood: menstruation, miscarriage, cancer,
cervical erosion/polyps
- Purulent: Vaginitis, cervicitis,
endometritis, retained tampon
T.vaginalis: frothy, watery, pale, yellow white
discharge
Candida (white thrush): thick cheesy, with
excoriations and pruritus
Case:
Leucorrhea, foul smelling, pruritis,
embarrassing
Associated symptoms: burning urination,
fever, dyspareunia, dysuria, spotting, lower
abdominal pain.
- Infertility (PRL), Lower abdominal pain
( PID, ectopic pregnancy)
- Sexual activity, Contraception
- Approach: explain, confidentiality, Have
Boyfriend before? Husband? Are u very
close/intimate with him/her? Is it a sexual
relationship? Sexually active? Is it
protected? What type of protection? All
the time? If not, r u sure he his your only
partner?
Man: Penis discharge, ulcer Non painful
(syphilis) burning sensation urinating
(gonorrhea)
OBSTETR1C HX - "I think I'm pregnant!"
l. Amenorrhea: LMP, EDD
Sickness (nausea/vomiting) marked at 12-21
wks, maybe precipitated by strong odors. So
don't get near
2. Sickness (nausea/vomiting) Marked at 12-21
wks
3. Breast:
Breast tenderness (tingling-frank pain)
Engorgement
Enlargement of Montgomery's tubercles (6-
8wks of gestation)
Colostrum at 16th wk
4. Quickening (1
st
perception of fetal
movements)18-20 wks in primigravidas, 1 mth
earlier in multiparas
5. Urinary
Frequency (norm 3-5/day and 1/night)
Nocturia, as increase intra-abdominal pressure
Mom:
- How many children their gender, birth wt,
breast feed? Complications of pregnancy.
Need to know each & every one.
- Antenatal care booking;
4 wks =0-32 wks 2 wks = 32-36wks Weekly
after that
- Problems with pregnancy
- Color coding: red, yellow, green, white
- Diet (Ca, Fe, Folate)
- Health (DM, HT, preeclampsia)
*glycosuria; SBP>30; DBP >15
- Fetal movement. Abortion/Full term
- Delivery types- vaginal/caesarian /assisted
- Complications
- Health of Baby, antenatal/postnatal
- Immunization of baby/mother HIV, Hep B
- Eg.G3P2Al.
P is viable birth 22 weeks, before that is A
12
MSK
13
Age:
ElderlyCOA
YoungCRheumatoid, Ankylosing
Spondylitis
Gender: MC AS, FC RA
Onset/Duration:
SuddenCdisc prolapsed
AcuteCacute osteomyelitis, septic
arthritis SA
InsidiousCOA, AS, RA
Site:
Large wt bearing joint(hip/knee)COA
Small joint (wrist, MP, PIP) C RA
Low backCOA, AS
Sacro-Illiac jointC AS
Big ToeCGout
Progression, Swelling
(infection/inflammation)
Symmetrical involvementCRA
Radiation: hip-knee. Sciatica-post
thigh
Char:
ThrobbingCSA, AOM, acute
hemathrosis,
Dull acheCOA, RA
Shooting sciaticaCPID
Night criesCTB, malignant tumor
(due to release of protective muscular
spasm at night)
Painkiller, Frequency
Severity:
Very severeCPID, AOM, SA, Gout
Mild to moderateCRA, OA
Early Morning Stiffness:
RA>30min
OA no EMS or relieve by movement
Deformities:
Advanced RA (swan neck)
Advanced OA, AS (bamboo spine)
Giving Away: knee, due to weight-
bearing, cartilage damage or muscular
weak (polio)
Systemic Features:
FeverCRA, AOM,SA,SLE
RashCSLE
Wt gain, fever, weakness, fatigue
Occupation:
Manual workerCOA
Maid's Anee, carpet workers knee
(Bursitis)
Sexual exposure (gonorrhea,syphilis)
F/HCHemophilia (hemoarthroses),
gout, TB, RA
Cases
Osteoarthritis: Wt bearing joint, Elderly,
Insidious onset, dull ache, morning stiffness
less than 30min. History of trauma over wt.
Aggravate by walking, squatting, relieve by
painkiller and rest
Malignancy: Pain (night cries)
associated symptoms: stiffness, swollen
Appetite decrease, lost of wt,
Risk factor: smoking, HT, Diabetes,
Sedentary lifestyle, over wt. Metastatic
normally to spine (breast Ca)
14
CNS
Pain: common
Characteristic ,severity, site, onset,
duration, temporal relationship, factors
Headache, back pain, facial pain
Numbness
Special symptoms
- Fits, faints turns
- Dizziness & vertigo (cerebellar)
- Altered vision, hearing and smell
(CN)
- Difficult in walking
- Incontinence
- Loss of memory and intellect
(dementia)
- Altered speech
Cases:
1. Fits
When, where, frequency
Events leading to attacks of
convulsion: sleep deprivation, stress,
fever, exhaustion, alcohol
Symptoms of aura with duration:
hallucination, dejavu (feel like
experiencing 2nd time) .
Features: tongue biting,
incontinence, cyanosis, excessive
salivation, aura, hallucination,
jerking of limbs, loss of
consciousness, how long
How he knows? Who else is
around?
Post-ictal symptoms & duration:
Drowsiness, lethargic, tired for
several hrs.
Diurnal variation?
Hobbies: Mt climbing, swimming,
speed sports.( dangerous)
2. DM:
Peripheral neuropathy
S/S Tingling n numbness
Slipping out a slippers
Autonomic neuropathy(GI)
Indigestion, decrease peristalsis,
bloating, vomiting after meals,
diarrhea and constipation intersperse
Gangrene, amputation,
Other clinical symptoms: retinopathy,
CHD nephropathy
3. Transient ischemic Attack (TlA)
Headache
Char: Pounding/Throbbing
Frequency/Duration/Site.
Symptoms preceding attack:
Dizziness, nausea, visual disturbance
(ischemia of ophthalmic artery during
TIA)
Associated symptoms: Nausea,
lethargic, weakness, vomiting,
disturbed vision
Precipitating factors: stress (work,
single), cheese, bright light, before
menstruation
Relieving factors: ponstan, sleep in
dark
F/H
4. SOL
Complaint: Left weakness 1 month,
numbness 1 week, left vision field
affected 3 days
One sided heavy headache - 1 month
Social: Smoke, Drink
Mental Behaviour changes:
Forgetful, short tempered
Dx: Slowly growing space occupying
lesion, brain tumor, Toxoplasma
gondii, Hydratid, Amoeboid Cyst
5. Strokes
Assoc with atherosclerosis, HT, Slurred
speech, hemiplegia
15
Physical examination
16
Cardiovascular
System
Checklist
Headings Action
1. Introduce
2. Permission 1. Put the bed into 45 angle
2. Wash hands
3. Adequate exposure
3. General
Inspection
1. Name, age, gender, racial
2. Conscious
3. Alert
4. Communicative
5. Well built not chacectic
6. No general discoloration
7. No respiratory distress
8. Not in obvious pain
9. No gadget attached
4. Hands 1. Color
(Cyanosis, Jaundice, Pallor)
2. Temperature
3. Moisture
4. Capillary refill
5. Clubbing
6. Splinter hemorrhage
7. Xanthomata
8. Oslers nodes (pain)
9. Janeway lesion
17
5. Pulse 1. Radial
2. Brachial
3. Carotid
4. Femoral
5. Popliteal
6. Posterior tibialis
7. Dorsalis pedis
Comment on:
1. Rate (for 1min, unless told)
2. Rhythm (R, RI, II)
3. Strength
4. Symmetry
(radio-radial, radio-femoral)
5. Character
6. BP
See behind
7. Face Eyes:
1- sclera (yellowish)
2- conjunctiva (pallor)
3- corneal archus
4- xanthelasma
Mouth: - oral hygiene
Headings Action
8. Neck (JVP) 1. Inspection
2. Measurement of JVP
height
3. Hepatojugular reflux
9. Precordium
Inspection 1. Size
2. Shape
3. Symmetry
4. Scars
5. Deformity (excavatum,
carinatum, kyphosis,
scoliosis)
6. Visible pulsation
(especially at the apex
region)
Palpation 1. Apex beat (comment!)
2. Parasternal heave
3. Thrill over the 4 region
-mitral
-tricuspid
-aortic
-pulmonary
Auscultation Auscultation over the 4
region for*
1. S1 & s2
2. Added sound
3. Murmurs
10. Pitting
edema
11. Thanks Always remember to thank
the patient
SIGNS/EXAMINATIONS SIGNIFICANCE
I
N
T
R
O

Greet, Introduce, Explain,
Permission (GIEP)
+ Wash & Warm hands.
+ 45 degrees
+ Adequate exposure
G
E
Age, gender, ethnic group, height,
weight, built, nutrition
E.g. Mr. Chan is a middle aged Chinese man of
average height and built. He is well nourished and of
18
N
E
R
A
L

I
N
S
P
E
C
T
I
O
N

average weight. He is conscious, alert, and co-
operative. He is not in any respiratory distress, no
general discoloration and he is not in obvious pain.
Respiratory distress:
1. Tachypnoea
2. Use of accessory muscle
3. Flaring of nostrils (ala-nasi movement)
4. Stridor/wheezing
5. Cyanosis
Mention:
(1) conscious
(2) alert
(3) co-operative
(4) no respiratory distress
(5) not in obvious pain
(6) no general discoloration
H
A
N
D
S

(1) Moisture & Temperature
Hypercapnea
(2) Color (normal = pinkish)
(a) cyanosis (blue)
(b) jaundice (yellow)
(c) pallor
(a) Peripheral deoxygenating
Cyanosis = blue discoloration of the skin and
mucous membrane, due to presence of
deoxygenated Hb in blood vessels (>50mg/L)
*does not occur in anemia
*central cyanosis in congenital heart disease
(b) Right heart Failure
(c) Anemia
(3) Clubbing
5 stages of clubbing:
(a) Increase nail fold fluctuation
(b) Loss of nail bed angle
(c) Increased Curvature
(d) Drumstick shape
(e) Pain
= increase in angle between proximal nail and nail
Seen in:
Cyanotic Congenital Heart Disease
Infective Endocarditis
(4) Capillary refill (Normal < 2s)
Press for at least 10s.
Impaired blood circulation e.g. atherosclerosis
(5) Splinter Hemorrhage = linear hemorrhages lying parallel to the long axis
of nail -Talley. Vasculitis of nail bed caused by IE
(6) Osler's Nodes
= red, raised tender nodules on pulps of the fingers
(or toes) or on the thenar or hypothenar eminences
Seen in IE
(7) Janeway Lesion = non tender, erythematous maculopapular lesions
containing bacteria which occur rarely on the palms
or pulps of the fingers in patient with IE
19
(8) Tendon Xanthomata
=yellow or orange deposits of lipid in the tendons
that occur in Type II hyperlipidaemia.
P
U
L
S
E
(1) Rate (normal 60-90 bpm)
+ Tachycardia (>100bpm)
+ Bradycardia (<60bpm)
(2) Rhythm Arrhythmia
(3) Volume
(4) Symmetry (delay)
Types: radio-radial, radio-femoral
Seen in
+ Atherosclerosis
+ Coarctation of aorta
+ Aortic (abdominal) aneurysm
E
Y
E
S
(1) Sclera - Jaundice Right Heart Failure
(2) Conjunctiva Pallor Anemia
(3) Corneal Archus Hypercholesterolemia
(4) Xanthelasma Hypercholesterolemia
M
O
U
T
H
Oral hygiene
Post streptococcal infection and dental caries related
to IE or rheumatic heart disease
N
E
C
K
JVP**see more behind
Mainly for RHF causing
congestive hepatomegaly
1. inspection & location
2. measurement
3. character
-hepatojugular reflux
-visible non palpable
-dual pulsation
C
H
E
S
T
INSPECTION
(1) Surgical scar
(2) Visible pulsation
(3) Deformities (pectus
excavatum and pectus carinatum)
Excavatum = inwards
Carinatum = outwards
PALPATION (*Warm hands first!)
(1) Locate Apex Beat
Don't lie about it. If can't find.
say so. After locating it count the
ribs and report the location.
Always report the location in
relation to midclavicular line.
(E.g. 3cm medials to MCL or 2
cm lateral to MCL). If the
(1) Displaced Apex beat
(a) Chest deformities
(b)Secondary to pleural effusion,
pneumothorax.
(c) Left ventricular dilatation
IF NOT PALPABLE
(a) obese / muscular people
20
examiner marks the particular
point, and it is near axilla, report
according to axillary lines.
(b) Hyperinflation of lung (asthma or emphysema)
(c) Pericardial Effusion
(2) Parasternal Heave
This is at LEFT parasternal border. Ask the pt to
breathe in and out then hold the breath after
expiration then use your hand to find any heave.
(3) Thrills at the 4 region
Report the anatomical location
Thrills= palpable murmurs
Mitral - 5
th
ICS at mid clavicular line
Tricuspid - 4
th
ICS at left parasternal border
Pulmonary 2
nd
ICS left parasternal border
Aortic 2
nd
ICS right parasternal border
AUSCULTATION ** see more behind
Auscultate the 4 areas. You MUST
use both diaphragm and bell
Bell ~ emphasize low pitched
sounds such as murmur of mitral
stenosis
Diaphragm~ for high pitch sounds.
It filters the low pitched sounds.
To show that you know how to
differentiate systolic and diastolic
murmur you have to auscultate and
feel for the carotid pulse at the
same time.
Causes of murmur
(1) Stenosis
(2) Murmur
(3) Anemia / thyrotoxicosis
(4) IE
(5) Congenital heart disease
If murmur coincides with carotid pulse then it's systolic
murmur.
Otherwise it's diastolic murmur.
Report on:
4. S1 & S2
5. Additional heart sound
6. murmurs
L
E
G
Pitting pedal edema
Press at bony prominences
(At least 15s)
Reason: Congestive Heart
Failure, Constrictive pericarditis
1. GIEP
2. PREPARATIONS
(a) Ask patient (i) Smoking
(ii) Caffeinated drinks
(iii) Enough rest! Enough sleep! Exercised before coming in
(b) Make sure patient free of clothing's
(c) Inspect the arm (i) Arterial-Venous fistula for dialysis
(ii) Scar
(iii) Lymph edema
21
(d) Palpate the brachial artery
(e) Position arm so that the brachial artery in antecubital crease at the level of the heart.
3. BLOOD PRESSURE CUFF
(a) Length of inflatable bladder should be 80% of upper arm circumference
(b) Width of inflatable bladder should be 40% of upper arm circumference
4. TECHNIQUE
(a) Place the inflatable bladder over the brachial artery 2.5 cm above antecubital creases.
(b) Secure the cuff.
5. PALPATORY METHOD
(a) Estimate the systolic pressure with the radial pulse. (Inflate 10mmHg at a time)
Reason : (i) Use it as an estimation to prevent discomfort from unnecessary high cuff
pressure.
(ii) To avoid auscultatory gap (a silent gap btw systolic & diastolic)
(b) Deflate & wait for 15s to 30s.
6. AUSCULTATORY METHOD
(a) Place the stethoscope on brachial artery.
(b) Inflate cuff rapidly.
(c) Deflate at 2-3 mmHg per second.
Systolic pressure appearance of sound
Diastolic pressure Total disappearance of the sound report to
the nearest 2 mmHg.
KOROTKOFF SOUND'S (Sounds heard when auscultate over brachial artery)
Phase 1 1st appearance of sound (SYSTOLIC PRESSURE)
Phase 2 & 3 Increasing loud sounds
Phase 4 Abrupt muffling of sound
Phase 5 Disappearance of sound. (DIASTOLIC PRESSURE)
*Phase 5 better estimate of diastolic pressure than phase 4 because it's less subjective and more
correlated with the diastolic pressure.
2 Situations where give false reading -) (1) BP cuff is too small
(2) If the patient's elbow is not flexed.
Few steps on JVP examinations;
1) Position at 45 degrees and ensure the muscle is relaxed by asking the patient to look at
the left.
2) Identify the double pulsation. It may be a bit difficult. Only report your findings. Use
natural light.
3) Estimate the vertical height. The ruler on the sternal angle must be vertical to the ground
(NOT TO THE PATIENT).
22
4) Then report the unit in cm of H
2
0. A normal value is less than 4cm of H
2
0.
Vein Internal jugular vein
Location Medial to sternocleidomastoid muscle
Enters neck through mastoid process, runs deep to sternocleidomastoid enters
thorax between sternal & clavicular head
Wave form a-atrial systole
c-ventricular systole
v- peak pressure in RA prior to opening of tricuspid valve
Causes of
increase JVP
1. Heart failure particularly RHF
2. Pericardial effusion
3. SVC obstruction
4. Tricuspid stenosis
CAROTID ARTERY JVP
Single pulsation
Double pulsation
Palpable
Visible, but not palpable
Not Occludable
Occludable
None
Varies with respiration
None
Varies with position
None
Hepato-jugular reflux
Rapid outward movement
Rapid inward movement
1. GIEP
2. INSPECTION (Common mistake)
(a) Loss of hair
(b) Muscle wasting
(c) Ulceration.
(d) Skin color (pallor / cyanosis)
(e) Surgical scar
3. PALPATION - Before touching patient always ASK patient whether there is any pain or not.
If yes and say, for an example, pain at right leg always starts with left leg.
Why must start with normal???
Reason: To have an idea on what is normal
23
Rule 1:
Vertical to floor
and at sternal angle
Rule 2:
Horizontal (parallel) to floor
and at upper most visible JVP
PATIENT
Height to be
measured
: The patient might have arterial disease on both legs.
How to palpate? It's use your back of your palm and start at the proximal part of the
leg and slowly shift your hand downwards to the distal part.
Check for (a) Skin temperature
(b) Tenderness
(c) Dry skin
4. PERFUSION
(a) Capillary refill
(b) Dorsalis pedis artery
(c) Posterior tibial pulse
(d) Popliteal pulse
(e) Femoral pulse
1) Radial = lateral to bony part of
radius
2) Brachial = medial to brachialis
muscle tendon
3) Carotid = medial to
sternocleidomastoid muscle
4) Femoral = just below the inguinal
ligament, midway between ASIS and
pubic symphysis
5) Popliteal = deep in the popliteal
fossa at the back of the knee just
medial to the midline
6) Posterior tibialis = bony groove
behind the medial maleolus (2cm
behind and below)
7) Dorsalis pedis = proximal end of 1
st

intermetatarsal spaces
24
Heart sounds
Additional sounds
Opening
snap
High pitched
Diastolic
Mitral stenosis
Systolic
ejection
click
Early systolic
High pitched
Aortic stenosis
Pulmonary
stenosis
Non
systolic
ejection
click
High pitched
Systolic
Mitral valve
prolapsed
Sl
M1+Tl
Systole
Loud-mitral stenosis
Soft-mitral regurgitation
S2
A2+P2
Diastole
Loud A2-systemic
hypertension
Soft A2-aortic stenosis +
aortic regurgitation
Loud P2-pulmonary
hypertension

S3
Gallop rhythm
Low pitched,
Mid diastolic
Physiologic =pregnancy
Pathologic=LVF, aortic
regurgitation, mitral
regurgitation
S4
Higher pitched gallop
Late diastolic
Physiological
=NONE!
Pathological
=systemic hypertension
25
Murmurs
Central cyanosis Peripheral cyanosis
Tetralogy of Fallot (congenital heart disease) Obstruction of large vessels
All parts of the bodies involved Mostly periphery
Signs of peripheral blood disease
1) No blood supply
a. Cold
b. Pale
c. No sweat (dry)
d. Hair loss
2) No nerve supply
a. Numbness
b. Tingling
3) No venous perfusion
a. Edema
b. Congestion / cyanosis
Left heart failure
Diastolic

Early
diastolic
Decrescendo
Aortic regurgitation
Pulmonary
regurgitation
Mid
diastolic
Mitral stenosis
Tricuspid stenosis
26
1. dyspnoea
2. basal crepitation
3. cyanosis
Right heart failure ***
1. JVP elevated
2. edema
3. liver enlargement and tenderness
27
Respiratory
System
28
Headings Action
1. Introdu
ce
2. Permiss
ion
1. Put the bed into 45 angle
2. Wash hands
3. General
Inspection 1. Name, age, gender, racial
2. Conscious
3. Alert
4. Communicative
4. Hands 1. Color
(Cyanosis, Jaundice, Pallor)
2. Temperature
3. Moisture
4. Capillary refill
5. Clubbing
6. Nicotine staining (NOT
TAR!)
7. Thenar and hypothenar
muscle wasting
8. Flapping tremors
(asterixis)
5. Pulse Comment on:
1. Rate (for 1min, unless told)
2. Rhythm (R, RI, II)
3. Strength
4. Symmetry
(radio-radial, radio-femoral)
5. Character
6. BP Mention only
7. Face
Eyes:
1- sclera (yellowish)
3- Horners syndrome
Nose:
1-blood
2-mucous or discharge
3-nasal polyps
4-engorged turbinate
5-deviated septum
Headings Action
Mouth:
1-oral hygiene
2- pharyngitis
3-tonsilitis
4-enlargment of tonsils
8. Neck
(trachea)
1. Position -Trachea
deviation
2. Movement-Tracheal tug
3. Length
4. Lymph nodes
9. Precordium
Inspection 1. Size
-AP diameter
-Transverse diameter
2. Shape
3. Symmetry (shape &
movement)
-AP diameter
-Transverse diameter
4. Scars
5. Deformity (excavatum,
carinatum, kyphosis,
scoliosis, flail chest)
6. Use of accessory muscle
for respiration (SCM)
*some of us do respiratory
rate
Palpation 1. Chest expansion
2. Tactile fremitus
3. Apex beat
Percussion + Apical
+ Upper
+ Middle
+ Lower
+ Laterals (axilla)
Auscultation 1. Auscultation on deep
breath in and out through
mouth for
-Breath sound
(N=Vesicular)
-Intensity
29
-Added sound
2. Vocal resonance
3. Whispering pectoriloquy
30
I
N
T
R
O

Permission (GIEP)
+ 45 degrees / sitting down
+ Adequate exposure
G
E
N
E
R
A
L

I
N
S
P
E
C
T
I
O
N

operative. He is not in any distress, no general
discoloration and he is not in obvious pain.
Note:
respiratory rate: normal <14/min
accessory muscle= sternocleidomastoid, platysma,
strap muscle
Mention:
(1) conscious
(2) alert
(3) co-operative
H
A
N
D
S

(1) Moisture & Temperature Hypercapnea
(a) cyanosis (blue)
(b) jaundice (yellow)
(c) pallor
(d) palmar erythema
(e) nicotine staining
(a) Peripheral deoxygenating
- V/Q imbalance
- pneumonia
- COPD
- pulmonary embolism
(b) cor-pulmonale
(c) anemia (chronic disease)
(d) polycythemia
(e) chronic smoker
(3) Clubbing
(a) Cancer
(b) Lung Suppurative Disease
- empyema
- Lung abscess
- bronchiectasis
(c) Fibrosing a1veo1itis
(4) Small Muscle Wasting in hand
Pancoast tumor suppressing TI
(5) Tremors
(a) flapping tremors
(b) fine tremors
(a) Hypercapnia or
hyperuremia due to heart
failure, respi failure, liver
failure, kidney failure or
uremia
(b) Patient on Beta agonist
P
U
L
S
E
(2) Rhythm
(3) Volume
+ Tachycardia (>100bpm)
+ Bradycardia (<60bpm)
31
F
A
C
E
EYES
(1) Jaundice
(2) Pallor
(3) Homer's Syndrome
Horner's Syndrome
(1) Constricted Pupils (miosis)
(2) Drooping eyelids (partial ptosis)
(3) Loss of sweating (anhydrosis)
(4) Enophthalmus
*ALL IPSILATERAL and
DUE TO LOSS OF SYM FUNCTION
NOSE
(1) Blood
(2) Sinus Discharge
(3) Septa Deviation (3) causing nasal obstruction
(4) Nasal Polyps
(4) asthma
(5) Engorged Turbinate (5) allergic rhinitis or other allergic conditions
MOUTH
(l) Oral Hygiene (1) bad oral hygiene predispose to pneumonia
(2) Cyanosis
(3) Pharyngitis (3) = inflammation of pharynx. Due to URTI
(4) Tonsilitis (enlarged tonsils) (4) = inflammation of tonsils. Due to URTI
N
E
C
K
(1) Position :- CHECK WITH
MEDIASTINUM ALSO
(1) Position
(a)PUSH
Pneumothorax
Tumor
Haemopneumothorax
(b)PULL
Lung fibrosis
Lung Collapse
(2) Length
From lower border of cricoid to
suprasternal notch :
Must be at least 3 fingers
(2) length
Emphysema Lung hyperinflation Ribs UP
Sternum up So the length will be less than 3
fingers
(3) Movement No Movement
(No tracheal tug)
(3) Aneurysm of arch of aorta
(4) Lymph nodes (palpation)
(4)Lung cancer
C
H
E
S
T
INSPEECTION
(1) Diameter
(1) Diameter:
+ AP < transverse; Normal
+ AP = transverse; barrel shape(hyperinflation)
+ AP > transverse; pigeon (hyperinflation,
asthma or emphysema)
(2) Shape
a. Pectus Excavatum a. inward (funnel) due to reduce lung capacity
b. Pectus carinatum
b. outward bowing (pigeon); chronic childhood
respiratory disease or rickets
C
(3) Movement
32
H
E
S
T
(a) A-P Expansion (PEN)
Say: PRESENT, EQUAL
NORMAL,
REDUCED EXPANSION VERY IMPORTANT!!!
For both AP + Transverse in almost all lung
diseases
Unilateral: fibrosis, consolidation, collapse, pleural
effusion, pneumothorax
Bilateral: COPD, diffuse pulmonary fibrosis
(b) Transverse Expansion
(c) Flail Chest (c )Fracture segments of ribs at both ends (blunt
injury)
(d) Paradoxical Breathing
Decrease transverse
expansion during inspiration
(d) Chronic Emphysema ribs become horizontal.
So, when diaphragm contracts it pulls down
ribs
(4) Skin a. scars
b. radiotherapy lesions
PALPATION (**warm hands first!!)
(1) Chest Expansion
Apex, middle, lower
SAY: Chest expansion present,
normal and equal at both sides
Note: apex is for AP chest expansion
Reduction in: Lung collapse, Lung fibrosis, lung
consolidation, atelectasis, COPD
(2) Vocal tactile fremitus
Can you please say 99?
SAY : Tactile Fremitus present
normal and equal at both sides.
DON'T FORGET AXILLA
Increase in:
Lung consolidation, Lung Fibrosis, Tumor
Decrease in :
Pneumothorax + lung collapse, hydrothorax
(3) Apex beat
(3) Apex beat
Towards: lower lobes collapsed, localized fibrosis
Away : pleural effusion, tension pneumothorax
Impalpable: hyperinflated 2
ndary
to COPD
PERCUSSION (technique is important)
Do at
1. apex,
2. on clavicle,
3. beneath clavicle, 2
nd
3
rd
4
th
5
th
4. upper + middle + lower axilla
SAY : Equal resonance on both
sides of the lung fields
Note: try to estimate percussing at the apex, upper,
middle and lower. Never forget the axilla!
Hyperresonance: Pneumothorax, Emphysema,
COPD
Dull : Consolidation, atelectasis, collapse, tumor
Stony dullness: pleural effusion, haemothorax,
empyema, hydrothorax, chylothorax
AUSCULTATION
(1) Normal Auscultation Bronchial Breath Sound ~
33
Similar place to that of
percussion
SAY
(a) No diminished breath sound
(b) No bronchial breath sound.
(c) No added sound such as
crackles, wheezes & pleural
friction rub
(d) Normal Vesicular breath
sounds heard
(a) Consolidation
(b) Peripheral tumor
(c) Just above pleural effusion line
Crackles ( non musical, louder at inspiration)
(a) CONSOLIDATION
(b) COPD
(c) TB cavity
Wheezing (musical and louder during expiration &
due to narrowing of airway)
(a) Asthma
(b) COPD
Pleural rub
Inflamed pleura in thrombo-embolism, pneumonia,
pulmonary Vasculitis
(2) Vocal Resonance (say 99)
Results same with tactile vocal
fremitus
(3) Whispering pectoriloquy
(whisper 123)
34
TITLE INSPECTION
TRACHEA &
MEDIASTINA
L SHIFT
CHEST
EXPANSION
(PALPATION)
TACTILE
VOCAL
FREMITUS
PERCUSSION AUSCULTATION
Pneumothorax
Reduced chest
expansion at the
affected site
Away from the
affected site
Reduced on the
affected site
Reduced on the
affected site
Hyperresonant
on the affected
site
Reduced breath
sound on the affected
site
Pleural
Effusion
Reduced chest
expansion on
affected side
Trachea shifted
away
from the affected
side
Reduced on the
affected site
Reduced on the
affected side
Stony dullness
on affected sides
Reduced breath
sounds on affected
side
Pleural Rub
Consolidation
Reduced chest
expansion on
affected side
No trachea shift
Reduced on the
affected site
Increased on the
affected side
Dullness on
affected
sides
Reduced breath
sounds on affected
side
Bronchial breathing
Crepitations
Lung
collapse
Reduced chest
expansion on
affected side
Trachea shifted
towards the
affected side
Reduced on the
affected site
Reduced on the
affected side
Dullness on
affected sides
Reduced breath
sounds on
affected side
Lung Fibrosis
Reduced chest
expansion
on affected side
Trachea shift
towards the
affected site
Reduced on the
affected site
Reduced on the
affected site
Dullness on
affected side
Reduced breath
sounds on
affected side
Emphysema
Reduced BOTH
sides
No trachea shift
Reduced length
Reduced BOTH
sides
Reduced BOTH
sides
Hyper resonant
or
normal
BOTH sides
Reduced breath
sounds both sides
Asthma
Reduced BOTH
sides
No trachea shift
Reduced BOTH
sides
Normal Hyper resonant
Prolonged
expiration
Wheezes
Abnormal pattern of breathing: Type of breathing.
Types Causes
1 Sleep apnea-cessation of airflow for more than 10 seconds
more than 10 times a night during sleep
Obstructive (e.g. obesity with upper
airway narrowing, enlarged tonsils,
pharyngeal soft tissue changes in
acromegaly or hypothyroidism)
2 Cheyne-Stokes' breathing - periods
of apnea (associated with reduced level of consciousness)
alternate with periods of hyperpnoea (lasts 30 s on average
and is associated with agitation).
This is due to a delay in the medullary chemoreceptor
response to blood gas changes
Left ventricular failure
Brain damage (e.g. trauma, cerebral
hemorrhage) High altitude
3 Kussmaul's breathing (air hunger)deep, rapid respiration due
to stimulation of the respiratory centre
Metabolic acidosis (e.g. diabetes
mellitus, chronic renal failure)
4 Hyperventilation, which results in alkalosis and tetany Anxiety
5 Ataxic (Biott) breathing-irregular in timing and depth Brainstem damage
6 Apneustic breathing-
inspiratory pause in breathing
Brain (pontine) damage
7 Paradoxical respiration - the
abdomen sucks inwards with
inspiration (it normally pouches outwards due to
diaphragmatic descent)
Diaphragmatic paralysis
Wheezing = continuous musical breath sound
= inspiratory wheeze; COPD
Crackles = interrupted, non musical breath sound
= peripheral airways collapsed on expiration
Stridor = rasping or coaching noise, loudest on inspiration
= obstruction of trachea or larynx (foreign bodies, inflammation or tumor)
Haematological
System
I
N
T
R
O

Permission (GIEP)
+ Lying down on bed with 1 pillow /
+ Sitting down on a chair
+ Adequate exposure
G
E
N
E
R
A
L

I
N
S
P
E
C
T
I
O
N

1. Racial origin
=> Thalassaemia
2. Pallor
=>Anemia
3. Bruising
=>Platelet disorder
4. Jaundice
=>Hemolytic anemia
5. Scratch marks
=>Pruritis
=>Lymphoma
=>Myloproliferative disorder
1. Racial origin
2. Pallor
3. Bruising
4. Jaundice
5. Scratch marks
H
A
N
D
S

1. Koilonychias
=dry, brittle, ridged, spoon-shaped
nails
2. Pallor (nail bed)
3. Digital infarction
4. Palmar creases pallor
5. Gouty arthritis
6. Pulse - tachycardia
7. Purpura, petechiae, ecchymoses
1. Koilonychias
=>dry, brittle, ridged, spoon-shaped nails
=>Fe deficiency anemia
=>Fungal infections
=> Raynaud's phenomenon
2. Pallor (nail bed)
=>Anemia
3. Digital infarction
=>Abnormal globulin (cryoglobulinamia)
4. Palmar creases pallor
=>Anemia
5. Gouty arthritis:
Felty's Syndrome
1. Thrombocytopenia
2. Hemolytic anemia
3. Myeloproliferative disease
4. Skin pigmentation
5. Leg ulceration
6. Hemophilia
6. Pulse - tachycardia
=>Anemia
7. Purpura, petechiae, ecchymoses
=>Thrombocytopenia or platelet dysfunction
=>Coagulation disorder
=>Systemic vasculitis
T
H
E

F
O
R
E
A
R
M
S

Hess test
- BP cuff on upper arm
- Inflated to 10 mmHg above
diastole
- 5min
- Deflate
- Petechiae (+)
=>Thrombocytopenia
=>Capillary fragility
T
H
E

F
A
C
E
1. Hair - grey hair & blue
eyes
2. Eyes - jaundice &
conjunctiva pallor
3. Mouth
Gum hypertrophy
Atrophic glossitis
Waldayer' s ring
~Monocytic leukemia
~Megaloblastic anemia
~NHL
A
X
I
L
L
A
R
Y

N
O
D
E
S
1. Apex/central
2. Lateral (above & lateral)
3. Pectoral (medial)
4. Infraclavicular
5. Subscapular
C
E
R
V
I
C
A
L

&

S
U
P
R
A
C
L
A
V
I
C
U
L
A
R

N
O
D
E
S

(
N
E
C
K
)
1. Submental
2. Submandibular
3. Jugular chain
4. Posterior triangle
5. Supraclavicular
6. Preauricle
7. Postauricle
8. Occipital
1. Site (position/extent)
Localized = Local infection, early
lymphoma
Generalized = Late lymphoma
2. Size: normal=<lcm
3. Color/temperature
4. Pain & tenderness
Pain = Infections or acute
inflammation
Painless = Lymphoma
5. Consistency
Hard = Carcinoma
Soft/rubbery = Lymphoma
6. Surface texture / overlying skin
Inflamed = Infection
Tethering = Carcinoma
7. Fixation
Fixed = Carcinoma

G
e
n
e
r
a
l
i
z
e
d

L
y
m
p
h
a
d
e
n
o
p
a
t
h
y
1. Lymphoma
2. Leukemia(ALL/CLL)
3. Infection (viral/protozoa)
4. Drugs
5. Infiltration (sarcoid)
6. Connective tissue disease
(RA/ SLE)
L
o
c
a
l
i
z
e
L
y
m
p
h
a
d
e
n
o
p
a
t
h
y
1. Local acute or chronic infection
2. Carcinoma metastases
3. Lymphoma - Hodgkin
Gastrointestinal
System
Headings Action
1. Introdu
ce
GIEP
2. Permiss
ion
1. Lying flat with one pillow
2. Wash hands
3.General
Inspection
1. Name, age, gender, racial
2. Conscious
3. Alert
4. Communicative
4. Hands
(i) Color - jaundice, cyanosis,
pallor, palmar erythema
(ii) Leuconychia
(iii) Clubbing
(iv) Koilonychia
(v) Small Muscle wasting
(vi) Dupuytren's contracture
(vii) Tremor : Flapping
* remember positive sign
first (color, moisture &
temperature)
5. Arms
(i) Spider naevi
(ii) Scratch mark
(iii)Bruising /petechiae/
ecchymoses / purpura
(iv) Axillary hair
6. BP Mention only
7. Face Eyes:
1- sclera (jaundice)
3- corneal archus
4- xanthelasma
Mouth:
(i) Hydration
(ii) Jaundice
(iii) Fetor hepaticus
(iv) Angular stomatitis
(v) Glossitis
(vi) Oral hygiene
(vii) leucoplakia
8. Chest (i) spider naevi
(ii) gynecomastia
9. Abdomen
Inspection (a) Size & shape
(b) Symmetry
(c) Deformity
(b) Umbilicus
(c) Movement with
respiration
(d) Scar
(e) Striae
(f) Dilated veins
(g) Obvious peristalsis
(h) Visible pulsation
(i) Obvious masses
Palpation 1. Light palpation
2. Deep palpation
3. Systemic palpation
4. Liver
5. Spleen
Percussion
+ General percussion
+ Liver span
+ Spleen (plus Traubes
space)
+ Shifting dullness
+ Fluid thrill
Auscultation 1. Bowel sound
2. Bruit (aortic & renal)
I
N
T
R
O

Permission (GIEP)
+ POSITION: FLAT with one pillow
+ Adequate exposure
G
E
N
E
R
A
L

I
N
S
P
E
C
T
I
O
N

Mention:
(1) conscious
(2) alert
(3) co-operative

H
A
N
D
S

(1) Moisture & Temperature Hypercapnea
(a) cyanosis (blue)
(a) live failure causes high oestrogen
(b) jaundice
(b) HA, hepatocellular, obstructive (pre, hepatic and
post jaundice)
(c) pallor (c) GI bleeding, parasite, PA in gastric
(d) palmar erythema

(d) Liver failure causes high oestrogen and
vasodilatation
(e) nicotine staining
(3) Clubbing
= increase in angle between proximal nail and nail
Seen in:
HCC
IBD
Liver cirrhosis
Celiac disease
(4) Capillary refill (Normal < 2s)
Press for at least 10s.
(5) Leuconychia
=opacity of the nails, leaving a rim of pink nail bed
on the top of the nail
Seen in; low albumin level due to :
Liver failure
Malabsorption
Kidney failure
(6) Koilonychia
=spoon shaped nails
Due to IDA, may be secondary to malabsoption.
(7) Small Muscle wasting in hand
Malabsorption
(8) Dupuytrens contracture
= thickening & shortening of palmar fascia Tendon
Xanthomata
1
st
stage = tenderness due to inflammation
2
nd
stage = thicken & contract due to fibrosis
Seen in chronic alcoholics
(9) Tremors flapping tremors
Hypercapnia or hyperuricaemia due to heart failure,
respiratory failure, liver failure kidney failure or
uraemia
A
R
M
S
(1) Spider naevi
= central arteriole which
radiate numerous small
vessels which look like spider
legs.
(1) If-more than 5, then it is due to liver cirrhosis
{increase in oestrogen}
(2) Scratch mark (2) Hyperuremia due to liver failure
(3) Bruising / petechiae /
ecchymosis / purpura
(3) Liver failure or Malabsorbtion
(4)Axillary hair (4)Liver failure
E
Y
E
S

(1) Jaundice
(2) Pallor
M
O
U
T
H
(1) Oral hygiene
(2) Fetor hepaticus (sweet smell
breath from methionine)
(2) Hepatocellular disease
(3) Hydration (3) Fluid intake, diarrhea, vomiting
(4) Jaundice
(5) Angular stomatitis
(5) Iron-deficiency anemia
(6) Glossitis
(6) B
12
-deficiency
(7) Leukoplakia
(7) Leukoplakia
= white colored thickening of the mucosa of the
tongue
Caused by:
Sore teeth (poor oral hygiene)
Smoking
Sepsis
Syphilis
C
h
e
s
t
(1) Spider naevi

= central arteriole from which radiate numerous
small vessels which look like spiders leg.
When noticed, press the point and the point will
disappear and upon releasing the point appears
back.
Seen in alcoholic live cirrhosis
(2) Gynecomastia
= enlargement of breast in male
Seen in chronic liver failure
A
B
D
O
M
E
N
GENERALS
(1) Patient must be supine & flat
(2) Hand must be at the side
(3) Ask him to breath in / out
(4) ASK patient whether he has
any pain before touching him
(5) WARM hands before touching
patient
(6) LOOK at patients face while
palpating
REMEMBER to ASK for pain, WARM hands and
look at the patients face while you are palpating his
abdomen.
COMMON mistake done by students.
Always try to have the habit of asking, then touch
then see patient.
INSPECTION
Vertical lines =
mid clavicular to
mid inguinal point
Horizontal lines =
(1) subcoastal lines - below the 10
th
rib
(2) trans-tubercle line - just below L5
**see in extra on how to determine trans-tubercle
(1) Size & shape (1) Size and shape
(a) Flat or
(a) Normal
(b) Distended or
(b) 6Fs (feaces, fat, fluid, fatal growth, flatus,
fetus)
(c) Scaphoid (c) Normal! lost weight
(2) Umbilicus
(a) Inverted/sunken
(2) Umbilicus
(a) Normal
(b) Flat
(b)
(c) Everted
(c) ascites, pregnancy
(c) Movement with respiration
(3) Reduced movement due to pain if there is
peritonitis
(4) Scar You may asked on different type of scars
(5) Striae (5) Rapid loss or gain of weight, pregnancy, Cushing's
syndrome (purple color)
(6) Dilated veins
- if around umbilicus it is
known as caput medusa
(6) Liver failure
(7) Obvious peristalsis
(7) Intestinal obstruction.
(8) Visible pulsation (8) Aortic aneurysm
(9) Obvious masses
PALPATION
Before palpating you have to do a
few things.
(1) Explain
(2) Ask for any pain
(3) WARM hands
(4) For LIGHT palpation DON'T
take your hands up.
DEEP - can lift up your hand.
(5) LOOK at patient while you are
palpating.
(6) NAME the region while light
palpation & go in order
(7) Flex joint at hand cup
(8) Forearm are at horizontal
Today I am going to touch (or palpate your
abdomen) I would like to start from a place furthest
away from any pain you have. Do you have any
pain anywhere around your abdomen / tummy?
Say for an example patient has no pain
say
"Alright. If you have any pain, please inform me."
Then, start wherever you like but be in order.
(1) LIGHT PALPATION
Things to say
(1) No pain/tenderness
(2) No guarding
(3) No masses
(1) LIGHT PALPATION
Things to remember
(1) Look at patient
(2) Name the regions
(3) DON'T lift up your hand
(2) DEEP PALPATION
Things to say
(I) No pain/tenderness
(2) No guarding
(3) No masses
(2) DEEP PALPATION
Things to remember
(1) Look at patient
(2) Move in during inspiration
(3) CAN lift up your hands
(3) LIVER
Things to say
(1) Liver is not palpable
(2) They might ask what you will
comment on if the liver edge
was palpable (site, size,
shape, consistency, surface,
border)
(3) LIVER
Things to remember
(1) Fingers point towards left axilla, parallel to
costal margin, lateral to rectus abdominis.
(2) START from RIF and slowly
move upwards.
(4) SPLEEN
Things to say; Spleen not
palpable
(4) SPLEEN
Things to remember
(1) Start from RIF
(2) Go towards the LHC
(3) Must cross the umbilicus
(4) Once reach the costal margin,
move along the costal margin
(5) Then lift up the spleen
A
B
D
O
M
E
N
PERCUSSION
(1) General percussion
Say: resonant
(1) general percussion
hyperresonant = gas distension
(2) Liver span
Percuss at mid clavicular line
Above - 2
nd
ICS; below - RIF
Normal span = 8 - 12 cm
(3) Spleen
Percuss from RIF
Then percuss the Traub's space
Lines for Traube's space
(a) mid axillary line ( not too sure)
(b) xiphisternal
(c) costal margin
(4) Shifting dullness
1
st
percuss starting from the
umbilicus and move laterally.
Then say it's resonant and you
can't get the point of dullness. The
lecturer will ask you to assume 1
point as the point of dullness. Then
ask patient to lie towards the
opposite direction and say you will
wait for 15s. Then start percussing
back. If resonant then shifting
dullness is present.
(4) shifting dullness
Mild to moderate ascites
Amount of fluid must be in the peritoneum for
shifting dullness = 500ml
5) Fluid thrill
Ask patient to put hand at the
centre reason: to prevent the shock
wave
Transmitting through fat and skin
(5) fluid thrill
Massive ascites
Minimum amount of fluid = 1000ml
(a) increased = gastroenteritis, mechanical
obstruction, blood in gut decreased = paralytic
ileus as in generalized peritonitis
(b) stenotic lesions in the blood vessel
(c) liver = inflammation + cancer spleen = infarcts
AUSCULTATION
(1) Bowel sounds
Once every 10 - 15 s
(2) Aortic bruit, Renal Bruit, Iliac
bruit (Know the anatomical
position)
GENERAL
Jaundice
Yellow discoloration of the sclera and skin
CAUSE: Hyperbilirubinaemia
Weight and
wasting
Failure of GIT to absorb food normally. May lead to weight loss and cachexia
CAUSE:
+ GI Malignancy
+ Alcoholic Cirrhosis
+ Folds of loose skin (hanging from abdomen and limbs)-suggest recent wt loss
+ Obesity can cause fatty infiltration of the liver(non alcoholic steatohepatitis)-
abnormal LFTs
SKIN
Pigmentation
CAUSES:
+ Generalized: chronic liver disease, especially in haemochromatosis
+ Malabsorption - Addisonian-type pigmentation ('sun kissed' pigmentation) of
the nipples, palmar creases, pressure areas and mouth
+
Peutz- Jeghers
Syndrome
Freckle-like spots(discrete brown black lesions) around mouth and buccal mucosa
And fingers and toes
CAUSE:
+ Assoc with hamartomas of the small bowel(50%) and colon(30%) which can
present with bleeding and intussusceptions
+ Autosomal dominant, Increased risk of GI adenocarcinoma
Acanthosis
Nigricans
Brown to black velvety elevations of the epidermis due to confluent papillomas
Site: axilla and nape of the neck
+ Assoc rarely with GI carcinoma (especially stomach) and lymphoma,
acromegaly, diabetes mellitus, endocrinopathies
Hereditary
haemorrhagic
telangiectasia
(Rendu-Osler-
Weber svnd)
Multiple small telangiectasia
Site: lips and tongue, may be anywhere on the skin, when present in GIT -can cause
chronic blood loss or even occasionally torrential bleeding
Cause:
+ Assoc A-V malformation in liver may be present
+ AD condition uncommon
Porphyria
cutanea tarda
Fragile vesicles on exposed areas of the skin and heal with scarring
Dark urine.
CAUSE :
+ Chronic disorder of porphyrin metabolism
+ Assoc with alcoholism, liver disease, Hepatitis C
Systemic
sclerosis
Tense tethering of skin
Often assoc with GER and GI motility disorders
NAILS
Leuconychia CAUSE:
+ Chronic liver disease or other disease - hypoalbuminaemia
+ Nail beds opacity, often leaving only a rim of pink nail bed at the top of nail
+ Thumb and index finger bilaterally most often involved
+ Compression of capillary flow by EC fluid
Muehrcke's
lines
Transverse white lines
CAUSE: Hvpoalbuminaemic states including cirrhosis
Clubbing
CAUSES: Cirrhosis(1/3
rd
pts)- may be related to A V shunting in the lungs resulting in
arterial oxygen desaturation
Severe long standing chronic liver disease
Inflammatory bowel disease
Celiac disease
PALMS
Palmar
eyrthema
'liver palms'
Reddening affecting thenar and hypothenar eminences often also-soles of the feet
CAUSES:
+ Chronic liver disease
+ Also seen: pregnancy, thyrotoxicosis, RA, polycythaemia etc
+ Maybe a normal finding especially in women
Anaemia
Pallor at palmar creases
CAUSES: GI blood loss, malabsorption of folate, vit B12,haemolysis(ex:
hypersplenism), chronic disease
Depuytren's
Contracture
Visible and palpable thickening and contraction of the palmar fascia causing
permanent flexion, most often of the ring finger
Often bilateral and occasionally affects the feet
Assoc with alcoholism (not liver disease), also found in some manual workers(may be
familial)
Palmar fascia- abnormally large amounts of xanthine - maybe related to pathogenesis
Hepatic Flap
(Asterixis)
Stretch out arms in front, separate fingers, extend wrists, for 15s
Jerky irregular flexion-extension movement at the wrist and metacarpophalangeal
joints often accompanied by lat movements of the fingers, rhythmical movements-
not synchronous on each side
HEPATIC ENCEPHALOPATHY
Interference with the inflow of joint position sense information to the reticular
formation of the brainstem. Rhythmical lapses of postural muscle tone
Occasionally: arms, neck, tongue, jaws and eyelids can also be involved
CAUSES
+ Liver failure
+ May also occur in cardiac, respiratory and renal failure
+ Hypoglycaemia
+ Hypokalaemia, hypomagnesaemia
+ Barbiturate intoxication
ARMS
Bruising
Ecchymoses (large bruising)- clotting abnormalities
CAUSES:
+ Hepatocellular damage- interferes with protein synthesis and production of all
the clotting factors except F8.
+ Obstructive Jaundice- shortage of bile acids in the intestine- may reduce
absorption of vitamin K- essential for reduction of clotting factors 279,10
Petechiae
Pinhead-sized bruises
CAUSES:
+ Chronic excessive alcohol consumption => BM depression => TCP
+ Splenomegaly 2
ndary
to portal HT => hypersplenism =>excessive destruction
of pits in spleen
+ Acute hepatic necrosis => DIC can occur
Muscle
Wasting
Late manifestation of malnutrition in alcoholic pts. Alcohol can also cause a proximal
myopathy
Scratch marks
Due to severe itch (pruritus)
CAUSES:
+ Obstructive or cholestatic jaundice
+ Commonly the presenting feature of primary biliary cirrhosis
+ Retention of an unknown substance normally excreted in bile? Bile salt
deposition in the skin?
Spider naevi
o Consist of a central arteriole from which radiate numerous small vessels which
look like spiders' legs
o Range in size from just visible to half a centimeter in diameter
o Their usual distribution is in the area drained by the SVC, so they are found on the
arms, neck and chest wall
o Can occasionally bleed profusely
o Pressure applied with a pointed object to the central arteriole causes blanching of
the whole lesion.
o Rapid refilling occurs on release of the pressure.
o >2 anywhere in the bodylikely to be abnormal
CAUSE:
+ Cirrhosis (usually due to alcohol), transiently occurs with viral hepatitis, 2nd to
5th months of pregnancy; disappears within 8 weeks of delivery.
+ Traditionally attributed to oestrogen excess
Normal hepatic function =>> inactivation of oestrogens(impaired in chronic liver
disease)
Oestrogens =>> dilatation effect on the spiral arterioles of the endometrium
Campbell de
Morgan spots
Flat or slightly elevated red circular lesions which occur on the abdomen or the front
of the chest.
Do not blanch on pressure and are very common
Venous stars
2-3cm lesions which can occur on the dorsum of the feet, legs, back and the lower
chest
Due to elevated venous pressure and are found overlying the main tributary to a
large vein.
Not obliterated by pressure.
Blood flow> from periphery to the centre of the lesion
EYES
Jaundice Sclera
Anemia Conjunctiva - pallor
Kayser-
Fleischer rings
Brownish green rings occurring at the periphery of the cornea, affecting the upper pole
more than the lower
Slit-lamp examination-often necessary to show them
CAUSE:
+ Due to deposits of excess copper in Descemet's membrane of the cornea
+ Found in : Wilson's disease(a copper storage disease which causes cirrhosis and
neurological disturbances)
Usually present by the time neurological signs have appeared
Pts with other cholestatic liver diseases can also have these rings
Iritis IBD
Xanthelasma
Yellowish plaques in the subcutaneous tissues in the periorbital region
Due to deposits of lipids
May indicate protracted elevation of the serum cholestrol
Pts with cholestasis: an abnormal lipoprotein (LP X) found in plasma and is assoc
with elevation of the serum cholesterol.
Common in pts with primary biliary cirrhosis
Periorbital
purpura
Following proctosigmoidoscopy ('black eye syndrome') - characteristic sign of
Amyloidosis (perhaps related to factor X deficiency)
Very rare
Fetor (bad
breath)
Causes:
+ Faulty oral hygiene
+ Ketosis (diabetic ketoacidosis excretion of ketones in exhaled air)
+ Uremia (fish breath, an ammonical odor)
+ Alcohol, paraldehyde
+ Putrid (anaerobic chest infections with large amount of sputum)
+ Cigarettes
Fetor hepaticus
Sweet smell
CAUSE: Severe hepatocellular disease and may be due to methylmercaptans
These sub-exhaled in breath and may be derived from methionine when this amino acid
is not demethylated by a diseased liver. Severe FH- fills the pts room-bad sign and
indicates a precomatose condition in many cases. Ask pt -exhale through the mouth
TONGUE
Lingua
nigra(black
tongue)
Elongation of papillae over the posterior part of the tongue which appears dark
brown
because of the accumulation of keratin, also due to bismuth compounds
No known cause
Geographical
tongue
Slowly changing red rings and lines which occur on the surface of the tongue
Not painful, comes and goes
Not of any significance, can be a sign of vitamin Bl2 deficiency
Leucoplakia
White - colored thickening of the mucosa of the tongue and mouth
Premalignant
Often no cause is apparent
May also occur on the larynx, anus and vulva
S CAUSES:
Sore Teeth(Poor Dental Hygiene), Smoking, Spirits, Sepsis Or Syphilis

Glossitis
Smooth appearance of the tongue which may also be erythematous
Due to atrophy of the papillae and in later stages there may be shallow ulceration
Often due to nutritional deficiencies to which the tongue is sensitive because of
the rapid turnover of mucosal cells
CAUSES:
Deficiency of the iron, folate and the vitamin B group especially B 12, common in
alcoholics, and in the rare carcinoid syndrome
Aphthous
ulceration
Commonest type of ulcer.
Begins as a small painful vesicle on the tongue or mucosal surface of the mouth
which may break down to forma painful shallow ulcer
Heal without scarring
Unknown cause, may indicate: Crohns or coeliac disease
Angular
stomatitis
Cracks at the corners of the mouth
CAUSES: VitB6, Vitamin B12, folate and iron deficiency.
NECK
Cervical LN
Palpate-especially supraclavicular nodes on the left side
May be involved with advanced gastric or other gastrointestinal malignancy, or
with lung cancer
Large left supraclavicular LN in combination with carcinoma of the stomach-
Troisier's sign
Gynaecomastia
May be a sign of chronic liver disease in males
May be unilateral or bilateral and the breasts may be tender
May be a sign of cirrhosis (especially alcoholic cirrhosis) or of chronic active
hepatitis
CLD - changes in the oestradiol to testosterone ration may be responsible
Cirrhotic pts - spironolactone, used to treat ascites is also a common cause
May occur in alcoholics without liver disease due to damage to the Leydig cells of
the testis from alcohol
ABDOMEN
Scars
Indicates previous surgery or trauma
Around the umbilicus for laparoscopic surgical scars
Older scars are white and recent scars are pink because the tissue remains vascular
Presence of stomas or fistulae.
Distension
Generalized abdominal distention may be present.
Shape of umbilicus gives clue: buried in fat-eats too much,
When peritoneal cavity is filled with large volumes of fluid (ascites) from
whatever cause, the abdominal flanks and wall appear tense and the umbilicus is
shallow or everted and points downwards.
Pregnancy, also the presence of a huge ovarian cyst- umbilicus pushed upwards by
the uterus enlarging from the pelvis
Fs CAUSES: fat(gross obesity), fluid(ascites), fetus, flatus(gaseous distention due
to bowel obstruction), feces, 'filthy' big tumor (ex: ovarian tumor or hydatid cyst) or
'phantom' pregnancy

Local
swellings
Enlargement of one of the abdominal or pelvic organs
Hernia
Protrusion of an intra-abdominal structure through an abnormal opening
CAUSES:
+ previous surgery weakening the abdominal wall,
+ congenital abdominal wall defect,
+ chronically increased intra-abdominal pressure
Prominent
veins
If present, direction of venous flow should be elicited at this stage.
A finger is used to occlude the vein and blood is then emptied from the vein
below the occluding finger with a second finger. The second finger is removed
and if the vein refills, flow is occurring towards the occluding finger.
Flow should be tested separately in veins above and below the umbilicus
Severe PORTAL HYPERTENSION: portal to systemic flow occurs through the
umbilical veins, which may, rather rarely, become engorged and distended.
Direction of flow is then away from the umbilicus.
Due to their engorged appearance-been likened to the mythical Medusa's hair
after Minerva had turned it into snakes. This sign-called a
caput Medusa (head of Medusa very rare usually only 1 or 2 veins (often
epigastric) are visible
Engorgement - can occur due to IVC OBSTRUCTION (usually due to a tumor or
thrombosis but sometimes due to tense ascites) (abdominal veins enlarge to
provide collateral blood flow from the legs, avoiding the blocked IVC-direction
of flow is upwards towards the heart.
To differentiate CM and IVC obstruction- determine the direction of flow below
the umbilicus
Prominent superficial veins can sometimes be congenital
Visible
pulsation
s
An expanding central pulsation in the epigastrium suggests an AAA
The abdominal aorta, however can be seen to pulsate in normal thin people
Visible
peristalsis
May occur in very thin normal people occasionally
Usually suggests intestinal obstruction
Pyloric obstruction due to peptic ulceration or tumor may cause visible peristalsis,
seen as a slow wave of movement passing across the upper abdomen from left to
right
Obstruction of the distal small bowel- similar movements in a ladder pattern in the
centre of the abdomen
Skin lesions
Vesicles of herpes zoster (occur in a radicular pattern-localized to only 1 side of
the abdomen in the distribution of a single nerve root).
H. Zoster can be responsible for severe abdominal pain -mysterious in origin till
the rash appears
Sister Joseph nodule- a metastatic tumor deposit in the umbilicus, the anatomical region
where the peritoneum is closest to the skin
Discoloration of the umbilicus where a faintly bluish hue is present - very rarely found
in cases of extensive haemoperitoneum and acute pancreatitis( Cullen's sign- the
umbilical 'black eye')
Acute pancreatitis (severe cases)- rarely skin discoloration occurs in the flanks
( Grey Turner's sign)
Striae
Stretching of the abdominal wall severe enough to cause rupture of the elastic
fibers in the skin
produce pink linear marks with a wrinkled appearance
When these are wide and purple colored -Cushing's syndrome may be
the cause
Much more common causes: ascites, pregnancy or recent wt loss
Asymmetrical
movement
Squat down beside the bed-pts abdomen at eye level
Ask pt to take slow deep breaths through the mouth and watch for
evidence of asymmetrical movement- indicates the presence of a mass
In particular- a large liver may be seen to move below the right costal margin or a
large spleen below the left costal margin
Hernia Hydrocele
Size Bigger Smaller
Site Inguinal (goes to) scrotum Purely scrotum
Shape Guard (elongated) Pear (oval)
Mobility Cannot get above swelling Can get above swelling
Hinge test (-) (+)
Reducibility Reducible Irreducible
Cough impulse (+) (-)
Internal ring
occlusion test
Reducible during coughing (DIR) Not reducible
Consistency Soft (bowel) Cystic (water)
Fluctuation test (-) (+)
Trans-
illumination test
Does not pass through (bowel) Light pass through (water)
1) Permission ***
2) Lying down left lateral facing
3) Bent the knees to the chest both or right leg
4) Patient at side / edge
5) Inspection
a. Scars
b. External hemorrhoids
c. Erythema
d. Changes in color
e. Sign of itching
f. Anal fissuring (skin crack)
g. Pus / discharge (STD)
h. Anal tags
6) Palpation
a. 1
st
= post wall
b. 2
nd
= lateral wall
c. 3
rd
= anterior wall for prostate (size & consistency)
d. 4
th
= ask to constrict to see tone
7) Fingers pulled out to look for:
a. Blood
b. Pus
c. Stool
8) THANK THE PATIENT
Endocrine
System
I
N
T
R
O

Permission (GIEP)
+ Adequate exposure
G
E
N
E
R
A
L

I
N
S
P
E
C
T
I
O
N

Mention:
(1) conscious
(2) alert
(3) co-operative
H
A
N
D
S

(1) Moisture
hyperactivity of sympathetic system causes increase
in sweatiness
(2) Temperature
Especially in the case of hyperthyroidism, there
might increase in body temperature.
(3) Acropachy (Clubbing) Acropachy is a clubbing in Graves disease.
(4) Onycholysis
=separation of nail from nail bed
Seen in Graves disease
(5) Fine tremors
Test with a piece of paper. It is due to sympathetic
over activities in hyperthyroidism or Graves
disease.
P
U
L
S
E
+ Tachycardia (>100bpm) = hyperthyroidism
+ Bradycardia (<60bpm) = hypothyroidism
(2) Rhythm
(3) Volume
Types: radio-radial, radio-femoral
A
R
M
S
1. Texture
Dryness hypothyroidism
2. Myxoedema
Hypothyroidism
3. Scratched marks
4. Biceps reflex
Delayed relaxation due to proximal myopathies in
hypothyroidism
5. BP
H
A
I
R
1. Brittleness
2. Coarseness
Both due to hypothyroidism
E
Y
E
S
INSPECTION
(1) Periorbital Puffiness
Hypothyroidism
(2) Thyroid Stare
Hyperthyroidism
(3) Exophthalmus
Complications:
a. Chemosis
b. Conjunctivitis
c. Corneal Ulceration
d. Optic Atrophy
e. Ophthalmoplegia
= protrusion of the eyeballs from the orbit. Easily
seen from the side of the patient.
Look at sclera, which are not covered by
lower eyelids
Seen in hyperthyroidism.
(4) Proptosis
Bulging of an eye
Seen in hyperthyroidism
(5) Chemosis
= oedema of conjunctiva and injection of sclera. It is
a complication of proptosis or exophthalmus
MOVEMENT
(1) Lid lag
Make sure the patient's head does not move.
Ask the patient to follow your finger down with
her eyes
Observe the lid. See if there is lagging behind
the eye ball
Lid lag retraction seen in hyperthyroidism
(2) Diplopia
Ask the patient to move the eyes without
moving the head
Ask the patient to follow your finger while you
draw H
This is also called the H test (more detail in
cranial test examination)
At the 4 corner of the H, ask the patient if
he/she sees two (double vision)
T
H
Y
R
O
I
D

G
L
A
N
D
INSPECTION
It is important that during inspection and palpation to ask the patient to take a sip of water.
This is to see if there is a swelling that moves up during swallowing.
Some thyroid mass are difficult to see un less swallowing.
(1) Surgical scar Thyroidectomy
(2) Swelling
1. Site.
2. Size.
3. Shape
4. Surface.
5. Symmetry.
6. Scar.
7. Color.
PALPATION (*Warm hands first!)
(1)
Palpation of the thyroid glands requires a special technique and a lot of practices. Try to
practice this procedure with lecturer instead. Palpation need to be done one at a time and
at one side. This is to reduce the effect of uncomfortable to the patient.
PRACTICE!!! IMPORTANT!!!
Comment on:
1. Tenderness.
2. Site.
3. Size.
4. Shape.
5. Surface.
6. Symmetry.
7. Consistency.
8. Margin.
9. Mobility.
10. Warmth.
11. Nodules.
(2) Trachea deviation
Similar to RESPI, trachea may be deviated in
presence on mass at the neck (e.g. goiter)
(3) Supra-clavicular lymph nodes
PERCUSSION
Retrosternal enlargement may cause dullness upon percussion. Please do check with the
lecturer on this. Especially on the point and site of percussion.
AUSCULTATION
Thyroid bruit
Thyroid bruit is caused by increase blood flow due
to increased visualization in hyperthyroidism
To prevent confusion with breath sound, ask the
patient to hold his/her breath.
I
N
T
R
O

Permission (GIEP)
+ Adequate exposure
G
E
N
E
R
A
L

I
N
S
P
E
C
T
I
O
N

operative. He is not in any respiratory distress, no
general discoloration and he is not in obvious pain.
H
A
N
D
S

&

A
R
M
S
(1) Moisture, Temperature &
Color (pallor)
(2) Clubbing
(3) Capillary refill
(4) Signs of infections
e.g. unhealed scars
(5) Signs of peripheral vascular
disease & nerves disease
e.g. loss of hairs, loss of sensation, loss of
sweatiness, warm / cold
(6) BP
Postural hypotension
(7) Insulin injections
P
U
L
S
E
(1) Rate (normal 60-90 bpm) (3) Volume
(2) Rhythm (4) Symmetry (delay)
H
E
A
D
(1) Blurred vision (3) Glaucoma
(2) Cataracts (4) Infections in mouth
L
O
W
E
R

L
I
M
B
S
INSPECTION PALPATION
1. Infection by Necrobiosis sp.
2. Color
3. Gangrene.
4. Ulceration.
1. Temperature.
2. Dorsalis pedis pulse.
3. Posterior tibialis pulse.
MOVEMENT SENSATION (see more in NS system)
1. Dorsiflexion.
2. Plantar flexion.
1. Cotton wool
2. Vibration (128Hz)
3. Temperature
4. Pin prick
5. Use sternal notch as a reference sensation
point.
6. Glove and stocking peripheral
neuropathy is a typical diabetic
neuropathy.
Thyroid gland (general goiter)
1. Inspection
Below cricoid cartilage (usually only the isthmus is seen, diffuse central swelling)
Check for enlargement / swelling (goiter)
Front and side of neck (localized / generalized swelling)
With a glass of water, ask the patient to take a sip of water and watch the patients
neck as the patient swallowing. (only goiter or thyroglossal cyst rise during
swallowing)
Shape and the inferior border when the patient is swallowing (if there is a swelling)
Scars
Prominent vein (often accompanied with filling of external jugular vein)
2. Palpation
+ From behind
+ Use both hands
+ Neck slightly flexed to relax the sternocleidomastoid muscle
+ Palpate one side at a time
+ Palpate for:
i. Right lobe
ii. Left lobe
iii. Lower border
iv. Isthmus
+ Check:
i. Size (if no lower border means it is retrosternal swelling)
ii. Shape (uniform / irregular, nodularity, condition of isthmus)
iii. Consistency (normal = soft. Stony hard = carcinoma)
iv. Tenderness (thyroiditis, bleed into cyst, carcinoma)
v. Mobility (if carcinoma, it is tether to gland)
+ note: repeat assessment with patient swallow
+ palpable thrill over the gland
+ cervical lymph nodes
+ carotid artery (feel for pulsation, absence of pulsation may indicate malignant
infiltration)
+ move to front to palpate with thumbs for any localized undetected mass and
trachea deviation
3. Percussion
+ Upper manubrium
4. Auscultation
+ Bruit-Auscultate over each lobe
+ Due to increased blood supply
+ Ask the patient to take a deep breath in and hold
Pambertons sign
- Test for inlet obstruction cause by retrosternal goiter
- Lift both arms
- Look for signs of congestion (plethora) and cyanosis
- Respiratory distress and inspiratory stridor may occur
- Veins distension at the neck
Hyperthyroidism
Excessive concentration of thyroid hormone
Anxiety
Irritability
Fatigue
Weight loss
Good appetite
Palpitations
Heat intolerance
Tremor
Sweating
Diarrhoea
+/- Eye signs
Tachycardia
Generalised lymphadenopathy
Complications
Atrial fibrillation
Dilated Cardiomyopathy
Osteoporosis
Amenorrhoea
Visual loss
Proximal myopathy
Common cause is Graves disease (autoimmune disease circulating TSHi stimulate
TSH receptor)
1. General inspection
a. Weight loss
b. Anxiety
c. Frightened facies
2. Hands
a. Fine tremors (sympathetic over activities)
b. Onycholysis (Plummers nail, nail separated from nail bed particularly the ring
fingers)
c. Acropachy (clubbing)
d. Palmar erythema (symphathetic veractivity
e. Warmth and sweatiness
f. Pulse (tachycardia / atrial fibrillation shortened refractory period)
g. Reflex (abnormal briskness)
h. Proximal myopathy (proximal muscle wasting and weakness)
3. Eyes
a. Exophthalmus (eyeball protrude from orbit, sclera not covered by lower eyelids,
only in Graves disease)
b. Proptosis complication (chemosis, conjunctivitis, corneal ulceration, optic atrophy
and ophthalmoplegia)
c. Thyroid stare (frightened)
d. Lid retraction (sclera visible above iris)
e. Lid lag (follow descending fingers, upper lid descend lags behind eyeball)
4. Neck
a. Examine thyroid enlargement
b. Thrill
c. Thyroidectomy scar
5. Arms
a. Raise above head
b. Proximal myopathies
c. BP
d. Reflex
6. Chest
a. Gynaecomastia (rare)
b. Systolic flow murmurs (increase CO)
7. Legs
a. pretibial myxoedema (bilateral, firm, elevated dermal nodules / plaque, pink /
brownish skin colored due to mucopolysaccarides accumulation)
b. proximal myopathy
c. hyper-reflexia
Causes
Graves disease (85%)
Toxic multinodular goitre
Toxic adenoma
Thyroiditis
Thyroid carcinoma
TSH-oma
Choriocarcinoma / Hydatidiform mole
Struma ovarii
Iatrogenic (eg, Amiodarone)
Hypothyroidism
1. General inspection
a. Mental and physical sluggishness
2. Hands
a. Peripheral cyanosis (low CO)
b. Skin swelling (cool & dry)
c. Yellow discoloration (palms, hypercarotenaemia)
d. Palmar crease pallor (chronic deficiency of foliate, B12, and iron)
e. Pulse (low volume and bradycardia)
f. Phalens sign (palm on flat surface, abduct thumb, touch pen)
3. Arms
a. Proximal myopathy
b. Hung up biceps reflex
4. Face
a. Yellow skin (hypercarotenaemia, not in sclera)
b. Alopecia
c. Vitiligo
d. Periorbital oedema
e. Eyebrows (loss / thinning)
f. Xanthelasma
g. Cool and dry skin
h. Scalp hair thinning
i. Tongue swelling
j. Coarse, croaking and slow speech
k. Bilateral nerve deafness
5. Thyroid gland
a. Goiter
6. Chest
a. Pericardial effusion
b. Pleural effusion
7. Legs
a. Achilles tendon reflex with delayed relaxation
b. Non pitting oedema (myxoedema)
Diabetes mellitus
1. general inspection
a. dehydration (osmotic diuresis)
b. obesity (type 2)
c. weight loss (signs, recent)
d. pigmentation (haemochromatosis)
e. endocrine facies (2
ndary
to Cushings or Acromegaly)
f. comatose (due to dehydration, acidosis and plasma hyperosmolality)
g. Kussmauls breathing (ketoacidosis)
2. lower limbs
a. inspection
i. skin (hairless, atrophied)
ii. non healing ulcers (toes)
iii. skin infections (boils, cellulites, fungal)
iv. pigmented scars (diabetic dermopathy, small rounded plaques, raised
borders, linear, shins)
v. necrobiosis lipoidica diabeticorum (shins, yellow scarred area, red margin)
vi. fat atrophy/hypertrophy
vii. quadriceps muscle wasting
viii. charcots joints (knee, recurrent unnoticed injury due to pain or
propioception loss)
b. palpation
i. fat atrophy / hypertrophy
ii. weak peripheral pulses (dorsalis pedis, posterior tibialis and popliteal)
iii. temperature of feet (cold-due to decrease blood supply)
iv. capillary return decreases
c. neurological examination
i. vibration sense (tuning fork 128Hz)
ii. propioception (joint position test)
iii. pain sensation (pin prick test)
iv. proximal muscle power
3. upper limbs
a. candida infections at the nails
b. insulin injection sites
c. BP (postural hypotension)
4. eyes
a. visual acuity may be reduced
5. ears
a. infections
6. mouth
a. candida infections
7. neck & shoulder
a. scleroderma (skin thickened, upper / back shoulders)
b. acanthosis nigricans (signs of insulin resistance)
Reproductive
System
Breast examination
I
N
T
R
O

Permission (GIEP)
Say: Good morning. I am a third
year medical student. May I
know your name?
Pt: Mrs. Lim
Say: Mrs. Lim, I would like to
examine your breasts, is that
okay?
Pt: Yes
Sit the patient up with chest
fully
Say: I would like to wash my
hands before examining the
patient.
**this part is very essential in that it
contribute half of your marks!!
+ Adequate exposure
+ Express the need to examine
+ Be assured of the privacy
+ Chaperone friends / examiner / nurse
+ take your clothes off with all respect your
bra as well try to use your own word
+ Permission
P
O
S
I
T
I
O
N
S
BODY HANDS
1) Lying flat breast will fall flat
2) 45 degrees semi recumbent
position
3) Erect gravity (sagging)
- pendulum bulky
4) Bend forward fixation of
- muscle
- skin
- bone
1) Resting relax the pectoral muscle
2) On hips contract the pectoral muscle
3) Above heads stretch skin and pectoral muscle
G
E
N
E
R
A
L

I
N
S
P
E
C
T
I
O
N
1) Middle age / reproductive age
2) Weight thin / cachexia
3) Anemic
4) Pain- obvious pain
5) Obvious masses lymph nodes
6) Scars - mastectomy
I
N
S
P
E
C
T
I
O
N
(1) size
Compare the two breast
Report = equal for both side (one side larger
may be normal)
(2) Shape Abnormal shape masses / swelling
(3) Symmetrical (nipple position)
1. distance from midline
2. distance from clavicle
(4) Skin
1. Color
+ Red = inflamed
+ Blue = bursitis / bruises
+ Black / pale = necrotizing gangrene
2. Dimpling
3. Swelling
4. Pigmentation
(5) NIPPLE
1. size
2. shape Normally cylindrical
3. conditions
+ everted / inverted
+ cracks
+ ulcer
+ discharge
4. color
+ pink
+ dark (in pregnancy)
(6) AREOLAR
+ size
+ shape
+ color
(7) Others
+ peau dorange
+ dilated veins
+ hemorrhagic spot
Note:
l. Retraction is caused by:
-Cancer
-Fibrosis
-Normal
2. Paget's diseases:
Breast ca causes unilateral, red, bleeding area.
1. Ask her to raise her arms above
her head and then lower them
slowly.
=This movement is to stretch the
pectoral muscles
Look for.
1. Tethering of the nipples or
skin
Say: No tethering of the
nipples or skin
2. Shift in relative position of
nipples or fixed mass
distorting breasts
Say: No shift in position of
nipples or fixed mass
3. Masses in axilla
2. Ask her to lean forward
=This is to accentuate breast fixation
Say: no visible fixation on breast
3. Ask her to rest her hands on her hips and press
them against her hips.
= This is known as the Pectoral Contraction
maneuver. Function: to accentuate dimpling or
fixation
Say: No visible dimpling or fixation
P
A
L
P
A
T
I
O
N
+ Scan with palm
+ Examine with pulp
+ Finger grip
+ Same for nipple and areolar
1. Site
2. Size
3. Shape
4. Surface smooth / regular
5. Skin surface
6. Edges
7. Consistency soft, firm, hard
8. Mobility / fixity
9. Temperature
10. Tenderness
11. Pulsation
**ALSO PALPATE FOR
LYMPH NODES
1. Axillary
2. Supraclavicular
3. Tail
Examine in concentric circular pattern feeling 4
quadrants of breast.
Start at areola and roll fingers over breast tissue.
a. Palpable breast mass present:
1. Position
2. Size
3. Shape
4. Surface -smooth/rough
5. Skin-color, dimple, fixed
6. Consistency-hard/firm/soft
7. Margin -regular/irregular
8. Tenderness
9. Fixation
10. Single or multiple lesions
11. Pulsation
12. Temperature
Cyst- painful, hard, smooth surface
Ca- irregular margin, fixed, firm, painless
Fibrocystic- irregular, rubbery Fibroadenoma-
smooth, discrete, rubbery
b. Nipple discharge
+ Bright blood (duct papilloma, fibroadenosis,
carcinoma)
+ Yellow serous (fibroadenosis)
+ Serous fluid (pregnancy)
+ Milky (lactation)
+ Green fluid (mammary duct ectasia)
c. Causes of breast enlargement:
1. cancer
2. mastitis
3. cysts, abscess, fibrosis
TETHERING = infiltration of suspensory ligament which enable the skin to move about
FIXITY = infiltration to skin causes the skin cannot be pinched
To measure symmetry:
- Measure the distance of nipple to clavicle
- Measure the distance of nipple to midline (sternum)
G
I
E
P
Explain
Strip to waist
I
N
S
P
E
C
T
I
O
N
S
(1) Breast
a. Symmetry
- size Equal on both side?
- shape Overall shape of both side
b.skin condition
- color Pinkish(normal), redness, discoloration, bruises.
- no dimpling Coopers ligament pulled down
- peau dorange Mouth of sebaceous gland blocked
- visible veins
- petechial
haemorrhage
Increase vascularity
- swellings
- discharging sinuses
(2) Nipple
a. Size/ height e.g. about 3-4 cm in height
b. Shape Normal cylindrical
c. Color Pinkish (nulliporous) dark (pregnant)
d. Everted / inverted
e. Cracks / ulcers
f. Discharge (blood, colostrums, milk, pus)
(3) Areola
a. Size
b. Color
c. Montgomery tubercles Few, numerous
P
A
L
P
A
T
I
O
N
(1) Scanning
Palpate quadrant by quadrant
then the axillary tail
(2) Details palpation (if swelling
present)
a. Site
b. Size Estimate the diameter
c. Shape Round, oval, elongated, irregular or well defined
margin
d. Surface
e. Skin over the swelling Color/condition of the skin over the swelling
f. Consistency Soft (lips), firm (nose), hard (forehead)
g. Fixed or mobile
I
N
T
R
O

Permission (GIEP)
+ Wash & Warm hands
+ Lie the patient down in the lithotomy
position with her head at 45 angle.
+ Adequate exposure
G
E
N
E
R
A
L

I
N
S
P
E
C
T
I
O
N

E.g. Mrs. Tan is a middle aged Chinese man of
**Always tell the patient what you
are about to do before you do it.
I
N
S
P
E
C
T
I
O
N
(1) External Genitalia
1. Rash
3. Warts
4. Scars
5. Sinus openings
6. Masses
7. Infestations
8. Other lesions
Announce what you are going to
do and then touch the patient on
the thigh with the back of your
hand before proceeding
1. Rash
(e.g. leucoplakia, redness, -swelling, excoriation) is
due to thrush or trichomoniasis )

(2) Separate the labia
1. Size and shape of clitoris
2. Discharge from urethral
orifice or vaginal outlet
2. Discharge from urethral or vaginal orifice:
Bloody-menstruation, miscarriage, cancer. cervical
Purulent- vaginitis, cervicitis, endometriosis,
retained tampon
NB:
a. Trichomonas vaginalis- frothy,
watery, pale, yellow white
discharge
b. Candida albicans (white
thrush)- thick cheesy discharge
with excoriations and pruritus
(3) Ask her to bear down:
1. Cystocele
1. Cystocele- descent of bladder through anterior
vagina wall
2. Rectocele
2. Rectocele- descent of rectum through posterior
vaginal wall
3. Uterine prolapse 3. Usually in multiple pregnancy
(4) Ask her to cough:
stress incontinence
P
A
L
P
A
T
I
O
N

(1) Clean labia
The 6 procedure of cleaning
+ 1 mons pubis
+ 2 labia majora
+ 2 labia minora
+ 1 on the midline
(2) Gentle palpation
Gently palpate the labia majora
and labia minora for mass
Mass :
Bartholin cyst/abscess in posterior part of labia
majora (normally not palpable)
(3) Internal examination
+ Insert lubricated index and
middle finger into vagina.
+ Avoid contact with the
anterior structures.
+ Place the other hand on the
patients lower abdomen
Do not forget to announce what you are going to do
and then touch the patient on the thigh with the back
of your hand before proceeding.
A. Examine the cervix
1. Palpate the cervix
1. Note for:
+ Size
+ Shape
+ Consistency
+ Position
2. Move cervix from side to side
Say: do you feel any pain?
Move cervix from side to side, and forward to note
for mobility & tenderness 3. Lift cervix forward
Say: do you feel any pain?
B. Palpate the anterior, posterior
and lateral fornices
Ovaries are not palpable. But if mass is present note
the
characteristic
location
C. Bimanual palpation of uterus
Note the:
uterus (anteverted or retroverted)
size
shape
consistency
tenderness
mobility
Function is to palpate the uterus
(if possible)
Large, nodular, mobile uterus - fibroids
Smooth, large - pregnancy, adenomyosis,
Submucous, fibroids
S
P
E
C
U
L
U
M

E
X
A
M
I
N
A
T
I
O
N
(1) Warm and lubricate the
speculum with hot water.
Announce what you are going
to do and then touch the
patient on the thigh with the
speculum to test for the
temperature.
(2) Insert the speculum into the
vagina and open it
Do not move the speculum while it is locked open.
(3) Inspect the cervix
1. Lesions
2. Discharge
(4) OBTAIN THE SPECIMEN
General Considerations
+ Pt must have an empty bladder
+ Pt must be appropriately gowned and draped
+ Use sterile gloves
+ Perineum brightly illuminated by lamp
+ Always tell the patient what you are about to do before you do it
+ Lie pt at 45 in the lithotomy position.
I
N
T
R
O

Permission (GIEP)
+ Wash & Warm hands
+ Lie the patient down with back resting on 30
angle.
+ Adequate exposure abdomen uncovered,
from lower chest to below her hips and place
a sheet over any exposed underwear.
G
E
N
E
R
A
L

I
N
S
P
E
C
T
I
O
N

E.g. Mrs. Chan is a middle aged Chinese man of
**chaperone may needed privacy
explained
I
N
S
P
E
C
T
I
O
N
(1) Nipple and areola Usually enlarged and darkens during pregnancy
(2) Abdominal distension
After 24 weeks fetal movement may be seen.
Indicating viability
(3) Linea nigra
Black line stretches from pubic symphysis upwards
in the midline
(4) Striae gravidum
Red stretch marks of current pregnancy
(5) Striae albicans
White stretch marks of previous pregnancy
(6) Umbilicus
+ Inverted
+ Flat (later stage)
+ Everted (polyhydromnios / multiple
pregnancy)
(7) Scars
Caesarian
P
A
L
P
A
T
I
O
N

(
u
s
u
a
l
l
y

a
f
t
e
r

2
0

w
e
e
k
s
)
(1) Fundal grip
To determine the position of head. Weather it is
breach or cephalic
(2) Lateral grip
To determine the back (vertebral) part of the fetus
and front (hands & legs)
Back Front
+ Hard
+ Smooth
+ Regular
+ Knobby
+ Hollow
+ Irregular
(3) Pelvic grip To determine the engagement of the fetus
(4) Fundal height measurement
Smaller
1. Smoking
2. Deformity
3. Low birth weight
4. Death
5. Low / decrease amniotic fluid
Larger
1. Multipara (twin/triplet)
2. GDM
3. Polyhydrosis
Things to take notes of: (things that we want to know on palpation)
1. number of fetus
2. height
3. lie longitudinal / oblique / transverse
4. presentation head (cephalic) / breech (buttocks) / shoulder
5. position vertex / brow / face
6. fetal heart sound (110-150bpm)
A
U
S
C
U
L
T
A
T
I
O
N
+ Usually after 18 weeks
+ Use the Pincard (fetoscope) or
Doppler
+ Place on the widest par over
the anterior shoulder of the
fetus
+ Facing mothers feet
+ Press gently
+ On Pincard, never touch it!
Renal
System
I
N
T
R
O

Permission (GIEP)
+ POSITION: FLAT with one pillow
+ Adequate exposure
G
E
N
E
R
A
L

I
N
S
P
E
C
T
I
O
N

GENERALS
Mention:
(1) conscious
(2) alert
(3) co-operative
Look for
1. Hyperventilation
[metabolic acidosis]
2. Hiccupping [ uraemic syndrome]
3. Uraemic fetor [uraemic syndrome]
4. Drowsy / comatose [nitrogen or toxin retention]
5. Seizures / coma
[Low serum Ca. nitrogen retention. Also with
overcorrection acidosis with bicarbonate]
6. Twitching [Ca ion imbalance]
SKIN
1. Sallow skin complexion
[dirty brown skin seen in CRF caused due to failure
to excrete urinary pigment]
2. Metallic color
[state grey to bronze color seen in chronic dialysis
patient with multiple transfusion]
3. Subcutaneous nodules [ca ion deposition]
4. Hydration status
Hydration:
1. Sunken orbits
2. Dry mucous membrane
3. Moribound appearance
4. Reduced skin tugor
5. JVP
H
A
N
D
S

(1) Moisture & Temperature
Hypercapnea
(2) Leuchonychia
=opacity of the nails, leaving a rim of pink nail bed
on the top of the nail
Seen in; low albumin level due to :
Liver failure
Malabsorption
Kidney failure
(3) Muehrkes nails
= white transverse lines near the end of nails
Seen in hypoalbuminaemia nephritic syndrome
(4) Mees lines
= single white band
Seen in ARF and arsenic poisoning
(5) Palmar crease pallor
= anemia
Seen in
- CRF
- Poor nutrition
- Blood loss / hemolytic anemia
- BM depression (effect of EPO)
(6) Beaus line (rare)
= non pigmented indented transverse band
Seen in catabolic state
(7) Half-and-half nails (rare)
= distal nail brown or red, proximal nail pink or
white
Seen in CRF
(9) Asterixis hepatic flap Seen in terminal CRF
(10) Scars & fistula and sign of
carpal tunnel syndrome
dialysis
A
R
M
S
(1) Bruising
=>nitrogen retention causing impaired PT
consumption thus causes decrease in platelet factor
III
Seen in CRF
(2) Scratch mark and excoriations Uraemic pruritis
(3) Uraemic frost
Fine white powder present on the skin where high
concentrations of urea have precipitated out of
sweat.
Seen in CRF.
(4) Skin pigmentation
=>failure to excrete urinary pigments
Seen in CRF
(5) Peripheral neuropathy &
Vasculitis
Seen in CRF
(6) Pulse & BP
Hypertension related renal disease.
Postural hypotension in ARF.

E
Y
E
S

(1) Jaundice
Liver hemachormatosis
(2) Pallor Hemolysis causing anemia
(3) Band keratopathy
Ca ion deposition beneath corneal epithelium in line
with interpalpebral fissures
Seen in 2
ndary
or 3
rtiary
hyperparathyroidism and CRF
treatment complication
M
O
U
T
H
(1) Oral trash
(2) Uraemic fetor
(3) Hydration
(4) Jaundice
(5) Mucosal ulcer
CRF
(6) Gingival hyperplasia
Thickening of gums
Complication of treatment for kidney transplant
patient
N
E
C
K
(1) JVP
Intravascular volume status
(2) Jugular vein puncture
Vascular access insertion (vaseath) - hemodialysis
(3) Carotid bruits
Seen in generalized atherosclerosis or CRF
C
H
E
S
T

(
r
a
r
e
)
Observe for
1. inspect for chest wall and
deformities
2. inspect for obvious breast
and skin discoloration
3. symmetry of respiratory
movement
4. visible apex beat
Examine for:
1. symmetrical percussion
2. chest expansion
3. auscultation for added
sound
4. apex beat
5. heart sound
CRF:
+ CCF
+ HPT (Na +H2O retention)
+ Pulmonary oedema (uraemic lung disease,
volume overload, uraemic cardiomyopathies)
+ Pericarditis (pericardial rub or cardiac
temponade)
+ Lung infections (immunosuppression)
A
B
D
O
M
E
N
(do normal abdominal examinations-similar to those in GI)
Pay attention to:
Inspection:
1. Nephrectomy Scars
(May have to roll patient over to
look at posterior aspect)
2. Peritoneal dialysis scars
3. Abdominal Distention
Palpation:
1. Bimanual ballotment (ask the
patient to breath deeply as you
ballot)
[size, surface and consistency]
2. Palpate for enlarged bladder
Percussion:
1. Shifting dullness
2. Percuss for enlarged bladder
Auscultation:
1. Renal bruit 2cm left and right
to umbilicus
Spleen
No palpable upper
border
Has splenic notch
Moves inferior-
medially on inspiration
Not ballot able
Dull on percussion
Friction rub audible
Kidney
Upper border palpable
No notch
Moves inferiorly
Ballot able
Resonance on percussion
Not audible
B
A
C
K
(1) Vertebral column punch
(gentle)
Punch on vertebral column with the base of fist
(2) Murphys kidney punch (the
kidney punch)
Punch at the renal angle for tenderness in infections.
(3) Sacral oedema
L
E
G
S
Look for
1. Oedema
2. Purpura
3. Pruritus
4. Pigmentation
5. Gouty tophi
The details of abdominal examinations in RENAL system
1. Inspection
a. Tenchkhoff catheter = peritoneal dialysis
b. Surgical scars = nephrectomy scars
c. Renal transplant scars = right / left iliac fossa
d. Distended abdomen = large polycystic kidney disease and ascitis (nephritic
syndrome or peritoneal dialysis
e. Scrotum masses
f. Genital oedema (IVC obstruction)
2. Palpation
a. Forward bulging = kidney enlarged
b. Backward bulging = perinephric abscesses
c. Left iliac fossa kidney = transplanted kidney
d. Renal (loin) tenderness = pylonephritis
3. Balloting
a. Left hand (balloting hand)
i. Under renal angle
ii. Finger moves not palm
b. Right hand (examining)
i. Anterior lumbar region
ii. Pressed downwards
4. Percussions
a. Fluid thrill
b. Shifting dullness
c. Percuss for enlarge bladder (percuss on the midline downwards)
d. Auscultatory-percussion
5. Auscultation
a. Bruit
i. Listen with diaphragm
ii. Next ask the patient to sit down to hear better
b. Diastolic bruit
i. Renal artery stenosis
ii. Atherosclerosis
c. Systolic bruit
i. Rarely renal artery stenosis
ii. Maybe from aorta or spleen
Kidney:
1. region = lumbar
2. edges = smooth rounded
3. on percussion = resonance
4. ballotable
*** Palpation
BREATH IN =>> deep and superior
BREATH OUT =>> move to next stage
Musculoskeletal
System
I
N
T
R
O

Permission (GIEP)
+ Sitting down
+ Adequate exposure
G
E
N
E
R
A
L

I
N
S
P
E
C
T
I
O
N

Mention:
(1) conscious
(2) alert
(3) co-operative
(4) distress / restlessness
(pallor)
I
N
S
P
E
C
T
I
O
N
+ 3D inspections (front, side and behind)
+ Start with normal
+ Sitting down comfortably
+ Proper exposure and warm hands
(1) Shape
(a) normal / equal
(b) rounded / deformity
(c) swelling / wasting

(2) Skin
Redness
Discoloration
Scars
Abrasion Shoulder

(3) Attitude
Levels of shoulder
Hanging / supported
(4) Movement
This is done by asking the patient to unbutton his /
her shirt to see if there are any limitations in
movement.
(5) Symmetry Compare the two shoulders
P
A
L
P
A
T
I
O
N
+ Tenderness
+ Exploration
+ Joints
+ tendons
+ ligaments
+ ligaments
+ Bursae
+ compare
Comment on:
+ pain
+ deformities swelling, temperature & mass
+ intact bones
(1) Sternoclavicular Joint
(5) Infraclavicular Fossa
(2) Clavicle (6) Acromion
(3) Acromioclavicular (7) Greater Tuberosity
(4) Spinous (Scapula)
Note: (Extra)
Triangle Of Symmetry
1. Corocoid (Thumb)
2. Acromion (2
nd
Finger)
3. Greater Tuberosity (Middle Fingers)
M
O
T
I
O
N
+ To see if the patient is able / unable to perform certain motion
+ Range of movement
+ 0=anatomical position
+ Comment: range of movement is from zero (0) to on your findings, not
whats the normal
(1) Abduction Look from anterior
(2) Adduction
(3) Extension Look from lateral
(4) Flexion
(5) Internal Rotation Look from posterior
(6) External Rotation Look from anterior
(7) Extension On Internal Rotation
(8) Flexion On External Rotation
S
P
E
C
I
A
L

T
E
S
T
(1) Apprehension test
= 90 abduction and light extension
PLUS 90 external rotation
Done in shoulder dislocation
(2) Neers test (RARE!)
Bursitis - subacromial impingement
- acromion processes impinge on bursa
(3) Hawkins test (RARE!)
Rotator cuff injuries
I
N
T
R
O

Permission (GIEP)
+ Lie down flat
+ Adequate exposure
G
E
N
E
R
A
L

I
N
S
P
E
C
T
I
O
N

weight, built, nutrition Comment especially on:
+ Pallor
+ Pain
+ Distress
I
N
S
P
E
C
T
I
O
N
+ 3D inspections (front, side and behind)
+ Start with normal
+ Proper exposure and warm hands
(1) Shape
(a) normal / equal
(b) rounded / deformity
(c) swelling / wasting
(2) Skin
Redness
Discoloration
Scars
Abrasion Shoulder
Laceration
(3) Attitude
Standing / supine
(5) Movement Gait
Ask the patient to walk.
Antalgic gait
= associated with painful leg or foot
Short leg gait
= the patient will dip down the short leg on walking
or bear weight bearing
Scissor gait
= legs are adducted. Seen in cerebral palsy
Waddling gait
= proximal myopathy
High stepping gait
= foot drop
Trendelenburg's
= pelvis tilts down to the opposite site instead tilts
up. Seen when hip is painful, weak, dislocated or
fractured
Stiff leg
= whole leg swung outwards to clear ground to
compensate (circumduction). Seen when hip /
knee arthrosed or cannot bend.
(6) Symmetry Compare the two hips on standing.
P
A
L
P
A
T
I
O
N
+ Tenderness
+ Exploration
+ Skin temperature
Comment on:
+ pain
+ deformities swelling, temperature & mass
+ intact bones
(1) Pubic Symphysis
(6) Femur Head
(2) Pubic Crest (7) Ischial Tuberosity
(3) Pubic Tubercles (8) Iliac Tubercle
(4) ASIS (9) Iliac Crest
(5) Greater Trochanter
Note: (extra)
Some of us did muscle on palpation which includes; gluteus, quadriceps, adductors and
hamstrings.
M
O
T
I
O
N
+ To see if the patient is able / unable to perform certain motion
+ Range of movement
+ 0=anatomical position
+ Comment: range of movement is from zero (0) to on your findings, not
whats the normal
(1) Abduction Look from anterior
(2) Adduction
(3) Extension Look from lateral
(4) Flexion
(5) Internal Rotation Look from posterior
(6) External Rotation Look from anterior
(7) Extension On flexion of knee
(8) Flexion On flexion of knee
M
E
A
S
U
R
E
M
E
N
T
**square the pelvis first!!
(2) True length
ASIS to upper part of medial
maleolus
(3) Apparent length
xiphisternum to upper part of
medial maleolus
see next page (extra) for more info
Fig. 10.41 True and apparent lengths of the lower
limbs.
Apparent length
True length
True shortening
Seen in:
Can be due to old fractures of
femur or tibia.
Apparent shortening
Seen in:
Adduction contracture of the hip
which has to be compensated for
by tilting of the pelvis.
S
P
E
C
I
A
L

T
E
S
T
(1) Thomas test
The test must be performed with
the patient lying face up a hard
surface.
+Place your left hand palm upwards
under the patient's lumbar spine.
+Passively flex both the patient's
legs (hips and knees) as far as
possible.
+Keep the non-test hip maximally
flexed (you will feel that the
lordotic curve of the lumbar spine
remains eliminated). Now ask the
patient to extend the test hip.
+Incomplete extension in this
position indicates a fixed flexion
deformity at the hip
+Picture on right shows Thomas test
on left leg.
Thomas's test measures fixed flexion deformity (inco-
mplete extension). This deformity may be masked by
compensatory movement at the lumbar spine or pelvis
and increasing lumbar lordosis.
(2) Trendelenburg's test
+ Stand in front of the patient and
ask the patient to stand on one
leg for 30 seconds and to repeat
with another leg.
+ Normally, the iliac crest on the
side with foot off the ground
should rise.
+ The test is abnormal if the
hemipelvis falls below the
horizontal line.
+ It maybe caused by gluteal
weakness or inhibition from hip
pain e.g. osteoarthritis or
structural abnormality e.g. coxa
vara
Trendelenburg's sign. Powerful gluteal muscles maintain the
position when standing on the left leg; weakness of the gluteal
muscles results in pelvic tilt when standing on the right
(3) Straight leg test
Greater trochanter
Site of shortening
The exact site of shortening is important. Firstly it is important to determine if it is above or
below the knee. This is best assessed by flexing both knees to 90, as illustrated.
Normal
Above the knee Below the knee
Shortening above the knee
In assessing shortening above the knee, it is important to decide whether it occurs above the greater
trochanter, or below the trochanter in the femoral shaft itself
Shortening above the greater trochanter can be determined by:
1. Placing one's thumbs on the AS IS with the middle fingers on the tip of the greater
trochanters (both side) and compare, using the sense of proprioception (muscle sense).
2. Bryant's Triangle is drawn as follows. The patient lays supine and a line drawn from the
ASIS down towards the bed. A second line is then drawn from the ASIS to the tip of the
greater trochanter. The third side of the triangle is a horizontal line, drawn proximally
from the greater trochanter in the line of the femur to meet the first line drawn. This third
line shows the amount of upward or downward displacement of the hip compared to the
normal side.
Normal Superior displacement Inferior displacement
ASIS
1. CERVICAL
I
N
T
R
O

Greet, Introduce, Explain, Permission (GIEP)
+ Sitting down
+ Adequate exposure
I
N
S
P
E
C
T
I
O
N
(1) Swelling

(2) Skin
Redness
Discoloration
Scars
Abrasion Shoulder

(3) Neck deformity

(4) Torticolis
Torticollis / wryneck
muscles of the neck contract ~ neck is
twisted to an unnatural position
cause:
-protective spasm due to trauma
-tonsillar infection
-vertebral body disease
-sternomastoid tumor (infant)
(5) Congenital webbing of the neck
Webbing of the neck
Absence of 1 or more cervical
vertebrae
e.g. Turner's Syndrome
(6) Symmetry
Check asymmetry in supraclavicular
fossa
P
A
L
P
A
T
I
O
N
+ Tenderness
+ Swelling
Comment on:
+ pain
+ deformities swelling,
temperature & mass
+ intact bones
M
O
T
I
O
N
(1) Extension look up Look from lateral
(2) Flexion look down
(3) Rotation look to right / left Look from above
(4) Lateral flexion - ask patient to tilt head onto Look from anterior
his right / left shoulders
*abnormalities may be due to cervical spondylosis
2. THORACIC & SACRAL
I
N
T
R
O

Greet, Introduce, Explain, Permission
(GIEP)
+ Standing
+ Adequate exposure
I
N
S
P
E
C
T
I
O
N
(1) Deformities
+ Scoliosis = lateral bending
+ Kyphosis = AP bending
+ Gibbus = localized kyphosis
+ Lumbar curvature / lordoisis
+ Swelling
Gibbus: TB of spine
(2) Skin
Scars
Sinuses
Color change
Hair tuft
Discoloration
Dimpling at base of spine
Soft tissues swelling

1. Hair tuft. discoloration or dimpling at
the base of the spine indicates spina
bifida
2. Soft tissue swelling may be due to:
-infection
-trauma
-tumors
P
A
L
P
A
T
I
O
N
Comment on:
+ pain
+ deformities swelling, temperature
& mass
+ intact bones
Feel for bony contour
(1) Tenderness
Seen in:- fracture
- TB
- Infection
(2) Muscle wasting
(3) Muscle pain
(4) Steps
M
O
T
I
O
N
(1) Extension
- lean backwards
(2) Flexion
- touch your toes with your knees straight
(3) Lateral Flexion
- slide your hands at the side of your hip
try to touch your knee
(4) Rotation
- ask the patient to sit and to twist around
to each side
S
P
E
C
I
A
L

T
E
S
T
(1) Schobers Test
+ A point is marked 10cm above a
line connecting the dimple of
Venus.
+ 5cm below the line
+ Upper end is anchored.
+ Ask pt to try and touch toes (flex).
Norm >5-10cm
Pathology indicates ankylosing spondylitis

(2) Straight Leg Raising Test
Stretch Test Sciatic Nerves
(A) neutral position
(B) straight leg raising limited by prolapsed
disc
(C) tension increased by dorsiflexion of foot
(D) root tension relieved by flexion at knee
(3) Stretch Test Femoral Nerves
Nervous
System
I
N
T
R
O

Permission (GIEP)
+ Sitting
+ Adequate exposure
I
N
S
P
E
C
T
I
O
N

(1) Overall about the patient (e.g. position, gaitetc)
(2) Muscle bulk
(3) Muscle wasting
(5) Involuntary movement
- Tics/twitches
- fasciculation
- tremors
T
O
N
E
*
*

a
s
k

t
h
e

p
a
t
i
e
n
t

t
o

r
e
l
a
x
(1) Upper limb
- Test muscle tone at the
shoulder, elbow, joint, and
wrist joint.
Say: Let your arms go loose
and let me move them for you.
+ Flex and extend wrists passively (to elicit
cogwheel rigidity)
+ Flex and extend at the elbows, pronate and
supinate at the forearm (to elicit the lead-pipe
rigidity and clasp-knife spasticity)
(2) Lower limb
Test tone by internally and
externally rotating the resting leg
and by raising the knee off the
bed.
Say: Let your leg go loose and
lax, and let me move it for you.
+ Passively flex and extend the leg at the knee and
hip.
+ Roll the extended leg, feeling for resistance.
+ Put your hand behind the knee and pull it
upwards, observing the foot to check whether or
not it flops.
+ If there is spasticity and increased tone, then test
for ankle clonus and patellar clonus.
(3) Patella clonus
With the pt in the supine
position, grasp the upper
edge of the patellar
between the thumb and
index finger and apply a
quick constant pressure in
a downwards direction.
+ In upper motor lesion the patella may manifest a
few jerks (unsustained clonus) or a constant
jerking as long as the pressure is applied.
(sustained clonus) *avoid prolonging this
maneuver as it is often painful to the pt
(4) Ankle clonus
- Ensure that the pt's knee is
semi-flexed and the foot
relaxed.
- The foot is suddenly
pushed dorsally with
moderate force and held
there.
+ In the upper motor lesions the posterior
muscles of the leg will enter into a persistent
contraction.
P
O
W
E
R
UPPER LIMBS
(1) Shoulder abduction: 'hold
your arms outwards at your
sides and keep them up, don't
let me stop you'
Chief movers: deltoids C5
(2) Shoulder adduction: 'push
your arms in towards you and
don't me stop you'
Chief movers: pectoral muscles C6-8
(3) Elbow flexion: 'bend your
elbows and pull me towards
you, don't let me stop you'
Chief movers: biceps C5
(4) Elbow extension: straighten
your elbows and push me
away, don't let me stop you
Chief movers: triceps C7
(5) Wrist extension: 'clench your
fist and cock your wrists up,
don't let me stop you'
Chief movers: C7
(6) Wrist flexion: 'now push the
other way'
Chief movers: C7
(7) Finger abduction: 'spread
your fingers wide apart and
don't me push them together'
Chief movers: dorsal interossei TI
(8) Finger adduction: 'hold
this piece of paper your
fingers and don't me snatch
it away'
Chief movers: palmar interossei TI
LOWER LIMBS
(9) Hip flexion: 'lift your leg
straight up and keep it there,
don't me stop you'
Chief movers: iliopsoas Ll-2
(10) Hip extension: 'push your leg
downwards into your bed and
Chief movers: glutei L4-5
(11) Hip adduction: 'push your
thigh inwards against my
hand'
Chief movers: adductors of the thigh L2-4
(12) Knee flexion: 'bend your
knee and pull your heel
towards you, don't let me stop
you'
Chief movers: hamstrings L5-S1
(13) Knee extension: 'Straighten
your knee and don't let me
stop you'
Chief movers: quadriceps L3-4
(14) Plantar flexion: 'push your
foot downwards against my'
Chief movers: gastrocnemius S 1
(15) Dorsiflexion: 'move your foot
up and don't let me stop you'
Chief movers: tibialis ant and long extensor L4-5
(16) Inversion of the foot: 'push
your foot inwards against my
hand'
Chief movers: tibialis ant and post L4
(17) Eversion of the foot: 'push
your foot outwards against my
hand'
Chief movers: extensor hallucis longus L5
(18) Extension of the great toe:
'pull your toe upwards and
Chief movers: extensor hallucis longus L5
R
E
F
L
E
X
E
S
(1) Biceps
-Place the pt's hands on his/her
abdomen.
-Place your index finger on the
biceps tendon and swing the
hammer on to your finger.
Nerve: musculocutaneous n.
Root: C5
(2) Brachioradial
-Place the arm flexed on to the
abdomen, place the finger on
the radial tuberosity, and hit
the finger with the hammer.
Nerve: radial n
Root: C6
(3) Triceps
-Draw the arm across the chest,
holding the wrist with elbow
at 90 degree.
-Strike the triceps tendon
directly with the tendon
hammer
Nerve: radial
Root: C7
(4) Knee
-Place the arm under the knee
so that the knee is at 90
degree.
-Strike the knee below the
patella.
Nerve: femoral
Root: L3-L4
(5) Ankle
Hold the foot at 90 degree with
a medial malleolus facing the
ceiling.
-The knee should be flexed and
lying to the side.
-Strike the Achilles tendon
directly.
Nerve: tibia
Root: SI-S2
(6) Abdominal
Scratch the abdominal wall
Afferent: segmental sensory nerve
Efferent: segmental motor nerve Root:
1. above the umbilicus (T8T9)
2. below the umbilicus (TIO-TII)
(7) Plantar
-Explain to the pt that you are
going to stroke the bottom
part of his foot.
-Gently draw a stick up a
lateral border of the foot and
across the foot pad.
-Watch the big toe and the
remainder of the foot.
Positive Babinski's sign
1. Hallux extends, the other toes spread.
2. Indicates UMNL.
Reinforcement
- If any reflex is unobtainable directly ask pt to reinforcement maneuver.
- In the arms, ask the pt to clench his teeth as you swing the hammer.
- In the legs, ask pt either to make a fist, or to link hands across his chest and pull
one against the other, as you swing the hammer.
C
O
O
R
D
I
N
A
T
I
O
N
1) Supination-pronation
2) Finger to nose
3) Toe to finger
4) Heel-knee-shin
VI Simple concept for motor
examination
By Dr. Htin Aung
I. Bulk
- Shape
- Wasting
- Convexity
- Comparisons
- Feel (inspection + palpation)
- UL=shoulder (e.g. deltoid)
- LL= hip (e.g. gluteus)
- Comment on:
i. Shape
ii. Formation
iii. Equal on both side
II. Involuntary movement
1) Fasciculation
a. Contraction of individual muscle bundles
b. Twitching
c. Bring about movement of limb
d. Seen in LMN lesion
2) Tremors
a. Resting
i. Pill rolling
ii. 5 Hz ( 5 times per seconds)
iii. Parkinson
b. Positional
i. Fine / flapping
ii. Flexion / extension
iii. 10 Hz
iv. Seen in: hyperthyroidism, sympathetic over activitiesetc.
c. Intentional / action
i. Putting a string into a needle
ii. Cerebella lesion
3) Tics
- Predictable muscular movement
- Causes unwanted motion and embarrassment
- Usually affect the upper limb
4) Dystonia
- Phasic, unpredictable movement
- Usually affect the upper limb
5) Chorea
- Ceaseless occurrence of rapid, jerky, dyskinetic involuntary movement
- Upper limb
- Faster
- Rhythmic
- Dance like
6) Athetosis
- Smoother
- Slower
7) Myoclonic jerk
- Strong and contractions of flexors & extensors
- epilepsy
8) Hemibalistic
a. explosive
III. Tone
= tension in the muscle due to partially contracting muscles
= it is the resistance offered by a muscle to pressure and stress
= q: cogwheel (extrapyramidal tract lesion) or lead pipe (UMNL)
= +: LMNL
IV. Power
= the ability to contract / make a movement
= normally test the ISOMETRIC CONTRACTION
= Do only one; either isometric / isotonic!!
V. Reflex
= exposed the part to be tested
= ask the patient to relax or do the reinforcement
= hold the tip of tendon hammer
= use the flex, not the wrist
= identify the tendon
= 7 spots namely (biceps, triceps, brachioradialis, abdominal, patella, tendo-achilis,
plantar)
VI. Coordination
1) Supination-pronation
2) Finger to nose
3) Toe to finger
4) Heel-knee-shin
C
O
T
T
O
N

W
O
O
L

(1) Light touch testing (posterior column & anterior spinothalamic tract)
- Touching the skin with
cotton wool
- Test it on anterior chest
with patient's eyes open
- Test each dermatome
- Always compare both sides
1. I'm going use this cotton wool to touch on your
skin
2. Can you feel it? (testing on the chest first)
3. Say "yes" when you can feel it
4. Please close your eyes (important!)
5. Are they the same in both sides?
6. Light touch sensation is normal/ reduced/ absent
P
I
N
-
P
R
I
C
K

(
r
a
r
e
l
y

d
o
n
e
)
(2) Pain (pinprick) testing (lateral spinothalamic tract)
- Use new pin or sharp stick
- Test it on chest with
patient's eyes open
- Sharp or dull
- Test each dermatome
- Compare right and left
1. I'm going to use this pin/stick to test your pain
sensation
2. This is sharp, and this is dull, can u differentiate
it? (chest)
3. say 'sharp' or 'dull'
4. please close your eyes
5. Are both sides the same?
6. Pain sensation is normal/ reduced! absent
V
I
B
R
A
T
I
O
N

(
1
2
8

H
z
)
(3) Vibration testing (posterior column)
- Use 128Hz tuning fork
- Let patient feel for it on the
chest
- Place it on the distal
interphalangeal joints
- If distal part sensation lost,
proceed to proximal joint-
wrist, elbow, shoulder
- Compare
1. I'm going to do a vibration test on you (place
it on the chest)
2. Can you feel that vibration?
3. say 'yes' when you can feel it, say 'stop' when
it disappear
4. please close your eyes
5. vibration sensation is normal / reduced/ absent
J
(4) Propioception testing (posterior column)
- Use distal interphalangeal
joint of index finger
- Stabilize the proximal
phalanx, move distal phalanx
up and down
- Tell patient which is up and
which is down with eyes open
- Ask patient close the eyes and
repeat 'up and down
movement' randomly
- Sense of position will loss
before movement
- Little finger is affected before
the thumb
1. I'm going to test your joint position
2. this is 'up' and this down
3. Please tell me this is up or down?
4. Sense of position is intact / lost
O
l
f
a
c
t
o
r
y
[
s
e
n
s
o
r
y
]
1. Smell:
Do you have runny nose?
Can you please close your eyes
and either nostril?
Please smell and identify.
Ask the patient to identify the smell.
Close one of the nostrils, and do with the patient
closing eyes.
- Coffee
- Flower
- Chocolates
O
p
t
i
c

1. Far Vision
+ Far vision test
+ Close one eye
+ Use Snellens chart
+ To determine farsighted / nearsighted
+ Report on fraction e.g. normal 20/20
2. Near Vision
Small print reading (e.g. newspaper)
Focal length (30cm)
To determine farsighted / nearsighted
3. Color
- Use Ishiharas chart
- To determine color
blind
- Ask the number or ask
to follow the lines
4. Visual Field
Instruction:
- Im going to test on your
field of vision
- Im going to compare
my and your field of vision,
assuming mine is normal
- Please look at my nose
bridge all the time
- I will move my finger
inwards, tell me once you
see it
+ Distance of about 1 arms length
+ Confrontation method
+ Close one eye
+ Close your eye too!! practice needed
+ See in EXTRA for explanation of abnormal
findings
5. Direct Light Reflex
This is done in dim or less bright room
Shone light from the side
Brief exposure of light on the eye
See the changes in size of pupils
6. Consensual Light Reflex
- Ask the patient to put hands on the nose (nose
bridge)
- This is to minimize light shone to the testing eye
- Shine light on right eye, left eye show changes
in pupil size
7. Accommodation Reflex
Instruction:
- Could you please look
as far as possible
- Now look at my finger
Accommodation reflex:
1. Convergence
2. pupil constriction
3. thickened lens (cannot be seen
8. Fundoscopy
3
,
4
,
6
[
m
o
t
o
r
]
1. H test
Instruction:
-I need to test the movement
of your eyes
-I need you to keep your
head still
-And please follow the
movement of my fingers
-Fingers put about 18 inches
away
Comment on:
1. Nystagmus
2. Diplopia (ask the patient while doing)
Sensory (major):
1. Touch (cotton wool)
2. Pain (pinprick)
Compare. Test at sternum or fingers
T
r
i
g
e
r
m
i
n
a
l

[
s
e
n
s
o
r
y

+

m
o
t
o
r
]
Motor:
1. bulk
2. involuntary movement
3. tone
4. power
5. reflex
Muscle:
1. Masseter Clench Teeth
2. Pterygoids Open Mouth
3. Temporalis
Power:
1) Open mouth push up and side to side
2) Close mouth open it!
Reflex:
1. Jaw Jerk
Open mouth, relax, put thumb in midline, tap
the thumb
2. Corneal Reflex
Explain that it will be uncomfortable, ask
patient to look far, come from side, cotton just
touch cornea.
F
a
c
i
a
l
[
m
o
t
o
r

+

s
e
n
s
o
r
y
]
Sensory (minor):
Sensation of anterior 2/3 of tongue
Motor (major):
1) Bulk check for symmetry
Angle of eye at the same level
Nasolabial fold at the same level
2) Involuntary movement Fasciculation & tics
3) Power:
+ Look up to wrinkle your forehead
+ Shut your eyes tightly and stop me from
opening them
+ Puff out your cheeks
+ Smile & show me your teeth
1. Whispering Test
+Close one ear
+Whisper from the back / side
+Ask the patient to repeat (e.g. 1,1,2,9)
+You can also do this test by destruction, that is, by
destructing the other ear while whisper at the
other( see Talleys video)
2. Rinnes Test
Use 256 Hz tuning fork or 512 Hz
Hit (vibrate) the tuning fork then put on the
mastoid
Process (just behind the ear)
Tell me if you hear sound
Tell me when it stops
Then put beside the ear
Do you hear any sound?
Result:
Abnormal = louder on mastoid process
Conduction deafness
E.g. inflammation, fibrosis & perforation of
tympanic membrane.
** remember air conduction is better than bone
conduction
3. Webers Test
-Hit(vibrate) the tuning fork then place it on center
of forehead
-Ask pt if they can hear on both sides
Result:
-In conduction deafness, it will be louder on the
affected side
-In nerve deafness, sound is absent
G
l
o
s
s
o
p
h
a
r
y
n
g
e
a
l
&

v
a
g
u
s
1. Hoarseness of voice
Recurrent laryngeal nerve (vagus)
Ask the patient to speak
Observe for hoarseness
2. Palate & uvula
Open your mouth
Put out your tongue
Say aaaahhh
Observe the movement of uvula
Normal = symmetrical move upwards
3. Gag reflex (RARE!)
+ Sensory (glossopharyngeal)
+ Motor (vagus)
4. Taste (RARE!) Posterior 1/3
Muscle:
1. Sternocleidomastoid
2. Trapezius
A
c
c
e
s
s
o
r
y

[
m
o
t
o
r
]
1. Bulk
+ Look and ask the patient to look to the side
+ Bulk is normal
+ Hypertrophied?
+ Wasting
+ Symmetry
2. Involuntary movement
Fasciculation
Tremors
Tics
3. Tone
Move head side to side
Shoulder up and down
Comment about the tone
4. Power
- SCM = turn your head against my hand. Note
the SCM contraction.
- Trapezius = shrug your shoulders, push up
hard
H
y
p
o
g
l
o
s
s
a
l
[
m
o
t
o
r
]

1. Bulk
Size (wasting?)
Positions
Symmetrical
2. Involuntary movement Fasciculation
Tremors
3. Power
- Up
- Down
- Side to side along the lips
- Press against cheek
Numerator / denominator (e.g. normal = 20/20)
Numerator = patients
Denominator = normal
20/70 = patient/normal LINE 3
Patient can read from 6m what a normal person
can read from 6m [NORMAL]
Normal person can read at 70 feet, but patient can
read at 20 feet [NEAR SIGHTED]
Normal person can read at 13 feet, but patient can
read at 20 feet [LONG SIGHTED]

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