Clinical Clerkship

7/30/2019 Clinical Clerkship

1/44Edited by CSMU HOW medical team Page 1

a clinical clerkship guideline for everyone

Disclaimer : the author do not accept any responsibility or legal liability for any errors inthe text or for the misuse or misapplication of material in this work



GENERAL PHYSICAL EXAMINATION

5 Important things before starting examination: (IPPEC)1. Introduce yourself patient

- examinerpatient- patient examiner

2. Permission- from examiner to start physical examination- from patient to examine him/her and to discuss finding

3. Positioning- lay patient flat for abdominal & neurological examination- prop up to about 45 degrees for CVS & chest examination

4.Exposure-adequetely- expose either from the begirinihg or during specific examinetibn

5. Comfortable - ensure patient is at their most comfortable position- ask if the patient is comfortable or not

General Inspection- stand at the end of the bed- 10 seconds: carefully observe the patient before commenting 11 things (PCLC RP HNG MA)

1. Position - is the patient lying flat, 45, sitting, left lateral or right lateral etc.2. Comfortability - Is the patient comfortable or not?3. Look - does the patient look well / ill?4. Consciousness & alertness - must ask about time, place & person (dont just say that person is

conscious/alert without even asking a question)5. Pain - is the patient in pain?6. Respiratory distress - is the pt in respiratory distress?

*note: 6 features of respiratory distressI. tachypnoea (>20 brath/minr)ii. flaring of the nasal alaeiii .pursed lipsiv. useofaccessory musclesv. subcostal & intercostal muscle retraction

vi. cyanosis (in sver resp. distrss)7. Hydrational status - examine the tongue, mucous rnernbran, skin turgor, sunken eyeball8. Nutritional status

-cachexic/obese (check BMI)-any obvious muscle wasting? (look at temporal muscle, vastus muscles & small muscles of thehand / interosseous mus.)

9. Gross deformity10. Movement - any abnormal / involuntary movement?11. Attachments (e.g. IV canulla)

Example: The patient is lying comfortably in supine position propped up to approximately 45

degrees. He does not look ill. He is conscious and alert to time, place & person. He is not in pain or

respiratory distress & his hydrational and nutritional status is adequate. There are no muscle wasting, nogross deformity and no abnormal movements. Theres an intravenous line attached to his right wrist



EXAMINATION OF CARDIOVASCULAR SYSTEM

1. Repeat 5 important point before examine the patient, IPPEC:I. Introduceii. Permissioniii. Positioning: prop up to approx. 45 degrees

(2 reasons: 1. to access JVP, 2. the pt may have orthophoea)iv. Exposure:

- Expose head, neck, upper and lower limbs adequately for general examination-Expose pericardium when proceed to specific examination of CVS

v. Comfortable make sure the pt is comfortable

2. General Inspection (PCLC PR HNG MA)3. General Examination

A. Upper limbs examine both sides at the same timei Palms

Moisture - dry @ moist Temperature - warm @ cold Colour - pink @ pale

ii.Fingers & Nails cyanosis - peripheral cyanosis capillary refilling clubbing

*note: stage of clubbingstage I - loss of angle between nail & nail bedstage II - increase longitudinal & transverse curvaturestage III - positive fluctuating teststage IV - drumstick appearance

*note: cardiovascular causes of clubbing :- Bacterial endocarditis- Cyanotic congenital heart disease

infective endocarditis stigmatas - splinter haemorrhages, Oslers nodes,Janeway lesion

iii.PulseRest the patients hands on the abdomen while palpating, count the pulse rate.for 30seconds, and then count the respiratory rate while keeping the finger on the pulse rate rhythm: regular / irregular (regular irregular @ irregularly irregular) volume radio-radial delay (e.g.: in subclavian artery narrowing) radio-femoral delay (e.g.: in coarctation of aorta) collapsing pulse

**note: causes of collapsing pulse:a. physiology: elderly, pregnancy, excercise

b. pathology: aortic regurgitation , patent ductus arteniosus, arteriovenous fistula,hyperdynamic circulation e.g: fever, anaemia)

iv. Blood Pressure

B. Neckaccess the jugular venous pressure

- 450,head isturned away from the midline (to relax the sternocleidomastoid muscle), detect a

pulsatile movement, differentiate it from carotid pulsation, measure it, assess the character ifabnormal.



-4 steps to distinguieh from carotid pulsation (need to be done before commenting that the JVP iselevated

1; palpate it. venous pulse is visible but not palpable

2; deep inspiration; JVP .decreaseon / with inspiration3; occlusion by gentle pressure; obliterated and then filled from above in venous pulsation

4; hepatojugular reflex; JVP rises transiently

*note: causes of elevated JVP- right ventricle failure- volume overload (e.g.: fluid over-infusion)- superior vena cava obstruction- tricuspid stenosis or regurgitation- pericardial effusion- constrictive pericarditis- arrythmias- complete heart block

C. Head1, Eyes

- conjunctiva; pink ~ pale- sclera; jaundice2, Mouth & Tounge

- tongue; moist, dry @ coated- central cyanosis- dental hygiene

3. Face- malar flush (in mitraI stenosis)

D. Lower limbI. pitting oedema

- look at thepatients face, press on the tibial prominence on both sides for15 seconds, andextend up to the knee joint if present

ii. peripheral pulses- fermoral arteries- popliteal arteries- posterior tibial arteries- dorsalis pedis arteries

4. Specific examination of the pericardiumA. Inspection

(undress the patient to waist, inspect carefully for 10 sec.)- Chest wall movement with each respiration?- Move symmetrically or not?- Chest wall deformity?- Surgical scar?- Dilated veins?- Skin discoloration?

- Visible pulsation (including visible apex beat)?- Pericordial bulge?

B. Palpationi. apex beat (mitral area)

- search for apex beat - start palpating from the most inferior lateral region & inchup towards the area below nipple- If its not palpable, roll the patient over to the left side (left lateral)



*note: causes of impalpable apex beat:a. obesityb. pleural & pericardial effusionc. chronic obstructive airway dss (emphysema @ chr bronchitis)d. shocke. dxtrocardia (palpable on the right side)

- locate the apex beat to show correct way of counting the ribs & intercostal spaces- access the character, if abnormal pulses

tapping (palpable 1st heart sound)

heaving (a forceful, sustained, undisplaced impulse pressure overload ,d/t aortic stenosis,or hypertension causing left ventricular hypertrophy without cavity enlargement)

thrusting (a forceful, unsustained & displaced down & laterally pressure overload d/t cavity

enlargement in mitral @ aortic regurgitation)

thrill (palpable murmur - time if present)ii. left sternal edge

(palpable with palm & heel)- parasternal heave (in R ventricular & L atrial hypertrophy)- thrill

iii. pulmonary area

- tapping (palpable 2nd heart sound in pulm. hypertension)- thrill

iv. aortic area- tapping (palpable 2nd heart sound in systemic hypertension)- thrill

C. Auscultation listen with the bell at apex beat (mitral area), roll the patient to the left side (listen for mitral stenosis) change to diaphragm(for low pitch murmurs), listen again at the apex beat, trace up to axilla

(radiation of murmur in mitral regurgitation) listen with diaphragm at the tricuspid, pulmonary & aortic areas, trace up to the right side of the

neck (radiation of murmur in aortic stenosjs) sit the patient up and listen at these 3 areas again

perform the dynamic manoeuvres (respiration) if the murmur is present listen at subclavian area (When patent ductus arteriosus is puspected)

for every auscultation, listen for;a. 1

st& 2

ndheart sound & their intensity (soft, normal@loud)

b. extra heart sound (S3 and S4)c. murmurd. other additional heart sound (e.g., opening snap, systolic injection click)e. fixed splitting 2

ndheart sound (only in pulmonary area -- -atrial septal defect)

If theres murmur, few features should be commentedi. timingii. the area of greatest intensity

iii.radiation*note: sites of radiation of murmur

1. mitral regurgitation left axilla

2. aortic stenosisright side of neck

3. aortic regurgitation left sternal border

iv.gradingv. changes with alteration in position (left lateral position or sitting forward)vi.effect of dynamic manoeuvres (mainly respiration)



Dynamic manoeuvres (respiration)1; right sided valve (tricuspid & pulmonary)2; left sided valves (mitral & aortic; ask the patient to inspire,then expire fully & hold)

*example. theres a pansystolic murrmur best heard over mitral area with radiationto the axilla.

Graded 3/6 and is accentuate during inspiration and on left lateral position -

5. Other relevant systemic examination1. the abdomen

lie the patient flat palpate the liver (tender hepatomegaly in right heart failure,pulsatile in tricuspid

regurgitation) and spleen (splenomegaly in infective endocarditis) look for ascites (in right heart failure)

2. the chest sit the patient up

perform on the back look for evidence of pleural effusion (in right heart failure)

auscultate for basal crepitations (in left heart failure)

*note: evidences for signs of heart failurea. right heart failure

- hepatomegaly (tender in acute case)- ascites- elevated JVP- pitting oedema (sacral @ ankle)- pleural effusion (small)

-b. left heart failure- displaced apex beat- basal crepitation (pulmonary oederna)- gallop rhythm- peripheral cyanosis- pulsus alternans (rare)

3. the back - -while the patient is sitting, feel the sacral oedemas

4. the fundus- look forRoths spots in retina (in infective endocarditis)- look forhypertensive retinopathy

the Keith - Wagener classification for retinopathy;Grade 1: arterial narrowing & increase tortuosityGrade 2: arteriovenous nippingGrade 3: haernorrhage & soft exudatesGrade 4: Grade 1-3 + papilloedema



EXAMINATION OF THE RESPIRATORY SYSTEM

1. Repeat 5 important points before examine the patient, IPPEC:1. Introduce2. Permission

3. Positioning - prop up to approx 450

(2 reasons: 1. to access JVP 2. pt may have orthophoea)

4. Exposureo expose head, neck, upper & lower limbs adequately for generalo examinationo expose the chest when proceeding to specific examination

5. Comfortable - make sure the pt is comfortable

2. General inspection; PCLC PR HNG MA

3. General examinationA.Upper limbs - examine both sides

i. Palms

- moisture - dry @ moist- temperature warm @cold- colour - pink @ pale

ii. Fingers & nails- cyanosis - peripheral cyanosis- capillary refilling- nicotine stained fingers- clubbing

*note: Respiratory causes of clubbingA. lung abscessB. bronchoectasisC. lung carcinoma, cystic carcinomaD. emphysemaE. pulmonary fibrosis, cyctic fibrosis

iii. Dorsal part of the hands small muscle wasting weakness of finger abduction(reason: apical lung neoplasm, Pancoasts Syndrome cause destruction of the T1intercostal nerve)

iv. Wrists palpate and look for tenderness(reasons : pericostal reaction in pulmonary hypertrophic osteoarthropathy d/t primary

lung carcinoma or pleural mesothelium)v. Pulse rate rhythm volume (increase volume bounding pulse in carbon dioxide retention)

pulsus paradoxus (the pulse weakens on inspirations)*note: causes of pulsus paradoxus:

a. severe asthmab. constrictive pericarditisc. pericardial effusiond. cardiac tamponade

vi. Blood Pressureif necessary, quality paradox in mmHg



vii. Flapping Tremor- occur in carbon dioxide retention

B. Headi. eyes

anaemic? jaundice? evidence ofHomers syndrome (result from compression or destruction of the cervical chain of

sympathetic trunk by apical lung neoplasm)

*note; 4 features of Homers syndrome

1. ipsilateral partial ptosis (levator palpable muscles are inneivated by sympathetic nerve 30-%,

occulomotor (CN Ill) nerve -70%)

2. ipsilateral papillary constriction

3. ipsilateral reduced sweating

4 enophthalmos

(*remernber that everything gets smaller)ii. nose & ears

- use pen-torch while examining- polyps- engorged turbinate

- deviated septum- nasal or ears dischargesiii.mouth & tongue

- tongue moist, dry or coated?- central cyanosis?

use pen-torch and tongue depressor- pharynx ejected?- tonsils enlarged?- gag reflex ask pt to say ah- throat ejected?

Iv. Character of the coughask the pt tocough to recognize the character of the cough

C. Neck jugular venous pressure

- elevated in cor pulrponale (right heart failure secondary to disease of the lung)

trachea deviation- explain to the pt briefly about what is going to be done to him/her- tell the patient that he/shell feel uncomfortable for awhile- relax the sternocleidomastoid muscles by dropping his chin and to lean slightly forward- rest the middle finger on the suprasternal notch and pass it on either side of the trachea as deeply

and inferiorly as possible- significant displacement of the trachea suggests, but is not specific for dss Of the upper zones of

the lung

*note: causes of the trachethl deviation

a. towards the lesion

- upper lobe collapse- upper lobe fibrosis

- pneumonectomy

b. away from the lesion- massive pleural effusion

- tension pneumothomax

- upper large mediastinal masses (e.g.: retrostemnal goiter)



iii. tracheal tug- finger resting on the tracheal feels it moving inferiorly during inspiration indicates the presence

of significant lung fibrosis or severe airflow obstructioniv. feel the distance from thecricoid cartilage to suprasternal notch

- measure in the number of finger breadths (hormally 3-4 of finger breadths)- the distance reduces in hyperinflation

D. Lower limbs- pitting oedema

4. Specific examination (of the chest)A. Inspection- now ask the patIent to undress to the waist- perform inspection, palpation, and auscultation on the front of the chest first- then sit the patient forward, repeat the examination on the back- if the examiners as to choose either one, posterior aspect is preferable because the findings are

easier to be elicited (not obscure by the presence of heart & lung)- assess the following

a. moves symmetrically with each respiration?b. chest wall deformity?

*note: Examples of the chest wall deformities:

1. barrel chest: ant-posterior diameter increase; seen in chronic hyperinflation (e.g.: asthma,

chronic obstructive pulmonary dss)

2.pigeon chest (pactus cavanium): a localized prominent sternum with a flat chest, seen in

chrohic obstructive pulmonary dss)

3. funnel chest (pectus excavatum): local sternum depression, a developmental defect4 Harrisons sulcus: a linear depression of the lower ribs at the diaphragm attachment site,

suggesting chronic childhood asthma or rickets5. kyphosis: increase forward spinal convexity

6. scoliasis: a lateral curvature

c. scars?- Including previous surgery & chest drainsd. dilated veins?

- occur in superior vena caval obstruction in lung neoplasm at the hilume. skin discoloration?f. visible pulsation?g. radiotherapy marking or skin changes

- erythema & thickening of the skin over the irradiated area- indicate previous treatment for underlying rnalignancy

B. Palpation- do not present in running commentary, present the summary of the findings after the

examinationa. chest expansion

- place the hand firmly on the chest laterally after a full expiration with the fingers apart andthumb lifted off the chest wall touching each other then ask the patient to inspire fully

- perform on upper, middle and lower parts- the chest expansion also can be measured from deep inspiration to full expiration, using a

tape measure (at the level of nipples)- the lung should expand symmetrically by at least 5 cm- reduced expansion on the side indicates a lesion on that side



*note: cause of reduced chest expansion:

i. unilateral- localized pulmonary fibrosis- consolidation- collapse- pleural effusion-

pneumothoraxii. bilateral(diffuse abnormality)- chronic airflow limitation- diffuse pulmonary fibrosis

b. apex beat- locate the apex beat-2 cause of lateral displacement: cardiornegaly & mediastinal shift (lower part)

c. vocal fremitus- ask the patient to repeat nenek-nenek (tak boleh satu-satu) while palpating the chest wall

with the palm of the hand- compare both sides- perform on upper, middle & lower parts- increase vocal fremitus indicates consolidation fibrosis and above pleural effusion: decrease

vocal fremitus indicates pleural effusion or collapseC.Percussion

- percuss all area including axillae, clavicles, and supraclavicular area- equivalent sites on the two sides are percussed consecutively for comparative purposes- listen & feel for

a. the natureb. symmetry

*note: different nature of percussion notes:1: resonant (normal)2: hyper resonant (pneumothorax)

3: dull: solid organ (liver@ heart) consolidation, collapse, pleural thickening, fibrosis-4: stony dull: pleural effusion (fluid-filled area)

- loss or decreased on hyperinflation (e.g.: emphysema @ asthma)- percuss for liver and cardiac dullness

D. Auscultation- ask the patient to breathe in and out, not too deep and not too fast- compare each side with the other- use the diaphragm in all areas except supraclavicular area (use bell)- listen for

a. breath soundi. intensity (compare on both sides, either normal, reduced or absent)

- causes of reduced breath sound include chronic airflow limitation (esp. emphysema ) pleuraleffusion, pneumothorax, pneumonia, a large neoplasm and pulmonary collapse

- causes of absent breath sounds are pleural effusion, pneumothorax or collapseii. nature (vesicular @ bronchial breath sounda)

*note: natures of breath sound1. vesicular breath sound

- normal breath sound- louder and longer on inspiration than expiration

- no gap between each phrases

2. bronchial breath sound

- abnormal breath sounds

- inspiration & expiration of equal length

- expiration sounds has higher intensity than inspiration

- gap in between the two phases

- present in lobar consolidation, fibrosis, collapse and above pleural effusion



B. added sounds- time it in relation to the respiratory cycle, either inspiration, expiration or both- for ronchi, besides timing determine either polyphonic or monophonic- for crackles, besides timing determine either fine or coarse- 3 types (ronchi, crackles and pleural rub)

*note: causes of the added breath sounds:

1. ronchi (wheezing)- airway obstruction (polyphonic or generalized)

- bronchial carcinoma (monophonic or localized)

- cardiac failure2. crackles

- pulmonary oedema, pneumonia and pulmohary fibrosis (fine crackles-crepitations)

- bronchoectasis (coarse crackles-rates)3. pleural rub

- pleurisy (pleural irritation d/t pneumonia, pulmonary infarction, etc

c. vocal resonance- same as for vocal fremitus (ninety-nine)- now ask the patient to sit up, repeat the examination on the back of the chest while

percussing, ask the patient to move the elbows forward across the front of the chest to movethe scapulae away from the lung field- while the patient is sittihg, palpate for cervical lymph nodes cervical & other lymph nodes:-

- submantel- submandibular- preaurical- pthstaurical- occipital- deep cervical chain- posterior triangular- supracla-vicular- scalene (importapt in lung carcinoma)

- look for the vertebrae tenderness (metastaais from lung carcinoma)- examine the heart for signs of cor pulmonale (e.g.: loud pulmonary 2nd heard sound, right

heart gallop rhythm)- examine the sputum if possible (colour, consistency, volume)

example: there is pleural effusion over the left lower zone evidenced by reduced chest expansion,decreased vocal resonance & fremitus, stony dull notes and reduced breath sounds over the leftlower zone.



Examination of gastrointestinal system

1. Repeat 5 important point before examine the patient, IPPEC:1.Introduce2.Permission3.Positioning - lying flat with 1pillow

4. Exposure- expose head, neck, upper & lower limbs adequately for general examination- expose the abdomen wheh proceeding to specific examination

5. Comfortable - make sure patient is comfortable

2. General inspection; PCLC PR HNGMA plus;i. drowsiness, confusion or disoriented (in hepatic encephalopathy)ii. skin discoloration (e.g.; generalized skin pigmentation in chronic liver dss, esp. in

haemochromatosis)

3. General examinationA. Upper limbs - examine both sides

i. Palms

- Moisture - dry @ moist- Temperature - warm @ cold- Colour - pink @ pale

- palmar erythema

ii. Fingers & nails- cyanosis - peripheral cyanosis- clubbing

*note : GI causes of clubbinga. cirrhosis (esp biliary cirrhosis)b. inflammatory bowel dsc. coeliac dsd. GI lymphomae. chronic active hepatitis

*note: Some GIT cause of anaemiaa. gastrointestinal blood loss (e.g.; tumour, ulcer, etc)b. malabsorption (e.g.; folate, vit. B 12,)c. haemolysis (e.g.: hypersplenism)d. bleeding disorders (clotting abnormalities in chronic liver dss)e. chronic dss

*note: causes of palmar erythema

1. physiology

- pregnancy- puberty- familial

2. pathology

- chronic liver dss

- rheumatoid arthritis

- thyrotoxicosis

- oral contraceptive pill- polycvthaemia


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iii. axillary hair loss - chornic liver ds

D) lower limb- pitting oedema

5. specific examination (of the abd)

A. inspection

from R side & foot of bed- Tell the examiner that for proper exposure, the patient should be exposed from the nipples down tothe mid-thight, but its more appriopriate to expose from the nipples down to the symphysis pubis(or pubic hair line)

- Inspect carefully for 10 seconds- Assess the following :

a. the shape of abd (distended, flat @ scaphoid?) mass? Location?b. symmetrical @ asymmetrical- if asymmetrical, note the position, shape, and size of any bulge or lumpc. movement with each respiration- sluggish or no respiration movement in diffuse peritonitis

d. the position of the umbilicus, any displacement & either inverted or everted- it is displaced upwards by a swelling arising from the pelvis or downwards by ascites- it may be everted in ascites- any mass on the side of the abdomen will push the umbilicus to opposite side

e. surgical scars- if present, comment on its location, its length, tender or not -tender as well as whether

bulging on coughing (incision hernia)f. prominent or dilated veins- do Harveys sign (to detect the direction of the flow) if present to differentiate between inferior

vena caval obstruction or caput Medusag. skin discoloration- e.g. : bluish hue in Cullens and Grey Turners sign in acute pancreatitis, purple coloured striae

in Cushing syndrome, ascites and pregnancyh. visible peristalsis (in pyloric stenosis and bowel obstruction)I. visible pulsation (in abdominal aortic aneurysm, s/t visible in very thin pt)j. cough impulse

- expose the inguinal region & ask the patient to cough- look for the presence of cough impulses over inguinal, femoral, umbilical, paraumbilical, and

incisional region- if presence, proceed to hernia examination

Example: The abdomen is not distended moves symmetrically with each respiration. The

Umbilicus is centrally located and inverted. Theres no surgical scar, dilated vein, skin

discoloration and visible peristalsis. The hernia orifices are not intact.

B. Palpation and percussion- knee down beside bed / sit at the chair / stand at right- make sure the hands are warm

- ask if they are any pain and start palpating away from that area

- palpate gently in each of 9 quadrants- look at the patients face while palpating to assess any tenderness

1. Superficial palpation - look fora. consistency (soft or tense)b. tenderness (including guarding, rigidity and rebound tenderness)

2. Deep palpation (use 2 hands, L hand above R hand) -3 purposes;i. deep tendernessii. palpate for massesiii.palpate for the solid viscera



Palpation for masses- to detect the abdominal masses as well as to describe its features if present*note : descriptive features of the abdominal masses

1. site2. shape3. size4. surface (smooth, regular @ irregular)5. consistency (soft, cystic, firm @ hard)6. edge (regular @ irregular)7. tenderness8. pulsatile or not (either expansile pulsation in aortic aneurysm or transmitted pulsation in a

tumor in front of abdominal aorta)9. mobility (in vertical and horizontal direction)10 .movement with respiration (place the hand to feel movement)11. whether one can get above the mass12. percussion notes (& its continuity with surrounding structures)13. fluctuation test & fluid thrill (if cystic)

- besides, it is important to decide1. what structures normally lie at that site and its relationship of mass to these structures

- this can be decided by insinuating fingers between mass and costal margin- the hand can be insinuated between the mass and costal margin in case of renal massbut not in case of splenic or hepatic masses

2. whether the mass in extra-abdominal (within the abdominal wall) or intra abdominal

*note : how to differentiate between extra & intra abdominal mass?a.rising test and leg lifting test

leg lifting test - make the abdominal muscles taut by asking the patient to raise hisshoulders from the bed orto raise both the extended legs from the bed. if themass is within the abdominal wall, the mass will disappear or become smaller

b. movement with respiration

c. the intra abdominal mass will move vertically with respiration

Palpate the solid visceraa. the liver

- ask the patient to breath in & out slowly- beginning in the right illiac fossae- use the radial border of index finger- confirm the lower border and define the upper border by percussion (normally upper limit is6th intercostal space)- if liver is palpable, measure the liver span- if hepatornegaly is present, comment on:

1; size (in cm beneath the costal margin)2; consistency (soft, cystic, firm @ hard)3; surface (smooth nodular, regular @ irregular)4; margin (well defined @ ill- defined) sharp, rounded, irregular etc

5. tenderness (tender in hepatitis, rapid liver enlargement e.g.: right heart failure,hepatocellular cancer, hepatic abscess)6; pulsation (in tricuspid regurgitation, hepatocellular cancer)7. bruits

b. the spleen- start in the right illiac fossae, by using the fingertips of the right hand and move towards theleft upper quadrant with each respiration (left hand behind rib cage, push it forward)

- as the right hand reach the left costal margin, the left hand cornpress firmly over the ribcage



- if spleen palpableits increase 2x size of normal spleen *note: criteria needed for palpable spleen;

1. size2. edge3. splenic notch4. surface

5. consistency6. tenderness- if the spleen is not palpable, roll the patient on the right side and repeat the palpation- percuss on 9th,10th & 11th intercostal space at mid-axillary line (Traubes space, normallytympanic sound) if splenomegaly : dullness at traube space

Characteristic features which distinguish between the left kidney & the spleen

Spleen Left kidney

- palpable upper border - palpable upper border

- not ballotable - ballotable

- notch on medial border / large ant border - no notch

- move inferiomedially on inspiration toward RIF - moves Inferiorly on inspiration

- dull to percussion - resonant on percussion (verlying bowel)- occationally friction rub present - no friction rub

- kidney enlarge medially and posteriorly

c. Murphys sign- done only if acute cholecystitis is suspected- 2 methods:i. the tips of the finger of the right hand are hooked under the right costal margin (9th costal

cartilage) at lateral border of rectusii.the left hand hold the abdomen laterally with the left thumb hooked beneath the costa!

margin at the midclavicular line- then ask the patient to inspire deeply- if the gallbladder inflamed, the patient will immediately wince with a catch in the breath

Palpate gall bladder- start from RIF same like liver- ask pt breath deeply

Courvoisiers law palpable GB + obstructive jaundice + non-tender- suspect malignancy, exp Ca of pancrease head- d/t GB is distended by back pressure caused by distal malignancy obstruction

d. Shifting dullness & fluid thrill (done only if shifting dullness is present)

C. Auscultationa. bowel sound

- place the stethoscope(diaphragm) to the lower right of the umbilicus- if present comment on its intensity (normally increased or decreased) character, intensity,

frequency- comment absent only after listening for 2 minutes with no bowel sound heard

b. renal bruitsplace the stethoscope(bell) at the upper left and right of the umbilicus and compress

- sit the patient up and examine the cervical lymph nodes esp. left supraclavicular lymph nodes(Virchows node) involved with advanced gastric (Troisiers sign) or other gastrointestinalmalignancy, involvement of these nodes gives a hint toward inoperatibility of tumour

- proceed to external genitalia and per rectal examination



*note : 5 important signs that the students tend to forget

1. flapping tremor2. fetor hepaticus3. cough impulses4 supraclavicular lymph nodes

5. external genitalia and per rectal examination

Example: the abdomen is soft and non tender. There was no mass palpable on deep palpation. The liverwas palpable 3 cm below the costal margin, it was firm in consistency, smooth in surface, well defined inmargin, non tender and non pulsatile. There was no bruits heard. The spleen and kidneys were notpalpable. Shifting dullness was negative. The bowel sounds were present and normal intensity. Therewere no renal bruits.



Examination of genitourinary system

1. Repeat 5 important point before examine the patient, IPPEC:1.Introduce2.Permission3.Positioning - lying flat with 1pillow

4. Exposure- expose head, neck, upper & lower limbs adequately for general examination- expose the abdomen wheh proceeding to specific examination


2. General inspection; PCLC PR HNG MA plus;i. drowsiness, confusion or disoriented (in uremic encephalopathy)ii. sallow exomplexioniii. hyperventialtion (metabolic acidosis)iv. hiccupsv. abnormal movements

3. General examination

A.Upper limbs - examine both sidesi. Palms

- Moisture - dry @ moist- Temperature - warm @ cold- Colour - pink @ pale

*note : some GUT causes of anaemiaa. poor nutrition (esp folate deficiency)b. blood lossc. erythropoietin deficiencyd. hemolysise. bone marrow suppresionf. chronic ds

ii. Fingers & nails- cyanosis - peripheral cyanosis- Leuconychia- White transverse lines mee line- Half and half nail (upper half red, lower half white)

iii)pulse - rate- rhythm- volume

iv)Forearms and amrs- stratch markds (d/t pruritus in calcium deposition)- bruising- skin pigmentation: urinary pigment- urea frost

- tophi: crystallized monosodium urate in joints with long standing hyperuricemia, esp. ingout- signs of peripheral neuropathy

v. Arteriovenous fistulae and shuntvi. Blood pressure: lying & standing if hypovolemia is suspectedvii. Flapping tremor: asterixis, in uremic encephalopathy

B.Heada. Eyes: - jaundice?

- anemic?- band kerotopathy? (d/t Ca

2+depositions beneath corneal epithelium)



b. Mouth & tongue:-tongue: moist, dry or coated?-central cyanosis

c. Breath: urernic fetor

C. Neck: assess JVPD. Lower limbs:

- Pitting edema- Bruising- Pigmentation- Scratch marks- Tophi- Signs of peripheral neuropathy or myopathy- Peripheral pulses

4. Specific examination (abdomen):- As in Specific examination of abdominal in GIT system- Plus extra examination:

Peritoneal dialysis scarsRenal punch (Murphys kidney punch) Bladder distension

- Per rectum examination

5. Other relevant examination:A. Chest & pericardium:

- check sign & symptom of congestive cardiac failure, pulmonary edema, pleural effusion,pericarditis

B. Back:-Vertebral tenderness, due to renal osteodystrophy- Sacral edema

C. Eye fundus: check for hypertensive & diabetic retinopathyD. Urine dipstick test: check for unnary tract infection

Renal angle tenderness

1. pt sit, arm across chest2. upper border 12

thrib

Lower border L : L2R : L3

3. put thumb over renal angle (btw12

thrib, lateral to sacrospinous

mus.)4. make jabbing movement(push

hard with thumb

* pasternatsky sign :+ve if tenderness present



EXAMINATION OF NERVOUS SYSTEM

Repeat 5 important points before examine the patient, IPPEC:I. Introduction2. Permission3. Positioning:

- Lying flat for general examination & examination of limbs- Sitting up in cranial nerves examination

4. Exposure:- Expose head, neck, upper & lower limbs adequately for general examination- Expose the area interest later

5.Comfortable: make sure the patient is comfortable

*note: the approach is to:a. recognize what is the underlyihg pathology e.g.: vascular, degenerationi,etc (mainly from history)b. identify what signs are presentc. consider where (what level) the lesion is

2. General inspection, PCLC PR HNG MA

3. General Examination4. Neurological ExaminationA. Mental state examination (MSE): higher centers assessment

-assess the following (briefly)i. Level of consciounessii. Orientation to time, place and person iii. Short & long term memoryiv. General knowledgev. Posturevi. Abnormal movement, e.g:tremorvii. Handednessviii. Speech

B. Cranial nerves examination:- ask the patient to sit on a chair or over the edge of a bed- sit in front of the patient at the same level- make sure all examination tools is already prepared

i. CN I (Olfactory): Sensory only, not routinely tested Asked if patient have noticed anything abnormal about their sense ofsmell Test by using bottles containing coffee or pepper mint (Close one nostril while the patient sniff

with the other)

ii. CN 2 (Optic): Sensory only, 5 components Visual acuity:

- ask patient to read some letters from a hand held eye chart (with glasses if normally worn).Test each eye separately.if severe deficit, acuity is reported as counting fingers, seeing handmovements or perception of light.

Color vision Visual field (Confrontation)- testeach eye individually. Remove patients eyeglasses first. Make sure your eyes are on

same level as patients. Both cover one opposing eye with one hand. Move a red hat p in frombeyond your visual field inwards and ask the patient to tell you when they can see them;Check each quadrant. Map the blind spot by asking about the disappearance of the pin around

Acute, reversble deliriumChronic, irreversible dementia


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Edited by CSMU HOW medical team Page 21

the center of the visual field of each eye. A more precise method of mapping the peripheralfieldsperimetry.

Pupils:- inspection: when the patient is looking at an intermediate distance, examine the pupil forsize,

shape, equality and regularity- light reflex, direct and consensual response- reaction to accommodation, looking for pupil constriction and convergence (other features is

ciliary muscle contraction) Fundoscopy:- common abnormalities are pappiloedema, optic atrophy, diabetic neuropathy, hypertensive

retinopathy and retinitis pigmentosis

iii. CN 3,4,6 (Occulomotor, Trochlear & Abducent) CN3:

a. motor supply to elevator palpabrae superior, if defect ptosisb. motor supply to all orbital muscle except superior oblique and lateral rectus muscle, ifdefect failure of certain movement, diplopia, nystagmus

c. parasympathetic tone to papillary reflex, if defect loss of light and accommodationreflexes

CN 4: motor supply to superior oblique muslce

CN 6: motor supple to lateral rectus muscle Steady the patients head and ask the patient to follow your finger (or a red hat pin), moving

up and down and then from side to side, the finger follow in H shape. Note any limitation ofeye movement, diplopia (in any direction of gaze), nystagmus (most commonly horizontalflickering of the eye medially from the lateral extreme gaze) to each side or any squint.

iv. CN 5 (Trigeminal): Sensory and motor motor nerve

- sensory:sensation to face (ophthalmic, maxilary and mandibular branches)-motor: muscle of mastication (temporalis, masseter and pterygoid muscles)

4 components:1. facial sensation: test sensation in distribution of each division comparing with the other

(pin prick for pain and cotton wool for light touch). Map out the sensory deficit if present

and test from the abnormal to normal region2. corneal reflex3. motor supplyto mastication muscles: look for any wasting of temporal and masseter

muscles. Ask patient to clench teeth and palpate for contraction of the masseter andtemporalis muscles. Ask them to hold the mouth open while you try to push it shut.Protrusion of jaw is by the pterygoid muscles and can be assessed against rsistance.

4.jaw jerk: increased in pseudobulbar palsy, decreased or absent in bulbar palsy

v. CN 7 (Facial): Sensory, motor and parasympathetic supply:

- sensorysensation of taste from floor of the mouth, soft palate and anterior 2/3 of tongue;somatic sensation from external auditory meatus and back of ear

- motorsupply muscles of facial expression

- parasympathetic:supply saliva and lacrimal gland 3 components:1. motor supply to facial muscle:

a) inspection, look for symmetry of face, flattening of nasolabial fold and drooping from thecorner of the mouth

b) ask the patient to wrinkle his forehead by Iooking upwards while you try to feel the musclestrength (frontalis), close eyes while you attempt to open them (orbicularis oculi), blow thecheeks oUt while you press the cheeks (buccinator) and show the teeth (orbicularis oris)


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2. taste sensation: usually not examined but asked the patient if he has noticed any recentchange

3. hearing sensation: usually not examined but asked the patient if he has noticed any hearingproblem (stapedius mus.)

In lower motor neuron lesions all muscles are affected, in upper neuron lesions, the upper halfof the face and emotional expression are spared, e.g. normal eye closure, and wrinkling of the

forehead.

vi. CN 8 (Vestibulotrochlear): Sensory to utricle, saccule and semicircular canals (vestibule) and organ of Corti (cochlear) Ask if the patient has noticed any difficulty in hearing Whisper in front of each of the patients ears while occluding the other and ask if she or he can hear it

and repeat on the other side If grossly defect, proceed to Rinnes and Webers test to differentiate between conductive and nerve

deafness

vii. CN 9, 10 (Glossopharyngeal & Vagus): CN 9:- sensoryto pharynx, carotid sinus and taste to posterior 1/3 of tongue- rnotorsupply to stylopharyngeous muscle- parasympathetic:parotid gland CN 10:-sensory to larynx-rnotor supply tocricothyroid and muscles of pharynx and larynx-parasympathetic:bronchi, heart and GIT by using a pen torch ahd a tongue depressor, ask the patient to open mouth and say aaaahhh. Note

any asymmetry of palatal movement( no palatal elevation on the affected side, with the uvula pulledtowards normal side)

by using spatula, test gently for gag reflex (not usually done) to check 9th sensory, 10th motorask thepatient to speak and cough, to access hoarseness or bovine cough.

viii. CN 11 (Accessory): Cranial root provides the motor supply to some muscles of soft palate and larynx.

Spinal root provides the motor supply to trapezius and sternocleidomastoid muscles. Ask patient to shrug shoulders and test against resistance Ask patient to turn his/her head to each site and test against resistance while feeling it bulk

(sternocleidomastoid).

ix. CN 12 (Hypoglossal): Provides motor supply to styloglossus, hypoglyssus and all intrinsic muscles of tongue. Inspect for wastjng and fasciculation in lower neuron lesion. Ask the patient to protrude tongue, if there is unilateral Iesion, the tongue will deviated towards side of

lesion

C. Upper limb1. Motor system (IPT PRC)

a. Inspection (SSS WAADF):-skin-scar-symmetry-wasting-attitude and posture-abnormal movement-deformity


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- fasciculation: if no fasciculation is seen, tapping over the bulk of brachioradialis and biceps muscleswith tendon hammer

b. Pronator driftAsk patient to hold his/her arms outstretched with palms facing upwards then ask patient to closetheir eyesThe weak arm gradually pronates and drifts downwardsOnly 3 causes:

1.upper motor neuron lesion (pyramidal)2. cerebellar disease (hypotonia)3.loss of proprioception

c. Tone Ensure the patient is relaxed Assess tone by:

1. rotation, supination and pronation of elbow joints2. flexing and extending elbow and wrist joints

Decide if tone is normal, increased (hypertonic) or decreased (hypotonic) Increased tone could be: clasp knife, lead pipe or cog wheel

d. Power Compare muscle power of one side to other of each group When testing muscle groups, think pf root supply and nerve supply Grade the power (0-5), testing the following movements:

I. shoulder abduction and adductionII. flexion and extension of armIll, elbow flexion with hand fully supinated and with the hand in mid positionIV. elbow extensionV. fingers flexion and extensionVI. fingers abduction and adductionVII. thumb oppositionVIII. hand grip

e. Reflexes Make sure the patient is resting comfortably If absent, test again following reinforcement maneuver (e.g. clenched teeth) Record the reflexes with number of +, from 0 (absent reflex) to +++ (exaggerated reflex and

clonus) 3 jerks to be tested:

i. biceps jerk (C5, C6)ii. triceps jerk (C7,C8)iii. Supinator jerk (C6,C7)

f. Coordination Mainly to test cerebella function (coordination voluntary movement) Can do these either now or at the end of the examination

3 test:i. finger nose test: look for intention tremor and past pointingii. rapidly alternating movements: slow and clumsy in dysdiachokinesia (inability to perform rapid

alternating movements)iii. rebound

2. Sensory systema. Pain:

- Test lateral spinothalamic tract


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- Pin prick test with sterile pin- With the patient eyes opened, let him/her recognize sharp and dull simulation with the pin

pricked on the anterior chest wall- Then ask the patient to close eyes and say whether the pin prick feels sharp pr dull- Begins proximally on the upper arm and test in each dermatome, also compare right with left in

the same dermatome

- Map out the extent of any area of dullness, always go from the area of dullness to area of normalsensation

b. Light touch:- Posterior columns and anterior spinothaIamic tract- With similar manner, testing by touching the skin with a wisp of cotton wool, ask the patient to

shut the eyes and say yes when the touch is felt.

c. Joint position sense:- Posterior column tract- Hold sides of the patients finger/thumb (distal interphalangeal joint) and demonstrate up and

down movement

d.Vibration:- Posterior column- Place a vibrating tuning fork (128Hz) on a bony prominence, e.g. radius and ask if the patient can

feel vibration- Vibration test is of value in the early detection of demyelination disease and peripheral

neuropathye. temperature:

- lateral spinothalamic tract

D. Lower limb1. Motor system( IT PRC)a. Inspection: (SSS WAADF)b. Tone and cIonus

- Tone: relax the patient,then:i. alternately flex and extend knee jointii. roll the patients leg from side to side iii. flex and extend the ankle joint- Clonus of ankle and knee: presept in upper motor neuron lesion due to hypertoniac. Power:- test the following movementsi. Hip flexion and extensionii. Hip abduction and adductioniii. Knee flexion and extensipniv. Dorsiflexion and plantar flexionv. Toe extension and flexiond. Reflexes:

- Knee jerk: L3, L4- Ankle jerk: S1 ,S2- When it is absent, ask the patient to clench teeth or try to pull clasped hands apart (Jendrassiks

manoeuver)- Babinski reflex (L5,S1 ,S2): extension of big toe indicates an upper motor neuron lesione. Coordination: heel shin test

2. Sensory system:- Test pain, light touch, joint positiOn and vibratiOn sensation as in the upper limbs

Hip flexion - psaos, iliacus (L2, L3)

Hip extensiongluteus maximus (L5, S1, S2)

Hip abductiongluteus medius, minumus, tensor fasciae latae(L4,L5,S1)

Hip adductionadductor longus, brevis, magnus (L2,L3,L4)


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E. Gait and Rhombers test: Ask the patient to get up from the bed Then ask the patient toi. Walk normallyii. Walk heel-to-toe, to exclude a midline cerebellar lesioniii. walk on toes, to test SIiv. Walk on heel, to test L5v. Stand up from squatting, to test proximal myopathyvi. Stand with heels together, 1

stwith eyes open, then with the eyes closed (Rhombergs test):

- loss of balance when eyes open or closed in cerebella lesion- loss of balance only when eyes are closed (positive Rhombergs) in propioceptive deficit


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EXAMINATION OF HAEMATOLOGICAL SYSTEM

Repeat 5 important points before examine the patient, IPPEC:1. Introduction2. Permission3. Positioning:

- Lying flat with 1 pillow4. Exposure:

- Expose head, neck, upper & lower limbs adequately for general examination- Expose the area interest later

5.Comfortable: make sure the patient is comfortable

2.General examinationPCLC PR HNG MA3.General and specific examination:

A. Upper Iimbsa. Palms:

Warm or cold? Dry or moist? Pink or pale?

b. Fingers and nails: Peripheral cyanosis koilonychias Joint swelling or deformity

c. Pulse: Pulse rate Rhythm Volume

d. Forearm and arms: Scratch marks: in myeloproliferative diseases and lymphomas Bruising, petechia or ecchymoses: in bleeding disorders Rashes: in lymphoma

e. Hess test:

Done in thrombocytopenia, abnormal platelet function or capillary fragility is suspected Deliberately inducing punctuate purpura on the forearm by inflating a cuff above the elbow at_____ mmHg for 3 mins

f. Blood pressure

B. Head:a. Eyes:

Jaundice? Anemia?

b. Mouth and tongqe: Tongue: moist, dry or coated? Central cyanosis Glossitis: in iron deficiency anemia and megaloblastic anemia

Angular stomatitis: in Vit B6, B12, folate and iron deficiency anemia hypertrophy of gums: in acute monocytic leukemia and scurvy gum or mucosa bleeding: petechiae, telangiectasia Mucosa ulceration Tonsillomegaly and adenoid enlargement (Waldeyers ring): involved in lymphoma

c. Face Frontal bossing Plethora: in polycythemia


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C. Lower limbs: Bruising, pigmentation or scratch marks Leg ulcers Pitting edema Neurological signs: in subacute combined degeneration and peripheral neuropathy

D. Abdomen: As in specific examination of abdomen in gastrointestinal system Look carefully forsplenomegaly, hepatomegaly and paraaortic nodes enlargement and

ascites Perform per rectal examination: for tumor or bleeding External genitalia examination to lookfortesticular infiltration in leukemia

E. Lymph nodes: Ask the patient to sit up Check:

i. Epitrochlear nodesii. Axillary nodesiii. Cervical and supraclavicular nodesiv. Inguinal nodes

Check the extent, sizes, consistency, tenderness, flexion, mobility and overlying skinF. Bone: look for bony tendernessG. Fundi: lookfor hemorrhages

*Note : Causes of Iymphadenopathy1. Localized:

Local infection: bacterial, virus, fungus Metastasis: local maglinancy Lyrpphoma: Hodgkins disease, non-Hodgkin;s lymphoma

2. Generalized: Infection: esp. viral (EBV,CMV, HIV, rubella), but also bacteria (TB, syphilis, brucelliosis) and

protozoa (toxoplasmosis) Lyrnphoproliferative: Hodgkin disease, non-Hodgkin lymphoma, CLL,AML Connective tissue disorder: SLE, rheumatoid arthritis Infiltration: sarcoidosis, histocytosis

Drugs: phenytoin (pseudolymphoma) Endocrine: thyrotoxicosis Dermatopathic: eczema, psoriasis

*note : Causes of splenomegaly1. Massive:

CML Myelofibrosis Malaria Kala-azar

2. Moderate: Above causes Portal hypertension Lymphoma Leukemia Thalassemia Storage diseese, e.g. Gauchers disease

3. Small: Above causes Infection: infection mononucleosis, hepatitis, infective endocarditis, TB, brucelliosis, schistomiasis Hemolytic anemia Megaloblastic anemia Connective tissue disease: SLE, rheumatoid arthritis lnfiltration:amyloidosis, saccoidosis Others: myeloproliferation disorders, polycythemia rubra vera, essential thrombocytopenia


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EXAMINATION OF SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)

I. Repeat 5 important point before examine the patlent, IPPEC:1. Introduce2. Permission3. Positioning: lying flat with I pillow

4. Exposure: expose head, neck, upper and lower adequately5. Comfort: make sure the patient is comfortable

2. General inspection: PCLC PR HNG MA: Beside the 11 things, look for Cushingoid appearance (due to steroid treatment), any abnormal

mental state (psychosis in lupus itself or steroid therapy), gross muscle wasting

3. General and specific examination:A. Upper limb:

a. Palms: warm or cold? dry or moist? pink or pale?

*note : Cause of anemia in SLE: Pancytopenia (bone marrow failure) Chronic disease Bleeding disorder from thrombocytopenia Steroid therapy: bone marrow suppression Peptic ulceration and bleeding disorder due to steroid therapy Hemolysis Hypersplenism

b. Fingers and nails: peripheral cyanosis signs of vasculitis rash: photosensitivity Raynaulds phenomenon: white-blue-red

nail fold infarct joint swelling or deformity

c. Pulse: rate rhythm volume

d. Forearm and nails: livedo reticularls: connected bluish-purple streaks without discrete borders in the form of a small

net purpura: due to vasculitis or autoimmune thrombocytopenia subcutaneous nodules joint swelling, tenderness or deformity

e. Blood pressure

f. Proximal myopathy: in active disease or steroid treatmentB. Head:a. Hair:

alopecia lupus hairs: short broken hairs above the forehead coarsea and dry

b. Eyes: Jaundice? Anemic? Scleritis?


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c. Mouth and tongue: Tongue: moist, dry or coated? Central cyanosis? Mouth ulcer

d. Face: erythematous butterfly rash over the cheeks and bridge of nose discoid lupus acne hirsutism

C. Lower limb: Bruising Leg ulcers Pitting edema Peripheral neuropathy Joint swellirig, tenderness or deformity Hip tenderness and movement restriction: in vascular necrosis

D. Abdomen: look of splenomegaly and hepatomegalyE. Cervical lymph node: sit the patient upF. Chest and pericardium:

look for pericardial rub (pericarditis), pleural rub (pleurisy), pleural effusion, endocarditis

*Extra: Look forproximal myopathy by asking the patient to stand up from squatting position Look for neurological features are suspected, e.g. cranial nerve lesions, cerebellar, ataxia etc. Urine dipstick forproteinuria, e.g. in neprhotic syndrome

*note: Long term effects of steroid therapy (check these features during physical examination)1. Gushing appearance moon like faces, central obesity and thin limbs2. Bruising and poor wound healing3. Proximal myopathy4. buffalo hump5. bony tenderness and pathological features in osoporosis6. psychosis

7. acne and hirustism8. purple striae9. edema: due to sodium and water retention10. peptic ulceration11. hypertension, aldosterone effect12. DM, due to steroids which are diabetogenic13. Avascular necrosis of femoral head


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EXAMINATION OF THYROID GLAND

1. Repeat 5 important point before examine the patient, IPPEC:1. Introduce2. Permission3. Positioning - prop up to approx 45

0

1. to access JVP2. For specific examination of thyroid gland

4. Exposureo expose head, neck, upper & lower limbs adequately for general

o examinationo expose the chest when proceeding to specific examination

5. Comfortable - make sure the pt is comfortable

2. General inspection, PCLC PR HNG MA- besides the 11 things, look for :

i. muscle wastingii. anxiety, frightened facies, irritable, incorperativeiii. abnormal involuntary movement

iv. fullness of neck

3.General examination:A. Upper limb:

a. palms- warm or cold?- dry or moist? (warm, moist and sweaty in thyrotoxicosis, cold and abnormal dryness and

coarseness of hair, difficulty in swallowing in hypothyroidism)- pink or pale?- palmar erythema? Present in thyrotoxicosis- jaundice? (hypocarotenarmia in hypothyroidism)

b. fingers and nails- peripheral cyanosis- thyroid acropathy (clubbing)- Fingers clubbing might be rare manifestation of thyrotoxic Graves disease- onycholysis (plummers nail, separation of the nail from its bed d/t sympathetic activity, other

causes are fungal nail infection ,psoriasis and trauma)- tingling sensation in hypothyroidism

c. pulse- rate- rhythm- volumn- collapsing pulse?

d. wrist- tap over the flexor retinaculum for Tinels sign (carpel tunnel is thickened in myxoedema)

e. reflex- biceps (hyperreflexia in thyrotoxicosis, normal contraction followed by delayed relaxation in

hypothyroidism)f. BPg. Tremor- ask the pt to straight out the arms in front and spread the fingers- rest a piece of paper on the hands to highlight the tremor more clearly- fine and high frequency tremor in thyrotoxicosis

h. proximal myopathy (in active disease or steroid treatment)- abduction of the shoulder jt and tested against resistence


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B. Headi. Hair: coarse andthinning oralopecia inhypothyroidismii. Eyes:

I. Jaundice?: note the sclera will never become yellow in hypercarotenaemia2. Anemic?3. Signs of Horner syndrome:

a. thyroid swelling affecting the sympathetic trunkb. signs including: ipsilateral partial ptosis, ipsilateral miosis, enophthalmos, ipsilateral

impaired sweating of the face4. Features of hypothyroidism:

a. Periorbital edemab. Loss of thinning of the outer 3

rdof eyebrow

c. Xanthelasma5. 4 eye signs of thyrotoxicosis (may be unilateral or bilateral)

a. Lid retraction:i. The upper eyelid is higher than normal and the lower lid is in its normal positionii. Caused by over activity of tbe involuntary (smooth muscle) part of the levator palpebrae

superior muscleiii. Look for :

1. sclera visible above iris (Dalrymptes sign)

2. lid lag (Von Graefes sign) byasking the patient to follow a descend finger, thedelayed drooping of the upper lid is noted the descent of the upper lid lag be-hind descent of the eye ball

b. Exophthalmos (proptosis):i. Protrusion of eyeball out of orbit: the eyelids are retracted and sclera becomes visible

below or all round the irisii. Caused by increased in fat / edema Icellular infiltration in retro-orbital space during the

eyeball forwardsiii. Only present in Graves disease

c. Ophthalmoplegia:i. Weakness of ocular muscles due to edema and cellular infiltration of these muscles

ii. Most often the superior and lateral rectus and inferior oblique muscles are affectediii. Paralysis of these muscles prevents the patient to looks upwards and outwards

d. Chemosis:i. Edema of conjunctiveii. The conjunctiva becomes edematous, thickened and crinklediii. Caused by obstruction of venous and lymphatic drainage of conjunctiva by increased retro-

orbital pressure

Note: Complication of exophthalmos:1. chemosis2. conjunctivitis3. corneal ulceration(due to inability to close eyelids)4. optic atrophy(due to optic nerve stretching)5. ophthalmoplegia6. protosis by standing behind the patient and looking downwards,

the eye will be visible anterior to superior orbital margin7. Joffroys sign: absence of wrinkles on forehead when patient

looks upwards8. StelIwags sign: staring look and infrequent blinking of eyes9. Moebiuss sign: inability or failure to converge eyeballs10. accomodation failure


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iii. Face: puffy face, skin thinning and doughy induration in hypothyroidismiv. Mouth and tongue: tongue moist, dry or coated? central cyanosis? tongue enlarged in hypothyroidism tremor of protruded tongue in thyrotoxicosisv. Voice: coarse, deep, hoarse, slow speech or voice in hypothyroidism

C. Lower limb: Pretibial myxedema: caused by mucopolysaccharide accumulation in Graves disease Non pitting edema - in hypothyroidism Reflex: knee or ankle Proximal myopathy

4.Specific examination of the thyroid gland:A. Inspection: The patient should be sit on chair or over the edge of the bed Pizzalos method: hands placed behind head and patient asked to push head backwards

against clasped hand, it makes the gland more prominent Observed the patient from the front and sides Ask the patient to swallow a sip of water

Ask the patient to open the mouth and then protrude the tongue Point to be described:

a. Presence of localized or general swelling?b. Site: midline or lateralc. Ascend during swallowing? Lower border of the gland can be noted?

Only goiter or thyroglossal cyst will rise during swallowing because attached to larynx, exceptneoplastic infiltration

d. Moves up upon tongue protrusion To differentiate goiter from thyroglossal cyst: thyroglossal cyst moves upwards upon tongue

protrusion, since the duct extends downwards from the foramen caecum to the isthmuse. Scars: thyroidectorny scar?f. Prominent veifls:

Dilated veins suggest retrosternal extension of goiter (thoracic inlet obstruction)

g. Skin changes: skin discoloration, redness?

B. Palpation: Inform the patient what you are going to do Begin the palpation from behind Thumbs of both hands are placed behind the neck and outer 4 fingers of each hand are

placed on each lobes and the isthmus

Cause of neck swelling:1. Midline: goiter (moves up during swallowing) thyroglossal cyst ( moves on po~cing out the tongue) submental lymph nodes parathyroid gland (very rare)2. Lateral: lymph node salivary glands, e.g. tumor, stones skin: sebaceous cyst or lipoma lymphatics: cyst hygroma (translucent)

carotid artery: aneurysm or rarely tumor (pulsatile) pharynx: pharyngeal pouch or brachial arch remnent,

brachial cyst


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Relax the sternocleidomastoid muscles by slightly flexed the neck or rotates the neck towardsthe side of palpation

To get more information about the particular nodules of thyroid gland, the patient is asked toextend the neck, to make the nodules more prominent for better palpation

Deglutition test while palpation carefully the lower border for any extension downwards During palpation, the following points should be noted:

a. diffuse or local swellingb. sizec. shape: oval, round, irregular, uniform etcd. surface:

smooth, nodular, boss elated, etc if a nodules which feels distinct from the remaining thyroid tissue is palpable,

determined its location, size, consistency, tenderness and mobility also decide if the whole gland feels nodular (multi-nodular goiter)

e. consistency: soft: normal, colloid goiter firm: simple goiter rubbery hard: Hashimotos thyroiditis hard: Riedels thyroiditis stony hard: carcinoma, calcification of cyst, fibrosis

f. margin: well-defined or ill definedg. tenderness:

caused by thyroiditis (subacute or rarely suppurative), bleeding into cyst or carcinomah. ascends on deglutitioni. to get below the gland:

feel the lower border because its absence suggest restrosternal extensionj. mobility:

in both horizontal and vertical planes fixity means malignant tumor or chronic thyroiditis

k. temperatureI. attach to the overlying skin and underlying structures, including sternocleidomastoid

musclesm. fluctuation

n. translucencyo. pulsation or thrill

Loheys method:stand in front of the patient, to palpate left lobe, thyroid gland ispushed to the left from right side by left hand, this make the left lobe more prominent

Feel each carotid pulsation, absence may indicate malignant infiltration by tumor Note the position of trachea, in order to define any deviation produced by

asymmetrical thyroid enlargement

C. Percussion: Percuss over the swelling Percuss over the manubrium sternum to exclude retrosternal goiter

D. Auscultation: Listen over each lobe for bruit: increased vascular supply in hyperthyroidism or usage of anti-

thyroid drug Pembertons sign:

ask the patient to rise both arms as high as possible, look for sign of congestion (plethora),cyanosis, respiratory distress, in respiratory stridor, neck veins distension

a test for thoracic inlet obstruction due to retreosternal goiter

5. Other relevant examination:A. Cervical and axiliary lymph nodes: Involved in carcinoma of thyroid, esp. pappilary


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B. Cardiovascular and respiratory examination Look for signs of congestive cardiac failure (complication of thyrotoxicosis), pleural effusion and

pericardial effusion (if hypothyroidism)

C. Evidence of metastasis If carcinoma is suspected Besides cervical lymph nodes, also look for bony, lung etc metastasis

*Note: causes of goiter1.Diffuse, homogenous goiter

hyperplastic (colloid goiter)simple goiterGraves diseaseThyroiditis, e.g. Hashimotos and subacute

2. Solitary noduleDominant nodule in multi-nodular goiter (50% cases)Degeneration or hemorrhage into colloid cyst or noduleBenign adenornaCarcinoma (primary or secondary)


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EXAMINATION OF THE BREAST

1. Repeat 5 important point before examine the patient, IPPEC:a. Introduceb. Permissionc. Positioning:

450or sitting Sitting up for specific examination of thyroid glandd. Exposure: Expose head, neck, upper and lower limbs adequately in general inspection and examination Expose the waist later in specific examination, must be able to see both breasts, the neck, whole

chest wall and the armse. Comfortable - make sure pt is comfortable

2. General inspection (PCLC PR HNG MA), and examination3. Specific examination of the breast:

A. Inspection: Ask the patient to rest the arms by sides of the body Inspect carefully and compare on both sides

Observed the following features:a. Asymmetry of size, shape and positionsb. Skin:

Color and texture: redness in eczema or infection Puckering or dimpling: when present underlying neoplasm orange peel appearance / peau d orange carcinoma of breast: due to blockage of

subcutaneous lymphatic vessels with edema of skin which deepens the opening of sweat glandsand follicles on the skin surface

Nodules: often enlarged Ulceration and fungal infection: late features of advanced carcinoma of the breast Engorged veins: commonly seen in large soft fibroadenoma, cystosarcoma phylloides and

rapidly growing sarcomac. Nipples and areola:

Presence?: both nipple presence or one is retracted or destroyed Position and symmetry:

compare the level of nipples on both sides normal: nipples at same horizontal level and point downwards and outwards in carcinoma: nipple of affected side is drawn towards the lump

Number: any accessory nipple? Surfaces: cracks, fissures or eczema?

d. Discharge: note the character and color: fresh blood, altered blood, pus, milk, serous, etc* lookat axilla, arms and supraclavicular fossa, there may be swelling caused by enlarged axillary

or supraclavicular lymph nodes, distended veins and wasted muscles* ask the patient to slowly raise her arms above the head, changes in shape of the breast

caused by lifting the arms often reveals lumps, puckering and distortion which is not visible when

the arms are by sides* Ask the patient to press her hands against her hips when the pectoral muscles were relaxed, itwill also accentuate any depression in the skin causes by tethering or fixity to underlying lump.

B. Palpation and percussion Ask the patient to point out the side of pain or lump Palpate the normal breast 1

st

If the breast is big, use another hand to support it Palpate the 4 quadrant symmetrically, inner upper,inner lower, outer lower, outer upper Palpate the affected side in similar sequence, compare with the normal side then feel the axilla tail


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a. Lump, if presence, the following points should be noted : site size shape surface margin consistency tenderness temperature fluctuation trans-illumination relation to skin

- 2 Ways:i. Move the lump side to side, to see if there is dimpling or tethering of the skinii. Slide the skin or pinch up the skin over the lump, not possible if the tumor is fixed to skin

1. Tethering: the malignant disease has to spread to Asley Coopers ligament, infiltration of these strands

makes them shorter and inelastic, thus pull the skin inwards resulting in puckering of the skin the lump can still be moved independently of the skin for some distance after which may cause

puckering of the skin

so tethering can be tested by moving the lump side to side and watching if the skin dimples atthe extremes of the movement

2. Fixlty: When there is direct and continuous infiltration of the skin by the tumor which cannot be moved

independently from the skin and the overlying skin cannot be pinched up3. Fixity to the breast tissue:

hold the breast tissue with one hand and gently moves the lump with the other hand Fibroadenoma is not fixed and moves freely Breast mouse: a carcinoma is fixed to the breast substance

4. Relation to the muscles (pectoralis major and serratus anterior) ask the patient to place hand on her hip lightly (relax) move the lump in the direction of the fibers 1

stand then to right angles to them, estimate the

mobility

then ask the patient to press her hip (contract pectoralis muscle), move the lump once more inthe same direction and compare the range of mobility

any restriction in mobility indicates fixity to the pectoral fascia and pectoralis majorb. Nipples:

if the nipple is retracted, press gently from both sides deep to the nipple this will erect it, if the retraction is congenital or spantaneous if it is due to carcinoma, the nipple

cannot be erected like this feel the breast deep to nipple, if there is palpable lump, see if moving it increased or causes

nipple retraction gently press on the nipple to see if there is discharge, note the appearance, character and color

of the dischargec. AxiIla and cervical lymph node

4. Other relevant examination: Look for distance metastasis Common sites for secondary deposits:

a. Lungsb. Bone(tenderness): ribs, spine, sternum pelvis, upper ends of femur and humerusc. Liver


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Examination of inguinal hernia

1. Repeat 5 important point before examine the patient, IPPEC:1.Introduce2.Permission3.Positioning - standing

4. Exposure- expose both the inguinal regions, at least from the level of the umbilicus to mid thigh


2. General inspection; PCLC PR HNG MA & examination

3. General examinationA) inspection:

- ask the pt to stand up- kneel down in front of pt- always examine both sides- ask the pt to cough until the size of the swelling becomes mximum- carefully inspect for few seconds

- observe the following features:1. position and extent

- left or right, or both?- inguinal, inguinal-scrotal (swelling in inguinal region extend down into the scrotum, or labia majora)

or scrotal region?- is the swelling in the groin above or below the inguinal legament?

2. overlying skin- reddened?- discoloration?- ulceration?- dilated vein?- surgical scar?

3. peristaltic movement?

4. cough impulses- ask pt to turn his face away from the examiner and cough- observe if the swelling expends with coughing- presence of expansile cough impulse is almost diagnostic of a hernia, but absence of this sign

does not exclude it (impulse on coughing will be absent in case of strangulated hernia,incarcerated hernia and when the neck of the sac becomes blocked by adhesions)

B) palpation- kneel down at the side of the pt, on the same side as the hernia- ask the pt if and where is any tenderness and examine with this in mind

1) the lump- size- shape- surface (smooth, nodular etc)- margin (well or ill confined)- consistency (soft, hard or firm)- tenderness- temperature- relation to overlying skin- trans-illumination test (to exclude hydrocele), by place the pen torch laterally over the lump- to get above the swelling, to differentiate a scrotal swelling from an inguinal-scrotal swelling (hernia)or rarely an infantile hydrocele


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2) cough impulse- compress the lump firmly with the fingers- ask the pt to turn his face away from the examiners and cough- see if the swelling expands with coughing coughing impulse

3) the testis- presence or absence of testis (undescended testis, ectopic testis or retractile testis)

4) reducibility- ask the pt to reduce the swelling completely- if it is not completely reduced, get the pt lying down and reduced again until its fully reduced - most hernia can be reduced, if hernia cannot be reduced its a irreducible herniaor an obstructed,

incarcerated or strangulated hernia5) ring occlusion test

- with the swelling completely reduced, press on the deep inguinal ring (1/2 inch above the mid-pointbetween the anterior superior iliac spine [ASIS] and the symphysis pubis) with the fingers

- get the pt up (if the pt is lying) and ask the pt to cough- a direct hernia wills show a bulge midial to the occluding finger but an indirect hernia will not find

any access.- then remove the finger and watch the hernia reappear (indirect hernia)- this is a confirmatory test to differentiate indirect inguinal hernia from a direct inguinal hernia

C. percussion

- resonant : contain gut- dull : contains omentum or extraperitoneal fatty tissue

D. auscultation - listen for bowel sounds (in enterocele)

4.Other relevant examination:a. Abdominal examination:

Look for causes of increased intra-abdominal pressure; enlarged prostate (per rectalexamination), chronic intestinal obstruction, large bladder, ascites & etc.

b. Chest examination: to exclude any causes of chronic cough, e.g. bronchitis

Example result after examination:On inspection: There was a swelling over the left inguinal region extending into left scrotum and increased in

size when the patient coughed. The skin was normal in color, no ulceration, no dilated vein or surgical scarOn palpation: A mass measuring 8cm x 4cm was felt which was not tender and there was no increased in

skin temperature The margin was well-defined, smooth surface and soft in consistency I could not get above the swelling. It was able to reduce and can be prevented from returning by pressure over the internal ring at

mid-inguinal point. Cough impulse was present. Tans-illumination test was negative. It was not attached to overlying skin. Both testis were felt and normal in size The swelling was resonance on percussion

On auscultation:bowel sound was heard


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Discussion notes: 2 diagnostic signs of uncomplicated hernia:

1. Impulse on coughing2. Reducibility

The differential diagnostic of inguinal hernia:1. Above the inguinal ligament: inguinal hernia vaginal hydrocele hydrocele of the cord or hydrocele of canal of Nuck undescended or ectopic testis lipoma of the cord

2. Below the inguinal ligament: femoral hernia lymph nodes enlargement saphena varix femoral aneurysm

*Examination should aim to answer these 5 questions:1. Is the swelling a hernia?2. If yes, is it inguinal or femoral hernia?

3. If inguinal hernia, is it indirect or direct?4. What is the content?5. Any complication presence?

1) How to differentiate hernia from other inguinal scrotal swelling? cough impulse and reducibility in most cases of hernia cant get above the swelling in hernia and infantile hydrocele as well palpable testis distinguish from undescended testis or ectopic testis trans-illumination test negative in hernia; positive or translucent in hydrocele and spermatocele

2) How to differentiate inguinal hernia from femoral hernia clinically? scrotal involvement nerve in femoral hernia bilateral is rare in femoral hernia

inguinal hernia is positioned above the inguinal ligament whereas a femoral hernia lies belowthe inguinal ligament

inguinal hernia bulges into corner of the mons veneris, above crease of the groin, where asfemoral hernia bulges into medial end of groin crease

inguinal hernia lies medial and above pubic tubercle whereas femoral hernia occur lateral andbelow the pubic tubercle, 2cm mediai to the femoral pulse, and do not involve the inguinal canal

3) How to distinguish indirect from direct hernia clinically?a. Indirect:

usually involves scrotum reduces upwards, then laterally and backwardsSwelling does not return with pressure over the internal ring at mid-inguinal point (ring occlusion

test-confirmatory)

b. Direct: seldom involves scrotum, unless untreated long standing cases reduces upwards and then straight backwards return on coughing with pressure over internal ring

4) Contest of the Sac:a. Fluid:

most common content derived from peritoneal exudates dull on percussion


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b. Omenturn (omentocele or epiplocele): firm non-fluctant and dull to percussion the 1

stpart goes in easily while the last part resent to be reduced

c. Intestine (enterocele): soft, resonant and fluctuant may have bowel sounds 1

stpart often difficult to reduce but the last part slips in easily

d. Extraperitoneal fate. Bladder

5) Complication of the hernia:a. Obstructed or incarcerated:

irreducible + intestinal obstructionb. Strangulated:

irreducible + arrest of blood supply to the contents (may or may not have intestinalobstruction)

c. Inflamed: when its content such as appendix, salphinx or a Meckels diverticulum becomes inflamed


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EXAMINATION OF THE VARICOSE VEINS

1. Repeat 5 important point before examine the patient, IPPEC:a. Introduceb. Permissionc. Positioning: standing

d. Exposure: expose thigh (groin region) until toee. Comfortable

*Note: 3 main questions must be considered during examination:1. Which system is invoIved?2. Which perforator or perforators are incompetent?3. Are the deep veins patent?

2. General inspection, (PCLC PR HNG MA) and examination3. Specific examination of lower limbs:

A. Inspection: carefully examine both lower limbs from thigh (groin region) down to toes, both front and back,

look for:

a. Site and Course: long saphenous: medial side of leg starting from anterior of the medial malleous to medial side

of knee and along the medial side of thigh upwards to saphenous opening short saphenous: from posterior of lateral malleolus upwards in the posterior aspect of leg and

end in popliteal fossab. Size: large, prominent, small and etcc. Swelling: localized: affecting a segment of venous system generalized: mostly due to deep vein thrombosisd. Skin, look for:i. color: redness indicates thrombophlebitis, white indicates excessive edema and lymphatic obstruction, congested

blue indicates deep vein thrombosisii. ulceration, eczema and pigmentation: esp around mallelousiii. edema or swelling might indicate deep vein thrombosisiv. lipodematosclerosis: skin becomes thickened, fibrosis, scleroses and pigmented due to

chronic venous hypertension which causes fibrin accumulationv. scars: due to venous ulcer or previous openingvi. venous stars: blue patch which consist of minute veins radiating from a single feeding vein

B. Palpation and percussion Patient still standing Gently feel along the course of the veins and feel the tension in the veins Do the following test:

1)Cruveilheirs sign: palpate the saphenous femoral junction (5cm below and medial to femoral pulse) and ask

patient to cough the presence of cough impulse indicates saphena-femoral incompetent

2) Chvriers tap sign ( Schwartz test): tap the distal varicosities and this will impart an impulse or fluid thrill to the finger at the

saphenous opening

3) Brodie-trendelenberg test: lie the patient down, elevate the limb to empty the veins, then apply tourniquet or press

over the saphenous opening and then ask patient to stand up again


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the test is to dertermine incompetency of sapheno-femoral junction and/or thecommunicating system:

i. Sapheno-femoral junction incompetent: the vein remain empty, which is confirmed by release the pressure and vein quickly filled up

from aboveii. Incompetent of communicating system:

The tourniquet or pressure over the saphenous opening remains in place but there isgradual filling of the vein from below (incompetent leg perforators)

The tourniquet is applied further down the limb, until after standing the veins are controlled. This will indicate the level of incompetent perforator.

4) Tourniquet test (Variant of Brodie-trendelenberg test): The patient lies down and the veins are emptied by elevating limb A tourniquet is applied high up in thigh as Brodie-Trendelenberg test but at the same time

several more tourniquet are applied in the leg to correspond to leg perforators Ask to patient to stand up If the veins above the tourniquet fill up and those below remain collapsed, it indicates

presence of incompetent communicating sapheno femoral junction (most important) mid-thigh perforators (5, 10 and 15cm above the medial malleolus)

5) Pratts test: this test is performed to know the position of the leg perforators An elastic compression bandage (Esmarch) is applied from toe to upper thigh which cause

an emptying of varicose veins Then a tourniquet is applied at the upper end of the compression bandage While the tournique in place, the compression bandage is unwind in a downward directionA blow-out will appear at the site constant perforator, indicated incompetent perforator

6) Morriseys test (Sapheno-femoral incompetence): empty the veins by elevating the leg, then ask the patient to cough forcibly an expansile impulse is felt in the long saphenous vein particuany at the saphenous

opening if the sapheno-femoral valve is incompetent

7) Fegans method: With the patient standing, mark the veins (ask the patients permission 1st), then with the

patient lying down, elevate the limb to empty the vein Palpate down the course of the vein and locate the gaps or pits in the deep fascia which

transmit the incompetent perforators

8) Perthes test (test for deep vein patency): place a tourniquet around the thigh, tightly enough to prevent any reflux down the vein and

ask the patient to walk for about 5 mins if the varicose remain unchanged or becomes more distended as well as the patient

experiencing a bursting pain, it indicates that the perforating veins and deep veins areblocked

operation is contraindicated in impatent deep veins

Auscultation: Listen for venous hum: can be heard at the saphena varix in severe cases Continuous bruits: in anterior- venous fistula causing varicosities

4. Other relevant examination:- AbdominaI examination including rectal and vaginal examination to exclude any pelvic or abdominal

causes for varicose veins


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Practically, not all the tests are done in the exam since most of the time it comes out in short case withlimited time. Therefore, there are only 3 important tests that, are required in the exam:

a. Schwartz testb. Brodie-trendelenberg test, andc. Perthes test

*Note: complication of varicose veins1. hemorrhage (minor trauma to dilated vein)2. phlebitis: occurs spontaneously or 2

0to minor trauma

3. ulceration: mostly due to deep vein thrombosis rather than varicose veins alone4. pigmentation5. eczema6. IipodermatoscIerosis7. calcification of the vein8. periositis in long standing ulcer over tibia9. equines deformity: only in long standing ulcer

*Note: cause of varicose vein in lower limb:1. Primary: causes unknown, the valves are incompetent both of the main vein or the communicating veins venous walls may be weak which permit dilatation causing incompetent of valves very rarely there may be congenital absence of valves2. Secondary: obstruction to venous outflow: pregnancy, fibroid, ovarian cyst, pelvic cancer, abdominal

lymphadenopathy, ascites, iliac vein thrombosis. retroperitoneal fibrosis destruction of valve in deep vein thrombosis high pressure flow in arteriorvenous fistula


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Examination of handsGeneral inspection : (expose till elbow, sitting up, hands on pillow)- cushingoid- weight- iritis, scleritis- obious other jt ds

- skin nails- small mus. of hands- deformation?RA : ulnar deviation, swan neck deformation, boutonniere deformation, z deformity of thumb OA : herberden nodes in DIP

Dorsal aspect- wrist- skin : scar, redness, atrophy, rash- swelling : distribution- deformity- muscle wasting, hollow ridges, btw metacarpel bone

Examination of hands- feel and move passively- wrist, MCP, DIP, PIP- Synovitis- effusion- range of movement- crepitus- ulnar styloid tenderness

Palmar surface- palmar tenderness by open close examiner hand with pts hand - 30s tingling in carpal tunnel synd?

Screening for MCP IP movement

- tight fist with encircling examiner hand done together- active flexion of each finger- if reduce movement do flexor profundus test hold the prox finger jt extended , instruc the pt to

bend the tip of finger, if pt can flex tip of finger, flexor profundus is intact

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