ILMU PENYAKIT DALAM

ADMINISTERING INJECTIONS
No Procedure

Assessment
1 Assess medical record to identify patien identification and whether any medications
are to be given to an individual patient
2 Do informed consent
Planning
2 Gather (set up) equipments
3 Select appropriate needle and syringe to be used
4 Wash your hands
5 Use gloves
Implementation
6 Check name of medication to be given from medical record
7 Take vial from shelf or drawer and Check label on medication: name,preparation of
drug,temperature,rute ofadministration,expired date
8 Preparing dosage as indicated on medical record
9 Draw up correct dosage of medication from vial:
- Open the seal of vial
- Clean top of vial and allow to dry
- Remove needle guard (one hand technique)
- Insert needle into vial through rubber stopper (vial on the table)
- Pick up vial with non dominant hand
- Withdraw correct volume of medication
- Remove syringe from the vial and recap the needle (with one hand technique)
- Examine for air bubbles and expel them
- Recheck volume of medication for accuracy and change the needle with another
one. Push a bit of drug to the tip of the needle.
- Re-examine vial to check the label and reassuring the dosage
- Place syringe, needle, and alcohol swab, medical record on cart
10 Approach and identify patient
11 Ask the patient to take a proper position as needed on examination table and
uncover the proper area.
12 Ask permission to touch the site of injection
13 Select the appropriate site for injection by identifying anatomical landmark
Give the injection :
14 Clean area with alcohol wipe, using circular motion, clean from inside outwards
14 Allow site to dry
15 Remove needle guard (one hand technique)
16 Re-check if there any bubbles and if dosage is correct in syringe
17 Say Basmallah
18 Insert the needle :
at a 90 degree angle (5/8 needle)
pull back on plunger*, if blood is visible, reposition the needle
inject the medication slowly
 withdraw needle quickly and wipe the area with alcohol swab.
Recap the needle with one hand technique
19 Cover the injection area with gauze
20 Return patient to a comfortable position
19 Place needle and syringe in the disposals (kidney dish)
Evaluation
20 Evaluate the patients condition 15 minutes after administering medication, note any
response to medication
Documentation
21 Documentation the following :
a.Date and time of administering medication
b.Dosage and type of injection
c.Patients response to medication
d.Name and signature of operators
IM INJECTION
No Procedure
1 Say Basmalah
2 Explain the procedure (informed) Get the patient agreement (consent)
Assessment
3 Assess medical record to identify patien identification and whether any medications
are to be given to an individual patient
Planning
4 Gather (set up) equipment
5 Select appropriate needle and syringe to be used
6 Wash your hands
7 Use gloves
Implementation
8 Check name of medication to be given from record
9 Check label, expired date, temperature, ROA on medication
10 Calculating & preparing dosage
11 Draw up correct dosage of medication from vial:
- Open the seal of vial
- Clean top of vial and allow to dry
- Remove needle guard with one hand technique
- Insert needle into vial through rubber stopper (vial on the table)
- Pick up vial with non-dominant hand
- Withdraw correct volume of medication
- Remove syringe from the vial and recap the needle with one hand technique
- Examine for air bubbles and expel them
- Recheck volume of medication for accuracy and change the needle with another
one.
- Re-examine vial to check the label and reassuring the dosage
- Place syringe, needle, and alcohol swab, medical record on cart
12 Approach and identify patient
13 Ask the patient to take a proper position as needed on examination table and
uncover the proper area
14 Ask permission to touch the site of injection
15 Select the appropriate site for injection by identifying anatomical landmark (
lateral third of SIAS to coccyx imaginary line ) *
Give the injection :
16 Clean area with alcohol wipe, using circular motion, clean from inside outwards
17 Allow site to dry
18 Remove needle guard (one hand technique)
19 Re-check if there any bubbles in syringe
20 Insert the needle:
at a 90 degree angle perpendicular
pull back on plunger (aspiration)
inject the medication slowly
withdraw needle quickly and swab/cover with alcohol wipe
Recap the needle with one hand technique*
Return patient to a comfortable position
Place needle and syringe in the disposals (kidney dish)
Evaluation
21 Evaluate the patients condition 15 minutes after administering medication
Documentation
22 Documentation the following:
a. Date and time of administering medication
b. Dosage and type of injection
c. Patients response to medication
d. Name and signature of operators
INTRACUTAN AND SUB CUTAN INJECTION
Intracutan (IC) Injection:
1. Stretch the skin out flat with your left thumb and forefinger.
2. Lay the syringe and needle almost flat along the skin.
3. Insert the tip of the needle just under the surface but in the thickness of the skin
just past the bevel.
4. Keep the needle FLAT along the skin, so that it goes into the top layer of the skin
only. Keep the bevel of the needle facing up.
5. Do not push too far and do not point down or the needle will go under the skin.
Then it will be subcutaneous instead of the intradermal injection.
6. To hold the needle in position, put your thumb on the lower end of the syringe near
the needle, but do not touch the needle.
7. Hold the plunger end of the syringe between the index and middle finger of your
right hand. Press the plunger in with your right thumb.
8. Inject 0.05 ml of vaccine and remove the needle.
Intramuscular (IM) injection in thigh
1. Gently stretch the skin flat between your thumb and forefinger.
2. Insert the needle at a 900 angle.
3. Quickly push the entire needle straight down through the skin and into the muscle.
Inject slowly to reduce pain.
Subcutaneous (SC) injection
1. Hold the syringe in one hand like pencil or a dart
2. Grasp the skin between the thumb and index finger with your other hand and pinch up.
3. Quickly thrust the needle all the way into the skin. Do not push the needle into the
skin slowly or thrust the needle into the skin with great force. Do not press down on the
top of the plunger while piercing the skin.
4. Insert the needle at a 45-degree angle.
After the needle is completely inserted into the skin, release the skin that you are
grasping. Press down on the plunger to release medication into the subcutaneous layer
in a slow, steady pace.
5. As the needle is pulled out of the skin, gently press a 2 x 2 gauze onto the needle
insertion site. Pressure over the site while removing the needle prevents skin from
pulling back, which may be uncomfortable. The gauze also helps seal the punctured
tissue and prevents leakage,
6. It is not serious if you notice blood at the site after the needle is removed. You may
have nicked a surface blood vessel when you injected, and blood is following the
needle track out to the surface. Simply press the site with a 2 x 2 gauze pad. Also, a
small amount of clear fluid may appear at the site. This may be medication that is
following the needle track to the surface. Again, apply pressure using a 2 x 2 gauze
pad.
TAKING A 12-LEAD ECG
No Procedures

Communication with patient

1 Greet the patient respectfully and with kindness, introduce yourself
Check patient identity including name, sex, age, medical record, and chief
2
complaint or clinical history.
3 Acquires verbal consent with explanations of procedure.
4 Ask the patient to lay down on the examination table
Preparation
You must ensure that the following have been checked:
The machine is plugged in or that the battery has been fully charged
5
All leads are secured correctly, are clean and in good working order
There is paper in the device
Setting ECG machine:
Press power button
Standard setting (date & time)
Filter is used (to help rule out interference)
Display channel (1 channel+rhythm)
ECG mode (manual recording mode)
6 Recording channel (1 channel+rhythm)
Check the speed on the ECG machine. It should be set to the standard reading
of 25 mm/second, unless you are instructed otherwise.
When performing the ECG, if part of a wave extends beyond the paper, reduce
the normal standardization to half standardization. Note this adjustment on the
ECG strip.
Ensure that calibration is set to 1mV
7 Wash hands
Applying electrodes
8 Electrodes should be fully in contact with the skin. If there are gross problems (e.g
sweating or hairy) appropriate measures should be taken.
If necessary, shave excess hair. Shaving is usually not necessary, but excess hair
will interfere with electrode adherence to the skin. Remove skin oil with the
alcohol sponges. Allow to dry. Rub the area of electrode placement briskly with
the 4 x 4 sponge to abrade the area slightly. The area will appear slightly red. This
removes dead skin cells, promoting better contact.
9 Attach the correct lead wire to each electrode.
10 Apply electrode gel or keratin cream at the electrode site to promote conductivity
electrodes. Make sure the electrode gel or keratin cream on these different parts of
the chest does not overlap or touch.
 Apply electrodes to the limbs several centimeters above the wrist and ankle.
Right arm lead wire is red, and labeled RA or R
11 Left arm lead wire is yellow, and labeled LA or L
Right leg lead wire is black, and labeled RL or N
Left leg lead wire is green, and labeled LL or F
12 Apply electrodes to the chest.
Avoid positioning the electrodes directly on bone, which will cause interference.
In the female, position the electrodes below the breast tissue. If the breasts are
large, you may have to position the breast laterally.
Palpate the clavicle (collarbone), which is considered the rst rib. Continue
palpating downward to the fourth rib. Move down slightly to the space between
the fourth and fth ribs.
Position lead V1 (red-white/C1) on the fourth intercostal space at the right
sternal border.
Position lead V2 (yellow-white/C2) directly opposite V1 on the fourth
intercostal space at the left sternal border.
Position lead V4 (brown-white/C4) on the fth intercostal space at the
midclavicular line.
Position lead V3 (green-white/C3) midway between V2 and V4.
Position lead V5 (black-white/C5) on the fth intercostal space at the left
anterior axillary line.
Position lead V6 (purple-white/C6) on the fth intercostal space at the left
midaxillary line.
13 Check the patients hands or feet do not contact with metal objects or metal bed.
14 Ask the patient to lie still and breath as normally as possible.
Recording ECG
15 Press button to acquire/record the ECG.
Check the tracing quality. If artifact is present, try to correct the problem. It may
be necessary to repeat recording ECG.
16 Write the patient identity in the ECG record.
17 Remove the lead wires and electrodes. Clean the conductive gel or keratin cream
from the patients skin.
18 Ensure patient comfort/thanks patient
19 Clean the leads with an approved solution.
20 Wash hands
INSERTING NASOENTERIC TUBE
No. Procedure
Preparation
1. Check all the equipment required and have a good condition :
- Nasoenteric Tube
- Stylet
- Hand gloves
- Lubricant
- Aquadest
- Stetoscop
- Syringe 10 cc
- Steril Drape
- Lamp/ penlight
- Plester
- Scissor
- Clamp
2. Explain the procedure and its goals to the patient.
3. Wash your hands with antiseptic soap
4. Dry and warm your hands with tissues
Implementation
1. Provide privacy
2. Explain procedure and its purpose
3. Place patient in sitting position with neck flexed slightly and head of bed elevated
to 45 degrees (semi fowler)
4. Inspect nares and determine optimal patency by having the patient breathe through
one nostril while the other is occluded temporarily.
Clean the nares if dirty using steril gauze
5. Wash hand and using steryl hands gloves
6. Place the drape to the patients chest
7. Estimate distance for placement into stomach by measuring the length from the tip
of the nose to the earlobe and then from the earlobe to the xiphoid process.
9. Observe marking on shaft of tube for guidance or with clamp
10. Lubricate stylet about 10 cm and insert into feeding tube
10. Lubricate chosen nostril with water-soluble lubricant.
11. Lubricate the end of the tube or activate the self lubricant with water and pass it
posteriorly
12. If The patient is alert and cooperative, ask him or her to swallow water to facilitate
tube passage
13. Once the tube is beyond the nasopharynx, allow the patient to rest
14. Have the patient flex the neck and swallow while the tube is advanced
15. If the patient begins to cough, withdraw the tube into the naso pharinx, and then
reattempt passage.
16. Confirm the passage into stomach by aspiration of gastric contents first with 2
technique :
1. Looking gastric content, end of NGT drawn to aqua
 2. Using spuit given air follow NGT and hearing the air buble through stetoscop
on epigastric position
and then abdominal x-ray film.
17. Secure tube to bridge of nose or upper lip with nonallergic tape or tube attachment
device.
18. Observe the gastric content (is it blood, mucus,etc)
DIGITAL RECTAL EXAMINATION
No Procedure
Introduction
1. Introduce yourself politely
2. Identify the patient correctly
Assessment
1 Assess the indications and contraindications of doing DRE to the patient
2 Ask the patient that he/she has been informed about DRE
Planning
1 Examine with assistant help. If possible examiner should have the same gender
with patient. Conduct the examination with good privacy.
2 Ask the patient to take off his/her underwear.
3 Help the patient to lay on the bed and in the litotomi position for DRE
4 Use the penlight/stand lamp to lighten buttock area
5 Wash you hand and Use the gloves
6 Wipe the perianal with wet gauze
7 Apply jelly to the index finger
Performing
1 Say Basmalah
2 Examiner position besides the patient
3 Assess patient position whether it is appropriate or not
4 Inspect the sacrococcygeal and perianal areas for lumps, ulcer, inflammation,
rashes, excoriation, fissure.
5 Touch at perianal (avoid vagal reflex) with middle finger and thumb
6 Insert the lubricated index finger into the anus gently with patient concern.
7 Examine tonus of the sphincter gently ( whether weak, strong, dry, smooth)
rectal mucosa circumferentially( smooth, granule surface )
rectal ampulla.( filled, empty, collapse or not)
Note any nodules, irregularities, or induration
8 Sweep your finger carefully (12 oclock) over the prostate gland on anterior
section of body, identifying its lateral lobes and median sulcus between them.
Note the size, shape, consistency, identify any nodules or tenderness of the
prostate.
9 Inform consent then examine Bulbocavernosus reflex ( if there is suspect shock
spinal): woman, gentle scratch perineum area. Man : scrath the pennile or pull the
catheter ) with other hand
10 Pull out the index finger gently, observe whether there are blood, mucous or
faeces on the glove
11 Wipe the anus with paper tissue
12 Take off the glove and put it into the bin.
13 Wash your hands thoroughly by using antiseptic soap
14 Help the patient to get off the bed and ask the patient to put on his/her underwear.
15 Say Hamdalah
Documentation
1 Date and time of the procedure
2 Write any findings in the patients medical record
3 Signature and name of the operator
PHYSICAL EXAMINATION OF ANTERIOR THORAX
No Procedure

Locating Chest Abnormalities to Locate vertically Anterior Chest

1. Say Basmallah
2. Identify the suprasternal notch
3. Move your down about 5 cm, find the horizontal bony ridge that join the
manubrium to the body of sternum
4. Move your finger laterally anf find the adjacent 2nd rib and costal cartilage
5. The first intercostal space below the 2nd rib is the second intercostals space
6. Identify mid sternal line, midclacivular line and anterior, posterior and mid axillary
line
Techniques of Anterior Chest Examination
Inspection
7. Place the patient insupine position
8. Your position is in the midline position in front of the patient
9. Inspect the shape of the chest and the way in which it moves
10. Findings deformities ot asymetry, abnormal retraction of interspace during
inspiration, impairment of respiratory movement on one or both side or a unilateral
lag (delay) in the movement
Palpation
Test Respiratory Expansion
11. Place your tumb about at the level of the parallel to Arcus costarum, your hands
grasping the lateral rib cage
12. Slide your hand medially a bit in order to raise loose skin folds between your tumb
and the spine
13. Ask the patient to inhale deeply
Tactile Fremitus
14. Use either the ball (the bony part of the palm at the base of the fingers) or the ulnar
surface of your hand and place it in both side of the chest symmetrically
15. Ask the patient to repeat the words ninety nine or one- one- one or tujuh puluh
tujuh or tujuh tujuh
16. Repeat this examination in other areas of the chest symmetrically
Percussion
17. Hyperextend the midle finger of your left hand (the pleximeter finger)
18. Press its distal interphalangeal joint firmly on the surface to be percussesd. Avoid
contact by any other part of the hand
19. Strike the pleximeter finger with the right middle finger (plexor), with a quick,
sharp but relaxed wrist motion
20. Aim the strike at your distal interphalangeal joint
21. Comparing two areas of the anterior chest
22 Identified the upper border of liver dullness
Auscultation
23. Listen to the breath sound with the diafragm of the stethoccope after instructing the
patient to breathe deeply through an open mouth
24. Compare symmetric areas of the lung, using the pattern sugested for percusion and
extending it to adjacent areas as indicated
25. Listen to the breath sounds, noting for the pitch, intensity and relative duration of
the expiration and inspiration phases
26. The normal breath sounds are: vesicular, bronkhovesicular and bronkhial
27. Identify any adventitious sounds that are superimposed on the usual breath sound.
Adventitious sounds are crackles, wheezes and rhonchi
28 If you hear adventitious sounds, listen for the following characteristics; loudness,
pitch, duration, number, timing in respiratory cycle, location, persisten of their
pattern, any change after a cough or a change in the patient position
Write up
29. Write up all significant findings in the medical record
30. Say Hamdallah
PE Cardiac Adult
No PHYSICAL EXAMINATION
1 Tell the patient what is going to be done
2 Help the patient to lay down on the examination table
3 Wash hands thoroughly with soap and water and dry with a clean dry cloth or hand
drier
4 The examiner should stand at the patients right side
5 General physical examination (described elsewhere)
6 Vital Sign Examination :
Blood pressure, pulse, heart rate, respiratory rate
Pulse and heart rate examined simultaneously
HEAD
7 Eye : conjunctiva, sclera
Nose : Nasal Flare
Mouth : cyanotic perioral
NECK
8 Jugular Venous pressure
- Make the patient comfortable
- Raise the head slightly on a pillow to relax the sternomastoid muscles
- Raise the head of the bed or table to about 300 and turn the patients head
slightly away from the side you are inspecting
- Identify the internal*/ external jugular vein and the highest point of pulsation in
the right internal*/ external jugular vein point in the lower half of the neck
*) if the internal vein is impossible to see, the external can be used
- Extend a long rectangular object or card horizontally from this point and a
centimeter ruler vertically from the 15terna angle
- Measure the vertical distance in centimeter above the 15terna angle where the
horizontal object acrosses the ruler.
- The 15terna angle is roughly 5 cm above the right atrium. Pressure measured is
recorded as 5+ .. cmH2O
- The distance is the JVP
9 The carotid pulse
- Assess amplitude and contour
The patient lying down with the head of the bed still elevated (300-450)
Inspect the neck for carotid pulsation
Place your left index and middle fingers (or left thumb) on the right carotid
artery on the lower third of the neck, press posteriorly and feel the
pulsation
For the left carotid use your right fingers or thumb.
Increase pressure until you feel a maximal pulsation and contour.
NEVER press both carotid artery at the same time
- Thrills and bruits
During palpation, detect the presence or absence of humming vibration or
thrills
Listen over both carotid arteries with the DIAPHRAGM of your
 stethoscope for a bruit
- Put the diaphragm of your stethoscope on the carotid area
- Ask the patient to hold breathing
ARM
8 The brachial artery
- The patients arm should rest with elbow extended, palm up
- Flex the elbow to a varying degree to get optimal muscle relaxation
- Cup your hand under the patients elbow.
- Use the index and middle finger to feel the pulse
(medial to bisceps tendon)
THORAX
9 Point of maximal impulse (PMI)
INSPECTION
- Supposed to be done in a well illuminate room
- Determine the location of PMI; Normally in Mid
clavicula line, Intercostal space V)
PALPATION
- Use your fingerpads to palpate the impulse
- Ventricular impulse may heave/lift your finger
- Check for thrill by pressing the ball of your hand firmly on the chest.
PMI at left ventricular area
Try to assess the PMI with the supine position
If you fail to assess the PMI try:
Left lateral decubitus position
Ask the patient to exhale fully and stop breathing for a second
When examining a woman, displace the left breast
upward or laterally.
Assess the location:
Normally on the interspaces 4th or 5th
Assess the diameter
In supine position, it usually less than 2,5cm and occupies one interspace.
Assess the amplitude
Usually small and feels brisk and tapping
Assess the duration
Normally it lasts through the 1st two third of systole
PMI at Right Ventricular area
Patient should rest supine at 300
Place the tips of your curved fingers in the 3rd, 4th, and 5th interspace.
Feel the systolic impulse of right ventricular
PERCUSSION
Careful percussion will usually reveal whether the heart is normal in size or whether
it is definitely markedly enlarged.
One should use the lightest percussion possible and, with experience, rely more and
more upon the vibratory sense
To determine the left border of the heart, percussion should begin at the lateral side
and percuss toward the sternum. The dullness usually reveal along mid clavicular
 line
To determine the left border of the heart percuss from left lateral toward medial.
Normally, the left border is in the anterior axillary line. The right border is in the
right 17terna line and the upper border (base of the heart) in the 2nd left interspace
10 The 1st, 2nd, 3rd, and 4th heart sound
S1
- Listen to entire precordium with the patient supine.
- The 1st heart sound occurs with the onset of the apex impulse and corresponds to
the beginning of ventricular systole. It has 2 components .one due to mitral valve
closure and the other due to tricuspid closure. Normally we are unable to
distinguish between these component. First heart sound (S1) is deeper and longer
than second heart sound (S2)
- The carotid pulse is a reliable timing device as it occurs immediately following
the S1
S2
- The S2 has also 2 components. One due to aortic closure and the other due to
pulmonic valve,.Aortic component precedes the pulmonic component
- The mitral valve area is located in 5th left intercostals space at the
midclavicular line.
- The pulmonary valve area is in the 2nd left intercostals space at the
parasternal line.
- The aortic valve area is above the right 2nd rib and the right 2ndintercostals
space at the parasternal line.
- The tricuspidvalve area is over the sternum at the junction of the corpus
sternum with the xiphoid process.
11 The presence or absence of any cardiac murmur.
When a heart murmur is heard, identify and describe its:
- Timing
* Decide the murmur (systolic or diastolic)
* Systolic murmur falling between S1 and S2.
* Diastolic murmur falling between S2 and S1
* Palpating the carotid pulse as you listen to the murmur. Murmur that
coincide with the carotid upstroke are systolic
- Location of maximal intensity
Find the location by exploring the area where you hear the murmur
Describe where you hear it best in terms of the interspace and its
relation to the sternum, apex, midsternal,midclavicular or axillary line
- Radiation or transmission from the PMI
Explore the area around a murmur
Describe where you hear it best.
- Intensity
The systolic murmur has 6 grades. Try to
grade murmurs using the 6 point scale as follow:
Grade 1: Very faint. May not be heard in all Position
Grade 2: Quiet. Heard immediately after placing the stethoscope
Grade 3: Moderately loud
 Grade 4: Loud, with palpable thrill
Grade 5: Very loud. May be heard when the stethoscope is partly off
the chest
Grade 6: Very loud with thrill. May be heard with stethoscope entirely
off the chest
The diastolic murmur has only 4 grades.
- Pitch
This is categorized as high, medium or low
- Quality
This is described in terms such as blowing, rumbling and musical
- Use two important position to listen for mitral stenosis and aortic
regurgitation
1. Ask the patient to rollpartly on to the left side into the left lateral
decubitus position
Place the bell of your stethoscope lightly on the apical impulse.
2. Sit up, lean forward,exhale completely and stop breathing in expiration
Pressing your stethoscope, listen along the left sternal border and at the
apex.
PHYSICAL EXAMINATION THYROID

No PHYSICAL EXAMINATION
1. Assess the patients level of consciousness, blood pressure, pulse rate, respiration,
temperature, height, body weight and BMI
2.As Assess the Face and Eyes examination :
Lid retraction, Periorbital Edema, Exophthalmos,
puffy face, a hoarse-husky voice
IV EXAMINATION OF THYROID GLAND
1. Observe the neck, especially as the patient swallows (ask the patient to sip and
swallow water.
2. Palpation
a. From the front of the patient
Use the thumbs of both hands
To palpate the right lobe: fix the left lobe with the right thumb; rotate the right
lobe slightly with your left thumb.
Same principle for the left lobe: fix the right lobe with the left thumb; rotate
the left lobe slightly with your right thumb
b. From the back of the patient
Ask the patient to flex the neck slightly forward to relax the
sternocleidomastoid muscles
Place the three fingers of both hands on the patients neck so that your index
fingers are just below the cricoid cartilage.
Ask the patient to sip and swallow water as before. Feel for thyroid isthmus
rising up under your fingers pads.
To palpate the right lobe: displace the trachea to the right, and then palpate the
lateral part of the right lobe which is lying between trachea and the relaxed
sternocleidomastoid muscle.
Same principle for the left lobe: displace the trachea to the left, and then
palpate the lateral part of the left lobe which is lying between trachea and the
relaxed sternocleidomastoid muscle
3. If the thyroid is enlarged, do auscultation to look for the bruit by placing bell
stethoscope above the lateral part of enlarged thyroid gland.
4. Measure the size of thyroid nodules/enlargement by drawing an outline on the skin
(or plastic put on the surface of thyroid nodule/enlargement)
V OTHER PHYSICAL EXAMINATION / ASSESSMENT
1. Assess the cardiac condition :
bradycardia or tachycardia
2. Assess the pulmonary condition :
Slow respiration, shortness of breath
3. Assess the Abdominal condition : slowed or rapid peristaltic
4. Assess the extremities condition :
Tremor
thyroid dermopathy
moist hand, warm
 dry skin
myxedema
5. Assess the Neuromuscular System:
slow or hyper reflexes
6 Assess the Musculoskeletal System:
muscular weakness
PEMERIKSAAN FISIK SISTEM RESPIRASI

No Steps/ Task
PHYSICAL EXAMINATION
I PREPARATION
1 Tell the patient what is going to be done
2 Help the patient on to the examination table
3 Wash hands thoroughly with soap and water and dry with a clean dry cloth or air
drier
4 The examiner should stand at the patients right side
II EXAMINATION TECHNIQUE
A General Physical Examination (described elsewhere)

B Locating Cervical Lymph Nodes

a. Make the patient comfortable and relax
b. Flexed the neck slightly forward and if needed slightly toward the examination
c. Palpate using the pads of your index and middle fingers
d. Move the skin over the underling tissue in each area
e. Describe location, quantity, size (diameter), consistency, movability, presence
specific formation (package).

Findings :
1 Preauricular in front of the ear
- Posterior auricular superficial to mastoid process
- Occipital at the base of the skull posteriorly
- Tonsilar at the angle of mandible
- Submandibular midway between the angle and the tip of the mandible.
These nodes are usually smaller and smoother than lobulated
submandibular gland against which they lie
- Submental in the midline a few cm behind the tip of mandible
- Superficial cervical superficial to sternomastoid
- Posterior cervical along the anterior edge of trapezius
- Deep cervical chain deep to the sternomastoid and often inaccessible to
examination. Hook your thumb and fingers around either side of the
sternomastoid muscle to find them
- Supraclavicular deep in the angle formed by the clavicle and the
sternomastoid

C TRACHEA
1. Inspect trachea for any deviation from its midline position.
2. Place the finger along one side of the trachea and note
the space between trachea and the sternomastoid.
3. Compare it with the other side. Normally the space
should be symmetrical.
Locating Chest abnormalities To locate vertically Anterior chest
D 1. Identify the suprasternal notch
 2. Move your down about 5 cm
3. Find the horizontal bony ridge that join the manubrium to the body of
sternum.
4. Move your finger laterally and find the adjacent 2nd rib and costal
cartilage
5. From here you can walk down the interspaces.
6. The first intercostals space below the 2nd rib is the second intercostals
space.

Posterior chest
1. Flaxed the patients neck forward
2. Find the most prominent process
3. The most prominent is the C7
4. When two process appear equally prominent they are C7 and T1
5. Then you can felt and counted the process below them
6. You can also estimating location from location of inferior angle of scapula
is usually leis at the level of the 7th rib of interspace.

To locate findings around the circumference of the chest

1. midsternal and vertebral are lines drops vertically mid sternal and
midvertebral
2. identify both end of the clavicle and the midclavicular line drops vertically
from the mid point of clavicle.
3. Anterior and posterior axillary lines drop vertically from the anterior and
posterior axillary folds
4. The midaxillary line drops from the apex of the axilla

TECHNIQUES OF CHEST EXAMINATION

Examine the posterior chest

Inspection
a. place the patient in supine position
b. your position is in the midline position in front of the patient
c. inspect the shape of the chest and the way in which it moves
d. findings : deformities or asymmetry, abnormal retraction of interspace during
inspiration, impairment of respiratory movement on one or both side or a
unilateral lag (delay) in the movement.

Palpation
Test respiratory expansion
1. place your thumb about at the level of and parallel to the 10th ribs, your hands
grasping the lateral rib cage.
2. Slide your hand medially a bit in order to raise loose skin folds between your
thumb and the spine.
3. ask the patient to inhale deeply
4. Watch the divergence of your thumbs during inspiration and feel for the range
and symmetry of respiratory as the thorax expands and feel for the extent and
symmetry of respiratory movement.

Tactile fremitus
1. use either the ball (the bony part of the palm at the base of the fingers) or the
ulnar surface of your hand and place it in both side of the chest symmetrically
2. ask the patients to repeat the words ninety nine or one one one
3. repeat this examinations in other areas of the chest symmetrically

Percussion
1. hyperextend the middle finger of your left hand (the pleximeter finger)
2. press its distal interphalangeal joint firmly on the surface to be percussed.
3. AVOID contact by any other part of the hand
4. Position your right forearm quite close to the surface with the hand cocked
upward. The right middle finger should be partially flexed, relaxed, and poised
to strike
5. Strike the pleximeter finger with the right middle finger (the plexor), with a
quick, sharp but relaxed wrist motion
6. Aim the strike at your distal interphalangeal joint.
7. Learn to identify five percussion notes which can be distinguished by
differences in their basic qualities of sound : intensity, pitch and duration.

Auscultation
1. instruct the patients to breath deeply through an open mouth
2. listen to breath sound with the diaphragm of your stethoscope
3. move your stethoscope from one side to the other and comparing symmetrical
areas of the lung
4. pattern of breath sound identified by their intensity, pitch, and relative
duration of their inspiratory and expiratory phases
5. the normal breath sounds are : vesicular, bronchovesicular and bronchial
6. listen for any added or adventitious sound that are superimposed on the usual
breath sound. Adventitious sounds are crackles (rales), wheezes and rhonchi
7. if you hear crackles, listen for the following characteristics
a. loudness, pitch and duration (summarized as fine or coarse crackles)
b. number (few to many)
c. timing in respiratory cycle
d. location on the chest wall
e. persistence of their pattern from breath to breath
f. any change after a cough or a change in the patients position
8. if you hear wheeze or rhonchi , note their timing and location and do they
change with deep breathing or coughing
9. if you hear abnormally located bronchovesicular or bronchial breath sound,
continue on to asses transmitted voice sound.
10. With stethoscope, listen in symmetrical areas over the chest, as you :
a. ask the patient to say ninety nine. Normally the sound transmitted
 through the chest wall are muffled and indistinct. Louder and clearer voice
sounds are called bronchophony
b. ask the patient to sal ee you will normally hear a muffled long E sound.
When ee is heard as ay. An E to A change (egophony) is present.
c. Ask the patient to whisper ninety nine or one two three . The
whispered voice is normally heard faintly and indistinctly. Louder, clearer
whispered sounds are called whispered pectoriloquy
PEMERIKSAAN FISIK ABDOMEN

No. Procedure

Preparation
1. Check all the equipment required and have a good light:
Examination couch
Stethoscope
2. Explain the procedure and its goals to the patient.
3. Wash your hands with antiseptic soap.
4. Dry and warm your hands with tissues.
Implementation
A General Examination:
5. General appearance:
Consciousness
Affect: distressed? Anxious?
Immobile
Move cautiously
Colour: Pallor? Flushing? Jaundice? Cyanosis?
6. Examine the vital signs:
Temperature
Pulse rate
Blood Pressure
Respiratory rate
7. Perform other systems examination, including cardio-pulmonary system.
8. Ask the patient politely to expose his/her abdomen.
B. Abdominal Examination:
Inspection
9. Inspect the movement:
Respiratory movement
Visible bowel peristaltic
10. Is there any scar on the skin of the abdomen?
11. Is there any abdominal distention?
Flatus/Gas ?
Fluid?
Fetus?
12. Is there any rashes and discolouration?
Cullens sign
Gray Turners sign
Ecchymosis of the abdominal wall
13. Is there any masses:
Tumors?
Hernial sites?
Masses with pulsation?
Palpation
14. Ask the patient to locate the site of maximum pain with the tip of a finger.
15. Using the palmar surface of your fingers, gently palpate the abdomen, starting
from a site farthest from the area of maximum pain, move gradually towards it.
While palpating, look to the face expression of the patient, and look for any signs
of :
Tenderness
Rebound tenderness
Muscle guarding
Rigidity
Murphys sign
Swelling or masses
Rovsings sign
Expansile pulsation
Hernial orifices
Scrotum in male
Percussion
16. Place the palmar aspect of your left hand on the abdomen, and gently percuss its
dorsal aspect with the tip of the middle finger of the right hand, moving all around
the abdominal region:
Is it tymphanitic?
Is it Dull?
Is there any shifting dullness?
Site of liver dullness? And is it disappeared?
Auscultation
17. Using stethoscope, and place it gently on the abdomen, listen to the bowel sounds
and bruit at least for one minute:
Absent?
High pitched and hyperactive?
Metallic sound?
Vascular bruit?
Write up
18. Write up all significant findings in the medical record.
19. Conclude your diagnosis and differential diagnosis, and order any necessary
special investigations
PEMERIKSAAN FISIK JAUNDICE

No. Procedure

Preparation
1. Greet the patient, Introduce yourself, Identify the patient
2. Explain the procedure, its goals to the patient, and ask for informed consent
3. Check all the equipment required and have a good light: Examination couch &
Stethoscope
4. Wash your hands with antiseptic soap & dry it
5. Say Basmallah
Implementation
A. General Examination:
6. General appearance:
- Consciousness
- Colour: jaundice
7. Examine the vital signs: Temperature, Pulse rate, Blood Pressure, Respiratory rate
8.* Examine the head:
- Eyes: sclera icteric
- Tongue: frenulum linguae icteric
- Fetor hepaticum
9.* Perform other systems examination:
- Thorax:- cardio- pulmonary system
- Spider naevi
- Gynecomastia
- Skin: palmar eritema
- Flapping tremor
10. Ask the patient politely to expose his/her abdomen.
B. Abdominal Examination:
Inspection
11. Inspect the movement:
- Respiratory movement
- Caput medusa
12. Is there any abdominal distention?
Palpation
13. Using the palmar surface of your fingers, gently palpate the abdomen,while
palpating, look to the face expression of the patient, and look for any signs of :
14. - Hepatomegaly ( Normaly up to 2 cm below arcus costarum and up to 2 cm
below the xipoid proccecus)
- Splenomegaly
- Enlarged Gall Bladder (courvoisier law)
- Abdominal lump
- Murphys sign
- Tenderness
Percussion
14. Place the palmar aspect of your left hand on the abdomen, and gently percuss its
dorsal aspect with the tip of the middle finger of the right hand, moving all around
the abdominal region: Tymphanitic? Dull?
- shifting dullness?
- liver dullness?
Auscultation
15. Using stethoscope, and place it gently on the abdomen, listen to the bowel sounds
and bruit at least for one minute:
Absent? High pitched and hyperactive? Metallic sound? Vascular bruit?
Write up
16. Write up all significant findings in the medical record.
17 Conclude your diagnosis and differential diagnosis, and order any necessary
special investigations
18. Say Hamdallah