Basic of Clinical

Examination for
OSCE

1
Semester III
1) Cardiovascular system
a. Physical examinations
b. Blood pressures
c. JVP and it’s 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

Semester V
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
5) Nervous system
a. Motor
b. Sensory
c. Cranial nerves

3
 HISTORY TAKING

History Taking
4
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

Personal details Social history

1) Name 1) Smoking
2) Age a. How many per day
3) Address b. How long the patient
4) Occupation* have been smoking
5) Religion / race 2) Alcohol
6) Marital status a. Type of alcohol
b. How much
Past medical history c. How long has the patient
1) Hospitalization been drinking
a. Year 3) Home
b. Reason for admission a. Type of housing
c. Diagnosis b. Environment
d. Where / medical center 4) Work
e. Duration of stay a. Working environment
f. Treatment b. Stress levels at work
2) Surgery 5) Diet
a. Diagnosis / reason for a. Meal habits
surgery b. Type of food
b. Year 6) Hobbies
c. Where / medical center a. Exercise
d. Treatment b. Any other activities
3) Long standing illness
a. Year & how long Family history
b. Diagnosis 1) Must cover 3 generation
c. treatment a. Parents
4) Allergy b. Siblings
a. Type of allergy c. Wife/husband
i. Drugs d. Children
ii. Food 2) If alive
iii. Animal a. Age
iv. Others b. Major illness
b. What happens when in 3) If passed away
contact (reaction) with a. When
the allergens b. Why

5
History of
presenting illness
(HOPI)
Sputum
GENERAL 1) Amount
I. Onset 2) Volume
II. Site / character 3) Color
III. Aggravating / relieving factors 4) Smell
IV. Timing – progression, duration, 5) Consistency
time of the day 6) Blood
V. Severity
VI. Associated symptoms
VII. What have you done about it? Stool / Vomitus
VIII. medication 1) Amount
2) Volume
Pain (chest / abdomen) 3) Color
=SOCRATES 4) Blood
1) Site 5) Smell
2) Onset 6) Consistency
3) Character
4) Radiation/spread Constipation
5) Associated symptoms 1. Frequency
6) Timing 2. Feeling of incomplete evacuation
7) Elevating/relieving factor 3. Consistency of feaces
8) Severity 4. Acute / chronic
5. Associated symptoms – pain,
*further explanation will be at The 15 bleeding.
wisdom of Dr. Htin Aung >>> 6. Time spent straining
7. Stool?
Shortness of breath (SOB) 8. Aggravating / relieving factors
1) Onset
2) Duration Diarrhea
3) Progression 1. Everything about stool,
4) Aggravating / relieving especially on consistency
5) Severity? Affecting sleep? 2. Frequency
6) Associated symptoms 3. Urgency of defecation
4. Abdominal pain
Cough 5. Aggravating / relieving factors
1) Productive/non productive 6. Severity
2) Intermittent / continuous
3) Time of the day Dysphagia
4) Blood 1. Liquid / solid
5) Severity 2. Painful
6) Aggravating / relieving factors 3. Regurgitates? Into nose?
7) Progression 4. Where (specific location) the
8) Associated symptoms food sticks

6
The History “THY FORMAT”
– from Dr. Htin Aung
1) Site : site of pain

2) Duration :
a. /12 (month)
b. /7 (days) MI: >10min
c. /24 (hours) AP: 5-10min
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 IHD
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? Breathlessness
 Etc Dyspnoea
On
9) Severity : mild / dull Exertion/Non-exertion/Resting
 B/D o NE  B/D o R
 B/D o E  B/D o less exertion than normal

7
10) Spread : IHD
- neck, jaw, left arm
- nerve cardiac plexus C4-T1
- “REFERRED PAIN”

11) Implication:
a. Weight
b. Work
c. Appetite
d. Sleep
e. Micturation
f. Bowel

12) Aggravating factor

13) Relieving factor

14) Seen other doctors

15) Associated symptoms

8
 CVS RESPIRATORY
Complaint: Chest tightness SOB: Epistaxis, hemoptysis, SOB, cough, sputum
Dyspnoea, Orthopnea, Paroxysmal color
Nocturnal Dyspnoea, Palpitation, Chest Asthma, Smoking
pain. Wheezing due to narrowed airway
Heart failure: ankle edema, Cough, SOB DD for Supra-clavicular swelling
PAD / PVD Intermittent claudication Metastasis: solid, hard, fixed
(claudication distance for PAD) Infection: warm, tender
Lymphoma: firm
1. Rheumatic fever 1. TB:
Sore throat (relapsing RF) Productive cough, high fever with night
Fever, sweat ,chills ( exposure to rain) sweats, wt loss, lymphadenopathy,
Relieve: panadol decrease appetite
Worries: excessive sweating, Investigation: AFB culture, CXR,
embarrassing history of RF, check Mantoux
family
2. IHD (Angina Pectoris) 2. Pneumonia
Pain: Location, Radiation, Duration, SOB
Exertion, Frequency, Progression, Sputum: color, consistency, volume,
Severity, Precipitating Factors blood, frothy
Risk: F/H, Diet (hi salt / fat), exercise, Relieve, aggravator
stress, smoke and alcohol. E.g.: Investigation: Sputum culture, PBS.

Severity
Past 3mth
Can do work
Past 1wk
Crushing,
X-ray
Heart (boot shaped) Tetralogy of Fallot
limited
activities Cardiophrenic angle
Frequency Twice a wk everyday Costophrenic angle
Kerley B line (heart failure)
Precipitating Carry >20kg Carry >5kg
Air fluid level (pleural effusion)
factors climb 3 stairs
Pneumoconiosis
3. Peripheral Arterial Disease (PAD)
TB coin lesion, consolidation and cavitation
Pain and cramp at unilateral limb
Renal IVP - hydroureter, calculi
Aggravate: walking claudication dist
Fracture - colles (radial bone), dinner fork
Relieve: sit down, rest
Osteoarthritis - osteophyte
F/H of arterial disease: HT, Heart
Osteosarcoma - sunburst
attack
Rheumatoid arthritis - Pannus
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. 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
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. 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
Palpable LN: question to ask
How long? Lump changed size? Painful?
Lost wt? Generally well?
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
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
3. Cholecystitis
Aggravate: Fatty food, egg
Associated symptoms: nausea, burping,
indigestion, fever, diarrhea, vomiting
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
10
 ENDOCRINE
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
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
RENAL
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.
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)
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)
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
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 (1st 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: ● Systemic Features:
ElderlyOA FeverRA, AOM,SA,SLE
YoungRheumatoid, Ankylosing RashSLE
Spondylitis Wt gain, fever, weakness, fatigue ●
● Gender: M AS, F RA Occupation:
● Onset/Duration: Manual workerOA
Suddendisc prolapsed Maid's Anee, carpet worker’s knee
Acuteacute osteomyelitis, septic (Bursitis)
arthritis SA ● Sexual exposure (gonorrhea,syphilis)
InsidiousOA, AS, RA ● F/HHemophilia (hemoarthroses),
● Site: gout, TB, RA
Large wt bearing joint(hip/knee)OA
Small joint (wrist, MP, PIP)  RA Cases
Low backOA, AS Osteoarthritis: Wt bearing joint, Elderly,
Insidious onset, dull ache, morning stiffness
Sacro-Illiac joint AS
less than 30min. History of trauma over wt.
Big ToeGout Aggravate by walking, squatting, relieve by
● Progression, Swelling painkiller and rest
(infection/inflammation)
● Symmetrical involvementRA Malignancy: Pain (night cries)
● Radiation: hip-knee. Sciatica-post associated symptoms: stiffness, swollen
thigh Appetite decrease, lost of wt,
● Char: Risk factor: smoking, HT, Diabetes,
ThrobbingSA, AOM, acute Sedentary lifestyle, over wt. Metastatic
hemathrosis, normally to spine (breast Ca)
Dull acheOA, RA
Shooting sciaticaPID
Night criesTB, malignant tumor
(due to release of protective muscular
spasm at night)
● Painkiller, Frequency
● Severity:
Very severePID, AOM, SA, Gout
Mild to moderateRA, 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)

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)
5. Strokes
Assoc with atherosclerosis, HT, Slurred
speech, hemiplegia
15
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
Physical examination

16
 Cardiovascular
System

Checklist
Headings Action 4. Hands 1. Color
1. Introduce (Cyanosis, Jaundice, Pallor)
2. Permission 1. Put the bed into 45° angle 2. Temperature
2. Wash hands 3. Moisture
3. Adequate exposure 4. Capillary refill
3. General 1. Name, age, gender, racial 5. Clubbing
Inspection 2. Conscious 6. Splinter hemorrhage
3. Alert 7. Xanthomata
4. Communicative 8. Osler’s nodes (pain)
5. Well built – not chacectic 9. Janeway lesion
6. No general discoloration
7. No respiratory distress
8. Not in obvious pain
9. No gadget attached

17
5. Pulse 1. Radial scoliosis)
2. Brachial 6. Visible pulsation
3. Carotid (especially at the apex
4. Femoral region)
5. Popliteal Palpation 1. Apex beat (comment!)
6. Posterior tibialis 2. Parasternal heave
7. Dorsalis pedis 3. Thrill over the 4 region
-mitral
Comment on: -tricuspid
1. Rate (for 1min, unless told) -aortic
2. Rhythm (R, RI, II) -pulmonary
3. Strength Auscultation Auscultation over the 4
4. Symmetry region for*
(radio-radial, radio-femoral) 1. S1 & s2
5. Character 2. Added sound
3. Murmurs
6. BP See behind
10. Pitting
7. Face Eyes:
1- sclera (yellowish) edema
2- conjunctiva (pallor) 11. Thanks Always remember to thank
3- corneal archus the patient
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,

SIGNS/EXAMINATIONS SIGNIFICANCE
INTRO

Greet, Introduce, Explain,  Wash & Warm hands.

Permission (GIEP)  45 degrees
 Adequate exposure
Age, gender, ethnic group, height, E.g. Mr. Chan is a middle aged Chinese man of
GE

weight, built, nutrition average height and built. He is well nourished and of

18
INSPECTION
NERAL Mention:
(1) conscious
(2) alert
(3) co-operative
(4) no respiratory distress
(5) not in obvious pain
(6) no general discoloration
HANDS
(1) Moisture & Temperature
(2) Color (normal = pinkish)
(a) cyanosis (blue)
(b) jaundice (yellow)
(c) pallor
(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
(4) Capillary refill (Normal < 2s)
Press for at least 10s.
(5) Splinter Hemorrhage
(6) Osler's Nodes
(7) Janeway Lesion
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
Hypercapnea
(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
= increase in angle between proximal nail and nail
Seen in:
Cyanotic Congenital Heart Disease
Infective Endocarditis
Impaired blood circulation e.g. atherosclerosis
= linear hemorrhages lying parallel to the long axis
of nail -Talley. Vasculitis of nail bed caused by IE
= red, raised tender nodules on pulps of the fingers
(or toes) or on the thenar or hypothenar eminences
Seen in IE
= 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
PULSE
(1) Rate (normal 60-90 bpm)
(2) Rhythm
(3) Volume
(4) Symmetry (delay)
(1) Sclera - Jaundice
EYES
(2) Conjunctiva – Pallor
(3) Corneal Archus
(4) Xanthelasma
MOUTH
Oral hygiene
NECK
JVP**see more behind
Mainly for RHF causing
congestive hepatomegaly
INSPECTION
CHEST
(1) Surgical scar
(2) Visible pulsation
(3) Deformities (pectus Excavatum = inwards
excavatum and pectus carinatum) 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
=yellow or orange deposits of lipid in the tendons
that occur in Type II hyperlipidaemia.
 Tachycardia (>100bpm)
 Bradycardia (<60bpm)
Arrhythmia
Types: radio-radial, radio-femoral
Seen in
 Atherosclerosis
 Coarctation of aorta
 Aortic (abdominal) aneurysm
Right Heart Failure
Anemia
Hypercholesterolemia
Hypercholesterolemia
Post streptococcal infection and dental caries related
to IE or rheumatic heart disease
1. inspection & location
2. measurement
3. character
-hepatojugular reflux
-visible non palpable
-dual pulsation
(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.
(2) Parasternal Heave
(b) Hyperinflation of lung (asthma or emphysema)
(c) Pericardial Effusion
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.

Thrills= palpable murmurs

(3) Thrills at the 4 region
Mitral - 5th ICS at mid clavicular line
Report the anatomical location
Tricuspid - 4th ICS at left parasternal border
Pulmonary – 2nd ICS left parasternal border
Aortic – 2nd ICS right parasternal border

AUSCULTATION ** see more behind

Auscultate the 4 areas. You MUST Causes of murmur
use both diaphragm and bell (1) Stenosis
(2) Murmur
Bell ~ emphasize low pitched (3) Anemia / thyrotoxicosis
sounds such as murmur of mitral (4) IE
stenosis (5) Congenital heart disease
If murmur coincides with carotid pulse then it's systolic
Diaphragm~ for high pitch sounds. murmur.
It filters the low pitched sounds. Otherwise it's diastolic murmur.

To show that you know how to Report on:

differentiate systolic and diastolic 4. S1 & S2
murmur you have to auscultate and 5. Additional heart sound
feel for the carotid pulse at the 6. murmurs
same time.
LEG

Pitting pedal edema Reason: Congestive Heart

Press at bony prominences Failure, Constrictive pericarditis
(At least 15s)

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
Rule 2: Rule 1:
Horizontal (parallel) to floor Vertical to floor
and at upper most visible JVP and at sternal angle
Height to be
measured
PATIENT

4) Then report the unit in cm of H20. A normal value is less than 4cm of H20.

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 1. Heart failure particularly RHF
increase JVP 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
 : 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 5) Popliteal = deep in the popliteal

radius fossa at the back of the knee just
2) Brachial = medial to brachialis medial to the midline
muscle tendon 6) Posterior tibialis = bony groove
3) Carotid = medial to behind the medial maleolus (2cm
sternocleidomastoid muscle behind and below)
4) Femoral = just below the inguinal 7) Dorsalis pedis = proximal end of 1st
ligament, midway between ASIS and intermetatarsal spaces
pubic symphysis

24
Heart sounds
A2+P2
Diastole
Loud A2-systemic
M1+Tl
hypertension
Systole
Sl S2 Soft A2-aortic stenosis +
Loud-mitral stenosis
aortic regurgitation
Soft-mitral regurgitation
Loud P2-pulmonary
hypertension

Gallop rhythm
Higher pitched gallop
Low pitched,
Late diastolic
Mid diastolic
Physiological
S3 Physiologic =pregnancy S4
=NONE!
Pathologic=LVF, aortic
Pathological
regurgitation, mitral
=systemic hypertension
regurgitation

Additional sounds
Early systolic
Non High pitched
High pitched Systolic High pitched
Opening systolic Systolic
Diastolic ejection Aortic stenosis
snap ejection Mitral valve
Mitral stenosis click Pulmonary
click prolapsed
stenosis

25
Murmurs
Diastolic

Decrescendo
Early Aortic regurgitation
diastolic Pulmonary
regurgitation
Mid Mitral stenosis
diastolic Tricuspid stenosis

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

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 Nose:
ce 1-blood
2. Permiss 1. Put the bed into 45° angle 2-mucous or discharge
2. Wash hands 3-nasal polyps
ion
3. Adequate exposure 4-engorged turbinate
3.General 5-deviated septum
Inspection 1. Name, age, gender, racial Headings Action
2. Conscious Mouth:
3. Alert 1-oral hygiene
4. Communicative
2- pharyngitis
5. Well built – not chacectic
3-tonsilitis
6. No general discoloration
4-enlargment of tonsils
7. No respiratory distress
8. Neck 1. Position -Trachea
8. Not in obvious pain
(trachea) deviation
9. No gadget attached
2. Movement-Tracheal tug
3. Length
4. Hands 1. Color
4. Lymph nodes
(Cyanosis, Jaundice, Pallor)
9. Precordium
2. Temperature
3. Moisture Inspection 1. Size
4. Capillary refill -AP diameter
5. Clubbing -Transverse diameter
6. Nicotine staining (NOT 2. Shape
TAR!) 3. Symmetry (shape &
7. Thenar and hypothenar movement)
muscle wasting -AP diameter
8. Flapping tremors -Transverse diameter
(asterixis) 4. Scars
5. Deformity (excavatum,
5. Pulse Comment on:
carinatum, kyphosis,
1. Rate (for 1min, unless told)
scoliosis, flail chest)
2. Rhythm (R, RI, II)
6. Use of accessory muscle
3. Strength
for respiration (SCM)
4. Symmetry
*some of us do respiratory
(radio-radial, radio-femoral)
rate
5. Character
Palpation 1. Chest expansion
6. BP Mention only 2. Tactile fremitus
7. Face 3. Apex beat
Eyes: Percussion  Apical
1- sclera (yellowish)  Upper
2- conjunctiva (pallor)  Middle
3- Horner’s syndrome  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
11. Thanks Always remember to thank

30
 INTRO
Greet, Introduce, Explain,  Wash & Warm hands.
Permission (GIEP)  45 degrees / sitting down
 Adequate exposure
Age, gender, ethnic group, height, E.g. Mr. Chan is a middle aged Chinese man of
INSPECTION
GENERAL

weight, built, nutrition
Mention:
(1) conscious
(2) alert
(3) co-operative
(4) no respiratory distress
(5) not in obvious pain
(6) no general discoloration
average height and built. He is well nourished and of
average weight. He is conscious, alert, and co-
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

(1) Moisture & Temperature Hypercapnea

HANDS

(2) Color (normal = pinkish)

(a) cyanosis (blue)
(b) jaundice (yellow)
(c) pallor
(d) palmar erythema
(e) nicotine staining
(3) Clubbing
(4) Small Muscle Wasting in hand
(5) Tremors
(a) flapping tremors
(b) fine tremors
(1) Rate (normal 60-90 bpm)
PULSE
(a) Peripheral deoxygenating
- V/Q imbalance
- pneumonia
- COPD
- pulmonary embolism
(b) cor-pulmonale
(c) anemia (chronic disease)
(d) polycythemia
(e) chronic smoker
(a) Cancer
(b) Lung Suppurative Disease
- empyema
- Lung abscess
- bronchiectasis
(c) Fibrosing a1veo1itis
Pancoast tumor suppressing TI
(a) Hypercapnia or
hyperuremia due to heart
failure, respi failure, liver
failure, kidney failure or
uremia
(b) Patient on Beta agonist
 Tachycardia (>100bpm)

(2) Rhythm  Bradycardia (<60bpm)

(3) Volume
(4) Symmetry (delay)

31
 Horner's Syndrome
FACE EYES
(1) Constricted Pupils (miosis)
(2) Drooping eyelids (partial ptosis)
(1) Jaundice
(3) Loss of sweating (anhydrosis)
(2) Pallor
(4) Enophthalmus
(3) Homer's Syndrome
*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
(1) Position
NECK

(a)PUSH
Pneumothorax
(1) Position :- CHECK WITH Tumor
MEDIASTINUM ALSO Haemopneumothorax
(b)PULL
Lung fibrosis
Lung Collapse
(2) Length (2) length
From lower border of cricoid to Emphysema →Lung hyperinflation →Ribs UP→
suprasternal notch : Sternum up →So the length will be less than 3
Must be at least 3 fingers fingers
(3) Aneurysm of arch of aorta
(3) Movement – No Movement
(No tracheal tug)
(4) Lymph nodes (palpation) (4)Lung cancer
INSPEECTION
CHEST

(1) Diameter:
 AP < transverse; Normal
(1) Diameter  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. outward bowing (pigeon); chronic childhood
b. Pectus carinatum
respiratory disease or rickets
(3) Movement
C

32
 (a) A-P Expansion (PEN)
HEST Say: PRESENT, EQUAL
NORMAL,
(b) Transverse Expansion
(c) Flail Chest
(d) Paradoxical Breathing
Decrease transverse
expansion during inspiration
(4) Skin
PALPATION (**warm hands first!!)
(1) Chest Expansion
Apex, middle, lower
SAY: Chest expansion present,
normal and equal at both sides
(2) Vocal tactile fremitus
Can you please say 99?
SAY : Tactile Fremitus present
normal and equal at both sides.
DON'T FORGET AXILLA
(3) Apex beat
PERCUSSION (technique is important)
Do at
1. apex,
2. on clavicle,
3. beneath clavicle, 2nd 3rd 4th 5th
4. upper + middle + lower axilla
SAY : Equal resonance on both
sides of the lung fields
AUSCULTATION
(1) Normal Auscultation
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
(c )Fracture segments of ribs at both ends (blunt
injury)
(d) Chronic Emphysema ribs become horizontal.
So, when diaphragm contracts it pulls down
ribs
a. scars
b. radiotherapy lesions
Note: apex is for AP chest expansion
Reduction in: Lung collapse, Lung fibrosis, lung
consolidation, atelectasis, COPD
Increase in:
Lung consolidation, Lung Fibrosis, Tumor
Decrease in :
Pneumothorax + lung collapse, hydrothorax
(3) Apex beat
Towards: lower lobes collapsed, localized fibrosis
Away : pleural effusion, tension pneumothorax
Impalpable: hyperinflated 2ndary to COPD
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
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
(2) Vocal Resonance (say 99)
Results same with tactile vocal
fremitus
(3) Whispering pectoriloquy
(whisper 123)
(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
34
 TRACHEA & CHEST TACTILE
TITLE INSPECTION MEDIASTINA EXPANSION VOCAL PERCUSSION AUSCULTATION
L SHIFT (PALPATION) FREMITUS
Reduced chest Hyperresonant Reduced breath
Away from the Reduced on the Reduced on the
Pneumothorax expansion at the on the affected sound on the affected
affected site affected site affected site
affected site site site
Trachea shifted Reduced breath
Reduced chest
Pleural away Reduced on the Reduced on the Stony dullness sounds on affected
expansion on
Effusion from the affected affected site affected side on affected sides side
affected side
side Pleural Rub
Reduced breath
Reduced chest Dullness on sounds on affected
Reduced on the Increased on the
Consolidation expansion on No trachea shift affected side
affected site affected side
affected side sides Bronchial breathing
Crepitations
Reduced chest Trachea shifted Reduced breath
Lung Reduced on the Reduced on the Dullness on
expansion on towards the sounds on
collapse affected site affected side affected sides
affected side affected side affected side
Reduced chest Trachea shift Reduced breath
Reduced on the Reduced on the Dullness on
Lung Fibrosis expansion towards the sounds on
affected site affected site affected side
on affected side affected site affected side
Hyper resonant
Reduced BOTH No trachea shift Reduced BOTH Reduced BOTH or Reduced breath
Emphysema
sides Reduced length sides sides normal sounds both sides
BOTH sides
Prolonged
Reduced BOTH Reduced BOTH
Asthma No trachea shift Normal Hyper resonant expiration
sides sides
Wheezes
Abnormal pattern of breathing: Type of breathing.

Types
1 Sleep apnea-cessation of airflow for more than 10 seconds
more than 10 times a night during sleep
Causes
Obstructive (e.g. obesity with upper
airway narrowing, enlarged tonsils,
pharyngeal soft tissue changes in
acromegaly or hypothyroidism)

2 Cheyne-Stokes' breathing - periods Left ventricular failure

of apnea (associated with reduced level of consciousness) Brain damage (e.g. trauma, cerebral
alternate with periods of hyperpnoea (lasts 30 s on average hemorrhage) High altitude
and is associated with agitation).
This is due to a delay in the medullary chemoreceptor
response to blood gas changes

3 Kussmaul's breathing (air hunger)deep, rapid respiration due Metabolic acidosis (e.g. diabetes
to stimulation of the respiratory centre 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- Brain (pontine) damage

inspiratory pause in breathing

7 Paradoxical respiration - the Diaphragmatic paralysis

abdomen sucks inwards with
inspiration (it normally pouches outwards due to
diaphragmatic descent)

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
  Wash & Warm hands.
INTRO

Greet, Introduce, Explain,

 Lying down on bed with 1 pillow /
Permission (GIEP)
 Sitting down on a chair
 Adequate exposure
1. Racial origin
INSPECTION
GENERAL

Age, gender, ethnic group, height, => Thalassaemia

weight, built, nutrition 2. Pallor
=>Anemia
3. Bruising
1. Racial origin
=>Platelet disorder
2. Pallor
4. Jaundice
3. Bruising
=>Hemolytic anemia
4. Jaundice
5. Scratch marks
5. Scratch marks
=>Pruritis
=>Lymphoma
=>Myloproliferative disorder
1. Koilonychias
HANDS

=>dry, brittle, ridged, spoon-shaped nails

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
Hess test
FOREARMS
THE
=>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 4. Skin pigmentation
2. Hemolytic anemia 5. Leg ulceration
3. Myeloproliferative disease 6. Hemophilia
6. Pulse - tachycardia
=>Anemia
7. Purpura, petechiae, ecchymoses
=>Thrombocytopenia or platelet dysfunction
=>Coagulation disorder
=>Systemic vasculitis

 BP cuff on upper arm

 Inflated to 10 mmHg above =>Thrombocytopenia
diastole =>Capillary fragility
 5min
 Deflate
 Petechiae (+)
 1. Hair - grey hair & blue
THE FACE eyes
2. Eyes - jaundice &
conjunctiva pallor
3. Mouth
Gum hypertrophy ~Monocytic leukemia
Atrophic glossitis ~Megaloblastic anemia
Waldayer' s ring ~NHL
1. Submental
AXILLARY NODES

NODES (NECK)
SUPRACLAVICULAR
CERVICAL &
1. Apex/central 2. Submandibular
3. Jugular chain
2. Lateral (above & lateral)
4. Posterior triangle
3. Pectoral (medial)
5. Supraclavicular
4. Infraclavicular
6. Preauricle
5. Subscapular 7. Postauricle
8. Occipital
1. Site (position/extent)
5. Consistency
Localized = Local infection, early
Hard = Carcinoma
lymphoma
Soft/rubbery = Lymphoma
Generalized = Late lymphoma
6. Surface texture / overlying skin
2. Size: normal=<lcm
Inflamed = Infection
3. Color/temperature
Tethering = Carcinoma
4. Pain & tenderness
7. Fixation
Pain = Infections or acute
Fixed = Carcinoma
inflammation
Painless = Lymphoma
Lymphadenopathy
Generalized

Lymphadenopathy
Localize

1. Lymphoma
2. Leukemia(ALL/CLL) 1. Local acute or chronic infection
3. Infection (viral/protozoa) 2. Carcinoma metastases
4. Drugs 3. Lymphoma - Hodgkin
5. Infiltration (sarcoid)
6. Connective tissue disease
(RA/ SLE)
 Gastrointestinal
System

Headings Action
1. Introdu GIEP
ce
2. Permiss 1. Lying flat with one pillow
ion 2. Wash hands
3. Adequate exposure
3.General 1. Name, age, gender, racial
Inspection 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
(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)
2- conjunctiva (pallor)
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  Shifting dullness
 Fluid thrill
Palpation 1. Light palpation Auscultation 1. Bowel sound
2. Deep palpation 2. Bruit (aortic & renal)
3. Systemic palpation 11. Thanks Always remember to thank
4. Liver
5. Spleen
Percussion  General percussion
 Liver span
 Spleen (plus Traube’s
space)
INTRO

Greet, Introduce, Explain,  Wash & Warm hands.

Permission (GIEP)  POSITION: FLAT with one pillow
 Adequate exposure
Age, gender, ethnic group, height, Mention:
INSPECTION
GENERAL

weight, built, nutrition (1) conscious

(2) alert
(3) co-operative
(4) no respiratory distress
(5) not in obvious pain
(6) no general discoloration
HANDS

(1) Moisture & Temperature Hypercapnea

(2) Color (normal = pinkish)

(a) live failure causes high oestrogen
(a) cyanosis (blue)
(b) HA, hepatocellular, obstructive (pre, hepatic and
(b) jaundice
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
= increase in angle between proximal nail and nail
Seen in:
 HCC
(3) Clubbing
 IBD
 Liver cirrhosis
 Celiac disease

(4) Capillary refill (Normal < 2s) Impaired blood circulation e.g. atherosclerosis
Press for at least 10s.
 =opacity of the nails, leaving a rim of pink nail bed
on the top of the nail
(5) Leuconychia 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.
Malabsorption
(7) Small Muscle wasting in hand
= thickening & shortening of palmar fascia Tendon
Xanthomata
1st stage = tenderness due to inflammation
(8) Dupuytren’s contracture
2nd stage = thicken & contract due to fibrosis
Seen in chronic alcoholics

Hypercapnia or hyperuricaemia due to heart failure,

respiratory failure, liver failure kidney failure or
(9) Tremors – flapping tremors uraemia

(1) Spider naevi (1) If-more than 5, then it is due to liver cirrhosis
ARMS

= central arteriole which {increase in oestrogen}

radiate numerous small
vessels which look like spider
legs.
(2) Scratch mark (2) Hyperuremia due to liver failure

(3) Bruising / petechiae / (3) Liver failure or Malabsorbtion

ecchymosis / purpura

(4)Axillary hair (4)Liver failure

EYES

(1) Jaundice
(2) Pallor

(1) Oral hygiene

MOUTH

(2) Fetor hepaticus (sweet smell (2) Hepatocellular disease

breath from methionine)
(3) Hydration (3) Fluid intake, diarrhea, vomiting
 (4) Jaundice
(5) Angular stomatitis (5) Iron-deficiency anemia
(6) Glossitis (6) B12-deficiency
(7) Leukoplakia
= white colored thickening of the mucosa of the
tongue
Caused by:
(7) Leukoplakia  Sore teeth (poor oral hygiene)
 Smoking
 Sepsis
 Syphilis

= central arteriole from which radiate numerous

small vessels which look like spider’s leg.
(1) Spider naevi When noticed, press the point and the point will
disappear and upon releasing the point appears
Chest

(2) Gynecomastia
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 patient’s face while
ABDOMEN
back.
Seen in alcoholic live cirrhosis
= enlargement of breast in male
Seen in chronic liver failure
REMEMBER to ASK for pain, WARM hands and
look at the patient’s 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.

palpating
INSPECTION
Vertical lines = Horizontal lines =
mid clavicular to (1) subcoastal lines - below the 10th rib
mid inguinal point (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
(b) Flat
(c) Everted
(c) Movement with respiration
(4) Scar
(5) Striae
(6) Dilated veins
- if around umbilicus it is
known as caput medusa
(7) Obvious peristalsis
(8) Visible pulsation
(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
(1) LIGHT PALPATION
Things to say
(1) No pain/tenderness
(2) No guarding
(3) No masses
(2) DEEP PALPATION
Things to say
(I) No pain/tenderness
(2) No guarding
(3) No masses
(2) Umbilicus
(a) Normal
(b)
(c) ascites, pregnancy
(3) Reduced movement due to pain if there is
peritonitis
You may asked on different type of scars
(5) Rapid loss or gain of weight, pregnancy, Cushing's
syndrome (purple color)
(6) Liver failure
(7) Intestinal obstruction.
(8) Aortic aneurysm
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 remember
(1) Look at patient
(2) Name the regions
(3) DON'T lift up your hand
(2) DEEP PALPATION
Things to remember
(1) Look at patient
(2) Move in during inspiration
(3) CAN lift up your hands
 (3) LIVER (3) LIVER
Things to say Things to remember
(1) Liver is not palpable (1) Fingers point towards left axilla, parallel to
(2) They might ask what you will costal margin, lateral to rectus abdominis.
comment on if the liver edge (2) START from RIF and slowly
was palpable (site, size, move upwards.
shape, consistency, surface,
border)
(4) SPLEEN
Things to remember
(1) Start from RIF
(4) SPLEEN
(2) Go towards the LHC
Things to say; Spleen not
(3) Must cross the umbilicus
palpable
(4) Once reach the costal margin,
move along the costal margin
(5) Then lift up the spleen
PERCUSSION
(1) General percussion (1) general percussion
Say: resonant hyperresonant = gas distension

Percuss at mid clavicular line

(2) Liver span Above - 2nd ICS; below - RIF
Normal span = 8 - 12 cm

Lines for Traube's space

(3) Spleen
(a) mid axillary line ( not too sure)
ABDOMEN

Percuss from RIF

(b) xiphisternal
Then percuss the Traub's space
(c) costal margin
(4) Shifting dullness (4) shifting dullness
1st percuss starting from the Mild to moderate ascites
umbilicus and move laterally.
Then say it's resonant and you Amount of fluid must be in the peritoneum for
can't get the point of dullness. The shifting dullness = 500ml
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.
 (5) fluid thrill
Massive ascites
Minimum amount of fluid = 1000ml
5) Fluid thrill
Ask patient to put hand at the
(a) increased = gastroenteritis, mechanical
centre reason: to prevent the shock
obstruction, blood in gut decreased = paralytic
wave
Transmitting through fat and skin ileus as in generalized peritonitis
(b) stenotic lesions in the blood vessel
(c) liver = inflammation + cancer spleen = infarcts

AUSCULTATION
Once every 10 - 15 s
(1) Bowel sounds
(2) Aortic bruit, Renal Bruit, Iliac
bruit (Know the anatomical
position)
 GENERAL
Yellow discoloration of the sclera and skin
Jaundice CAUSE: Hyperbilirubinaemia

Failure of GIT to absorb food normally. May lead to weight loss and cachexia
CAUSE:
 GI Malignancy
Weight and
 Alcoholic Cirrhosis
wasting
 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
CAUSES:
 Generalized: chronic liver disease, especially in haemochromatosis
Pigmentation  Malabsorption - Addisonian-type pigmentation ('sun kissed' pigmentation) of
the nipples, palmar creases, pressure areas and mouth

Freckle-like spots(discrete brown black lesions) around mouth and buccal mucosa
And fingers and toes
Peutz- Jeghers CAUSE:
Syndrome  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
Brown to black velvety elevations of the epidermis due to confluent papillomas
Acanthosis Site: axilla and nape of the neck
Nigricans  Assoc rarely with GI carcinoma (especially stomach) and lymphoma,
acromegaly, diabetes mellitus, endocrinopathies
Multiple small telangiectasia
Hereditary
Site: lips and tongue, may be anywhere on the skin, when present in GIT -can cause
haemorrhagic chronic blood loss or even occasionally torrential bleeding
telangiectasia Cause:
(Rendu-Osler-  Assoc A-V malformation in liver may be present
Weber svnd)  AD condition uncommon

Fragile vesicles on exposed areas of the skin and heal with scarring
Dark urine.
Porphyria CAUSE :
cutanea tarda  Chronic disorder of porphyrin metabolism
 Assoc with alcoholism, liver disease, Hepatitis C

Tense tethering of skin

Systemic
Often assoc with GER and GI motility disorders
sclerosis
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 Transverse white lines

lines CAUSE: Hvpoalbuminaemic states including cirrhosis

CAUSES: Cirrhosis(1/3rd pts)- may be related to A V shunting in the lungs resulting in

arterial oxygen desaturation
Clubbing Severe long standing chronic liver disease
Inflammatory bowel disease
Celiac disease

PALMS
Reddening affecting thenar and hypothenar eminences often also-soles of the feet
Palmar CAUSES:
eyrthema  Chronic liver disease
'liver palms'  Also seen: pregnancy, thyrotoxicosis, RA, polycythaemia etc
 Maybe a normal finding especially in women
Pallor at palmar creases
Anaemia CAUSES: GI blood loss, malabsorption of folate, vit B12,haemolysis(ex:
hypersplenism), chronic disease

Visible and palpable thickening and contraction of the palmar fascia causing
permanent flexion, most often of the ring finger
Depuytren's Often bilateral and occasionally affects the feet
Contracture 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

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
Hepatic Flap formation of the brainstem. Rhythmical lapses of postural muscle tone
(Asterixis) 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
 Ecchymoses (large bruising)- clotting abnormalities
CAUSES:
 Hepatocellular damage- interferes with protein synthesis and production of all
Bruising 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
Pinhead-sized bruises
CAUSES:
 Chronic excessive alcohol consumption => BM depression => TCP
Petechiae
 Splenomegaly 2ndary to portal HT => hypersplenism =>excessive destruction
of pits in spleen
 Acute hepatic necrosis => DIC can occur
Muscle Late manifestation of malnutrition in alcoholic pts. Alcohol can also cause a proximal
Wasting myopathy
Due to severe itch (pruritus)
CAUSES:
 Obstructive or cholestatic jaundice
Scratch marks
 Commonly the presenting feature of primary biliary cirrhosis
 Retention of an unknown substance normally excreted in bile? Bile salt
deposition in the skin?
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.
Spider naevi o Rapid refilling occurs on release of the pressure.
o >2 anywhere in the body»»likely 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

Flat or slightly elevated red circular lesions which occur on the abdomen or the front
Campbell de
of the chest.
Morgan spots Do not blanch on pressure and are very common

 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
Venous stars large vein.
 Not obliterated by pressure.
 Blood flow> from periphery to the centre of the lesion
 EYES
Jaundice Sclera
Anemia Conjunctiva - pallor
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

Kayser- CAUSE:
Fleischer rings  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
 Yellowish plaques in the subcutaneous tissues in the periorbital region
 Due to deposits of lipids
 May indicate protracted elevation of the serum cholestrol
Xanthelasma
 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

Following proctosigmoidoscopy ('black eye syndrome') - characteristic sign of

Periorbital
Amyloidosis (perhaps related to factor X deficiency)
purpura Very rare

Causes:
 Faulty oral hygiene
 Ketosis (diabetic ketoacidosis – excretion of ketones in exhaled air)
Fetor (bad
 Uremia (fish breath, an ammonical odor)
breath)
 Alcohol, paraldehyde
 Putrid (anaerobic chest infections with large amount of sputum)
 Cigarettes
Sweet smell
CAUSE: Severe hepatocellular disease and may be due to methylmercaptans
Fetor hepaticus 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

 Elongation of papillae over the posterior part of the tongue which appears dark
Lingua
brown
nigra(black
 because of the accumulation of keratin, also due to bismuth compounds
tongue)
 No known cause
  Slowly changing red rings and lines which occur on the surface of the tongue
Geographical
 Not painful, comes and goes
tongue
 Not of any significance, can be a sign of vitamin Bl2 deficiency

 White - colored thickening of the mucosa of the tongue and mouth

 Premalignant
 Often no cause is apparent
Leucoplakia  May also occur on the larynx, anus and vulva
“S” CAUSES:
Sore Teeth(Poor Dental Hygiene), Smoking, Spirits, Sepsis Or Syphilis

 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
Glossitis 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
 Commonest type of ulcer.
 Begins as a small painful vesicle on the tongue or mucosal surface of the mouth
Aphthous
which may break down to forma painful shallow ulcer
ulceration
 Heal without scarring
 Unknown cause, may indicate: Crohn’s or coeliac disease

Angular Cracks at the corners of the mouth

stomatitis CAUSES: VitB6, Vitamin B12, folate and iron deficiency.

NECK
 Palpate-especially supraclavicular nodes on the left side
 May be involved with advanced gastric or other gastrointestinal malignancy, or
Cervical LN with lung cancer
 Large left supraclavicular LN in combination with carcinoma of the stomach-
Troisier's sign

 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
Gynaecomastia
 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
  Indicates previous surgery or trauma
 Around the umbilicus for laparoscopic surgical scars
Scars
 Older scars are white and recent scars are pink because the tissue remains vascular
 Presence of stomas or fistulae.

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.
Distension  Pregnancy, also the presence of a huge ovarian cyst- umbilicus pushed upwards by
the uterus enlarging from the pelvis
“F”s 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
Enlargement of one of the abdominal or pelvic organs
swellings
Protrusion of an intra-abdominal structure through an abnormal opening
CAUSES:
Hernia  previous surgery weakening the abdominal wall,
 congenital abdominal wall defect,
 chronically increased intra-abdominal pressure
 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.
Prominent  Due to their engorged appearance-been likened to the mythical Medusa's hair
after Minerva had turned it into snakes. This sign-called a
veins
 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 An expanding central pulsation in the epigastrium suggests an AAA
pulsation The abdominal aorta, however can be seen to pulsate in normal thin people
s
Visible  May occur in very thin normal people occasionally
peristalsis  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

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
Skin lesions 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)

Stretching of the abdominal wall severe enough to cause rupture of the elastic
fibers in the skin
Striae  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

 Squat down beside the bed-pts abdomen at eye level

Asymmetrical  Ask pt to take slow deep breaths through the mouth and watch for
movement 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 Reducible during coughing (DIR) Not reducible
occlusion test
Consistency Soft (bowel) Cystic (water)
Fluctuation test (-) (+)
Trans- Does not pass through (bowel) Light pass through (water)
illumination test

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. 1st = post wall
b. 2nd= lateral wall
c. 3rd= anterior wall for prostate (size & consistency)
d. 4th= 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
 INTRO
Greet, Introduce, Explain,
 Wash & Warm hands.
Permission (GIEP)
 Adequate exposure

Age, gender, ethnic group, height,

INSPECTION
GENERAL

weight, built, nutrition Mention:

(1) conscious
(2) alert
(3) co-operative
(4) no respiratory distress
(5) not in obvious pain
(6) no general discoloration
HANDS

(1) Moisture hyperactivity of sympathetic system causes increase

in sweatiness

Especially in the case of hyperthyroidism, there

(2) Temperature
might increase in body temperature.

(3) Acropachy (Clubbing) Acropachy is a clubbing in Grave’s disease.

=separation of nail from nail bed

(4) Onycholysis
Seen in Grave’s disease

Test with a piece of paper. It is due to sympathetic

(5) Fine tremors
over activities in hyperthyroidism or Grave’s
disease.
PULSE

(1) Rate (normal 60-90 bpm)  Tachycardia (>100bpm) = hyperthyroidism

 Bradycardia (<60bpm) = hypothyroidism

(2) Rhythm
(3) Volume
(4) Symmetry (delay) Types: radio-radial, radio-femoral
1. Texture Dryness – hypothyroidism
ARMS

2. Myxoedema Hypothyroidism
3. Scratched marks
Delayed relaxation due to proximal myopathies in
4. Biceps reflex
hypothyroidism
5. BP
HAIR
1. Brittleness Both due to hypothyroidism
2. Coarseness

INSPECTION
EYES

Hypothyroidism
(1) Periorbital Puffiness
Hyperthyroidism
(2) Thyroid Stare
(3) Exophthalmus = protrusion of the eyeballs from the orbit. Easily
seen from the side of the patient.
Complications:  Look at sclera, which are not covered by
a. Chemosis lower eyelids
b. Conjunctivitis Seen in hyperthyroidism.
c. Corneal Ulceration
d. Optic Atrophy
e. Ophthalmoplegia

Bulging of an eye
(4) Proptosis Seen in hyperthyroidism

(5) Chemosis = oedema of conjunctiva and injection of sclera. It is

a complication of proptosis or exophthalmus
MOVEMENT

• Make sure the patient's head does not move.

• Ask the patient to follow your finger down with
(1) Lid lag her eyes
• Observe the lid. See if there is lagging behind
the eye ball
• Lid lag retraction seen in hyperthyroidism

 Ask the patient to move the eyes without

moving the head
 Ask the patient to follow your finger while you
(2) Diplopia 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)
 INSPECTION
THYROID GLAND 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

1. Site.
2. Size.
3. Shape
(2) Swelling
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. 6. Symmetry.
2. Site. 7. Consistency.
3. Size. 8. Margin.
4. Shape. 9. Mobility.
5. Surface. 10. Warmth.
11. Nodules.
Similar to RESPI, trachea may be deviated in
(2) Trachea deviation 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 is caused by increase blood flow due
to increased visualization in hyperthyroidism
To prevent confusion with breath sound, ask the
Thyroid bruit patient to hold his/her breath.
 INTRO Greet, Introduce, Explain,  Wash & Warm hands.
Permission (GIEP)  Adequate exposure

Age, gender, ethnic group, height,

INSPECTION
GENERAL

E.g. Mr. Chan is a middle aged Chinese man of

weight, built, nutrition
average height and built. He is well nourished and of
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.
HANDS & ARMS

(1) Moisture, Temperature &

Color (pallor)
(2) Clubbing
Impaired blood circulation e.g. atherosclerosis
(3) Capillary refill
(4) Signs of infections e.g. unhealed scars
(5) Signs of peripheral vascular e.g. loss of hairs, loss of sensation, loss of
disease & nerves disease sweatiness, warm / cold

(6) BP Postural hypotension

(7) Insulin injections
PULSE

(1) Rate (normal 60-90 bpm) (3) Volume

(2) Rhythm (4) Symmetry (delay)

HEAD

(1) Blurred vision (3) Glaucoma

(2) Cataracts (4) Infections in mouth

INSPECTION PALPATION
LOWER LIMBS

1. Infection by Necrobiosis sp. 1. Temperature.

2. Color 2. Dorsalis pedis pulse.
3. Gangrene. 3. Posterior tibialis pulse.
4. Ulceration.
MOVEMENT SENSATION (see more in NS system)
1. Cotton wool
2. Vibration (128Hz)
3. Temperature
4. Pin prick
1. Dorsiflexion.
5. Use sternal notch as a reference sensation
2. Plantar flexion. 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 patient’s
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
Pamberton’s 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 Grave’s 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 (Plummer’s 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 Grave’s 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. Phalen’s 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 (2ndary to Cushing’s or Acromegaly)
f. comatose (due to dehydration, acidosis and plasma hyperosmolality)
g. Kussmaul’s 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. charcot’s 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
Greet, Introduce, Explain,
INTRO

Permission (GIEP) **this part is very essential in that it

• Say: Good morning. I am a third contribute half of your marks!!
year medical student. May I
know your name?
• Pt: Mrs. Lim  Wash & Warm hands.
• Say: Mrs. Lim, I would like to  Adequate exposure
examine your breasts, is that
 Express the need to examine
okay?
 Be assured of the privacy
• Pt: Yes
• Sit the patient up with chest  Chaperone – friends / examiner / nurse
fully  “take your clothes off with all respect your
• Say: I would like to wash my bra as well” try to use your own word
hands before examining the  Permission
patient.
BODY HANDS
POSITIONS

1) Lying flat – breast will fall flat

2) 45 degrees – semi recumbent
1) Resting – relax the pectoral muscle
position
3) Erect – gravity (sagging)
2) On hips – contract the pectoral muscle
- pendulum bulky
4) Bend forward – fixation of
- muscle
3) Above heads – stretch skin and pectoral muscle
- skin
- bone
INSPECTION
GENERAL
1) Middle age / reproductive age
2) Weight – thin / cachexia
3) Anemic
4) Pain- obvious pain
5) Obvious masses – lymph nodes
6) Scars - mastectomy
INSPECTION

Compare the two breast

(1) size Report = equal for both side (one side larger
may be normal)

(2) Shape Abnormal shape – masses / swelling

1. distance from midline

(3) Symmetrical (nipple position)
2. distance from clavicle
(4) Skin
 Red = inflamed
1. Color  Blue = bursitis / bruises
 Black / pale = necrotizing gangrene
2. Dimpling
3. Swelling
4. Pigmentation
(5) NIPPLE
1. size
2. shape Normally cylindrical
 everted / inverted
 cracks
3. conditions
 ulcer
 discharge
 pink
4. color
 dark (in pregnancy)
 size
(6) AREOLAR  shape
 color
 peau d’orange
(7) Others  dilated veins
 hemorrhagic spot
Note:
 l. Retraction is caused by:
-Cancer 2. Paget's diseases:
-Fibrosis Breast ca causes unilateral, red, bleeding area.
-Normal
1. Ask her to raise her arms above
her head and then lower them 2. Ask her to lean forward
slowly. =This is to accentuate breast fixation
=This movement is to stretch the
pectoral muscles Say: no visible fixation on breast
Look for.
1. Tethering of the nipples or
skin
Say: No tethering of the 3. Ask her to rest her hands on her hips and press
nipples or skin them against her hips.
2. Shift in relative position of = This is known as the Pectoral Contraction
nipples or fixed mass maneuver. Function: to accentuate dimpling or
distorting breasts fixation
Say: No shift in position of Say: No visible dimpling or fixation
nipples or fixed mass
3. Masses in axilla
 Scan with palm
PALPATION

 Examine with pulp

 Finger grip
 Same for nipple and areolar
1. Site Examine in concentric circular pattern feeling 4
2. Size quadrants of breast.
3. Shape Start at areola and roll fingers over breast tissue.
4. Surface – smooth / regular
5. Skin surface a. Palpable breast mass present:
6. Edges 1. Position
7. Consistency – soft, firm, hard 2. Size
8. Mobility / fixity 3. Shape
9. Temperature 4. Surface -smooth/rough
10. Tenderness 5. Skin-color, dimple, fixed
11. Pulsation 6. Consistency-hard/firm/soft
7. Margin -regular/irregular
**ALSO PALPATE FOR 8. Tenderness
LYMPH NODES 9. Fixation
1. Axillary 10. Single or multiple lesions
2. Supraclavicular 11. Pulsation
3. Tail 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)
GIEP INSPECTIONS Explain
Strip to waist
(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 Cooper’s ligament pulled down
- peau d’orange Mouth of sebaceous gland blocked
- visible veins
- petechial Increase vascularity
haemorrhage
- 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…
(1) Scanning
PALPATION

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
 INTRO  Wash & Warm hands
Greet, Introduce, Explain,  Lie the patient down in the lithotomy
Permission (GIEP) position with her head at 45° angle.
 Adequate exposure
Age, gender, ethnic group, height,
INSPECTION
GENERAL

weight, built, nutrition E.g. Mrs. Tan is a middle aged Chinese man of
average height and built. He is well nourished and of
average weight. He is conscious, alert, and co-
**Always tell the patient what you operative. He is not in any distress, no general
are about to do before you do it. discoloration and he is not in obvious pain.
INSPECTION

(1) External Genitalia Announce what you are going to

1. Rash do and then touch the patient on
3. Warts the thigh with the back of your
4. Scars hand before proceeding
5. Sinus openings
6. Masses 1. Rash
7. Infestations (e.g. leucoplakia, redness, -swelling, excoriation) is
8. Other lesions due to thrush or trichomoniasis )

(2) Separate the labia

1. Size and shape of clitoris
2. Discharge from urethral or vaginal orifice:
2. Discharge from urethral
Bloody-menstruation, miscarriage, cancer. cervical
orifice or vaginal outlet
Purulent- vaginitis, cervicitis, endometriosis,
retained tampon

NB:
a. Trichomonas vaginalis- frothy, b. Candida albicans (white
watery, pale, yellow white thrush)- thick cheesy discharge
discharge with excoriations and pruritus

(3) Ask her to bear down:

1. Cystocele- descent of bladder through anterior
1. Cystocele
vagina wall
2. Rectocele- descent of rectum through posterior
2. Rectocele
vaginal wall
3. Uterine prolapse 3. Usually in multiple pregnancy

(4) Ask her to cough:

stress incontinence
 The 6 procedure of cleaning
PALPATION  1 mons pubis
(1) Clean labia  2 labia majora
 2 labia minora
 1 on the midline

(2) Gentle palpation Mass :

Gently palpate the labia majora Bartholin cyst/abscess in posterior part of labia
and labia minora for mass majora (normally not palpable)

(3) Internal examination

 Insert lubricated index and
middle finger into vagina. Do not forget to announce what you are going to do
 Avoid contact with the and then touch the patient on the thigh with the back
anterior structures. of your hand before proceeding.
 Place the other hand on the
patients lower abdomen
A. Examine the cervix
1. Note for:
 Size
1. Palpate the cervix  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
3. Lift cervix forward for mobility & tenderness
• Say: do you feel any pain?

Ovaries are not palpable. But if mass is present note

B. Palpate the anterior, posterior the
and lateral fornices • characteristic
• location

C. Bimanual palpation of uterus

Note the:
Function is to palpate the uterus
• uterus (anteverted or retroverted)
(if possible)
• size
• Large, nodular, mobile uterus - fibroids
• shape
• Smooth, large - pregnancy, adenomyosis,
• consistency
Submucous, fibroids
• tenderness
• mobility
 (1) Warm and lubricate the
SPECULUM EXAMINATION 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
Do not move the speculum while it is locked open.
vagina and open it

(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.

INTRO
Greet, Introduce, Explain,
Permission (GIEP)
Age, gender, ethnic group, height,
INSPECTION
GENERAL
weight, built, nutrition
**chaperone may needed privacy
explained
(1) Nipple and areola
INSPECTION
(2) Abdominal distension
(3) Linea nigra
(4) Striae gravidum
(5) Striae albicans
(6) Umbilicus
(7) Scars
PALPATION (usually after 20 weeks)
 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.
E.g. Mrs. Chan is a middle aged Chinese man of
average height and built. He is well nourished and of
average weight. He is conscious, alert, and co-
operative. He is not in any distress, no general
discoloration and he is not in obvious pain.
Usually enlarged and darkens during pregnancy
After 24 weeks fetal movement may be seen.
Indicating viability
Black line stretches from pubic symphysis upwards
in the midline
Red stretch marks of current pregnancy
White stretch marks of previous pregnancy
 Inverted
 Flat (later stage)
 Everted (polyhydromnios / multiple
pregnancy)
Caesarian
 To determine the position of head. Weather it is
(1) Fundal grip
breach or cephalic
To determine the back (vertebral) part of the fetus
and front (hands & legs)
Back Front
(2) Lateral grip  Hard  Knobby
 Smooth  Hollow
 Regular  Irregular

(3) Pelvic grip To determine the engagement of the fetus

Smaller
1. Smoking
2. Deformity
3. Low birth weight
4. Death
(4) Fundal height measurement 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)
AUSCULTATION

 Usually after 18 weeks

 Use the Pincard (fetoscope) or
Doppler
 Place on the widest par over
the anterior shoulder of the
fetus
 Facing mother’s feet
 Press gently
 On Pincard, never touch it!
 Renal
System
  Wash & Warm hands.
INTRO
Greet, Introduce, Explain,
Permission (GIEP)  POSITION: FLAT with one pillow
 Adequate exposure
GENERALS
INSPECTION
GENERAL

Mention:
(1) conscious
(2) alert
Age, gender, ethnic group, height, (3) co-operative
weight, built, nutrition (4) no respiratory distress
(5) not in obvious pain
(6) no general discoloration

Look for
[metabolic acidosis]
1. Hyperventilation

2. Hiccupping [ uraemic syndrome]

3. Uraemic fetor [uraemic syndrome]

4. Drowsy / comatose [nitrogen or toxin retention]
[Low serum Ca. nitrogen retention. Also with
5. Seizures / coma
overcorrection acidosis with bicarbonate]

6. Twitching [Ca ion imbalance]

SKIN
[dirty brown skin seen in CRF caused due to failure
1. Sallow skin complexion
to excrete urinary pigment]

[state grey to bronze color seen in chronic dialysis

2. Metallic color
patient with multiple transfusion]

3. Subcutaneous nodules [ca ion deposition]

Hydration:
1. Sunken orbits
2. Dry mucous membrane
4. Hydration status 3. Moribound appearance
4. Reduced skin tugor
5. JVP
 Hypercapnea
HANDS
(1) Moisture & Temperature
=opacity of the nails, leaving a rim of pink nail bed
on the top of the nail
Seen in; low albumin level due to :
(2) Leuchonychia
 Liver failure
 Malabsorption
 Kidney failure
= white transverse lines near the end of nails
(3) Muehrke’s nails
Seen in hypoalbuminaemia – nephritic syndrome
= single white band
(4) Mee’s lines Seen in ARF and arsenic poisoning
= anemia
Seen in
 CRF
(5) Palmar crease pallor  Poor nutrition
 Blood loss / hemolytic anemia
 BM depression (effect of EPO)

= non pigmented indented transverse band

(6) Beau’s line (rare) Seen in catabolic state
= distal nail brown or red, proximal nail pink or
white
(7) Half-and-half nails (rare)
Seen in CRF

(9) Asterixis – hepatic flap Seen in terminal CRF

(10) Scars & fistula and sign of dialysis
carpal tunnel syndrome
=>nitrogen retention causing impaired PT
ARMS

consumption thus causes decrease in platelet factor

(1) Bruising
III
Seen in CRF
(2) Scratch mark and excoriations Uraemic pruritis

Fine white powder present on the skin where high

(3) Uraemic frost concentrations of urea have precipitated out of
sweat.
Seen in CRF.
=>failure to excrete urinary pigments
(4) Skin pigmentation
Seen in CRF
(5) Peripheral neuropathy & Seen in CRF
Vasculitis
 Hypertension related renal disease.
(6) Pulse & BP
Postural hypotension in ARF.
(1) Jaundice Liver hemachormatosis
EYES

(2) Pallor Hemolysis causing anemia

Ca ion deposition beneath corneal epithelium in line
with interpalpebral fissures
(3) Band keratopathy
Seen in 2ndary or 3rtiary hyperparathyroidism and CRF
treatment complication
(1) Oral trash
(2) Uraemic fetor
(3) Hydration
MOUTH

(4) Jaundice
(5) Mucosal ulcer CRF
Thickening of gums
(6) Gingival hyperplasia Complication of treatment for kidney transplant
patient
(1) JVP Intravascular volume status
NECK

(2) Jugular vein puncture Vascular access insertion (vaseath) - hemodialysis

(3) Carotid bruits
Observe for
1. inspect for chest wall and
deformities
2. inspect for obvious breast
and skin discoloration
CHEST (rare)
Seen in generalized atherosclerosis or CRF
CRF:
 CCF
 HPT (Na +H2O retention)
 Pulmonary oedema (uraemic lung disease,
volume overload, uraemic cardiomyopathies)

3. symmetry of respiratory  Pericarditis (pericardial rub or cardiac

movement temponade)
4. visible apex beat  Lung infections (immunosuppression)
Examine for:
1. symmetrical percussion
2. chest expansion
3. auscultation for added
sound
4. apex beat
5. heart sound
(do normal abdominal examinations-similar to those in GI)
Pay attention to:
ABDOMEN

Inspection:
1. Nephrectomy Scars
(May have to roll patient over to
look at posterior aspect)
2. Peritoneal dialysis scars
3. Abdominal Distention
 Spleen Kidney
Palpation:
No palpable upper Upper border palpable
1. Bimanual ballotment (ask the
border
patient to breath deeply as you
ballot)
Has splenic notch No notch
[size, surface and consistency]
2. Palpate for enlarged bladder
Moves inferior- Moves inferiorly
Percussion:
medially on inspiration
1. Shifting dullness
2. Percuss for enlarged bladder
Not ballot able Ballot able
Auscultation:
1. Renal bruit – 2cm left and right
Dull on percussion Resonance on percussion
to umbilicus
Friction rub audible Not audible
(1) Vertebral column punch
Punch on vertebral column with the base of fist
(gentle)
BACK

(2) Murphy’s kidney punch (the

Punch at the renal angle for tenderness in infections.
kidney punch)
(3) Sacral oedema
Look for
1. Oedema
LEGS

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
Kidney: *** Palpation
1. region = lumbar BREATH IN =>> deep and superior
2. edges = smooth rounded BREATH OUT =>> move to next stage
3. on percussion = resonance
4. ballotable

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
Musculoskeletal
System
 INTRO

Greet, Introduce, Explain,  Wash & Warm hands.

Permission (GIEP)  Sitting down
 Adequate exposure

Age, gender, ethnic group, height,

INSPECTION
GENERAL

weight, built, nutrition

Mention: E.g. Mr. Chan is a middle aged Chinese man of
(1) conscious average height and built. He is well nourished and of
(2) alert average weight. He is conscious, alert, and co-
(3) co-operative operative. He is not in any distress, no general
(4) distress / restlessness discoloration and he is not in obvious pain.
(5) not in obvious pain
(6) no general discoloration
(pallor)
 3D inspections (front, side and behind)
INSPECTION

 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
Levels of shoulder
(3) Attitude Hanging / supported
This is done by asking the patient to unbutton his /
(4) Movement her shirt to see if there are any limitations in
movement.
(5) Symmetry Compare the two shoulders
PALPATION

 Tenderness  Bursae
 Exploration  compare
 Joints
 tendons
 ligaments Comment on:
 ligaments  pain
 deformities – swelling, temperature & mass
 intact bones
 (1) Sternoclavicular Joint
(2) Clavicle
(3) Acromioclavicular
(4) Spinous (Scapula)
(5) Infraclavicular Fossa
(6) Acromion
(7) Greater Tuberosity
Note: (Extra)
Triangle Of Symmetry
1. Corocoid (Thumb)
2. Acromion (2nd Finger)
3. Greater Tuberosity (Middle Fingers)

 To see if the patient is able / unable to perform certain motion

MOTION

 Range of movement
 0°=anatomical position
 Comment: “range of movement is from zero (0) to…” – on your findings, not
what’s 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
= 90° abduction and light extension
SPECIAL TEST

PLUS 90° external rotation

(1) Apprehension test
Done in shoulder dislocation

Bursitis - subacromial impingement

(2) Neer’s test (RARE!) - acromion processes impinge on bursa

(3) Hawkin’s test (RARE!) Rotator cuff injuries

 INTRO
Greet, Introduce, Explain,  Wash & Warm hands.
Permission (GIEP)  Lie down flat
 Adequate exposure
Age, gender, ethnic group, height,
INSPECTION
GENERAL

weight, built, nutrition Comment especially on:

 Pallor
 Pain
 Distress

 3D inspections (front, side and behind)

INSPECTION

 Start with normal

 Proper exposure and warm hands
(a) normal / equal
(1) Shape (b) rounded / deformity
(c) swelling / wasting
• Redness
• Discoloration
(2) Skin • Scars
• Abrasion Shoulder
• Laceration
(3) Attitude Standing / supine
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
(5) Movement – Gait
High stepping gait
Ask the patient to walk.
= 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.
 Comment on:
PALPATION  Tenderness  pain
 Exploration  deformities – swelling, temperature & mass
 Skin temperature  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.
 To see if the patient is able / unable to perform certain motion
MOTION

 Range of movement
 0°=anatomical position
 Comment: “range of movement is from zero (0) to…” – on your findings, not
what’s 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
Apparent length
MEASUREMENT

True length

**square the pelvis first!!

(2) True length
True–shortening
ASIS toSeen in:part of medial
upper
maleolusCan be due to old fractures of
(3) Apparent length tibia.
femur or –
Apparent shortening
xiphisternum to upper part of
Seen in:
medial maleolus
Adduction contracture of the hip
which has to be compensated for
see next pageby(extra)
tilting for more
of the info
pelvis.

Fig. 10.41 True and apparent lengths of the lower

limbs.
 (1) Thomas test Thomas's test measures fixed flexion deformity (inco-
SPECIAL TEST The test must be performed with mplete extension). This deformity may be masked by
the patient lying face up a hard compensatory movement at the lumbar spine or pelvis
surface. and increasing lumbar lordosis.

 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.

(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 Trendelenburg's sign. Powerful gluteal muscles maintain the
vara 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

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.

Above the knee Below the knee

Normal

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. ASIS

Greater trochanter

Normal Superior displacement Inferior displacement

1. CERVICAL
INTRO
 Wash & Warm hands.
Greet, Introduce, Explain, Permission (GIEP)
 Sitting down
 Adequate exposure

(1) Swelling
INSPECTION

(2) Skin
• Redness
• Discoloration
• Scars
• Abrasion Shoulder

(3) Neck deformity

Torticollis / wryneck
muscles of the neck contract ~ neck is
twisted to an unnatural position
cause:
(4) Torticolis
-protective spasm due to trauma
-tonsillar infection
-vertebral body disease
-sternomastoid tumor (infant)
Webbing of the neck
Absence of 1 or more cervical
(5) Congenital webbing of the neck vertebrae
e.g. Turner's Syndrome

Check asymmetry in supraclavicular

(6) Symmetry
fossa
PALPATION

Comment on:
 pain
 Tenderness  deformities – swelling,
 Swelling temperature & mass
 intact bones
MOTION

(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
INTRO

Greet, Introduce, Explain, Permission  Wash & Warm hands.

(GIEP)  Standing
 Adequate exposure
(1) Deformities
INSPECTION

 Scoliosis = lateral bending

 Kyphosis = AP bending
 Gibbus = localized kyphosis
 Lumbar curvature / lordoisis Gibbus: TB of spine
 Swelling
(2) Skin 1. Hair tuft. discoloration or dimpling at
• Scars the base of the spine indicates spina
• Sinuses bifida
• Color change 2. Soft tissue swelling may be due to:
• Hair tuft
• Discoloration -infection
• Dimpling at base of spine -trauma
• Soft tissues swelling -tumors

Comment on:
PALPATION

 pain Feel for bony contour

 deformities – swelling, temperature
& mass
 intact bones
Seen in:- fracture
(1) Tenderness - TB
- Infection
(2) Muscle wasting
(3) Muscle pain
(4) Steps
(1) Extension
MOTION

- 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
SPECIAL TEST

(1) Schober’s 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
  Wash & Warm hands.
INTRO
Greet, Introduce, Explain,
Permission (GIEP)  Sitting
 Adequate exposure
(1) Overall about the patient (e.g. position, gait…etc)
INSPECTION

(2) Muscle bulk

(3) Muscle wasting
(5) Involuntary movement
- Tics/twitches
- fasciculation
- tremors
TONE** ask the patient to relax

(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.
(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.
 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)
 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  In upper motor lesion the patella may manifest a
position, grasp the upper few jerks (unsustained clonus) or a constant
edge of the patellar jerking as long as the pressure is applied.
between the thumb and (sustained clonus) *avoid prolonging this
index finger and apply a maneuver as it is often painful to the pt
quick constant pressure in
a downwards direction.
(4) Ankle clonus
 Ensure that the pt's knee is  In the upper motor lesions the posterior
semi-flexed and the foot muscles of the leg will enter into a persistent
relaxed. contraction.
 The foot is suddenly
pushed dorsally with
moderate force and held
there.
 UPPER LIMBS
POWER (1) Shoulder abduction: 'hold Chief movers: deltoids C5
your arms outwards at your
sides and keep them up, don't
let me stop you'
(2) Shoulder adduction: 'push
your arms in towards you and Chief movers: pectoral muscles C6-8
don't me stop you'
(3) Elbow flexion: 'bend your Chief movers: biceps C5
elbows and pull me towards
you, don't let me stop you'
(4) Elbow extension: “straighten Chief movers: triceps C7
your elbows and push me
away, don't let me stop you”
(5) Wrist extension: 'clench your Chief movers: C7
fist and cock your wrists up,
don't let me stop you'
(6) Wrist flexion: 'now push the Chief movers: C7
other way'
(7) Finger abduction: 'spread Chief movers: dorsal interossei TI
your fingers wide apart and
don't me push them together'
Chief movers: palmar interossei TI
(8) Finger adduction: 'hold
this piece of paper your
fingers and don't me snatch
it away'
LOWER LIMBS
(9) Hip flexion: 'lift your leg Chief movers: iliopsoas Ll-2
straight up and keep it there,
don't me stop you'
Chief movers: glutei L4-5
(10) Hip extension: 'push your leg
downwards into your bed and
don't let me stop you'
(11) Hip adduction: 'push your Chief movers: adductors of the thigh L2-4
thigh inwards against my
hand'
(12) Knee flexion: 'bend your Chief movers: hamstrings L5-S1
knee and pull your heel
towards you, don't let me stop
you'
(13) Knee extension: 'Straighten Chief movers: quadriceps L3-4
your knee and don't let me
stop you'
 (14) Plantar flexion: 'push your Chief movers: gastrocnemius S 1
foot downwards against my'
(15) Dorsiflexion: 'move your foot Chief movers: tibialis ant and long extensor L4-5
up and don't let me stop you'
(16) Inversion of the foot: 'push Chief movers: tibialis ant and post L4
your foot inwards against my
hand'
(17) Eversion of the foot: 'push Chief movers: extensor hallucis longus L5
your foot outwards against my
hand'
(18) Extension of the great toe: Chief movers: extensor hallucis longus L5
'pull your toe upwards and
don't let me stop you'
(1) Biceps
REFLEXES

-Place the pt's hands on his/her

abdomen. Nerve: musculocutaneous n.
-Place your index finger on the Root: C5
biceps tendon and swing the
hammer on to your finger.
(2) Brachioradial
-Place the arm flexed on to the
Nerve: radial n
abdomen, place the finger on
Root: C6
the radial tuberosity, and hit
the finger with the hammer.
(3) Triceps
-Draw the arm across the chest,
holding the wrist with elbow Nerve: radial
at 90 degree. Root: C7
-Strike the triceps tendon
directly with the tendon
hammer
(4) Knee
-Place the arm under the knee
Nerve: femoral
so that the knee is at 90
Root: L3-L4
degree.
-Strike the knee below the
patella.
(5) Ankle
Hold the foot at 90 degree with
a medial malleolus facing the
ceiling. Nerve: tibia
-The knee should be flexed and Root: SI-S2
lying to the side.
-Strike the Achilles tendon
directly.
 Afferent: segmental sensory nerve
(6) Abdominal Efferent: segmental motor nerve Root:
Scratch the abdominal wall 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.
Positive Babinski's sign
-Gently draw a stick up a
1. Hallux extends, the other toes spread.
lateral border of the foot and
2. Indicates UMNL.
across the foot pad.
-Watch the big toe and the
remainder of the foot.

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.
COORDINATION

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 activities…etc.
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
 : 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
 (1) Light touch testing (posterior column & anterior spinothalamic tract)
COTTON WOOL

 Touching the skin with
cotton wool
 Test it on anterior chest
with patient's eyes open
 Test each dermatome
 Always compare both sides
(2) Pain (pinprick) testing (lateral spinothalamic tract)
PIN-PRICK (rarely done)
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

1. I'm going to use this pin/stick to test your pain

 Use new pin or sharp stick sensation
 Test it on chest with 2. This is sharp, and this is dull, can u differentiate
patient's eyes open it? (chest)
 Sharp or dull 3. say 'sharp' or 'dull'
 Test each dermatome 4. please close your eyes
 Compare right and left 5. Are both sides the same?
6. Pain sensation is normal/ reduced! absent
(3) Vibration testing (posterior column)
VIBRATION (128 Hz)

 Use 128Hz tuning fork 1. I'm going to do a vibration test on you (place
 Let patient feel for it on the
it on the chest)
chest
 Place it on the distal 2. Can you feel that vibration?
interphalangeal joints 3. say 'yes' when you can feel it, say 'stop' when
 If distal part sensation lost, it disappear
proceed to proximal joint-
4. please close your eyes
wrist, elbow, shoulder
 Compare 5. vibration sensation is normal / reduced/ absent
(4) Propioception testing (posterior column)
J
  Use distal interphalangeal 1. I'm going to test your joint position
joint of index finger 2. this is 'up' and this “down”
 Stabilize the proximal 3. Please tell me this is up or down?
phalanx, move distal phalanx
up and down 4. Sense of position is intact / lost
 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
[sensory]
Olfactory

1. Smell: Ask the patient to identify the smell.

Do you have runny nose? Close one of the nostrils, and do with the patient
Can you please close your eyes closing eyes.
and either nostril?  Coffee
Please smell and identify.  Flower
 Chocolates
1. Far Vision  Far vision test
Optic

 Close one eye

 Use Snellen’s 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 Ishihara’s chart
 To determine color
blind
 Ask the number or ask
to follow the lines
 4. Visual Field
Instruction:
 I’m going to test on your
field of vision
 I’m 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
5. Direct Light Reflex
6. Consensual Light Reflex
7. Accommodation Reflex
Instruction:
 Could you please look
as far as possible
 Now look at my finger
8. Fundoscopy
1. H test
[motor]
3,4,6
 Distance of about 1 arm’s length
 Confrontation method
 Close one eye
 Close your eye too!! – practice needed
 See in EXTRA for explanation of abnormal
findings
 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
 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
Accommodation reflex:
1. Convergence
2. pupil constriction
3. thickened lens (cannot be seen
Comment on:

Instruction: 1. Nystagmus
 I need to test the movement 2. Diplopia (ask the patient while doing)
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
Sensory (major): Compare. Test at sternum or fingers
1. Touch (cotton wool)
2. Pain (pinprick)
 Motor: Muscle:
Trigerminal
[sensory + motor]
1. bulk 1. Masseter – Clench Teeth
2. involuntary movement 2. Pterygoids – Open Mouth
3. tone 3. Temporalis
4. power Power:
5. reflex 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.
Sensory (minor):
[motor + sensory]
Facial

Sensation of anterior 2/3 of tongue

Motor (major): Angle of eye at the same level

1) Bulk – check for symmetry 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 Talley’s video)
 2. Rinne’s 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. Weber’s 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
1. Hoarseness of voice  Recurrent laryngeal nerve (vagus)
& vagus
Glossopharyngeal

 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
[motor] 1. Bulk  Look and ask the patient to look to the side
Accessory  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
1. Bulk  Size (wasting?)
[motor]
Hypoglossal

 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 = patient’s
Denominator = normal

6/6 = patient/normal LINE 8 Patient can read from 6m what a normal person
can read from 6m [NORMAL]

20/70 = patient/normal LINE 3 Normal person can read at 70 feet, but patient can
read at 20 feet [NEAR SIGHTED]

20/13 = patient/normal LINE 10 Normal person can read at 13 feet, but patient can
read at 20 feet [LONG SIGHTED]