Medicine Clinics Guide: Summary of Bates Tables From DR Dominguez

MEDICINE CLINICS GUIDE
Summary of Bates
Tables from Dr Dominguez
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Contents
HISTORY TAKING ..............................................................................................................................6
I. GENERAL DATA ....................................................................................................................6
II. CHIEF COMPLAINT .........................................................................................................6
III. HISTORY OF PRESENT ILLNESS ..............................................................................6
IV. PAST MEDICAL HISTORY ............................................................................................7
V. OB GYNE HISTORY ..............................................................................................................8
VI. FAMILY HISTORY ............................................................................................................8
VII. SOCIAL and ENVIRONMENTAL ................................................................................9
VIII. REVIEW OF SYSTEMS ............................................................................................ 10
PHYSICAL EXAMINATION (NORMALS) ............................................................................... 12
GENERAL INFORMATION ...................................................................................................... 12
GENERAL SURVERY.................................................................................................................. 12
VITAL SIGNS ................................................................................................................................. 12
SKIN .................................................................................................................................................. 13
HEAD, EYES, EARS, NOSE, THROAT, NECK ................................................................... 13
THORAX AND LUNGS ............................................................................................................... 17
CARDIOVASCULAR SYSTEM ................................................................................................. 19
ABDOMEN ..................................................................................................................................... 20
LOWER EXTREMITIES............................................................................................................. 21
MEDICINE 1 SKILLS LABORATORY ....................................................................................... 23
I. CORE SKILLS........................................................................................................................ 23
A. FEVER ............................................................................................................................ 24
B. HIGH BLOOD PRESSURE ...................................................................................... 26
C. HEADACHE.................................................................................................................. 28
II. INTEGUMENTARY SYSTEM ..................................................................................... 33
III. HEENT................................................................................................................................ 38
A. HEAD .............................................................................................................................. 38
B. EYES................................................................................................................................ 38
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C. EARS ............................................................................................................................... 50
D. NOSE............................................................................................................................... 55
E. MOUTH, THROAT AND NECK PROBLEMS ................................................... 58
IV. CARDIOVASCULAR SYSTEM.................................................................................... 63
A. CHEST PAIN ................................................................................................................ 63
B. PALPITATIONS .......................................................................................................... 67
C. SHORTNESS OF BREATH: DYPSNEA, ORTHOPNEA OR PND .............. 69
D. SWELLING OR EDEMA .......................................................................................... 72
E. CARDIOVASCULAR PHYSICAL EXAMINATION SKILLS ......................... 73
V. RESPIRATORY SYSTEM.................................................................................................. 90
A. MEDICAL COMMUNICATION SKILLS ............................................................. 90
B. PHYSICAL EXAMINATION SKILLS ........................................................................... 90
VI. BREAST........................................................................................................................... 102
VII. GASTROINTESTINAL SYSTEM ............................................................................ 107
A. DYSPHAGIA .............................................................................................................. 114
B. ABDOMINAL PAIN ................................................................................................ 115
C. DIARRHEA ................................................................................................................ 118
D. VOMITING................................................................................................................. 122
E. JAUNDICE .................................................................................................................. 123
F. CONSTIPATION .......................................................................................................... 124
G. GI PHYSICAL EXAMINATION SKILLS .......................................................... 126
VIII. PERIPHERAL VASCULAR SYSTEM ................................................................ 128
A. MEDICAL COMMUNICATION SKILLS .......................................................... 128
B. PHYSICAL EXAMINATION ................................................................................ 129
VII. GENITOURINARY SYSTEM ......................................................................................... 140
B. PHYSICAL EXAMINATION ................................................................................ 144
XIII. ANUS, RECTUM AND PROSTATE........................................................................... 164
Rectal Examination ........................................................................................................... 165
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IX. MUSCULOSKELETAL SYSTEM ............................................................................. 170
A. LOW BACK PAIN .................................................................................................... 173
B. NECK PAIN ............................................................................................................... 175
C. JOINT PAIN ............................................................................................................... 177
D. EXAMINATION OF THE MUSCULOSKELETAL SYSTEM .................... 180
VIII. NERVOUS SYSTEM ....................................................................................................... 188
The Brain................................................................................................................................ 188
The Spinal Cord ................................................................................................................... 192
Peripheral Nervous System .......................................................................................... 192
The Cranial Nerves ............................................................................................................ 192
The Peripheral Nerves..................................................................................................... 192
Motor Pathways.................................................................................................................. 194
Sensory Pathways .............................................................................................................. 196
Dermatomes. ................................................................................................................... 198
B. SCREENING NEUROLOGIC EXAMINATION .............................................. 205
C. Mental Status Exam.............................................................................................. 216
XI. ENDOCRINE SYSTEM ..................................................................................................... 225
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HISTORY TAKING
I. GENERAL DATA
 Name
 Baguio Address
 Home Address
 Age
 Birthdate
 Birthplace
 Sex
 Race/Nationality
 Religion
 Marital Status
Single
Married
Widower
Legally Separated
 How many children
 Occupation
 Date of Admission/Consultation
# of Consultation
 Referring Physician
 Informant
o % Reliability
II. CHIEF COMPLAINT

III. HISTORY OF PRESENT ILLNESS
 Onset (date and time)
 Location and Radiation
 Duration
 Characteristic / Quality
 Aggravating / Precipitating Factor(s)
 Relieving Factors
 Severity (Rate 1 – 10)
 Setting/ Timing
 Associated manifestations/symptoms
 Medications taken
o what, how many, dosage
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IV. PAST MEDICAL HISTORY
 Birth and Development
 Manner of Birth (NSVD or CS)
 Immunizations and vaccinations
o BCG, DPT, OPV, MMR, Hepa B
o Flu, meningococcemia, Hib, Cervical CA
 Allergic &Hypersensitivity reactions
o Foods, drugs
 Childhood Illness
o Chickenpox, measles, mumps, dengue
 Adult diseases
o Asthma, Allergies, HPN, DM, PTB, Cardiac, Renal problems,
stones, CA
o Treatment
 Communicable diseases
 Surgical Operations (Major & Minor)
o What, when, where, how
 Injuries/accidents
 Hospital admissions/ Confinements/Check ups
o What, when, where, how, how long
o Tests
o Treatment / Medications
 Other Medications
o Laxative, HPN drugs, sleeping pills, vitamins
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V. OB GYNE HISTORY
 Menarche (Date, duration)
 Menstrual Cycle (Regular/Irregular)
 Menses
o Duration
o No. of pads used per day
o Dysmenorrhea?
 Last Mentrual Period
 Papsmear
 Hx of gynaecological diseases
 Pregnancies (OB Scoring)
o Gravida
o Parity
o Term
o Abortion
o Live
 Complications during pregnancy
 Family Planning Acceptor?
 Sexual History
 No. of sexual partners
 Last sexual intercourse
VI. FAMILY HISTORY

 Father and Mother
o Living
o Cause of death
o Age of death
 Siblings
o Number
o Living
o Cause of death
o Age of death
 Heritable diseases
o HPN, DM, CA. Stones, Cardiac, Arthritis, Migraine
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VII. SOCIAL and ENVIRONMENTAL
 Educational attainment
 Exposure to endemic diseases
 Religious beliefs
 Occupational history
 Activities of daily living
o Vices
 Smoking, Drinking

o Physical Activity (exercise)
o Lifestyle Habits
o Sleeping Pattern
o Diet / food preference
 Coffee intake
 Living arrangement
o Location
o Storeys, rooms
o Number of occupants
o CR
o Water source
 Cooking, eating
 Boiled (how long)
o Garbage disposal
o Pets?
o Social relationship in the house
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VIII. REVIEW OF SYSTEMS
 General: Weight (usual, change), Fatigue, Fever, Chills, Paleness, Night
sweats, Dizziness
 Skin: Rash, Lumps, Itching, Sores, Moles (change in size and color), Hives,
Pigmentation (changes), changes in hair or nails
 Head and Neck: Headache, Trauma, Pain, Stiffness, Swelling, light
headedness, Swollen glands, Goiter,
 Eyes: Pain, icteric sclera, Redness , Dryness, Tearing, Use of Corrective
Lenses,
Visual Dysfunction, Blurring, Flashes of light, Diplopia, Scotoma, Glaucoma,
Cataracts,
 Ears: Difficulty or decreased hearing, Tinnitus, Pain, Discharges,
Vertigo/dizziness, Infection, Discharges
 Nose: Epistaxis, Dryness, Pain, Discharges, Obstruction, Smell Dysfunction,
Sneezing,
Frequent colds, hay fever, and sinus trouble/pain
 Mouth and Throat: Soreness in the mouth, Soreness in the throat, Neck
Pain, Ulcers, Hoarseness, Dryness, Gum and Dental Problems
 Breasts: Discharges, Lumps/Masses, Pain, Discomfort, Bleeding, Infection,
Self-examination practices
 Respiratory: Cough, Dyspnea, Shortness of breath, Sputum (color and
character), Hemoptysis, Cyanosis, Wheezing/asthma, Occupational
exposure, Tuberculosis exposure, past PPD, Pneumonia, Emphysema,
Previous X-Ray
 Cardiac: Chest Pain/discomfort, Orthopnea, Paroxysmal Nocturnal
Dyspnea, Palpitations, Murmurs, Undue Fatigue, Edema, Cyanosis,
Syncope, Hypertension, Past Heart Diseases, Rheumatic Fever, Exercise
Limit, results of pas ECG and other CV tests
 Peripheral Vascular: Intermittent Claudication, Leg Cramps, Ulcers,
Varicose Veins,
Non healing wounds, swelling in calves, color changes in fingertips during
cold weather, swollen
 GastroIntestinal: Anorexia, Heartburn, Nausea, Retching, Vomiting,
Dysphagia, Hematemesis, Indigestion, Melena, Hematochezia, Heartburn,
Abdominal Pain, Hernia, Hemorrhoids, Color and characteristic of stools,
change In bowel habits, pain in passing stool, Rectal bleeding, Use of
Laxatives, liver or gall bladder problems, hepatitis
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 Renal and Urinary: Dysuria, Hematuria, Incontinence, Nocturia, Urinary
Frequency, Burning Pain, Dribbling, Urgency, Kidney Stones, Suprapubic
pain
 Gynecological: Abdominal bleeding, Vaginal discharge, Itchiness, Soreness,
Lumps, Dysmenorrhea, Pelvic Pain, Dyspareunia, Contraceptive Use,
History of venereal diseases, Abortions, Birth control pills, Menopause
 Male Genitalia: Pain, Swelling, Urethral Discharges, Hernias, Testicular
Pain, Masses,
Hx of venereal diseases, Erectile dysfunction/potency, sexual habits, ulcers,
condom use
 Musculoskeletal: Muscle Pain, Joint Pains, Cramps, Weakness,
Stiffness, Arthritis, Tenderness, History of Trauma, Swelling, Limitation of
Motion, Neck or Low back Pain, arthralgia
 Hematological: Anemia, Excessive Bleeding, Easy Bruising, Past
Transfusions
 Endocrine and Metabolic: Weight Change, Polydipsia, Polyphagia,
Polyuria, Hair Change, Heat / Cold Intolerance
 Nervous System: Headaches, Syncope, Seizures, Weakness, Head
Trauma, Stroke, Sleep Disorder, Coordination Problems, Paralysis,
Sensory Disturbance, Motor Problem (pns and needles or involuntary
movements), Tremors, Memory Loss, Pins and needles
 Psychiatric / Emotional: Anxiety, Depression, Loss of Control,
Nervousness, Tension, Memory Change, Nervousness, Suicide Attempts,
Substance Abuse, changes in mood, changes in insight
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PHYSICAL EXAMINATION (NORMALS)
GENERAL INFORMATION
PROCEDURE WHAT TO SAY
 Wash or sanitize hands before beginning “Good morning/ afternoon,
examination ma’am/sir ______. I am
 Display a professional demeanor towards the
______, a second year
patient during the exam
o Introduce yourself as a medical medical student and I am
student here with Doctor _______ to
o Use patient’s last name conduct a physical
o Dress appropriately in white coat examination on you”
o Appropriate interaction with the
patient - sensitivity to privacy, comfort and
dignity
 Drape the patient appropriately during each
segment of the exam
 Use proper sequencing of the examination
and proper pacing
 All palpation and auscultation must be done
on bare skin
GENERAL SURVERY
1. Observe general state of health, posture, Patient is conscious,
motor activity, gait, hygiene, body or breath coherent, alert, not in pain,
odors, facial expressions, affect, level of not in cardiopulmonary
consciousness, manner of speaking distress.
Patient is appropriately
2. Obtain height and weight, temperature
dressed for the weather and
is oriented to 3 spheres
*BMI (AP): 18-24.9
VITAL SIGNS
3. Explain to the patient the procedures to be
done Normal temp: 36.5-37.5
4. Position the patient in comfortable sitting
position. Arms abducted, slightly flexed at the
elbow and raised at heart level
5. Deflate the cuff then center the bladder of
the cuff over the brachial artery
6. Estimate the systolic pressure by palpation
of the radial artery then rapidly inflate the cuff
until the radial pulse disappears. Read this
pressure then deflate cuff.
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7. Take the BP using auscultation. Place NORMAL BP :
the bell of the stethoscope over the
brachial artery.
8. Inflate the cuff until 30 mmHg above
the palpated Systolic Pressure then
deflate slowly at a rate of 2-3 mmHg/sec
9. Note the systolic (Korotkoff 1) and
diastolic pressure (Korotkoff 5)
10. Take the radial pulse for 1 min. use NORMAL PR: 60-100 bpm
the pads of the index finger and middle
fingers, compressing the radial artery
until maximal pulsation is detected.
11. Count the respiratory rate in 1 min NORMAL RR: 16-20 rpm
by watching the movement of the chest
wall
SKIN
12. Assess skin moisture. Identify Upon inspection, there are no scars,
lesions (note location , distribution, no lesions, there is no palor, no
arrangement, type and color) jaundice, no cyanosis. The skin is
13. Inspect and palpate hair and nails. warm to touch, good skin turgor, no
Study hands and feet. rashes, no petechiae, no
pigmentations.
Capillary refill: 1-2 seconds
HEAD, EYES, EARS, NOSE, THROAT, NECK
HEAD
14. HEAD: Examine the hair, scalp, skull There are no scars, no lesions no
and face. gross deformities, good hair
distribution, no tenderness.
EYES
26. Check visual acuity using a Snellen “Pakitakpan po ang kanang mata.
eye chart Position the patient 20 ft from Hanggang saan po ang klaro? Paki
the chart. dikta o ang mga letra. Pabaliktad
27. Ask patient to cover one eye with a naman po. Yung kabilang mata
card and read the smallest line of print naman po.”
28. Repeat the procedure covering the
other eye.
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29. Asses visual fields. Ask the patient to Visual fields are normal.
look with both eyes into your eyes.
30. While you return the patient’s gaze,
place your hands 2 ft apart, lateral to
patient’s ears
31. Instruct the patient to point to your
fingers as soon as they are seen
32. Slowly move your wriggling fingers of
both your hands along the imaginary bowl
toward the line of gaze until the patient
identifies them
33. Repeat the pattern in the upper and
lower temporal quadrants
34. Inspect external eyes. Stand in front of Non sunken eyeballs, no
the patient and survey eyes for position periorbital edema,
and alignment. anicteric sclerae
35. Inspect the eyebrows and eyelids
36. Inspect the region of the puncta, Pink palpebrae
conjunctiva and sclera. Ask the patient to conjunctiva, clear corneal
look up as you depress both the lower lids film, pupils 2-3mm, no
with your thumb discharges
37. Inspect the cornea and lens, using a Pupils are Equally round
penlight shined obliquely across the eye and Reactive to Light and
38. Inspect the iris, pupils for size and Accomodation
shape and symmetry
39. Asses pupillary reflexes. Ask the patient Right and Left pupils are
to look into the distance and shine a bright constricting with light,
light obliquely into each pupil in turn both on direct and indirect
light reflex tests.
40. Assess Extraocular movements: From 2 Reflection is symmetrical

ft directly in front ff the patient, shine a on both eyes
light into the patient’s eye and ask the
patient to look at it. There are no extraocular
41. Ask the patient to follow your finger or movementin all six
pencil as you sweep through the six quadrants
cardinal directions of gaze
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42. Opthalmoscopic Exam: Turn the lens disc to the The red-orange reflex is
0 diopter observed and the retinal
43. Hold opthalmoscope in your right hand to vessels are seen.
examine the patient’s right eye and hold it in your
left hand to examine patient’s left eye
44. Instruct the patient to look slightly up and over
your shoulder
45. Place yourself about 15 inches away from the
patient. Shine light on pupil and look for the red-
orange reflex. Then examine the optic disc, retinal
vessels, retina and macula
EARS
15. Inspect the external ear or auricle. Normally set ears, no
16. Inspect auditory canal with otoscope, selecting discharges, no impacted
the largest available speculum cerumen, intact tympanic
17. Position the patient’s head to allow the best membrane
insertion of the otoscope.
18. Pull the auricle gently upwards and backwards
to straighten the canal (Pediatric patient:
downwards and backward)
19. Hold the otoscope between the thumb and
fingers
20. Insert the speculum gently into the ear canal
and do inspection of the auditory canal, cone of
light, tympanic membrane
21. Asses hearing (auditory acuity): Ask the patient Air conduction is heard longer
to occlude one ear with a finger then examiner than bone conduction.
whispers softly from 1-2 ft away towards the un-
occluded ear So dapat, pag nilipat mo from
22. IF ACUITY IS DIMINISHED, check air and bone bone to ear, maririnig parin
conduction: niya yung sound kahit
Weber test: test for lateralization. Place the lightly natanggal mo na sa jaw niya
vibrating tuning fork firmly on top of the patient’s yung tuning fork.
head
23. Ask where the patient hears it
24. Rinne test: Compare air and bone conduction.
Place the base of a lightly vibrating tuning fork on
the mastoid bone.
25. When the patient can no longer hear the sound,
quickly place the fork close to the ear canal and ask
whether the sound can still be heard.
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NOSE AND PARANASAL SINUSES
46. Inspect the anterior and inferior No lesions, no discharges,
surfaces of the nose. Push gently on the tip No congestion, No alar
of the nose to widen the nostrils. flaring
47. Inspect the inside of the nose using the
otoscope with the largest available
speculum. Tilt the patient’s head back
slightly and insert the speculum.
48. Inspect the nasal septum, inferior and
middle turbinates.
49. Palpate the frontal and maxillary
sinuses.
MOUTH AND PHARYNX
50. Inspect the lips Moist lips, Pinkish mucosa,
51. Inspect oral mucosa and tongue blade no circumoral cyanosis, no
under good light congestion, no ulcers, no
52. Inspect the gums, teeth and hard palate exudates, no teeth and
53. Inspect the tongue and floor of the gum discoloration, Tongue
mouth. Ask the patient to put out his is at the midline, tonsils are
tongue not inflamed
54. Ask the patient to put his tongue on the
roof of the mouth.
55. Inspect the pharynx. Tongue in normal
position. Ask the patient to say “ah” and
inspect the soft palate, tonsils and pharynx.
You may use a tongue blade.
NECK
56. Palpate the lymph nodes in the ff No supraclavicular or
sequence: Preauricular, post auricular, suprasternal retractions,
occipital, tonsillar, submandibular, no neck vein engorgement,
submental, superficial cervical, deep No cervical LAD, No
cervical chain, supraclavicular tenderness
57. Inspect trachea and feel for any Trachea is at the midline
deviation. Place your finger along one side and is not deviated
of the trachea and note the space between
it and sternomastoid. Compare with the
other side.
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58. Inspect the thyroid gland. Tip the The thyroid gland is not enlarged
patient’s head back a bit and inspect the
region below the cricoid cartilage.
59. Palpate the thyroid gland. Flex the
neck slightly forward. Place the fingers
of both your hands on the patient’s neck
with index finger just below the cricoid
cartilage. Ask the patient to swallow.
THORAX AND LUNGS
POSTERIOR THORAX
60. The patient should be sitting with Upon inspection, the posterior
the posterior thorax exposed. thorax has n scars, n lesions, no
61. Doctor assumes a midline position pigmentations, no irregularities, no
behind the patient. deformities
62. Inspect the cervical, thoracic and
lumbar spine (check for ROM at the end There is normal and symmetrical
of the PE) chest wall expansion, no retracted
63. Palpate the spinous process of each breathing
vertebra, noting tenderness with your
thumb.
64. Place your thumbs at the 10th ribs
with your fingers loosely grasping the
rib cage and gently slide them medially.
65. Ask the patient to inhale deeply and
observe whether your thumbs move
apart symmetrically.
Tactile fremitus
66. Use either the ball of your plam or
the ulnar surface of your hand for
palpation.
67. Ask the patient to repeat the words
“ninety-nine.” You may palpate one side
at a time or use both hands
simultaneously to compare sides
68. Palpate in four locations on both
sides of the chest and compare
“Tactile fremitus is felt in all four
quadrants”
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Percussion and Auscultation
69. Ask the patient to keep both arms
crosses in front of the chest
70. Press the DIP joint of your L middle
finger firmly against the chest wall,
avoiding contact w/ other fingers. Strike
DIP joint w/ the tip of your R middle finger,
swinging from the wrist
71. Percuss in 7 areas on each side
72. Auscultate for breath sounds. Instruct
the patient to breathe deeply through an
open mouth.
73. Listen with the diaphragm of the “Resonant sounds heard in
stethoscope in the 7 areas. all 7 quadrants”
“There is clear breathe
sounds, no crackles, no
wheezes, no ronchi”
ANTERIOR THORAX
External Thorax Upon inspection, the
74. The patient may be either sitting or posterior thorax has n
supine. The drape should be adjusted to scars, n lesions, no
allow exposure of the area being examined. pigmentations, no
75. Inspect the shape of the patient’s chest irregularities, no
and movement of the chest wall. deformities
There is normal and

symmetrical chest wall
expansion, no retracted
breathing
Tactile Fremitus
76. Palpate for tactile fremitus on the 3
areas illustrated
“Tactile fremitus is felt in all three

quadrants”
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77. Percuss the anterior and lateral
chest on the 6 areas illustrated
78. Auscultate the anterior chest
comparing sides in the 6 areas
“Resonant sounds heard in all 6

quadrants”
“There are clear breathe sounds, no
crackles, no wheezes, no ronchi”
CARDIOVASCULAR SYSTEM
78. Patient should be supine, elevated to Adynamic precordium, Normal
30° with the examiner on the R side of rate, regular rhythm, no murmurs,
the patient. The drape should be no thrills
arranged to expose the precordium. Normal JVP: ≤3-4 at sternal angle
79. Observe the jugular venous ≤8-9 (+10) at R atrium
pulsations and measure jugular venous
pressure in relation to the sternal angle.
80. Inspect and palpate the carotid The carotid pulse is strong, with
pulsations. Listen for carotid bruits regular rhythm
using the bell of the stethoscope. No bruit sounds heard
81. Inspect the precordium
a. look for the apical impulse
b. look for any other movements
82. Palpate for precordium. Used palmar
surfaces of several fingers to locate the
PMI
i. Displace a woman’s breast upward
or laterally or ask her to do this for you
ii. Note location of PMI, amplitude
and duration
83. Palpate for the RV impulse along the
lower L sternal border
84. Auscultation of the heart. Listen to The carotid pulse is strong, with
the heart (w/ diaphragm) in the R 2nd regular rhythm
ICS, L 2nd ICS, L 3rd or 4th ICS and the No bruit sounds heard , no
lower L sternal border (5th ICS) and at murmurs, no thrills
the apex
85. Listen to the heart (w/ bell) in the
same 5 listening areas
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ABDOMEN
86. Patient supine with arms at side or Non pigmented, no scars,
folded across the chest lesions, Globular, non-
87. Drape should only expose the abdomen distended, normoactive,
from just above the xyphoid process to the tympanic, soft, no
symphysis pubis. tenderness, no masses, no
88. Examiner at the R side of the patient organomegally,
89. Inspect the abdomen
90. Auscultate the abdomen There are normal
a. Place the diaphragm gently on the tympanitic bowel sounds.
abdomen No aortic bruits heard
b. Listen for bowel sounds.
c. Listen for aortic bruit on the midline
just above the navel
91. Percuss on 4 quadrants
92. Percuss for liver dullness
d. define the lower edge in the
midclavicular line starting at a level below
the umbilicus
93. Define the upper edge of the liver
dullness in MCL, starting in the are of lung
resonance Normal liver span:
94. Measure in centimeters (w/ ruler) the MCL: 6-12 cm
vertical span of the liver Sternum: 4-cm
95. Percuss for splenic dullness. Percuss
along the L lower chest walls b/n the lung
resonance above the costal margin moving
laterally. Ask the patient to take a deep
breath and percuss again in this area.
96. Palpate the abdomen in 4 quadrants No masses, no tenderness

and in the suprapubic and epigastric areas.
Use a gentle, light dipping motion.
97. Palpate the abdomen deeply in 4
quadrants. Use a firmer dipping motion.
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98. Palpate for the liver edge
a. Place your R hand on the R
abdomen lateral to the rectus muscle,
beginning more than 3 fingerbreadths
below the costal margin
b. Ask the patient to take a deep
breath
99. Palpate upwards trying to feel the
descending liver edge, using a rocking
motion. May also use the “hooking
technique”
100. Palpate for a spleen tip
a. Reach over and around the patient
w/ your L hand to support and press
forwards the lower L rib cage
101. Press inwards towards the spleen
w/ your R hand, beginning at least 3
fingerbreadths below the L costal
margin. Ask the patient to take deep
breaths, trying to feel the spleen tip as it
comes down to meet your fingertips.
Assess for costovertebral tenderness. There is no costovertebral
102. Place the ball of one hand on the tenderness
costovertebral angle and strike it with
the ulnar surface of your fist.
LOWER EXTREMITIES
103. Peripheral Vascular System No gross deformities, equal
a. Patient supine, palpate the ff pulses: peripheral pulses, capillary refill is
femoral, popliteal, inguinal normal
Inspect for lower extremity edema,
discoloration or ulcers. Palpate for
pitting edema.
b. Patient standing: Inspect for
varicose veins.
104. Musculoskeletal System
Note any deformities or enlarged joints.
If indicated, palpate the joints, check
ROM (Rage Of Motion)
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MEDICINE 1 SKILLS LABORATORY
I. CORE SKILLS
A set of must-know PE skills that have to be done on ALL patients
General General appearance, level of consciousness, orientation
Survey
Vital Signs - blood pressure
- calculate BMI
- heart rate, respiratory rate, temperature
Skin Skin inspection
HEENT - external inspection of eye
- pupillary reaction to light
- inspection of oropharynx and dentition
- lymph node palpation (cervical, supraclavicular, axillary)
- palpation of thyroid gland
- examination of optic fundi
Heart - carotid artery palpation and bruit
- JVP
- PMI
- cardiac auscultation with diaphragm and bell
Chest/Lungs - Thorax inspection
- Chest percussion posteriorly
- chest auscultation anteriorly and posteriorly
Abdomen - abdominal inspection
- abdominal auscultation
- palpate abdomen in all quadrants
- liver palpation
- inguinal lymph node palpation
Extremities - inspection of extremities and joints
- palpate for edema
- palpate posterior tibial or dorsalis pedis pulses
Neurologic - assessment of speech
- cranial nerves
- motor exam of upper and lower extremities (strength and tone)
- DTRs (biceps and patellar)
- Sensory exam
- Gait
23
A. FEVER
General Data Age, gender, occupation, place of residence
HPI - When did it start? How long have you been having fever?
- Pattern of the fever? particular time of the day that you feel
feverish?
- Does it come and go/worsen/improve? How bad is it?
- - Does anything make it better or worse?
- Did you feel anything else? (headache, shaking chills, rashes,
cough, colds, dysphagia, dysuria, diarrhea, wounds, joint
swelling, genital discharge)
Past Medical - comorbid conditions (e.g. asplenia, severe alcoholic liver
History disease, IV drug use, HIV infection, diabetes, malignancy, organ
transplantation, chemotherapy, stroke, renal failure); when
were they first diagnosed
- medications, dose, compliance, reason/s for discontinuation
- previous confinements, Prior trauma
- Recent URTI, influenza, varicella, measles, dengue
- history of instrumentation (foley catheter, central IV line,
feeding ostomy)
- Lacerations, burns, surgery, body piercing, decubiti, foreign
bodies (nasal packing, tampons, prosthetic devices)
- vaccination history, allergies
- OB/gyne history, recent sexual contacts, sexual history
Family History - exposure to family members with infectious conditions
Social, - History of travel, wading in flooded waters
Environmental - Contact with pets / animals, tick or mosquito exposure, animal
History bites
- prevalent infectious diseases in the neighborhood
- Social or occupational contact with ill individuals
- consumption of street food
ROS 3-5 representative symptoms per system apart from those
asked in the HPI
General - signs of breathlessness or distress. - level of sensorium
Survey
Skin Rashes (location, distribution, arrangement, type and color),
moisture, pallor, jaundice, mottling
24
HEENT - Eyes: conjunctiva for erythema, discharge
- Ears: otoscopy to check for discharges
- Nose: sinus tenderness, nasal discharge, nasal congestion
- Throat: dental caries, tonsillopharyngeal wall congestion,
tonsillar exudates, swollen gums
- Mouth: check lips and tongue for hydration status
- Neck: lymphadenopathy
Back Costovertebral angle tenderness
Extremities - assess warmth, sweating
- check for wounds, joint swelling
- palpate for edema, axillary and inguinal lymphadenopathy
examination Rectal: anal and rectal tenderness, erythema, prostatic
tenderness (males)
Genital exam: discharges, irritation or erythema, cervical
wiggling (females)
Fever or pyrexia refers to an elevated body temperature.

 Hyperpyrexia refers to extreme elevation in temperature, above 41.1°C
(106°F)
 Hypothermia refers to an abnormally low temperature, below 35°C (95°F)
rectally
The chief cause of hypothermia is exposure to cold. Other predisposing
causes include reduced movement as in paralysis, interference with
vasoconstriction from sepsis or excess alcohol, starvation, hypothyroidism,
and hypoglycemia. Older adults are especially susceptible to hypothermia and
also less likely to develop fever.
Fever may be caused by infection, trauma such as surgery or crush injuries,
malignancy, blood disorders such as acute hemolytic anemia, drug reactions, and
immune disorders such as collagen vascular disease.
Chills (shaking and recurrent) suggest more extreme swings in temperature
and systemic bacteremia.
Cushing’s syndrome: generalized fat in simple obesity; truncal fat with
relatively thin limbs in
25
B. HIGH BLOOD PRESSURE
General Data Age, gender, race, occupation
HPI - When did it start? How long have you been hypertensive?
- Do you remember the blood pressure reading that was taken? How bad is it? (in terms
of how it affects them)
- What activities were you doing when you felt that way? Why did you have your blood
pressure taken?
- Does anything make it better? or worse?
- Did you feel anything else? (symptoms of possible target organ damage: occipital
headache, dizziness, palpitations, easy fatigability, impotence, weakness, transient
blindness, angina, orthopnea, paroxysmal nocturnal dyspnea, edema, intermittent
claudication
** If patient is for follow-up regarding control of BP, also ask for side effects of
medications like headache, palpitations, and edema (CCBs); bradycardia or wheezing
(beta blockers), cough (ACE inhibitors); dizziness on upright position (orthostatic
hypotension)
Past Medical - hyperlipidemia
History - previous BP readings, medications, dose and compliance (if any)
- previous confinements due to high BP, CAD, stroke, CKD, glomerulonephritis, polycystic
kidney disease, obstructive sleep apnea
- intake of drugs that induce hypertension (NSAIDS, COX 2 inhibitors, cocaine,
amphetamines, illicit drugs, decongestants, steroids, oral contraceptive pills,
erythropoietin)
Family History - hypertension
- premature cardiovascular disease (men aged <55 or women aged <65)
Social, - smoking history
Environmental - excessive alcohol intake
History - excessive salt intake
- physical activity
ROS (causes of General: weight loss, weight gain, sleep apnea, daytime somnolence, snoring, erratic
secondary sleep,
hypertension) Skin: pallor, perspiration
HEENT: headache, blurring of vision, goiter
Cardiac: palpitations, tachycardia
Renal: tea-colored urine, oliguria, dysuria, hesitancy, difficulty in urination
Endocrine: muscle weakness, spells of sweating, palpitations and tremors, heat or cold
intolerance
Plus 2-3 symptoms per system apart from those stated above
General Survey Moon facies, central obesity (Cushing’s syndrome)
Vital Signs - To diagnose hypertension: Obtain accurate blood pressure reading based -on the
average of 2 or more properly measured, seated BP readings on each of 2 or more office
visits, with verification on the contralateral arm
- To determine orthostatic hypotension as a consequence of aggressive BP lowering:
accurate BP reading, check for orthostatic hypotension (Check the blood pressure and
heart rate with the patient lying down. Have the patient sit up AND WAIT 2-3 minutes
before rechecking the blood pressure and heart rate. If safe, repeat with the patient
standing.)
Skin Thin skinfold, ecchymoses, plethora, acne, hirsutism in women, red or blue
striae(Cushing’s syndrome)
26
Abdomen - abdominal auscultation for bruits (renovascular hypertension)
- palpate for enlarged kidneys (polycystic kidney disease), distended urinary bladder
(obstructive uropathy), abnormal aortic pulsation (abdominal aortic aneurysm)
Extremities - palpate femoral pulses
- auscultate for femoral bruits
- proximal muscle weakness (Cushing’s syndrome)
Hypertension, assessment also includes its effects on target “end organs”—

the eyes, heart, brain, and kidneys. Look for hypertensive retinopathy, left
ventricular hypertrophy, and neurologic deficits suggesting stroke. Renal
assessment requires urinalysis and blood tests of renal function.
Hypertension, kinds:
 White coat hypertension - constituting roughly 15% to 20% of Stage 1
hypertensives, the office blood pressure is high but ambulatory pressures
are normal, so cardiovascular risk is low.
Orthostatic hypotension: a fall in systolic pressure of 20 mm Hg or more,
especially when accompanied by symptoms and tachycardia. Causes include
drugs, moderate or severe blood loss, prolonged bed rest, and diseases of the
autonomic nervous system.
Pressure difference of more than 10–15 mm Hg occurs in subclavian steal
syndrome, aortic dissection.
Pulseless: In rare cases, patients are pulseless due to occlusive disease in the
arteries of all the limbs from Takayasu arteritis, giant cell arteritis, or
atherosclerosis.
Sitting preference: there is a preference for sitting upright in left-sided heart
failure and for leaning forward with arms braced in chronic obstructive pulmonary
disease.
 Turner’s syndrome, very short stature, childhood renal failure, and
achondroplastic and hypopituitary dwarfism
27
C. HEADACHE
General Age, gender, occupation, place of residence
Data
HPI - When did it start? Was it a sudden or gradual onset? Since the
onset, how has the pain continued – i.e. constant or coming and
going? How long have you been having headache?
- Where do you feel the pain?
- Can you describe its character? Does it move anywhere?
- Does it come and go/worsen/improve? (in terms of how it affects
them) How bad is it? Can you grade its severity from 1 to 10 (1 is
the least and 10 is the most)
- What were you doing at that time?
- Did you feel anything else?
(fever, colds, cough, vomiting, visual flashes, blurring of vision,
diplopia, loss of consciousness, neck stiffness, rashes, toothache,
dizziness, gait disturbance)
Past - history of EENT infections, sinusitis, hypertension, meningitis,
Medical migraine, brain tumor
History - medications, dose
- previous confinements
- Prior trauma
- menstrual history
- allergies
Family - hypertension, brain tumors, migraine
History
Social, - History of travel
Environmen - occupational history, stress
tal History
ROS 3-5 representative symptoms per system apart from those asked in
the HPI
General - signs of distress.
Survey - level of sensorium, gait, manner of speaking
Skin Rashes (note location, distribution, arrangement, type and color),
moisture
28
HEENT - Eyes: measure intraocular pressure, use of corrective lenses
- Ears: otoscopy to check for ear infection (discharges, bulging
tympanic membrane)
- Nose: sinus tenderness, nasal discharge, nasal congestion
- Throat: dental caries, tonsillopharyngeal wall congestion, tonsillar
exudates, swollen gums
- Mouth: check lips and tongue for hydration status
- Neck: taut cervical bands and trapezius
Extremities - assess warmth, sweating
- palpate for axillary and inguinal lymphadenopathy
29
30
31
32
II. INTEGUMENTARY SYSTEM
Itching (generalized), without apparent rash, include causes such as dry skin, pregnancy, uremia,
jaundice, lymphomas and leukemia, drug reaction, lice and, less commonly, diabetes and thyroid disease.
Skin Cancers: Basal and squamous cell skin cancers usually arise in sun-exposed areas, particularly the
head, neck, and upper limbs. Melanomas are associated with sun exposure but are often on nonex- posed
areas subject to intermittent sunburns such as the trunk and thighs.
 Basal cell carcinoma. These skin cancers consist of immature cells similar to those in the basal
layer of the epidermis, and account for roughly 80% of all skin cancers. They usually arise in
sun-exposed areas, especially the head and neck. Classically they appear as pearly
erythematous translucent papules, but may also be subtle red macules or display even other
morphologies. Basal cell carcinomas tend to grow slowly and almost never metastasize.
 Squamous cell carcinoma. This type consists of more mature cells usually resembling the
spinous layer of the epidermis, accounting for approximately 16% of skin cancers. These
cancers are often crusted hyperkeratotic lesions with a rough surface or flat reddish patches
with an inflamed or ulcerated appearance. Metastasis is rare, occurring in 1% of cases.
 Melanoma. Melanomas arise from the pigment-producing melanocytes in the epidermis that
give skin its color, and account for the remaining 4% to 5% of skin cancers. Melanomas are
potentially the most lethal of the skin cancers, although almost 100% of thin, early-stage
melanomas can be cured. The incidence of melanomas has doubled in recent decades and is
increasing more rapidly than any other cancer.3–5 Lifetime risk is 1 in 75. Indoor tanning
increases risk by 75%, and melanoma is now the most common cancer in young adults ages 25
to 29. Melanomas can spread rapidly to the lymph system and internal organs; they cause 80%
of deaths from skin cancer.6 Mortality rates are highest in white men, possibly due to lower
“skin awareness” and lower rates of self-examination.
o Screening for Melanoma: the ABCDEs. Both clinicians and patients should apply the
ABCDE method when screening moles for melanoma. The sensitivity of this mnemonic
for detecting melanoma ranges from 50% to 97%, and specificity ranges from 96% to
99%.11
o The average patient has 15 to 30 moles, or nevi. Common types include:
 Junctional nevi—typically brown macules
 Intradermal nevi—typically skin-colored papules
 Compound nevi—typically brown macules
33
34
35
36
37
III. HEENT
A. HEAD
Look for redness and scaling that may indicate seborrheic dermatitis or psoriasis; soft lumps that may
be pilar cysts (wens); pigmented nevi.
An enlarged skull may signify hydrocephalus or Paget’s disease of bone. Palpable tenderness or step-
offs may be present after head trauma.
Acne is found in many adolescents. Hirsutism (excessive facial hair) occurs in some women with
polycystic ovary syndrome.
B. EYES
38
39
40
41
42
43
44
Visual Terms and Problems:
 Vision of 20/200 means that at 20 feet the patient can read print that a person with
normal vision could read at 200 feet. The larger the second number, the worse the
vision. “20/40 corrected” means the patient could read the 40 line with glasses (a
correction).
 Absence of a red reflex suggests an opacity of the lens (cataract) or possibly of the
vitreous. Less commonly, a detached retina or, in children, a retinoblastoma may
obscure this reflex. Do not be fooled by an artificial eye, which has no red reflex.
 Miosis refers to constriction of the pupils, mydriasis to dilation.
 When the lens has been removed surgically, its magnifying effect is lost. Retinal
structures then look much smaller than usual, and you can see a much larger expanse
of the fundus.
 In a refractive error, light rays from a distance do not focus on the retina. In myopia,
they focus anterior to the retina; in hyperopia, posterior to it. Retinal structures in a
myopic eye look larger than normal.
 Difficulty with close work gests hyperopia (farsightedness) or presbyopia (aging
vision); with distances, myopia (nearsightedness)
 Diplopia or double vision is seen in lesions in the brainstem or cerebellum, or weak-
ness or paralysis of one or more extraocular muscles, as in horizontal diplopia from
palsy of cranial nerve (CN) III or VI, or vertical diplopia from palsy of CN III or IV.
Diplopia in one eye, with the other closed, suggests a problem in the cornea or lens.
 Myopia is impaired far vision.
 Presbyopia is impaired near vision, found in middle-aged and older people. A
presbyopic person often sees better when the card is farther away.
 Simple anisocoria, or a difference in pupillary size of 0.04 mm or greater, is visible in
approximately 35% of healthy people. If pupillary reactions are normal, anisocoria is
considered benign.
o Compare benign anisocoria with Horner’s syndrome, oculomotor nerve
paralysis, and tonic pupil.
 Nystagmus, a fine rhythmic oscillation of the eyes. A few beats of nystagmus on
extreme lateral gaze are normal. If you see this, bring your finger in to within the field
of binocular vision and look again.
o Sustained nystagmus within the binocular field of gaze is seen with
various neurologic conditions. See Table 17-7, Nystagmus, pp. 755–756.
 In paralysis of the CN VI, illustrated below, the eyes are conjugate in right lateral
gaze but not in left lateral gaze.
45
 If sudden unilateral visual loss is painless, consider vitreous hemorrhage from
diabetes or trauma, macular degeneration, retinal detachment, retinal vein occlusion,
or central retinal artery occlusion. If painful, causes are usually in the cornea and
anterior chamber as in corneal ulcer, uveitis, traumatic hyphema, and acute glaucoma.
Optic neuritis from multiple sclerosis may also be painful. Immediate referral is
warranted.18
 If bilateral and painless, medications that change refraction such as cholinergics,
anticholinergics, and steroids may contribute. If bilateral and painful, consider
chemical or radiation exposures.
 Slow central loss occurs in nuclear cataract (p. 268), macular degenera- tion19 (p.
232); peripheral loss in advanced open-angle glaucoma (p. 262); one-sided loss in
hemianopsia and quadrantic defects (p. 265).
 Moving specks or strands suggest vitreous floaters; fixed defects, or scotomas, suggest
lesions in the retina or visual pathways.
 Flashing lights or new vitreous floaters suggest detachment of vitreous from retina.
Prompt eye consultation is indicated.
 Glaucoma
o Occasionally the iris bows abnormally far forward, forming a very narrow angle with
the cornea. The light then casts a crescentic shadow.
o This narrow angle increases the risk for acute narrow-angle glaucoma—a sudden
increase in intraocular pressure when drainage of the aqueous humor is blocked.
o In open-angle glaucoma, the common form of glaucoma, the normal spatial relation
between iris and cornea is preserved and the iris is fully lit.
 An enlarged blind spot occurs in conditions affecting the optic nerve such as glaucoma,
optic neuritis, and papilledema.
 Inward or outward deviation of the eyes; abnormal protrusion in Graves’ disease or
ocular tumors.
 Upstarting palpebral fissures in Down syndrome.
 Red inflamed lid margins in blepharitis, often with crusting
 Excessive tearing may be from increased production or impaired drainage. In the first
condition, causes include conjunctival inflammation and corneal irritation; in the
second, ectropion and nasolacrimal duct obstruction.
 Dryness may occur from impaired secretion in Sjögren’s syndrome.
46
47
48
49
C. EARS
 In chronic otitis externa, the skin of the canal is often thickened, red, and itchy.
 Pain occurs in the external canal in otitis externa and, if respiratory infection, in the inner
ear in otitis media. It may also be referred from other structures in the mouth, throat, or neck.
In acute otitis externa, shown below, the canal is often swollen, narrowed, moist, pale, and
tender. It may be reddened.
 Look for the red bulging drum of acute purulent otitis media; the amber drum of a serous
effusion.
 An unusually prominent short process and a prominent handle that looks more horizontal
suggest a retracted drum.
 A serous effusion, a thickened drum, or purulent otitis media may decrease mobility.
50
 Nontender nodular swellings covered by normal skin deep in the ear canals suggest exostoses.
These are nonmalignant overgrowths which may obscure the drum.
 Unusually soft wax, debris from inflammation or rash in the ear canal, or discharge through a
perforated eardrum is present in acute or chronic otitis media.
 Medications that affect hearing include aminoglycosides, aspirin, NSAIDs, quinine, and
furosemide.
51
52
Air conduction describes the normal first phase in the hearing pathway. An alternate
pathway, known as bone conduction, bypasses the external and middle ear and is used for
testing purposes. A vibrating tuning fork, placed on the head, sets the bone of the skull into
vibration and stimulates the cochlea directly. In a normal person, air conduction is more
sensitive than bone conduction.
In unilateral conductive hearing loss, sound is heard in (lateralized to) the impaired ear.
Explanations include otosclerosis otitis media, perforation of the eardrum, and cerumen.
In unilateral sensorineural hearing loss, sound is heard in the good ear.
In conductive hearing loss, sound is heard through bone as long as or longer than it is through
air (BC = AC or BC > AC). In sensorineural hearing loss, sound is heard longer through air (AC
> BC).
Note that older adults with presbycusis have higher frequency hearing loss, making them
more likely to miss consonants, which have higher frequency sounds than vowels.
Note also that tuning fork tests do not distinguish normal hearing from bilateral
neurosensory loss or from mixed conductive and neurosensory loss. Sensitivity and
specificity of the Rinne test are 60% to 90% and 95% to 98%. Sensitivity of the Weber test is
about 55%; specificity for neurosensory loss is about 79% and for conductive loss, 92%.41
 Hearing disorders of the external and middle ear cause conductive hearing loss.
External ear causes include infection (otitis externa), trauma, squamous cell
carcinoma, and benign bony growths such as exostoses or osteomas. Middle ear
disorders include congenital conditions, benign cholesteatomas and otosclerosis,
tumors, and perforation of the tympanic membrane.
 Movement of the auricle and tragus (the “tug test”) is painful in acute otitis externa
(inflammation of the ear canal), but not in otitis media (inflammation of the middle
ear). Tenderness behind the ear may be present in otitis media.
 Patients who answer “yes” are twice as likely to have a hearing deficit; for patients
who report normal hearing the likelihood of moderate to severe hearing impairment
is only 0.13.45
 Disorders of the inner ear cause sensorineural hearing loss from congenital and
hereditary conditions, presbycusis, viral infections such as rubella and
cytomegalovirus, People with sensorineural loss have particular trouble
understanding speech, often complaining that others mumble; noisy environments
make hearing worse. In conductive loss, noisy environments may help.
 Ménière’s disease, noise exposure, and acoustic neuroma.
 Tinnitus is a common symptom, increasing in frequency with age. When associated
with hearing loss and vertigo, it suggests Ménière’s disease.
 Vertigo represents vestibular disease, usually from peripheral causes in the inner ear
such as benign positional vertigo, labyrinthitis, and Ménière’s disease.
 Ataxia, diplopia, and dysarthria signal central neurologic causes in the
cerebellum or brainstem such as cerebral vascular disease or posterior fossa tumor;
also consider migraine. Feeling light-headed, weak in the legs, or about to faint points
to presyncope from arrhythmia, orthostatic hypotension, or vasovagal stimulation.
53
54
D. NOSE
55
56
In viral rhinitis, the mucosa is reddened and swollen; in allergic rhinitis, it
may be pale, bluish, or red.
Nasal polyps are pale saclike growths of inflamed tissue that can obstruct the
air passage or sinuses. Conditions conducive to polyps include allergic rhinitis,
aspirin sensitivity, asthma, chronic sinus infections, and cystic fibrosis.
Local tenderness, together with symptoms such as pain, fever, and nasal
discharge, suggest acute sinusitis involving the frontal or maxillary sinuses.
Transillumination may be diagnostically usefuL
 Rhinorrhea refers to drainage from the nose and is often associated

with nasal congestion, a sense of stuffiness or obstruction. These
symptoms are frequently accompanied by sneezing, watery eyes, and
throat discomfort, and itching in the eyes, nose, and throat.
o Causes include viral infections, allergic rhinitis (“hay fever”), and
vasomotor rhinitis. Itching favors an allergic cause.
 Seasonal onset or environmental triggers suggest allergic rhinitis.
 Drug-induced rhinitis occurs in excessive use of decongestants, or use
of cocaine.
 Acute bacterial sinusitis is unlikely until viral URI symptoms persist
more than 7 days; both purulent drainage and facial pain should be
present for diagnosis (sensitivity and specificity are above 50%).
 Consider a deviated nasal septum, nasal polyp, foreign body, granuloma
(Wegener’s), or carcinoma.
 Epistaxis is bleeding from the nasal passages. Bleeding can also
originate in the paranasal sinuses or nasopharynx. Note that bleeding
from posterior nasal structures may pass into the throat instead of out
the nostrils. Ask the patient to pinpoint the source of the bleeding. Is it
from the nose, or has the patient actually coughed up or vomited blood,
termed hematemesis and hemoptysis? These conditions have very
different causes.
o Local causes of epistaxis include trauma (especially nose-
picking), inflammation, drying and crusting of the nasal mucosa,
tumors, and foreign bodies.
o Anticoagulants, NSAIDs, and coagulopathies can contribute to
epistaxis.
57
E. MOUTH, THROAT AND NECK PROBLEMS
Sore throat or pharyngitis is a frequent complaint, usually associated with
an acute URI.
Centor’s clinical prediction rule for streptococcal and Fusobacterium
necrophorum pharyngitis helps guide diagnosis and treatment of bacterial
infection: fever history, tonsillar exudates, swollen tender anterior cervical
adenopathy, and absence of cough.
Enlarged tender lymph nodes commonly accompany pharyngitis.
A sore tongue may result from local lesions as well as from systemic illness.
Bleeding from the gums, especially when brushing teeth, is a common

symptom. Ask about local lesions and any tendency to bleed or bruise
elsewhere. Bleeding gums are most often caused by gingivitis (p. 287).
Hoarseness refers to a change in voice quality, often described as husky,

rough, harsh, or lower-pitched than usual. Causes range from diseases of the
larynx to extralaryngeal lesions that press on the laryngeal nerves. Ask the
patient about environmental allergies, acid reflux, smoking, and inhalation of
fumes or other irritants.
If hoarseness is acute, voice overuse and acute viral laryngitis are the most
likely causes.
If hoarseness lasts more than 2 weeks, refer for laryngoscopy and consider
causes such as hypothyroidism, reflux, vocal cord nodules, head and neck
cancers, and neurologic disorders like Parkinson disease, amyotrophic lateral
sclerosis, or myasthenia gravis
Bright red edematous mucosa underneath a denture suggests denture sore

mouth. There may be ulcers or papillary granulation tissue.
Assymetric protrusion of the tongue lesion of CN XII

CN X paralysis, the soft palate fails to rise and the uvula deviates to the
opposite side
58
59
60
 Enlargement of a supraclavicular node, especially on the left, suggests
possible metastasis from a thoracic or an abdominal malignancy.
 Tender nodes suggest inflammation; hard or fixed nodes suggest
malignancy.
61
62
IV. CARDIOVASCULAR SYSTEM
A. CHEST PAIN
General Data Age, gender, occupation
HPI - When did it start? Was it a sudden or gradual onset? Since the
onset, how has the pain continued – i.e. constant or coming and
going?
- Can you describe its character?
- Does it move anywhere?
- How bad is it? Can you grade its severity from 1 to 10 (1 is the
least and 10 is the most)
- What were you doing at that time? Any recent straining/lifting?
(fever, dyspnea, weakness, productive cough, pleuritic chest
pain, nausea, vomiting, heartburn/reflux, dysphagia, swollen
tender legs, syncope, hemiplegia, paraplegia, vesicular lesions)
IMPORTANT: QUANTIFY PATIENT’S BASELINE LEVEL OF ACTIVITY
Past Medical - history of hypertension, diabetes, hyperlipidemia, prior angina or
History myocardial infarction, cancer, pulmonary embolism/DVT, pro-
clotting disorder, heartburn
- medications, dose, use of pills, on Sildenafil
- previous confinements, recent surgery, recent immobility,
- allergies
Family History - hypertension, diabetes, premature cardiovascular disease or
sudden death
Social, - History of long haul flights
Environmenta - occupational history, stress
l History - smoking and dietary history
- intake of alcoholic beverage
- physical activity
ROS 3-5 representative symptoms per system apart from those asked
in the HPI
63
64
65
 A clenched fist over the sternum suggests angina pectoris; a finger
pointing to a tender area on the chest wall suggests musculoskeletal pain;
a hand moving from neck to epigastrium suggests heartburn.
 Anxiety is the most frequent cause of chest pain in children;
costochondritis is also common.
 Cough can be a symptom of left- sided heart failure.
66
B. PALPITATIONS
General Age, gender, occupation
Data
HPI - When did you first notice palpitations?
- Since the onset, how did it continue – i.e. continuous
or coming and going?
- Can you describe its character – i.e. fast or slow?
Regular or irregular? Did you notice extra beats? Can
you tap the beat with your hand?
(fever, dyspnea, weakness, chest pain, syncope,
feeling faint, leg swelling, anxiety, sweating, tremors,
weight loss)
Past - history of hypertension, diabetes, hyperlipidemia,
Medical prior angina or myocardial infarction, stroke, heart
History murmurs or valve problems, thyroid problems
- medications, dose
- allergies
Family - hypertension, diabetes, premature cardiovascular
History disease or sudden death, stroke, heart murmurs or
valve problems, thyroid problems
Social, - occupational history, stress
Environme - smoking and dietary history (including coffee intake)
ntal History - intake of alcoholic beverage
- physical activity
ROS 3-5 representative symptoms per system apart from
those asked in the HPI
67
A fully described murmur might be: a “medium-pitched, grade 2/6,
blowing decrescendo diastolic murmur, heard best in the 4th left
interspace, with radiation to the apex” (aortic regurgitation).
The degree of dyspnea in patients with chronic obstructive pulmonary disease
(COPD) predicts 5-year survival better than forced expiratory volume in one
second (FEV1).
Anxious patients may have episodic dyspnea during both rest and exercise, and
also hyperventilation, or rapid, shallow breathing.
68
C. SHORTNESS OF BREATH: DYPSNEA, ORTHOPNEA OR PND
HPI - How long have you been short of breath? Do you normally get
short of breath?
- Has it got worse recently?
- Did it come on suddenly or gradually?
- What were you doing at the time?
- Is there anything that makes it better or worse?
- How far can you walk before having to stop due to
breathlessness?
- Do you get short of breath on lying flat? How many pillows do
you sleep on?
- Do you ever wake up in the middle of the night feeling
breathless?
(fever, cough, hemoptysis, sputum production, pleuritic chest
pain, leg swelling, anxiety, swollen lips, rash, anorexia, weight loss)
History myocardial infarction, heart murmurs or valve problems, heart
failure, thyroid problems, asthma, COPD, cancer, pulmonary
embolism/DVT, pro-clotting disorder, heartburn
- medications, dose, use of diuretics
- previous confinements, recent surgery or immobility, previous
chest injury or trauma
- allergies
Family - hypertension, diabetes, premature cardiovascular disease or
History sudden death, heart murmurs or valve problems, asthma, hay
fever, cancer
Social, - history of long haul flights
- physical activity
in the HPI
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D. SWELLING OR EDEMA
HPI - When did it start?
- Since the onset, how did it continue – i.e. continuous or coming
and going?
- Have you had any swelling anywhere? Where?... Anywhere else?
- When does it occur?
- Is it worse in the morning or at night?
(dyspnea, orthopnea, paroxysmal nocturnal dyspnea,
weakness, chest pain, oliguria, change in color of urine, difficulty
in urination, anorexia, weight loss, abdominal pain, jaundice, leg
heaviness)
Past Medical - history of hypertension, diabetes, prior angina or myocardial
History infarction, heart murmurs or valve problems, chronic kidney
disease, chronic liver disease, cancer
- medications, dose
- allergies
Family - hypertension, diabetes, premature cardiovascular disease or
History sudden death, heart murmurs or valve problems
Social, - occupational history
Environment - smoking and dietary history
al History - intake of alcoholic beverage
- physical activity
in the HPI
Edema from extravascular fluid retention is visible in conditions like heart

failure, nephrotic syndrome, and liver failure.
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E. CARDIOVASCULAR PHYSICAL EXAMINATION SKILLS
General Survey General appearance, level of consciousness, orientation
- signs of distress or breathlessness
- look at the surrounding environment for oxygen, fluid restriction signs
- calculate BMI
Skin Skin inspection (Assess warmth, cold sweats or diaphoresis, presence of cyanosis,
pallor, vesicular lesions)
HEENT - external inspection of eye (check for arcus senilis, xanthelasma, conjunctiva for
anemia)
- inspection of oropharynx and dentition
- Ears: check for ear lobe crease
- check lips and tongue for central cyanosis
- lymph node palpation (cervical, supraclavicular, axillary)
- JVP
- PMI
- palpate for heaves and thrills
- cardiac auscultation with diaphragm and bell noting rate, rhythm, heart sounds
(S1, S2, S3, S4) and murmurs ( also Listen at the apex with patient turned toward
left side for low-pitched sounds)
Chest/Lungs - Thorax inspection (especially scars from previous thoracic surgeries)
- Check for chest wall tenderness
- chest auscultation anteriorly and posteriorly (crackles, wheezes, rhonchi)
Abdomen - abdominal inspection
- abdominal auscultation
- palpate abdomen in all quadrants
- liver palpation
- palpate for edema
Neurologic - assessment of speech
- cranial nerves
- motor exam of upper and lower extremities (strength and tone)
- DTRs (biceps and patellar)
- Sensory exam
- Gait
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The left and right ventricles pump blood into the systemic and pulmonary arterial trees, respectively.
Cardiac output, the volume of blood ejected from each ventricle during 1 minute, is the product of heart
rate and stroke volume. Stroke volume (the volume of blood ejected with each heartbeat) depends in
turn on preload, myocardial contractility, and afterload.
●● Preload refers to the load that stretches the cardiac muscle before contraction. The volume of blood
in the right ventricle at the end of diastole constitutes its preload for the next beat. Right ventricular
preload is increased by increasing venous return to the right heart. Physiologic causes include
inspiration and the increased volume of blood flow from exercising muscles. The increased blood volume
in a dilated right ventricle of heart failure also increases preload. Causes of decreased right ventricular
preload include exhalation, decreased left ventricular output, and pooling of blood in the capillary bed or
the venous system.
●● Myocardial contractility refers to the ability of the cardiac muscle, when given a load, to shorten.
Contractility increases when stimulated by action of the sympathetic nervous system and decreases
when blood flow or oxygen delivery to the myocardium is impaired.
●● Afterload refers to the degree of vascular resistance to ventricular contraction. Sources of resistance
to left ventricular contraction include the tone in the walls of the aorta, the large arteries, and the
peripheral vascular tree (primarily the small arteries and arterioles), as well as the volume of blood
already in the aorta.
 Pathologic increases in preload and afterload, called volume overload and pressure overload,
respectively, produce changes in ventricular function that may be clinically detectable. These
changes include alterations in ventricular impulses, detectable by palpation, and in normal
heart sounds. Pathologic heart sounds and murmurs may also develop. A PMI greater than 2.5
cm is evidence of left ventricular hypertrophy (LVH), or enlargement, seen in hypertension and
aortic stenosis.
 Similarly, displacement of the PMI lateral to the midclavicular line or greater than 10 cm lateral
to the midsternal line also suggests LVH.
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A hypovolemic patient may have to lie flat before you see the neck veins. In contrast, when jugular
venous pressure is increased, elevating the patient’s head to 60 degrees or even 90 degrees may be
required. In all these positions, the sternal angle usually remains about 5 cm above the right atrium, as
diagrammed above.
 In patients with obstructive lung disease, venous pressure may appear elevated on expiration
only; the veins collapse on inspiration. This finding does not indicate heart failure.
 An elevated JVP is 98% specific for an increased left ventricular end diastolic pressure and low
left ventricular ejection fraction, and increases risk of death from heart failure.16,86
 Local kinking or obstruction is the usual cause of unilateral distention of the external jugular
vein.
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 The first elevation, the presystolic a wave, reflects the slight rise in atrial pressure that
accompanies atrial contraction. It occurs just before S1 and before the carotid pulse.
 The following trough, the x descent, starts with atrial relaxation. It continues as the right
ventricle, contracting during systole, pulls the floor of the atrium downward. During ventricular
systole, blood continues to flow into the right atrium from the venae cavae.
 The tricuspid valve is closed, the chamber begins to fill, and right atrial pressure begins to rise
again, creating the second elevation, the v wave. When the tricuspid valve opens early in
diastole, blood in the right atrium flows passively into the right ventricle, and right atrial
pressure falls again, creating the second trough, or y descent.
 To remember these four oscillations in an oversimplified way, think of the following sequence:
atrial contraction, atrial relaxation, atrial filling, and atrial emptying. You can think of the a
wave as atrial contraction and the v wave as venous filling. To the naked eye, the two descents
are the most obvious events in the normal jugular pulse. Of the two, the sudden collapse of the x
descent late in systole is more prominent, occurring just before S2. The y descent follows S2
early in diastole.
 Prominent a waves occur in increased resistance to right atrial contraction, as in tricuspid
stenosis; also in first-degree atrioventricular block, supraventricular tachycardia, junctional
rhythms, pulmonary hypertension, and pulmonic stenosis.
 Absent a waves occur in atrial fibrillation. Large v waves occur in tricuspid regurgitation, and
constrictive pericarditis
 Increased jugular venous pressure is highly correlated with both acute and chronic right and
left-sided heart failure. It is also seen in tricuspid stenosis, chronic pulmonary hypertension,
superior vena obstruction, and pericardial disease such as tamponade and constrictive
pericarditis.
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 Diastolic murmurs usually indicate valvular heart disease. Systolic
murmurs may indicate valvular disease but often occur when the heart
valves are normal. Murmurs detected during pregnancy should be
promptly evaluated for possible risk to the pregnancy and the need for
termination, especially from aortic stenosis and pulmonary
hypertension.
 For example, a murmur best heard in the 2nd right interspace often
originates at or near the aortic valve.
 A loud murmur of aortic stenosis often radiates into the neck in the
direction of arterial flow, especially on the right side. In mitral
regurgitation, the murmur often radiates to the axilla, suggesting the
role of bone conduction. An identical degree of turbulence would cause
a louder murmur in a thin person than in a very muscular or obese
person. Emphysematous lungs may diminish the intensity of murmurs.
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 Murmurs originating in the right side of the heart tend to vary with
respiration more than left-sided murmurs.
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 Apical Impulse
o Pregnancy or a high left diaphragm may displace the apical impulse upward and to the
left.
o Lateral displacement from cardiac enlargement is seen in heart failure,
cardiomyopathy, and ischemic heart disease. Displacement also occurs from
deformities of the thorax and mediastinal shift.
o Lateral displacement outside the midclavicular line makes cardiac enlargement and a
low left ventricular ejection fraction 3–4 and 10 times more likely, respectively.
 Atrial fibrillation: Palpation of an irregularly irregular rhythm indicates atrial fibrillation. For
all irregular patterns, an ECG is needed to identify the type of rhythm.
 Auscultatory gap that is unrecognized may lead to serious underestimation of systolic
pressure (150/98 in the example below) or overestimation of diastolic pressure. An
auscultatory gap is associated with arterial stiffness and atherosclerotic disease.
 Bruits: Although usually caused by atherosclerotic narrowing of the internal carotid artery,
bruits can also arise from a tortuous carotid artery with intraluminal turbulence, external
carotid arterial disease, aortic stenosis, the hypervascularity of hyperthyroidism, and external
compression from thoracic outlet syndrome.
 Coarctation of the aorta results from narrowing of the thoracic aorta, usually proximal but
sometimes distal to the left subclavian artery.
 Coarctation of the aorta and occlusive aortic disease are distinguished by hypertension in the
upper extremities and low blood pressure in the legs, and by diminished or delayed femoral
pulses.
 Cyanosis (Central), causes include advanced lung disease, congenital heart disease, and
hemoglobin- opathies. The cyanosis of heart failure is usually peripheral, reflecting
deoxygenation or impaired circulation. In COPD and pulmonary edema, hypoxia may give rise
to central cyanosis. Jaundice suggests liver disease or excessive hemolysis of red blood cells.
 Causes of decreased pulsations include decreased stroke volume and local factors in the
artery such as atherosclerotic narrowing or occlusion.
 Impulses
o A sustained, high-amplitude impulse that is normally located suggests left
ventricular hypertrophy from pressure overload (as in hypertension). If such an
impulse is displaced laterally, consider volume overload.
o A sustained low-amplitude (hypokinetic) impulse is seen in dilated
cardiomyopathy.
o A brief middiastolic impulse indicates an S3; an impulse just before the systolic apical
beat itself indicates an S4.
o A marked increase in amplitude with little or no change in duration occurs in
chronic volume overload of the right ventricle, which can occur in atrial septal defect.
o An impulse with increased amplitude and duration occurs with pressure overload
of the right ventricle, as in pulmonic stenosis or pulmonary hypertension.
 Pressure on the carotid sinus may cause a reflex drop in pulse rate or blood pressure.
 Pulsus alternans and bigeminal pulse vary beat to beat; paradoxical pulse varies with
respiration, described on the next page.
 Pulsus alternans: Alternately loud and soft Korotkoff sounds or a sudden doubling of the
apparent heart rate as the cuff pressure declines. Placing the patient in the upright position
may accentuate this finding.
 A tortuous and kinked carotid artery may produce a unilateral pulsatile bulge.
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V. RESPIRATORY SYSTEM
A. MEDICAL COMMUNICATION SKILLS
HPI - When did it start? How long have you been coughing?
- Do you bring out phlegm? What color is it? How much phlegm do you
think you cough up in a day?
- When do you cough?
- How bad is it?
- Have you noticed any blood in your sputum?
(fever, runny nose, dyspnea (quantify distance to breathlessness),
orthopnea, paroxysmal nocturnal dyspnea, weakness, chest pain,
vomiting, heartburn/reflux, dysphagia, edema, swollen tender legs,
anorexia, weight loss, swollen lips, rash, wheezes, hoarseness of voice)
Past Medical - history of prior angina or myocardial infarction, stroke, cancer,
History heartburn, asthma, atopy, hay fever, pulmonary tuberculosis, sinusitis,
pulmonary embolism/DVT, pro-clotting disorder
- medications, dose, use of OCPs
- previous confinements, recent surgery, recent immobility
- allergies
Family History - premature cardiovascular disease or sudden death, asthma, eczema,
hay fever
Social, - History of travel, long haul flights
Environmental - occupational history
History - smoking history
- physical activity
- pets
ROS 3-5 representative symptoms per system apart from those asked in the
HPI
B. PHYSICAL EXAMINATION SKILLS

-Similar to examination of cardiovascular system
COPD: Prolonged expiration is common
Respiratory rates that are rapid tend to increase the discrepancy between
oral and rectal temperatures. In these situations, rectal temperatures are more
reliable.
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 Dullness replaces resonance when fluid or solid tissue replaces air- containing
lung or occupies the pleural space beneath your per- cussing fingers. Examples
include: lobar pneumonia, in which the alveoli are filled with fluid and blood cells;
and pleural accumulations of serous fluid (pleural effusion), blood (hemothorax),
pus (empyema), fibrous tissue, or tumor. Dullness makes pneumonic and pleural
effusion 5 and 18 times more likely, respectively.
 Generalized hyperresonance may be heard over the hyper inflated lungs of COPD
or asthma. Unilateral hyperresonance suggests a large pneumothorax or possibly
a large air-filled bulla in the lung.
 Pleural effusions may be transudates, seen in atelectasis, heart failure, and
nephrotic syndrome, or exudates, seen in numerous conditions including
pneumonia, tuberculosis, pulmonary embolus, pancreatitis, and malignancy.
 Wheezing occurs in partial airway obstruction from secretions and tissue
inflammation in asthma, or from a foreign body.
 Viral upper respiratory infections are the most common cause of acute cough.
Also consider acute bronchitis, pneumonia, left ventricular heart failure, asthma,
or a foreign body. Post infectious cough, bacterial sinusitis, asthma occur in
subacute cough; postnasal drip, asthma, gastroesophageal reflux, chronic
bronchitis, bronchiectasis in chronic cough.
 Blood originating in the stomach is usually darker than blood from the respiratory
tract and may be mixed with food particles.
 Audible stridor, a high-pitched wheeze, is an ominous sign of upper airway
obstruction in the larynx or trachea.
 Accessory muscle use in COPD signals difficulty breathing. Lateral displacement of
the trachea occurs in pneumothorax, pleural effusion, or atelectasis The AP
diameter also may increase in chronic obstructive pulmonary disease (COPD),
although evidence is conflicting.
 Asymmetric expansion in pleural effusion
 Retraction occurs in severe asthma, COPD, or upper airway obstruction
 Unilateral impairment or lagging indicates pleural disease from asbestosis or
silicosis; it is also seen in phrenic nerve damage or trauma
 Note intercostal tenderness over inflamed pleura.
 Look for bruises over a fractured rib.
 Although rare, sinus tracts indicate infection of the underlying pleura and lung (as
in tuberculosis, actinomycosis). Unilateral decrease or delay in chest expansion
occurs in chronic fibrosis of the underlying lung or pleura, pleural effusion, lobar
pneumonia, pleural pain with associated splinting, and unilateral bronchial
obstruction.
 Fremitus is decreased or absent when the voice is higher pitched or soft or when
the transmission of vibrations from the larynx to the surface of the chest is
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impeded by a thick chest wall, an obstructed bronchus, COPD, or pleural changes
from effusion, fibrosis, air (pneumothorax), or an infiltrating tumor.
 Asymmetric decreased fremitus occurs in unilateral pleural effusion,
pneumothorax, neoplasm due to decreased transmission of low frequency
sounds; asymmetric increased fremitus occurs in unilateral pneumonia from
increased transmission through consolidated tissue.
 Breath sounds may be decreased when air flow is decreased (as in obstructive
lung disease or muscular weakness) or when the transmission of sound is poor (as
in pleural effusion, pneumothorax, or COPD).
 A gap suggests bronchial breath sounds.
 Fine late inspiratory crackles that persist from breath to breath suggest abnormal
lung tissue.
 Clearing of crackles, wheezes, or rhonchi after coughing or position change
suggests inspissated secretions, seen in bronchitis or atelectasis.
 Increased transmission of voice sounds suggests that air-filled lung has become
airless
 Persons with severe COPD may prefer to sit leaning forward, with lips pursed
during exhalation and arms supported on their knees or a table.
 If “ee” sounds like “A,” an E-to-A change, or egophony, is present, seen in lobar
consolidation from pneumonia. The “A” has a nasal bleating quality, and should
be localized. In patients with fever and cough, the presence of bronchial breath
sounds and egophony more than triples the likelihood of pneumonia.
 Louder, clearer whispered sounds are called whispered pectoriloquy.
 Abnormal retraction occurs in severe asthma, COPD, or upper airway obstruction
Underlying disease of lung or pleura
 Tender pectoral muscles or costal cartilages suggest, but do not prove, that chest
pain has a musculoskeletal origin.
 Dullness replaces resonance when fluid or solid tissue replaces air- containing
lung or occupies the pleural space. Because pleural fluid usually sinks to the
lowest part of the pleural space (posteriorly in a supine patient), only a very large
effusion can be detected anteriorly.
 The hyperresonance of COPD may totally replace cardiac dullness.
 The dullness of right middle lobe pneumonia typically occurs behind the right
breast. Unless you displace the breast, you may miss the abnormal percussion
note.
 A lung affected by COPD often displaces the upper border of the liver downward
and lowers the level of diaphragmatic dullness posteriorly.
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VI. BREAST
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VII. GASTROINTESTINAL SYSTEM
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 Visceral pain varies in quality and may be gnawing, burning, cramping, or aching. When it becomes
severe, it may be associated with sweating, pallor, nausea, vomiting, and restlessness.
 Visceral periumbilical pain may signify early acute appendicitis from distention of an inflamed
appendix. It gradually changes to parietal pain in the right lower quadrant from inflammation of the
adjacent parietal peritoneum.
 Parietal pain originates from inflammation in the parietal peritoneum. It is a steady, aching pain
that is usually more severe than visceral pain and more precisely localized over the involved
structure. It is typically aggravated by movement or coughing. Patients with this type of pain usually
prefer to lie still.
 Referred pain is felt in more distant sites, which are innervated at approximately the same spinal
levels as the disordered structures. Referred pain often develops as the initial pain becomes more
intense and thus seems to radiate or travel from the initial site. It may be felt superficially or deeply
but is usually localized.
 Pain of duodenal or pancreatic origin may be referred to the back; pain from the biliary tree, to the
right shoulder or the right posterior chest.
 Pain from pleurisy or inferior wall myocardial infarction may be referred to the epigastric area.
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A. DYSPHAGIA
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B. ABDOMINAL PAIN
General Data Age, gender, occupation, religion, residence
HPI - When did it start? Was it a sudden or gradual onset? Since the onset,
how has the pain continued – i.e. constant or coming and going?
- Can you describe its character?
- Does it move anywhere?
- How bad is it? Can you grade its severity from 1 to 10 (1 is the least
and 10 is the most)
(fever, dyspnea, weakness, cough, chest pain, vomiting,
heartburn/reflux, halitosis, sore throat, dysphagia, indigestion, belching,
early satiety, jaundice, dysuria, oliguria, hematuria, hesitancy, diarrhea,
constipation, obstipation, edema, hematochezia, melena, weight loss,
genital discharge)
History myocardial infarction, arrhythmia, cancer, heartburn, peptic ulcer
disease, gallstones
- medications, dose,
- previous confinements, previous blood transfusions, trauma or surgery
- allergies
- FOR FEMALES: OB-gyne history, menstrual history
- sexual history
- Hepatitis B vaccination
Family History - hypertension, diabetes, premature cardiovascular disease or sudden
death, cancer
Environmental - occupational history, stress
History - smoking and dietary history
- source of water for drinking and domestic purposes
- garbage segregation and collection, waste disposal
- physical activity
HPI
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C. DIARRHEA
General Data Age, gender, occupation, residence
HPI - When did it start?

- How long have you had it?
- Can you describe your stool? (consistency, color, odor)
- How bad is it? How often do you pass stool in a day?
- How much stool do you pass?
- When was the last formed stool that you passed?
(fever, weakness, abdominal pain, nausea, vomiting, dizziness on
standing, oliguria, hematochezia, weight loss, alternating diarrhea
and constipation, palpitations, tremors, polyphagia)
History infarction, cancer, thyroid disorder, infectious diarrhea, lactose
intolerance
- medications, dose, recent antibiotic use, use of laxatives,
magnesium-containing antacids, antineoplastic agents
- allergies
- sexual history
sudden death, cancer, infectious diarrhea
- water source, garbage segregation and collection, waste disposal
- physical activity
ROS 3-5 representative symptoms per system apart from those asked in
the HPI
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D. VOMITING
HPI - When did it start? How long have you been vomiting?
- Can you describe the character of your vomitus? How much do
you vomit?
- How bad is it? How many times do you vomit in a day?
- When do you vomit?
(fever, weakness, cough, chest pain, heartburn/reflux,
dysphagia, headache, weight loss, abdominal pain, diarrhea,
constipation, obstipation)
History infarction, cancer, heartburn, peptic ulcer disease, gallstones,
cancer
- medications, dose,
- allergies
-last menstrual period
sudden death
- water source, garbage collection, waste disposal
- physical activity
in the HPI
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E. JAUNDICE
HPI - When did it start? Was it a sudden or gradual onset?

(fever, dyspnea, orthopnea, paroxysmal nocturnal dyspnea,
weakness, cough, chest pain, nausea, vomiting, abdominal pain,
edema, alternating diarrhea-constipation, tea-colored urine,
hematuria, whitish or cream-colored stools, pruritus, anorexia,
weight loss)
Past Medical - prior angina or myocardial infarction, congestive heart failure,
History cancer, gallstones
- medications, dose, use of illicit intravenous drugs
- previous confinements, blood transfusions, tattoos
- allergies
- sexual history
sudden death, cancer, jaundice
- water source, garbage collection, disposal of waste
- physical activity
in the HPI
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F. CONSTIPATION
HPI - When did it start? Was it a sudden or gradual onset?
- Can you describe your stool?
- When was the last time you moved your bowels?
(abdominal pain, abdominal distention, weight loss, blood in
the stools, vomiting, anal pain, rectal fullness, alternating
diarrhea-constipation, tenesmus, fatigue, anhedonia, sleep
disturbance
Past Medical - history of stroke, diabetes, cancer, trauma, spinal cord injury,
History hypothyroidism, Hirschsprung’s disease, irritable bowel syndrome
- medications, dose, use of opiates, anticholinergics, antacids
containinag calcium or aluminum, laxatives
- previous confinements, recent surgery, recent immobility,
- allergies
- last menstrual period
Family History - diabetes, cancer
Social, - History of travel (unfamiliar surroundings)
- physical activity
in the HPI
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G. GI PHYSICAL EXAMINATION SKILLS
General General appearance, level of consciousness, orientation
Survey - signs of distress or breathlessness
- Assess level of hydration
- calculate BMI
Skin Skin inspection (Assess hydration, presence of cyanosis,
pallor, jaundice, easy bruising)
HEENT - external inspection of eye (check for icteric sclerae,
arcus senilis, xanthelasma, conjunctiva for anemia)
- inspection of oropharynx and dentition (check for any
aphthous ulcers)
- check hydration of lips and tongue
- lymph node palpation (cervical, supraclavicular,
axillary)
- JVP
- PMI
- palpate for heaves and thrills
- cardiac auscultation with diaphragm and bell
Chest/Lung - Thorax inspection (examine chest for spider nevi and
s gynecomastia)
- chest auscultation anteriorly and posteriorly
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Abdomen - abdominal inspection (shape, symmetry, abdominal
distention, scars, striae, prominent veins, hernia, visible
peristalsis)
- abdominal auscultation (note whether bowel sounds
are absent, hypoactive, normoactive or hyperactive;
also listen for metallic tingling)
- percuss abdomen
- palpate abdomen in all quadrants (direct and rebound
tenderness; guarding, abdominal rigidity, masses)
- liver palpation
- assess for CVA tenderness
SPECIAL MANEUVERS:
A. Assessing ascitis
 shifting dullness
 fluid wave
B. Assessing appendicitis
 McBurney’s point tenderness
 Rovsing’s sign
 Psoas sign
 Obturator sign
 Assessing acute cholecystitis
- Murphy’s sign
C. Mass in abdominal wall
- ask patient to raise the head and shoulders or
to strain down, thus tightening the abdominal
muscles. Feel for the mass again
- palpate for edema
Digital Rectal Examination and/or pelvic examination
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VIII. PERIPHERAL VASCULAR SYSTEM
General Age
Data
HPI O – Onset
(OPQRSTL) P – Palliating and Provoking factors
Q – quality
R – Radiation
S – Site and Severity
T – Timing
L - Location
Associated Manifestations (PAD warning signs):

(fatigue, aching, numbness, intermittent
claudication, erectile dysfunction, poorly healing or
nonhealing wounds of legs or feet, abdominal pain
after meals, weight loss)
Past - diabetes, dyslipidemia, hypertension, known
Medical atherosclerotic coronary, carotid, or renal artery
History disease, abdominal aneurysm
Family - diabetes, dyslipidemia, hypertension, known
History atherosclerotic coronary, carotid, or renal artery
disease, abdominal aneurysm
Social, - smoking and dietary history
Environmen - intake of alcoholic beverage
tal History - physical activity
ROS 3-5 representative symptoms per system apart from
those asked in the HPI
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B. PHYSICAL EXAMINATION
INSPECTION
 Begin by washing your hands. Introduce yourself to the patient and clarify
their identity. Explain what you would like to do and gain their consent.
 Fully expose the upper and lower extremities. Observe their size,
symmetry and skin color, hair distribution, including any obvious
abnormalities such as edema, muscle wasting or scars.
 Now focus the observation towards the patient’s legs, feet and toes. Signs
to note:
 Any signs of gangrene or pre-gangrene such as missing toes or blackening
of the extremities.
 The presence of any ulcers – ensure you check all around the feet,
including behind the ankle and between the toes. These may be venous or
arterial – one defining factor is that venous ulcers tend to be painless
whereas arterial are painful.
 Any skin changes such as pallor, change in colour, varicose eczema or sites
of previous ulcers.
 Presence of any varicose veins – often seen best with the patient standing.
PALPATION:
 This should include an assessment of the temperature of each extremity.
Starting distally, feel with the back of your hand and compare the
extremities to each other noting any difference.
 Check capillary return by compressing the nail bed and then releasing it.
Normal colour should return within 2 seconds.
 Any varicosities which you noted in the observation should now be
palpated. If these are hard to the touch, or painful when touched, it may
suggest thrombophlebitis.
 Finally for palpation, you should feel for the abdominal aorta and each of
the peripheral pulses. These are:
o Radial and brachial pulses, epithrochlear nodes
 Aorta‚ this should be palpated just to the left of the midline in the
epigastrium, note whether the pulsation in expansile as in an aneurysm.
 Femoral‚ feel at the mid inguinal point, below the inguinal ligament.
 Popliteal‚ ask the patient to flex their knee to roughly 45 degrees keeping
their foot on the bed, place both hands on the front of the knee and place
your fingers in the popliteal space.
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 Posterior tibial‚ felt posterior to the medial malleolus of the tibia.
 Dorsalis pedis‚ feel on the dorsum of the foot, lateral to the extensor
tendon of the great toe.
 You should feel these on both sides and comment on their strength,
comparing one side relative to the other.
 Check for radio-femoral delay by palpating both the radial and femoral
pulses on one side of the body at the same time. The pulsation should
occur at the same time, any delay may suggest coarctation of the aorta.
AUSCULTATION
1. Take blood pressure in both arms
2. Listen for femoral and abdominal aortic bruits.
SPECIAL TECHNIQUES:
1. Buerger’s Test: This involves raising both legs to 60 degrees until maximal
pallor of the feet develops, usually within a minute. Either maintenance of
normal color or slight pallor is normal. Then ask the patient to sit up with legs
dangling. Compare both feet, noting the time required for: a) return of
pinkness to the skin (about 10 secs or less);
b) filling of veins of the feet and ankles (normally about 15 secs). In dark-
skinned persons, inspect the soles of the feet for these changes.
* Marked pallor on elevation and on dangling legs OR unusual rubor of the
dependent leg suggest arterial insufficiency
2. Allen test: Patient should rest with hands in lap, palms up. Ask the patient to
make a tight fist with one hand; then compress both radial and ulnar arteries
firmly between your thumb and fingers. Next, ask the patient to open the hand
into a relaxed, slightly flexed position (extending the hand fully may cause pallor
and a falsely positive test). Release your pressure over the ulnar artery. If the
ulnar artery is patent, the palm flushes within about 3-5 secs. Patency of the radial
artery may be tested by releasing the radial artery while still compressing the
ulnar artery.
* Persisting pallor indicates arterial occlusion.
On completion, thank the patient for their time and ensure they are comfortable
and well-covered. Remember to wash your hands and report your findings to the
examiner.
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VEINS
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LYMPHATICS
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FLUID EXCHANGE
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VII. GENITOURINARY SYSTEM
HPI O – Onset, gradual or sudden
(OPQRST) P – Palliating and Provoking factors
Q – quality
R – Radiation
T – Timing
Associated Manifestations:
Fever, back pain
Urinary symptoms: Blood in urine, dysuria, frequency,
urgency, nocturia, amount changes, feeling of incomplete
emptying, hesitancy, dribbling, incontinence (overflow
incontinence, stress incontinence), loin pain, vomiting, renal
colic, bladder or bowel dysfunction
1. Sexual history (TO BE ASKED LAST!!!): urethral discharge (color,
consistency, amount), sexually active, pain during/after
intercourse, painful erections (priapism), joint pains, eye
inflammation, impotence, infertility
Past Medical  Similar problem in the past. If so, how treated.
History  Previous operations, recent groin injuries, trauma, mumps
 Previous urology consults or laboratory testing
 UTIs, urinary obstructions, STD's, prostate problems
 Hypertension, Diabetes, MI, neurologic diseases, cancer treatments
 Impotency treatments, if any
 Sexual history
Family History  similar complaints or diseases (as stated in the past medical history)
in the family
 does partner have similar symptoms
Social,  occupational history, stress, travel history
Environmental  smoking and dietary history
History  intake of alcoholic beverage
 physical activity
HPI
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B. PHYSICAL EXAMINATION
General examination
 Establish whether the patient is distressed due to pain or appearing
unwell, suggesting systemic illness and possibly kidney failure.
 Note whether there is evidence of anaemia.
 All patients with urological symptoms should have their blood pressure
measured.
 Signs of dehydration may indicate kidney failure or polyuria associated
with diabetes.
 Lymphadenopathy may indicate metastatic spread from any urological
cancer.
Abdominal examination
 Abdomen may be distended due to large polycystic kidneys or ascites due
to nephrotic syndrome.
 Auscultation for a renal bruit in renal artery stenosis (heard above the
umbilicus, 2 cm to the left or right of the midline and also in both flanks
with the patient sitting up).
 Percussion for the presence of ascites (shifting dullness) and for an
enlarged bladder.
 Palpate for an enlarged bladder or an abdominal aortic aneurysm.
 The kidneys are examined by bimanual examination with a hand
posteriorly lifting up the kidney towards the examining abdominally placed
hand.
 Tenderness over the kidney should be tested by gentle pressure over the
renal angle.
 Palpation for renal enlargement or masses. An enlarged kidney usually
bulges forwards. In polycystic kidney disease, there may also be
hepatomegaly from hepatic cysts.
 Hernias and hernial orifices.
Neurological examination
 Dermatome sensory loss of the perineum or lower limbs and lower limb
motor dysfunction suggest possible spinal cord or root pathology.
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Male genital examination
 As this is an intimate examination it is pertinent to gain a good rapport
with your patient, maintain good communication and ensure the patient’s
dignity at all times. Remember to offer a chaperone for this skill.
 Firstly, wash your hands. Introduce yourself to the patient, explain to them
what the examination will entail and gain his consent. Don gloves.
 The patient should be exposed from the waist down, and with his shirt
pulled up. Testicular examination is best performed with the patient
standing. You should kneel down or sit in front of and to the side of the
patient, NOT directly in front of the patient.
 Inspect the penis on all sides and note any obvious lumps, swellings, ulcers
or scar.
 Inspect the scrotum. This is easier to do if you move the penis out of the
way; you could ask the patient to do this for you. Again inspect all sides of
the scrotum and not forgetting to lift it so that you can inspect the
posterior aspect. Take note of any obvious lumps, swellings, ulcers or
scars.
 Individually palpate each testicle. If you have identified or been told about
any abnormalities, examine the “normal” side first. This is a bimanual
technique using the thumb and index finger of each hand. Using both
hands gently feel the whole testicle noting any palpable abnormalities. Ask
the patient if he experiences any pain. Note that if you cannot palpate one
of the testicles then you should feel along the course of the inguinal
ligament for an undescended testicle.
 Palpate the epididymis and spermatic cord on both sides.
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Female genitalia
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Internal Examination
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Bimanual Examination
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 Primary dysmenorrhea results from increased prostaglandin production during the luteal
phase of the menstrual cycle, when estrogen and progesterone levels decline.
 Causes of secondary dysmenorrhea include endometriosis, adenomyosis (endometriosis
in the muscular layers of the uterus), pelvic inflammatory disease, and endometrial
polyps.
o Other causes of secondary amenorrhea include low body weight from any cause,
including malnutriion and anorexia nervosa, stress, chronic illness, and
hypothalamic– pituitary–ovarian dysfunction.
o Causes vary by age group and include pregnancy, cervical or vaginal infection or
cancer, cervical or endometrial polyps or hyperplasia, fibroids, bleeding
disorders, and hormonal contraception or replacement therapy. Postcoital
bleeding suggests cervical polyps or cancer, or, in an older woman, atrophic
vaginitis.
 Causes of postmenopausal bleeding include endometrial cancer, hormone replacement
therapy, and uterine and cervical polyps.
 Amenorrhea followed by heavy bleeding suggests a threatened abortion or dysfunctional
uterine bleeding related to lack of ovulation
 Superficial pain suggests local inflammation, atrophic vaginitis, or inadequate lubrication;
deeper pain may be from pelvic disorders or pressure on a normal ovary. The cause of
vaginismus may be physical or psychological.
 The most common cause of acute pelvic pain is pelvic inflammatory disease (PID),
followed by ruptured ovarian cyst, and appendicitis.16 STIs and recent IUD insertion are
red flags for PID. Always rule out ectopic pregnancy first with serum or urine testing.
 Also consider mittelschmerz, or pain from ovulation at midcycle, ruptured ovarian cyst,
and tubo-ovarian abscess.
 Delayed puberty is often familial or related to chronic illness. It may also arise from
abnormal function of the hypothalamus, anterior pituitary gland, or ovaries.
 Excoriations or itchy, small, red maculopapules suggest pediculosis pubis (lice or
“crabs”). Look for nits or lice at the bases of the pubic hairs.
 Enlarged clitoris is seen in masculinizing conditions.
 An imperforate hymen occasionally delays menarche. Be sure to check for this possibility
when menarche seems unduly late in relation to the development of a girl’s breasts and
pubic hair.
 Three to 5 years after menopause, ovaries are atrophic and usually nonpalpable. In
postmenopausal women, investigate a palpable ovary for possible ovarian cyst or ovarian
cancer. Pelvic pain, bloating, increased abdominal size, and urinary tract symptoms are
more common in women with ovarian cancer.
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XIII. ANUS, RECTUM AND PROSTATE
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Rectal Examination
 The patient lies on the left side with the buttocks near the edge of the examining table or bedside with
the right knee and hip in slight flexion. Drape the patient appropriately.
 Using a gloved hand, the examiner spreads the buttocks apart and inspects the sacroccygeal and perianal
areas.
 The patient then is asked to bear down to check again for rectal or anal masses.
 To assess neuromuscular integrity, each side of the buttocks is scratched with the gloved finger to elicit
the superficial anal reflex (the anal "wink"), a function of L 1 and L2.
 Next, using a generous amount of water-soluble gel for lubrication, the gloved index finger is inserted
gently into the rectum. If you feel the sphincter tighten, pause and reassure the patient. When the
sphincter relaxes, proceed. The examiner should evaluate the anal sphincter tone, tenderness,
induration, irregularities or nodules.
 Insert you finger into the rectum as far as possible. Rotate your hand clockwise then counterclockwise to
palpate the entire rectal surface. Note any nodules, irregularities or induration. To bring a possible lesion
into reach, take your finger off the rectal surface, ask patient to strain, and palpate again. (SEE TABLE 15-
2 P. 593 AND TABLE 15-2 P. 594)
 Rotate your hand further counterclockwise to examine the posterior surface of the prostate gland.
Sweep your finger carefully over the prostate gland, identifying its lateral lobes and median sulcus
between them. Note the size, consistency, median sulcus, and presence of nodules. The normal prostate
is rubbery and nontender. (SEE TABLE 15-3, P. 595)
 Gently withdraw you ringer, and wipe the anus or give the patient tissues. Note the color of any fecal
matter on your glove.
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Change in bowel pattern, especially stools of thin pencil-like shape, may warn of
colon cancer. Blood in the stool may be from polyps or cancer, or from
gastrointestinal bleeding or local hemorrhoids; mucus may accompany villous
adenoma.
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Proctitis may be indicated by itching, anorectal pain, tenesmus, or discharge or
bleeding from infection or rectal abscess. Causes include gonorrhea, chlamydia,
lymphogranuloma venereum, receptive anal intercourse, ulcerations of herpes
simplex, chancre of primary syphilis (see Table 13-1, Sexually Transmitted
Infections of Male Genitalia, p. 534). Itching in younger patients may be from
pinworms.
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IX. MUSCULOSKELETAL SYSTEM
 Articular structures include the joint capsule and articular cartilage,
the synovium and synovial fluid, intra-articular ligaments, and juxta-
articular bone. Articular cartilage is comprised of a collagen matrix
containing charged ions and water, allowing the cartilage to change
shape in response to pressure or load, acting as a cushion for
underlying bone. Synovial fluid provides nutrition to the adjacent
relatively avascular articular cartilage.
o Articular disease typically involves swelling and tenderness of
the entire joint and limits both active and passive range of
motion due either to stiffness or to pain.
 Extra-articular structures include periarticular ligaments, tendons,
bursae, muscle, fascia, bone, nerve, and overlying skin.
o Extra-articular disease typically involves selected regions of the
joint and types of movement.
 Ligaments are ropelike bundles of collagen fibrils that connect bone to
bone.
 Tendons are collagen fibers connecting muscle to bone.
 Bursae are pouches of synovial fluid that cushion the movement of
tendons and muscles over bone or other joint structures.
 Bursae. Easing joint action are bursae, roughly disc-shaped synovial
sacs that allow adjacent muscles or muscles and tendons to glide over
each other during movement. They lie between the skin and the convex
surface of a bone or joint (as in the prepatellar bursa of the knee, p.
652) or in areas where tendons or muscles rub against bone, ligaments,
or other tendons or muscles (as in the subacromial bursa of the
shoulder, pp. 617–618).
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A. LOW BACK PAIN
HPI O – Onset
(OPQRSTL) P – Palliating (rest, forward flexion) and Provoking
factors (movement, cough, Valsalva maneuver)
Q – quality
R – Radiation
T – Timing
(fever, numbness or paresthesia or weakness
of buttock or lower extremity, bladder or bowel
dysfunction, dysuria, hematuria, weight loss, pain
at night or present at rest, cough)
Past Medical - cancer

History - intravenous drug use
- blunt trauma or vehicular accident
- osteoporosis
-NSAID use precautions: medicine allergy,
asthma, peptic ulcer disease, myocardial
infarction, chronic kidney disease
Family History - cancer, arthritis
Social, - History of heavy lifting, prolonged immobility
- physical activity
ROS 3-5 representative symptoms per system apart
from those asked in the HPI
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B. NECK PAIN
HPI O – Onset
Q – quality
R – Radiation
T – Timing
(headache, dizziness, numbness or paresthesia
or weakness of shoulder and upper and lower
extremities, muscle spasm and stiffness and
tightness in upper back and shoulders, hand
clumsiness, urinary frequency, gait changes)
Past Medical - cancer

History - intravenous drug use
- blunt trauma or vehicular accident
- osteoporosis
- NSAID use precautions: medicine allergy,
Family History - cancer, arthritis
- physical activity
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C. JOINT PAIN
HPI O – Onset
Q – quality
R – Radiation
S – Site (pattern of involvement if polyarticular)
and Severity
T – Timing (has the pain progressed rapidly or
insidiously)
(fever, signs of inflammation, morning
stiffness, changes in level of activity, rash,
anorexia, weight loss, weakness, conjunctivitis,
diarrhea, abdominal pain, urethritis, mental
status change)
Past Medical - cancer chemotherapy
History - blunt trauma or vehicular accident
- sexual history
- NSAID use precautions: medicine allergy,
Family History - arthritis, SLE, rheumatoid arthritis, gouty
arthritis
- physical activity
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D. EXAMINATION OF THE MUSCULOSKELETAL SYSTEM
The examination of all joints follows the general pattern of “look, feel, move” as well as an
assessment of function.Wash your hands and introduce yourself to the patient. Clarify the patient’s
identity and explain what you would like to examine and gain their consent.Ensure that areas to be
examined are appropriately exposed.At the end of the examination, allow the patient to dress and
thank them. Wash your hands and report your findings to the preceptor.
i. Spine Examination
1. INSPECTION: The patient should be standing. Examine the patient from behind, looking for any
obvious abnormalities such as scars. Note muscle bulk, wasting, symmetry of each side and look
for any scoliosis. Now look from the side to check for the normal curvatures of the spine (cervical
lordosis, thoracic kyphosis and lumbar lordosis).
CLUES AND SIGNS OF SCOLIOSIS

 Head not centered over the pelvis
 One shoulder (convex side) may be higher than the other
 One scapula may be higher or more prominent than the other
 With arms hanging loosely, more space is noted between arm and body on one side
 One hip (convex) side may appear higher or more prominent than other
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How to do the PE
 Patient bends forward, spine horizontal to the floor, while holding palms together, arms
extended
 Examine from side and behind the patient
 Look for a “rib hump” (hallmark of a scoliotic curve greater than 10 degrees)
 Make sure pelvis is not dipping on one side and leg length is symmetric
2. Cervical spine movements which are assessed are lateral flexion (place ear on shoulder),
rotation (look over shoulder), flexion (put chin on chest) and extension (look at the ceiling).
3. Examine also for spine movements like lumbar flexion (touch toes), extension (lean backwards),
lateral flexion (run their hand down the outside of their leg) and thoracic rotation (fix the pelvis
then ask the patient to turn to each side).
4. PALPATION: Feel along the entire length of the spine, palpating each spinous process and
checking with the patient for any tenderness. Now palpate the sacroiliac joints (dimple of the back)
and finally the paraspinal muscles. As it is difficult to observe the patient’s face for signs of
discomfort, you should regularly ask them if what you are doing is painful.
5. Special test: straight leg raise test (SLRT) which assesses for nerve entrapment such as sciatica.
Raise the patient’s relaxed and straightened leg, flexing the leg at the hip, then dorsiflex the foot.
Another maneuver is first raise the patient’s leg with the knee flexed, then extend the leg. Assess
the degree of elevation at which pain occurs, the quality and distribution of pain, and the effects of
dorsiflexion. Pain radiating into the ipsilateral leg is a positive SLRT for lumbosacral radiculopathy
or sciatica. Foot dorsiflexion further increases leg pain. Increased pain when the contralateral
healthy leg is raised is a positive crossed SLRT.
6. An extension to this station could be to perform an Upper Limb Neurological Examination or

Lower Limb Neurological Examination if your findings suggest nerve entrapment from the cervical
or lumbar spine.
ii. Shoulder Examination

1. INSPECTION: The patient should be standing for this examination. Inspect the shoulder
joint from the front, side and back. Look for symmetry, wasting, scars or obvious bony
deformity.
2. Feel over the joint and its surrounding areas for the temperature of the joint. A raised
temperature may suggest inflammation or infection in the joint.
3. Systematically feel along both sides of the bony shoulder girdle. Start at the
sternoclavicular joint, work along the clavicle to the acromioclavicular joint, feel the
acromion, and then around the spine of the scapula. Feel the anterior and posterior joint
lines of the glenohumeral joint and finally the muscles around the joint for any
tenderness.
4. The movements of the joint should start being performed actively. Ask the patient to
bring their arm forward (flexion), bend their arm at the elbow and push backwards
(extension). Bring their arm out to the side and up above their head (abduction). Flex the
elbow and tuck it into the side and move the hand outwards (external rotation). And
finally see how far they can place their hand up their back (internal rotation).
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5. Once all of these movements have been performed actively, you should perform them
passively and feel for any crepitus while moving the joints.
6. Special tests for rotator cuff tear:
 Impingement test (Bates, p. 624): place the shoulder out at 90 degrees with the arm
hanging down, press back on the arm and check for any pain.
 Empty can test (Bates, p. 625): elevate arms to 90’ and internally rotate arms with the
thumbs pointing down, as if emptying a can. Ask patient to resist as you place downward
pressure on the arms. Positive test is weakness.
 Test infraspinatus strength (Bates, p. 625): Ask patient to place arms at the side and flex
the elbows to 90’ with the thumbs turned up. Provide resistance as the patient presses
the forearms outward. A positive test is weakness.
7. Function tests: These involve the patient placing their hands behind their head and behind
their back. This checks that they can perform everyday tasks.
iii. Elbow Examination

1. Inspect the front to check the carrying angle, from the side to check for a fixed flexion deformity,
and from behind and on the inside to check for scars, swellings, rashes, rheumatoid nodules and
psoriatic plaques.
2. Feel the elbow, assessing the joint temperature relative to the rest of the arm.
3. Palpate the olecranon process as well as the lateral and medial epicondyles for tenderness.
4. Check movements at the elbow joint: flexion, extension, pronation and supination. Once these
have been assessed actively they should be checked passively feeling for crepitus.
5. Special tests:
a. Tennis elbow localises pain over the lateral epicondyle, particularly on active extension of the
wrist with the elbow bent.
b. Golfer’s elbow pain localises over the medial epicondyle and is made worse by flexing the wrist.
Check each of these individually to eliminate them.
iv. Hand & Wrist Examination

1. Inspect both hands for swellings (note which joints are involved and whether the changes are
symmetrical or not), deformities, muscle wasting, scars – particularly carpal tunnel release scars,
skin changes, rashes, nail pitting, onycholysis, nailfold vasculitis, palmar erythema.
2. Now examine the hands. Start proximally and work towards the fingers. Assess the temperature
over the joint areas and compare these with the temperature of the forearm.
3. Check radial pulses, palpate the wrist joints with your thumbs on the extensor surface and your
index fingers on the flexor surface, work your way distally to the carpal bones.
4. Now squeeze over the row of metacarpophalangeal joints while watching the patient’s face for
any discomfort. Palpate MCP joints gently, bimanually with your thumbs on the dorsum and index
fingers on the palm. Palpate the interphalangeal joints using thumbs on one side and index finger
on the other side of the joint.
5. The movements which should be assessed are: wrist flexion, wrist extension, finger extension,
finger flexion, finger abduction, thumb abduction, thumb opposition
6. Special tests:
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a. Phalen’s maneuver (for carpal tunnel syndrome): Forced flexion of the wrist, either against
the other hand or by the examiner for 60 seconds will recreate the symptoms of carpal tunnel
syndrome.
b. Froment’s sign (to check Ulnar nerve function): Ask the patient to hold a piece of paper
between their thumb and index finger; this will check the function of the adductor pollicis. In a
patient with Ulnar nerve palsy the interphalangeal joint of the thumb will flex to compensate.
7. Functional assessment: Ask patient to form a power grip around your middle and index fingers;
then a pincer grip against your index finger; and lastly asking your patient to pick up a small object
such as a coin.
v. Hip Examination
1. Ask patient to walk for you. This allows you to assess muscle bulk around the hip joint, ensure
that you check both hips from behind, the side and in front. Compare both hips for any asymmetry.
Check the gait for: an antalgic gait, limp or a Trendelenburg gait, and waddling due to proximal
muscle wasting.
2. While the patient is still standing, perform the test for Trendelenburg’s Sign. Ask the patient to
alternately stand on one leg. Stand behind the patient and feel the pelvis. It should remain level or
rise slightly. If the pelvis drops markedly on the side of the raised leg, then it suggests abductor
muscle weakness in the leg the patient is standing on.
3. Now ask the patient to lie flat on the bed. Begin with a general observation of the hip and legs.
Check muscle bulk and symmetry as well as any obvious abnormalities such as scars.
Now check both the apparent and true length of the leg. True leg length discrepancy is found by
measuring from the anterior superior iliac spine to the medial malleolus. Apparent leg length
discrepancy is measured from the xiphisternum or umbilicus to the medial malleolus.
4. As the hip joint lies deeply there is little to palpate. Assess the temperature of the joint
compared to surrounding tissue. Palpate the greater trochanter as any tenderness here could
suggest trochanteric bursitis.
5. Movements to be assessed at the hip are flexion, extension, internal rotation and external
rotation. Flexion is performed by flexing the knee to 90 degrees and passively flexing the hip by
pushing the knee towards the chest. Extension is performed by placing your hand under the
patient’s ankle and asking them to push your hand into the bed. Internal and external rotation are
also performed with the knee flexed and by inverting the knee for internal rotation and everting it
for external rotation.
6. Special test: Thomas’ test. Place your hand under the patient’s lumbar spine to stop any lumbar
movements and fully flex one of the hips. Observe the other hip; if it lifts off the couch then it
suggests fixed flexion deformity of that hip.
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vi. Knee Examination
1. To begin, ask the patient to walk for you. Observe any limp or obvious deformities such as scars
or muscle wasting. Check if the patient has a varus (bow-legged) or valgus (knock-knees)
deformity. Also observe from behind to see if there are any obvious popliteal swellings such as a
Baker’s cyst.
2. Next ask the patient to lie on the bed to allow a further general inspection. Look for symmetry,
redness, muscle wasting, scars, rashes, or fixed flexion deformities.
3. Now palpate the knee joint, start by assessing the temperature using the back of your hands and
comparing with the surrounding areas
4. Palpate the border of the patella for any tenderness, behind the knee for any swellings, along all
of the joint lines for tenderness and at the point of insertion of the patellar tendon.
Finally, tap the patella to see if there is any effusion deep to the patella (BULGE sign – see Bates
video).
5. The main movements which should be examined both actively and passively are flexion and
extension. A full range of movements should be demonstrated and you should feel for any
crepitus.
6. Special tests to assess the cruciate ligaments:
◦ Anterior drawer test: Flex the knee to 90 degrees and sit on the patient’s foot.
Pull forward on the tibia just distal to the knee. There should be no movement. If
there is however, it suggests anterior cruciate ligament damage. Another test for
ACL damage is Lachman’s test.
◦ Posterior drawer test: With the knee in the same position, observe from the side
for any posterior lag of the joint, this suggests posterior cruciate ligament
damage.
◦ Assess the collateral ligaments. Do this by holding the leg with the knee flexed to
15 degrees and place lateral and medial stress on the knee. Any excessive
movement suggests collateral ligament damage.
◦ Perform McMurrays test to assess for meniscal damage. Hold the knee up and
fully flexed, with one hand over the knee joint itself and the other on the sole of
that foot. Stress the knee joint by medially and laterally moving the foot. Pain or
a click is a positive test, confirming meniscal damage.
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vii. Ankle & Foot Examination
1. Inspect the joint with the patient standing
◦ Watch the patient walk, observing for a normal heel strike, toe-off gait.
◦ Look at the alignment of the toes for any valgus or varus deformities.
◦ Examine the foot arches, checking for pes cavus (high arches) or pes planus (flat
feet).
◦ Feel the Achilles tendon for any thickening or swelling.
◦ Finally should you inspect the patient’s shoes, note any uneven wear on either
sole and the presence of any insoles.
2. Ask the patient to lie on the bed, and perform a further general inspection. Check the symmetry,
nails, skin, toe alignment, toe clawing, joint swelling and plantar and dorsal calluses.
3. Feel each foot for temperature, comparing it to the temperature of the rest of the leg.
4. Next palpate the joint, start by squeezing over the metatarsophalangeal joints while observing
the patient’s face. Also palpate over the midfoot, ankle and subtalar joint lines for any tenderness.
You should also palpate the foot pulses.
5. Assess all active movements of the foot. These movements are: inversion, eversion, dorsiflexion
and plantar flexion, of the great toe as well as of the ankle.
6. Movements should then be tested passively: Foot inversion, Foot eversion , Dorsiflexion ,
Plantarflexion , Toe dorsiflexion , Toe plantar flexion
7. Finally examine the midtarsal joints by fixing the ankle with one foot and inverting and everting
the forefoot with the other.
Pain (Chronic) may be a spectrum disorder related to mental health and somatic conditions. See
Chapter 5, Behavior and Mental Status, Symptoms and Behavior
Pain (Chronic) is defined in several ways: pain not associated with cancer or other medical
conditions that persists for more than 3 to 6 months; pain lasting more than 1 month beyond the
course of an acute illness or injury; or pain recurring at intervals of months or years. Chronic
noncancer pain affects 5% to 33% of patients in primary care settings. More than 40% of patients
report that their pain is poorly controlled.
Weakness, especially if localized in a neuroanatomical pattern, suggests possible neuropathy or
myopathy.
Pain Scale
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VIII. NERVOUS SYSTEM
The Brain
 The brain has four regions: the cerebrum, the diencephalon, the
brainstem, and the cerebellum. Each cerebral hemisphere is subdivided
into frontal, parietal, temporal, and occipital lobes.
 The brain is a vast network of interconnecting neurons (nerve cells),
consisting of cell bodies and their axons—single long fibers that
conduct impulses to other parts of the nervous system.
 Brain tissue may be gray or white. Gray matter consists of aggregations
of neuronal cell bodies. It rims the surfaces of the cerebral
hemispheres, forming the cerebral cortex. White matter consists of
neuronal axons that are coated with myelin. The myelin sheaths, which
create the white color, allow nerve impulses to travel more rapidly.
 Deep in the brain lie additional clusters of gray matter. These include
the basal ganglia, which affect movement, and the thalamus and the
hypothalamus, structures in the diencephalon. The thalamus processes
sensory impulses and relays them to the cerebral cortex. The
hypothalamus maintains homeostasis and regulates temperature, heart
rate, and blood pressure. The hypothalamus affects the endocrine
system and governs emotional behaviors such as anger and sexual
drive. Hormones secreted in the hypothalamus act directly on the
pituitary gland.
 The internal capsule is a white-matter structure where myelinated
fibers converge from all parts of the cerebral cortex and descend into
the brainstem. The brainstem, which connects the upper part of the
brain with the spinal cord, has three sections: the midbrain, the pons,
and the medulla.
 Consciousness relies on the interaction between intact cerebral
hemispheres and a structure in the diencephalon and upper brainstem,
the reticular activating (arousal) system.
 The cerebellum, which lies at the base of the brain, coordinates all
movement and helps maintain the body upright in space.
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The Spinal Cord
 Below the medulla, the central nervous system extends into the elongated spinal cord,
encased within the bony vertebral column and terminating at the first or second
lumbar vertebra. The cord provides a series of segmental relays with the periphery,
serving as a conduit for information flow to and from the brain. The motor and
sensory nerve pathways relay neural signals that enter and exit the cord through
posterior and anterior nerve roots and the spinal and peripheral nerves.
 The spinal cord is divided into segments: cervical, from C1 to C8; thoracic, from T1 to
T12; lumbar, from L1 to L5; sacral, from S1 to S5; and coccygeal. The spinal cord is
thickest in the cervical segment, which contains nerve tracts to both the upper and
lower extremities.
 Note that the spinal cord is not as long as the vertebral canal. The lumbar and sacral
roots travel the longest intraspinal dis-tance and fan out like a horse’s tail at L1–2,
giving rise to the term cauda equina. To avoid injury to the spinal cord, most lumbar
punctures are performed at the L3–4 or L4–5 vertebral interspaces.
Peripheral Nervous System
The peripheral nervous system consists of both cranial nerves and peripheral nerves that
project to the heart, visceral organs, skin, and limbs. It controls the somatic nervous system,
which regulates muscle movements and response to the sensations of touch and pain, and the
autonomic nervous system that connects to internal organs and generates autonomic reflex
responses. The autonomic nervous system consists of the sympathetic nervous system, which
“mobilizes organs and their functions during times of stress and arousal, and the
parasympathetic nervous system, which conserves energy and resources during times of rest
and relaxation.”
The Cranial Nerves
Twelve pairs of special nerves called cranial nerves emerge from the cranial vault through
skull foramina and canals to structures in the head and neck. They are numbered sequentially
with Roman numerals in rostral to caudal order as they arise from the brain. Cranial nerves III
through XII arise from the diencephalon and the brainstem, illustrated below. Cranial nerves I
and II are actually fiber tracts emerging from the brain. Some cranial nerves are limited to
general motor or sensory functions, whereas others are specialized, producing smell, vision, or
hearing (I, II, VIII).
Functions of the cranial nerves (CN) most relevant to the physical examination are
summarized on the next page.
The Peripheral Nerves
The peripheral nervous system includes spinal and peripheral nerves that carry impulses to
and from the cord. Thirty-one pairs of nerves attach to the spinal cord: 8 cervical, 12 thoracic,
5 lumbar, 5 sacral, and 1 coccygeal. Each nerve has an anterior (ventral) root containing motor
fibers, and a posterior (dorsal) root containing sensory fibers. The anterior and posterior
roots merge to form a short spinal nerve, <5 mm long. Spinal nerve fibers commingle with
similar fibers from other levels in plexuses outside the cord, from which peripheral nerves
emerge. Most peripheral nerves contain both sensory (afferent) and motor (efferent) fibers.
Like the brain, the spinal cord contains both gray matter and white matter. The gray matter
consists of aggregations of nerve cell nuclei and dendrites that are surrounded by white tracts
of nerve fibers connecting the brain to the peripheral nervous system. Note the butterfly
appearance of the gray- matter nuclei and their anterior and posterior horns.
192
193
Motor Pathways
Motor pathways are complex avenues that extend from upper motor neurons through long
white matter tracts to synapses with lower motor neurons, and continue to the periphery
through peripheral nerve structures. Upper motor neurons, or nerve cell bodies, lie in the
motor strip of the cerebral cortex and in several brainstem nuclei; their axons synapse with
motor nuclei in the brainstem (for cranial nerves) and in the spinal cord (for peripheral
nerves). Lower motor neurons have cell bodies in the spinal cord, termed anterior horn cells;
their axons transmit impulses through the anterior roots and spinal nerves into peripheral
nerves, terminating at the neuromuscular junction.
Three kinds of motor pathways impinge on the anterior horn cells: the corticospinal tract, the
basal ganglia system, and the cerebellar system. Additional pathways originating in the
brainstem mediate flexor and extensor tone in limb movement and posture, most notably in
coma (see Table 17-14, p. 762)
194
195
All of these higher motor pathways affect movement only through the lower motor neuron
systems, sometimes called the “final common pathway.” Any movement, whether initiated
voluntarily in the cortex, “automatically” in the basal ganglia, or reflexly in the sensory
receptors, must ultimately be translated into action via the anterior horn cells. A lesion in any
of these areas will affect movement or reflex activity.
When the corticospinal tract is damaged or destroyed, its functions are reduced or lost below
the level of injury. When upper motor neuron systems are damaged above the crossover of its
tracts in the medulla, motor impairment develops on the opposite or contralateral side. In
damage below the crossover, motor impairment occurs on the same or ipsilateral side of the
body. The affected limb becomes weak or paralyzed, and skilled, complicated, or delicate
movements are performed poorly when compared with gross movements.
In upper motor neuron lesions, muscle tone is increased and deep tendon reflexes are
exaggerated. Damage to the lower motor neuron systems causes ipsilateral weakness and
paralysis, but in this case, muscle tone and reflexes are decreased or absent.
Disease of the basal ganglia system or cerebellar system does not cause paralysis, but can be
disabling. Damage to the basal ganglia system produces changes in muscle tone (most often an
increase), disturbances in posture and gait, a slowness or lack of spontaneous and automatic
movements termed bradykinesia, and various involuntary movements. Cerebellar damage
impairs coordination, gait, and equilibrium, and decreases muscle tone.
Sensory Pathways
Sensory impulses not only participate in reflex activity, as previously described, but
also give rise to conscious sensation, calibrate body position in space, and help regulate
internal autonomic functions such as blood pressure, heart rate, and respiration.
A complex system of sensory receptors relays impulses from skin, mucous
membranes, muscles, tendons, and viscera that travel through peripheral projections into the
posterior root ganglia, where a second projection of the ganglia directs impulses centrally into
the spinal cord. Sensory impulses then travel to the sensory cortex of the brain via one of two
pathways: the spinothalamic tract, consisting of smaller sensory neurons with unmyelinated
or thinly myelinated axons, and the posterior columns, which have larger neurons with
heavily myelinated axons.
The peripheral component of the small fiber spinothalamic tract arises in free nerve
endings in the skin that register pain, temperature, and crude touch. Within one or two spinal
segments from their entry into the cord, these fibers pass into the posterior horn and synapse
with secondary neurons. The secondary neurons then cross to the opposite side and pass
upward into the thalamus.
In the posterior column system, the peripheral large fiber projections of the dorsal
root ganglia transmit the sensations of vibration, proprioception, kinesthesia, pressure, and
fine touch from skin and joint receptors to the dorsal- root ganglia, where they travel through
central projections to second-order sensory neurons in the medulla. Fibers projecting from
the secondary neurons cross to the opposite side at the medullary level and continue on to the
thalamus.
At the thalamic level, the general quality of sensation is perceived (e.g., pain, cold,
pleasant, unpleasant), but fine distinctions are not made. For full perception, a third group of
sensory neurons sends impulses from the thalamus to the sensory cortex of the brain. Here,
stimuli are localized and higher-order discriminations are made.
196
Lesions at different points in the sensory pathways produce different kinds of sensory
loss. Patterns of sensory loss, together with their associated motor findings, help you to
identify where the causative lesions might be. A lesion in the sensory cortex may not impair
the perception of pain, touch, and position, for example, but does impair finer discrimination.
A person so affected cannot appreciate the size, shape, or texture of an object by feeling it and,
therefore, cannot identify it. Loss of position and vibration sense, with preservation of other
sensations, points to disease of the posterior columns, whereas loss of all sensations from the
waist down, together with paralysis and hyperactive reflexes in the legs, indicates transection
of the spinal cord. Crude and light touch are often preserved despite partial damage to the
cord, because impulses originating on one side of the body travel up both sides of the cord.
197
Dermatomes. A dermatome is the band of skin innervated by the sensory
root of a single spinal nerve. Knowledge and testing of dermatomes help
localize a lesion to a specific spinal cord segment.
198
199
200
201
Disorders of Speech:
 Dysarthria refers to defective articulation.
 Aphasia refers to a disorder of language. The patient may have
difficulty talking or understanding others. Two common kinds of
aphasia—Wernicke’s and Broca’s. A person who can write a correct
sentence does not have aphasia.
202
203
General Data Age, gender, occupation, HANDEDNESS
HPI O – Onset
P – Palliating and Provoking factors
Q – quality
R – Radiation
T – Timing (include duration and course)
- HEADCHE: eye fatigue, eye redness, sandy
sensation in the eyes, vision problems, nasal
congestion, ear infection, fever, stiff neck, nape
pain, change in mental status, loss of
consciousness, vomiting, photophobia, aura,
weight loss, memory problems
- DIZZINESS: hearing loss, tinnitus, vomiting,
unsteady gait, dysarthria, motor and sensory
deficits
Past Medical - history of cancer, HIV infection, pregnancy, risk
History factors for stroke (hypertension, diabetes,
dyslipidemia, atrial fibrillation, carotid artery
disease)
- medications
- recent head trauma
Family History - similar illnesses in the family
Social, - caffeine intake, illicit drug use
- physical activity
204
B. SCREENING NEUROLOGIC EXAMINATION
Mental Status Level of consciousness, coherence, orientation

Examination
Cranial Nerve
Examination
1. CN I Identify odorant (e.g. toothpaste, coffee) with eyes closed
2. CN II Visual acuity, visual field, fundoscopy
3. CN III, IV, VI Pupillary size and reflex, check EOMs
4. CN V Facial sensation to light touch and temperature;
OPTIONAL: corneal reflex, jaw clench (motor component)
5. CN VII Test eyebrow elevation, forehead wrinkling, eye closure,
6. CN VIII smiling, cheek puff
Ability to hear finger rub or whispered voice with each ear
7. CN IX, X OPTIONAL: Weber’s, Rinne’s
8. CN XI Position and symmetry of palate and uvula at rest and with
9. CN XII phonation (“aah”); gag reflex
Shrug shoulders and head rotation to each side against
resistance
Inspect tongue for atrophy, fasciculations, position with
protrusion and strength when extended against inner surface
of cheeks on each side
Motor Examination Look for muscle atrophy and check extremity tone; assess
extremity strength
Grading muscle strength:
0 = no movement
1 = flicker or trace of contraction but no joint movement
2 = movement with gravity eliminated
3 = movement against gravity but not against resistance
4- = movement against mild resistance
4 = movement against moderate resistance
4+ = movement against strong resistance
5 = full power
Tap biceps and patellar reflexes
Sensory examination Ask whether patient can feel light touch and temperature of a
cool object in each distal extremity; check double
simultaneous stimulation using light touch on hands
Coordination/Cerebellar Rapid alternating movements of the hands; finger-to-nose
and heel-knee-shin maneuvers
Gait Observe patient while walking normally, on the heels and
toes, and along straight line
205
206
207
208
209
210
211
212
213
214
Headaches: Primary headaches include migraine, tension, cluster, and chronic daily
headaches; secondary headaches arise from underlying structural, systemic, or infectious
causes such as meningitis or subarachnoid hemorrhage and may be life-threatening.
Headaches: Thunderclap headaches reaching maximal intensity over several minutes occur
in 70% of patients with subarachnoid hemorrhage, and are often preceded by a sentinel leak
headache from a vascular leak into the subarachnoid space.
Headaches: Migraine and tension headaches are episodic and tend to peak over several hours.
New and persisting, progressively severe headaches raise concerns of tumor, abscess, or mass
lesion.
Headaches: Unilateral headache occurs in migraine and cluster headaches. Tension
headaches often arise in the temporal areas; cluster headaches may be retro-orbital. Nausea
and vomiting are common with migraine but also occur with brain tumors and subarachnoid
hemorrhage. Approximately 60% to 70% of patients with migraine have a symptom prodrome
prior to onset. About a third experience a visual aura, such as spark photopsias (flashes of
light), fortifications (zig-zag arcs of light), and scotomata (area of visual loss with surrounding
normal vision).
Valsalva maneuvers may increase pain from acute sinusitis or from mass lesion due to
changing intracranial pressure.
Lethargic patients are drowsy but open their eyes and look at you, respond to questions, and
then fall asleep.
Obtunded patients open their eyes and look at you, but respond slowly and are somewhat
confused.
Depression: Look for tense posture, restlessness, and anxiety fidgeting; the crying, pacing,
and hand-wringing of agitated depression; the hopeless, slumped posture and slowed
movements. Grooming and personal hygiene may deteriorate in depression, schizophrenia,
and dementia.
Manic Episode the agitated and expansive movements
OCD: Excessive fastidiousness may be seen with obsessive–compulsive disorder. One-sided
neglect may result from a lesion in the opposite parietal cortex, usually the nondominant side.
Schizophrenia; watch for the anger, hostility, suspiciousness, or evasiveness of patients with
paranoia; the elation and euphoria of mania; the flat affect and remoteness of
Moods include sadness and deep melancholy; contentment, joy, euphoria, and elation; anger
and rage; anxiety and worry; and detachment and indifference.
Memory: Recent memory is impaired in dementia and delirium. Amnestic disorders impair
memory or new learning ability and reduce a person’s social or occupational functioning, but
they do not have the global features of delirium or dementia. Anxiety, depression, and mental
retardation may also impair recent memory.
Poor performance may be a useful sign of dementia or may accompany aphasia, but it must
be assessed in terms of the patient’s intelligence and education.
Fatigue is a common symptom of depression and anxiety, but also consider infections (such as
hepatitis, infectious mononucleosis, and tuberculosis); endocrine disorders (hypothyroidism,
adrenal insufficiency, diabetes mellitus, panhypopituitarism); heart failure; chronic disease of
the lungs, kidneys, or liver; electrolyte imbalance; moderate to severe anemia; malignancies;
nutritional deficits; and medications.
215
C. Mental Status Exam
216
217
Thought Process
218
Thought Content
219
220
Personality disorders
221
222
223
224
XI. ENDOCRINE SYSTEM
Genetic Alterations:
 Hypogonadism: long limbs in proportion to the trunk
 Marfan’s syndrome: height loss in osteoporosis and vertebral compression fractures
 Masked hypertension is more problematic. In these patients, approximately 10% of
the general population, the office blood pressure is normal but the ambulatory blood
pressure is high, indicating high risk of cardiovascular disease.
Malnutrition: Poverty, old age, social isolation, physical disability, emotional or mental
impairment, lack of teeth, ill-fitting dentures, alcoholism, and drug abuse increase the
likelihood of malnutrition.
Weight changes, rapid changes (over a few days) suggest changes in body fluids, not tissues.
Weight gain associated drugs such as: tricyclic antidepressants; insulin and sulfonylurea;
contraceptives, glucocorticoids, and progestational steroids; mirtazapine and paroxetine;
gabapentin and valproate; and propranolol.
Weight loss associated drugs include anticonvulsants, antidepressants, levodopa, digoxin,
metformin, and thyroid medication.
Weight loss include gastrointestinal diseases; endocrine disorders (diabetes mellitus,
hyperthyroidism, adrenal insufficiency); chronic infections, HIV/ AIDS; malignancy; chronic
cardiac, pulmonary, or renal failure; depression; and anorexia nervosa or bulimia.
Weight loss is caused by malignancy, diabetes mellitus, hyperthyroidism, chronic infection,
depression, diuresis, and successful dieting.
Weight loss with relatively high food intake suggests diabetes mellitus, hyperthyroidism, or
malabsorption. Consider also binge eating (bulimia) with clandestine vomiting.
When the thyroid gland is retrosternal, below the suprasternal notch, it is often not palpable.
Retrosternal goiters can cause hoarseness, shortness of breath, stridor, or dysphagia from
tracheal compression; neck hyperextension and arm elevation may cause flushing from
dilatation of the external jugular veins and obstruction of the thoracic inlet. Usually they
present in the fifth decade; over 85% are benign. Soft in Graves’ disease; firm in Hashimoto’s
thyroiditis, malignancy. Benign and malignant nodules, tenderness in thyroiditis.
225
Hyperthyroidism
Note the rim of sclera from proptosis, an abnormal protrusion of the eyeballs in
hyperthyroidism, leading to a characteristic “stare” on frontal gaze. If unilateral, consider an
orbital tumor or retrobulbar hemorrhage from trauma.
In lid lag of hyperthyroidism, a rim of sclera is visible above the iris with downward gaze.
Poor convergence of eyes
oily, warm and velvety skin, fine and silky hair
Hypothyroidism
Scaliness in seborrheic dermatitis; lateral sparseness in hypothyroidism.
dry and cold skin, sparse hair
Assess thyroid function and ask about any evidence of an enlarged thyroid gland or goiter. To
evaluate thyroid function, ask about temperature intolerance and sweating. Opening questions
include, “Do you prefer hot or cold weather?” “Do you dress more warmly or less warmly than
other people?”
With goiter, thyroid function may be increased, decreased, or normal.
Intolerance to cold, preference for warm clothing and many blankets, and decreased sweating
suggest hypothyroidism; the opposite symptoms, palpitations, and involuntary weight loss
suggest hyperthyroidism (p. 291).
226

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MEDICINE CLINICS GUIDE

II. CHIEF COMPLAINT

VI. FAMILY HISTORY

40. Assess Extraocular movements: From 2 Reflection is symmetrical

There is normal and

“Tactile fremitus is felt in all three

“Resonant sounds heard in all 6

96. Palpate the abdomen in 4 quadrants No masses, no tenderness

Fever or pyrexia refers to an elevated body temperature.

Hypertension, assessment also includes its effects on target “end organs”—

 Rhinorrhea refers to drainage from the nose and is often associated

Bleeding from the gums, especially when brushing teeth, is a common

Hoarseness refers to a change in voice quality, often described as husky,

Bright red edematous mucosa underneath a denture suggests denture sore

Assymetric protrusion of the tongue lesion of CN XII

Edema from extravascular fluid retention is visible in conditions like heart

B. PHYSICAL EXAMINATION SKILLS

HPI - When did it start?

General Data Age, gender, occupation

HPI - When did it start? Was it a sudden or gradual onset?

Associated Manifestations (PAD warning signs):

General Data Age, gender, occupation

Past Medical - cancer

General Data Age, gender, occupation

Past Medical - cancer

CLUES AND SIGNS OF SCOLIOSIS

6. An extension to this station could be to perform an Upper Limb Neurological Examination or

ii. Shoulder Examination

iii. Elbow Examination

iv. Hand & Wrist Examination

6. Special tests to assess the cruciate ligaments:

General Data Age, gender, occupation, HANDEDNESS

Mental Status Level of consciousness, coherence, orientation

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